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APPENDIX D. THE GENEVA CONVENTIONS AND COMBAT STRESS-
RELATED CASUALTIES ........................................................ D-1
D-1. Special Relevance to Medical Combat Stress Control ........................... D-1
D-2. Special Considerations for Medical Combat Stress Control Activities ........ D-1
D-3. The Law of War ........................................................................ D-5
D-4. Protection of the Wounded and Sick ................................................ D-6
D-5. Protection and Identification of Medical Personnel ............................... D-9
D-6. Protection and Identification of Medical Units and Establishments,
Buildings and Material, and Medical Transports ............................... D-10
D-7. Loss of Protection of Medical Units and Establishments ........................ D-12
D-8. Conditions Not Compromising Medical Units and Establishments of
Protection .............................................................................. D-13

«APPENDIX E. MEDICAL REENGINEERING INITIATIVE FOR MENTAL HEALTH
AND COMBAT STRESS CONTROL ELEMENTS IN THE
THEATER OF OPERATIONS ................................................. E-1

Section I. Overview of Changes ................................................................. E-1
E-1. Unit Mental Health Sections .......................................................... E-1
E-2. Combat Stress Control Units ......................................................... E-2

Section II. Unit Mental Health Sections in the Theater of Operations .................. E-5
E-3. Location and Assignment of Unit Mental Health Sections ...................... E-5
E-4. Utilization in Garrison ................................................................. E-5
E-5. Division Mental Health Sections ..................................................... E-6
E-6. Area Support Medical Battalion Mental Health Sections ........................ E-11
E-7. Mental Health Personnel in the Armored Cavalry Regiments and
Separate Brigades .................................................................... E-15

Section III. Combat Stress Control Company ................................................. E-15
E-8. Medical Company, Combat Stress Control (TOE 08467A000) ................ E-15
E-9. Headquarters Section .................................................................. E-17
E-10. Combat Stress Control Preventive Section ......................................... E-22
E-11. Combat Stress Control Fitness Section ............................................. E-25

Section IV. Combat Stress Control Detachment .............................................. E-30
E-12. Medical Detachment, Combat Stress Control (TOE 08567AA00) ............. E-30
E-13. Detachment Headquarters ............................................................. E-31
E-14. Preventive Section ...................................................................... E-34
E-15. Combat Stress Control Fitness Section ............................................. E-36

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GLOSSARY ..................................................................................................... Glossary-1

REFERENCES ................................................................................................. References-1

INDEX ............................................................................................................ Index-1

PREFACE

This field manual (FM) establishes medical doctrine and provides principles for conducting combat stress
control (CSC) support operations from forward areas to the continental United States- (CONUS) based medical
facilities. This manual sets forth tactics, techniques, and procedures (TTP) for CSC units and elements operating
within the theater of operations (TO). This TTP is applicable to operations across the operational continuum. It
is important that the users of this manual be familiar with FM 22-51. This manual supports the Army Medical
Department’s (AMEDD) keystone manual, FM 8-10. Readers should have a fundamental understanding of FMs
8-10-3, 8-10-5, 8-10-6, 8-10-8, 8-10-14, 8-10-24, 8-42, 8-55, 63-20, 63-21, 100-5, and 100-10.

The staffing and organizational structure presented in this publication reflects information in the most current
living tables of organization and equipment (TOE) as of calendar year 1993. However, staffing is subject to change
to comply with manpower requirements criteria outlined in AR 570-2. Your TOE can be subsequently modified.

«The Medical Reengineering Initiative (MRI) update has been added to this publication as Change 1,
Appendix E. Organizational changes to CSC elements as a result of MRI were incorporated into the A-series TOE.
CSC elements will convert from the L-series to the A-series TOE in the near future based on Department of the
Army (DA) timelines.

This publication is in agreement with the American, British, Canadian, and Australian (ABCA) Quadripartite
Standardization Agreement (QSTAG) 909, Principles of Prevention and Management of Combat Stress Reaction,
Edition 1.

«The proponent of this publication is the United States (US) Army Medical Department Center and School
(AMEDDC&S). Send comments and recommendations on DA Form 2028 directly to Commander, AMEDDC&S,
ATTN: MCCS-FCD-L, 1400 East Grayson, Fort Sam Houston, Texas 78234-6175.

Unless this publication states otherwise, masculine nouns and pronouns do not refer exclusively to men.

Use of trade or brand names or trademarks in this publication is for illustrative purpose only, and does not imply
endorsement by the Department of Defense (DOD).

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PREFACE

This field manual (FM) establishes medical doctrine and provides principles for conducting combat
stress control (CSC) support operations from forward areas to the continental United States- ( CONUS)
based medical facilities. This manual sets forth tactics, techniques, and procedures (TTP) for CSC units
and elements operating within the theater of operations (TO). This TTP is applicable to operations across
the operational continuum. It is important that the users of this manual be familiar with FM 22-51. This
manual supports the Army Medical Department’s (AMEDD) keystone manual, FM 8-10. Readers should
have a fundamental understanding of FMs 8-10-3,8-10-5,8-10-6, 8-10-8,8-10-14,8-10-24, 8-42,8-55,63-
20, 63-21, 100-5, and 100-10.
The staffing and organization structure presented in this publication reflects information in the most
current living tables of organization and equipment (TOE) as of calendar year 1993. However, staffing is
subject to change to comply with manpower requirements criteria outlined in AR 570-2. Your TOE can
be subsequently modified.
This publication is in agreement with the American, British, Canadian, and Australian (ABCA)
Quadripartite Standardization Agreement (QSTAG) 909, Principles of Prevention and Management of
Combat Stress Reaction, Edition 1.
The proponent of this publication is the United States (US) Army Medical Department Center and
School (AMEDDC&S). Send comments and recommendations on Department of Army (DA) Form 2028
directly to Commander, AMEDDC&S, ATTN: HSMC-FCD, Fort Sam Houston, Texas 78234-6123.
Unless this publication states otherwise, masculine nouns and pronouns do not refer exclusively to
men.
Use of trade or brand names or trademarks in this publication is for illustrative purpose only, and does
not imply endorsement by the Department of Defense (DOD).

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CHAPTER 1

CONTROL OF COMBAT STRESS

1-1. Stress Control Stress is one of the body’s processes for dealing
with uncertain changes and danger. Elimination
a. Control of Stress. In one’s own of stress is both impossible and undesirable in
soldiers and in the soldiers of the enemy, control the Army’s peacetime or combat mission.
of stress is often the decisive difference between
victory and defeat across the operational con-
tinuum. Battles and wars are won more by 1-2. Combat Stress Threat
controlling the will to fight than by killing all of
the enemy. Soldiers that are properly focused by a. Stressors in Combat. Many stres-
training, unit cohesion, and leadership are most sors in a combat situation are due to deliberate
likely to have the strength, endurance, and alert- enemy actions aimed at killing, wounding, or
ness to perform their combat mission. In these demoralizing our soldiers and our allies. Other
soldiers, combat stress is controlled and positive stressors are due to the natural environment.
combat stress reactions, such as loyalty, self- Some of these stressors can be avoided or
lessness, and acts of bravery, are more likely to counteracted by wise command actions. Still
occur. However, uncontrolled combat stress other stressors are due to our own calculated or
causes erratic or harmful behavior, impairs miscalculated choice, accepted in order to exert
mission performance, and results in disaster and greater stress on the enemy. Sound leadership
defeat. works to keep these within tolerable limits and
prepares the troops mentally and physically to
b. Responsibility For Stress Control. endure them. Some of the most potent stressors
Control of stress is the commander’s responsibility can be due to personal or organizational problems
(see FM 22-51) at all echelons. The commander in the unit or on the home front. These, too,
is aided in this responsibility by the noncom- must be identified and, when possible, corrected
missioned officer (NCO) chain of support; the or controlled. See FMs 8-10, 8-10-8, and 22-51
chaplaincy; unit medical personnel; general, for additional information on the overall threat,
principal, and special staff, and by specialized medical threat, and combat stress threat.
Army CSC units and mental health personnel.
b. Stress Casualties. The combat stress
c. Control or Management. The word threat includes all those stressors (risk factors)
control is used with combat stress (rather than which can cause soldiers to become stress
the word management) to emphasize the active casualties. Stress casualties include—
steps which leaders, supporting medical per-
sonnel, and individual soldiers must take to keep Battle fatigue (BF) cases which
stress within an acceptable range. This does not are held for treatment at medical treatment
mean that control and management are mutually facilities (MTFs) for more than a day.
exclusive terms. Management is by definition
the exercise of control. Within common usage, Misconduct stress behaviors
however, and especially within Army usage, cases that have committed breaches of discipline
management has the connotation of being a which require disciplinary confinement.
somewhat detached, number-driven, higher
echelon process rather than a direct, inspi- Post-traumatic stress disorder
rational, and leadership-oriented process. Control (PTSD) cases which disable the soldier for months
of stress does not imply elimination of stress. or years after the battle.

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The combat stress threat also includes some (4) The physical stressors evoke
wounded in action (WIA) or disease and nonbattle specific “stress reflexes,” such as shivering and
injury (DNBI) casualties whose— vasoconstriction (for cold), sweating and
vasodilation (for heat), or tension of the eardrum
Disabilities are a direct con- (for noise), and so forth. A soldier’s stress reflexes
sequence of carelessness or inefficiency due to can counteract the damaging impact of the
stress. stressors up to a point but may be overwhelmed.
(5) The distinction between mental
Recovery and return to duty and physical stressors is rarely obvious.
(RTD) is complicated by unresolved stress issues.
(a) Mental stressors can also
In a broader sense, the combat stress threat also produce some of the same stress reflexes
includes the missed opportunities and increased nonspecifically (such as vasoconstriction,
casualties (killed, wounded, and/or taken sweating, adrenaline release). These stress
prisoner) that come from impaired decision reflexes can markedly increase or decrease an
making or faulty execution of mission due to individual’s vulnerability to specific physical
excessive stress. stressors. Mental stressors presumably cause
changes in the electrochemical (neurotransmitter)
c. Mental Stressors and Physical systems in the brain.
Stressors. A rough distinction can be made
between those stressors which are “mental” and (b) Physical stressors can
those which are “physical.” result in mental stress because they cause
discomfort, impair performance, and provide
(1) A mental stressor would be one information which poses a threat.
in which information is sent to the brain, with
only indirect physical impact on the body. This (c) Physical stressors can
information may place demands on and evoke interfere directly with brain functioning and
reactions from either the perceptual and cognitive therefore with perceptual and cognitive mental
system, or the emotional systems in the brain, or abilities, thus increasing the stresses.
from both.
(d) Light, noise, discomfort,
and anxiety-provoking information may interfere
(2) A physical stressor is one which with sleep, which is essential to maintain brain
has a direct, potentially harmful effect on the efficiency and mental performance.
body. These stressors may be external environ-
mental conditions or the internal physical/ (6) Because of this intermeshing of
physiologic demands required by or placed upon “physical” and “mental” stressors and stress
the human body. responses, no great effort needs to be invested in
distinguishing them until the physical stressors
(3) Table 1-1, Combat Stressors, reach the degree where they require specific (and
gives examples for the two types of mental perhaps emergency) protective measures and/or
stressors (cognitive and emotional) and the two treatment. Prior to that point, medical and
types for physical stressors (environmental and mental health personnel should assume that both
physiological). physical and mental stressors are usually present

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and interacting. They should treat both types of physical stressor, sufficient to produce more than
stressors simultaneously as standard procedure. “routine” stress reflexes, is often required to
achieve greater tolerance or acclimatization to
d. Positive Stress. Positive stress is that stressor. Well-known examples are
that degree of stress which is necessary to sustain cardiovascular and muscle fitness and heat and
and improve tolerance to stress without cold acclimatization. Stressors which overstrain
overstraining and disrupting the human system. the human system can clearly retard
Some level of stress is helpful and even necessary acclimatization and even permanently impair it.
to health. Insufficient stress leads to physical For instance, in the “physical stress” example
and/or mental weakness. A moderate response given, excessive physical work can cause
to stress actually improves performance. Soldiers temporary or permanent damage to muscles,
who have been trained to manage their responses bones, and heart, while extreme heat and cold
to a stressful situation by maintaining neither can cause heatstroke or frostbite with
too low nor too high a level of activation perform permanently reduced tolerance to heat or cold.
tasks better. Progressively greater exposure to a The same may be true of emotional or mental

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stress, although the mechanism is less clear. Up history and mission (this sense is called unit
to a point, mental stress (even uncomfortable or esprit de corps or simply esprit).
painful mental stress) may increase tolerance to
future stress without any current impairment. A The above positive combat stress behaviors
higher level may cause temporary overtrain but combine to form unit cohesion—the binding force
may heal as strong or stronger than ever with that keeps soldiers together and performing the
rest and restorative processing. More severe mission in spite of danger and death. The
overstrain, however, may severely weaken ultimate positive combat stress behaviors are acts
tolerance to future stress. There is reason to of extreme courage and almost unbelievable
believe that immediate treatment can greatly strength. They may even involve deliberate self-
reduce the potential for chronic disability, even sacrifice. Positive combat stress behaviors can be
for impairing emotional overstrain. brought forth by sound military training, wise
personnel policies, and good leadership. The
results are behaviors which are often rewarded
1-3. Stress Behaviors in Combat with praise and individual and/or unit recog-
nition. For additional information on positive
a. Combat Stress Behaviors. Combat combat stress behaviors, see FM 22-51.
stress behavior is the generic term which covers
the full range of behaviors in combat, from highly c. Misconduct Stress Behaviors.
positive to totally negative. Table 1-2 provides a Examples of misconduct stress behaviors are
listing of positive stress responses and behaviors, listed in the center column of Table 1-2. These
plus two types of dysfunctional combat stress range from minor breaches of unit orders or
behaviors—those which are misconduct stress regulations to serious violations of the Uniform
behaviors and those which are labeled BF. Code of Military Justice (UCMJ) and the Law of
Land Warfare. As misconduct stress behaviors,
b. Positive Combat Stress Behaviors. they are most likely to occur in poorly trained,
Positive combat stress behaviors include undisciplined soldiers. However, misconduct can
heightened alertness, strength, endurance, and also be committed by good and even heroic
tolerance to discomfort. Both the fight or flight soldiers under extreme combat stress. In fact,
stress response and the stage of resistance can misconduct stress behaviors can become the
produce positive combat stress behaviors when second edge of the double-edged sword of highly
properly in tune. Examples of positive combat cohesive and proud units. Such units may come
stress behaviors include— to consider themselves entitled to special priv-
ileges and as a result, relieve tension unlawfully
The strong personal trust, when they stand-down from their combat mission.
loyalty, and cohesiveness (called horizontal They may lapse into illegal revenge when a unit
bonding) which develops among peers in a small member is lost in combat. Such misconduct stress
military unit. behaviors can be prevented by stress control
measures, but once serious misconduct has
The personal trust, loyalty, and occurred, soldiers must be punished to prevent
cohesiveness (called vertical bonding) that further erosion of discipline. Combat stress, even
develops between leaders and subordinates. with heroic combat performance, cannot justify
criminal misconduct. Combat stress may, how-
The sense of pride and shared ever, constitute extenuating circumstances for
identity which soldiers develop with the unit’s minor (noncriminal) infractions in determining

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nonjudicial punishment under Article 15, UCMJ. close to the soldier’s unit provides the best poten-
Combat stress may also constitute an extenuating tial for returning the soldier to duty. Recovered
circumstance in the sentencing proceedings of a BF casualties who are accepted back in their units
court-martial. See FM 22-51 for additional infor- are at no more risk of recurrence than their fellow
mation on misconduct stress behaviors. soldiers.
d. Battle Fatigue. Battle fatigue is also e. Overlapping of Combat Stress Be-
called combat stress reaction or combat fatigue. haviors. The distinction between positive combat
Fatigue by definition is the distress and impaired stress behaviors, misconduct stress behaviors,
performance that comes from doing something and BF is not always clear. Indeed, the three
(anything) too hard and/or too long. The term categories of combat stress behaviors may
battle fatigue is applied to any combat stress overlap. Soldiers with BF may show misconduct
reaction which is treated. All BF is treated (as stress behaviors and Vice versa. Soldiers who
all types of fatigue) with the four Rs—— exemplify the positive combat stress behaviors
may suffer symptoms of BF and may even be BF
Reassure of normality. casualties before or after their performance of
duty. Excellent combat soldiers may commit
Rest (respite from the work). misconduct stress behaviors in reaction to the
stressors of combat before, after, or during their
Replenish physiologic status. otherwise exemplary performance. However,
combat stress, even with good combat behaviors,
Restore confidence with activi- does not excuse criminal acts.
ties.
f. Post-Traumatic Stress Disorders.
See Table 1-2 for examples of BF. The BF behav- Symptoms of post-traumatic stress are persistent
iors which are listed near the top may accompany or recurring stress responses after exposure to
excellent combat performance, and are often extremely distressing events. As with BF, post-
found to some degree in all soldiers. These are traumatic stress symptoms can be normal/
normal, common signs of BF. Those behaviors common signs or warning signs. These signs and
that follow are listed in descending order to symptoms do not necessarily make the soldier a
indicate progressively more serious warning casualty nor does the condition warrant the label
signs. Warning signs deserve immediate atten- of a disorder. This becomes PTSD only when it
tion by the leader, medic, or buddy to prevent interferes with occupational or personal life goals.
potential harm to the soldier, others, or the mis- These signs and symptoms sometime occur
sion. If the soldier responds quickly to helping months or years after the event and may
actions, warning signs do not necessarily mean include—
he must be relieved of duty or evacuated.
However, he may require further evaluation at Painful memories.
an MTF to rule out other physical or mental Actions taken to escape painful
illness. If the symptoms of BF persist and make memories such as—
the soldier unable to perform duties reliably,
then MTFs, such as clearing stations and Substance abuse.
specialized CSC teams, can provide restorative
treatment. At this point, the soldier is a BF Avoidance of reminders of
casualty. For those cases, prompt treatment the traumatic event.

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Social estrangement. ambitious countries who are hostile toward the
US or toward nations important to the US.
Withdrawal. Consequently, the danger of regional armor-
heavy battles at the high-intensity end of the
Post-traumatic stress disorder often follows inade- continuum of conflict, and even of regional
quately treated BF. It often follows misconduct nuclear, biological, and chemical (NBC) war, may
stress behaviors in those who committed mis- paradoxically increase over the next decades.
conduct under stress, as well as in the victims,
reluctant participants, caregivers, and observers. (2) Alternatively, hostile states (or
Post-traumatic stress disorder can occur in ethnic/religious factions encouraged by them)
soldiers who showed no maladaptive stress behav- may attempt to overthrow friendly nations or
iors at the time of the trauma. Post-traumatic attack the US interest by conducting terrorist or
stress disorders can occur or recur years after the insurgency operations. These attacks may
event, usually at times of excessive stress. In require counteractions by US combat forces. In
addition to their primary mission during war, operations other than war (OOTW), contingency
leaders, chaplains, and medical and CSC per- operations may be needed to protect US lives,
sonnel have the additional responsibility of property, and international standards of humane
preventing or minimizing subsequent PTSD. The conduct in third world countries which are
most important preventive measure for PTSD is otherwise of little concern to the US. These
routine after-action debriefing in small groups. operations will likely be conducted on short
If properly debriefed, soldiers will often not notice, under conditions of high operational
develop clinical PTSD or misconduct stress security. They will also be subject to intense and
behaviors. Experiences of excessive stress can be near-instantaneous media coverage.
accepted and diverted into positive growth. For
additional information on PTSD, its prevention, b. High-Technology Joint and Coa-
and treatment, see FM 22-51. lition Operations. Most combat and contingency
operations will be joint operations. Many will
involve working in coalition with countries whose
1-4. Stressors and Stress in Army Opera- customs and culture are quite different from our
tions own. The US will make maximal use of our
technological superiority in intelligence-gathering
a. The Changing Focus. The emerging and weapons systems to mobilize overwhelming
concept for Army operations in the post-cold war forces at the decisive point for quick and certain
era has reoriented the nation’s military capability victory. However, those systems can only be as
away from a primary focus on potential large scale effective as the stress tolerance of the human
war against Soviet forces in Europe. The focus commanders and soldier/operators make them.
has shifted towards a more ambiguous threat The combining of highly lethal weapons systems
from current or future regional powers around from different branches, services, and allies
the world. creates an intrinsic risk of friendly fire casualties.
This risk, too, must be calculated and the stress
(1) High technology weapons are consequences controlled.
available from a number of sources throughout
the world. The dissolution of the Soviet empire c. Brigade Task Force Operations. The
may disperse quantities of high technology Army operations concept makes the brigade the
weapons (and weapons design expertise) to critical unit for CSC prevention and immediate

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intervention, more so than in previous wars. Support to counter drug opera-
Divisional and separate brigades and armored tions.
cavalry regiments (ACRs) will be combined into
task forces for rapid-deployment contingency Peacekeeping operations.
operations. Within campaigns, brigade task
forces will be rapidly organized for specific, brief, Arms control.
violent battles. During battles, the task forces
can cover great distances quickly, concentrate for Combatting terrorism.
decisive action, and perhaps reconstitute at
different tactical support areas than the ones from Show of force.
where they started. Between battles, brigades
may remain widely dispersed. A brigade which Attacks and raids.
is armed with modern weapons systems has more
firepower and covers a larger area of responsi- Noncombatant evacuation op-
bility than a World War I (WWI) or WWII erations.
division. At the small unit level, the importance
of individual soldiers to the unit’s combat power Peace enforcement.
is also greatly increased for weapons operators
and leaders. It is equally true for critical combat Support for insurgences and
support (CS) and combat service support (CSS) counterinsurgencies.
specialists. Rear battle, in the form of long-range
artillery fire, enemy airborne/air assault units, Support to domestic civil au-
guerrilla activity, air interdiction, and terrorist thorities.
or missile attacks, may strike far behind the
battle area. Army mental health/CSC organi- The rules of engagement for each of the above
zation and doctrine were first designed to support operations are unique to that situation. Require-
WWI and WWII divisions. Our new mental ments to maintain neutrality provide a show of
health/CSC doctrine and units must adapt to force only, engage in constructive humanitarian,
these changing conditions by assuring integral or other such actions may require that only defen-
CSC support at brigade level while improving sive actions be taken once attacked. In conflict,
coverage throughout the supported area. however, the opponents may deliberately seek to
provoke our forces into committing misconduct
d. Military Operations Other Than stress behaviors. By committing criminal acts,
War. In addition to war, there will be many the role of the US Forces would be degraded in
other Army missions which are prolonged. The the eyes of local, US, and world populations. In
National Command Authority may commit US light of this, the CSC role in the prevention of
Army units to military OOTW including— misconduct stress behaviors is extremely impor-
tant. For definitive information pertaining to
Conflict. OOTW, see FM 100-5.
Nation assistance.
e. Neuropsychiatric Disorders.The
Security assistance. focus of CSC is on the prevention and treatment
of stress-induced disability in otherwise normal
Humanitarian assistance and soldiers. Mental health/CSC personnel, by virtue
disaster relief. of their professional training and experience, are

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also best qualified to diagnose, treat, and recom- Monitor stressors and stress in
mend RTD or disposition for the endemic units.
neuropsychiatric (NP) disorders. These NP
disorders include the schizophrenic-type psychotic Advise command on measures
disorders, mood disorders, anxiety disorders, to reduce or control stress and stressors before
organic mental disorders, personality disorders, they cause dysfunction.
and substance abuse disorders. These NP dis-
orders are significant impediments to combat Reduce combat stress-related
readiness and also to peacetime training. Sound casualties by training leaders, medical person-
prevention and screening programs as identified nel, chaplains, and soldiers on stress-coping
in Army Regulation (AR) 40-216, as well as early techniques.
recognition and treatment, assist the command
in maintaining the fighting strength. Promote positive combat stress
behavior and progressively increase stress toler-
1-5. Army Combat Stress Control ance to meet the extreme stress of combat.

a. Focus of Army Combat Stress Con- Recognize and treat BF and
trol. The focus of Army CSC is toward— other stress reactions as early and as far forward
as possible.
Promotion of positive mission-
oriented motivation. Accomplish the earliest RTD
of most soldiers who become stress-related
Prevention of stress-related casualties.
casualties.
Facilitate the correct disposi-
Treatment and early RTD of tion of soldiers whose BF, misconduct stress
soldiers suffering from BF. behaviors, and NP disorders do not allow RTD.
Prevention of harmful combat
stress reactions such as misconduct stress Reduce PTSD, chiefly by train-
behaviors and PTSD. ing and assisting after-action debriefings and by
leading critical event debriefings.
b. Implementation. The CSC program
is implemented by mental health/CSC person-
nel organic to the divisions, the medical 1-6. Historical Experience
companies of separate brigades, and the area
support medical battalions (ASMBS) in the corps The AMEDD identified "CSC” as a separate
and communications zone (COMMZ) (see functional mission area in 1984, but CSC is not
Chapters 2 and 3). These mental health/CSC new. Historical experience in the Civil War,
personnel are augmented by the CSC company or WWI, WWII, Korea, Vietnam, the Arab-Israeli,
detachment. Combat stress control companies and other wars has demonstrated the basic
and detachments are assigned to the corps and in principles of combat psychiatry and combat
the COMMZ (see Chapters 2 and 3). Primary mental health. The goal is to preserve the
goals of mental health/CSC personnel when fighting strength by minimizing losses due to BF
implementing this program are to— and NP disorders.

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a. World War I. In 1917, before sending b. World War II. During the time
the American Expeditionary Force to Europe, the between WWI and WWII, CSC insights and the
US Army sent a medical team to see what our principles learned were forgotten. It was believed
new allies had learned from hard experience that prior screening could identify and exclude
about casualty care. Based on the finding of this most of the soldiers who would be prone to psycho-
team in the combat psychiatry area, The Surgeon neurosis and breakdown in combat. That
General of the Army recommended that we adopt screening was glaringly unsuccessful. The WWI
a three-echelon system similar to that of the system was reinstituted during the Tunisia cam-
British Army. He also recommended that we paign, and the condition formerly identified as
implement their policies to return soldiers with “war neurosis” was officially labeled combat
“war neurosis” (commonly mislabeled shell shock) exhaustion. By late in the war, the Mediter-
to duty. Accordingly, in WWI, we assigned a ranean and European theaters again had
psychiatrist to each division (first echelon) to train psychiatrists assigned to each division. Most
the unit leader and medical personnel. The maneuver battalions had “rest centers” in their
psychiatrist trained unit leaders and medical “kitchen trains” (where recovering soldiers were
personnel to recognize and treat simple fatigue monitored by the battalion surgeon). There were
cases in their own units. Many US stress “exhaustion centers” in the regimental or combat
casualties were returned to duty after resting a team trains area, monitored by the regimental
few days in the 150-cot field hospital which was surgeon. The division psychiatrist trained the
located in the division rear. By direction of The regimental and battalion surgeons in combat
Surgeon General’s NP consultant, the official psychiatry. During combat, the psychiatrist
diagnostic label for these types of cases while the triaged and treated combat exhaustion cases at
soldier was still in the division area was “Not Yet the division clearing company and supervised
Diagnosed, Nervous,” (also adapted from the their further rehabilitation for 3 to 5 days at the
British and abbreviated NYDN). The psychiatrist division’s “training and rehabilitation center.”
screened out and evacuated soldiers with serious There were also (once again) Army NP centers
NP disorders. Behind the division (second (clearing companies with psychiatric supervisors
echelon), we had special neurological hospitals and specially trained staff’) behind the divisions,
(150-bed facilities with psychiatrist supervisors). Psychiatric consultants were at Army level, and
They treated the relatively few NYDN cases who specialized base hospitals were located in the
did not RTD within the division in a few days. COMMZ. In heavy fighting during WWII, some
They also treated some soldiers with “gas mania,” divisions had one BF casualty for every five,
who believed they had been gassed when in fact three, even two WIAs. However, highly trained
they had not been. Further to the rear, we had and cohesive units rarely had more than one BF
Base Hospital 117 (third echelon), staffed by casualty for ten WIA. That ratio illustrated the
psychiatrists, nurses, specially trained medics, value of strong leadership in preventing BF even
and occupational therapists. These medical under conditions of extreme stress.
professionals salvaged many soldiers who did not
fully recover in the neurological hospitals. This c. Korea. In each division, the division
three-echelon system worked well. However, on psychiatrist was assisted by a social work
occasions when the tactical situation interfered specialist and a clinical psychologist specialist
with forward treatment, it clearly showed the (initially, enlisted specialists; later officers).
importance of treating the soldiers close to their These professionals functioned very effectively in
units. Overall, a large percent of WWI “war treating combat exhaustion (what is now referred
neurosis” cases were RTD. to as BF). It should be stated that there was

1-10
FM 8-51

some confusion during the initial hasty mobili- surveys to assess the soldiers’ level of unit cohe-
zation and deployment and many combat sion and their self-perceived readiness for combat.
exhaustion cases were inadvertently evacuated The stress assessment teams provided feedback
to Japan. The lessons of WWII were institu- to units and to the Army Central Command on
tionalized in a specialized unit, the "KO Team" how to control stress and enhance morale and
(medical detachment, psychiatric). The primary readiness. They also provided training to leaders
mission of this mobile unit was to augment a and troops on stress control. Corps- and theater-
medical clearing company and make it into an level OM Teams reached the theater in late
NP center. Late in the conflict, 85 percent of the October and December. The mobile teams
BF cases returned to combat within 3 days. An actively undertook the command consultation and
additional 10 percent returned to limited duty in training mission to corps and echelon above corps
several weeks, and only 5 percent were evacuated units. They reinforced the activities of the divi-
to CONUS. sion mental health sections. During Operation
Desert Storm, division mental health/CSC teams
d. Vietnam. In Vietnam, division men- were deployed forward. These teams worked with
tal health sections were located and worked at units who had suffered casualties. Combat stress
the main base camp areas. They sometimes sent control teams from the corps were deployed
consultation teams or enlisted behavioral science behind the brigades. These teams saw few stress
specialists to visit base camps and fire bases. casualties during the ground offensive because of
Many of these draftee mental health personnel its rapid and highly victorious pace which lasted
were professionals with masters- or doctorate- only 100 hours. During demobilization after
level degrees. Traditional “combat exhaustion” Operation Desert Storm, a systematic effort was
was rarely seen, and most cases of BF were conducted by chaplains and mental health per-
handled within the units. Substance abuse, the sonnel to prepare soldiers and their families for
lack of discipline, and even commission of the changes and stressors of reunion. Some units
atrocities were significant problems but were not which had especially difficult experiences received
clearly recognized as misconduct stress behav- special debriefings.
iors. By mid-1971, 61 percent of all medical
evacuations from Vietnam were NP patients
(mostly substance abuse). Two KO Teams served 1-7. Principles of Combat Psychiatry
with distinction in Vietnam, but because of
the different nature of war, functioned mostly
as psychiatric augmentation to an evacuation The basic precepts of combat psychiatry have
hospital and as mobile consultation teams. In been documented in every US war in this century.
1972, based on the Vietnam experience, the KO Our allies through similar experiences have
Team was redesigned into the OM Team. further documented these basic precepts. The
principles of combat psychiatry are—
e. Operation Desert Shield/Storm. Be-
ginning in September of 1990, stress assessment a. Maximize Prevention.
teams from the US Army Medical Research and
Development Command were deployed in support (1) Achieve primary prevention.
of Operation Desert Shield. These teams con- Control (and when feasible, reduce) stressors
ducted surveys of many combat, CS, and CSS which are known to increase BF and misconduct
units in the TO. These stress assessment teams stress behaviors. Some of the factors which
used small group interviews and questionnaire increase stress and stress casualties include—

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FM 8-51

Being a new soldier (first Prevent contagion by rap-
time in combat) in a unit. idly segregating and treating dramatic BF
casualties and disciplining minor misconduct
Home front worries. stress behaviors.
Intense battle with many Reintegrate recovered BF
killed in action (KIA) and WIA. casualties back into their units.
Insufficient tough, realis- Taking and publicizing
tic training. appropriate disciplinary actions for criminal
misconduct stress behaviors.
Lack of unit cohesion.
(3) Achieve tertiary prevention.
Lack of trust in leaders, Minimize the potential for chronic disability
equipment, and supporting arms. (PTSD), both in soldiers who show BF and those
who do not. This is done by—
Sleep loss.
Having an active pre-
Poor physical condition- ventive program (debriefings) during and
ing (dehydration, malnutrition). immediately after combat and/or traumatic
incident.
Debilitating environmen-
tal exposure. Conducting end of tour
debriefings for units and unit members’ families.
Inadequate information.
Remaining sensitive to
High degree of uncer- delayed or covert post-traumatic stress signs and
tainty and ambiguity. symptoms and providing positive intervention.
(This is primarily the role of leaders, chaplains,
Absence of an achievable and health care providers. )
end of the mission in sight.
b. Treat Battle Fatigue. Proximity, im-
Inadequate sense of pur- mediacy, expectancy, and simplicity (PIES) are
pose. all extremely important in the treatment of BF.
(2) Achieve secondary prevention. (1) Proximity. Proximity refers to
Minimize acute disability (morbidity) by training the need of treating soldiers as close to their units
leaders, chaplains, and medical personnel to— and the battle as possible. It is a reminder that
overevacuation should be prevented.
Identify early warning
signs and symptoms of BF/combat stress or mis- (2) Immediacy. Immediacy indi-
conduct stress. cates that BF requires treatment immediately.
Intervene immediately (3) Expectancy. Expectancy re-
with the soldiers to treat the warning symptoms lates to the positive expectation provided to BF
and control the relevant stressors. casualties for their full recovery and early RTD.

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FM 8-51

(4) Simplicity. Simplicity indi- b. Reassure. At every echelon, give
cates the need for using simple, brief, immediate, explicit reassurance to the soldier.
straightforward methods to restore physical well- Explain to him that he has BF and this is a
being and self-confidence by using nonmedical temporary condition which will improve quickly.
terminology and techniques. Actively reassure everyone that it is neither
cowardice nor sickness but rather a normal
c. Make Differential Diagnosis, But reaction to terribly severe conditions. Provide
Defer Psychiatric Diagnosis. Distinguish life- or these soldiers with the expectation that they will
function-threatening medical or surgical con- be RTD after a short period of rest and physical
ditions as soon as possible and provide those replenishment and involve them in useful
patients emergency treatment. Treat all others activities, as appropriate.
using PIES to the safest maximum extent
possible. Let the response to treatment sort out c. Separate. Keep BF soldiers sepa-
the true NP disorders. The nonresponders should rated from those patients with serious medical,
be evacuated to the echelon of care appropriate surgical, or NP conditions. This is done because
for their treatment (either COMMZ or CONUS association with serious medical, surgical, or
facilities) where treatment continues and the final psychiatric patients often worsens symptoms and
diagnosis is determined. delays recovery. Those few BF casualties who
show overly dramatic symptoms of panic anxiety,
depression, and/or physical or memory problems
need to be kept separate from all other types of
1-8. Generic Treatment Principles for patients (including other BF casualties). This is
Battle Fatigue done until those symptoms cease so as not to
adversely affect other BF soldiers.
The generic treatment principles provided below
apply at all echelons throughout the TO. Their
applications may differ based on a particular NOTE
echelon and other factors pertaining to the
mission, enemy, terrain, troops, and time Association of recovering BF casualties
available (METT-T). with hold for treatment (patients
expected to RTD within 72 hours) cases
who have minor injury or illness is not
a. Initial Assessment. In the initial harmful.
assessment, a brief but adequate medical and
mental status examination is performed. This
examination should be appropriate to the echelon No sharp distinction should be made between
of care and should rule out any serious physical other convalescent soldiers and those recovering
mental illness or injury. Always consider the from BF. Indeed, many of the soldiers with minor
possibility of trauma to the head or trunk. Other wounds or illnesses also have BF and should be
surgical, medical, NP, and drug and alcohol treated with the principles of PIES. These
misuse disorders may resemble BF, but they soldiers can be treated together provided they are
require emergency treatment. It is important to not in their "contagious” stage and RTD for both
recognize symptoms to avoid performing un- is imminent.
necessary tests. Often it is best to treat for BF
while covertly observing for other more serious d. Simple Treatment with Rest and Re-
conditions. plenishment. Keep treatment for BF deliberately

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FM 8-51

simple. Provide relative relief from danger but careful not to let "unmanageability” become well-
maintain a tactical atmosphere which is not too known as the criteria for “escape by evacuation,”
comfortable. Provide rehydration, sleep, and since that could lead others to follow the bad
hygiene. example.
e. Restore Confidence. Restore confi- i. Manageable Battle Fatigue, but Un-
dence by structured military work details, responsive to Initial Treatment. Those man-
physical exercise, and recreation. Get the soldier ageable BF casualties who (after initial
to talk about what happened to him. Provide treatment) do not improve sufficiently within the
supportive counseling as needed to clarify memo- allotted time to RTD are also sent unobtrusively
ries, to provide the opportunity to express back to the next higher echelon, with expressed
feelings, and to regain perspective. Reinforce the positive expectations for further treatment. This
soldier’s identity as a soldier and a member of his sustains the positive expectation of rapid recovery
unit, not as a patient. for BF casualties who are just arriving.
f. Avoid Sedatives and Tranquilizing j. Hospitalization. As stated above, do
Medications. Avoid sedative or tranquilizing not hospitalize a BF casualty unless absolutely
medication unless essential to manage sleep or necessary for safety. Those BF casualties who do
agitated behavior. The BF soldier needs to main- require brief hospitalization for differential
tain a normal state of alertness, coordination, and diagnosis or acute management should be
understanding. If the BF soldier is not medi- transferred to a nonhospital treatment setting as
cated, he can take care of himself and can respond soon as their conditions permit. Those who reach
to and accept his treatment. hospitals as an inappropriate evacuee should be
told they are only experiencing BF; they should
g. Evacuation and Hospitalization. Do be returned to their unit area or other forward
not evacuate or hospitalize BF casualties unless area as soon as possible to recover in a non-
absolutely necessary. Evacuation and hospital- hospital facility.
ization delay recovery and significantly increase
chronic morbidity, regardless of the severity k . Restoration and Reconditioning.
of the initial symptoms. It is better to transport Ideally, BF casualties are not evacuated to
BF casualties in general-purpose vehicles, not CONUS without having had an adequate
ambulances (and especially not air ambulances), restoration and/or reconditioning trial in both
unless no other means of transportation is the combat zone (CZ) and the COMMZ. The
feasible. Evacuation should be approved by a treatment strategies of these programs assist
single qualified authority (for example, if the recovering BF soldiers in regaining skills and
soldier is to leave the division, by the division abilities needed for combat duty. These skills
psychiatrist, in accordance with AR 40-216). and abilities include concentration, team work,
work tolerance, psychological endurance, and
h. Unrnanageable Cases. Soldiers whose physical fitness. Restoration is a 1- to 3-day
BF (or psychiatric} symptoms make them too program which is conducted in both the division
disruptive to manage at a given echelon should and the corps areas. Restoration is normally
be evacuated only to the next higher echelon with conducted by the medical detachment, CSC and/
the expressed positive expectation of improve- or the mental health section in the division. In
ment. The next higher echelon will reevaluate the corps area, restoration is conducted by the
the soldier for manageability. However, be medical detachment, CSC and/or the mental

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FM 8-51

health section of the ASMB. Reconditioning is a their unit’s own CSS elements), HOLD (requires
7- to 14-day program that requires hospital medical holding at this echelon for treatment),
admission for accountability of BF cases. It is and REFER (requires evacuation to the next
conducted in a nonhospital setting by the medical higher echelon for further evaluation and treat-
company, CSC in both the corps and COMMZ. ment) (see Chapter 6).
(4) Stabilization. This function
1-9. Combat Stress Control Functional provides stabilization of severely disturbed BF
Mission Areas and NP patients. They are evaluated for RTD
potential or prepared for further treatment or
a. Functional Roles. The principles of evacuation, if required (see Chapter 7).
combat psychiatry and the methods for pre-
vention and treatment of BF are exercised in six (5) Restoration. Restoration in-
functional mission areas for mental health/CSC volves treatment with rest, food, water, hygiene,
personnel and units. These functional mission and activities to restore confidence within 1 to 3
areas have differing priorities depending on the days at forward medical facilities. Between 55
situation. They are defined below and are and 85 percent of BF casualties should RTD with
analyzed in detail in subsequent chapters of this restoration treatment (see Chapter 8).
manual.
(6) Reconditioning. Recondition-
(1) Consultation. Consultation in- ing involves treatment with physical training and
volves the liaison and preventive advice and an intensive program of psychotherapy and mili-
assistance to commanders and staff of supported tary activities. Reconditioning programs are con-
units (see Chapter 4). ducted for 7 or more days in a nonhospital setting
in the corps area. Additional reconditioning may
(2) Reconstitution support. Re- be provided in the COMMZ (see Chapter 9). No
constitution support is that assistance provided more than 5 to 10 percent of BF casualties should
to attrited units at field locations. Reconstitution eventually be evacuated to CONUS.
is an extraordinary action that commanders plan
and implement to restore units to a desired level
of combat effectiveness commensurate with NOTE
mission requirements and available resources
according to FM 100-9. Reconstitution is a total All CSC functions since WWII except
process which involves the sequence of reor- reconstitution support were suc-
ganization, assessment, and regeneration. Men- cessfully demonstrated repeatedly.
tal health/CSC personnel support reconstitution Although the terminology has changed,
as a part of a consolidated team (see Chapter 5). the functions remain the same. Recon-
stitution support has been identified as
(3) Combat neuropschiatric tri- a separate mission to meet the special
age. Combat NP triage (as distinguished from hazards and requirements of war.
surgical triage) is the process of sorting combat
stress-related casualties and NP patients into
categories based on how far forward they can be b. Priority of Functional Mission
treated. These categories are DUTY (RTD Areas. The six functional mission areas listed
immediately), REST (light duty for 1 to 2 days in above are in the usual order of their doctrinal

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FM 8-51

priority for allocation of assets when workloads upon the total situation. Subsequent chapters of
exceed resources. However, the functions have this manual will discuss each of the functional
different relative importance in different sce- areas and provide basic TTP for accomplishing
narios or phases of the operation. The CSC com- them. These chapters will also address how CSC
mander must set priorities and allocate resources functional areas interface with other functional
to accomplish missions in each program based areas.

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FM 8-51

CHAPTER 2

MENTAL HEALTH AND COMBAT STRESS CONTROL
ELEMENTS IN THE THEATER OF OPERATIONS

Section I. UNIT MENTAL HEALTH SECTIONS IN THE THEATER

2-1. Locations and Assignments of Unit health section provides mental heath/CSC
Mental Health Sections services throughout the division. This section,
acting for the division surgeon, has staff respon-
Mental health sections are located in the sibility for establishing policy and guidance for
divisions, the corps, and the COMMZ. In the the prevention, diagnosis, treatment, and man-
divisions, they are assigned to the medical agement of NP, BF, and misconduct stress
company of the main support battalion (MSB). behavior cases within the division area of opera-
In the corps and COMMZ, they are assigned to tions (AO). It has technical responsibility for the
the ASMB headquarters. In separate brigades, psychological aspect of surety programs. The staff
they are assigned to the medical company. of this section provides training to unit leaders
and their staffs, chaplains, medical personnel, and
troops. They monitor morale, cohesion, and
2-2. Division Mental Health Section mental fitness of supported units. Other respon-
sibilities for the division mental health section
The division mental health section is assigned to staff include—
the main support medical company (MSMC),
which is a division support command (DISCOM) Monitoring indicators of dysfunc-
asset (see FMs 8-10-1, 8-10-3, and 63-21). tional stress in units.
Evaluating NP, Bl, and misconduct
NOTE stress behavior cases.
The responsibilities of the division Providing consultation and triage as
mental health section extend to all requested for medical/surgical patients exhibiting
division elements and require a mental signs of combat stress or NP disorders.
health/CSC presence at the combat
maneuver brigades. Supervising selective short-term
restoration for HOLD category BF casualties ( 1
to 3 days).
The division mental health section is the medical
element in the division with primary respon- Coordinating support activities of
sibility for assisting the command in control- attached corps-level CSC elements.
ling combat stress. Combat stress is controlled
through sound leadership, assisted by CSC The division mental health section normally
training, consultation, and restoration programs collocates with the MSMC clearing station. For
conducted by this section. The division mental a listing of major equipment assigned, see
health section enhances unit effectiveness and Appendix A. The staffing of the division mental
minimizes losses due to BF, misconduct stress health section allows for this section to be split
behaviors, and NP disorders. Under the direction into teams which deploy forward to provide CSC
of the division psychiatrist, the division mental support, as required, to brigades in the division.

2-1
FM 8-51

Normally, each brigade is supported by a brigade Maintain communications and
CSC team. This team consists of a mental health unity of efforts when division mental health sec-
officer who is designated the brigade mental tion personnel are dispersed to the brigades.
health officer and a behavioral science NCO that
is designated the brigade CSC coordinator. If no Provide the points of contact to
mental health officer is available, the senior integrate reinforcing CSC teams throughout the
behavioral science noncommissioned officer in division.
charge (NCOIC) substitutes as the brigade CSC
team leader. The division psychiatrist oversees
all brigade CSC teams and provides consultation
as necessary.
a. Mental Health/Combat Stress Con-
trol Support. The division psychiatrist provides
input to the division surgeon on CSC-related
matters. He works with the division medical
operations center (DMOC) to monitor and
prioritize mental health support missions in
accordance with the division combat health
support (CHS) operation plans (OPLANs) or
operation orders (OPORDs). Coordination for (1) Psychiatrist. The division psy-
mental health personnel augmentation is chiatrist (Major [MAJ], Medical Corps [MC], area
accomplished through the MSB Operations and of concentration [AOC] 60WOO) is the officer in
Training Officer (US Army) (S3) and the DMOC. charge of the division mental health section. The
psychiatrist is also a working physician who
b. Division Mental Health Section applies the knowledge and principles of psychi-
Staff. The division mental health section is atry and medicine in the treatment of all patients.
staffed as shown in Figure 2-1. The consolidation He examines, diagnoses, and treats, or recom-
of assigned mental health officers and behavioral mends courses of treatment for personnel suffer-
science specialists in one division mental health ing from emotional or mental illness, situational
section provides unity of CSC support for all maladjustment, BF (combat stress reactions), and
division prevention, training, and treatment misconduct stress behaviors. His specific func-
responsibilities of the section. It provides tions include—
multidisciplinary mental health professional
expertise to— Directing the division’s
mental health (combat mental fitness) program.
Supervise and train the
behavioral science NCOs and specialists. Being a staff consultant
for the division surgeon on matters having psy-
Provide staff input to the chiatric aspects, which include—
commands within the division AO.
Personnel reliability
Assure clinical evaluation and program.
supervision of treatment for all NP and problem-
atic BF cases before they leave the division. Security clearances.

2-2
FM 8-51

Alcohol and drug Conducting surveys and
abuse prevention and control programs (ADAPCPs). evaluating data to assess unit cohesion and other
factors related to prediction and prevention of
Planning CSC support for both BF casualties and misconduct stress
supported units. behaviors.
Conducting mental health/ Performing psychological
CSC Operations. and neuropsychological testing to evaluate psy-
chological problems, psychiatric and organic men-
Providing staff consulta- tal disorders, and to screen misconduct stress
tion for the MSMC commander and for supported behaviors and unsuitable soldiers.
commands within the division.
Apprising unit leaders,
Being responsible for as- primary care physicians, and other clinical per-
suring the diagnosis, treatment, restoration, and sonnel regarding the assessment of individual and
disposition of all NP and problematic BF cases. unit mental health fitness program.
Participating in the diag- Providing consultation for
nosis and treatment of the sick, injured, and unit commander and CSC coordinators (mental
wounded, especially those who can RTD quickly. health NCOs working at the brigade level) re-
garding problem cases.
Providing consultation and
training to physicians, physician’s assistants, unit Counseling and providing
leaders, chaplains, and other medical personnel therapy or referral for soldiers with psychological
regarding diagnosis, treatment, and management problems.
of BF, misconduct stress behavior, and NP Serving as the brigade
disorders. mental officer for one maneuver brigade (nor-
Prescribing treatment and mally teamed with a behavioral science NCO).
disposition for soldiers with NP conditions. (3) Social work officer. The social
work officer (CPT, MS, AOC 73A67) assists in the
Providing supervision and development, management, and supervision of
training of assigned and attached mental health the division’s mental health (combat mental fit-
personnel. ness) program. He applies the mental health
principles and his knowledge of social work in
(2) Clinical psychologist. The the performance of his duties. His responsibilities
clinical psychologist (Captain [CPT], Medical include—
Service Corps [MS], AOC 73B67) assists in the
development, management, and supervision of Evaluating the social in-
the division’s mental health (combat mental fit- tegration of BF and misconduct stress behavior
ness) program. His special responsibilities apply soldiers in their units and families.
to the knowledge and principles of psychology to
include— Coordinating and ensuring
the return of recovered stress casualties to duty
Evaluating the psycholog- and their reintegration into their original or new
ical functioning of soldiers. units.

2-3
FM 8-51

Identifying and resolving Coordinating additional
organizational and social environmental factors mental health support with the supporting medi-
which interfere with combat readiness. cal detachment, CSC, or other corps-level CSC
elements supporting the division.
Ensuring support for sol-
diers and their families from Army and civilian Supervising restoration of
community support agencies. BF casualties at the MSMC by the patient-holding
squad and division mental health section subordi-
Apprising unit leaders, nate personnel.
primary care physicians, and other clinical per-
sonnel of available social service resources. Serving as leader of a
brigade CSC team when no mental health officer
Providing consultation to is available.
unit commanders and to division mental health
section personnel regarding problem cases. Conducting classes on
selected mental health topics for senior NCOs
Counseling and providing within the division.
therapy or referral for soldiers with emotional
psychological problems. (5) Behavioral science noncom-
missioned officers. There are three behavioral
Serving as brigade mental science NCOs (E-6, MOS 91G30 and E-5 [two],
health officer for one maneuver brigade, teamed
with one of the behavioral science NCOs. 91G20) assigned to the division mental health
section. These three NCOs are brigade CSC
(4) Senior behavioral science non- coordinators and are deployed to the forward
commissioned officer. The senior behavioral sci- support medical companies (FSMCs) located in
ence NCO (E-7, military occupational specialty the brigade support areas (BSAs) of the division.
[MOS] 91G40) is the section sergeant for the They assist the brigade surgeons with matters
division mental health section. This senior NCO pertaining to mental health/CSC. As required,
assists the division psychiatrist and mental health the brigade CSC coordinators participate in staff
officers in accomplishing their duties. He pro- planning to represent and coordinate mental
vides assistance with management of both the health/CSC activities throughout the brigade.
technical and tactical operations of the section They are especially concerned with assisting and
and supervises subordinate members. His specific training—
duties include—
Small unit leaders.
Keeping the division psy-
chiatrist and mental health officers informed. Unit ministry teams.
Monitoring, facilitating, Battalion medical platoons.
and supervising the training activities of the
division mental health section. Patient-holding squad and
treatment squad personnel of the FSMC.
Monitoring and coordinat-
ing situation reports from division mental health They provide training and advice in the control
section personnel deployed within the BSAs. of stressors, the promotion of positive combat

2-4
FM 8-51

stress behaviors, and the identification, handling, effectiveness of the soldier, precipitating factors
and management of misconduct stress behavior causing the soldier to have BF, and RTD
and BF soldiers. They coordinate training and potential.
support to the brigade by the mental health
officers of the division mental health section. The When the brigades are tactically deployed, the
behavioral science NCOs collect and record social brigade CSC coordinators use the division
and psychological data and counsel personnel clearing stations operated by the FSMCs as the
with personal, behavioral, or psychological centers of their operations but are mobile
problems. Their general duties include— throughout the AO. Their priority functions are
to prevent unnecessary evacuations and to coordi-
Assisting in a wide range nate RTD, not to treat cases. Through the brigade
of psychological and social services. surgeons they keep abreast of the tactical situ-
ation and plan and project requirements for CSC
Compiling caseload data. support when units are pulled back for rest and
recuperation.
Providing counseling to
soldiers experiencing emotional or social problems. (6) Behavioral science specialist.
There are three behavioral science specialists
Referring soldiers to spe- (E-4 and E-3, MOS 91 G1O). These specialists
cific mental health officers, physicians, or assist division mental health section officers and
agencies when indicated. NCOs in gathering social and psychological data
to support patient evaluation. Under the super-
Assisting with group de- vision of the mental health officer and NCOs, they
briefings, counseling, and therapy sessions, and provide initial screening of patients suffering emo-
leading group discussions. tional disorders. Their specific duties include-
Providing individual case Providing supportive coun-
consultation to commanders, NCOs, chaplains, seling for patients experiencing emotional or
battalion surgeons, and physician assistants social problems.
within the supported brigade.
Collecting information Assisting in the evalu-
from units regarding unit cohesion and morale ation of emotionally and mentally impaired
which include— soldiers.

Obtaining data on Assessing a patient’s
disciplinary actions. mental status (level of functioning capacity), and
his need for professional services.
Collecting informa-
tion with questionnaires. Deploying to an FSMC to
assist an NCO brigade CSC coordinator or mental
Conducting struc- health oficer.
tured interviews.
Serving as squad leader
Collecting information on for up to 12 junior enlisted grade BF soldiers in a
individual BF cases pertaining to the prior restoration program.

2-5
FM 8-51

Collecting information Evaluating NP, BF, and misconduct
from units, including questionnaires, surveys, stress behavior cases.
and data regarding soldiers/patients. One of
these behavioral science specialists will be Providing consultation and triage as
assigned as the CSC coordinator for the division requested for patients exhibiting signs of combat
support, area (DSA). stress reactions.
In addition to the above duties, they operate and Providing selective short-term
maintain assigned vehicles. restoration for HOLD category BF cases.
Coordinating support activities with
2-3. Area Support Medical Battalion Men- medical company, CSC elements, when attached
tal Health Section or in support of the ASMB.
The mental health section is the medical element a. Mental Health Support. The ASMB
with primary responsibility for assisting units in S3 and the mental health section monitor and
the corps support area in controlling combat stress. prioritize mental health support missions in coor-
Combat stress is controlled through vigorous pre- dination with the medical brigade/group head-
vention, consultation, and restoration programs. quarters.
These programs are designed to maximize the
RTD rate of BF soldiers by identifying combat
stress reactions and providing rest/restoration b. Mental Health Section Staff. The
within or near their unit areas. Under the direc- ASMB mental health section is staffed as shown
tion of the ASMB psychiatrist, the mental health in Figure 2-2, For a listing of major items of
section provides mental health/CSC services equipment assigned, see Appendix A. The consoli-
throughout the ASMB’s AO. The mental health dation of assigned mental health officers and
section collocates with the headquarters and sup- behavioral science specialists under one section
port company (HSC) clearing station and deploys in the HSC of the ASMB assures unity of the
mental health/CSC personnel within the ASMB’s CSC support throughout the AO for prevention
AO (see FM 8-10-24). This section has staff training and treatment responsibilities. It
responsibility for establishing policy and guidance assures multidisciplinary mental health profes-
for the prevention, diagnosis, and management sional expertise to—
of NP, BF, and misconduct stress behavior cases
within the ASMB. It has technical responsibility Train and supervise the behav-
for the psychological aspect of surety programs. ioral science NCOs and specialists.
The staff of this section provides training to unit
leaders and their staffs, chaplains, medical per- Provide staff input to supported
sonnel, and troops. They monitor morale, cohe- commands.
sion, and mental fitness of supported units. Other
responsibilities for the mental health section staff Provide clinical evaluation and
include— supervision of treatment for all NP and problem-
atic BF cases at a central location.
Providing command consultation
and making recommendations for reducing Maintain communications with
stressors. the medical brigade/group and corps resources.

2-6
FM 8-51

Provide selected officer exper- Participating in the diag-
tise for brief intervention where required through- nosis and treatment of the sick, injured, and
out the AO. wounded, especially of those who can RTD
quickly.
Providing consultation
and training to unit leaders, chaplains, and
medical personnel regarding identification and
management of BF (combat stress reaction), mis-
conduct stress behaviors, and NP disorders.
Providing therapy or re-
ferral for soldiers with NP conditions.
Providing supervision and
training of assigned and attached mental health
and CSC personnel.
(1) Psychiatrist. The psychiatrist
(MAJ, MC, AOC 60W00) is the section leader. (2) Social work officer. The social
The psychiatrist is also a working physician who work officer (CPT, MS, 68R00) performs social
applies the knowledge and principles of psychia- work functions of providing direct services, teach-
try and medicine in the treatment of all patients. ing, and training. He provides consultation ser-
He examines, diagnoses, and treats, or recom- vices for soldiers assigned to units within the
mends courses of treatment for personnel suf- ASMB’s AO. The social work officer assists in
fering from emotional or mental illness, situa- the development, management, and supervision
tional maladjustment, combat stress reaction, BF, of the battalion’s mental health (combat mental
and misconduct stress behaviors. His areas of fitness) program for the AO. His responsibilities
responsibility include— are to apply the knowledge and principles of social
work to—
Implementing CSC sup- Evaluate the social rela-
port according to the CHS plan. tedness of BF and misconduct stress behavior
soldiers in their units and families.
Conducting mental health
CSC operations. Identify and resolve orga-
nizational and social environmental factors which
Providing staff consulta- interfere with combat readiness.
tion for the ASMB commander and for supported
commands within the supported AO. This in- Ensure support for
cludes the personnel reliability program, security soldiers and their families from Army and civilian
clearances, and ADAPCPs. community support agencies.
Diagnosing, treating, and Apprise unit leaders, pri-
determining disposition of NP, BF, and miscon- mary care physicians, and other clinical person-
duct stress behavior cases. nel of available social service resources.

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FM 8-51

Provide consultation to the assistant section sergeant and aids the section
unit commanders and to mental health section sergeant with the accomplishment of his duties.
personnel regarding problem cases. Behavioral science NCOs collect and record social
and psychological data and counsel personnel
Counsel and provide ther- with personal, behavioral, or psychological prob-
apy or referral for soldiers with psychological lems. All these NCOs assist with the manage-
problems. ment of the mental health section. These NCOs
may be deployed with area support medical com-
Coordinate and ensure the panies (ASMCs) as CSC coordinators to provide
return of BF and NP soldiers to duty and their mental health/CSC support. They assist the
reintegration into their original or new units. ASMCs with matters pertaining to mental health/
CSC. As required, the CSC coordinators partici-
(3) Senior behavioral science non- pate in staff planning to represent and coordinate
commissioned officer. The senior behavioral mental health/CSC activities throughout the
science NCO (E-7, MOS 91G40) is the section ASMCs’ AO. They are especially concerned with
sergeant for the battalion mental health section. assisting and training—
This senior NCO assists the mental health officers
in accomplishing their duties. He provides assist- Small unit leaders.
ance with management of both the technical and
tactical operations of the section and supervises Unit ministry teams.
subordinate members. His specific duties include-
Battalion medical platoons.
Keeping the ASMB psy- Patient-holding squad and
chiatrist and mental health officers informed. treatment squad personnel of the ASMC.
Monitoring, facilitating, They provide training and advice in the control
and supervising the training activities of the of stressors, the promotion of positive combat
mental health section. stress behaviors, and the identification, handling,
and management of misconduct stress behaviors
Monitoring and coordinat- and BF soldiers. They coordinate training and
ing situation reports from mental health section support to the supported units by the mental
personnel deployed within the battalion’s AO. health officers of the ASMB mental health
section. The behavioral science NCOs collect and
Coordinating additional record social and psychological data and counsel
mental health support for the battalion’s AO as personnel with personal, behavioral, or psycho-
directed with the medical brigade/group. logical problems. Their general duties include-
Conducting classes on Assisting in a wide range
selected mental health topics for senior NCOs of psychological and social services.
within the AO.
Compiling caseload data.
(4) Behavioral science noncommis-
sioned officers. There are four behavioral science Providing counseling to
NCOs assigned to the section (one E-6, MOS soldiers experiencing emotional or social prob-
91G30, and three E-5, MOS 91 G20). The E-6 is lems.

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Referring soldiers to tactical situation and plan and project require-
specific mental health officers, physicians, or ments for CSC support when units are pulled
agencies when indicated. back for rest and recuperation.
Assisting with group de- (5) Behavioral science specialist.
briefings, counseling and therapy sessions, and There are three behavioral science specialists
leading group discussions. (E-4 and E-3, MOS 91 G1O). These specialists
assist mental health officers and NCOs in
Providing individual case gathering social and psychological data to support
consultation to commanders, NCOs, chaplains, patient evaluation. They provide initial screening
battalion surgeons, and physician assistants of patients suffering emotional disorders. In addi-
within the supported brigade. tion to their duties, they operate and maintain
assigned vehicles. Under the supervision of a
Collecting information mental health officer or an NCO, their specific
from units regarding unit cohesion and morale duties include—
which include—
Providing supportive coun-
Obtaining data on seling for patients experiencing emotional or
disciplinary actions. social problems.
Collecting informa- Assisting in the evalua-
tion with questionnaires. tion of the emotionally disturbed or mentally ill.
Conducting struc- Assessing a patient’s men-
tured interviews. tal status (level of functioning capacity) and his
need for professional services.
Collecting information on
individual BF soldier cases pertaining to— Deploying to an ASMC to
assist an NCO CSC coordinator or mental health
Prior effectiveness of officer.
the soldier.
Serving as squad leader
Precipitating factors for up to 12 junior enlisted grade BF soldiers in a
causing BF. restoration program.
Potential for RTD
2-4. Mental Health Personnel in the
When the supported units are tactically deployed, Separate Brigades
the behavioral science NCOs use the clearing
stations operated by the ASMCs as the centers of In the separate brigades, both light and heavy,
their operations, but the NCOs are mobile mental health personnel are assigned to the
throughout the AO. Their priority functions are medical company, separate brigade. In the light
to prevent unnecessary evacuations and to separate brigade, one behavioral science NCO
coordinate RTD, not to treat cases. Through the is assigned to the medical company clearing
ASMC commanders, they keep abreast of the section. He functions as a brigade CSC

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FM 8-51

coordinator and advises the commander on identified for the brigade CSC coordinator. When
mental health/CSC issues. In the heavy separate a separate brigade is attached to a division,
brigade, the medical company has a mental the mental health personnel assigned to that
health section which consist of a behavioral sci- brigade work with and come under the tech-
ence NCO and two behavioral science specialists. nical supervision of the division mental health
The NCO’s duties are also consistent with those section.

Section II. COMBAT STRESS CONTROL COMPANY

2-5. Medical Company, Combat Stress regiments in the corps. The medical detachment,
Control (TOE 08-467L000) CSC will be discussed in Section III of this chapter.
The medical company, CSC is employed in the c. Assignment. The medical company,
COMMZ and the CZ. In the corps areas, it sends CSC may be assigned to a medical command
teams forward, as required, to reinforce CSC (MEDCOM), medical brigade or medical group.
elements operating in the divisions. The medical It may be further attached to an ASMB. For a
companies, CSC and medical detachments, CSC listing of major items of equipment assigned, see
(TOE 08-567 LA00) are replacing the medical de- Appendix A.
tachments, psychiatric (OM Teams), which are
under the H-series TOE. d. Organization. The medical company,
CSC is organized into a headquarters section, a
a. Mission. A medical company, CSC preventive section, and a restoration section. The
(Figure 2-3) provides comprehensive CSC support company is dependent on appropriate elements
for two or more divisions and their corps slices of the MEDCOM, medical brigade, or medical
(combat, CS, and CSS units). This comprehensive group for administrative and medical logistical
support involves all six CSC functions that were support, medical regulating, BF casualty deliv-
discussed in Chapter 1 to a varying degree based ery, and medical evacuation. The company is
on the threat and tactical operations support re- dependent on appropriate elements of the corps
quirements. or COMMZ for finance, legal, personnel and ad-
ministrative services, food service, supply and
b. Basis of Allocation. The basis of field services, supplemental transportation, and
allocation for the medical company, CSC is 0.4 local security support services. When conducting
unit per division supported. One medical com- a large restoration or reconditioning program,
pany, CSC will normally support two divisions the medical company, CSC is dependent on the
and their corps slice in a high-intensity conflict. medical-holding company for attachment of a
In a mid-intensity conflict, because of the reduced medical-holding platoon to support the program.
likelihood of BF casualties, a medical company, When medical company, CSC elements or teams
CSC may be able to support up to five divisions, are deployed to division areas, they are dependent
The medical company, CSC is supplemented by on the division medical companies (such as the
allocation of a variable number of CSC medical MSB medical company or the forward support
detachments. The basis of allocation for CSC battalion [FSB] medical company) for patient
medical detachments is one unit per division, and accounting, transportation, food service, and field
one unit per two or three separate brigades or service support.

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e. Employment in the Theater. The CSC may be attached to ASMBs, combat sup-
medical company, CSC operates in the corps port hospitals (CSHs), or other corps medical
area and deploys its assets forward, as required, units. The task-organized CSC element is also
in support of operations for supported divi- deployed into the supported division areas,
sions and separate brigades. In the corps area, as required, to augment the medical detach-
it provides CSC support on an area basis and ment, CSC and organic division mental health
conducts CSC consultation, restoration, and re- section/CSC personnel. The medical company,
conditioning programs. The medical company, CSC provides advice and assistance to its
CSC normally operates from the medical brigade higher headquarters on combat stress and NP
or group headquarters. The medical company, issues.

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FM 8-51

2-6. Headquarters Section Power generation equipment
repairman.
The headquarters section provides command and
control (C2) and unit-level administrative and Cook (three).
maintenance support to its subordinate sections
when they are collocated with the company. The Personnel from the headquarters section are
headquarters section may also provide assistance deployed with teams or task-organized CSC ele-
to detached elements by making site visits if the ments as required.
elements are within a feasible distance for ground
transportation. The medical company, CSC ele- a. Company Commander. The medical
ments normally deploy with limited maintenance company, CSC commander (Lieutenant Colonel
and are without administrative support. When [LTC], MC, AOC 60W00) plans, directs, and
these CSC elements deploy, they are dependent supervises the operations of the company. The
on the supported units for patient accounting, commander is also responsible for the training,
transportation, food service, and field services. discipline, billeting, and security of the company.
The personnel assigned to the headquarters sec- He provides daily reports to his higher head-
tion include— quarters as established by the tactical standing
operating procedures (TSOPs) and corps reporting
Company commander. procedures. He serves as the NP consultant on
the staff of the medical group. As a psychiatrist,
Chaplain. he coordinates with command and unit physicians
regarding care and disposition of BF casualties
Medical operations officer. and NP patients. He exercises clinical super-
vision over all treatment provided by the CSC
First sergeant. sections and detachments. He performs physical
and mental status evaluations in emergency or
Supply sergeant. command evaluation situations; this includes
diagnosing, prescribing initial treatment, and
Nuclear, biological, and chemi- determining disposition. The commander inter-
cal NCO. faces with higher and supported headquarters
and with supported CSC medical detachments,
Unit clerk. ASMB mental health sections, and division men-
tal health sections. He keeps informed on CSC
Commander’s driver/behavior- operations through daily reports and by frequent
al science NCO. visits to task-organized CSC elements deployed
from his company.
Prescribed load list (PLL)
clerk. b. Chaplain. The chaplain ( CPT,
Chaplain [CH], AOC 56AOO) provides religious/
Armorer. ethical education and perspective to the dispersed
sections for the prevention and treatment of BF
Motor sergeant. and misconduct stress behaviors. He interfaces
CSC activities with unit ministry teams in
Light-wheeled vehicle mechanic maneuver units, hospital chaplains, and with
(two). staff chaplains at each headquarters level. The

2-12
FM 8-51

chaplain usually accompanies the medical com- manages the administrative activities of the com-
pany, CSC commander when he visits supported pany command post (CP). He supervises the
units and task-organized CSC elements deployed company activities of the unit clerk and maintains
in support of those units. The chaplain has a liaison between the commander and assigned
chaplain’s kit to conduct services but is without a NCOs. He provides guidance to enlisted members
chaplain’s assistant. The chaplain’s primary role of the company and represents them to the com-
is to aid CSC personnel in preventive stress con- mander. He plans, coordinates, supervises, and
trol and in working with BF casualties and mis- participates in activities pertaining to organi-
conduct stress behaviors. In addition to his coor- zation, training, and combat operations for the
dination, liaison, and training duties, he provides company. He assists the company commander in
religious support to BF casualties and to staff as the performance of his duties. The first sergeant
available time and support requirements permit. also assists the medical operations officer and
performs the duties of an operations NCO.
Medical Operations Officer. The
medical operations officer (CPT, MS, AOC 70B67) e. Supply Sergeant. The supply
is the principal assistant to the company com- sergeant (E6, MOS 76Y30) requests, receives,
mander on all matters pertaining to the tactical stores, safeguards, and issues general supplies
employment of company assets. He is responsible and salvages equipment authorized to the com-
for overseeing operations and administrative, pany. He maintains the company supply records,
supply, and maintenance activities within the supervises unit supply operations, and maintains
company. His responsibilities also include— accountability for all equipment organic to the
company.
Coordinating administrative
activities with the staff of the higher medical f Nuclear, Biological, and Chemical
headquarters. Noncommissioned Officer. The NBC NCO (E5,
MOS 54B20) coordinates NBC defense operations
Ensuring unit operations and for the company. He supervises training pertain-
communications security. ing to procedures and techniques of NBC defense.
He predicts the effects of weather and terrain on
Keeping the commander chemical operations. His responsibilities also
current on the corps’ and supported divisions’ include preparing predictions on nuclear fallout
tactical situations. and on nuclear, chemical, and biological down-
wind hazards. He prepares and evaluates NBC
Assisting the commander with reports and computes expected radiation effects
development of CSC support estimates and plans. affecting personnel, equipment, and operations.
This NCO is the technical advisor to the unit
Training. commander on matters pertaining to NBC func-
tions. He provides expertise and training in the
Coordinating movement orders operations and maintenance of NBC equipment
and logistical support for deployed company and supervises decontamination of unit equip-
elements. ment, supplies, and personnel (not patients). At
time of heavy caseloads (unless the unit is in an
d. First Sergeant. The first sergeant active NBC environment), he serves as squad
(E8, MOS 91B50) serves as the principal enlisted leader for up to ten BF casualties in recondition-
assistant to the company commander. He ing or restoration.

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FM 8-51

g . Unit Clerk. The unit clerk (E4, MOS assists with general supply activities and operates
75B10) provides and coordinates personnel and the vehicle assigned to the supply element.
administrative support to company personnel and
maintains unit administrative records. He also k. Motor Sergeant. The motor sergeant,
advises on and coordinates personnel actions for a senior vehicle mechanic (E-6, MOS 63 B30),
recovering BF casualties or RTD soldiers that supervises and performs maintenance on unit
require other administrative actions. vehicles. He advises, trains, and supervises other
maintenance personnel assigned to the company.
h. Commander’s Driver/Behavioral His responsibilities also include—
Science Noncommissioned Officer. The com-
mander’s driver/behavioral science NCO (E5, MOS Preparing daily work sheets
91G20) assists the commander and chaplain as a and charts.
vehicle driver. He performs surveys and collects
information on stress and stressors in units which Supervising scheduled mainte-
the commander visits. He also checks the status nance and repair services.
of recovered stress casualties.
Implementing the Army Oil
i. Prescribed Load List Clerk. The Analysis Program.
logistic automation specialist (PLL clerk [E5,
MOS 92A20]) also serves as the maintenance shop Recommending maintenance
clerk. He performs duties involving supply of procedures.
repair parts and maintenance of equipment
records. He initiates and maintains records on Supervising and performing
equipment use, operations, history, maintenance, vehicle recovery operations.
modifications and calibration. He is responsible
for requesting, receiving, recording, and storing Ensuring that company equip-
parts and tools. In addition, he issues such parts ment meets calibration times and services.
to motor vehicle and power generation repair
personnel as required. He is also responsible l. Light-Wheeled Vehicle Mechanic.
for— There are two light-wheeled vehicle mechanics
(one E-5, MOS 63B20 and one E-3, MOS 63BIO)
Providing input for the mate- who perform organizational maintenance and
riel readiness report. work under the supervision of the motor sergeant.
They perform organizational preventive main-
Assisting in the scheduling of tenance and repairs on gasoline and diesel-fueled,
maintenance and repair services. light-wheeled vehicles. Light-wheeled vehicles
include prime movers designated as 5 tons or less
Issuing tools to motor vehicle and their trailers and associated items. Duties of
and power generation repair personnel, as re- the light-wheeled vehicle mechanics include—
quired.
Diagnosing malfunctions of
j. Armorer. The supply specialist/ light-wheeled vehicles and associated items.
armorer (E4, MOS 92Y1O) maintains the weapons
storage area, issues and receives munitions, and Troubleshooting engine/equip-
performs small arms unit maintenance. He ment problems using technical manuals (TMs).

2-14
FM 8-51

test yand diagnostic measurement equipment n. Cooks. Three cooks (two E4 and one
(TMDE), and other equipment as required. E3, MOS 94B10) provide food service (tray-pack
heating) for the company when it is assembled.
Applying applicable safety pre- More often, they are deployed with a task-
cautions. organized CSC element and further attached for
work with the food service section of the sup-
Performing scheduled mainte- ported medical unit. They also train CSC per-
nance and repairs on vehicles and equipment sonnel on food tasks which may be used as a part
assisted by the vehicle operator. of their CSC restoration or reconditioning pro-
gram. They serve as work group leaders for BF
Maintaining and accounting for casualties performing food service tasks as part
tools and equipment issued to him. of the BF casualty’s treatment.
Deploying with company
element (task-organized CSC element) to provide 2-7. Preventive Section
maintenance for company or attached vehicles.
When deployed, they work with the maintenance This section has 6 psychiatrists, 6 social work
section/element of the unit to which the task- officers, and 12 behavioral science specialists
organized CSC element is attached. assigned to the section. This section can divide
into six 4-person combat stress preventive teams.
m. Power Generation Equipment Re- Elements of the section may also be task-
pairman. The power generation equipment re- organized with elements of the restoration section
pairman (E4, MOS 52D1O) performs unit main- to form task-organized CSC elements for deploy-
tenance functions. The major functions and tasks ment to conduct CSC operations. The company
of the repairman include— commander will appoint the combat stress pre-
ventive team or task-organized CSC element
Applying applicable safety pre- leaders, considering rank, professional qualifica-
cautions. tions, and especially experience. The preventive
section’s responsibilities include—
Inspecting equipment, deter-
mining category of maintenance and extent of Providing preventive consulta-
repairs, and recording results. tion.
Classifying unserviceable com- Assisting units with REST
ponents and assemblages as required. category BF cases and RTD of recovered BF
casualties.
Performing preventive main-
tenance checks and services (PMCS) on shop Providing NP triage and stabi-
equipment. lization as required.
Maintaining and accounting for Supervising restoration of cat-
tools issued. egory HOLD BF casualties by medical personnel.
Training unit personnel on how Providing medical, psychiatric,
to properly operate and perform user mainte- and social work expertise to restoration and re-
nance on assigned generators. conditioning programs.

2-15
FM 8-51

Deploying combat stress pre- Providing therapy or referral
ventive teams to reinforce CSC elements opera- for soldiers with NP disorders.
ting in the divisions and corps areas.
Providing supervision and train-
Providing reconstitution men- ing of assigned and attached mental health
tal health support to physically and mentally personnel.
exhausted units.
Conducting and supervising unit
a. Psychiatrist. The six psychiatrists survey interviews and critical event debriefings.
(MAJ [three], CPT [three], MC, AOC 60W00)
assigned to this section examine patients and b. Social Work Officer. Six social work
provide consultation. They make neuropsycho- officers (MAJ [two], CPT [four], MS, AOC 73A67)
logical and medical diagnosis and prescribe and are assigned to this section. They provide pro-
provide treatment. They also direct disposition active consultation, give individual and group
of patients. The senior psychiatrist performs the counseling, supervise restoration/reconditioning,
duties of section leader and directs the activities and coordinate RTD of recovered cases. They also
of the section when the section is assembled. provide staff advice and coordinate Army and
Psychiatrists assigned to this section may be civilian social services support. These social work
deployed in support of CSC operations with the officers may be divided among several task-
section, or as members of either a combat stress organized CSC elements or be utilized as a memb-
preventive team or a task-organized CSC ele- er of a combat stress preventive team. When
ments. When deployed as a member of a combat deployed as a member of a combat stress preven-
stress preventive team or a task-organized CSC tive team or task-organized CSC element, the
element, the psychiatrist’s duties include— social work officer’s duties include—
Establishing and providing Evaluating psychosocial (unit
CSC support. and family) functioning of soldiers with BF and
misconduct stress behavior.
Providing staff consultation to
supported units as required. This includes Coordinating and ensuring the
nuclear surety, security clearances, and alcohol return of recovered BF and NP soldiers to duty
and drug abuse preventive program. and their reintegration into their original or new
unit.
Being responsible for the
diagnosis, treatment, rehabilitation, and disposi- Identifying and resolving or-
tion of NP and problematic BF cases. ganizational and social environmental factors
which interfere with combat readiness.
Participating in the diagnosis
and treatment of the wounded, ill, and injured, Coordinating support for sol-
especially of those who can RTD quickly. diers and their families through Army and civil-
ian community support agencies, when possible.
Consulting and providing
training to unit leaders and medical personnel Apprising unit leaders, pri-
regarding identification and management of NP mary care physicians, and others health care
disorders, BF, and misconduct stress behaviors. providers of available social service resources.

2-16
FM 8-51

Providing consultation to sup- personnel with personal, behavioral, or psycho-
ported unit commanders and to other mental logical problems. They assist with the manage-
health/CSC personnel regarding problem cases. ment of the preventive section. The NCOs also
deploy as NCOICs of combat stress preventive
Counseling and providing teams, or as members of task-organized CSC
therapy or referral for soldiers with psychological elements. Their general duties include—
problems.
Assisting in a wide range of
Conducting and supervising psychological and social services.
unit survey interviews and critical event de-
briefings. Compiling caseload data and
referring patients to specific mental health
c. Preventive Section Sergeant. The officers and physicians in supporting MTFs.
senior behavioral science NCO (E-7, MOS 91G40)
is the preventive section sergeant. This senior Providing counseling to sol-
NCO provides management assistance to the diers experiencing emotional or social problems.
mental health officers for both the technical and
tactical operations of the section. He supervises Assisting with group counsel-
subordinate members. His specific duties ing and debriefing sessions and leading group
include— discussions.
Keeping the section leader Collecting data in unit survey
informed. interviews pertaining to unit cohesion, morale,
and individual mental readiness for combat.
Monitoring, facilitating, and
supervising the training activities of the section. Assisting in critical event de-
briefings.
Monitoring and coordinating
situation reports from deployed task-organized e. Behavioral Science Specialist.
CSC elements or combat stress preventive teams. There are six behavioral science specialists (three
E-4 and three E-3, MOS 91G20) assigned to the
Conducting classes on selected section. These specialists assist the mental health
mental health topics for senior NCOs of supported officer and NCOs in gathering social and psycho-
units. logical data to support patient evaluations. Under
the supervision of the mental health officer and
Conducting and supervising NCOs, they provide initial screening of patients
unit survey interviews and critical event de- suffering emotional or social problems. In addi-
briefings. tion to their duties, they operate and maintain
assigned vehicles. Under the supervision of the
d. Behavioral Science Noncommiss- mental health officer, their specific duties
ioned Officer. There are five behavioral science include—
NCOs (two E-6, MOS 91G30 and three E-5, MOS
91G20). The two NCOs (E-6) act as assistant Serving as team leaders and
section sergeant and assist the section sergeant providing supportive counseling to BF casualties
with his duties. The NCOs collect and record and misconduct stress behaviors cases experienc-
social and psychological data and counsel ing emotional or social problems.

2-17
FM 8-51

Assisting in the evaluation of The section leader position may be held by any of
BF casualties and misconduct stress behaviors. the officers assigned to the section. The company
commander will appoint the section leader based
Assessing the mental status of on rank, professional qualifications, and
BF casualties and misconduct stress behaviors especially experience. This same rationale is used
(level of functioning capacity) and their need for in selecting leaders for the task-organized CSC
professional services. elements and combat stress restoration teams.
Collecting data in unit survey a. Occupational Therapy Officer. Four
interviews. OT officers (MAJ [two], CPT [two], Army Medical
Specialist Corps [SP], AOC 65A00) are assigned
Assisting in critical event de- to the section. They serve as environmental
briefings. managers using daily living task, physical recon-
ditioning, work, and other activities to counteract
combat stress reactions. Preventive treatment
2-8. Restoration Section programs include individual work assignments,
organized group work projects, common soldier
The restoration section consists of 4 psychiatric task review, stress management education,
nurses, 4 clinical psychologists, 4 occupational recreation, and physical reconditioning. Their
therapy (OT) officers and 4 patient administration responsibilities include—
specialists. It also has 1 senior psychiatric ward-
master, 7 psychiatric specialists, 8 OT specialists, Providing command consulta-
and 12 behavioral science specialists. This section tion to leaders regarding work schedules and
can divide into four combat stress restoration restorative off-duty activity programs.
teams. Elements of this section are usually task-
organized with elements of the preventive section Performing functional occupa-
to form task-organized CSC elements which tional evaluations of BF casualties.
operate restoration or reconditioning centers. At
these centers, they provide NP triage, diagnosis, Performing neuromuscular
stabilization, treatment, and disposition. Section evaluations, especially upper extremities and
personnel, as members of task-organized CSC hands.
elements or combat stress restoration teams, also Assigning BF casualties to
deploy routinely to provide preventive consulta- physical reconditioning and work groups.
tion and reconstitution support to units in the
corps area. They reinforce and may reconstitute Overseeing physical recondi-
medical detachment, CSC teams in the division tioning and work programs for BF casualties.
support areas.
Selecting appropriate activities
NOTE based on a BF casualty’s assessment.
The priority role for all CSC personnel Evaluating functional work ca-
is the prevention of BF and other pacity.
stress-related casualties. This is as
true for the restoration section as it is Modifying reconditioning pro-
for the preventive section. grams as required.

2-18
FM 8-51

Maintaining records of therapy/ Conducting nursing reports in
treatment. accordance with TSOPs to update section
members.
Reporting status of BF casual-
ties to psychiatrists and staff members on a daily Conducting and supervising
basis, or in accordance with the TSOPs. unit survey interviews and critical event
debriefings.
Conducting unit survey inter-
views and critical event debriefings. c. Clinical Psychologist. There are
four clinical psychologists (MAJ [one], CPT
b. Psychiatric/Mental Health Nurse. [three], MS, AOC 73B67) assigned to the section.
The section consist of four psychiatric/mental Their duties include—
health nurses (MAJ [two], CPT [two], Army Nurse
Corps [AN], AOC 66C00). The two majors posi- Providing diagnostic expertise
tions should be filled by clinical nurse specialists for triage.
(AOC 66C7T). The psychiatric nurses provide
specialized care, as required, for all BF, miscon- Conducting psychological and
duct stress behaviors and NP casualties, espe- neuropsychological testing.
cially those with severe behavioral disturbances
and/or concurrent physical illness or injury. They Providing behavioral treatment
administer medications according to the and counseling.
psychiatrist/physician’s orders. The clinical nurse
specialist (AOC 66 C7T), when properly trained, Conducting and supervising
prescribes medications under the supervision of surveys of unit cohesion, morale, and individual
a psychiatrist/physician. In coordination with the mental readiness for combat.
psychiatrist, clinical psychologist, occupational
therapist, and other section members, the psy- Providing command consulta-
chiatric nurses responsibilities include— tion.
Conducting individual and Supervising subordinate per-
group therapy and stress control education sonnel.
sessions.
Conducting and supervising
Providing preventive and com- critical event debriefings.
mand consultation, especially to medical units.
d. Senior Behavioral Science Noncom-
Assisting with the development missioned Officer. The senior behavioral science
of the RTD plan for each case. NCO (E-7, MOS 91G40) assists the section leader
and the clinical psychologist with the accomplish-
Ensuring the BF casualty’s ment of their duties. He provides assistance to
therapeutic program, as outlined in the RTD plan, the mental health officers with their adminis-
is followed. trative and clinical duties. He supervises the
behavioral science specialists working with the
Monitoring the BF casualty’s clinical element of the section. He assists with
status and record pertinent case data. the management and operations of the clinical

2-19
FM 8-51

element of the section. He provides assistance management and operations (technical and tacti-
with the management of operations (technical and cal) of the section, His specific duties include—
tactical ) of the section. His specific duties in-
clude— Keeping the section leader in-
formed.
Keeping the section leader
informed. Monitoring, facilitating, and
supervising the training activities of assigned
Monitoring, facilitating, and personnel.
supervising the training activities of subordinates
in the clinical element. Monitoring and coordinating
situation reports from deployed restoration and
Monitoring and coordinating reconditioning centers, either with task-organized
situation reports from deployed task-organized CSC elements or combat stress preventive teams.
CSC elements or combat stress preventive teams.
f. Psychiatric Noncommissioned Offi-
Conducting classes on selected cer. Two psychiatric NCOs (E-6, MOS 91F30,
mental health topics for senior NCOs of supported and E-5, MOS 91F20) are assigned to the section.
units. They manage and provide supervision for the BF
casualty’s care. They deploy with either combat
Conducting and supervising stress restoration teams or task-organized CSC
unit survey interviews and critical event de- elements. They function as BF casualty care
briefings. managers for the restoration and reconditioning
centers. They assist the psychiatric nurse(s)
e. Senior Psychiatric Wardmaster. with—
The psychiatric wardmaster (E7, MOS 91F40) Planning and executing the
assists the section leader with administrative and establishment, disestablishment, and movement
clinical duties and supervises the restoration or of the restoration or reconditioning center.
reconditioning center operations. He provides
direct supervision for the seven psychiatric spe- Conducting restoration and re-
cialists (MOS91F) and three patient administra- conditioning center operations.
tion specialists (MOS71G) (ward clerks). If the
restoration and reconditioning centers’ operations Providing guidance and train-
are centrally located, he assists with the overall ing to subordinate psychiatric specialists and
management of their operations. If the section other BF casualty care providers.
divides into two or more task-organized CSC
elements, he manages the restoration and recon- Administering medications.
ditioning center that is most likely to have the
greatest need. His responsibilities include As squad leaders, they provide direct supervision
assisting with planning and executing the estab- for BF casualties and monitor their progress.
lishment, disestablishment, movement, and They also assist with unit survey interviews and
operations of the restoration and reconditioning critical event debriefings.
centers. He is responsible for assisting the psy-
chiatric nurses with BF casualty care activities. g. Psychiatric Specialist. Five psychi-
He also assists the section leader with the atric specialists (three E-4 and two E-3, MOS

2-20
FM 8-51

91F20) provide BF casualty care and intervention, Their general duties include—
as required. These specialists deploy with either
the combat stress restoration teams or task- Assisting in a wide range of
organized CSC elements. Their duties include— psychological and social services.
Following the RTD plans for Assisting with initial screening
cases placed under their supervision. and assessment of new cases.
Coordinating with the psychi- Compiling caseload data and
atric nurse and other staff members on questions referring BF casualties to specific mental health
pertaining to the RTD plan. officers and psychiatrists.
Providing direct supervision for Providing counseling to BF ca-
BF casualties (as squad leaders) and monitoring sualties experiencing emotional or social prob-
their progress. lems.
Recording and reporting to the Assisting the psychologist with
psychiatric nurses and other mental health staff administration of psychological testing.
members on the status and any other pertinent
observation of cases assigned to them. Assisting with group counsel-
ing and therapy sessions and leading group dis-
Assisting with unit survey in- cussions.
terviews and critical event debriefings.
Assisting with unit survey in-
Operating and maintaining terviews and critical event debriefings.
assigned vehicles.
i. Behavioral Science Specialist. Six
h. Behavioral Science Noncommiss- behavioral science specialists (three E-4 and three
ioned Officer. Five behavioral science NCO (two E-3, MOS 91G20) are assigned to the section.
E-6, MOS 91G30, and three E-5, MOS 91G20) Their duties are consistent with those previously
are assigned to the section. Their responsibilities identified above (2-7e ).
include—
j. Occupational Therapy Noncommis-
Collecting and recording social sioned Officer. Three OT NCOs (one E-6, MOS
and psychological data. 91L30, and two E-5, MOS 91L20) are assigned to
the section. They assist the occupational thera-
Counseling soldiers with per- pists with—
sonal, behavioral, or psychological problems.
Evaluating functional capacity
Assisting with the manage- and supervising physical reconditioning pro-
ment of the section. grams.
Deploying as members of com- Coordinating and setting up
bat stress preventive team or task-organized CSC work programs with supported and supporting
elements. units and overseeing work programs.

2-21
FM8-51

Supervising and ensuring ap- patient statistics of all BF casualties seen by the
propriate training for subordinate OT specialists company element. He is normally located with
and other mental health personnel. the company headquarters but makes visits to
task-organized CSC elements as required to ensure
Providing BF casualty status company elements are complying with patient
updates to the occupational therapists and other administrative requirements. He is responsible
staff members as required. for forwarding the Medical Summary Report (RCS
Med-302 [R3]) in accordance with AR 40-400, and
Providing direct supervision of ensures that all BF casualty accountability and
BF casualties and squad leaders. status reports are forwarded as directed by higher
Assisting with unit survey in- headquarters. He initiates the field medical card
terview and critical event debriefings. (FMC) (DD Form 1380) on all BF casualties seen
for consultation and medical treatment and those
The OT NCOs deploy with either combat stress placed in the center for restoration or recondition-
restoration teams or task-organized CSC elements. ing programs. He ensures that all restoration
and reconditioning centers maintain the Daily
k. Occupational Therapy Specialist. Five Disposition Log. He supervises subordinate pa-
OT specialists (two E-4 and three E-3, MOS91L20) tient administrative specialists. He coordinates
work under the supervision of the occupational transportation and evacuation, as required, for
therapists and OT NCOs. Their duties include— BF casualties sent rearward for additional resto-
ration or reconditioning and for recovered BF
Assisting the occupational casualties returning to their units.
therapists with evaluating functional capacity.
m . Patient Administration Specialists.
Assisting with the supervision The patient administration specialists (two E-4
of work programs. and one E-3, MOS71G20) participate in the in-
processing of BF casualties into restoration and
Assisting with the identifica- reconditioning centers. They are responsible for
tion of useful work projects. initiating reports and forms identified in the
preceding paragraph. They maintain the Daily
Assisting with organizing ac- Disposition Log. When deployed with a combat
tivities which facilitate the recovery of the BF stress restoration team or task-organized CSC
casualties. elements, they work with the patient admin-
Serving as team leader for up istration section of the medical unit to which the
to 12 BF casualties. task-organized CSC element or combat stress
restoration team is attached. Through the patient
Assisting with unit survey administration section of the unit they are
interviews and critical event debriefings. attached to, they coordinate BF casualty evac-
uation and transportation requirements. They
These OT specialists deploy with combat stress maintain assigned vehicles and operate company
restoration teams or task-organized CSC elements. radios. They coordinate the disposition of BF
casualties through supporting unit communica-
1. Patient Administration Noncom- tions assets. Patient administration specialists
missioned Officer. The patient administration deploy with combat stress restoration teams or
NCO(E-5,MOS 71G) is responsible for managing task-organized CSC elements.

2-22
FM 8-51

Section III. COMBAT STRESS CONTROL DETACHMENT

2-9. Medical Detachment, Combat Stress Local security support.
Control (TOE 08-567LA00)
Unit maintenance services.
The medical detachment, CSC (Figure 2-4) is a
23-person unit composed of a headquarters, a The detachment is dependent on units to which
combat stress preventive section, and combat attached for support to include—
stress restoration teams. The modular CSC teams
found in the medical detachment, CSC are similar Medical administration.
to those found in the CSC medical company. The
medical detachment, CSC provides CSC planning, Logistical, including health ser-
consultation, training, and staff advice to C2 vices logistics.
headquarters and the units to which they are
assigned regarding— Medical regulating of patients.
Combat and noncombat stres- Battle fatigue casualty evac-
sors affecting the troops. uation.
Mental readiness. Coordination for RTD of recov-
ered BF soldiers.
Morale and cohesion.
Personnel resources to guard
Potential for BF casualties. enemy prisoner of war (EPW) patients provided
by the echelon commander.
The detachment provides NP triage, basic stabili-
zation, and restoration for BF casualties. Under Food service.
some circumstances, it may provide recondition-
ing for NP and alcohol and drug abuse patients. Supply and field services.
This unit is dependent on support from appro-
priate elements of the corps to include— Local security support.
Religious. Unit maintenance services.
Finance. a. Mission. The medical detachment,
CSC provides comprehensive CSC support to a
Legal. division, or to two or three separate brigades or
regiments. As the tactical situation permits, this
Personnel and administrative. detachment can provide all six of the CSC func-
tions identified, but reconditioning is unlikely
Food service. when it is deployed forward of the corps. For a
listing of major items of equipment assigned, see
Supply and field services. Appendix A.

2-23
FM 8-51

2-24
FM 8-51

b. Assignment. The medical detach- teams. He coordinates with the command sur-
ment, CSC is normally assigned to a corps medical geon and mental health sections regarding care
brigade with further attachment to a medical and disposition of patients. He exercises clinical
group, medical company, CSC, ASMB, or to a supervision over treatment in all the CSC teams.
DISCOM of a supported division. He provides NP expertise to supported unit head-
quarters. In conjunction with supported unit
headquarters and MTFs, the detachment com-
2-10. Detachment Headquarters mander plans CSC support for the unit’s opera-
tions. He deploys the detachment’s teams sepa-
The detachment headquarters provides C2 for the rately, or task organizes personnel across teams
detachment. The headquarters section is re- as needed to form task-organized CSC elements.
sponsible for planning, coordinating, and imple- He appoints team leaders based on best quali-
menting CSC support for supported units. The fications by experience as well as by AOCs.
headquarters has two personnel assigned: the
detachment commander and the detachment b. Detachment Noncommissioned Offi-
NCOIC. The detachment commander also serves cer In Charge. The detachment NCOIC (E-7,
as a treating physician with the preventive sec- MOS 91G) assists the detachment commander in
tion. The detachment NCOIC (a senior behav- the accomplishment of his duties. He performs
ioral science NCO) also serves as the restoration administrative duties; he receives and consoli-
team sergeant. Detachment officers and NCOs dates reports from deployed detachment elements
from the preventive team and the restoration and forwards them to higher headquarters. The
team may be assigned additional duties which detachment NCOIC coordinates support for the
enhance the overall effectiveness of the head- detachment and for detachment elements deploy-
quarters section. Additional duty responsibilities ed to supported units. He represents the com-
may include— mander at staff meetings and on-site visits to the
CSC teams when the commander is occupied with
Maintenance. clinical duties. When the detachment is divided
into combat stress preventive and combat stress
Training. restoration teams or task-organized CSC
elements, the NCOIC normally locates with the
Security, plans, and operations. combat stress restoration team. The combat
stress restoration team is usually the largest and
Nuclear, biological, and chemi- rear-most of the medical detachment, CSC
cal defense officer/NCO. elements. It is usually located closest to the
supported unit headquarters and coordinating
supply. staff (DMOC and MSB headquarters).
These duties may be rotated to achieve maximum
cross-training. 2-11. Preventive Section
a. Detachment Commander. Thede- This section has three psychiatrists, three social
tachment commander, a psychiatrist (MAJ, MC, work officers, and six behavioral science special-
AOC 60W00), performs normal C2 and supervi- ists assigned to the section. This section can
sory functions as well as serving as a treating divide into three 4-person combat stress preven-
physician in one of the combat stress preventive tive teams. Combat stress control preventive

2-25
FM 8-51

team leaders are selected by the detachment coordinate CSC operations, as required, and per-
commander based on experience as well as on form those duties previously identified above
grade and specialty. Elements of the section may paragraph 2-7 a).
also be task-organized with elements of the resto-
ration team to form task-organized CSC elements b. Social Work Officer. Three social
for special CSC operations. The preventive sec- work officers (MAJ [one], CPT [two], MS, AOC
tion’s responsibilities include— 73A67) are assigned to this section. These social
work officers usually deploy as members of the
Providing preventive consulta- combat stress preventive teams, but could remain
tion support to leaders, chaplains, and medical with the combat stress restoration team based on
personnel located in and around the brigade sup- mission requirements. As a member of a combat
port area. stress preventive team or other CSC element,
in addition to those duties identified above
Assisting nonmedical units (paragraph 2-7 b), the social work officer’s duties
with REST category BF casualties and the RTD include—
of recovered BF soldiers.
Evaluating soldiers with BF
Providing NP triage and stabi- and misconduct stress behavior.
lization.
Supervising subordinate per-
Supervising restoration of sonnel.
HOLD category BF casualties by medical per-
sonnel and providing restoration for selected c. Preventive Section Sergeant. The
cases. senior behavioral science NCO (E-6, MOS 91G30)
is the preventive section sergeant. His duties are
Providing medical, psychiatric, the same as those previously identified above
and social work expertise to restoration programs (paragraph 2-7 c).
staffed by medical detachment, CSC restoration
team. d. Behavioral Science Noncommis -
sioned Officer. There are two behavioral science
Deploying to units to provide NCOs (E-5, MOS 91 G20). These two NCOs act
reconstitution support. as assistant section sergeant and assist the sec-
tion sergeant with his duties. Their duties are
a. Psychiatrist. The three psychiatrists consistent with those identified above (paragraph
(MAJ [also the detachment commander], CPT 2-7 d). They deploy as NCOICs of teams and may
[two], MC, AOC 60W00) are assigned to this be assigned as the team leader for up to 14 BF
section. The senior psychiatrist/detachment casualties in a restoration center.
commander directs the activities of the section.
Psychiatrists assigned to this section are usually e. Behavioral Science Specialist.
deployed in support of CSC operations as mem- There are three behavioral science specialists (two
bers of a combat stress preventive team, but may E-4 and one E-3, MOS 91G20) assigned to the
remain with the combat stress restoration team section. These specialists perform those duties
under some circumstances. These psychiatrists previously identified above (paragraph 2-7 e). In
will usually associate closely with the supported addition to their duties, they operate and
FSMC’s area support treatment team. They maintain assigned vehicles.

2-26
FM8-51

2-12. Restoration Team Monitoring, facilitating, and
supervising the training activities of
The restoration team provides staff and equip- subordinates.
ment for operating a restoration or (rarely) re-
conditioning center. The center provides NP Monitoring and coordinating
triage, stabilization, treatment, and disposition. situation reports from deployed combat stress
The team, or its members, deploy as necessary to preventive teams.
provide consultation and reconstitution support
to units. The combat stress restoration team Conducting classes on selected
leader’s AOC is immaterial; any of the officers mental health topics for senior NCOs of supported
assigned to the section may be appointed as the units.
team leader by the unit commander. The com-
mander will base his selection on experience as c . Psychiatric Noncommissioned Offi-
well as specialty and grade. cer. The psychiatric NCO (E-5, MOS 91F20)
manages and provides supervision for BF casualty
a. Occupational Therapy Officer. The care. He deploys with the combat stress restora-
OT officer (CPT, SP, AOC 65AOO) performs those tion team to supervise and function as the BF
duties previously identified above (paragraph casualty care manager for the restoration center.
2-8 a). He assists with establishment, disestablishment,
and movement of the team. The psychiatric NCO
b. Psychiatric/Mental Health Nurse. also assists with conducting restoration and re-
The psychiatric/mental health nurse (MAJ, AN, conditioning center operations. His duties are
AOC 66COO) provides specialized nursing care consistent with those identified above {paragraph
and management of BF casualties. This position 2-8 f). As a squad leader, he may provide direct
should be filled by clinical nurse specialist (AOC supervision for up to 12 BF casualties. He may
66C7T). The duties of the psychiatric/mental be deployed temporarily to reinforce a combat
health nurse are consistent with those previously stress preventive team.
identified above (paragraph 2-8 b).
f Psychiatric Specialist. The psychia-
c. Clinical Psychologist. The clinical tric specialist (E-4, MOS 91F20) provides BF
psychologist (CPT, MS, AOC 731367) assigned to casualty care and intervention, as required. His
the section performs those duties previously duties are consistent with those identified above
identified above (paragraph 2-8 c). (paragraph 2-8 g). This specialist may be tempo-
rarily deployed to reinforce a combat stress
d. Senior Behavioral Science preventive team. In addition to his duties, he
Noncommissioned Offiicer. The senior behavioral operates and maintains the assigned vehicle.
science NCO (E-7, MOS 91G40) is also the
detachment NCOIC. He assists the combat stress g. Behavioral Science Noncommiss-
restoration team leader with the accomplishment ioned Officer. The behavioral science NCO (E-5,
of his duties. He provides assistance with the MOS 91G20) assists the clinical psychologist. His
management of technical and tactical operations duties are consistent with those identified above
of the team. His specific duties include— (paragraph 2-7 d). He assists with the manage-
ment of the combat stress restoration team. This
Keeping the team leader NCO may be assigned temporarily to reinforce/
informed. augment a combat stress preventive team.

2-27
FM 8-51

h. Behavioral Science Specialist. The the supervision of the occupational therapist and
behavioral science specialist (E-4, MOS 91G20) OT NCO. His duties are consistent with those
assists the mental health officer in gathering identified above (paragraph 2-8 k).
social and psychological data to support BF cas-
ualty evaluations. His duties are consistent with
those identified above (2-7 e). In addition to his k. Patient Administration Specialist.
duties, he operates and maintains the assigned The patient administration specialist (E-4, MOS
vehicle. He may be deployed to reinforce/augment 71G20) is responsible for initiating the reports
a combat stress preventive team. and forms identified in paragraph 2-8 m above.
i. He maintains the Daily Disposition Log. He
Occupational Therapy Noncommiss- interfaces with the supporting MTF’s patient
ioned officer. The OT NCO (E-5, MOS 91L20)
assists the occupational therapist. His duties are administration section on arrival and disposition
consistent with those identified above (paragraph of HOLD category BF casualties. He coordinates
2-8 j). He also functions as team leader for up to evacuation and transportation requirements, as
12 BF casualties in restoration. required. He maintains assigned vehicle and
operates the detachment radio. He coordinates
j. Occupational Therapy Specialist. the disposition of BF casualties through the sup-
The OT specialist (E-4, MOS91L20) works under porting unit’s radio communications net.

2-28
C 1,FM 8-51

«FOR INFORMATION ON MENTAL HEALTH AND COMBAT STRESS CONTROL ELEMENTS
REORGANIZED UNDER THE MRI, SEE APPENDIX E.

CHAPTER 2

MENTAL HEALTH AND COMBAT STRESS CONTROL
ELEMENTS IN THE THEATER OF OPERATIONS

Section I. UNIT MENTAL HEALTH SECTIONS IN THE THEATER
2-1. Locations and Assignments of Unit section provides mental health/CSC services through-
Mental Health Sections out the division. This section, acting for the division
surgeon, has staff responsibility for establishing policy
Mental health sections are located in the divisions, the and guidance for the prevention, diagnosis, treatment,
corps, and the COMMZ. In the divisions, they are and management of NP, BF, and misconduct stress
assigned to the medical company of the main support behavior cases within the division area of operations
battalion (MSB). In the corps and COMMZ, they are (AO). It has technical responsibility for the psycho-
assigned to the ASMB headquarters. In separate logical aspect of surety programs. The staff of this
brigades, they are assigned to the medical company. section provides training to unit leaders and their staffs,
chaplains, medical personnel, and troops. They
2-2. Division Mental Health Section monitor morale, cohesion, and mental fitness of
supported units. Other responsibilities for the division
The division mental health section is assigned to the mental health section staff include—
main support medical company (MSMC), which is a
division support command (DISCOM) asset (see FMs • Monitoring indicators of dysfunctional
8-10-1, 8-10-3, and 63-21). stress in units.

• Evaluating NP, BF, and misconduct
NOTE stress behavior cases.

The responsibilities of the division mental • Providing consultation and triage as
health section extend to all division requested for medical/surgical patients exhibiting signs
elements and require a mental health/CSC of combat stress or NP disorders.
presence at the combat maneuver brigades.
• Supervising selective short-term restora-
tion for HOLD category BF casualties (1 to 3 days).
The division mental health section is the medical
element in the division with primary responsibility for • Coordinating support activities of
assisting the command in controlling combat stress. attached corps-level CSC elements.
Combat stress is controlled through sound leadership,
assisted by CSC training, consultation, and restoration The division mental health section normally
programs conducted by this section. The division collocates with the MSMC clearing station. For a
mental health section enhances unit effectiveness and listing of major equipment assigned, see Appendix A.
minimizes losses due to BF, misconduct stress The staffing of the division mental health section allows
behaviors, and NP disorders. Under the direction of for this section to be split into teams which deploy
the division psychiatrist, the division mental health forward to provide CSC support, as required, to

2-1
C 1, FM 8-51

brigades in the division. Normally, each brigade is • Maintain communications and
supported by a brigade CSC team. This team consists unity of efforts when division mental health section
of a mental health officer who is designated the brigade personnel are dispersed to the brigades.
mental health officer and a behavioral science NCO
that is designated the brigade CSC coordinator. If no • Provide the points of contact to
mental health officer is available, the senior behavioral integrate reinforcing CSC teams throughout the
science noncommissioned officer in charge (NCOIC) division.
substitutes as the brigade CSC team leader. The
division psychiatrist oversees all brigade CSC teams DIVISION MENTAL HEALTH SECTION STAFF
and provides consultation as necessary.
Psychiatrist
Clinical Psychologist
a. Mental Health/Combat Stress Control Social Work Officer
Support. The division psychiatrist provides input to Senior Behavioral Science NCO (NCOIC, E-7)
the division surgeon on CSC-related matters. He Behavioral Science NCO (E-6)
Behavioral Science Sergeant (E-5) (two)
works with the division medical operations center Behavioral Science Specialist (three)
(DMOC) to monitor and prioritize mental health
support missions in accordance with the division combat
health support (CHS) operation plans (OPLANs) or Figure 2-1. Division mental health section staff.
operation orders (OPORDs). Coordination for mental
health personnel augmentation is accomplished through
(1) Psychiatrist. The division psy-
the MSB Operations and Training Officer (US Army)
chiatrist (Major [MAJ], Medical Corps [MC], area of
(S3) and the DMOC.
concentration [AOC] 60W00) is the officer in charge
of the division mental health section. The psychiatrist
b. Division Mental Health Section Staff. is also a working physician who applies the knowledge
The division mental health section is staffed as shown and principles of psychiatry and medicine in the
in Figure 2-1. The consolidation of assigned mental treatment of all patients. He examines, diagnoses, and
health officers and behavioral science specialists in one treats, or recommends courses of treatment for
division mental health section provides unity of CSC personnel suffering from emotional or mental illness,
support for all division prevention, training, and situational maladjustment, BF (combat stress
treatment responsibilities of the section. It provides reactions), and misconduct stress behaviors. His
multi-disciplinary mental health professional expertise specific functions include—
to—
• Directing the division’s
• Supervise and train the behavioral mental health (combat mental fitness) program.
science NCOs and specialists.
• Being a staff consultant for
the division surgeon on matters having psychiatric
• Provide staff input to the com-
aspects, which include—
mands within the division AO.
• Personnel reliability
• Assure clinical evaluation and program.
supervision of treatment for all NP and problematic
BF cases before they leave the division. • Security clearances.

2-2
FM 8-51

CHAPTER 3

COMBAT STRESS CONTROL OPERATIONS
IN THE COMBAT ZONE

Section I. DIVISION MENTAL HEALTH/COMBAT
STRESS CONTROL OPERATIONS

3-1. Division Mental Health Section De- NP and CSC to include handling and treatment
ployment of NP patient and combat stress-related
casualties. The psychiatrist also initiates the
If the division deploys tactically, the division coordination for corps CSC augmentation as
mental health section deploys the brigade CSC required.
teams by echelon with the brigade FSMCs. A
team consists of one mental health officer plus an
NCO. When the division is assembled in an 3-2. Division Combat Stress Control Es-
assembly area or garrison, the mental health timate and Plan
officers may consolidate at the MSMC. The
division psychiatrist deploys with the MSMC or a. Mental Health/Combat Stress Con-
earlier as needed. The division psychiatrist trol Estimates. The division psychiatrist, assisted
covers the MSMC in the DSA and uses it as a by the division mental health section staff,
base of operations. Those division mental health prepares mental health/CSC estimates as directed
section assets that were not deployed with the or required for CHS operations. Mental health/
FSMCs will establish the division mental health CSC estimates are developed in accordance with
section near the area support squad treatment FM 8-55, FM 8-42 and division CHS TSOPs (see
element (division clearing station). As stated in Appendix B). Mental health/CSC estimates are
Chapter 2, the division mental health section submitted via technical medical channels to the
routinely details one behavioral science NCO to DMOC which collects them for the division
each of the brigades; these NCOs perform the surgeon. Estimates are provided via command
functions of brigade CSC coordinator. The mental channel (if formal tasking) through the MSMC
health officers from the division mental health and MSB headquarters to the DMOC which
section are designated as the brigade mental collects them for the division surgeon. The
health officers. They join the brigade CSC division psychiatrist may coordinate directly with
coordinators to form the brigade CSC teams when the division surgeon or DMOC to obtain division/
the brigades deploy away from the MSMC. Other DISCOM staff input. These estimates are used
division mental health section personnel are by the division surgeon and DMOC to develop
deployed to the supported BSAs to augment/ the division CHS OPLANs/OPORDs. The mental
reinforce the brigade CSC teams as required. The health/CSC estimate may include—
division psychiatrist actively supports the brigade
CSC teams in their unit-based preventive mental Mental health status of the
health and training programs and will also deploy division.
to brigade level to provide assistance, or make
consultation site visits to the FSMCs. During Current status of morale and
tactical operations, the division psychiatrist unit cohesion in division units.
provides a 24-hour NP triage capability at the
MSMC. He trains and supervises MSMC treat- Status of mental health/CSC
ment platoon personnel in all areas pertaining to personnel/elements.

3-1
FM 8-51

Battle fatigue casualty esti- Providing divisionwide mental
mates. health/CSC coverage.

Fatigue, sleep loss. Ensuring policies and proce-
dures for the prevention, acquisition, restoration,
Percent of casualties; intensity and treatment for BF, misconduct stress behav-
of combat. ior, and NP disorders are clearly defined and
disseminated.
Home-front stressors (natural
disaster, unpopular support of the conflict, Providing consultation ser-
terrorist attacks in or around home base). vices.

Restoration requirements. Establishing restoration areas
as required at division MTFs.
Corps CSC support require-
ments. Coordinating requirements for
mental health/CSC augmentation.
The mental health/CSC estimate should include
any assumptions required as a basis for initiating, Providing reconstitution sup-
planning, or preparing the estimates. Any mental port.
health/CSC deficiencies are identified, using
those tactical courses of action listed in the Coordinating for corps-level
commander’s estimate. The advantages and mental health/CSC support.
disadvantages of each tactical course of action
under consideration from the mental health/CSC Establishing procedures for the
standpoint are provided. In addition, the estimate timely and accurate reporting of BF, misconduct
provides methods of overcoming deficiencies or stress behavior, and NP disorders seen by division
modifications required in each course of action. mental health section elements/personnel.

b. Mental Health/Combat Stress Con- The division psychiatrist, assisted by the mental
trol Plan. The division psychiatrist, assisted by health staff, is responsible for supervising and
the division mental health section staff, develops coordinating the implementation of the division
the mental health/CSC input for the division CHS mental health/CSC support operations. Imple-
OPLAN/OPORD in accordance with FMs 8-55 menting the mental health/CSC support in
and 8-42. This input is based on the mental accordance with CHS annex of the division
health/CSC estimate and feedback from the OPLAN/OPORD should include—
commander, MSB support operations section,
DMOC, and division surgeon. The division Ensuring that DSA and BSA
psychiatrist and mental health officers must consultation duties are delineated.
ensure that all mental health/CSC requirements
for the division are included in their input for the Coordinating as required and
division OPLAN/OPORD. The mental health/ permitted by the MSMC and MSB commander
CSC subparagraph in the CHS annex of the with the DMOC and supporting corps CSC
division OPLAN/OPORD should include— elements.

3-2
FM 8-51

Coordinating the establish- mental health/CSC augmentation. Request for
ment of restoration and reconditioning centers corps-level mental health/CSC support is
with supporting corps-level CSC elements. normally coordinated by the DMOC with the
supporting medical brigade or group. The deploy-
Establishing procedures for ment of the medical detachment, CSC is discussed
units to request mental health/CSC support. in Section III of this chapter. It must be recog-
nized that corps CSC assets can be diverted to
Deploying and reinforcing bri- other areas of the corps by the medical brigade or
gade CSC teams and other division mental health medical group even during heavy combat. The
section personnel, as required, to support CSC medical detachment, CSC may be deployed for
requirements. peacetime contingency operations. The medical
detachment, CSC support is likely to be
Ensuring transportation of BF intermittent and selective in OOTW (conflicts).
casualties in nonambulance vehicles (such as The division mental health section plans must be
cargo trucks returning empty after delivering prepared to provide CSC coverage without
their loads) is coordinated by the DMOC in ac- augmentation.
cordance with the TSOP.
b. Brigade Mental Health/ Combat
Stress Control Support.
3-3. Division Mental Health Section Em-
ployment
(1) A behavioral science NCO is
The employment concept for mental health routinely detailed to each FSMC to assist the
support in the division is dependent on the brigade with CSC. This NCO performs duties as
effectiveness of the division combat, mental fitness the mental health liaison NCO and brigade CSC
program. It is also dependent on the assignment coordinator. He works for the brigade surgeon
and proper distribution of division mental health under the general supervision of a division mental
personnel. It is essential that medical com- health section officer. Specifically, one mental
manders promote training which include field health officer from the division mental health
experience and cross-training of critical non- section is designated as the brigade mental health
medical skills. For division mental health officer. The brigade CSC coordinator routinely
personnel to fill their roles in combat, they must circulates throughout the brigade to train and
be thoroughly familiar with the units they advise brigade and supporting personnel to
support. They must also be known and trusted include—
by the leaders and personnel of the supported
units. Medical personnel.
a. Division Mental Health/Combat Chaplains.
Stress Control Support. The MSMC commander
prioritizes division mental health section missions Combat lifesavers.
based on input from the division psychiatrist and
on the provisions of the division CHS plan. The
division mental health section coordinates Unit leaders.
through the MSMC commander, MSB support
operation, and the DMOC when requesting Soldiers (unit members).

3-3
FM 8-51

The brigade CSC coordinator establishes and strophic events. The psychiatrist and mental
conducts unit preventive mental health and health officers provide CSC prevention training,
training programs for the supported brigade and consultation, critical event debriefing, and
attached units operating with the brigade. restoration support when indicated.

(2) When a brigade is deployed (5) The brigade CSC teams deploy
forward, the brigade mental health officer (with with the supported brigade CSS elements to their
a division mental health section vehicle) and BSAs. The brigade CSC teams maintain knowl-
(optionally) a behavioral science specialist will edge of the tactical situation, normally through
also deploy to the BSA. The brigade mental the brigade surgeons. They assist the brigade
health officer and the brigade CSC coordinator surgeons with planning and projecting require-
together form the brigade CSC team. The brigade ments for stress casualty prevention and recon-
CSC team visits supported units regularly within stitution support. It is important that the brigade
the BSA and goes forward for consultation to the CSC teams keep the brigade surgeons and
supported maneuver battalions, as transportation supported commanders updated on CSC issues.
and other missions permit. The brigade mental The brigade CSC teams also have a responsibility
health officer advises the FSMC on mental health/ to keep the division psychiatrist informed in
CSC issues and provides technical supervision for accordance with the TSOP. The brigade CSC
treatment of NP or BF casualties. He provides teams request reinforcement from the division
direct supervision for other division mental health mental health section, as required, especially
section personnel deployed to the BSA. The when there is an increase in the stress casualty
brigade mental health officer ensures adequate and NP caseloads that are beyond their capability
professional standards for all counseling by CSC to handle. When reinforced, the brigade CSC
coordinators and for command consultation ac- team orients and updates the mental health/CSC
tivities. augmenting personnel on CSC issues and require-
ments. The brigade CSC teams use the clearing
(3) Severe BF or NP cases which stations of the FSMCs as the centers of their
cannot be managed at the FSMCs clearing operations but must not be confined to that
stations are evaluated by the brigade CSC team. location. The priorities of functions for brigade
These cases may be sent to the MSMC for CSC teams in support of the brigades are—
evaluation by the division psychiatrist or his
representative. No NP or BF casualty is evacu- (a) Deploying forward to am-
ated from the division without being evaluated bulance exchange points (AXPs) and combat
by the division psychiatrist or his representative. trains to provide preventive support and imme-
diate stress control intervention when possible.
(4) The division psychiatrist may
also deploy to units throughout the division in (b) Triaging BF casualties,
response to requests for consultation. The divi- misconduct stress behaviors, and NP disorders
sion psychiatrist regularly visits the brigade CSC prior to their evacuation, and advising the
teams in the BSA and reinforces them at times attending physician to prevent overevacuation.
of special need. He identifies problems in units
and provides or coordinates consultation follow- (c) Facilitating the treatment
ing critical events such as a fatal accident, rear of BF REST category cases in their battalions’
battle incident with loss of life, or other cata- field trains.

3-4
FM 8-51

(d) Advising FSMC health being able to converse with unit personnel and
care providers on treatment requirements for BF understand about what they do.
casualties.
Monitoring units for morale,
(e) Coordinating the RTD unit cohesion, and indicators of excessive stress/
process for recovered BF casualties. stressors.

(f) Facilitating postcombat Advising unit commanders,
stress debriefings at small units. leaders, and personnel on stress management and
coping techniques.
(6) The employment. of the medical Identifying, providing, or coor-
detachment, CSC provides for a CSC preventive dinating training on mental health/CSC subject
team to augment the brigade CSC team at the areas.
FSMC in each BSA. The CSC preventive team
has a psychiatrist, social work officer, and two Providing preventive consul-
behavioral science specialists. This team has a tation.
5/4-ton vehicle for transportation. This corps CSC
preventive team could be diverted elsewhere. The Providing feedback to the
brigade CSC team and brigade must be prepared brigade surgeon and division psychiatrist on the
to function without them. The mission of the mental health status of supported units.
CSC preventive team is discussed in Section III
of this chapter. Monitoring the progress of
c . Unit-Level Mental HealthlCombat
REST and DUTY category BF soldiers that are
recovering in their units.
Stress Control Support. Unit-level mental health/
CSCsupport is provided by the brigade CSC team (1) When a division mental health
and the division psychiatrist, as required. The section’s vehicle is in the BSA, the brigade CSC
brigade CSC team officer and the NCO (or the team uses this vehicle to visit supported units. If
brigade CSC coordinator alone) conduct site visits a designated vehicle from the division mental
to all the units in the BSA on a frequent basis. health section is not available (as when the
The brigade CSC team ideally has preestablished brigade CSC coordinator is working without the
points of contact (officers and NCOs) in each unit. brigade mental health officer being present), it is
Site visits by the brigade CSC team to supported necessary to find alternative means of getting to
units are performed for several reasons which the supported units. The transportation needs
involve both the units and the brigade CSC team. are dependent on the size of the BSA and the
The primary reasons for these frequent site visits amount of traffic movement between units. In
include— some situations when there are short distances
between units, it may be feasible for the brigade
Establishing trust and confi- CSC team to walk to the supported units located
dence between the brigade CSC team and unit in the BSA or to coordinate rides with unit vehi-
personnel. cles. The unit ministry teams (chaplains) can be
especially helpful because of the common features
Establishing familiarity with of CSC and the chaplains’ ministry and CSC
the unit’s operations, mission, and tasks and support.

3-5
FM 8-51

(2) The brigade CSC team must training for patient-holding squad personnel.
keep the FSMC informed of their whereabouts. The CSC team’s guidance and training will
This is done by reporting to the FSMC (using the include the emotional and behavioral aspects of
visited unit’s radio or land lines) immediately patient care for the minimally sick and wounded
upon arriving and again just before departing, as well as for BF and NP cases. Following the
specifying the next destination. The brigade CSC treatment protocol established by the division
team provides updates on the CSC situation at psychiatrist, and in accordance with the mental
the unit just visited by using short brevity-coded health/CSC plan, the brigade CSC team makes
messages. This constant contact with the FSMC recommendations on the triage, management,
permits the redirecting of the brigade CSC team and treatment of combat stress-related cases.
to areas of special need. Triaging of BF cases into the appropriate cate-
gories is essential for effective management and
(3) When combat is imminent or treatment. Management and treatment of the
ongoing, the brigade CSC team may deploy following triage categories are examples of how
forward to the AXPs to provide rapid evaluation the brigade CSC team can manage combat stress-
and CSC intervention. The brigade mental health related casualties in the BSA. Additional infor-
officer and brigade CSC coordinator may be at mation on combat NP triage, restoration, and
different locations. In some situations, one or consultation is provided in subsequent chapters.
both may go forward to a battalion aid station The BF casualty may be triaged and placed in
(BAS) located in the combat trains area. one of the following categories:
(4) During lulls before or after DUTY
combat actions, the brigade CSC coordinator may
go forward to unit combat trains and BASS for REST
preventive consultation. They meet with a unit
in reserve that has experienced intensive combat HOLD
or other problems. The brigade CSC team may
use the division mental health section vehicle, REFER
ride in ambulances, or travel with the logistic
package convoy or reconstitution teams going
forward. The brigade CSC team updates and (1) Mild BF cases who reach the
assists any mental health/CSC personnel sent to brigade MTF will be triaged as DUTY category.
the brigade for reinforcing/augmentation support. Some of these cases will require a brief time to
recuperate (less than an hour to no more than 6
d. Clinical Duties of the Brigade Com- hours). This short period for recovery may
bat Stress Control Team in the Brigade Support include—
Area. The brigade CSC team provides assistance
to unit-level medical officers and physician assis- Food and nourishment.
tants, as required, to ensure correct disposition
for BF, misconduct stress behavior, and NP cases. Fluid to drink.
At the BSA, the brigade CSC team assists in
patient triage and in the evaluation of problematic A quiet place to nap.
BF and NP cases. The brigade CSC team assists
the attending physician and patient-holding Reassurance to the sol-
wardrnaster in providing general guidance and dier.

3-6
FM 8-51

The opportunity for talk- feasibility of holding BF casualty cases at the
ing about his experiences. FSMC depends on the tactical situation, patient
work load, and the soldiers’ symptoms. Res-
The DUTY category cases are sent back to their toration treatment for HOLD category cases
units with recommendations for full duty. If the placed in the patient-holding area of the FSMC
soldier’s unit is known to be in reserve status includes—
where everyone is resting and recovering, a lower
level of combat functioning could still qualify as Reassuring that BF is
DUTY BF. However, if a soldier is classified as normal and temporary.
DUTY, he must be capable of caring for himself
and responding appropriately to his duties if the Providing a respite from
unit comes under attack. extreme danger or stress.
(2) REST category cases from ma- Ensuring dehydration.
neuver units may require being away from far-
forward areas for a few days. Normally, these Providing replenishment
cases are sent for 1 to 2 days of duty in the (food and hygiene).
soldiers’ own battalion HSC or battery. Alter-
natively, these soldiers may be held in BSA units Providing the opportunity
under the control of the FSMC or brigade for rest (sleep).
Adjutant (US Army) (S1) for 1 or 2 days. In both
situations coordination is required, and the Recounting (verbally re-
soldier must be accounted for until he returns to constructing) the recent stressful events and
his own unit. REST category cases placed in units regaining perspective.
are monitored by the brigade CSC team. The
brigade CSC team monitors these cases either by Restoring confidence
direct interview or by talking with the soldier’s through activities which maintain the individual’s
supervisors. The brigade CSC team listens to the identity as a soldier.
soldier’s story and gives perspective-reorienting
counseling when indicated. REST cases are (4) REFER category are BF and
returned to the FSMC and placed in the HOLD NP cases which cannot be safely held or treated
category if symptoms persist and they fail to at the FSMC. These cases may be triaged into
improve. These cases will be provided restoration the REFER category at the initial evaluation or
treatment and additional evaluation at the FSMC. they may be cases that have not responded to
These cases are accounted for until they RTD with initial restoration treatment at the FSMC. These
their own units. cases are evaluated at the FSMCs by the division
psychiatrist or mental health officers if they are
(3) HOLD category BF cases are in the forward areas, or they are sent to DSA
those who require medical observation and clearing station for evaluation and disposition by
assistance. If feasible, these cases are provided division mental health section or the designated
restoration treatment at the FSMCs for 1 day (or alternates. The preferred method of evacuating
up to 3 days if RTD is expected). When these these cases is by nonmedical vehicle, but ground
cases are held in the FSMC’s patient-holding ambulances are used, as necessary. Physical
area, it should be emphasized to them that BF restraints and/or medication are used during
soldiers are not patients, just tired soldiers. The transportation only if necessary for safety.

3-7
FM 8-51

NOTE treatment and placed in the MSMC patient-
holding section. The total period of time for
A few BF or NP symptoms could also holding BF casualties in the division is 72 hours.
be caused by life- or limb-threatening If the BF casualty is held in the BSA for 24 hours,
medical/surgical conditions. These ca- he can be held in the DSA only for an additional
sualties may be evacuated directly to a 48 hours. These cases are provided restoration
corps-level hospital as determined by treatment at the MSMC for up to 3 days. The
the attending physician. feasibility of holding BF casualty cases at the
MSMC depends on the tactical situation, patient
work load, and the soldiers’ symptoms. Res-
Wounded casualties with concurrent BF or NP toration treatment for HOLD category cases
symptoms, who are either combative or violent, placed in the patient-holding section of the MSMC
are placed in patient restraints as determined by is the same as identified for the FSMCS. The
the attending physician. If these types of patients number of days (within the 72-hour time frame)
are evacuated by air ambulance, physical of restoration that the MSMC can provide could
restraints are required. The preferred method of be shortened or lengthened, depending on the
transporting an unwounded BF casualty is by a tactical situation, available resources, and the
nonmedical vehicle. The use of a nonmedical actual or projected caseloads.
vehicle would help prevent the BF casualty from
thinking that his condition is anything other than (1) The division psychiatrist, as-
just being a very tired soldier. On the other hand, sisted by the clinical psychologist and social work
by placing the BF casualty in an ambulance which officer (if they are not deployed to the BSAS),
is clearly marked with the symbol of the red exercises technical supervision for the man-
crosses, the BF casualty is under a protected agement of BF soldiers and NP patients placed in
status according to the rules established by the the patient-holding section. If possible, these
Geneva Conventions. The decision that confronts cases are housed away from the ill, injured, or
the health care provider is which of two methods wounded patients.
is more beneficial for the overall safety and
recovery of the BF casualty. (2) The division psychiatrist may
designate a behavioral science specialist to assist
e. Mental Health/Combat Stress Con- the patient-holding squad with treatment of BF
trol Support in the Division Support Area. The casualties. This treatment consists of replen-
division mental health section personnel locate ishing sleep, hydration, nutrition, hygiene, and
near and work with the DSA clearing station to general health and restoring confidence through
ensure mental health/CSC coverage to support group activities, appropriate military work
the DSA is available. They evaluate BF, mis- details, and individual counseling, as needed.
conduct stress behavior, and NP cases referred These activities include those patients with
from throughout the division AO. The initial minor wounds, injuries, and illnesses who do not
triage of cases from the DSA is the same as need continual bed rest and who may have BF
performed in the BSAs. The division mental symptoms.
health section staff in the DSA spends substantial
time with evaluating the REFER category BF (3) The division psychiatrist fol-
casualty sent from the forward areas of the lows the soldiers' progress, reevaluates, and gives
division. Any of the REFER cases with good individual attention, as needed. Medication is
potential for RTD within 72 hours are held for prescribed sparingly and only when needed to

3-8
FM 8-51

temporarily support sleep or manage disruptive He works under the direct supervision of the
symptoms. Those cases who (on initial evaluation division psychiatrist or the division mental health
or after a period of observation) have a poor section NCOIC. The CSC coordinator’s activities
prognosis for RTD, or whose behavior is too can be closely supervised and reinforced by the
disruptive or dangerous to manage in the holding division psychiatrist; this position requires less
facility, are evacuated to the supporting corps- experience and independence than the brigade
level hospital. Such patients must be suitably CSC coordinators. This is a suitable preparatory
restrained and medicated for transport. The training assignment for less senior behavioral
evacuation priority for these NP patients is science specialists before they become brigade
routine. CSC coordinators. However, the special problems
of BF in CS and CSS units in the rear area make
(4) Those cases who (on initial the DSA CSC coordinator’s role no less important
evaluation or after observation) require longer to the success of the division. It is essential to
than the holding policy at the division-level MTF assign an individual with whom the units can
allows but who have reasonable prognosis for identify and develop trust.
RTD within the corps evacuation policy are
transferred to a corps-level restoration and (1) During lulls in tactical activi-
reconditioning facility. Corps restoration and ties, the DSA CSC coordinator conducts classes
reconditioning facilities are staffed and operated on mental fitness; provides consultation for unit
by the medical company, CSC. leaders; provides crisis intervention counseling
for soldiers; and gives counseling and referral for
(5) Soldiers sent directly from a troubled soldiers.
division MTF to a restoration and reconditioning
center will ideally be transported in trucks, not (2) During tactical operations, the
ambulances. Prior coordination with the division DSA CSC coordinator keeps current on the
Assistant Chief of Staff (Personnel) (Gl) and corps location and status of CS/CSS units, continues to
Adjutant General (AG) personnel replacement provide consultation to these units, and coor-
system may facilitate the returning of recovered dinates the resting of DUTY and REST BF
BF casualties to their original units. soldiers in or near their units.
(6) For all recovered BF soldiers
returned to duty from the DSA, the division
mental health section coordinates with the 3-4. Reinforcement of Brigade Combat
division G1 and with the soldier’s unit. The Stress Control Team Using Division
coordination is made directly or through the CSC Mental Health Section Assets Only
coordinator in the DSA or brigade CSC team in
the BSAS, the chaplains’ ministry, or other a. Consultation Visits. Frequent visits
channels. This is to ensure successful rein- to the BSAs and their brigade CSC teams should
tegration of these soldiers back into their units. be scheduled on a routine basis by the division
psychiatrist. These consultation visits may
f. Division Support Area Combat last hours or even 1 to 2 days. The division
Stress Control Coordinator. The CSC coordinator psychiatrist, in coordination with the MSMC
in the DSA performs functions similar to those of commander, the DMOC, and the division surgeon,
the brigade CSC coordinators for units located in should consider enhancing support in the forward
the division rear but on a less independent scale. areas—

3-9
FM 8-51

(1) When increased numbers of options to reinforce the brigade CSC teams in the
cases are being evaluated and followed at an forward areas with division mental health section
FSMC such that the brigade CSC team cannot assets:
provide continuous coverage and still perform
their consultation mission. (1) Send one behavioral science
specialist to reinforce a brigade CSC team at the
(2) If a member of the brigade CSC FSMC holding facility.
team becomes a casualty.
(2) Place two brigade CSC teams
(3) When (in a static tactical situ- temporarily in support of a brigade that has large
ation) there are more cases who can be held for numbers of BF casualties.
treatment at a particular BSA clearing station
than its holding squad staff can manage. (3) Deploy himself forward to
supervise and assist the brigade CSC team until
the situation or crisis has been resolved.
(4) When conditions do not permit
REFER cases to be evacuated to the DSA for
evaluation. 3-5. Corps-Level Mental Healtl/Combat
Stress Control Support Reinforce-
(5) When there is a mass casualty ment
situation and additional BF and NP diagnostic
expertise is needed to triage those patients who The division psychiatrist should consider re-
require immediate evacuation and those who can questing additional corps-level mental health/
be treated locally for quick RTD. CSC augmentation when—
(6) When a battalion- or company- Caseload and/or geographical dis-
sized unit stands down (pulled back) for rest and persion prevents the division mental health
recuperation or for regeneration. When the section from providing divisionwide consultation
reconstitution process requires regeneration of services.
heavily attrited units, mental health/CSC
personnel should deploy along with other CSS Combat stress-related casualties are
contact teams to assist surviving members, beyond the treatment capabilities of division
assuring that all members get good quality rest mental health section and whatever corps CSC
and physical recuperation. During the “after- assets that are attached.
action debriefing,” mental health/CSC personnel
assist surviving members to review their recent A battalion or brigade is withdrawn
combat experiences and restore a positive coping from a forward area back into the DSA for rest
perspective to the group. Mental health/CSC and reconstitution.
personnel also assist with integrating survivors
and replacements into cohesive teams (see Enemy forces have used NBC weap-
Chapter 5). ons.
b. Options for Reinforcing the Brigade Other high stress factors (such as
Mental Health/Combat Stress Control Support. heavy losses as a result of prolonged and intense
The division psychiatrist may use the following battles) are present.

3-10
FM 8-51

The division psychiatrist may request, through from the corps will be provided by the medi-
the MSMC commander, the MSB support cal detachment, CSC or by elements from the
operations section, and the DMOC, reinforc- medical company, CSC. Both the medical
ing CSC support from corps. The DMOC company, CSC and medical detachment, CSC
coordinates corps CSC support with the medical operations are discussed in Sections III and IV of
brigade or group. Mental health/CSC support this chapter.

Section II. AREA SUPPORT MEDICAL BATTALION MENTAL
HEALTH/COMBAT STRESS CONTROL SUPPORT OPERATIONS
3-6. Mental Health Section Employment Other high stress factors occur,
to include—
a. Area Support Medical Battalion
Mental Health Support. The ASMB mental Major accidents or disas-
health section deploys with the HSC of the ASMB. ters to a unit.
When the ASMB deploys tactically, the mental
health section collocates with the battalion Heavy losses as a result
headquarters but disperses its personnel and of rear battles.
resources to support the ASMB’s entire AO. The
ASMB commander prioritizes the area mental Friendly fire incidents.
health support mission based on input from the
ASMB psychiatrist and battalion medical Heavy casualties or suf-
operations center in accordance with medical fering among noncombatants.
brigade/group and ASMB CHS plans. Battalion
CP personnel coordinate with the ASMB
psychiatrist and the ASMCs for the deployment The ASMB psychiatrist may use four options to
of the mental health section’s assets to support reinforce mental health support within the
their AO. Each ASMC is normally allocated one supported AO:
NCO CSC coordinator. The battalion CP, in
consultation with the ASMB psychiatrist, should (1) Send one junior behavioral
consider enhancing mental health/CSC resources science specialist to the patient-holding section
within an ASMC’s AO when— of the ASMC to reinforce the CSC coordinator
previously deployed from the mental health
Stress-related casualties are section.
beyond the treatment capabilities of an ASMC
and its CSC coordinator. (2) Send the social work officer or
the ASMB psychiatrist to the ASMC. This allows
A battalion- or company-sized the CSC coordinator to relocate to other areas, as
unit is withdrawn from a forward area back into necessary. This officer can go unaccompanied to
the ASMC AO for rest and regeneration. other locations within the supported AO. The
CSC coordinator coordinates the requirements
Enemy forces have used NBC for such actions with the ASMC headquarters
weapons. element.

3-11
FM 8-51

(3) Use one mental health officer CSC coordinators’ counseling and command
and one behavioral science specialist for a mobile consultation activities.
team. They are provided a vehicle for movement
to each location. The mobile team has the (2) One behavioral science NCO
flexibility to move and provide CSC support at from the mental health section is allocated to each
successive locations. ASMC where he routinely serves as the mental
health section’s CSC coordinator for the supported
(4) Augment the mental health AO. The CSC coordinator provides behavioral
section with a CSC team from the supporting CSC science advice to the ASMC commanders and
company or detachment. Augmentation of men- treatment teams in assessment and triage. He
tal health personnel should be considered (or trains the patient-holding squad personnel in
planned) for all scenarios in which increases management of stress casualties who must be
in BF and NP casualties are anticipated. The held for restoration and treatment. The CSC
mental health section coordinates through the coordinator also trains patient-holding squad
ASMB commander and battalion CP when re- personnel in stress intervention techniques for
questing additional mental health/CSC support. other DNBI patients. He visits units throughout
The ASMB CP (medical operations center) the AO to routinely support recovery of DUTY
forwards requests for mental health/CSC aug- and REST category BF soldiers. In addition to
mentation through the medical brigade/group to the above, the CSC coordinator will—
the CSC company. In the COMMZ, the request
is sent to the medical brigade. Assist with the reinte-
gration of recovered BF casualties into their
original or new units.
b. Area Mental Health/Combat Stress
Control Support Operations. Upon deployment Provide command consul-
of the ASMB to its AO, area mental health sup- tation.
port operations begin. The psychiatrist and one
or two junior behavioral science specialists Conduct training for
routinely locate at and work with the HSC leaders in stress control principles and tech-
clearing station. The social work officer and niques.
NCOIC (senior behavioral science specialist) may
also locate with the HSC clearing station or with Facilitate after-action de-
the battalion headquarters. briefings.
(1) The social work officer and Conduct critical incident
NCOIC as directed by the battalion psychiatrist stress debriefings, as necessary.
coordinate mental health section activities with
the battalion CP. Coordination includes activities (3) To foster a good working re-
such as traveling to ASMCs and supported units lationship with supported units, the CSC
and obtaining status updates of ASMCs and coordinator (and all mental health personnel )
supported units. The social work officer and should deploy to observe the unit at work or in
NCOIC actively support the CSC coordinators in tactical training exercises. The mental health/
their unit-based preventive mental health and CSC mission objective is to become familiar with
training programs. They provide technical each of the different types of units and includes
supervision and quality assurance over all the the—

3-12
FM 8-51

Unit’s mission. medication or restraints is by a nonambulance
ground vehicle. If physical restraints and/or
Equipment. medications are required during evacuation, the
preferred method of transport is by ground
Vocabulary (words and ambulance. An air ambulance should be used
operational or technical terms which are com- only if no other means of transportation is
monly used in the unit). available. Physical restraints are used only
during transport and medications are given only
Working conditions. if needed for reasons of safety.

Typical stressors. b. Time and Distances Factors. When
time and distance factors preclude the evacuation
of BF and NP cases to the HSC, these cases may
This knowledge is essential to gain the trust and be evacuated to the nearest CSH, field hospital
confidence of the unit’s leaders and troops. It is (FH), or general hospital (GH) for evaluation and
necessary information for evaluating soldiers and treatment by that hospital’s NP service. (These
their mental fitness to perform duties. cases are not evacuated to a mobile army surgical
hospital [MASH].) Consultation with the ASMB
psychiatrist via telephone or radio is appropriate
3-7. Disposition of Battle Fatigue and prior to evacuation. Direct evacuation from the
Neuropsychiatric Cases from the ASMC clearing stations is accomplished without
Area Support Medical Battalion consultation when the BF or NP patient also has
a life- or limb-threatening medical or surgical
The ASMCs refer BF and NP cases who cannot condition, or a life-threatening NP condition (for
be managed at the ASMC clearing stations to the example, a suicide attempt) which cannot be
psychiatrist at the HSC clearing station as soon stabilized at the ASMC clearing station. This
as tactical conditions permit. decision is made by the attending physician, but
ideally, the CSC coordinator should be advised.
a. Preferred Method of Transport for Cases with true NP disorders, or who do not
Battle Fatigue and Neuropsychiatric Cases. The respond to brief restoration treatment, are evacu-
preferred method of transport for those BF and ated to supporting corps hospital or to the medical
NP cases that are manageable without the use of company, CSC.

Section III. SUPPORT OPERATIONS CONDUCTED BY THE MEDICAL
DETACHMENT, COMBAT STRESS CONTROL

3-8. Medical Detachment, Combat Stress other medical C2 headquarters and may be
Control Employment further attached to supported medical companies
or medical company, CSC. Its employment in
a. Medical Detachment, Combat Stress the theater depends on the intensity of the
Control Support Operations. The CSC medical conflict. The medical detachment, CSC is
detachment is assigned to a medical group or employed in all intensities of conflicts whenever

3-13
FM 8-51

a division or two separate brigades/regiments are Deploys to provide recon-
deployed. stitution support to units undergoing hasty or
deliberate reorganization.
b. Support for Division Combat Opera-
tions During War. The medical detachment, CSC In some operations, however, some or all of the
may be attached to the CSC medical company for CSC preventive team personnel may remain back
C2. The detachment receives administrative and at the supporting corps-level medical company or
maintenance support from the CSC company be concentrated at another brigade or recon-
headquarters. The detachment’s teams are rein- stitution site with a heavier work load.
forced or provided personnel replacements by
CSC teams or task-organized CSC elements from (a) While the brigade is on
the company when necessary. A CSC detachment. the move, BF soldiers who cannot return imme-
which supports a division is usually attached to diately to their forward units may be rested and
the supported division’s MSMC of the MSB. It is transported by their own unit’s field trains. They
under the operational control of the MSB and eat, drink, restore hygiene, catch up on sleep,
MSMC but works under the technical supervision talk, and perform useful duties while regaining
of the division psychiatrist and division surgeon. full effectiveness on the move. The readiness of
Long-term relationships of CSC detachments with units to keep such cases will depend on their
specific divisions are standard. However, as a knowing that trusted CSC personnel are present
corps asset, the detachment (or its modular as backup. The BF cases who require medical
teams) may be cross-attached to support other observation for only a few hours are transported
units or missions as work load requires. It with the CSC preventive teams and the FSMC.
depends on the unit(s) to which it is attached for
administrative and logistics support. (b) Any stress casualties who
require more extensive restoration must be
(1) Upon the initial attachment of transported to the rear echelon of the medical
the detachment, its three 4-person CSC pre- detachment, CSC at the MSMC. Transportation
ventive teams are usually further attached. One in backhaul supply trucks is preferred to ground
CSC preventive team is attached to each FSMC or air ambulances for most BF casualties. If the
well before combat is imminent. This permits distances involved require the use of supply
them to link up with and augment the brigade’s helicopters or air ambulances, the CSC personnel
CSC team and the FSMC. Each CSC preventive must assure that the BF casualties do not overfly
team provides another mental health officer and the next echelon and are not evacuated further
a psychiatrist (with a behavioral science specialist to the rear than necessary.
and vehicle) to increase triage, stabilization, and
restoration capability at the FSMC. The CSC (2) The medical detachment, CSC’s
preventive team performs the following: 11-person CSC restoration team (including the
NCOIC of the headquarters section) remains
Conducts regular visits to with the division mental health section at the
the BSA to provide consultation throughout the MSMC in the DSA. The detachment has tents
FSB while the CSC restoration team is further and equipment to operate a restoration center
forward. and provides expertise in clinical psychology,
psychiatric nursing, and OT. The center provides
Operates further forward intensive restoration treatment for RTD within 3
during ongoing combat by cross-exchanging days. The CSC restoration team provides triage
personnel with the brigade CSC team. and stabilization at the MSMC and consultation

3-14
FM 8-51

to nearby division units. The CSC restoration only two maneuver brigades, the CSC preventive
team staff may go forward by truck or air team which includes the detachment commander
ambulance to temporarily reinforce or recon- normally remains with the division mental health
stitute a CSC preventive team at the brigade, or section and CSC restoration team in the DSA.
to escort BF casualties in truck backhaul to the
restoration center. The CSC restoration team c. Support to Separate Brigades or
personnel give reconstitution support to attrited Armored Cavalry Regiments During War. A sepa-
units, especially when the units return to the rate brigade or ACR in a mid- to high-intensity
DSA. The C3C restoration team supplements the conflict is dependent on division or corps CSC
division psychiatrist, brigade CSC teams, CSC assets for support.
preventive teams, and chaplains and leaders in
after-action debriefings. They help integrate the (1) A medical detachment, CSC
recovered soldiers and new replacements into the which supports two or three separate brigades or
units during reorganization activities. regiments is normally attached to the medical
group or the medical company, CSC which sup-
(3) The medical detachment, CSC ports the AO.
and its elements are dependent on the units to
which they are attached for food, water, fuel, (2) If two brigades or ACRs are
maintenance, and administrative support. supported, two of the detachment CSC preventive
teams are deployed forward and attached to the
(4) When the DSA is tactically too FSMCs of the two supported brigades or ACRs.
unstable to allow restoration, the CSC restoration The detachment commander’s team locates where
team and perhaps the CSC preventive section it can best provide backup support to the forward
may locate further to the rear. They may locate elements and coordinates administrative and
with an ASMB or a corps hospital which is close logistical support. The CSC preventive teams
enough for them to continue their support to the with each separate brigade operate as described
division. above for divisional brigades, except they are
(5) When all three CSC preventive reinforcing a brigade CSC team which has only a
teams are forward at the brigades, the detach- behavioral science NCO in charge. The ACRs
ment commander/psychiatrist is forward with one have no CSC team to reinforce. The CSC pre-
of the CSC preventive teams. This is usually ventive team, therefore, needs to be much more
acceptable, as the detachment is attached active in making contact and establishing trust
(operational control [OPCON]) to the MSMC and cohesion with the following elements and
under the supervision of the division psy- personnel:
chiatrist. Under some situations, the detachment Medical company person-
commander may elect to remain with the CSC nel.
preventive team. He may leave his CSC pre-
ventive team with only one social work officer Battalion or squadron
and two behavioral science specialists if work load medical platoons.
at the BSA is light. In other situations, he may
elect to send the clinical psychologist from the Brigade or regiment chap-
CSC restoration team to take his place. The lain and unit ministry teams.
detachment NCOIC and the officers of the CSC
restoration team keep the commander informed Unit commander and
and represent him as needed. If the division has leaders at all levels.

3-15
FM 8-51

It is especially important that this process begins (2) Several CSC restoration and
as far in advance of the onset of combat operations CSC preventive teams from two or more CSC
as possible, preferably before deployment. medical detachments may be consolidated under
the command of the senior medical detachment,
(3) If a third separate brigade is CSC commander to staff a central reconditioning
supported, the detachment commander’s CSC program for the corps. This may also function
preventive team deploys to it. as an alcohol/drug detoxification rehabilitation
program. The CSC center will also provide
(4) The CSC restoration team consultation and treatment support to military
either locates with the detachment commander police (MP) confinement facilities where mis-
and provides restoration treatment at that conduct stress behaviors may have led to
location or augments a corps-level MTF where incarceration (see Appendix C).
cases from the supported brigades can best be
treated. It integrates its restoration and recon- (3) In OOTW, if the force deployed
ditioning programs with those of the other is smaller than a division, a medical detachment,
supporting CSC units. CSC would not be required to provide CSC
support. In such cases, either the medical com-
d. Combat Stress Control Detachment pany, CSC or the medical detachment, CSC may
in Operations Other Than War. In a prolonged be tasked with providing either a CSC team or
conflict involving a contingency corps with one or a task-organized CSC element. The CSC team
more divisions and/or several separate brigades or the task-organized CSC element is attached to
and regiments, only CSC medical detachments the supporting medical headquarters or to an
(no CSC medical company) maybe mobilized. For MTF and conducts its mobile consultation
contingency operations of short duration, task- mission.
organized CSC elements from the CSC medical
detachments could be deployed.
3-9. Medical Detachment, Combat Stress
(1) The CSC preventive teams Control Interface and Coordination
supporting the brigades may operate out of a Requirements
central base of operations. The teams go forward
to the BSAS (base camps or fire bases) when The medical detachment, CSC must interface
coordinated by the division mental health section. with its higher medical headquarters element and
Such visits would be in response to— with the unit to which they will be attached. The
higher headquarters may be the medical brigade,
Anticipated battle. medical group, medical company, CSC or an
ASMB. The medical brigade or medical group
Post-action debriefing re- which controls a CSC company will normally
quirements. utilize that CSC company to monitor the CSC
Alcohol/drug problems in detachment. The CSC company makes recom-
a unit. mendations regarding the employment and
support of any medical detachment, CSC as-
Incidents of misconduct signed to their AO. This includes CSC medical
stress behaviors. detachments that have been attached to the
supported divisions. The medical company, CSC,
Unit rotation in or out of in turn, will task its task-organized sections to
theater. support specific CSC medical detachments. When

3-16
FM 8-51

required, the task-organized CSC elements may Class VIII (medical supply)
reinforce or provide replacement personnel for status and supply requirements.
those CSC medical detachments. Maximal com-
munications are encouraged between the CSC Casualty Feeder Reports.
medical detachments and the task-organized CSC
elements directly through technical channels. Statistical summaries per-
The mental health staff sections of the medical taining to work load, including consultation and
brigade and medical group ensure that CSC triage activities, restoration or reconditioning
medical companies are updated. They provide center censuses, and special reconstitution sup-
the medical company, CSC headquarters and the port activities.
relevant task-organized CSC elements with
information copies of all status reports received Operation plans.
from the CSC medical detachments in their AO.
For detailed information pertaining to medical Operation orders.
company, CSC headquarters and task-organized
CSC elements, see Section IV. Normally, the Personnel replacement for the
detachment is attached for OPCON to an MSMC detachment.
of the MSB in the divisions. If it is supporting in Medical intelligence informa-
the corps area, then it could be attached to a
medical company, CSC, an ASMB, or directly to tion.
the medical group. Interface and coordination Mental health/CSC consulta-
are essential if CSC support requirements are to tion taskings and results.
be accomplished.
a. Interface Between the Detachment Maintenance requirements and
and Its Higher Headquarters. The medical request.
detachment, CSC interfaces with its higher
headquarters pertaining to its assigned mission. Replacement and reconstitu-
It provides estimates and has input to the tion operations.
OPLANs. The detachment receives its OPORDs Civil-military operations.
from the higher headquarters. Interface between
the detachment and the staff of its higher Host-nation support.
headquarters will focus on providing CSC which
includes preventive activities and consultation Communications (signal opera-
support. Interface between the detachment and tion instructions [S0I], access to message centers
higher headquarters staff elements will include and nets, and transmission of CSC messages
the following subject areas: through medical and other channels).
Combat stress control opera-
tions. Mass casualty plan.
Assignment or attachment of Road movement clearances.
the medical detachment, CSC elements.
Tactical updates.
Daily personnel and equipment
status reports. Contingency operations.

3-17
FM 8-51

Return-to-duty and nonreturn- Status of FSMCs and CSC pre-
to-duty procedures. ventive teams.
Medical evacuation procedures Communications (SOI).
(air and ground ambulances).
Changes in locations of sup- Operational support require-
ported unit. ments.
b. Interface and Coordination with the Civil-military operations.
Unit That Has Operational Control of the Medical
Detachment. Combat Stress Control. The head- Restoration operations.
quarters of the unit with OPCON is responsible
for providing the administrative and logistical
support requirements of the detachment. These Reinforcement and personnel
requirements are normally identified in the replacement.
attachment order. If not identified in the
attachment order, they must be coordinated Maintenance.
by the detachment’s higher headquarters prior
to deployment. The CSC detachment must Personnel replacement.
coordinate daily with the headquarters staff and
section leaders (if required) of the unit to which Road movement and clear-
they are attached. The staff shares information antes.
with the detachment commander or his repre-
sentative. Daily updates pertaining to the threat, Casualty reporting and ac-
tactical situation, patient/BF casualty status, and countability.
changes in CHS requirements are provided to the
detachment. Coordination activities and subject Patient-holding procedures.
area information exchange should include—
Command and control proce- Nuclear, biological, and chemi-
dures. cal defensive operations.

Section IV. SUPPORT OPERATIONS CONDUCTED BY THE MEDICAL
COMPANY, COMBAT STRESS CONTROL
3-10. Medical Company, Combat Stress war, one medical company, CSC may support
Control Employment from two to five divisions depending on the level
of operations. The company is reinforced by
a. Medical Company, Combat Stress attachment of a variable number of CSC medical
Control Support Operations. The medical com- detachments. Normally, one CSC detachment is
pany, CSC is assigned to a MEDCOM, medical allocated per division and one per two or three
brigade, or medical group. The medical company, separate brigades or regiments in the corps. The
CSC is employed for a war when estimates medical detachment, CSC is discussed earlier in
indicate large numbers of BF casualties. During Section III.

3-18
FM 8-51

b. Methods of Operations for the Medi- Stabilization under emer-
cal Company, Combat Stress Control. Methods gency situations; normally, this is the mission of
of operations for the medical company, CSC are the hospital NP ward/service (see Chapter 7).
dependent on the CSC support requirements and
the tactical situation. The CSC medical company Restoration (in areas
commander can deploy modular CSC preventive where the task-organized CSC element is closer
and CSC restoration teams from the company’s to the soldier’s units than an ASMC, or by sending
preventive and restoration sections. He also has a team to reinforce an ASMC) (see Chapter 8).
the option to combine elements from both sections
to form task-organized CSC elements, depending Reconditioning (the
on CSC requirements. The personnel in the pre- unique mission of the CSC company’s task-
ventive and restoration sections do not have to be organized CSC elements in corps and in most
task-organized in rigid compliance with the mod- scenarios, but of lower priority than the missions
ular CSC preventive and CSC restoration team listed above) (see Chapter 9).
building blocks. For example, one task-organized
CSC element may be given most of the psychiatric Temporary support (send-
nursing assets, while another may receive more ing CSC teams to reinforce the medical detach-
of the OT resources. This decision would be based ment, CSC which are operating forward in the
on the shifting requirements set by the recon- division and brigade areas, or when reconstitution
ditioning or restoration caseloads at different support and restoration work loads require).
places and other priority missions. The intent is
to give the commander flexibility to accomplish Reinforcement of the
his changing mission requirements for CSC. medical detachment, CSC, division mental health
section, or ASMB mental health section, if
(1) Task-organized CSC element necessary or providing replacement personnel.
employment. The task-organized CSC elements
are employed to provide CSC support in their (2) Restoration and especially re-
area of responsibility. They must coordinate conditioning are provided for BF soldiers and
with the supporting ASMB and hospital NP selected NP and alcohol/drug misuse cases from
resources within their AO. The task-organized the supported division and corps units. The task-
CSC element leader is responsible for allocating organized CSC elements attach to or collocate
the CSC resources which the medical company, with medical units as near to the supported units
CSC commander has given his element. He must as is tactically feasible. In the initial intensive
meet the changing requirements for— phase of conflict, CSC teams may be dispersed
to reinforce the CSC medical detachments in
Preventive consultation the divisions. They may be attached to an ASMC
and CSC education in the corps (supporting the or a CSH where they can readily support the
ASMB) (see Chapter 4). divisions and heavily committed corps units. In
Reconstitution support (a this phase, reconditioning treatment in the corps
major, but intermittent priority mission tasked area will rarely continue beyond 3 days, in
by the higher headquarters) (see Chapter 5). addition to the initial 3 days of restoration. As
the conflict stabilizes and the requirement for
Neuropsychiatric triage restoration decreases, reconditioning extends to
(shared with the ASMB and hospital NP seven days. If feasible, and with approval of the
consultation services) (see Chapter 6). corps commander, it is extended to 14 days. The

3-19
FM 8-51

task-organized CSC element’s combat fitness and quarters. Each task-organized CSC element
reconditioning center is usually attached (not sends modular teams forward to reinforce the
OPCON) to a CSH. medical detachment, CSC in the supported divi-
sion, as needed. Table 3-1 shows the ways that
(3) A task-organized CSC element teams could be distributed as task-organized CSC
from the medical company, CSC usually deploys elements to support two to five divisions.
in the corps area behind each supported divi-
sion. The task-organized CSC element behind (4) When not task-organized with
each division has two or three CSC preventive a CSC preventive team, the CSC restoration
teams and one to three CSC restoration teams, teams normally collocate with a CSH or with the
depending on support requirements. Each task- HSC of an ASMB. Both the CSH and head-
organized CSC element may be reinforced by quarters and support company of the ASMB
one or two support personnel (cook, mechanic) provide a psychiatrist. This is of lesser impor-
detailed from the medical company, CSC head- tance if the psychiatric nurse of the CSC

3-20
FM 8-51

restoration team is a clinical nurse specialist or if centers behind each division. However, under
the psychologist is especially trained to prescribe some circumstances, the medical company, CSC
medications. A CSC restoration team may be may consolidate teams to establish a large recon-
deployed forward without a CSC preventive team ditioning center which supports two or three
to support a heavily committed division or an divisions. Reconditioning facilities normally lo-
ASMC in the corps. cate near a CSH. Figure 3-1 illustrates the task-
organized CSC elements of the CSC medical
c. Reconditioning Centers. The medi- company operating a reconditioning center near
cal company, CSC will use task-organized CSC a CSH. For definitive information on recondi-
elements to staff separate, small reconditioning tioning center operations, see Chapter 9.

3-21
FM 8-51

3-11. Medical Company, Combat Stress Casualty feeder reports.
Control Coordination and Interface
Requirements Work load summaries includ-
ing consultation and triage activities, restoration
The medical company, CSC coordinates with its or reconditioning center censuses, and special
higher medical headquarters element and with reconstitution support activities.
the units to which the company’s CSC elements
will be attached. The higher headquarters may Operation plans and orders
be the medical brigade or medical group.
Interface and coordination are essential for Personnel replacement for the
providing and ensuring CSC support require- detachment.
ments to prevent or limit the effects of combat
stress and the number of BF casualties are Medical intelligence informa-
accomplished. tion.
a. Coordination and Interface between Status of restoration center(s).
the Medical Company and Its Higher Head-
quarters. The medical company, CSC coordinates Status of reconditioning cen-
with its higher headquarters pertaining to its ter(s).
assigned mission. The mental health staff section
of the medical brigade and medical group are Mental health/CSC consulta-
points of contact for this coordination. It provides tion.
estimates and has input to the OPLANs. The
company receives its OPORDs from the higher Maintenance requirements and
headquarters. Interface between the company requests.
and the staff of its higher headquarters will focus
on providing CSC, which includes preventive Replacement and reconstitu-
activities and operating restoration and recon- tion operations.
ditioning centers for the support divisions. This
interface between the company and higher Civil-military operations.
headquarters staff elements will include the
following subject areas: Host-nation support.
Combat stress control opera- Communications (S01, access
tions. to message center and nets, and transmission of
Assignment or attachment of CSC messages through medical and other chan-
the CSC preventive teams, CSC restoration nels).
teams, or task-organized CSC elements from the
company. Mass casualty plan.

Daily personnel and equipment Road movement clearances.
status reports.
Tactical updates.
Class VIII status and resupply
requirements. Contingency operations.

3-22
FM 8-51

Return-to-duty and nonreturn- Changes in CHS requirements.
to-duty procedures.
Coordination activities and exchange of subject
Medical evacuation procedures area information should include—
(air and ground ambulances).
Command and control proce-
Locations of supported units or dures.
changes in their location.
Status of F’SMCs and CSC pre-
ventive teams.
b. Interface and Coordination with the
Unit that has Operational Control of the Medical Communications.
Company, Combat Stress Control Teams or Task-
Organized Combat Stress Control Elements. The Operational support require-
headquarters of the unit with OPCON is re- ments.
sponsible for providing the administrative and
logistical support requirements of the company’s Civil-military operations.
teams or task-organized CSC elements. These
requirements are normally identified in the Restoration operations.
attachment order. If not identified in the at-
tachment order, they must be coordinated by the Reinforcement and reconstitu-
medical company, CSC headquarters prior to the tion.
deployment of its elements. Deployed teams or
task-organized CSC elements from the medical Reconditioning center opera-
company, CSC coordinate daily with the head- tions.
quarters staff and section leaders (if required)
of the unit to which they are attached. That Maintenance.
headquarters transmits the CSC element’s
messages and reports to the receiving medical Personnel replacement.
headquarters via medical C2 channels. The team/
task-organized CSC elements’ leader shares Road movement and clear-
information with team members and updates the antes.
medical company, CSC commander as required.
The medical company, CSC elements are provided Casualty reporting and ac-
daily updates from the headquarters element of countability.
the unit to whom attached. These daily updates
may include information pertaining to: Patient-holding procedures.
Threat situation. Nuclear, biological, and chemi-
cal defensive operations.
Tactical situation.
Hospital admission and dispo-
Patient/BF casualty status. sition procedures.

3-23
FM 8-51

CHAPTER 4
COMBAT STRESS CONTROL CONSULTATION

4-1. Priorities and General Principles reinstated at the earliest possible time. If not
quickly reinstated, other functions could soon be
a. Primary Emphasis of Combat Stress overwhelmed by the casualty caseload.
Control. The primary emphasis of CSC is on the
enhancement of positive, mission-oriented motiv- (1) Army operations during war.
ation and the prevention of stress-related During war, the primary efforts are toward the
casualties. Combat stress control personnel pro- prevention of and successful RTD of BF casual-
vide consultation and training (either formal or ties. Historically, BF casualties have represented
informal) on many topics including— from one-sixth to one-third of all battle casualties
in high-intensity wars. Failure to reduce/prevent
Enhancement of unit cohesion, BF casualties or RTD a large numbers of these
leadership, and readiness. cases could affect the outcome of key battles. The
fast pace of the high-technology battle requires
Risk factors (stressors). that CSC preventive consultation be ongoing
before the fighting starts.
Recognition signs of stress
symptoms and behaviors. (2) Operations other than war. In
Leaders’ actions to control conflict and peacetime contingency operations,
stressors and stress. CSC consultation activities are more focused
toward prevention of misconduct stress behaviors
Individual stress management and on maintaining unit cohesion, morale, and
techniques and skills. esprit de corps than on preventing BF casualties.
This is done because BF casualties are rarely seen
b. Combat Stress Prevention. Combat in OOTW, but the reported incidence of mis-
stress prevention programs reduce the incidence conduct stress behaviors are relatively frequent.
of new combat stress-related casualties. These The enemy in 00TW may deliberately use stress
programs promote the early recovery and RTD of to try to provoke our soldiers to commit misc-
stress casualties. They reduce the cases which onduct. Misconduct, especially commission of
could otherwise overload the CHS system. Over- atrocities, not only endangers mission accom-
all, combat stress prevention programs are signi- plishment but can severely damage US or allied
ficant combat multipliers which enhance the national interests.
Army’s fighting strength and its ability to perform
its mission while significantly reducing the (3) All intensities of conflict. Psy-
number of casualties. chologically, traumatic and catastrophic events
occur in war and OOTW. Combat stress control
personnel must be prepared to provide CSC inter-
NOTE vention. Combat stress control preventive pro-
grams and CSC intervention for catastrophic
Overall, consultation has the highest events will assist in protecting soldiers from
priority among the CSC functions. PTSDs.
c. Modes of Combat Stress Control
If consultation is deferred due to tactical or other Consultation. Combat stress control consultation
critical situations, consultation services should be is defined as providing expert advice, education,

4-1
FM 8-51

training, and planning assistance. The objectives Misconduct.
of consultation are the improvement of psycho-
logical readiness and the prevention and treat- Other stress disorders.
ment of BF, misconduct stress behaviors, PTSDS,
and all stress-related problems. This consultation (2) Consultation may be provided
support is provided to commanders, leaders, and in response to a specific request or be initiated by
the staff and medical personnel of supported mental health personnel. Methods for providing
units. Consultation on all topics related to the consultation and training include—
prevention, treatment, and RTD (or other
disposition) of BF casualties, misconduct stress One-on-one.
behaviors, PTSDS, and NP disorders is provided. Small discussion group.
(1) Combat stress control person- Large groups.
nel are the primary resource for advice and train-
ing on ways to control stressors and stress. Sup- Consultation is an ongoing process which is per-
porting CSC personnel interface with— formed in both peacetime and wartime. It is
conducted before, during, and after combat.
Unit commanders.
(3) Consultation is best initiated
Staff elements. through face-to-face contact, preferably at the
supported unit’s location. Telephone and radio
Leaders. may be used to set up further sessions or to
provide follow-up consultation. Audio tapes and/
Chaplains (very impor- videotapes may also be used if the unit or meeting
tant contact). site has the equipment to play them, Follow-up
consultations also works best when the face-to-
Medical personnel (other face contact method is used.
than mental health/CSC personnel).
(4) Successful consultation is de-
Other personnel. pendent on trust and the familiarity established
between the consultant and the soldier(s) with
Leaders at all levels must be made aware that whom he is working. Especially in a hierarchical,
CSC measures can reduce BF casualties to fewer high-stress, time-pressured setting like the Army,
than one per ten WIA and can expedite the early the consultant must possess a credible military
return of BF casualties to full duty (see FM 22- bearing. He should have a thorough knowledge
51). These measures also help in reducing pro- of the military (the units, missions, vocabulary,
blem behaviors and incidents which detract from acronyms, and skills involved). He must be realis-
the overall readiness of a unit. Some of these tic and self-confident about the accomplishment
detractors include— of his work. In some instances, sufficient rank
may also be necessary. These visible military
Substance abuse. features are often more important in establishing
credibility than are academic or clinical creden-
Suicides. tials. In a peacetime environment, academic and
clinical credentials are important for long-term
Home front problems. credibility.

4-2
FM 8-51

(5) Therefore, when possible, the and especially the NCOs must have sufficient
consultant should establish contact and rapport rank and experience to establish face-to-face
with the personnel of supported units long before validity as advisors and counselors to line officers
action becomes imminent. In general, the longer and senior NCOs. Similarly, each mental health
the relationship is established prior to the onset discipline (psychiatry, clinical psychology, social
of tactical operations, the greater the effectiveness work, psychiatric nursing, and OT) has areas of
of the consultation. unique professional expertise. A multidisci-
plinary approach is required which provides
d. Consultants. All mental health/CSC mutual access to each discipline at key levels in
professional disciplines and enlisted MOSS may the CSC unit organization. There must also be
serve as consultants in mental health/CSC areas. sharing of information within the CSC units to
increase the areas of shared expertise.
(1) There are five disciplines in the
mental health/CSC area and each one has specific (3) Other personnel will be in-
subject areas. These disciplines include— volved in recognition and control of stress as a
result of their position or duty assignments.
Psychiatry. Consultation and training to develop them into
effective CSC consultants is a high priority for
Psychiatric nursing. mental health/CSC personnel. These personnel
will include—
Clinical psychology.
Unit leaders.
Social work.
Chaplains and chaplains’
Occupational therapy. assistants.
Consultants will naturally rely and focus on their Other physicians and
specific specialty. Each of the disciplines should physician assistants.
also be able to provide routine consultation for all
basic topics. Therefore, it is essential that in- Combat medics.
formation be shared ongoing among the five
mental health disciplines and between officers Other supporting medical
and their enlisted assistants. This mutual under- personnel.
standing also expedites the appropriate referral
to the relevant specialist, as required.
NOTE
(2) Experience shows that the CSC
consultation mission (and to a lesser extent, the The role of a good consultant is to train
treatment mission) is functionally divided into others to use his knowledge rather than
professional mental health-credentialed officer to guard his information as a trade
responsibilities and experienced mental health secret.
NCO responsibilities. Since each has a unique
role, neither officer nor NCO can do the other’s
business with full effectiveness. The solution is e. Audience for Consultation. The
to form cohesive officer/NCO teams. The officer target audiences for consultation vary, depending

4-3
FM 8-51

on location and mission. Consultation and train- NOTE
ing activities should be identified, prioritized, and
scheduled to achieve maximum participation from A critical issue is to ensure that medical
all supported units. Depending on the units in personnel do not overdiagnose stress
the area of support, broad types or categories of casualties.
personnel are considered for consultation activi-
ties. These personnel may include—
Stress cases should not be diagnosed as NP or
The command or unit surgeon physical disability cases. Stress cases should not
and his staff. be prematurely evacuated out of the theater with-
out adequate trial of the CSC restoration and
Staff chaplain and unit minis- reconditioning program.
try team.
4-2. Consultant Activities During Pre-
The senior commander and the deployment and During Buildup and
senior NCO (of the unit or the command ser- Waiting Phases in the Theater of
geants major of the corps, division, brigade, and/ Operations
or battalion).
a. Knowledge of the Supported Units.
Staff officers and NCOs, includ- The mental health/CSC personnel should train
ing adjutant and personnel (S1/G1), intelligence in the field with the units they will support during
( S2/G2 ), operations (S3/G3), logistics (S4/G4), civil combat. They must become knowledgeable of
affairs (G5), DMOCS, and the judge advocate these units and familiar with their personnel.
general (JAG). Through contact with supported units and in-
volvement in training activities, mental health/
Company-grade leaders, espe- CSC personnel gain the trust and confidence of
cially company commanders, executive officers, those personnel. The trust, confidence, and famil-
first sergeants, platoon leaders, and platoon ser- iarity of unit personnel will significantly enhance
geants. mental healthlCSC personnel’s ability to perform
their mission. All available time during pre-
Assembled troops of combat, deployment and build up in the TO should be
CS, and CSS units. utilized to gain familiarity with any new units.
Mental health/CSC personnel must also make an
Medical personnel including effort to maintain relationships already estab-
physicians, physician assistants, dentists, nurses, lished through training. Some of the information
practical nurses, medical specialists and NCOs, provided below pertains to establishing relation-
and the nursing services of CZ and COMMZ ships with the new unit and may apply to main-
hospitals. taining relationships.
Some of these medical personnel may be recent (1) Present a briefing on the men-
additions to their units who are likely to be from tal health/CSC mission and its relevance at com-
the Professional Filler System (PROFIS) or Indi- mander calls, officer/NCO professional develop-
vidual Ready Reserve. Such individuals may ment sessions, and as part of the combat
have special need for quick education in CSC orientation of new replacement units arriving in
principles. the TO.

4-4
FM 8-51

(2) Arrange to visit unit leaders Treating EPWs according
and work areas. Choose times when they can to the provisions of the Geneva Conventions.
explain and demonstrate their mission. Partici-
pate as an observer at the crew and team level in Orienting soldiers to the
maneuver or live fire training exercises. Empha- customs, traditions, religion, and other socio-
size that the purpose of the visit involves the economic values of the civilian population.
mental health/CSC mission to support them
during combat. Explain to them that the mental Recognizing the over-
health/CSC mission requires that mental health/ stressed soldier.
CSC personnel be knowledgeable of what they
do; that the mental health/CSC personnel need Recognizing signs of sub-
to be aware of stressful conditions associated with stance abuse and preventing, treating, and re-
their mission. habilitating abusers.
Improving leadership
(3) Attend ceremonies of supported skills for interviewing, counseling, and assisting
units and participate in their unit activities such problem soldiers.
as physical training.
Developing leadership
(4) Provide briefings, classes, in- skills to conduct after-action debriefings (rou-
formation papers, and more importantly practical tinely and for serious accidents, or combat situa-
exercises in topics which are relevant to the mis- tions).
sion scenario. Topics should include—
Conducting grief manage-
Combat stress/BF recog- ment (the chaplain should be included).
nition and management (appropriate for the
branch, rank, and duties of the audience). Improving time manage-
ment, organizational skills, and leisure time skills.
Techniques for building Controlling family issues,
unit cohesion. including how to access supporting agencies such
as—
Performing stress man-
agement and relaxation techniques. Red Cross.

Maintaining performance Army Community
in continuous and sustained operations. Service.
Army Emergency
Ensuring psychological Relief.
preparation for NBC defense.
Exceptional Family
Preventing BF and mis- Member Program.
conduct stress behaviors by defending against the
stresses of terrorism, guerrilla operations and Family Advocacy
restrictive rules of engagement. Program.

4-5
FM 8-51

Medical care and the (2) Results should be shared with
Civilian Health and Medical Programs of the the junior leaders first and should be worded in
Uniformed Services and Delta Dental Plan. positive terms: “Here is what looks good, here is
what needs more work, and here are some ideas
Preparing families for (not orders) for how to do it.”
deployment of the service member’s unit.
(3) The questionnaire should be
NOTE administered in a way that guarantees anonymity
to the responders: It is best to administer it all at
Time invested in consultation is never one time and to have it handed out and collected
wasted. New knowledge, insight, and by the mental health/CSC surveyors, not the unit
points of contact are always worth leaders.
gaining. Just ask questions and listen.
(4) Questionnaires need to be brief,
b. Conduct Unit Survey and Focus simple, unambiguous, and easily hand- or
Interviews. Interview 8 to 12 soldiers as a group machine-scored to provide quick feedback. Stand-
and ask a series of general or structured ques- ardized, well-documented survey instruments are
tions. Survey interviews use open-ended ques- best. Sharpened pencils and firm writing surfaces
tions and seek answers to a wide range of issues. must be supplied. Shelter from adverse weather
Focus interviews use more direct questions to (or water-resistant questionnaire sheets) may be
answer a specific issue; for example, the adequacy necessary when surveys are conducted in the
of the unit’s sleep plan. In both types of inter- field.
views, the responses are recorded and trends are
identified. These interviews can be done in the NOTE
field as battlefield interviews and can be used to
debrief and to gather data, Collected data is then Survey instruments which are cur-
used as a basis to train or provide consultation. rently being used include Department
of the Army Pamphlet (DA PAM) 600-
c. Administer Survey Instruments 69. Currently under development and
(Questionnaires). Survey questionnaires are nor- testing by Walter Reed Army Institute
mally used in conjunction with briefings, focused of Research is another survey titled
interviews, classes, or field exercises. They are “Psychological Readiness for Combat
used to assess unit cohesion, confidence, readi- Survey” (see Appendix B).
ness for combat, and familiarity with stress con-
trol, or to identify areas which need further train- d. Monitor Stress Risk Factors
ing or command attention. Surveys may also be (Stressors) and Indicators of Stress in Units.
conducted to answer specific command questions Information about stressors and stress in a unit
about unit morale and readiness. Survey results may be obtained by coordinating with various
and recommendations are provided to unit leaders. sources. These sources of information include—
(1) Such surveys work best when Sl/G1, S2/G2, S3/G3 staffs,
they are endorsed (and perhaps mandated) by commanders, command sergeants major and first
higher command, but are advertised and imple- sergeants,
mented as an aid to the junior leaders, not a pass-
fail test. Military police blotter reports.

4-6
FM 8-51

Unit surgeons. Commission of terrorism
or atrocities by the enemy.
Preventive medicine (PVNTMED)
reports and personnel. Likelihood of temptations
for substance abuse.
Chaplains.
Recent losses and/or new
Judge advocate general. replacements in the unit.
Change in leadership.
NOTE
(2) Monitor indices of excessive
Information obtained from the above stress in units. Mental health/CSC personnel
sources involves the statistical implica- monitor known warning signs of excessive stress
tions without violation of AR 340-21, to identify units which need special consultation.
The Army Privacy Act Program. Some of these warning signs are—
Many disciplinary actions
in a unit.
Stress on the home front may be monitored by
the unit’s rear detachment, keeping in touch with High absent without leave
the post’s Deputy for Personnel and Civilian (AWOL) rates.
Affairs (DPCA) and various medical department
activity (MEDDAC) mental health and patient Inspector general com-
care services. plaints.
(1) Monitor known stressors such Increased requests for
as— transfers.
Number of days/months Alcohol or drug intoxica-
tion and driving while intoxicated charges.
Substandard living condi- High sick call rates.
tions.
Preventable diseases
Social isolation from sur- (sexual misbehavior).
roundings due to distance, climate, foreign
culture, and hostile locals. Fights, minor injuries, and
self-inflicted wounds.
Inspector general (IG) or
very important person visitor. Suicide gestures/attempts/
completions.
Insufficient facilities or
funds for mission training or morale/welfare/ Homicide threats, at-
recreation support. tempts, and completions.

4-7
FM 8-51

(3) Monitor home front (rear de- recommend rehabilitation, medical treatment, or
tachment) indices of excessive stress, such as— administrative disposition.
Spouse and child abuse.
4-3. Combat Stress Control Consultant
Bad checks. Activities for Staff and Operational
Planning
High numbers of separa-
tions and divorces. a. Planning. It is important that CSC
personnel be involved in the overall planning
Significant numbers of process. Combat stress control personnel provide
couples in counseling. advice and assistance to commanders and staff
on CSC issues. These issues may include—
Family members caught
shoplifting or an involvement in other crimes or Providing measures for
misdemeanors. monitoring and controlling stressors.
Financial problems. Providing stress casualty
estimates.
e. Conduct Transition (Change of Com-
mand) Workshops. Mental health/CSC personnel Providing CSC input for
conduct transition (change of command) work- reconstitution support.
shops for supported units. These workshops are
normally requested by the incoming commander. Conducting CSC preven-
The primary purpose of these workshops is to— tive operations.
Facilitate staff discussion of Deploying CSC assets for-
what the staff sees as the unit’s (and staffs) ward to provide immediate restoration support.
strong points and the areas needing more work.
Establishing procedures
Provide the new commander for CSC reconditioning, including resource and
the opportunity to discuss his leadership style and coordination requirements.
his expectations and set priorities for the staff.
Establishing procedures
f. Conduct Personal Reliability Screen- with supporting battalion S1s for transporting BF
ing. Personal reliability screening is required by casualties who are able to RTD to their units.
AR 40-501, or it may be command directed.
Providing input on using
g. Supporting and Assisting Alcohol mental health/CSC asset for supporting host-
and Drug Prevention and Control Programs. In nation or humanitarian civil assistance operations.
the TO, there are no formal alcohol or drug sup-
port groups. Therefore, mental health/CSC per- (1) Combat stress control per-
sonnel promote the establishment of ad hoc sonnel provide the command surgeon input for
alcoholic support groups or other support groups. inclusion in the CHS estimate and plan. Combat
They evaluate cases of alcohol/drug abuse and stress control personnel are included early in the

4-8
FM 8-51

mission planning process to ensure adequate CSC Attaching corp-level CSC
resources are included in the CHS plan. teams base on casualty estimates to the
supporting medical company in the BSA, DSA, or
(2) To enhance the performance of corps area.
CSC personnel in the decision-making and plan-
ning process, they should be provided realistic Providing warning orders
training. This training can include participation to backup CSC teams in the division rear or corps
in activities such as field training and CP area.
exercises. Additionally, mental health/CSC per-
sonnel must be given the opportunity to learn, The warning orders alert CSC teams to prepare
practice, and perfect their skills for providing unit to deploy forward or to detach personnel to rein-
consultation and the other five functional mission force the teams already forward. This forewarn-
areas associated with CSC and mental health. ing is especially important if the backup teams
This is accomplished through their participation need to reduce their ongoing treatment caseload.
in various training exercises.
(2) Rapid reaction. For rapid reac-
b. Combat Stress Control S.taff Plan- tion, CSC personnel and teams require staff
ning in Combat. The CSC consultant must assure actions to identify where they need to move once
that staff planners keep in mind that CSC must the actions have started. The staff must also
be proactive and rapidly reactive. coordinate this move. Certain events should be
recognized and reacted to when they occur. These
(1) Proactive measures. Proactive events include—
measures include the pre-positioning of CSC per-
sonnel to the maximum extent possible to support Having high numbers of
those units that are most likely to experience WIAs and stress casualties at a location which
combat actions. This will change from day to was not anticipated or covered by CSC resources.
day. In order to anticipate and prioritize, the
planner should also evaluate the likelihood that Receiving reports that a
the combat action will involve the special risk unit has experienced an especially traumatic inci-
factors for BF casualties and misconduct stress dent (such as casualties from friendly fire).
behaviors (see Appendix B). Pre-positioning may
include— It would be helpful for CSC personnel to partici-
pate in the unit’s after-action debriefing (see sub-
Deploying organic CSC sequent paragraphs and after-action debriefing
personnel far forward to areas of need. in Chapter 5). Definitive information on CHS
planning is found in Appendix B and in FMs 8-
Sending CSC personnel to 10, 8-10-5, 8-42, and 8-55.
an AXP behind the battalion entering combat.
Sending CSC personnel to 4-4. Consultation During Mobilization
a BAS in the combat trains, and Deployment
Sending additional organic a. Planning and Consultation Activi-
CSC personnel to the BSA with the supporting ties. During mobilization, contingency plans are
FSMC. reviewed and updated, as required, Combat stress

4-9
FM 8-51

control elements provide any revised information 4-5. Consultation Support During Combat
to the command surgeon for inclusion in CHS
estimates and plan. In addition to mobilizing a. Establishment. The CSC consultant
their own assets, CSC elements will initiate con- (or team or unit) needs a secure base camp from
sultant functions immediately. All command and which to operate. Small consultation teams may
staff briefings should have a CSC representative be able to integrate themselves into the quarters
present to ensure CSC personnel are aware of of the supporting unit. Large CSC teams will
developing situations. Supported units are in- provide their own shelter. Combat stress control
formed as necessary on changes/updates to the teams are usually either assigned or attached to
CSC operating procedures. medical units for support.
b. Coordination with Supported Units. (1) Depending on the echelon, the
All supported units are contacted by CSC person- supporting medical unit may be an FSMC (in the
nel to confirm preestablished points of contact BSA), an MSMC (in the DSA), or an ASMC
(POCs) or to identify new POCs. Coordination (operating within a base cluster in the corps and
visits to newly supported units must be brief to COMMZ). Combat stress control teams or units
ensure they do not hamper the unit’s mobilization may also collocate with a CSH, FH, GH, or a
process. Only essential information pertaining medical headquarters unit (ASMB, medical
to CSC consultation and support should be dis- group, medical brigade, MEDCOM). Combat
cussed. Liaison consultants can also gain valu- stress control personnel with primary consulta-
able information and insight about the unit by tion missions are organic to the above hospital
listening and observing without being in the way. and medical headquarters. In other cases, the
CSC personnel are attached to the medical unit
c. Home Station Support. During mo- for support, either as individuals or as teams
bilization, the disruption of the family, finances, composed of 1 to 15 or more personnel.
and other personal matters can adversely affect
the morale of the deploying soldier. It is impor- (2) Attachment of CSC elements
tant, therefore, to facilitate the transition from must be coordinated with the supporting medical
home station to the deployment area. Combat unit by the headquarters issuing the attachment
stress control personnel should— order. Coordination must include provision for
quarters, food, and fuel. After attachment, the
Remind commanders and lead- command surgeon will brief the CSC element on
ers of the importance of these issues. the threat, SOI procedures, and other pertinent
information as required by the situation.
Work toward greater partici-
pation of family members in established family b. Continuation of Consultation and
support groups. Training Activities. During combat, consultation
and training activities are continued. These ac-
Assist with the activation of tivities may be curtailed or suspended as a result
family support groups and coordinate home sta- of the tactical situation but are continued as soon
tion command support when possible. as the situation permits. The consultant coordi-
nates with the command surgeon on CSC infor-
Ensure commanders provide mation to be presented to the commander. If
the locations of established family assistance cen- possible, the CSC personnel accompany the com-
ters to family members. mand surgeon when this information is briefed.

4-10
FM 8-51

It is important that senior commanders and staff Facilitating RTD and rein-
are briefed on the CSC operation. When the tegration of recovered cases into units by coor-
senior leadership understands the importance of dinating with patient administration, the S1/Gl,
CSC consultation and prevention programs, and directly with soldiers’ unit leaders, chaplains,
maximum participation within the command is and medics,
achievable.
c. Staff Planning. Staff planning is
(1) Movement outside of secure conducted in coordination with the unit surgeons
areas such as BSAs, DSAs, or base clusters will (medical company commander). As new opera-
be restricted. Any movement outside of secure tions or changes in the tactical situation evolve,
areas involves increased risk and requires prior estimates and plans must be reviewed and up-
coordination. The increased threat brought on dated as required.
by combat requires that all CSC personnel be d. Periodic Visits to Supported Units.
proficient in performing their common soldier The CSC consultant conducts periodic visits to
skills. Any CSC support mission requiring g-round supported units. These visits should occur on a
movement outside the secure area must be coor- predictable, recurring basis. The objective is
dinated and approved. This coordination is accom- simply to maintain contact and find out what is
plished with either the tactical operations center really happening. Once the pattern is estab-
(TOC) or base cluster operations center. In most lished, field phones or radio contact can fill the
cases, preferred movement outside a secure area gaps when visits are impractical.
is done by convoy and has MP or other security
elements. Some main supply routes (MSRs) may (1) It is essential that the consult-
be considered secure during daylight hours after ant (or consultant officer/NCO team) establish a
they have been cleared by security forces. In communications network so that he can be con-
other situations, CSC personnel may follow re- tacted quickly anywhere in the course of making
turning ground ambulances to their destination. rounds. If the consultant does not have a radio,
In all cases, CSC personnel must have approval it is important that he keep the supporting medi-
prior to departing any secure area. cal unit headquarters informed of his location and
schedule. This is accomplished by passing a
(2) Priority for CSC consultation message through the supporting unit head-
during combat focuses on those areas with great- quarters. The consultant uses brevity code
est, immediate potential to conserve fighting messages (in accordance with TSOPs) which can
strength. These areas include— be transmitted quickly by host-unit signal per-
sonnel. If the schedule changes, he informs the
Implementing the CSC supporting medical unit of the change.
support plan. (2) Visiting supported units in the
immediate vicinity (within the BSA, DSA, or base
Assisting units with rest- cluster) is accomplished on a daily basis when
ing of DUTY and REST category BF cases in their REST BF cases are being held in their unit areas
units when possible. for light duty or rest. In most instances, the units
visited will be headquarters and headquarters
Advising and assisting companies (HHCs) or CSS units. It is required
with medical triage to prevent unnecessary that CSC personnel know the location of all BF
evacuation of BF cases. cases and monitor their status on a daily basis.

4-11
FM 8-51

(3) Each consultant when visiting area. The consultant should advise unit medical
a unit first makes contact with the previously personnel or the commander to send any BF
identified POCs. If the consultant team includes casualties judged to be at risk of serious medical/
an officer and an NCO, they naturally divide the emotional illness to the supporting MTF for NP
people to be talked with according to officer/NCO evaluation. At the supporting MTF, the BF
status and rank. The consultant speaks with the casualty receives further NP triage, stabilization,
junior leaders who have BF casualties in their restoration, or evacuation.
sections. If advice or assistance is needed, this
facilitates the identification of problem areas. He e. Initial Evaluation at a Medical
speaks with the BF casualties as necessary to Treatment Facility. At the MTF, REST, HOLD,
monitor their progress. These “work-ups” are or REFER BF cases are evaluated by general
brief and factual, with only sufficient items re- medical personnel (for example, at the clearing
corded in the consultants notebook to remind the station). This evaluation may include advice and
CSC provider of important details. These consul- an interview by the CSC consultant, when
tation cases are “carded for record only” on DD present. If the CSC person is a psychiatrist, he
Form 1380. (For additional use of DD Form 1380, may elect to perform the examination and triage
refer to AR 40-66 and FMs 8-10-6 and 8-230. ) of the BF casualty.
(4) The consultant advises unit (1) Battle fatigue cases that re-
leaders on the care and handling of BF casualties. quire medical observation and treatment are man-
Potential subject areas will include how to— aged as discussed in Chapters 8 and Chapter 9.
Talk with soldiers experi- (2) Battle fatigue cases judged able
encing BF. to RTD to their unit areas include those soldiers—
Provide reassurance. Treated and returned to
duty immediately (category DUTY).
Ensure rest/sleep require-
ments are met. Placed on limited or light
duty for 1 to 3 days of rest under the control of
Provide adequate nour- the soldier’s own battalion HHC or the brigade
ishment and fluid replenishment. S1 (category REST).
Practice personal hygiene. Given light duties.
Conduct work activities.
NOTE
Provide recreation (if pos-
sible). Maneuver units positioned in forward
areas only have those personnel who
Initiate after-action de- are fit for full duty. Limited or light
briefings. duty is nonexistent in these units. If
BF cases are sent directly to these units,
(5) When BF casualties appear they must be able to perform full duties
unmanageable, they are not held in their unit for their own and the unit’s safety.

4-12
FM 8-51

If limited or light duty cases (REST category) are headquarters element of the temporary unit
members of maneuver units operating in forward coordinates for transportation. Logistical vehicles
areas, alternative units are used. Alternative supporting forward areas are the most likely
units may include the battalion’s HHC which is means for returning soldiers to their units.
positioned with the field trains. Under some
circumstances, CSS units (such as a headquarters (2) Combat stress control person-
and headquarters detachment [HHD], mainte- nel may be required to enter forward areas to
nance, or supply company of the FSB) may be provide special reintegrating instructions for a
used temporarily for REST BF casualties. Alter- BF casualty that is returning to duty. Commonly,
native units out of the BF casualty’s organiza- a brief note or oral instructions provided to the
tional structure are not usually preferred, as the soldier or the unit leader are the methods used to
individual soldier does not have any social, get instructions to unit commanders and first
emotional, or administrative ties with the unit. sergeants. Special instructions may also be sent
forward via the chaplain/unit ministry team or
(3) Transportation of BF cases re- ambulance drivers relaying instruction to the
turning to their units from the supporting medical BAS. These instructions will assist medics and
company may require coordination. The patient unit leaders on how to maximize successful rein-
administration specialist of the medical company tegration of the recovered soldier.
may be required to contact the brigade S1 of the
soldier’s unit and request the unit provide trans- g.. Reevaluation of REST Battle
portation. In other instances, transportation for Fatigue Cases Who Do Not Improve. Soldiers who
the BF cases back to their unit may be coord- fail to improve sufficiently to return to their
inated through the support operations section, original duties and unit in several days must be
movement control officer, or the TOC. These reevaluated. During this evaluation, the CSC
sections can identify any vehicles going to the consultant attempts to rule out malingering,
soldier’s unit area. The use of ambulances or situations with too much “secondary gain, ” or
medical vehicles (such as the CSC vehicle) to other physical and mental disorders (see the com-
transport soldiers back to their unit is not per- bat NP triage functions, Chapter 6).
mitted under the Geneva Conventions (see
Appendix D). The transporting of soldiers to their (1) Advising the supervisors to in-
unit area could cause a loss of protected status crease positive expectation, reduce the comfort of
for those medical personnel involved. For addi- the facility (the secondary gain), and/or having
tional information pertaining to the Geneva Con- the first sergeant or other members of the unit
ventions, see Appendix D. visit the soldier may be sufficient to achieve full
f. RTD.
Monitoring the Progress of REST
Battle Fatigue Cases. As previously discussed (2) A few cases may be recom-
the progress of soldiers returned to or held in mended for reassignment to CSS jobs in the same
their unit for rest or light duty is monitored by battalion. However, this must be kept to a mini-
the CSC consultant. mum so as not to undermine positive expectation
of full recovery and lead to resentment or imita-
(1) When those soldiers being held tion by other soldiers. If job reclassification and
in temporary units for quarters, rest, or light duty reassignment is judged necessary, it will usually
are ready to return to the original duty unit, the be to another unit.

4-13
FM 8-51

(3) Cases of REST BF who fail to leader about the normal stress process and reac-
respond after 1 to 3 days of rest are reevaluated. tions may have to take the place of the sharing of
Based on the reevaluation, these BF cases are personal experiences.
either held for restoration treatment at the sup-
porting MTF or evacuated one echelon for more (3) Critical event debriefings are
intensive restoration or reconditioning treatment reserved for exceptionally traumatic events. They
(see Chapters 8 and 9). are lead by trained critical event debriefers,
usually in teams of two to four persons. The
h. Debriefings. Combat stress control teams are led by CSC personnel but may include
consultation following potentially traumatic trained chaplains, medical personnel, and line
events involves three types of debriefings. The officers and NCOs. The participants in the critical
three types of debriefings are— event debriefing may be members of the same
unit; they may include strangers thrown together
After-action debriefings. by chance by a highly traumatic event (for
example, members of a unit responsible for a
Large group debriefings. “friendly fire” incident).
Critical event debriefings. (4) After-action, large group, and
critical event debriefings share common features
(1) After-action debriefings should but differ from each others in significant ways.
be conducted by all leaders of small units after all Each type of debriefings is preferred for a particu-
operations. After-action debriefings are especially lar situation, but a combination of these debrief-
important after a difficult action. The leader(s) ings may be used for some situations. The CSC
extend the lessons learned orientation of the consultant should be prepared to—
standard after-action review (AAR) to include
sharing and recognizing the feelings, emotions, Teach other personnel
and thoughts of team members. (See Chapter 5 how to lead or facilitate the above debriefings.
for after-action debriefings.)
Facilitate each type.
(2) Large group debriefing may be
an expedient method when small group debrief- Lead or conduct each type.
ings are impractical. Alternatively, the large group
debriefing may be the culmination of the after- Know when each is appro-
action debriefing or critical event debriefing of priate.
the component squads, platoons, or small groups.
The leader may be either the unit’s leader or a Combat stress control debriefings are described
facilitator from outside the unit. Since everyone in Chapter 5.
cannot be encouraged to take an active part, the
leader encourages representatives of the for-mal
or informal subgroups to review their subgroup’s 4-6. Consultation to Medical Treatment
actions and experiences. Expressions of feelings Facilities
are again encouraged, respected, and validated.
Individuals who were not specifically asked to a. Providing Consultation to Medical
speak are encourage to speak up if they feel there Treatment Facilities. Consultation for hospital
is more that needs to be said. Information by the and Echelon II MTF staffs is provided by organic.

4-14
FM 8-51

attached, or collocated CSC units or elements. quickly and must be held temporarily “for rest”
Hospital neuropsychiatry staffs provide are not being “admitted” or ‘hospitalized,” ( their
consultation primarily to hospital staffs but also medical records may show that they technically
advise MTFs and nonmedical units operating are admissions).
within their area of support. Consultation
assistance may include— (3) Coordinate and organize a non-
patient area for placement of these cases. Life
Evaluating newly arrived cases support and administrative support is provided
to rule out BF or NP disorders or triaging for by the MTF. Nonmedical personnel may be used
possible admission or retention and disposition. to staff this area and provide supervision for cases
in a nonpatient status. The selected area should
Evaluating cases already on be quiet and away from high traffic areas. A
the wards or in a holding section with medical/ relatively quiet area will afford these cases the
surgical diagnoses that include BF or NP opportunity to rest and sleep. Personnel that are
disorders. providing supervision for these cases should be
briefed on handling and caring for these soldiers.
Providing consultation and It is important that these soldiers be provided
training for medical staff on combat stress the opportunity to talk about what has happened
prevention and methods of controlling stressors. to them. It is also important that these soldiers
be given useful light duties which reaffirm their
nonpatient status.
NOTE
(4) Monitor the progress of all
Stress reaction in medical personnel is cases and determine their disposition in accord-
often denied or overlooked. Thus, the ance with corps and theater evacuation policies.
consultant’s efforts may have to be These cases are either returned to their unit after
active during consultation to medical sufficient time of rest ( 1 to 3 days) as DUTY or
personnel. REST BF casualties, or they are transferred to
an MTF established for restoration or recondi-
tioning of BF casualties.
b. Evaluating and Triaging New Pa-
tients. The majority of these patients will be seen c. Consultation fbr Medical and Surgi-
in triage or the emergency medical treatment cal Patients with Neuropsychiatric Conditions.
area of a hospital or medical company. When Neuropsychiatric personnel may be requested to
providing CSC training to personnel working in evaluate medical and surgical patients who are
these areas, the consultant should— being held at MTFs. These medical and surgical
patients when suffering NP disorders can be
(1) Emphasize the importance of divided roughly into five overlapping groups.
giving immediate reassurance to the unwounded
BF (stress) cases and moving them away immedi- (1) Organic mental disorders
ately from the surgical holding or emergency which may include conditions such as—
medical treatment areas.
Disruptive confusion.
(2) Emphasize that even those
cases who cannot be returned to their units Disorientation.

4-15
FM 8-51

Hallucinations and agita- Any condition that causes
tion after high fever, or metabolic disruption of paralysis,
brain functions.
Empathic management by all health care provid-
Amnesia and poor im- ers is critical and can greatly facilitate rehabilita-
pulse control following head injury. tion and minimize PTSDs. This is important even
if the patient appears to be unconscious.
The consultant recommends psychiatric treatment
modalities (for example, drugs and restraints) and (4) Patients with wounds that re-
nursing measures which are compatible with the quire hospitalization but will be returned to duty
underlying diagnosis and treatment. within the theater. Some of these patients have
residual BF and reactions to the circumstances of
(2) Major psychiatric illness coin- trauma. A few of these patients experience antici-
cidental to a medical or surgical condition, or patory BF at the prospect of returning to combat.
perhaps responsible for it, as in serious suicide These patients should be placed in a minimal care
attempts. The consultant recommends NP treat- area as soon as their condition permits and be
ment which is compatible with the illness or provided treatment which is similar to that pro-
injury and the treatments prescribed for it. vided to BF cases.
(3) Patients with ongoing or poten- (5) Soldiers reacting to home front
tial psychiatric reactions to their injuries or the problems unrelated to their combat duties or
circumstances of the trauma. Many soldiers expe- injuries. The consultant helps identify problems,
rience initial relief and even euphoria on being provides guidance as appropriate, and mobilizes
wounded. They may feel a sense of relief because social service support agencies, if applicable.
they are honorably out of action and in the care
of the medics. They may sense this feeling of d. Providing Combat Stress Control
euphoria as a result of receiving morphine. Only Consultation to Medical Personnel. Medical per-
later may the implications of a life of physical sonnel are not immune to the increased stress
disability begin to depress them. Some of these associated with supporting combat operations. It
patients may be willing and even desperate to is important that medical personnel are not over-
tell the story of what happened. Other patients looked and that CSC consultation support be
may exhibit signs of depression, hostility, agita- provided to all MTFs, medical units, and medical
tion, or other behaviors as a reaction to their elements in the theater.
situation and injuries. Potential psychiatric reac-
tions may occur in any patient, but soldiers with (1) Neuropsychiatric and CSC con-
some types of wounds and injuries are considered sultation personnel advise the chain of command
to be at special risk. These wounds or injuries and supervisors about general measures to buffer
include— the intense stressors associated with providing
combat medical care. These stressors may
Genital wounds. include—
Major amputations. Providing round-the-clock
emergency care for severely injured patients.
Serious disfigurement.
Facing the moral dilemma
Blindness. of placing patients in the surgical triage

4-16
FM 8-51

“Expectant” category (these patients receive only Providing leisure time and
supportive care as time permits). recreational activities, if possible.
Facing the moral dilemma Training on how to con-
of saving the grossly, lamentably disabled when duct routine and special after action debriefings
there is not a mass casualty situation and they do or rap sessions (and to use shift changes construc-
not have to be placed in the surgical “Expectant” tively for these purposes).
category. This is even more difficult if the patient
is asking to be euthanatized. (3) Remember, it is not only direct
patient care givers who undergo extreme stress.
Facing the moral dilemma Do not forget food service, laboratory, main-
of placing patients in the surgical “minimal” or tenance, and administration personnel. Mortuary
RTD category. Those soldiers are expected to affairs personnel also require special support and
return to the horrors and dangers of combat; most consideration.
medical personnel are not subjected to similar
risk. (4) The NP/CSC consultants work
closely with MTFs’ and commands’ chaplains on
Treating and providing these issues that create stress in health care
care for wounded soldiers who are related or providers and other medical personnel. The
someone whom they know. chaplains also deserve help in dealing with their
own emotional responses. The CSC consultants
Maintaining appropriate themselves are not immune to stress and must
interpersonal relationships when everyone is rely on each other and the chaplains to share the
under extreme stress. strain. A plan for care of CSC personnel should
be in place. The plan should provide for assess-
Knowing how to unwind ment of the emotional well-being of the CSC
during lulls in the action without slipping into consultant. Use a rotating roster to assure that
misconduct stress behaviors. the mental health professionals are aware of the
status of other team members.
Dealing with the boredom
when patient activities come to a halt for long (5) The consultant provides one-
periods of time. on-one or small group therapy when appropriate.
(2) Combat stress control consult-
ants’ recommendations for resolving or reducing 4-7. Consultation During Demobilization
those stressors identified above include— and Homecoming
Establishing a sleep plan At the conclusion of the conflict, as military
and shift schedules. activities phase down or as units or individuals
rotate home, CSC personnel advise command on
Developing time-manage- stress issues.
ment skills.
a. Scheduling Considerations. The
Building team and unit consultant strongly recommends that some free
cohesion. time be scheduled for all soldiers who are

4-17
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deploying home. During this time, these soldiers debriefings for leaders of small units, chaplains,
are provided the opportunity to talk about their and others, or for ad hoc collections of individuals
experiences with their comrades or with others with similar combat experiences. The CSC con-
who experienced similar stressors. sultant may conduct or participate in such de-
briefings for units or individuals at special risk,
(1) These times when soldiers dis- such as former prisoners of war (POW) or victims
cuss experiences should be initiated days before of friendly fire. The debriefings for units or
departure by air. If sea transport is used, this individuals begin while they are still in the TO, if
could be accomplished during travel. feasible, and may continue soon after return to
CONUS.
Keep this time as free as
possible from mission duties. (1) The debriefings focus on the
common experiences of war. These events may
Keep teams, squads, and include—
platoons together.
Traumatic experiences
(2) Keep unit personnel together (death of buddies).
for several days after reaching the home station.
Morally conflicting issues
Do not immediately grant (death of noncombatants).
block leaves to the unit.
Frustrations (rules of
Maintain a half-day, light- engagement, errors of leadership, and perceived
duty schedule. failures of support).
A feeling of loss at the
Grant soldiers liberal com-
mander’s time, as needed, to resolve personal breaking of the bonds formed with the combat
problems. unit.
Delay in the rebonding
(3) Appropriate memorial ceremo- with home and family.
nies and celebrations are recommended, both in
the TO before departure and at the home station. (2) The soldiers are forewarned of
These events recognize and provide comfort to the normal, common symptoms which combat
those who have suffered. Such rituals give a veterans experience on return to a peacetime
sense of closure. These events should— environment. Normal, common symptoms may
include—
Encourage grass roots
participation rather than being dictated from Bad dreams.
above.
Alerting reactions to
Use or adapt traditional stimuli or situations similar to those of combat.
ceremonies.
A sense of being different
b. Postcombat Debriefing. Combat and alienated from others who have not been
stress control personnel will participate in formal through combat (including spouse and family).

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FM 8-51

This can lead to social withdrawal and perhaps a d. Noncombat Debriefings. Similar de-
sense of letdown and boredom. briefing procedures are equally important follow-
ing noncombat deployments such as 6-month
c. Reunion Briefings. Combat stress peacekeeping rotations or prolonged training mis-
control personnel, chaplains, and others give sions. Issues discussed are different.
group briefings to all soldiers and units. The
briefers forewarn of the common strains that e. Continuing Debriefings. A continu-
often develop in relationships between spouses ing debriefing process may extend over weeks or
and their families during long separations. months in some special cases. Follow-up de-
briefings will be especially relevant when—
(1) Soldiers are prepared for the
ways that their families, friends, and society may Reserve Component units are
have changed since they were deployed. Special demobilized after a prolonged period of active
attention may be needed to explore popular feel- duty.
ings about the war and how veterans can expect
to be treated by civilians. If this is likely to be Units are deactivated as a
negative, ways to cope are illustrated. result of reduction in force.
(2) While troops are being de- Large numbers of personnel
briefed in the theater, similar debriefings should are being considered for reduction in force. Such
be conducted with families in CONUS to prepare major changes are in themselves highly stressful
them for the returning soldiers. and can lead to much inefficiency, distress, and
long-term problems unless the personnel are sup-
(3) When feasible, unit families are ported and aided with coping skills and pro-
included in the later home station debriefings. cedures.

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FM 8-51

CHAPTER 5

COMBAT STRESS CONTROL FOR RECONSTITUTION SUPPORT

5-1. Reconstitution Support (a) Immediate reorganization
is the quick and usually temporary restoring of
Reconstitution is extraordinary actions that com- degraded units to minimum levels of effec-
manders plan and implement to restore units to tiveness. Normally, the commander implements
a desired level of combat effectiveness commen- it in the combat position or as close to that site as
surate with mission requirements and available possible to meet near term needs.
resources. Besides normal support actions, recon-
stitution may include— (b) Deliberate reorganization
is done to restore a unit to the specified degree of
Removing the unit from combat. combat effectiveness. Usually, more time and
resources are available further to the rear.
Assisting the unit with external Procedures are similar to immediate reorgani-
assets. zation except that some personnel and weapons
system replacement resources may be available,
Reestablishing the chain of com- equipment repair is more intensive, and more
mand. extensive cross-leveling is possible.

Training the unit for future opera-
tions. NOTE

Reestablishing unit cohesion. When used in reorganization, cross-
leveling involves the movement of
All CSC personnel should be thoroughly familiar personnel and/or equipment between
with FM 100-9. The following summarizes the units to achieve equalization. The pro-
doctrine and elaborates on stress issues and cess is accomplished while maintaining
mental health/CSC actions in support of unit or restoring the combat effectiveness
reconstitution. of the units involved.

a. Reconstitution Process. Reconstitu-
tion of units transcends normal day-to-day force (2) Assessment measures a unit’s
sustainment actions. It is defined as extra- capability to perform its mission. It occurs in two
ordinary actions that are planned and phases. The unit commander conducts the first
implemented by commanders to restore units to a phase. He continually assesses his unit before,
desired level of combat effectiveness commen- during, and after operations. If he determines it
surate with mission requirements and availability is no longer mission capable even after reorga-
of resources. Reconstitution is a total process. nization, he notifies his commander. Higher
Its major elements are reorganization, asses- headquarters either changes the mission of the
sment, and regeneration, in that order. unit to match its degraded capability or removes
it from combat. External elements may also have
(1) Reorganization primarily in- to assess the unit after it disengages. This is the
volves a shifting of internal resources and is second phase. These elements do a more
accomplished as either immediate or deliberate thorough evaluation to determine regeneration
reorganization. needs. They also consider the resources available.

5-1
FM 8-51

(3) Regeneration is required when unit. Some of the key issues in estimating the
heavy losses of personnel and equipment leave a CSC needs of the unit include—
unit combat ineffective and unable to continue
its mission. Regeneration has two variations: Determining the percent-
incremental regeneration or whole-unit re- age and nature of casualties.
generation (a and b, below, explain each).
Regeneration involves rebuilding a unit through Looking at the duration of
large-scale replacement of personnel, equipment, operations and environmental exposure.
supplies, and if required, internal reorganization;
reestablishing or replacing essential C2; and Estimating the loss and
conducting mission essential training for the current effectiveness of leaders.
reconstituted unit.
Evaluating attitudes, per-
(a) Incremental regeneration ceptions and level of confidence of unit survivors.
is the massive infusion of individual personnel
replacements and single items of equipment into Evaluating the status of
the surviving unit elements. nutrition and hydration.
(b) Whole-unit regeneration (2) The scale of CSC involvement
is the replacement of whole units, or definable depends on the size of the unit, the nature and
Subelements such as squads, crews, and teams. extent of the attrition it has suffered, the location
b. Authority for Reconstitution. Re- of the reconstitution site, and the time and
constitution decisions belong to the commander. resources available.
The commander controlling assets to conduct a
regeneration decides whether to use resources for (3) The S1/G1, S4/G4, and medical
this purpose. The commander of the attrited unit staffs also coordinate the dispatch of the
decides to reorganize when required. The unit regeneration task force teams. These teams
commander begins the reconstitution process. occupy the reconstitution site before arrival of
the exhausted unit. The reconstitution task force
c. Characteristic of Regeneration. The guides each element of the arriving units into its
defining characteristic of regeneration, as dis- designated areas. The regeneration task force
tinct from simple internal reorganization or provides for the immediate needs of the survivors.
consolidation, is the massive infusion of This should include persona] gear, sleeping bags,
personnel, equipment, and assistance at the and tentage to replace lost or damaged items.
direction of higher headquarters. The process Assistance teams may include cooks, medical
begins with an initial survey by a team sent by teams, repair and maintenance teams for
the higher headquarters. This team determines vehicles, and ordnance and special equipment
the status and needs of the attrited and exhausted personnel. Medical teams provide sick call
unit as it moves to the regeneration site. services while organic medical personnel rest. As
required, CHS and other teams may include—
(l) Combat stress assessment of
unit personnel should be included in the initial Combat stress control per-
evaluation. The supporting medical element sonnel/team.
should include CSC personnel (teams) as part of
their initial regeneration support efforts to the Preventive medicine team.

5-2
FM 8-51

Dental team. (2) Combat stress control recon-
stitution support requirements for larger units
Nuclear, biological, and that are undergoing regeneration in the division
chemical decontamination teams. rear, corps, or COMMZ will vary. Factors which
influence the requirements include—
Personnel service team.
The size of the unit.
Combat service support
contact teams. Number of subunits
which have suffered heavy casualties.
Replacement personnel are sent to the re-
constitution site, and when present, CSC The extent of emotional
personnel will assist with their assimilation into trauma.
the regenerated unit.
Time available.
d. Scope of Combat Stress Control
Inwolvernent in Reconstitution Support. The CSC Combat stress control personnel required to
reconstitution support mission ranges from support regeneration is dependent on the above
providing assistance to small units close to the factors. A guideline is provided in Table 5-1.
battle that are undergoing reorganization to
providing assistance to large units involved in
regeneration conducted far to the rear.
(1) Combat stress control recon-
stitution support may not be available for small
unit-level elements such as a platoon undergoing
immediate reorganization. If CSC personnel are
deployed this far forward, the CSC reconstitution
support mission will merge into the consultation
mission to units held in reserve. Ideally, a two or
four-person CSC team might deploy to a company-
sized unit with the other maintenance and
medical teams. The CSC team assists the
command with the deliberate reorganization of
small unit-level elements and facilitates after- e . Phases of Combat Stress Control
action debriefings by and for all leaders in the Reconstitution Support. Reconstitution support
company. The CSC team may conduct critical is divided into phases, based on the changing of
event debriefings if the unit has experienced an the unit. The pattern is similar to that of
especially traumatic (tragic, horrible) event. The restoration of an individual BF casualty. The
CSC team could also conduct critical event relative time and effort required for each phase
debriefing if the after-action debriefing shows varies, depending on the recent experience of
other issues need to be resolved. The availability the unit. For example, physical/physiologic
of the CSC team and the time to provide such replenishment may be extremely important in
support will depend on mission priorities and some situations and completely unnecessary in
current work load. others.

5-3
FM8-51

NOTE The medical group social
work officer or psychologist,
The following paragraphs pertain to
the phases of CSC support provided to The medical brigade or
combat arms units which have been MEDCOM psychiatrist or social work officer.
engaged in heavy, continuous fighting.
(3) Movement orders for the eval-
uation team and for the subsequent assistance
5-2. Phase I: Preparation and Deploy- team are generated and coordinated by the higher
ment headquarters (for example, the FSB, DISCOM
[DMOC], or medical group headquarters). The
a. Coordination. Coordination for de- CSC elements move as part of a convoy with the
ploying a CSC reconstitution support mission is other contact teams and CSS elements.
accomplished through the supporting medical
unit. b. Familiarity with the Unit. Recon-
stitution support works best when the attrited
(1) The headquarters which orders unit already has familiarity, trust, and confidence
the reconstitution effort must be aware of the with the CSC personnel (teams). Those CSC
importance of CSC involvement in the task and personnel need to be familiar with the unit, its
of the availability of resources. The command history including recent experiences, equipment,
surgeon is responsible for recommending what mission, and key people. Ideallyj this includes at
CHS assets are committed for reconstitution least a few known, face-to-face POCs. If that is
support. It is the responsibility of the CSC not available, a positive reputation with strong
commander or the psychiatrist to provide endorsements from respected second parties
consultation training to all command surgeons so helps. The endorsement of the higher head-
they are aware of the importance of including quarters is essential.
CSC personnel in all reconstitution operations.
(2) The initial evaluation team c. Unfamiliarity with the Unit. A CSC
should include a CSC member. Depending on team which deploys to a completely unfamiliar
the size and location of the unit, this could be— unit under these extreme stress conditions will
be at a disadvantage but can overcome it by—
A brigade CSC team
member. Getting all the information it
can on the unit prior to arrival.
The division psychiatrist
or a mental health officer from the division Coordinating with and using
mental health section or attached CSC elements. the chain of command, chain of support, organic
mental health, and medical personnel and
A psychiatrist or a mental chaplains to obtain information.
health officer from the medical company, -
CSC or
the medical detachment, CSC. Demonstrating competence
(quickly), self-sufficiency, and helpfulness with-
An ASMB psychiatrist, out appearing as if trying to step in and take
social work officer, or NCO in the corps. over.

5-4
FM 8-51

5-3. Phase II: Reduction of Human (4) Ensure leaders and troops are
Physical/Physiologic and Cognitive given a brief orientation on what they will be
Stressors doing and when it will happen.
a. Monitoring. The CSC team mon- (5) Provide hot showers right
itors the unit to assure that the following steps away, if feasible. If not feasible, the unit should
are taken by unit leaders and the reconstitution be provided time for sleep as soon as possible.
support elements. The CSC personnel ensure, as
needed, that the following aspects of recon- (6) Allow for sleep under the best
stitution treatment are being accomplished. They conditions possible for 8, 12, or 16 hours
report any short-falls to the reconstitution control (depending on the degree of sleep debt and the
element. amount of time available).

NOTE (a) It is best to sleep through
the night and awaken in the morning to continue
The Sl/Gl and S4/G4 staff of supply the program, but in forward locations this may
and services or quartermaster units is be reversed (sleep in the day, awaken at night) to
maintain reverse cycle requirements.
responsible for providing the means for
warming or cooling, rehydrating,
feeding, and sheltering. They are also (b) If possible, have other
responsible for latrine and shower units provide perimeter security so that all
facilities. These are not the respon- members of the exhausted unit can sleep at the
sibilities of CSC personnel or units. same time.

(c) Unit leaders need this
(1) Treat environmental exposure sleep most! The reconstitution support elements
immediately by providing shelter, cooling, provide security and all necessary support
warming, and/or drying, as necessary. actions, while unit leaders are ordered to sleep so
they will not feel that they have to stay awake.
(2) Push oral, palatable fluids im-
mediately (cool or warm, depending on the (d) If necessary, the CSC
temperature) to correct probable dehydration. team psychiatrist prescribes fast-acting medi-
cations that are rapidly eliminated from the body.
(3) Provide plenty of good palat- For example, diphenhydramine (Benadryl), or
able food, mostly carbohydrate but with some ternazepam (Restoril) are given to those key
protein, and as much as they want to eat. The personnel who do not relax and respond positively
food may be soups which simplify preparation and to strong suggestion or approval. Low dose
combine feeding and fluid replacement. A-rations diazepam (Valium) is permissible under some
are best. Tray-packs are acceptable but require circumstances but not preferred. Chlorpromazine
special effort. Heating tray-packs will improve (Thorazine) should not be used for this purpose.
texture; providing optional condiments and spices Before admimistering minor tranquilizers, the
will be a plus. Meals, ready-to eat (MREs) also prescriber must ascertain if the soldier has a
can be used if efforts are made to heat them and history of alcohol or drug abuse and specifically if
additional condiments are provided. the soldier is in recovery.

5-5
FM 8-51

b. Involvement of Combat Stress (1) Unit personnel are awakened
Control Personnel During Physical/Physiologic for a good, hot, high-protein breakfast (A-ration
Replenishment. The importance of physical/ if possible; tray-pack is acceptable if well-heated
physiologic measures should not be underesti- when served).
mated in the haste of the reconstitution efforts.
Combat stress control elements through their (2) Unit personnel work to restore
actions should encourage and facilitate their hygiene (shower, shave, good latrine facilities,
speedy delivery. and clothing exchange) and take care of personal
gear.
(1) Delay, loss, or nonavailability
of equipment and materiels when and where (3) Some CSC personnel assist by
needed may hamper the speedy delivery of organizing self-help activities involving the troops
physical/physiologic measures. If this happens, as the unit’s leaders concentrate on the debriefing
the CSC teams along with other medical support process. These CSC personnel continue to gather
and CSS teams must be prepared to step in and data by—
assist the attrited unit to improvise self-help.
Observation.
(2) Combat stress control teams
facilitate the means to boil water to heat tray- Structured interviews
packs or MREs, to prepare hot soups, and to with individuals or small groups.
provide hot water for shaving, sponge baths, or
bucket showers. Personnel from the reconstituted Short, easily scored ques-
unit will provide most of the labor. tionnaires.
(3) Facilitating restorative sleep
under adverse conditions is more difficult because 5-4. Phase III: After-Action Debriefing
CSC units do not carry large volumes of sleeping
bags, ground pads, cots, or tents. They can a. Small Team and Subunit After-
provide disposable ear plugs (an effective way to Action Debriefing. Surviving unit leaders begin
dampen distracting background noise) and the after-action debriefing process during lulls in
cravats (to cover eyes against bright daylight). the battle or as soon as the mission or time
Disposable foil “space blankets” should be avail- permits. In some instances, the after-action
able for use in cold or wet weather when better debriefings may not be accomplished until the
shelter and bedding are not available. unit reaches a reconstitution site. Standard after-
action debriefings as described in FM 22-51 will
(4) During the intensive physical be conducted by all unit elements to obtain a clear
replenishment phase, the CSC personnel will and accurate assessment of what really happened.
learn as much as they can about the recent expe- After-action debriefing will be conducted by the
riences of the involved unit and coordinate a plan leaders of teams, crews, squads, sections, and
of action to meet the specific needs of the unit platoons within the company. If the original
and its situation. leader was replaced, the new leader will conduct
the after-action debriefing. Attached personnel,
c. Continuing Physiologic Replenish- such as medics, forward observers, engineers, or
ment. After sleep, physiologic replenishment artillery fire support team, are included in the
continues. unit after-action debriefings.

5-6
FM 8-51

b. Ascending Levels of Leader After- clarified. The right lessons are more likely to be
Action Debriefing. Once the subunit debriefings learned.
are completed, the company commander conducts
his after-action debriefing for the subordinate The junior leaders can com-
leaders. Subsequent debriefings are held at municate their clearer understanding of the
battalion, brigade, and even division levels in larger picture back down to their subordinates.
large scale reconstitution efforts. The unit’s
TSOPs will identify who attends the after-action
debriefing at a particular level. For example, at It provides transition work-
the company level, all the leaders in the company shops for new leaders if the unit has suffered a
will attend the company commander’s after-action loss of key leaders and staff. If a new commander
debriefing. The battalion commander’s after- is required, this type of workshop facilitates his
action debriefing will involve all company com- assumption of command.
manders, first sergeants, key battalion staff,
sergeants major and may be key NCOs within the c. Large Group Debriefings. At each
battalion. Regardless of what level the leader level, it may be possible for soldiers and junior
attends, he brings his unit’s/subunit’s consensus leaders to listen to the next higher level of leader
(reconstruction) of what really happened. Also, debriefing(s). This, in effect, constitutes a large
he is prepared to brief about the emotional group briefing. Large group debriefings involve
reactions of his personnel to the events that lower echelon personnel. However, large group
occurred. The participating leaders share their debriefings can only be conducted at a relatively
information along the succeeding time-line of the safe site. There must be adequate time to conduct
larger operation. The senior commander, NCO, the debriefing. The large group debriefings are
and key staff personnel contribute their input to not conducted if personnel are involved with
the reconstruction of the event. As in the AAR, equipment repair, reissue, and other recuperative
the after-action debriefing identifies operational activities. The large group debriefing maximizes
lessons learned. In addition, the after-action the sharing of common experiences and the
debriefing shares, acknowledges, and normalizes extension of unit cohesion.
the feeling raised by the event. It also enhances
vertical and horizontal bonding of personnel d. Attached Support Personnel (Spe-
which is the essential framework of unit cohesion. cialty Branch) Debriefings. Attached personnel
The senior leaders then take the group’s will participate in the after-action debriefing
consensus (reconstruction) on to the next higher process with the unit to whom they are attached.
level of leader debriefing. The process of after- They contribute their own perspectives on the
action debriefings from the bottom up has the event in concert with other attached support
following advantages: personnel. Later, if METT-T at the reconstitution
site allows, these support personnel should be
Each level can reconstruct drawn together by their parent units to debrief.
the most accurate picture possible of what ac- The objectives of this specialty debriefings is to
tually happened. They build upon the already derive lessons learned and to express and
clarified memories and observations of each normalize the intense emotions involved. Unlike
subunit. the small unit or leader after-action debriefings,
the specialty debriefings will usually not be
Misconceptions, misunderstand- reconstructing the overall event on a common
ings, and unrealistic expectations are likely to be time line. Rather, they share their different

5-7
FM 8-51

experiences of practicing their common specialty (4) The trained facilitator assists
in different situations. the after-action debriefing process by—
e. Facilitators in After-Action De- Helping the debriefing
briefings. When a unit has suffered especially leaders assure the ground rules are clearly stated
distressing or traumatic events, the commander and understood by all personnel.
should request trained facilitators to assist with
the debriefing process. These facilitators should Asking questions to get a
be present with the unit through all levels of the clear picture of what actually happened—when,
after-action debriefing process. The higher head- where, how, and to whom.
quarters of the unit that has experienced a
traumatic event should request debriefing Assuring that the com-
facilitators and assure that they are available at plete time line is filled in, extending from before
the scheduled time and place. Certain situations the critical incidents all the way through to the
are best handled by trained facilitators. These aftermath.
situations may include—
Assuring the process
Teams or units whose key stays constructive and does not turn destructive.
leaders were casualties or were replaced and now
new leaders are conducting the debriefing. Ensuring the ground
rules are followed, military bearing and respect
Serious friendly fire incidents maintained, and verbal attacks or scapegoating
or other disastrous mistakes. not permitted.
(1) It is essential that the facil- Assisting with the valida-
itators be perceived as impartial, friends of tion and normalization of feelings, such as fear,
the units, trustworthy, and privileged to main- guilt, and grief, as they come out by providing
tain confidentiality about what is shared in the broader or expert perspective.
the debriefing. They must not be perceived as
investigators or “spies” from the higher Monitoring the partici-
headquarters, inspector generals, or criminal pants for signs of serious distress and/or
investigators. detachment or psychological withdrawal from the
group.
(2) The facilitators should have
received formal instruction in critical event Encouraging those sol-
debriefings. Ideally, they will have participated diers with signs of serious distress to work
in or led prior critical event debriefings. through the distress or withdrawal during the
debriefing.
(3) The trained facilitator can be
from the CSC or mental health team. He may be Checking with those indi-
an officer or NCO of any professional or para- viduals one-on-one after the debriefing.
professional discipline. Line unit officer or NCOs
(peer debriefers) who have had critical event Providing group with in-
debriefing training can also be effective formation about what assistance is available to
facilitators. help them with working out their distress.

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Advising the unit and NOTE
leadership about whether a follow-up formal
critical event debriefing would be worthwhile. At least one trained and experienced
critical event debriefing facilitator
should be included in critical event
NOTE debriefings.
Often, a well-facilitated, after-action
debriefing will make a formal critical (2) The techniques of a critical
event debriefing unnecessary. event debriefing are similar to those of after-
action debriefings but are more dependent on the
skills and experience of the facilitator. The
b. Conducting Critical Event Debriefi- facilitator must be able to recognize and intervene
ings. Information obtained by after-action to help those in serious distress.
debriefings or from the higher headquarters
pertaining to the traumatic event is provided to
CSC personnel. This information is used to 5-5. Phase IV. Rebuilding Unit Cohesion
determine which subunits need more direct
involvement. Critical event debriefings are then
scheduled (with the approval of the leaders that a. Assisting Units to Rebuild Cohesion.
were involved) with those units/subunits where a Combat stress control personnel advise the
highly disruptive or traumatic event occurred. commanders and staff on planning the reas-
Combat stress control personnel will conduct the signment of surviving unit members and the
critical event debriefing or will advise (previously assignments of replacements. This advice is
trained) unit chaplains and medical participants based on the results of the leader-level
on how to conduct the critical event debriefings. debriefings. AG information, and any other
pertinent observation/data collected by the CSC
(1) The need for critical event de- team. The objectives of this process are to
briefings is indicated by— maximize remaining unit cohesion and promote
new bonding. Some of the techniques and
Evident distress of many principles that may be employed to maintain
participants. enhance unit cohesion during the redistribution
and replacement process include—
A consensus of the par-
ticipants at the after-action debriefing that they Keeping a new/replacement
want to talk more about the event. buddy pair, crew, or small team together and
assigning all members to the same platoon or
Evident reluctance of unit section of the attrited unit. Depending on the
members to talk through the event in the after- specific circumstances, new/replacement per-
action debriefing under their own leadership. sonnel may not be kept together. They may be
dispersed among small closely-knitted groups of
The expressed wished for veterans.
a consolidated or combined debriefing, bringing
the unit together with representatives of other Assigning veteran soldiers from
involved units, such as the survivors of a friendly other attrited units or sections so that level of
fire incident with the perpetrators. expertise is not lost. These personnel should also

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be transferred as crews or teams, or at least as BF soldiers as a result of unit after-action
buddy pairs. debriefings. When soldiers are provided the op-
portunity to talk about what has really happened
b. Small Unit Leaders and Veterans to them, they may exhibit true signs of BF. This
Integrate New Replacements. Small unit leaders may be apparent as one observes their reactions,
actively integrate all new soldiers while CSC interactions, and behaviors during the debriefing
personnel, unit ministry teams, or medical platoon process. Battle fatigue cases may be identified by
members monitor and provide feedback. New their leaders or buddies, by self-referral, or by
replacements are introduced throughout the unit. the CSC staff observations. When these soldiers
Group discussions are conducted for— are identified as having BF, begin treatment.
without flagging them as patients.
Combinations of older veterans
reassigned from other parts of the unit. (1) Since the unit is in a stand-
down position. CSC personnel can initiate
Newer veterans returning to treatment quickly. They will determine the
duty from medical channels. severity of the BF and initiate rest, light duty, or
other appropriate activities.
Replacements from rear area
jobs in corps and COMMZ. (2) Those BF cases that tempo-
rarily require continuous medical observation
Replacements fresh from may be rested and watched by the treatment team
CONUS. (part of the reconstitution support package) or at
In these group sessions, the story of the recent the BAS after its personnel have the opportunity
action, as clarified in the after-action debriefing, to rest.
are discussed. Feedback to the small unit leaders
from, CSC personnel pertaining to the process (3) A few of these BF cases may
should include— require evacuation, but only to the next rearward
echelon.
Identifying potential problems
and recommending solutions.
5-6. Phase V: Performing Final Combat
Recommending additional meet- Stress Control Requirements for
ings with CSC personnel for further ventilation, Reconstitution Support
discussion, or work group sessions.
a. Phase V. Phase V begins after the
Recommending individual or newly reconstituted unit has had additional sleep,
group training on combat stress, stress man- food, and opportunities for hygiene. Unit
agement, relaxation techniques, and BF. personnel, during this phase, are working actively
with each other and with the reconstitution
Recommending unit leaders, support teams to prepare the unit for return to
assisted by chaplains, conduct memorial services combat.
for the unit’s dead.
b. Unit Cohesion. Combat stress con-
c. Assisting Individual Soldiers with trol personnel monitor the ongoing work activities
Battle Fatigue. Small unit leaders may identify to ensure that unit cohesion is being built and

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that veterans are accepting and teaching the new can provide confidence-building and stress-
replacements. Questionnaire-type surveys may reducing physical exercise. They are scheduled
be administered to collect comprehensive data. in ways which maximize the development of
Combat stress control personnel continue to familiarity and cohesive bonds within and
advise unit leaders and facilitate further group between the recently reassembled unit.
work sessions and transition workshops. Note
that the word is facilitate, not lead or direct. d. Closing Out Reconstitution Support.
It is essential that the reconstitution support
c. Building Unit Confidence. The team close out (officially end) its role with each
successful completion of military training, such unit in the formal reconstitution process. The
as crew drills, squad and platoon tactics, and field reconstituted units are left with positive
training exercises (FTXs), will assist in building expectations that the unit and its individual
unit cohesion and confidence. Depending on the soldiers will be able to perform their mission and
location and time available, CSC personnel may do well on their own. Ideally, the same CSC
help commanders organize recreational activities personnel (team) will continue to provide CSC
and/or sports competitions. Sporting activities support when the unit returns to combat.

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CHAPTER 6
COMBAT NEUROPSYCHIATRIC TRIAGE

6-1. Triage that a small number of NP cases may have
weapons and be so potentially dangerous that
a. Definition and Comparison. Combat they deserve the highest priority for manage-
NP triage is the sorting of BF, NP and substance ment regardless of the type of triage being con-
abuse cases (including those with physical injury) ducted.
based on how far forward they can be managed
and treated to maximize rapid RTD. Combat NP (3) In combat NP triage, diagnostic
triage derives from the proven combat psychiatry knowledge, experience, and sound judgment are
principles of PIES (Proximity to the unit; Im- important at the front end of the process and at
mediacy in initiating treatment for all cases; the most forward feasible echelon. Interviewing
expressed Expectancy of providing rapid and full skills are essential if potentially critical mental
recovery; and Simplicity by using simple and symptoms, such as paranoid or suicidal ideation
short treatment methods. ) and thought disorders, are to be identified. Those
symptoms bear directly on safe management. In
(1) Combat NP triage is fundamen- such cases, diagnosis itself is deliberately de-
tally different from surgical triage. Surgical ferred. The decision on where to send the case is
triage divides cases into the categories of Im- determined on whether the case can be managed
mediate, Minimal, Delayed, or Expectant based safely for hours to days with simple treatment at
on how soon, if at all, they will go to surgery. the forward echelon. If manageable, they remain
The Immediate cases go to surgery immediately with the forward echelon. If they are unman-
because any delay is likely to result in death or ageable, they are sent rearward only one echelon
permanent disability, such as loss of a limb. Mini- where the decision process is repeated.
mal cases do not require surgery and can RTD
with a minimal investment of time and effort. In b. Combat Neuropsychiatric Triage
surgical triage, stress and psychiatric casualties Categories. Combat NP triage involves the sort-
would all be categorized as Minimal because they ing of cases into categories based on where they
never go to surgery. Delayed cases can wait for can be treated. There are four combat NP triage
surgery without suffering increased risk of per- categories. The four categories are—
manent harm. Expectant cases are not expected
to survive, given the amount or type of treatment DUTY cases.
that is available to give them, so they do not go to
surgery at all. REST cases.
(2) With BF, however, there is a HOLD cases.
significant increased risk of lifelong psychiatric
disability from prolonged delay of treatment, just REFER cases.
as there is a risk of physical disability from delay
of medical-surgical treatment. Most cases are (1) DUTY cases return to their
expected to recover and RTD with prompt and original small unit, either for full duty or for light
correct treatment, no matter how disabling their duty with extra rest and replenishment. This
symptoms appear. For these reasons, triage offi- option depends on the small unit’s mission, re-
cers need to be taught that stress and psychiatric sources, and the soldier’s symptoms. The triager
casualties need to be referred for treatment as must, therefore, be familiar with the unit’s situa-
soon as possible. It should always be remembered tion and take that into account.

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NOTE emergency treatment of the potential emergency
must be available at this medical echelon.
Maneuver units positioned in forward
areas must have only personnel who (4) REFER cases present problems
are fit for full duty. Limited or light similar to the HOLD cases, but—
duty is nonexistent in these units. If REFER cases are too dis-
BF cases are sent forward to these ruptive and burdensome for this medical echelon,
units, they must be able to perform full given its mission and resources.
duties for their own safety and the
safety of the unit. This echelon cannot pro-
vide the acceptable level of diagnostic and treat-
(2) REST cases are not return im- ment capability if an emergency occurs.
mediately to the small unit because the unit can-
not provide an adequate environment for rest. c. Distinguishing Categories by Signs
REST cases need brief respite, physical replenish- and Symptoms. It should be obvious that the
ment, and less demanding duties for hours to days four combat NP triage categories are not sharply
at a less dangerous or better-resourced setting. distinguishable based on the signs and symptoms
These cases do not require close medical or mental of the case.
health observation or full-time treatment. The (1) The boundaries of each category
respite and replenishment can be provided in a are influenced as much or more by the changing
nonmedical CSS element which supports their tactical situation and the resources available as
original unit. This option, too, depends on the by the symptoms. The category may change
resources and mission of the available CSS units automatically with time or as the case moves
as well as on the soldier’s symptoms. Someone in through the system. For example, REFER auto-
the receiving unit must take responsibility for en- matically becomes HOLD when the cases reach
suring the soldier is fed, rested, performing some the echelon which can manage and treat them.
useful work, and kept accounted for. There must
be a reliable transportation link to return the sol- (2) This flexibility is entirely in
dier to his original unit after a day or two of rest. keeping with the intent of the labeling system for
BF soldiers. The intent is to avoid giving BF
(3) HOLD cases are those who do soldiers a psychiatric label that sticks with them
require close medical observation and evaluation for life. It is also in keeping with the highly
because either— changeable nature of BF symptoms. Battle fa-
tigue symptoms tend to become fixed when inap-
Their symptoms are po- propriately labeled and mistreated.
tentially too disruptive or burdensome for any
available CSS unit or element. (3) Like the triage categories in
surgical triage, the categories in combat NP triage
Their symptoms could be are brevity codes. Each brevity codes (labels) sum-
caused by a medical, surgical, or NP condition marizes in one word where the case should be man-
which could suddenly turn worse and require aged and what treatment should be received in
emergency treatment. the immediate short term given the current situa-
tion. It has no other meaning and only transitory
In addition, the resources to provide the necessary relevance. Figure 6-1 provides a decision tree or
medical observation and adequate stabilization or flow diagram for sorting in combat NP triage.

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6-3
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6-2. Considerations (2) Neuropsychiatric screening.
Problem cases will require examination by a phy-
a. Importance of Expertise of Medical sician with NP training. This expertise must be
and Mental Health Personnel. As noted above, available no further to the rear than the DSA
making the diagnosis of specific psychiatric dis- (AR 40-216), and whenever feasible, should be
orders is officially deferred when managing BF. available at the BSA.
However, the medical and mental health per-
sonnel must be alert to the fact that many physi- (a) All physicians and phy-
cal or psychiatric illnesses may resemble BF, yet sician assistants must be able to perform and
require specific and even emergency treatment. document neurological screening and mental
It may be a matter of life or death to correctly status examinations in order to identify problem
make those diagnoses early. In more severe cases cases.
of BF, there is increased difficulty in recognizing
such illnesses, and the expertise of medical per- (b) The other mental health
sonnel is particularly important. Either the psy- disciplines must also be trained to perform a basic
chiatrist or the clinical psychologist should make physical screening examination. These personnel
diagnostic evaluations if the present of an NP include clinical psychologists, social work officers,
disorder is suspected or must be differentially occupational therapists, and appropriate enlisted
diagnosed. personnel.
(1) Physical screening. All REFER (3) Considerations during physical
and HOLD cases deserve an adequate review of screening. While a brief physical examination is
body systems and a quick physical examination. essential, the clinician must resist the tempta-
The examination includes vital signs, head/eyes/ tion to order tests or procedures that do not
ears/nose/throat. chest, abdomen, and extremi- directly influence case management, Do not, for
ties with simple testing of reflexes and muscle example, draw lines on the soldier’s skin to docu-
strength. Negative or normal findings need to be ment where the changes in sensation occur. Such
documented on the FMC or according to AR 40-66. lines, and medical tests in general, tend to vali-
Any positive findings from the physical examina- date and fix the symptoms in the mind of the
tion should, of course, be evaluated further. If patient. Needless tests may delay RTD and pro-
the examiner has not checked various body sys- vide a distinct incentive to remain incapacitated
tems, it is not reassuring to tell a soldier that his because of secondary gains, especially if there is
physical or mental complaints are “only BF." a chance of evacuation to a safer, more comfort-
DUTY and REST cases should also get this brief able area.
examination when time and setting allow.
(4) Treatment considerations (overtly
and covertly). The work-up therefore should be
NOTE limited to those essential steps which ensure
the medical safety of the soldier and determine
Previous observations in FTXs suggest whether he can—
that the physical examination is often
neglected for cases who have been Return to his unit.
labeled stress, BF, or psychiatric. This
undermines the credibility of the BF Return to another unit for
diagnosis and must not be allowed. rest.

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Receive treatment at this 6-3. Differential Diagnostic Problems
medical facility.
a. Low-Grade Environmental or Stress-
Be evacuated to the next Related Illnesses. Low-grade environmental or
rearward echelon. stress-related illnesses drain the soldiers’ strength
and confidence. Chronic diarrhea and slight fever
If no threat to life or permanent function is from subclinical malaria or a virus may exhaust,
involved, it is often best to treat overtly for BF demoralize, and contribute to BF among soldiers.
while monitoring covertly and providing general These conditions should be treated medically,
treatment for the other possibilities. concurrently with the physical replenishment,
rest, reassurance and organized activities which
(5) Restoring confidence after tem- restore the soldier’s confidence. If they persist in
porary disability. As BF is often caused by a spite of rest and symptomatic treatment, a more
combination of mental, physical, and physiologic aggressive workup and treatment is indicated.
stressors, there is no need to try to force the
soldier to accept emotional rather than physical b. Dehydration. Dehydration deserves
explanations for his inability to function well. special mention because it can be very subtle.
Many soldiers find it easier to recover confidence Soldiers under battlefield or heavy work
if they can believe that most of their problems conditions become extremely dehydrated without
resulted from physical overload. The term BF feeling thirsty. This is especially likely in
deliberately covers both sets of causes. mission-oriented protective posture (MOPP) and/
or arctic gear. In both conditions, it is mechani-
(6) Ruling out serious medical/ cally dificult to drink. An insufficient circulation
surgical causes. If soldiers who are believed only of thick, dehydrated blood is less able to carry
to have BF must be evacuated to a hospital for oxygen to the brain and muscles. This can result
diagnostic tests to rule out worse possibilities, in instant BF.
they should be told specifically that this is just a
precaution. They should be seen immediately on c. Hyperthermia. Hyperthermia (over-
arrival by the hospital psychiatrist and scheduled heating) in an otherwise healthy individual often
for the tests as soon as possible. The Principle of first causes mild elation and excessive energy.
Immediacy requires that expedient treatment be This may be followed by irritability, disorienta-
provided. Such BF cases are not routine cases tion, and confusion. When core body temperature
and should have priority just below that of sol- reaches 105° to 106ºF, the soldier may become
diers with life- and limb-threatening physical belligerent, combative, and have visual hallucina-
diagnoses. Remember, BF soldiers can suffer tions. If brain temperature rises further, the
lifelong psychological disability as a consequence soldier collapses and convulses in heatstroke.
of delay. These soldiers may require restraints and must
be cooled as rapidly as possible. In hot climates,
b. Importance of Recognizing Physical hyperthermia is expected, but it can occur in
Conditions. Paragraph 6-3 lists some of the physi- chemical protective gear (MOPP), cold weather
cal conditions which should be kept in mind in clothing, or during heavy physical work even in
the differential diagnoses of BF. Some of these temperate and cold climates. As these examples
conditions may exist concurrently and be a con- illustrate, hyperthermia is caused by a mismatch
tributing cause to the BF, but require specific between environment, activity, clothing, and
additional treatment. shelter.

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d. Hypothermia. Hypothermia may muscle overuse (and of heatstroke or crush inju-
cause an individual to become disoriented when ries) in which myoglobin from damaged muscle
core body temperature falls below 94°F. The cells injures the kidneys. This can cause acute
person may move and speak slowly. His skin renal failure and death, or chronic renal insuffi-
looks and feels warm, leading him to take off ciency. A warning sign is dark (tea-colored) urine,
clothing. He may even resemble a zombie. Hypo- but without laboratory testing, this is not easily
thermia is as likely in cool, or even warm (night- distinguished from the concentrated urine of de-
time), wet climates as it is in extremely cold ones. hydration. Cases with significant rhabdomyolysis
It is also caused by a mismatch between environ- should be evacuated immediately to a hospital. If
ment, activity, and clothing or shelter. Heat must kidney failure develops, they should be evacuated
be provided to the hypothermic soldier to prevent to CONUS.
death. If the soldier is extremely hypothermic,
care must be taken to avoid cardiac arrhythmia g. Head Trauma. Concussion may
during rewarming. stun the individual and cause amnesia, residual
confusion, and perhaps impulsive behavior. For
any case of suspected head trauma and for any
NOTE case of significant memory loss (especially for a
A simple rule of thumb is: If the soldier discrete period of time), check scalp, eyes, ears,
is overheated, help him cool off. If nose, cranial nerve signs, and vital signs for
there is any possibility he is cold or evidence of head injury. Negative as well as any
hypothermic, warm him up. Have him positive signs are recorded. The main concerns
drink cool or warm liquids suitable for are—
the condition since he is probably dehy-
drated. (1) Epidural hematoma (a blood clot
forming between the skull and the tough
membrane that covers the brain). This is usually
e. Overuse Syndromes. Overuse of due to arterial bleeding, with onset of symptoms
muscles, joints, and bones that have not been of increased intracranial pressure within minutes
prepared for the strain of field duties can lead to to a few hours. It can progress rapidly to coma
persisting stiffness, pain, swelling, and orthopedic and respiratory arrest.
injuries. If severe, these injuries may require
evacuation to a hospital for evaluation by an (2) Subdural hematoma (a blood
orthopedic surgeon, an occupational therapist, or clot forming between that tough membrane and
a physical therapist. Even if these injuries are the brain itself). This is usually venous bleeding
avoided, the unfit person who overexerts have with slower onset and progression but can lead to
days of stiffness, aching, and weakness. During coma and death.
this time, such cases are likely to have BF if
further demands are made on them. Physical (3) Intracranial pressure with
fitness exercises are a regular part of the treat- either epidural or subdural hematomas which
ment of BF. For these cases, the exercises should may become life threatening. If one pupil be-
first be limited to warm-up and stretching-type comes larger than the other, there is little time
calisthenics. left to evacuate the soldier to a hospital. Hyper-
ventilating the soldier can buy time by decreasing
f. Rhabdomyolysi.s. Rhabdomyolysis is blood flood to the brain and temporarily reducing
one potentially dangerous complication of severe intracranial pressure. An organic or attached

6-6
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surgical squad may drill burr holes to relieve monitoring would be appropriate if there are
intracranial pressure. When a surgical squad is serious concerns about the risk. In addition, the
not present, these patients are evacuated to the soldier is awakened every hour to check and
supporting hospital by the most expedient means record state of consciousness according to the
available. Glasgow Scale (Table 6-l). A11ow sufficient time
after awakening for the soldier to recover from
(4) If a head injury is suspected, the normal sleep inertia (grogginess on
continue to monitor mental status and vital awakening). This precaution will only slightly
signs periodically, especially respiration even decrease the restorative quality of the sleep which
though physical findings are negative. Continuous can be made up by letting the soldier sleep longer.

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(5) Skull x-rays are unlikely to physical and neurologic examination, or complete
show evidence of intracranial hematoma in young relief of symptoms following hypnosis or strong
adults. They may confirm a fracture of the skull, positive suggestions could demonstrate convinc-
but such a fracture would be highly unlikely in ingly that this is only BF. It is best to be cautious
someone who shows no bruises or other signs of a and keep the spine immobile during care and
hard blow to the head. If there is significant transportation. Send the soldier to where ade-
evidence of a severe blow, with or without skull quate X rays can be done while still expressing
fracture, patients are evacuated to a hospital with optimism that this may be only temporary BF or
neurosurgical capabilities. spinal bruising.
i. Postconcussion. Postconcussion syn-
NOTE dromes may persist weeks to months beyond the
period of acute concussion. Postconcussion syn-
A problem with evacuation to a corps dromes may include perceptual or cognitive im-
hospital is that soldiers are counted as pairment, poor impulse control, and difficulty in
a loss to their units. The personnel planning ahead. These are often accompanied by
replacement system counts soldiers as cranial nerve deficits or soft neurological signs.
a loss to their units as soon as they If severe and documented by examination or neuro-
cross the division/corps boundary. psychological testing, this could weigh against
rapid RTD. It may necessitate recommending
reclassification and retraining to another duty.
The system does not provide for returning soldiers
to their old division, let alone their own platoon,
unless such a return is individually coordinated NOTE
according to the TSOP. If returned to combat in
a strange unit, recovered BF or concussion cases, Like a concussion case, it is important
like all other soldiers, will for a time be at high to return cases who prove to have only
risk for BF or injury. After intracranial hemor- BF to their original units if recovery at
rhage has been ruled out at the hospital, trans- the CSC reconditioning center is rapid.
ferring the soldier briefly to the CSC recondi-
tioning center (see Chapter 9) may facilitate more
selective RTD. j. Abdominal Trauma. Ruptured
spleen or other intraperitoneal bleeding may
h. Spinal Cord Trauma. Pressure, cause shock. The soldier may arrive in a fetal
bruising, and hematomas of the spinal cord, as position and be unresponsive but with reflex
well as severing of the spinal cord, can cause “guarding” due to peritonitis. A case such as this
spinal shock, with loss of sensory and/or motor was misdiagnosed as “catatonia” and sent to an
functions below the level of the injury in the Israeli mental health team in Lebanon as one of
affected dermatome and muscle group patterns. over twenty stress cases in a true mass casualty
The loss of function may be bilateral, unilateral, situation. The team checked the vital signs and
or partial. These cases could be confused with correctly returned the soldier for emergency
paralysis or sensory-loss forms of BF. Further surgery.
manipulation of a fractured spine can worsen or
make permanent the spinal cord damage. In- k. Air Emboli and Focal Brain Isch-
formation from the history of onset, a cautious emia. High blast overpressures from an incoming

6-8
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high explosive ordnance can produce air emboli seen, you can be hit.” However, the second part
(bubbles in the blood) and focal brain ischemia of the saying, “If you can be hit, you can be killed,”
(small areas in the brain which cannot get oxygen is not so true. The flashes of light the person
because the blood flow has been interrupted). sees may even warn him to take action to evade
Nuclear explosions can do this, as can high explo- the missile or bullet that may follow. However,
sives when shock waves are magnified by reflec- after laser eye injury has happened to several
tion within bunkers, buildings, and trenches. A leaders or gunners in a unit or as rumors of it
few cases die within seconds, perhaps with no spread, other soldiers who must view the enemy
other sign of injury, although ruptured eardrums, may find their own vision failing for purely psy-
general trauma, and evidence of pulmonary chological reasons. Vision is one of mankind’s
damage should be detectable. More cases may primary means of relating to the world; it is used
survive but have stroke symptoms which could by those who have it in performing most tasks.
run the full range from loss of muscle strength Vision is also the medium for many pleasures.
and/or loss of sensation in parts of the body (hemi- Fear of major degradation of visual acuity and
paresis, hemianesthesia) to mild or major speech especially total blindness is, therefore, an un-
disturbances, depending on the size, number, and usually strong fear. In the imagination of some
location of bubbles that are lodged in the body. soldiers, especially those whose careers, activities,
and self-image depend on vision, blindness may
(1) Some air emboli may leave rank high as a crippling wound which makes a
areas of permanent brain cell destruction and dis- person helpless and an object of pity.
ability. Other smaller ones may allow consider-
able or complete recovery of functions in minutes (1) If the laser beam causes a small
to weeks. This occurs if collateral circulation retinal blood vessel to bleed inside the eyeball,
keeps the cells alive until the bubbles resorb or if the person will see red. If blood inside the eye is
neighboring areas of the brain relearn the func- confirmed on examination, these soldiers should
tion. However, even in those who have full and be evacuated to a hospital with verbal reassur-
rapid recovery of brain functions, the symptoms ance that they may RTD soon. If the soldier is
may persist as the pure loss-of-functions type of seeing red but no blood is confirmed on ophthal-
BF. This would be because the soldier’s extreme moscopic examination, treat as BF.
anxiety and internal conflict have been uncon-
sciously relieved by his honorable status as a (2) If the laser does not hit a blood
patient. vessel, the soldier may see only flashes of light,
followed quickly by some painless loss of vision.
(2) Specific treatment, if air emboli If the damage is peripheral vision, the soldier may
are suspected from the history of onset and physi- never know it. However, if he was looking exactly
cal findings, is to assure the best feasible oxygen- at the laser source, there will be major loss of
ation of the brain. visual clarity with no pain. These symptoms may
resemble visual forms of BF.
l. Laser Eye Injury. Today’s laser
range finders/target designators cause small (3) With simple retinal burns, most
burns on the retina if they shine directly into the of the visual symptoms are due to the swelling
eye, even at great distances and especially if around the very tiny burns. Much of the vision
viewed through optics. The fact that lasers travel may recover within hours to days with rest, re-
silently at the speed of light along a line of sight assurance, and nonspecific treatment, the same
adds new urgency to the saying, "If you can be as for BF. The only permanent result may be a

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constellation of small black dots in the soldier’s m. Middle Ear Injuries/Diseases. Tem-
visual field or a peripheral visual field defect of porary’ loss of hearing can be caused by a
which the soldier is unaware. decreased acoustic sensitivity following a brief
extremely intense noise (explosive) or less intense,
(4) Treatment following a sus- longer duration noise. Tinnitus (ringing in the
pected laser injury is extremely important, Calm, ears) can also result from acoustic nerve damage
professional treatment at each echelon of medical or irritation as well as from high doses of drugs,
care is mandatory. Assurance that the injury is such as aspirin. Hearing loss or perceiving noises
not life threatening and that chances for some, if in the ears can also be BF symptoms. Cumula-
not total, recovery is good. The potential psychol- tively, loud noise causes permanent damage to
ogical effects of lasers could be enormous. It is the cochlea, resulting in hearing loss especially
imperative that secondary gain for these patient for the higher frequencies. This is why routine
be minimized. This is accomplished by prompt use of earplugs and ear covers in noisy situations
RTD of those individuals with temporary flash- is so important for many (if not all) military
blindness, noncritical (nonfoveal) burns of the occupations. However, there are other combat
retina without hemorrhage, and those who are situations where acute hearing is essential and
experiencing purely psychogenic visual loss. If earplugs cannot be worn. Distinguishing physio-
an error is to be made, it should be to RTD logic from psychogenic hearing loss may require
questionable injuries, provided the risks are that the patient be evaluated by an otolaryn-
minimal for further injury or accident. Medical gologist (ear, nose and throat specialist).
management of stress reactions for patients
suffering from real or imagined laser injuries is n. Peripheral Neuropathies. These in-
like stress management of other injuries. Repeat clude compression neuropathies which are espe-
the reassurance that symptoms will improve with cially likely in military settings (for example,
rest, nutrition, hygiene, and the expectation of rucksack palsy). Depending on severity, they may
an early return to the soldier’s unit. require temporary job reclassification during
(5) Future development of lasers convalescence. As they are not life threatening,
as deliberate antipersonnel weapons may produce a hasty diagnosis should not precede a trial of
more pain and permanent effects. A high-energy restoration treatment.
laser weapon could cause the unprotected eye to
boil and burst. It could cause burns to exposed o. Uncommon but Endemic Neurologic
skin and set clothes on fire. This would be a Disorders. These are physical diseases whose
considerably more fearsome weapon, although symptoms (at least initially) are primarily mental
one which makes differential diagnosis of real or behavioral (although eventually documentable
from psychogenic injury much easier. If these by neurological or laboratory examination). Ex-
are encountered as a surprise, without adequate amples include:
preparation and training of the troops, the psy-
chological impact will be magnified. That may (1) Guillain-Barre syndrome (mus-
produce more cases of BF, some with visual cle paralysis, usually without sensory loss, which
symptoms. Laser-protective eyewear has been ascends the legs and arms, then the trunk, over
fielded; getting soldiers to wear it is an important hours to days). It is sometimes triggered by
issue for command and NCO emphasis. immunizations, as might be given to troops de-
ploying overseas. It often progresses to a life-
(6) For more information on the threatening situation as the muscles of respira-
threat of laser to the eye, see FM 8-50. tion become involved. This requires evacuation

6-10
FM 8-51

to COMMZ and CONUS. Fortunately, recovery degrade the increased levels of mission perform-
is usually complete, but it takes months to years. ance demanded by combat or may result in with-
drawal symptoms when access to alcohol is inter-
(2) Multiple sclerosis. This disease rupted by deployment. Minor alcohol withdrawal
can mimic many types of BF with its sometimes is identical to the normal common signs of BF
transitory, shifting motor, sensory, speech, and and requires no special treatment. However, it is
cognitive/emotional symptoms. It is made worse important to prevent the onset of major alcohol
by stress and may be difficult to diagnose. Once withdrawal if the history or physical findings of
confirmed, true multiple sclerosis cases should be chromic heavy drinking suggest that is likely.
evacuated to CONUS, as should other rare,
progressive diseases like Lou Gehrig’s disease (2) Intoxication or withdrawal from
(amyotrophic lateral sclerosis). Multiple sclerosis alcohol, barbiturates, and tranquilizers may be
on the battlefield is not likely to be more common mistaken for BF; however, these conditions re-
than in any other population of young to middle- quire special treatment. Withdrawal seizures or
aged adults. impending or ongoing delirium tremens need
emergency treatment with diazepam, another
(3) True convulsive seizure disor- benzodiazepine, or phenobarbital to stabilize for
ders. This may be a rare sequela of prior RTD evacuation and detoxification in a corps hospital.
head injury or a common sequela of sublethal or Dosage will be determined by the treating
chronic nerve agent exposure. These are treated physician.
with the normal anticonvulsant medications. If
soldiers who are anxious about nerve agent attack (3) Overuse of stimulants (such as
observe someone having a seizure, that may deliberate abuse or the desire to stay alert) may
trigger an epidemic of purely psychogenic sei- cause panic attacks, manic hyperactivity, rage
zures. Pseudoseizure (becoming unconscious, attacks, or a condition which closely mimics acute
falling down, and shaking all over) sometimes paranoid schizophrenia. Those patients with
occurs as a BF symptom. The extremely anxious paranoid psychosis can be treated with standard
soldiers may also have urinal and fecal incon- antipsychotic drugs such as chlorpromazine or
tinence during the pseudo seizure, as loss of haloperidol but may take 7 to 10 days to fully
bladder and bowel control at times of extreme recover. Cessation of amphetamines after pro-
danger is common. In a civilian setting, incon- longed use causes a “crash” (extreme sleepiness,
tinence during pseudoseizure is unusual. lethargy, overeating) and perhaps even a “crash
and burn” with possible serious depression and
P. Substance Misuse/Abuse. These suicidal thinking. This condition may require
may be examples of misconduct combat stress 1 to 2 weeks of hospitalization to assure safe
behaviors but are not necessarily reactions to recovery,
combat stress. Drug and alcohol abuse are
epidemic in US civilian society, especially among (4) Hallucinogenic drugs cause
adolescents and young adults, and continue to be sensory distortion, panic, bizarre thoughts, and
a problem in the Army in spite of prevention potentially dangerous actions. These may be
programs. employed by the enemy as chemical or biological
warfare agents. Phencyclidine hydrochloride
(1) Heavy habitual use of alcohol, (PCP) is especially problematic since it also blocks
even by otherwise capable officers and NCOs, may pain and tends to make those under its influence
go unnoticed in peacetime. However, it may paranoid, violent, and abnormally strong.

6-11
FM 8-51

Hallucinogenic drug psychosis should not be treatment (fluids, cooling). These measures will
treated with antipsychotic drugs. Physically sustain the soldier until the atropine is cleared in
restrain, sedate with diazepam or lorazepam, if 6 to 18 hours. Do not give chlorpromazine or
necessary, and evacuate for stabilization and diphenhydramine as they make the condition
further evaluation. worse. Diazepam may be used if sedation is
essential. In hot, humid climates, individuals who
(5) Inhalation of fumes (either by have inadvertently taken an overdose of atropine
accident or as deliberate abuse) and carbon- and are exhibiting signs of atropine intoxication
monoxide poisoning can cause disoriented, should have their activity restricted. In addition,
abnormal behavior. Supportive treatment and, these casualties must be kept as cool as possible
in cases such as carbon monoxide poisoning, for 6 to 8 hours after injection to avoid serious
specific antidotes or medication may be needed. incapacitation. Usually, the casualties will re-
cover fully in 24 hours or less from a significant
q. Anticholinergic Delirium. In com- overdose of atropine.
bat, atropine may be a problem since we equip
our troops with atropine injectors to use as first (2) Physostigmine (a rapidly cleared
aid against nerve agents. Even 2 milligrams (mg) antinerve agent) is the specific antidote for atro-
(one atropine injector) without nerve agent chal- pine; it must be titrated carefully over hours to
lenge can cause rapid pulse, dry mouth, slightly avoid overdose or relapse. This may be imprac-
dilated pupils, decreased sweating (hot, dry, tical in mass casualty situations. If available, it
flushed skin), and perhaps urinary retention. In can be used to confirm the diagnosis. Physostig-
some individuals, 6 mg of atropine (equal to three mine needs to be given in repeated doses only to
atropine injectors) may cause hallucination and those relatively few cases of atropine overdose
disorientation (without a nerve agent challenge). who are in danger of death from excessive body
Such effects may be more common in sleep- temperature (heatstroke) or cardiovascular col-
deprived soldiers. Similar effects can also occur lapse due to the high pulse rate.
from eating certain plants. When soldiers are
heat-stressed from exercise, clothing, or exposure r. Anticholinesterases. Nerve agent is
to hot, desert, or tropical environments, doses of an anticholinesterase similar to many insecti-
atropine tolerated well in temperate climates may cides. Low-dose nerve agent exposure may pro-
be even more incapacitating. In the heat-stressed duce miosis (pinpoint pupils) without other signs;
individuals, doses of atropine tolerated well in this will seriously decrease vision except in very
temperate climates may be seriously incapaci- bright light and cause eye pain when attempting
tating by degrading the sweating mechanism. to focus. This may take hours to days to improve
Such situations can sharply reduce the combat spontaneously, depending on the degree and type
effectiveness of troops who have suffered little or of exposure. Giving atropine eye drops will only
no exposure to a nerve agent. One dose (2 mg) of relieve the spasm if the soldier has been taking
atropine can reduce the efficiency of heat-stressed pyridostigimine as a pretreatment; the soldier will
soldiers. Two doses (4 mg) will sharply reduce then have several hours with very large pupils
combat efficiency, and 6 mg will incapacitate (bothered by bright light) and will have difficulty
troops for several hours. focusing on near objects, especially fine details.
Evidence gathered from affected insecticide
(1) Stabilization is achieved workers suggests that mild personality changes,
through reassurance, physical restraints (if insomnia with bad dreams, and chronic persistent
require for combative behavior), and supportive depressive symptoms (similar to common BF) may

6-12
FM 8-51

be seen even after use of an antidote. Low-dose Survival guilt is common
nerve agent exposure may lower the seizure with BF, as are feelings that death would be a
threshold of many soldiers. True epileptic seizure relief, would end the suspense, and is so likely
cases must be distinguished from those soldiers that it should be expected. Such cases are un-
who may have pseudoseizures and need only likely to commit suicide but may fail to take
treatment for BF. adequate precautions for safety. They may be
safer with trusted comrades who can watch out
s. Endemic “Functional” Major Psych- for them (as DUTY BF) than with an unfamiliar
iatric Disorders. These (especially schizophreni- CSS unit and categorized as REST BF. If they
form/schizophrenic disorder, major depression, cannot be held in their own unit, they should be
and bipolar disorder) will continue to occur at triaged as HOLD rather than REST unless the
approximately the same rate as in peacetime CSS unit where they are attached can provide
Active and Reserve Component personnel. They close supervision.
should be evacuated to CONUS as soon as they
can be distinguished from temporary BF or Sleep loss, emotional and
substance-related conditions with good potential physical fatigue with apathy, and loss of appetite
for RTD. However, that cannot be accomplished can mimic retarded depression. However, the
without some period of observation which soldier should regain energy, appetite, and per-
approximates the doctrinal restoration treatment spective quickly with sleep, hygiene, and good
for BF. That stabilization must be conducted in a A rations.
sufficiently secure, structured setting that
assures safety for violent or self-destructive Significant anxiety on top
behavior. A few soldiers who have been diagnosed of the depression could mimic a severe agitated
with psychiatric disorders by a civilian physician depression but should also improve quickly with
may deploy to the theater. These soldiers may rest in a relatively safe place.
hide the fact that they are taking psycho-
therapeutic medication to keep the diagnosis off Serious suicidal intent is
their military record. Once in the theater they more likely in soldiers who have suffered severe
may experience a relapse or self-refer themselves disappointment on the home front (Dear John
to an MTF when their medication supply is letters) or who have, in fact, committed errors
exhausted. The evaluating psychiatrist must about which they have reason to feel guilty (such
determine if the soldier can function without the as accidental fratricide). While such cases should
medication. If the soldier requires medication, be treated as BF, special attention should be given
can he be restabilized on a drug which can be to ensure their safety and to work on the under-
provided in the theater? Can the drug be given lying problem. Cases with depressive symptoms
without risk of harmful side effects? If the which do not improve in 1 to 3 days go for 7 to 14
alternatives are not feasible, the soldier must be days of reconditioning. Brief hospitalization on
evacuated out of the theater. The following the CSH’s NP ward with suicide precautions may
guidelines are proposed for management of cases be necessary for those who are judged danger-
with significant symptoms that suggest a major ously suicidal. If the depression has not improved
psychiatric disorder: after being sent for reconditioning in the
COMMZ, these cases meet the Diagnostic and
Statistical Manual of Mental Disorders. Third
(1) Severe retarded or agitated Edition, Revised (DSM III-R) criterion for major
depression with suicidal preoccupation. depression (2-weeks duration).

6-13
FM 8-51

(2) Predominantly auditory verbal t. Endemic Personality Disorders.
hallucinations and schizophrenic-type thought Preexisting personality disorders may make a
disorder. soldier unable to adapt to military life. However,
numerous studies have failed to show a relation-
This could be due to ship between personality disorders and the likeli-
stimulant misuse in a good soldier or a brief hood of breakdown in combat. Even so, once
reactive BF in response to extreme stress. This soldiers with personality disorders have become
is not a condition which can be managed in a BF casualties, they may have greater difficulty
1- to 3-day restoration program without excessive recovering and returning to duty. Those who
disruption for the other BF soldiers. The poten- malinger (deliberately fake illness to avoid duty)
tial risk of an open environment with many must be detected and RTD or have administrative
loaded firearms is too great. Send this case to a action initiated by the unit.
hospital with NP staff for stabilization. If sym-
ptoms improve quickly with rest or with anti- (1) A documented (DSM III-R)
psychotic medications, transfer the soldier for- personality disorder which also interferes with
ward to the reconditioning center to prepare for the soldier’s ability to perform duty is a basis for
RTD. If psychotic symptoms persist, evacuate to administrative discharge (Chapter 5, AR 635-
the COMMZ and CONUS. 200). The responsibility of the evaluating psychi-
atrist or psychologist is to certify that the soldier’s
Auditory but nonverbal unacceptable behavior is part of a true personality
hallucinations (such as hearing battle sounds, disorder. This is measured by DSM III-R’s strict
perhaps also with visual hallucination of battle criteria, specifically—
sights) are more likely to be BF with potential for
limited RTD in the TO. It is part of a long-stand-
ing pattern that has been evident since childhood
(3) Paranoid delusions without or early adolescence.
formal thought disorder. If this follows severe
sleep loss, it may clear completely with reassur- It is present in other as-
ance and sleep. If it does not, consider the nature pects of the soldier’s life besides military duties.
of the delusion and the sociocultural context. Is
it likely to interfere with mission performance It is inflexible and has not
and/or could it lead to inappropriate violent changed in spite of reasonable efforts to correct
behavior? If yes, HOLD or REFER (evacuate) for it.
further evaluation. If no, RTD with appropriate
advice to command or comrades about how to It interferes with military
handle to get best performance. duty.
(4) Manic episode. This could be This diagnosis may not be appropriate for someo-
due to sleep loss and stress, stimulant misuse, or ne who is still in adolescence, as may be the case
bipolar disorder. The soldier may be too dis- with some basic trainees and first tour soldiers.
ruptive to keep at forward locations. If sedations The lifelong label of a personality disorder as
(with physical restraint, if necessary) result in explanation for military discharge must not be
improvement after good sleep, consider RTD. If applied unless all of the features are present, even
mania persists, evacuate to next echelon for fur- though the soldier himself, as well as the com-
ther evaluation. mander, may wish to take this easy way out.

6-14
FM 8-51

(2) In the CZ, it may be difficult to insists on rapid evacuation, the diagnosis of
get the long-term occupational and social history personality disorder (and recommendation for
needed to truly document that a soldier’s behavior chapter discharge ) may best be deferred for
is due to a personality disorder and not just to BF further evaluation in CONUS. In the CZ, com-
or an adjustment disorder. In principle, soldiers mand should be unwilling to allow so easy a way
should not be medically evacuated from the home which might encourage malingering. They
theater for poor performance or misconduct. If should require RTD, job reclassification, or
the soldier’s emotional or mental state does disciplinary action, unless true BF is present and
preclude return to useful duty and command does not respond sufficiently to treatment.

6-15
FM 8-51

CHAPTER 7

COMBAT STRESS CONTROL STABILIZATION

7-1. Priority for Stabilization physiological stress, and the possibility of direct
NP effects of some NBC agents.
Combat stress control stabilization is the acute
management of the small percentage of BF and (3) Examples of these CSC cas-
NP cases who have severe behavioral dis- ualties requiring immediate stabilization were
turbances. The behavior seriously disrupts the provided in paragraph 6-3.
functioning of the unit and may even pose a
danger to the soldier or others. In some cases, b. Full Stabilization. Full stabilization
the underlying medical condition may also be a goes beyond securing the safety of the patient
danger to the soldier’s life. Combat stress control and those around him. It prepares the patient
stabilization can be divided into initial emergency for an evaluation of his potential for RTD in the
stabilization and full stabilization. near future. If RTD within the evacuation policy
is not feasible, it prepares the patient for safe,
a. Initial Emergency Combat Stress long-distance evacuation. Full stabilization is
Control Stabilization. Initial emergency CSC normally the responsibility of the NP ward and
stabilization has been achieved when the consultation service (module of the hospital unit
disturbed soldier is in physical restraints, can be base) in every CSH, FH, and GH.
given an adequate physical examination, and (1) Full stabilization is desirable
may, if necessary, be sedated for evacuation. This for the sake of the soldier’s future treatment and
may be all that can be done at forward echelons for the potential of returning some soldiers to
by nonpsychiatric personnel or by CSC personnel duty. However, full stabilization is personnel
in a mass casualty situation. Stabilizing severely intensive with a relatively low RTD payoff. For
disturbed soldiers will always have an extremely that reason, full stabilization has the lowest
high priority, especially when they become priority of the six CSC functions. Providing only
agitated or combative. Such cases can cause sufficient initial stabilization to allow evacuation
serious harm to others as well as to themselves, from the theater may be accepted in order to
especially in a presence of loaded firearms, maintain the other CSC functions.
explosives, powerful machinery, and life or death
missions. (2) However, because of the low
priority for evacuation of NP patients as com-
(1) Violent behavior is quite rare pared to the large surgical caseload, it is quite
in pure BF but is one form of misconduct stress likely that NP patients will accumulate in the CZ
behavior. Some NP disorders are prone to or COMMZ. Even adequate initial stabilization
violence, especially paranoid psychotic states. will require continued resources.
Violence is also more likely with disruption
of brain functioning due to organic factors such
as intoxication, hyperthermia, or metabolic 7-2. Use of Restraints in Initial (Emer-
imbalance. gency) Stabilization
(2) Increased numbers of these a. Physical Restraints. Physically re-
severe BF cases can be expected during high straining soldiers with presumed BF goes against
NBC threat situations. This is due to increased the treatment message of normality and positive
organic brain syndromes caused by antidotes expectation. However, some NP and a few BF
(such as atropine), heat stress, the heightened cases may be—

7-1
FM 8-51

Seriously disoriented and con- Lockable, padded leather cuff restraints are safest
fused. but may be in short supply. Other methods such
as using two litters (sandwiching the patient
Paranoid. between the litters and using straps for securing)
or straps, sheets, improvised strait-jackets or any
Delusional. other field expedients may be used. Regardless
of the method, the soldier placed in restraints
Hallucinatory. must be checked frequently. This is done to guard
against nerve injuries or impaired circulation
Suicidal. leading to skin ulcers or gangrene. It is also
important to check that the soldier is not secretly
Agitated and restless. escaping from restraints. The soldier is provided
verbal reassurances with positive expectations for
Manic and intrusive. his recovery each time he is checked.
Threatening violence.
7-3. Use of Medication in Initial (Emer-
Restraining these soldiers may be necessary to gency) Stabilization
ensure safety of the soldier and other personnel.
Physical restraints also minimize disruptions of a. Administering Medication. Admin-
medical or restoration activities (especially when istering medication to an uncooperative and
staff are few). It also permits medical evacuation unrestrained severe BF soldier can be extremely
by ground (preferred) or air ambulance. difficult; unfortunately, the effects of the
medication may act too slowly to be much help.
b. Subduing and Restraining an Agi- Once the soldier is in restraints, the medication
tated or Disruptive Soldier. The best way to is no longer essential and serves mainly to reduce
subdue and restrain agitated or disruptive the risk of escape. Medications will reduce an
soldiers is verbally, by reassurance and re- agitated soldier’s resistance to the restraints, thus
orientation. If that fails, a nonthreatening show diminishing the disturbance of other BF soldiers
of strength may suffice. Otherwise, decisive in the vicinity.
coordinated action by five helpers, one on each
limb, one to hold the head, is preferred to get the b. Observing for Reactions. The soldier
soldier face down on the ground. More helpers is observed for any reactions. Be concerned that
get in each other’s way. Fewer may be all that the medication does not interact badly with any
are available but risk more injury to the staff biochemical already present in the disturbed
from bites, blows, or kicks. The patient also is soldier. Do not give chlorpromazine for anti-
more likely to be injured. It is inadvisable to cholinergic delirium. If hallucinogenic drug
attempt subduing an agitated case one-on-one. intoxication is suspected, the use of any
The restraining team should continue to talk with antipsychotic drug is contraindicated. The use
and provide reassurance to the resisting patient of diazepam for pathological intoxication with
during the take-down. alcohol or barbiturates is also contraindicated.
c. Methods of Restraining. Once the c. Rapid Sedation. Rapid sedation
soldier is face down, mechanical restraints can with antipsychotic drugs (repeating high doses
be applied if sufficient personnel are available. every half hour until the patient is sedated) was

7-2
FM 8-51

widely practiced in the early 1980s. This method be needed to get information on prior history and
did not improve overall recovery time signifi- functioning. The further from the unit the soldier
cantly and did tend to cause more side effects has been evacuated, the more difficult it is
such as dystonic spasms of the neck, back, or to contact the soldier’s unit. Full stabilization
eye muscles. Now, even in known psychiatric normally takes several days.
patients who must be restabilized after stopping
their previously successful medication, it is a. Follow the Principles for Treating
more common practice to build up antipsychotic Battle Fatigue. To the extent compatible with
drugs gradually. To achieve an antianxiety and safety, the stabilization program should adhere
sedative effect, the patient is initially treated to the principles and methods for treating battle
with a benzodiazepine (such as diazepam or fatigue:
lorazepam). Lorazepam, if available, has the
advantage of being more consistent when given (1) PIES:
intramuscularly.
Proximity to the soldier’s
d. Effects of Antipsychotic Drugs. Anti- unit.
psychotic drugs can take several hours to
days to take effect. Early administration of Immediate initiation of
chlorpromazine or another antipsychotic drug treatment.
may confuse the clinical picture for the next
evaluator if the soldier is evacuated. The evalu- Expectation of rapid and
ator will not know whether any changes in the full recovery.
soldier’s behavior over the next day or two was Simplicity of approach.
due to the reassurance, sleep, hydration, and
reduced anxiety (from increasing distance from (2) The four Rs:
the battle), or whether it is just due to the medi-
cation. The medication must be discontinued if Reassurance of normality.
the soldier is to RTD. Therefore, the recom-
mendation for most cases is to use no medication Rest.
unless it is truly necessary for management.
If medication is required, use as low a dose Replenishment of nutri-
as is effective of a benzodiazepine (usually tion, hydration, hygiene, and sense of physical
diazepam or lorazepam, although a shorter acting well-being.
benzodiazepine, such as temazepam, would be
better when available). Restoration of confidence
through talk and activities.
7-4. Full Stabilization in Combat Stress (3) Maintain and reinforce the sol-
Control dier’s identity as a soldier.
Full stabilization in CSC includes adequate evalu- Battle-dress uniform, not
ation of RTD potential. This requires assessment pajamas, as soon as they can be allowed safely.
of mental status and performance capability over
time without excessive drug effects or limitations Rank distinctions and ap-
on activity. Contact with the soldier’s unit may propriate military courtesy.

7-3
FM 8-51

Responsible for self-care For that reason, most full stabilization will be
and helping others. conducted in the CSH, FH, or GH. All of these
hospitals have an inpatient psychiatric capa-
b. Evaluation and Treatment Modali- bility. Those soldiers who improve and have
ties. The evaluation and treatment modalities the potential for RTD are then transferred to
include— a reconditioning program.

Individual interviews for ob- b. Neuropsychiatric Ward. Military
taining complete medical history. hospital NP wards in the TO can be catego-
rized as either in fixed/planned facilities, fixed/
Mental status examination. improvised facilities, or mobile facilities.

Laboratory and x-ray workup, (1) Fixed/planned facilities are in
as indicated. buildings which were designed or premodified
to serve as psychiatric wards. These could be in
Physical examination (should US Army fixed hospitals, allied military hos-
be thorough). pital, or host-nation civilian hospitals. Depending
on degree of modernity and enlightenment of
Specialty consultations as indi- psychiatric treatment, these should provide—
cated. Security design for pro-
tection against suicide.
Group sessions.
Seclusion areas.
Recreational activities.
Comfortable and reason-
Occupational (work) history. ably civilized surroundings.
These can provide the safest setting for initial
7-5. Stabilization Treatment Facilities stabilization, or for holding cases until they can
be evacuated. They may already be divided into
Stabilization Facilities. Ideally, sta- maximum security closed wards and open wards
bilization is conducted by qualified mental health which allow for more responsible self-controlling
personnel in a nonhospital (medical company behavior. If such facilities are to be used for the
clearing station ) military setting, to maximize treatment and evaluation of soldiers for possible
positive expectation and minimize chronicity. RTD, it requires steps to maintain a military
However, it must be kept separate from the setting for the wards and the treatment routine.
restoration or reconditioning facilities, as the
presence of these dramatically symptomatic (2) Fixed/improvised facilities are
soldiers is very disruptive to the treatment of BF in buildings which were not designed or pre-
casualties. More sophisticated procedures and viously modified for use as psychiatric wards.
laboratory and x-ray capabilities may be required These buildings have been taken over for this
than is available at medical company clearing purpose. They will require assessment and
station (for example, lumbar puncture and usually some modification to make them safe,
cerebral spinal fluid examination and analysis). including—

7-4
FM 8-51

Impassable screens on the (high security) and “open” (moderate/minimal)
windows. security area. The latter could be a standard GP
large tent (the same as those of the minimal care
Covering of electrical out- wards [MCW]) located close to the TEMPER tent
lets. of the official NP ward. The specialists (MOS
91C and 91B) of the MCW could be given on-the-
Removal of hazard for sui- job-training in supervision and military group
cidal or violent acting out. activities for the moderate/minimum security
cases if the NP staff is too small.
Separation of wards into closed and open is
desirable if layout and staffing allows. Here, c. Mixed Neuropsychiatric/Medical Sur-
too, it is important to maintain a military gical Ward. The NP ward may be expected to
environment and routine to the degree patient admit those NP cases with concurrent physical
safety allows, especially on the open ward. illness or injury and concurrent significant
mental symptoms unless the patient’s condition
(3) Mobile facilities are those requires that he be in the intensive care unit, or
which are in tent, extendable, modular, person- in isolation because of contagious disease. The
nel (TEMPER) or general purpose (GP) large mental symptoms could be—
tents. The principal advantage of the (hospital)
TEMPER tents, as assembled into Deployable Caused by organic brain dis-
Medical System (DEPMEDS) hospitals, is their ruption (such as drug intoxication or withdrawal).
climate control capability. This may be a sig- Functional NP disorders which
nificant safety advantage for treating seriously
disturbed patients in restraints with high-dose are coincidental to the illness or injury.
medication, which can disrupt normal thermal Functional and in reaction to
regulations. Both TEMPER and standard tents the traumatic situation which caused the injury.
pose greater problems for security than do fixed
facilities. The staff may, therefore, have to rely The NP staff must be prepared to react thera-
more than is ideal on physical and/or chemical peutically whatever the cause of the disturbed
restraints. Blankets or screens can be used to behavior. In the event of many medical/surgical
isolate or segregate problem patients from others. cases, the NP ward could receive overflow
Such partitions reduce behavioral contagion but medical/surgical cases. Therefore, NP ward staff
provide little true protection. Standard mobile must remain current in basic nursing and wound
hospital beds on high, lightweight metal legs must care skills.
be replaced with standard low, stable cots to hold
strong, agitated patients in restraints. The cots d. Combat Support Hospital Neuro-
also make a more “military” setting and can be psychiatric Ward Staff. Definitive information is
used as seats for group activities. As in the fixed provided on the CSH NP ward staff capabilities
facilities, it is best to have a separate “closed” in FM 8-10-14.

7-5
FM 8-51

CHAPTER 8

COMBAT STRESS CONTROL RESTORATION

8-1. Restoration of Battle Fatigue Casu- requirements for cases and unit safety while
alties awaiting (and during) evacuation.
a. Restoration. Restoration is the l-to (2) To the greatest extent possible,
3-day treatment of BF casualties at medical units preventive consultation, operational planning and
which are as close to the BF casualties’ units as RTD-related coordination must continue or the
their condition and the tactical situation allow. influx will worsen!
Restoration can be divided into first line (the
furthest forward, with few staff, under very (3) Combat stress control per-
limiting and fluctuating conditions), second line sonnel should be freed up for reconstitution
(still limited, but with more expert staff and more support missions even if that means evacuating
predictability) and third line (performed at some BF casualties who appear likely to require
Echelon III or Echelon IV hospital). disproportionate effort for restoration. Otherwise,
more BF soldiers who could have recovered and
b. Screening and Treatment. Adequate returned to duty in their units will just add to the
medical screening and treatment must be done in already great work load for restoration.
the supported units by organic medical platoons
or by the supporting medical companies. The BF d. Categories of Restoration. Resto-
casualties who enter restoration should be only ration can be categorized as first line, second line,
those HOLD and REFER cases who require or third line, depending on where it is provided.
continuous medical and/or mental health The three categories may also differ in duration
evaluation and observation for 24 hours or more. of restoration which they usually provide. This
Although still on their unit roll, they are not is dependent on the level of specialized skill,
available to that unit for even limited duty and experience, and knowledge of the providers.
are, therefore, true casualties. DUTY (mild) cases
will have been returned to their small units and
REST (moderate) cases sent to rest in their units’
CSS elements. 8-2. Generic Tactics, Techniques, and
Procedures of Restoration
c. Restoration Priority. Restoration
usually has the fifth priority following con- a. Reprieve from Extreme Stress.
sultation, reconstitution support, combat NP Initial restoration begins at the most forward
triage, and minimal essential stabilization. echelon where the label “REFER BF” can be
However, when true BF casualties are numerous, changed to “HOLD. ” Normally, restoration
or when the tactical situation makes it difficult facilities are part of (or collocate with) the clearing
for forward units to manage DUTY and REST BF station of the supporting medical company.
cases, the influx of BF cases may force restoration
to take a temporarily higher priority. (1) Criteria for when to hold cases
for restoration were discussed under combat NP
(1) To the maximum extent pos- triage in Chapter 6.
sible, restoration should be increased. This
means a lower priority for reconditioning and (2) Restoration is not feasible at
stabilization being restricted to the minimum locations which are consistently under artillery.

8-1
FM 8-51

air, or direct-fire attack, unless they are ex- area is close to the host unit’s field kitchen and
ceedingly well fortified and resistant to damage. other support facilities.
However, safety on the modern deep battlefield
is never complete; relative security is sufficient (6) Restoration facilities collocated
to provide restoration. If there is potential for with medical units in the BSAs and DSAs will
attack, there should be reasonable cover and often be restricted by the local commander from
defensive position to provide a sense of relative displaying the red cross on the grounds that
safety to a jumpy combat soldier. A good work it reveals the entire unit’s location. This is
detail for recovering BF casualties is the digging, consistent with the principle of treating BF cases
building, and camouflaging of these positions. as “soldiers, not patients.” In the corps area, there
is a greater chance that the medical unit will
(3) Ideally, the location is still be allowed to display the red cross. The restor-
“within sound of the artillery,” that is, within the ation (and/or reconditioning) facility leader will
sounds of the distant booms or rumble that need guidance on whether to display the red
remind the soldier that comrades are still in cross or not. If the red cross is displayed, there
battle. Other relatively distant noises, such as is greater assurance of protection under the
helicopters, aircraft taking off, or road traffic, are Geneva Conventions, For discussion of the issue
also acceptable provided they are not so noisy as of Geneva Conventions status and its limitations
to disrupt sleep. on CSC activities, see Appendix D.
(4) In addition, the location should b. Reassurance. Restoration begins
not be one from which a move is likely within 24 after the initial combat NP triage evaluation
(or 48) hours. If there is a significant possibility described in Chapter 6. Immediate reassurance
of a move, only those cases who can participate is given to BF soldiers,
actively in the move with minimal supervision
should be held for treatment at this location. Any (1) Tell them that they are tem-
time the unit is given a warning order to standby porarily joining the unit, not as patients, but as
to displace, the CSC staff may have to conduct a soldiers who need a couple days to recover from
quick sorting of the cases on hand. The staff uses BF. Emphasize that BF is a normal response to
more stringent combat NP triage criteria and extremely abnormal conditions and that rapid
sends to the next-line restoration facility all those recovery is also normal.
who are not readily transportable with the team. (2) Orient the BF casualty to the
program. Tell them that they will get plenty of
(5) The specific site of the resto- food and beverages, good sleep, a chance to clean
ration facility should be out of immediate (close) up, and light duties for 1 or 2 days (or at most, 3
sight of the triage area. Battle fatigue casualties days). By that time, they will have regained
should not be able to see severely wounded strength and confidence and will return to their
soldiers come into the MTF. The expectant area unit.
or temporary morgue areas, when mass casualty
situations occur, should also not be seen from the (3) Reassure them (as much as you
restoration facility. It may be close to, but ideally honestly can) about safety and what to do in the
slightly separate from, the treatment area for event of an attack or march order.
RTD wounded and DNBI cases. However, these
can merge if provision is made to stabilize overly (4) Personal possessions are not
dramatic cases elsewhere. Ideally, the restoration taken away. These personal items remind the

8-2
FM 8-51

soldiers of their normal lives and are a comfort in the soldiers, but is kept at a central place until
time of stress. The soldiers are expected to take the soldier is ready to RTD or be evacuated.
care of their personal items. This applies even to
knives or other weapons (with the exception of (3) The initial interview and ac-
firearms), unless there is significant reason for tivities depend upon the symptoms of the BF
concern that this soldier might harm himself or casualty and the degree of physical/psychologic
others. Soldiers for whom there is such concerns stress in relation to the cognitive/emotional stress.
need stabilization and should be segregated, at The attitude of the interviewer should be that of
least temporarily, from the restoration program. a good, caring leader. As a leader, he is getting
to know the recent experience, background, and
(5) If the soldier arrives with a skills of a new soldier just assigned to his unit as
firearm, the weapon is secured by the medical a combat transfer, not as a therapist doing an
company supply element. Ammunition, grenades, intake interview.
mines, or other explosives must also be collected
and turned-in. The soldier should be told that A BF casualty who is in
this is the TSOP for all medical units. Tell the good physiologic shape, but who clearly has much
BF soldier that his weapon will be returned to to talk about, should be encouraged to talk im-
him if he is assigned guard duty or if the medical mediately.
unit is under the threat of an attack.
c. Structured Military Environment. More often tending to and
Maintain a structured military chain of command. restoring physiologic status comes first. The
When the BF soldier is processed into the order of priority varies with the nature of the
restoration program, he is received as a soldier deprivation.
performing temporary duty and not as a patient.
(4) The newly arrived soldier is not
(1) Assign the BF casualty to a assigned to a ward tent as a patient but rather to
“squad” under supervision of a specific squad the squad’s quarters tent. In many situations, it
leader. At larger facilities, several squads may will be appropriate and necessary for the squad
be organized into a platoon, under a platoon leader(s) to sleep in the same tent with the team
leader. In a extremely large restoration center, members. Ponchos or blankets can be hung to
several platoons could be organized into a com- screen off areas where true patients are resting
pany. The squad leader may be a CSC unit or and to provide privacy.
mental health section officer, NCO, or section
member, or a member of the host medical unit’s d. Replenishment of Physiologic Status.
patient-holding squad. In a pinch, a carefully
selected line NCO with a minor wound or injury (1) Restore temperature regula-
that temporarily prevents his RTD may be tion. Get the soldier under shelter and cool down
detailed as a squad leader. Ideally, each squad if overheated, warm up if cold, dry off if wet.
leader should not have more than 6 to 8 BF
casualties to supervise. For brief peak periods,
the squad leader may be assigned 10 to 12 BF (2) Replenish hydration with pal-
casualties to manage. atable beverages (cool if hot, warm or hot if cold).

(2) The soldier’s FMC (filled out Soups are ideal as they
during combat NP triage) is not kept attached to are also foods.

8-3
FM 8-51

Milk, soft drinks, Kool- (a) Wash face and hands with
Aid, and fruit juices are good. wash cloth, warm/hot water and soap. The men
shave with hot water, soap or lather, and sharp
Minimize caffeine-type safety razors. This may extend to a partial or full
stimulants in coffee, tea, or beverages, unless sponge bath, if feasible. The restoration facility
increased wakefulness is desired. needs a supply of sundry packs plus a basin.

Intravenous fluids may (b) Hot showers, if available.
be used in exceptional cases when speed of A quartermaster shower/bath unit may be present
dehydration is important. Effort is then required in a corps base defense cluster DSA or BSA. The
to reinforce the fact that the soldier is not a shower point may be some walking or riding
patient and that this is just routine. distance away, and scheduled hours of operations
should be considered.
(3) Replenish nutrition. Offer the (c) In hot or temperate
best possible filling meal, preferably high in weather, CSC personnel (and/or the host medical
carbohydrates with some protein. unit) should set up a field shower.
(a) A-rations from the host This could be an
unit’s field kitchen are best. Hot tray-packs Australian shower bucket, a collapsing canvas
(especially the noodles and potatoes tray) and bucket with nozzle. A shower could be improvised
even hot MREs are acceptable.If the latter are by perforating other large buckets or 55-gallon
used, try to have some special seasonings or drums (see FM 21-10).
garnishes to increase variety and palatability.
Break up and stir most tray-pack selections to The shower can be
normalize their texture and appearance, rather screened with poncho liners for privacy and given
than serving them as a solid rectangular “brick.” a wooden pallet “floor” above the water run-off.
In cold weather, a tent with a heater would need
(b) Since BF casualties may to be dedicated to the shower.
arrive at any time, day or night, a restoration
facility must have means to quickly heat food. Hot water from the
The minimum standard is a large pot of water field kitchen or an alternate source is blended
ready to boil at all times. If the supporting field with cool water to give a suitable shower temp-
kitchen cannot provide this, CSC personnel erature. Dry, clean towels are also necessary,
should coordinate for other arrangements. since most of the BF casualties will not bring their
own.
(c) If a BF casualty is too The hot shower is
tired, anxious, or depressed to eat at first, provide an excellent way for new arrivals to relax and
an assigned area for sleeping. “Three hots and a unwind before sleep, if they are not already too
cot” are essential throughout the period of exhausted, or if harsh weather does not make it
restoration. too difficult. Otherwise, it can be an “event” or
“duty activity” for subsequent restoration days.
(4) Restore hygiene. Unless the
soldier is totally exhausted and already falling (d) The importance of clean
asleep, institute some personal hygiene. clothes (if available) depends on the condition of

8-4
FM 8-51

(how wet, sweaty, filthy, bloody, or torn) the BF able earplugs) and darkness (perhaps facilitated
casualties’ own battle-dress uniforms. by a cravat blindfold).

In principle, BF ca- (a) Bedding may be on a cot,
sualties should remain in combat uniform which a ground pad, an air mattress, or field expedient
includes helmet and protective mask. Reasonably hay, pine needles, or leaves. The quality of sleep
complete load bearing equipment (LBE) and clean is important, especially for the first night or two,
uniforms are desirable. However, BF casualties so the shelter should be as comfortable as is
do not need to be in uniform while sleeping, practical and neither too cold nor too hot.
provided adequate sleeping gear (bedding) is
available. (b) The soldier should be told
bad dreams will probably occur soon after he falls
A problem may arise asleep and be reassured that they are normal and
because medical treatment companies, unlike that he should go back to sleep if awakened.
hospitals, do not stock either patient pajamas
(which BF casualties should not be given on (c) Muscle stretching rou-
principle), spare uniforms, or a large supply of tines, massage, and other simple relaxation
sleeping bags. Nor do they have an organic techniques may help the tense or anxious soldier
laundry. get to sleep. If available, audiotapes of relaxing
background sounds can be played.
Those personnel who (d) Medication for sleep
are supervising BF casualties must work with the should not be used if food, a hot shower, or
medical company’s supply element to priority relaxation will do. However, BF casualties who
requisition necessary clothing, bedding, and are too tense, depressed, or frightened to sleep
equipment items through the supporting logistic can be given just enough sleep medication to help
element (the FSB, MSB, or area support bat- them doze off. Possible sleep aids are—
talion’s S4). It may be necessary to improvise
until required items are available. In the corps, Diphenhydramine, a
the AG replacement company will issue RTD sedative antihistamine in most medication sets).
soldiers new clothing, as required,
Low-dose diazepam.
A field-improvised A dosage of 2.5 or 5 mg may be administered.
laundry (hot water pots and soap) plus patching The trouble with diazepam is that it and its active
and sewing repairs may also be a useful “work metabolizes are slowly cleared from the body.
project” for the recovering BF casualty. Their continued presence in the body and brain
may interfere with motor coordination and task
(5) Restorative sleep should be performance the next day. The persistence of
as normal as possible. Most BF casualties will some pharmacologic antianxiety effect may seem
fall asleep quickly with only strong positive like an advantage, but it actually interferes with
reassurance that they will be safe, provided they the treatment, which is based on helping the
have relative comfort compared to what they soldier master his own anxiety himself.
have been used to. It is important to minimize
interruptions to sleep. As much as possible, Temazepam, if avail-
ensure relative quietness (facilitated by dispos- able. This has a biological half-life under 8

8-5
FM 8-51

hours and should have no residual sedation, (3) Conduct basic soldiering skills.
antianxiety, or motor skill deficit the next day. See FM 8-10 and Appendix D for the limitation
of the Geneva Sick and Wounded Convention
Triazolam (Halcion). regarding who may teach what to whom.
This sleep aid is even more rapidly cleared but
has been reported to produce some memory f. Structure Activities During Unit
problems, especially if sleep is interrupted. The Formations. Provide structure to the day’s
person may appear to be normal, but does not activities through regular group formations.
remember his experiences later. Some people
have difficulty in learning new information the (1) Regularly scheduled forma-
following day. tions provide occasions to announce the day’s
schedule of activities, assign tasks/details to each
(e) Antianxiety drugs should squad leader, introduce new members, and allow
not be given routinely during restoration. In most participation by BF casualties in planning how to
cases, soldiers should not be medicated even with carry out the assigned activities.
their anxiety. Unmedicated soldiers will be better
able to participate actively in their own recovery (2) The leaders keep everyone
and perform with appropriate capability if the informed by briefings on the “big picture” and
facility comes under attack or must move. tactical situation, with special attention to the
activities of the BF casualties’ units of origin.
Obtain and circulate command information fact
(f) The duration of sleep
should be sufficient to make substantial progress sheets and newspapers. Radio and/or television
in repaying the sleep debt. It should also begin may be available in the theater which are good
the process of restoring a reasonable sleep/wake sources for information.
cycle. The start time and wake-up time should Assign Duties and Work Details.
be flexible but tend towards sleeping most of g.
the night and being awake all day (or split shift, (1) Assign militarily relevant work
with sleep in the graveyard shift plus an after- details at the MTF, preferably to pairs or groups
noon nap). Initial sleep should be 8 to 12 plus which include BF casualties and non-BF casu-
hours. alties. Examples include—
e. Support the Soldier’s Military Iden- Digging foxholes and slit
tity. Sustain the soldier’s identity as a soldier. trenches.
(1) Maintain appropriate rank dis- Filling sandbags.
tinctions, titles, and military courtesies from the
outset. Erecting and garnishing
camouflage when permitted.
(2) Expect the soldier to maintain
military bearing, personal appearance, uniform Providing perimeter guard
(to include LBE [with canteen, rolled poncho, or air watch.
and first-aid dressing pack as a minimum]),
protective mask, and helmet when outdoors Performing vehicle pre-
unless under special circumstances. ventive maintenance or repair.

8-6
FM 8-51

Cleaning equipment. that keep them moving and flexible while they
recover strength.
Work activities must be coordinated with ap-
propriate commanders and subordinates well in (c) Tasks should be chosen to
advance of casualty flow. exercise relevant manual and cognitive skills and
to ensure a successful and satisfying performance.
(2) Other obviously relevant and
necessary work details include assisting with food (d) Utilize soldiers’ skills to
preparation and food service at the supporting teach each other.
field kitchen. Battle-fatigue casualties may be
used for loading, unloading, and moving supplies. h. Schedule Relaxing Activities. Pro-
Repairing clothing and equipment, operating the vide enjoyable, relaxing activity.
field expedient shower, and improving or making
a new latrine are additional appropriate work (1) Provide physical training and
details. Assisting with the care and movement of ensure all are involved in an exercise program.
other minor wounded and ill may be done and is
especially indicated for BF medical personnel.
However, these and other duties must not expose (2) Organize cooperative/competi-
the BF soldiers to the critically injured or those tive physical team games (involving BF casualties
awaiting treatment (except for those medics who and non-BF casualties). Examples include relay
are in the final stage of recovery just before RTD). or cross-country races; tug-of-war; touch football,
volleyball, or soccer (using a real or improvised
(3) Tasks and work details are as- ball); softball; or stick ball. These games should
signed according to the status and needs of each be short, vigorous, and balanced with rest and
case. replenishment, as well as the work details.

(a) Some BF casualties need (3) Organize cooperative/competi-
heavy physical activity to work off energy and tive mental games for teams or pairs of soldiers.
complete the unfinished stress-release process. These include card games or board games like
They should be given tools which make this sat- chess and checkers.
isfying. Give them shovels and picks that can
really move dirt and show accomplishment in (4) Equipment for the physical and
minutes, not little entrenching tools that just mental games can be brought from home upon
scratch away at the surface. deployment. Equipment may be mailed by friends
and family on request. The equipment may be
obtained from the morale/welfare/recreation set
NOTE or purchased from host nation retailers. Some of
the equipment for games may be constructed out
Soldiers who may be violent or unstable of otherwise worthless trash as an individual or
should not be given tools which could team project.
be used to harm themselves or others.
(5) Teach relaxation techniques in
group relaxation sessions in which the mental
(b) Other BF casualties who health/CSC person talks everyone through the
are already physically drained need light duties technique.

8-7
FM 8-51

i. Debriefing, Ventilation, and Coun- based on the counselor’s understanding of the
seling. Mental health/CSC personnel (or medics soldiers’ common experiences and the way they
trained by mental health/CSC personnel) provide are coping with them. These small, focused
individual or small group discussion and coun- groups can often confirm the message of normal,
seling. shared experiences better than the counselor can
by himself.
(1) Formal critical event debrief-
ing or ventilation is not usually done in large (5) As BF casualties recover, the
formations or group activities during brief res- counseling process shifts towards how recovering
toration. The turnover is too rapid to form highly BF casualties can return to their small units and
supportive relationships and a clear therapeutic be accepted there. The counselor must work with
mind-set. Instead, the tendency is for the high the CSC coordinator or other resources (such as
percentage of new BF casualties (all of whom have the unit chaplains) who can assist this reinte-
had different bad experiences and who are gration. Ways to coordinate and facilitate RTD
strangers to the group and to each other) to were discussed in Chapter 4.
amplify rather than resolve the distress. When
the group begins to move in this direction, the
leader reassures the distressed soldiers that he 8-3. First-Line Restoration
will talk with them later and redirects the group’s
attention to the next scheduled activity. a. First-Line Restoration in the Divi-
sion. In the division, first-line restoration is
usually provided at the FSMC. It is provided by
(2) After each new arrival has set- personnel organic to the FSMC, usually assisted
tled in, he is interviewed in detail by the assigned and supervised by mental health officers and
squad leader and/or by the mental health/ NCOs from the division mental health section.
CSC supervisor or consultant. This interview The combat stress preventive teams from corps-
reviews exactly what happened to bring the
soldier here. The focus is on recent events in the level CSC units may also assist and supervise
soldier’s unit or back home rather than on the restoration at the FSMC (See Chapters 2 and 3).
remote past. (1) The FSMC is usually located in
the BSA which is 25 to 30 kilometers behind the
(3) The process is similar to after- forward line of own troops (FLOT) so that it is
action or critical event debriefings. As the details just beyond the range of the enemy’s main
are described, the feelings naturally come out or, artillery support, however, not beyond range of
at least, show enough signs that they can be longer-range tube and rocket artillery, air attack,
reflected and validated as honest and normal. or forces for special operations.
The counselor works patiently to get all the facts
and feelings out, then subtly helps to put them (2) Depending on the tactical situ-
into a perspective that reinforces their normality ation, the BSA may have to displace forward or
in the combat context. The counselor leads the rearward as part of the scheme of maneuver,
soldier to seeing how to handle the same or other or have to displace very hastily to escape per-
crisis should a similar situation recur. sistent bombardment or an enemy probe or
breakthrough.
(4) The counselor may bring one,
two, or more other recovering BF casualties (3) For these reasons, restoration
together to talk with the new arrival. This is in the BSA will often be limited to 2 days or even

8-8
FM 8-51

1 day, or may have to be temporarily suspended. perhaps a mental health officer from the ASMB
At other times, when the brigade is being held in mental health section (see Section II of Chapter
reserve, 3 days may be feasible. 3). If there are large numbers of BF casualties,
the ASMCs could also be reinforced by a team
(4) In OOTW (conflict), the FSMC from a corps CSC unit.
may be located at a relatively large and secure
fire base or base cluster. Since each scenario (1) The ASMC has a holding ca-
is situationally dependent, the command sur- pacity of 40 cots.
geon will establish holding times for first-line
restoration. (2) The corps area is likely to be
free from artillery attack, except for large, long-
b. Separate Brigades or Armored Cav- range rockets or the smaller rockets or mortars
alry Regiments. In separate brigades or ACR, of infiltrating unconventional forces. Air attack
first-line restoration should usually be provided is still possible.
at the medical company, separate brigade or at
the medical troop, ACR. It is provided by per- (3) Corps ASMCs will be relatively
sonnel organic to the FSMC, perhaps assisted and unlikely to have to move on short notice except
supervised by a combat stress preventive team potentially in rear battle situations. Restoration
from a corps-level CSC unit. up to 3 days (and even to 4 days) should usually
be feasible.
(1) In many scenarios, the sepa-
rate brigade (or regiment) may be in action (4) Those ASMCs in the COMMZ
similar to that of divisional brigades. Its medical should be even safer and more stable than those
company in the BSA would share the same types in the corps, except in the theater NBC envi-
of difficulties as the division’s FSMCs. ronment. However, they are also vulnerable to
rear battle situations.
(2) In other scenarios, the brigade/
regiment may be in division or corps reserve. It d. Medical Company Restoration Sup-
may also be engaged in rear battle against forces port. Support provided for restoration is a re-
which lack the long-range artillery capability of sponsibility of the supporting medical companies.
the enemy’s main force, but may be more likely
to infiltrate and harass. The squadrons of an
ACR may also be highly dispersed far from the NOTE
regimental medical troop. They may be supported
by the organic medical platoon. This squadron Combat stress control teams bring
may depend on corps ASMCs for its Echelon II specialized skills and perhaps some
medical care, including CSC. supplies to help with their critical RTD
mission, but do not relieve the local
c. Corps and Communications Zone medical commanders of their ultimate
First-Line Restoration. For CS and CSS units in responsibility.
the corps or COMMZ, first-line restoration should
be provided by ASMCs with responsibility for
their AO. It is provided by personnel organic to (1) When total casualties are light,
the ASMC, assisted and supervised by NCOs and patient-holding squad elements in division- and

8-9
FM 8-51

corps-level medical companies provide resources (5) The medical unit’s holding re-
where BF casualties can be rested, fed, and sources are available only when WIA and DNBI
restored. The patient-holding squad personnel rates are low. Battle-fatigue rates rise in direct
(two 91Cs and two 91Bs) serve as treaters. proportion to the intensity of combat (as reflected
Ideally, the treatment will be under the technical in the WIA rate). It will be at times of such heavy
supervision of the mental health section or CSC fighting, when the holding assets are preempted
team personnel. for emergency medical and minor surgical care,
that it is most important to restore BF casual-
(2) The holding squad will have ties close to their units. At other times, mini-
two GP medium or large tents with up to 40 cots. epidemics of gastrointestinal, upper respiratory,
When there are few patients, the second tent can or other infectious diseases may fill the holding
be the “rest tent” for HOLD BF casualties and cots to the exclusion of BF casualties. That BF
other minor DNBIs. The first tent remains ready casualties are moved out into “expedient shelters”
to receive new arrivals, some of whom may be to make way for true patients is, of course,
seriously injured. At some times, of course, the consistent with the message of treatment that
company commander may decide to keep one tent they themselves are “not sick. ” However, if
packed on the truck, ready to "jump” if a move is weather is inclement and no “expedient shelter”
ordered. is available, these soldiers are evacuated to a
second-line restoration center unless assets are
(3) Those BF casualties whose hastily sent forward and set up for them.
symptoms are not dramatic (primarily those
showing extreme fatigue, other normal/common (6) Obviously the medical com-
“psychosomatic” symptoms, and simple memory pany’s patient-holding resources cannot be relied
loss which could also be due to concussion and upon for consistent first- or second-line CSC
therefore require a period of medical observation) support at times of mass casualties. The organic
can be mixed in with the minimally wounded and mental health sections in the divisions or in the
minor DNBI cases. Recovering BF casualties ASMB in the corps are without BF casualty-
whose more dramatic symptoms have improved holding capability of their own. If restoration is
can also be billeted with true “patients” as long as still to continue to return the BF casualties to
their imminent RTD is emphasized. Selectivity duty quickly, reinforcing CSC teams must bring
may be required to ensure they do not “catch” the sufficient assets. This includes lightweight/low-
symptoms of the disease patients, either through cube tentage, working tools, and means to heat
true infection or unconscious imitation. water to be able to provide the very basic shelter,
food, and hygiene which are the minimum
(4) Those cases who are showing essentials for treatment.
more dramatic symptoms of anxiety, depression,
physical disability, memory loss, or gross dis-
organization can be quartered temporarily in
a separate tent or expedient shelter. These 8-4. Second-Line Restoration (Fatigue
patients are under the observation of trained Center)
medical or CSC personnel. If sufficient shelter is
not available for these BF casualties, evacuation a. Location of Second-Line Restoration.
to a second-line restoration facility is required. If Each of the forward locations listed above should
transported by nonmedical vehicle, an attendant be backed up by a second-line restoration capa-
must accompany these BF casualties. bility at a location which is relatively less likely

8-10
FM 8-51

to have to move on short notice. It should have d. Restoration Techniques. The tech-
sufficient NP/mental health staff expertise to niques of restoration at the fatigue center are
manage the more problematic cases. These may essentially the same as at the more forward
include clinical psychology, psychiatric nursing, locations. The number of cases at any one time
and OT, in addition to social work and psychiatry. is likely to be larger since they may be coming
The facility should be able to hold these cases from several forward MTFs and staying longer
for 3 days and conduct a stable, well-organized (up to 3 days). Dealing with the more symp-
“fatigue center. ” Fatigue centers may be located tomatic soldiers will also require more interview
at the MSMC in the division or at the HSC of an and treatment skills.
ASMB (in the corps or COMMZ).
e. Neuropsychiatric Disorders. Some
b. Fatigue Center. The name “fatigue of the soldiers sent back from the first-line
center” is suggested for this facility for two medical companies will prove to have true NP
reasons. First, it is a central place where fa- disorders which require further evacuation to a
tigued soldiers are sent to rest and recover their corps hospital. The second-line fatigue center,
strength. Second, it does not sound too attrac- therefore, needs to have a neuropsychiatrically
tive—not as attractive and desirable as a rest trained physician or psychiatric clinical nurse
center. While there, the soldier will be assigned specialist to provide stabilization capability.
to work details which can be tiring and not
especially fun. f. Reinforcement by Combat Stress
Control Teams. Combat stress control teams
c. Cases Received at the Fatigue Cen- which reinforce to setup a “fatigue center” should
ter. The fatigue center receives all REFER BF bring sufficient tents and equipment to provide
cases who must be evacuated from the first-line formal “holding” for 20 to 40 BF casualties. This
medical companies. Many of these cases may be can then provide basic shelter” for up to twice
sent back for purely tactical reasons, but others that number in the event of a mass casualty
are evacuated because their symptoms are too situation.
dramatic or unstable to manage so close to the
battle. Other soldiers requiring restoration may
come from nearby units in rear battle. 8-5. Third-Line Restoration

a. Operating a Fatigue Center at an
NOTE Echelon III or Echelon IV Hospital. In some
scenarios, units with soldiers in need of
Transportation of BF casualties from restoration may be significantly closer to a CSH
BSA to DSA or from ASMC to the in the corps and a FH or a GH in the COMMZ
ASMB’s HSC will be an exception to than to any of the ASMB’s medical companies.
the usual flow of WIA from the site In such cases, the principles of immediacy and
of initial stabilization directly to proximity justify conducting a restoration
hospitals in the corps. For this reason, program (fatigue center) at the hospital.
transportation of BF casualties
requires special attention and should (1) Staffing would be as an addi-
be in nonambulance vehicles, if tional duty to the NP ward, the consultation
possible. service, and the MCWs. These personnel could

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be reinforced by teams from the medical company, are present in the same BSA are returned directly
CSC. to their units. For example, a soldier from an
infantry company can return through his infantry
(2) If a task-organized CSC ele- headquarters and headquarters company, whose
ment from the corps medical company, CSC field trains are part of the BSA. The medical
collocated with the CSH (usually to staff a re- company patient administration specialist notifies
conditioning program as described in Chapter 9), the unit (or equivalent) to send someone to get
it could also provide restoration. the soldier.
b. Considerations for Restoration at a (1) Consultation by the CSC team
Hospital. with leaders of the BF casualty’s parent unit
facilitates the recovered soldier’s acceptance and
(1) The threat to a CSH is similar transportation back to his unit. Some special
as to the ASMB. The CSH can move only after cases may require reassignment to another unit
much preparation with external assistance. which is coordinated through the recovered
(2) Restoration at a CSH must be soldier’s battalion S1.
kept clearly separate from the NP ward and (2) This soldier has been kept on
ideally from the MCW. It should also be separate
from any reconditioning (14 day) program. the rolls by his unit during the 1 to 3 days du-
ration of treatment. The summary of treatment
for medical statistical purposes is captured by
8-6. Return to Duty or Further Referral carding for record only, utilizing the FMC. Care
of Restoration Cases provided to this soldier will be considered out-
patient treatment and any documentation will be
Battle-fatigue symptoms do not necessarily done on the FMC. A copy of the FMC is sent
improve completely while the prospect of combat back to the major MEDCOM in the TO upon
continues. The positive expectancy is for RTD of release of the soldier.
the soldier with sufficient confidence that he can
do his job. It does not require that the soldier b. Recovered Soldiers in the Division
feels happy, sad, or frighten about his situation. Rear. Recovered BF soldiers who have completed
The soldier’s condition may continue as post- restoration treatment in the DSA are returned
traumatic stress symptoms, if not necessarily as to duty by contacting the division personnel
PTSDs. The symptoms/disorders may occur after replacement company. If the soldier’s unit is in
the war is over and the soldier has returned the DSA, his unit is called. Coordination for
home. Most BF casualties in restoration are return of the soldier to his original unit or for
ready to RTD when they have regained sufficient reassignment to a new unit is accomplished
confidence in themselves and their symptoms through the G1 section. Direct consultation with
have returned to the range of the "normal/ the forward area unit receiving the recovered BF
common signs.” These normal/common signs are soldier is coordinated with the forward deployed
outlined in Graphic Training Aid (GTA) 21-3-4. CSC personnel supporting the unit’s AO.
Every reasonable effort should be made to send
these soldiers back to their original unit. c. Recovered Soldiers in the Corps.
Return to duty of recovered BF soldiers in the
a. Recovered Soldiers in the Brigade corps depends on where they received their
Support Area. Recovered cases from units that treatment. If an ASMC provided the treatment,

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FM 8-51

then the ASMC calls the soldier’s unit to provide command unit in the corps could be used. This
transportation. If the recovered soldier was must be coordinated with the soldier’s unit prior
evacuated to the HSC of the ASMB for to his disposition.
restoration, his RTD must be coordinated. The
RTD of these soldiers may be complicated be- e. Referral to Reconditioning. Those
cause there may not be a routine means of who need further mental health/CSC professional
transporting personnel between the remote treatment are temporarily reclassified as having
base defense clusters. Either the soldier’s unit "REFER" BF and are sent to the supporting
must come the distance to collect him or other reconditioning program, if one is available. This
transportation must be coordinated. Alterna- movement should not be called an evacuation. It
tively, he may be returned to his unit by way of should be done without much fanfare (so as not
the personnel replacement company. Main- to attract the attention of newly arrived BF
taining accountability for such cases is crucial— casualties). The preferred method of sending the
otherwise, they get lost in the medical evacuation REFER BF casualty is by ground, not air, and in
or transportation system and no one knows where a GP vehicle, not an ambulance. If ambulances
they are. must be used, these REFER BF casualties should
go as ambulatory (not litter) cases.
d. Completing the Recovery. Some
cases in restoration do not improve sufficiently in f. Referral to Hospital. A few cases
3 days to be ready to return to their units and full may be identified by the division or other psy-
duty. The cases which are making progress may chiatrists as having an NP disorder which
need additional time to complete the recovery. requires evacuation to a hospital. These may go
Some may need only another 1 to 3 days, which by ground (or air) ambulance as litter patients.
need not be spent under full-time medical or
mental health/CSC care. Soldiers who require g. Referral for Administrative Actions.
only 1 to 3 days of additional rest for full recovery A few cases may be identified as malingerers who
may be placed in their units’ CSS trains as do not respond to counseling and refuse to RTD.
REST BF cases. The CSS trains in the BSA, at a They are turned over to their parent unit for
DISCOM unit in the DSA, or in a corps support administrative disposition.

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CHAPTER 9

COMBAT STRESS CONTROL RECONDITIONING

9-1. Reconditioning Treatment Program maintained on a less-intensive program. This
program would entail more work details and less
a. Overview of Reconditioning. Recon- individual and group therapy until staffing ratio
ditioning programs are intensive efforts to return can be restored.
BF casualties to duty when they have not
improved sufficiently with 1 to 3 days of (2) At times when reconditioning
restoration. In the corps area these programs cases far exceed the staff available to treat them,
are normally 7- to 14-days long but can be as reconditioning may be limited to fewer days per
short as 3 days, depending on the corps soldier or may be discontinued altogether. This
evacuation policy. Reconditioning may continue change will effect some of those soldiers in the
as long as 28 days in the COMMZ, depending on reconditioning program who might be returned
the theater evacuation policy. These programs to duty with additional treatment (and might
are conducted in a nonpatient care setting by be protected from subsequent PTSD). They will
medical CSC, NP, and mental health personnel. be evacuated to the COMMZ and/or CONUS to
Reconditioning also can include rehabilitation of maximize RTD of those soldiers with the best
those BF casualties who were evacuated to a potential.
hospital without receiving restoration treatment.
It can include NP and alcohol/drug patients and (3) Reconditioning, like restora-
minor misconduct stress cases with good potential tion, can be provided by successive echelons.
for RTD. Conducting reconditioning programs Treatment facilities in the COMMZ or corps
is a mission of the medical company, CSC. rear should continue to treat the evacuees with
Reconditioning can also be provided on a small relentless positive expectation. This is called
scale by the medical detachment, CSC under second-line reconditioning. The program should
special circumstances. Reconditioning is also continue as third-line reconditioning for those
provided by the combined NP ward and con- evacuated to CONUS.
sultation services, the OT/PT sections, and the
clinical psychologist of FHs in the COMMZ.
b. Priority of Reconditioning Pro- 9-2. Reconditioning Program Methods
grams. Reconditioning programs have lower
priority than restoration programs. This is a. Reconditioning Extends Restoration.
because they are manpower intensive and have Reconditioning is similar to restoration but more
a lower return of RTD for the effort invested. orchestrated over longer periods of time, is more
When the number of BF cases who may need 1 to intensive, and it requires a higher staff-to-case
3 days of restoration treatment is high, additional ratio. Reconditioning puts special emphasis on
CSC personnel should be sent forward from a highly structured military unit environment
reconditioning programs to reinforce forward and schedule of activities. Treatment strategies
restoration teams. The reconstitution support assist recovering soldiers in regaining skills
mission may also need to draw upon recondi- needed for combat duty. These skills and abilities
tioning program staff. include concentration, team work, work tolerance,
psychological endurance, and physical fitness.
(1) If a shortage of reconditioning
staff is only temporary, it may not be necessary b. Military Unit Structure. As in res-
to evacuate the excess caseload. They may be toration, the soldiers are not treated like patients

9-1
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on a ward under the care of therapists. Rather, NOTE
the BF casualties are treated like other soldiers
assigned to a military unit which requires— Display of unit emblems, mottoes,
streamers, and other distinctive de-
Assignment to a squad or team vices should be encouraged to focus the
with a staff member as squad or team leader. soldier’s attention on his unit of origin
and his identification with it.
Wearing the prescribed uni-
form and appropriate LBE.
e. Physical Reconditioning Activities.
Physical reconditioning activities may include—
c. Physical Replenishment. Recon-
ditioning continues to provide physical Calisthenics and stretching ex-
replenishment (food, hydration, sleep) and ercises.
hygiene (shower), especially in the first few days.
Later in the program, the comfort factor may be Running in formation.
intentionally decreased; for example, by
substituting MREs for some A-ration meals and Competitive sports.
by assigning recovering soldiers to night duties.
These duties may include fire watch, perimeter f. Individual Counseling and Therapy.
or gate guards, or radio watch. Individual counseling and therapy may include—
d. Unit Formations. Unit formations Abreaction (redescribing and
are held on a regularly scheduled basis. The remembering the traumatic events in detail and
purpose of the formation is to— releasing pent-up emotions).
Disseminate information. Working through personal
grief, guilt, and home-front issues.
Account for all personnel.
For some cases, psychothera-
Announce the daily work and peutic drugs for brief symptom relief, or tapering
training plan or changes. off drugs used in stabilization or detoxification.
For some cases, hypnosis or
Break out or cross-attach sub- amytol interviews to uncover repressed memories.
elements into small groups for activities or details.
g. Group Sharing and Validation.
Introduce new unit members. Group sharing and validation of common ex-
periences and issues include—
Brief on the tactical and world
situation, especially as it relates to the soldiers’ Restoration of perspective
units of origin. through realistic reappraisal of the traumatic
events.
Assign physical and occupa-
tional activities. Cognitive reframing.

9-2
FM 8-51

h. Group Training in Relaxation Tech- Building better showers or
niques. Group training in relaxation techniques latrines.
is provided and includes—
m. Work Assignments. Work assign-
Abdominal breathing. ments to medical units for real work details are—

Breathing for meditation. Coordinated and monitored by
the reconditioning program OT staff.
Progressive muscle relaxation/
autogenic training. Increased over the course of
the program and gradually displace most of the
Focused imagining of relaxing therapy and training sessions.
situations.
Considered protected status
i. Group Training in Life Skills. since they are patients.
Group training in life skills is provided to assist n. Tempora.y Reassignment to Combat
with— Support or Combat Service Support Units. When
recovering soldiers are temporarily assigned as
Control of impulses and anger. part of their reconditioning program to CS or CSS
units for work, the—
Appropriate assertiveness in
the military context. Assignment of the soldier is for
24 hours of each day.
j. Common Soldier Task and Suruival
Skill Drills. Common soldier task and survival Soldiers are no longer in a pro-
skill drills may be provided as individual and as tected status under the Geneva protocol.
team competition.
Combat stress personnel con-
k. Drug and Alcohol Abuse Counseling. tinue to work with the soldier in preparing him
Drug and alcohol abuse counseling may be pro- for RTD to his original unit, or reassignment to a
vided through individual or group work sessions new unit.
as indicated.
l. Reconditioning Program Work Proj- 9-3. First-Line Reconditioning Centers
ects. Reconditioning program work projects may
include— a. Combat Fitness Reconditioning Cen-
ters. Combat fitness reconditioning centers in
Improving and reinforcing the corps are staffed by task-organized CSC
defensive positions such as entrenching and elements from the medical company, CSC. In
sandbagging. OOTW, a reconditioning center could be estab-
lished by a task-organized CSC element from one
Improving living conditions or more detachments, CSC. This is done only
such as making furniture or installing packing if the medical company, CSC has not been
crate floors. deployed. Also, if the inpatient NP work load is

9-3
FM 8-51

light, a small reconditioning program may be is dependent on the supporting hospital for
staffed by personnel from the NP ward and communications, food services, shower facilities,
consultation service of a CSH. A reconditioning and other areas of support. The combat fitness
center usually collocates with a CSH but must reconditioning center works with the supporting
maintain its separate, nonhospital identity. hospital by sending work parties of recovering
soldiers to assist in food preparation and delivery
b. Area for Establishment. While the and cleanup chores. The recovering soldiers from
hospital is often in the open, the combat fitness the reconditioning center may also be used for
reconditioning centers should be in or close to assisting with work details throughout the
the tree line or under camouflage. It should not hospital but must be under direct supervision of
be situated near the morgue, triage area, or either hospital or mental health/CSC personnel.
helicopter pad. It should be placed in an area
where incoming ambulances are not seen as they d. Medical Records. The combat fit-
off load their patients. Often the best area for ness reconditioning center uses the supporting
establishing the combat fitness reconditioning hospital’s medical records section to maintain the
centers is next to the CSH staffs’ quarters tents permanent case records.
(not among the wards). This is normally close
to the food service kitchen, the showers, and (1) Cases who were initially ad-
the laundry. There the BF casualties receive mitted to a hospital ward for stabilization are
replenishment and perform work details. The transferred to the combat fitness reconditioning
CSC unit (CSC restoration and CSC preventive centers, and the combat fitness reconditioning
teams combine as a task-organized CSC element) centers staff continues to keep the standard hos-
can provide their own tents for staff quarters and pital chart. The soldier is given any personal
the operations center. They can accommodate a effects that were secured by the patient adminis-
moderate number of soldiers in their own tents tration section at the time of his initial admission.
for reconditioning (20 per GP large tent in the
task-organized CSC element). If the recondi- (2) Cases who are “transferred”
tioning case census exceeds the capability of the from a restoration facility go directly to the
task-organized CSC element to provide tentage, combat fitness reconditioning center. They
the additional tents are requested from the should not be admitted through the supporting
medical company, CSC headquarters. If tents hospital’s admission area. However, all patient
cannot be provided, additional shelters and admission steps except securing personal items
sleeping facilities are requested from the host and affixing a hospital identification wrist
CSH. In some situations, local buildings may band are done upon their arrival at the combat
be used or other arrangement made through fitness reconditioning center. These steps are
host-nation agreements. The combat fitness accomplished or monitored by the patient
reconditioning centers may be augmented by an administration specialist assigned to the medical
element from the medical company, holding. The company, CSC. The combat fitness recondi-
patient care providers of the holding facility can tioning center also initiates a hospital chart on
also be trained (under the supervision of mental each case.
health/CSC personnel) to serve as squad leaders,
each supervising six to ten BF soldiers. (a) Cases in the combat fit-
ness reconditioning center are counted as patients
c. Working with the Supporting Hos- in the reconditioning center on the daily hospital
pital. The combat fitness reconditioning center census.

9-4
FM 8-51

NOTE coordination should be conducted to move the
combat fitness reconditioning centers to collocate
These cases are counted as patients on with (and receive logistical support from) a quar-
the daily hospital census. The cases termaster or personnel unit. Hospital charts/
are not counted as occupied beds when medical records would continue to be kept by the
reporting the hospital bed occupancy. nearby CSH.
h. Division Fatigue Center. Under spe-
(b) Upon disposition from the cial circumstances in OOTW, a division “fatigue
combat fitness reconditioning center, whether for center” with few cases in need of restoration could
RTD, retraining for other duty, or evacuation, change mission to become a small reconditioning
the combat fitness reconditioning center’s center. Under these special circumstances the
psychiatrist prepares the chart for further medical detachment, CSC personnel could staff a
evacuation or writes the discharge summary and very small reconditioning program. Any patient
closes the hospital’s chart. admitted to this program would be carried as an
admission to the supporting CSH. Inpatient
e. Stabilization. Stabilization of seri- records are initiated and maintained by CSC
ously disturbed NP or BF casualty cases should personnel. Upon completion of the reconditioning
be the responsibility of the collocated hospital’s program, the inpatient record is forwarded to the
organic NP personnel and NP care ward. Neuro- supporting CSH.
psychiatric ward cases should not disrupt or infect
the combat fitness reconditioning center’s
nonpatient status, RTD-oriented activities, and 9-4. Disposition of First-Line Recondi-
atmosphere. Cases can be transferred easily tioning Cases
between the hospital’s inpatient NP ward and the
tents of the combat fitness reconditioning center. a. Status of Reconditioning Cases.
Some reconditioning cases will be able to return
f. Multiple Small Reconditioning Cen- to far-forward CS or CSS duty. However, many
ters. The preferred option in a corps-sized of the soldiers who need reconditioning will be
operation is to have a separate, small recon- unable to return to their original unit. This could
ditioning center collocated with a hospital behind be a result of combat operations or the nature of
each division. That combat fitness reconditioning their symptoms which prevent their return to
center treats soldiers from that division plus original units.
supporting corps units located in its AO. This
maintains the principle of proximity and favors (1) Ideally, BF casualties who un-
immediacy and simplicity by avoiding prolonged dergo a 14-day restoration program in the corps
transportation of cases. The maintenance of unit should not be crossed off the division’s personnel
identification (most soldiers wearing the same rolls (as specified in AR 40-216). However, in
division patch) also aids the positive expectation. high casualty situations, the division commander
Limited resources or geography, however, may will be unwilling to wait two weeks on the un-
require use of consolidated reconditioning centers, certain chance that he will get his old BF soldier
which would each support several divisions. (now improved) back again. The commander will
want to count soldiers as losses to the division if
g. Mature Theater. In a mature thea- they are gone more than 3 days in order to req-
ter, once action in the corps has stabilized, uisition replacements. Even when BF casualties

9-5
FM 8-51

are no longer on the division’s rolls, every fea- assignment for these newly formed two- to five-
sible effort should be made to return those BF person teams.
cases who recover fully to their original units.
This is desirable even if that unit has already (3) For some cases, it may be best
received a replacement and is technically not to have the recovering BF casualty (as part of
eligible to receive another. Most units in combat their reconditioning program) visit with nearby
are chronically understrength and they can also units during the day (returning to the combat
anticipate more losses in the near future. An fitness reconditioning center at night) before
overly strict interpretation of the replacement being returned to duty for assignment. Any work
policy should not prevent the mutually beneficial performed during such visits must conform to
return of a recovered soldier to his unit. The the Geneva Conventions (see Appendix D).
division psychiatrist and the CSC unit teams who Alternatively, the recovering BF casualty may
are attached to reinforce that division should be assigned to the CSS unit 24 hours/day on
maintain frequent contact with the combat fitness temporary duty as a REST BF casualty until he
reconditioning centers which supports the is ready for reassignment (preferably in pairs or
division (as specifically directed in AR 40-216). groups) to other units.
Coordination efforts, through the DMOC and the
personnel replacement system by division mental b. Evacuation Policy.
health/CSC personnel, should attempt to facili-
tate return of recovered soldiers to their original
units. (1) Army Regulation 40-216 speci-
fies that there should be a 14-day reconditioning
program in the corps. This recognizes the fact
that the additional days substantially increase the
NOTE RTD rate. At the NP clearing companies in
WWII, the average length of stay was 11.4 days.
The CSC consultant should also ensure The corps evacuation policy is at the discretion of
that everyone knows that it is just as the theater commander. In some situations, the
important (if not more so) to return maximum length of stay may be set by the theater
recovered WIA and DNBI soldiers to commander at 7 days.
their original units whenever possible.
(2) If the corps evacuation policy
is less than 14 days, the mental health/CSC staff
(2) More commonly, reconditioned psychiatrist of the medical brigade should request
soldiers may need reassignment (and perhaps an exception for BF casualties in reconditioning
reclassification into new MOSS) and/or on-the-job programs. He submits the case via the com-
training into new combat, CS, or CSS roles. If mander, medical brigade, through the corps
recovered BF casualties cannot be returned to surgeon to the corps commander. The following
their previous small unit, they should be formed facts apply:
into small (two to five persons) cohesive groups
or teams which can be reassigned to a new unit (a) The reconditioning pro-
together (or to the unit of one of those soldiers). gram, because of its austerity, is not a significant
The combat fitness reconditioning centers must logistical burden to the corps—it requires only
coordinate with the personnel replacement food, water, and shelter for the cases, plus the
system and nearby CSS units to find a suitable supplies and equipment from quartermaster units

9-6
FM 8-51

that rearm the recovered soldier for combat or ing capability will be required for the estimated
other duties. 10 percent of the RTD wounded who also have
significant BF. This capability could be improved
(b) Because the combat fit- somewhat by attaching a platoon of the medical
ness reconditioning center maintains a military company, holding.
setting, it is not a conspicuous target. Its case-
load performs useful work details and perimeter (2) It is still important to minimize
defense, either for medical units or for all the hospital atmosphere and to treat the cases
type units, depending on its chosen Geneva not as patients but as soldiers being reconditioned
Conventions status (see Appendix D). for combat-related duties. (The same is true for
the convalescing WIA with concurrent BF.) The
(c) The increase in RTD of facility should be in a separate building with its
BF casualties (mostly to CSS units) frees assigned own rigorous schedule of therapeutic activities,
soldiers for other duties, reduces the accu- physical training, and work projects.
mulation of cases with poorer prognoses in the
COMMZ, and minimizes chronic disability. b. Option 2—Combat Stress Control
Units. A medical company, CSC may be allocated
c. Evacuation. Reconditioning cases to the COMMZ and assigned to the medical
who do not recover sufficiently to return to some brigade. The medical company, CSC, reinforced
duty within the designated evacuation period are with a patient-holding capability, may establish
evacuated from corps to COMMZ. They are best separate “nonhospital” reconditioning centers in
transported in GP trucks and buses, bus the COMMZ.
ambulances, or an ambulance train. In the latter
two cases, they should be assigned helper tasks. (1) In OOTW, task-organized CSC
Use air evacuation if there is no other alternative. elements of a medical company or a medical
detachment, CSC combine with a 240-cot platoon
of the medical company, holding. Attach this
9-5. Second-Line Reconditioning in the combat fitness reconditioning center to a FH or
Communications Zone GH.

a. Option 1—Field Hospital. Establish (2) Limited conflict is defined here
reconditioning programs in the COMMZ at one as either—
or more FH. The FH is preferred to the GH
because it is dedicated to RTD of convalescing (a) A relatively small conflict
cases. It has a psychologist and OT personnel which does not require all CSC units in the
assigned to the hospital unit’s medical holding. forward areas of the corps.
These personnel are in addition to the NP ward
and consultation service personnel assigned to the (b) The late stages of a larger
hospital unit base. war when fighting has stabilized or ceased, so
that CSC units can be withdrawn from forward
(1) The FH has sufficient mental areas to provide reconditioning in the COMMZ.
health staff to conduct a small reconditioning In the latter (late in the war) situation, some
program, provided it is not preoccupied with of the work load may include cases who have
NP cases. However, most of its recondition- accumulated in the COMMZ. These cases may

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FM 8-51

not have received mental health/CSC treatment 9-6. Third-Line Reconditioning
because there were insufficient evacuation assets
to transport them to CONUS along with the a. Battle Fatigue Casualties That Fail
wounded and the true NP cases. These would to Improve. Those BF casualties who do not
make a difficult, but still potentially rewarding improve sufficiently to RTD in the COMMZ are
caseload. sent to CONUS. If these BF casualties have not
been found to have some NP or physical disorder,
c. Second-Line Reconditioning Cases. they should be transferred to a third-line re-
Most second-line reconditioning cases will conditioning center in CONUS. If they have NP
no longer need much physical replenishment. or physical disorders which warrant discharge
The combat fitness reconditioning center from the Army, they are sent to the Department
programs continue to emphasize physical fit- of Veterans Affairs for additional treatment and
ness, soldier skills, work details, and individual/ follow up. The facilities for the reconditioning
group counseling/psychotherapy. Cases will be centers should be located at MEDDACs or medical
retrained for CSS duties in COMMZ and corps. centers which are on active Army posts that
As soon as the recovering soldiers are ready, provide the military atmosphere and the
the retraining site can shift to on-the-job training opportunity for job retraining in actual units.
at a nearby CSS unit. This training begins
as a day job, returning each night to the b. Sending to Appropriate Recondi-
combat fitness reconditioning center. Later, tioning Center. The BF casualty should be sent
the soldier may be placed full time in the new to the reconditioning center which is best suited
unit (as DUTY BF) while being followed-up for the retraining to be done. This center is often
periodically by the combat fitness reconditioning not the one that is nearest the soldier’s home of
center’s staff. record.

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FM 8-51

APPENDIX A

LISTING OF MAJOR ITEMS OF EQUIPMENT FOR
THEATER ARMY MEDICAL COMBAT STRESS CONTROL
UNITS AND ELEMENTS

A-1. General

The major items of equipment in this listing are authorized by the base TOE and other required items
are authorized by the common table of allowances (CTA).

A-2. Medical Company, Combat Stress Control

a. Headquarters Section.

(1) Major items authorized by the base TOE and assigned to the headquarters section
include—

Truck, cargo, tactical, 2 l/2-ton (two each); one truck has a winch.
Trailer, cargo, 1 l/2-ton (one each).
Truck, utility, l/4-ton (one each).
Trailer, cargo, l/4-ton (one each).
Tow bar, motor vehicle (one each).
Generator, 5 kilowatt (one each).
Radio set, AN/VRC 90 (one each).
Radio set, control group, AN/GRA-39 (one each).
Tool kit, general mechanic, automotive (three each).
Tool kit, carpenters (one each).
Tool kit, small arms repairman (one each).
Camouflage screen support system (nine each).

(2) Major items of CTA equipment assigned to the headquarters section include—

Tent, general purpose, large (one each).
Tent, general purpose, medium (two each).
Tent, general purpose, small (three each).
Tent, vehicle maintenance (one each).
Tent liner, general purpose, Iarge (one each).
Tent liner, general purpose, medium (two each).
Tent, general purpose, small (three each),
Panel marker set, Geneva (three each).

A-1
FM 8-51

b. Preventive Section.

(l) Major items authorized by the base TOE and assigned to the preventive section
include—

Truck, cargo, tactical, 5/4-ton (six each) with 3/4-ton trailers, cargo (six each).
Medical equipment set, sick call, field (six each).
Clinical psychologist set, field (one each).
Generator, 5 kilowatt (one each).
Camouflage screen systems for woodland and desert.

(2) Major items of CTA equipment assigned to the preventive section include—

Tent, general purpose, medium (six each).
Tent liner, general purpose, medium (six each).
Panel marker, Geneva (six each).

c. Restoration Section.

(1) Major items authorized by the base TOE and assigned to the restoration section
include—

Truck, cargo, tactical, 5/4-ton (four each) with four trailers, cargo.
Truck, cargo, 2 l/2-ton (four each) with trailers, 1 l/2-ton (four each).
Trailer, tank, 1 l/2-ton, water, 400 gallons (two each).
Generator, 3 kilowatt (four each).
Medical equipment set, sick call, field (four each).
Clinical psychologist set, field (four each).
Tool kit, carpenters (four each).
Camouflage screen systems, woodland and desert.

(2) Major items of CTA equipment assigned restoration section include—

Tent, general purpose, large (ten each).
Tent, general purpose, medium (four each).
Tent, general purpose, small (four each).
Tent liner, general purpose, large (ten each).
Tent liner, general purpose, medium (four each).
Tent liner, general purpose, small (four each).
Panel marker, Geneva (four each).

A-2
FM 8-51

A-3. Medical Detachment, Combat Stress Control
a. Detachment Headquarters.
(1) Major items authorized by the base TOE and assigned to the restoration section
include—
Truck, cargo, tactical, 5/4-ton with trailers, cargo, 3/4-ton.
Generator, 3 kilowatt (one each).
Radio set, AN/VRC 90.
Telephone set, TA312 (one each).
Camouflage screen systems, woodland and desert.
(2) Major items of CTA equipment assigned to the headquarters section include—
Tent, general purpose, small (one each).
Tent liner, general purpose, small (one each).
b. Preventive Section.
(1) Major items authorized by the base TOE and assigned to the preventive section
include—
Truck, cargo, tactical, 5/4-ton (three each) with 3/4-ton trailer, cargo (three each).
Medical equipment set, sick call, field (three each).
Clinical psychologist set (three each).
Telephone set, TA 312 (three each).
Tool kit, carpenter (three each).
Camouflage screen systems, woodland and desert.
(2) Major items of CTA equipment assigned to the preventive section include—
Tent, general purpose, medium (three each).
Tent liner, general purpose, medium (three each).
c. Restoration Team.
(1) Major items authorized by the base TOE and assigned to the restoration section
include—
Truck, cargo, tactical, 5/4-ton (two each) with trailers 3/4-ton, cargo (two each).
Truck, cargo, 2 l/2-ton with trailer, 1 1/2-ton (one each).
Trailer, tank, 1 l/2-ton, water, 400 gallons (one each).
Medical equipment set, sick call, field (one each).
Tool kit, carpenters (two each).

A-3
FM 8-51

Camouflage screen systems, woodland and desert.
Clinical psychologist set (one each).
Telephone set, TA 312 (one each).
(2) Major items of CTA equipment assigned to the restoration section include—
Tent, general purpose, large (two each).
Tent, general purpose, medium (one each).
Tent, general purpose, small (one each).
Tent liner, general purpose, large (two each).
Tent liner, general purpose, medium (one each).
Tent liner, general purpose, small (one each).
Panel marker set, Geneva (two each).

A-4. Division Mental Health Section
a. Major items authorized by the base TOE and assigned to the mental health section include—
Truck, utility, 5/4-ton (three each).
Clinical psychologist set (one each).
Camouflage screen support system (thirteen each).
Telephone set, TA-312/PT (one each).
b. Major items of CTA equipment assigned to the division mental health section include—
Tent, general purpose, medium (one each).
Tent liner, general purpose, medium (one each).
Panel marker set, Geneva (one each).

A-5. Area Support Medical Battalion Mental Health Section
a. Major items authorized by the base TOE and assigned to the mental health section include—
Truck, cargo, tactical, 2 l/2-ton (one each),
Truck, utility, 3/4-ton (three each).
Camouflage screen support system (thirteen each).
Telephone set, TA-312/PT (one each).
b. Major items of CTA equipment assigned to the headquarters section include—
Tent, general purpose, medium (one each).
Tent liner, general purpose medium (one each).
Panel marker set, Geneva (one each).

A-4
FM 8-51

APPENDIX B

COMBAT STRESS CONTROL ESTIMATES AND PLAN
Section I. GUIDE FOR THE DEVELOPMENT OF THE COMBAT
STRESS CONTROL ESTIMATE OF THE SITUATION

B-1. Combat Stress Control Estimate to generate the most stress casualties. The medi-
cal detachment or CSC company—
The CSC planner must prepare the CSC
estimate in cooperation with the senior staff Receives the CSC esti-
surgeon who is responsible for preparing the mates from the division mental health section or
overall CHS estimate. The overall CHS esti- ASMB mental health section and coordinates
mate, and especially the PVNTMED estimate, directly with each.
provide important information (see FMs 8-55 and
8-42). Develops its CSC estimate
in conjunction with its higher medical C2 unit.
a. Some issues may require the CSC Prepares to receive recon-
planner to work directly with the staff sections of ditioning cases at different regions of the battle-
the combat command: S1/Gl, S2/G2, S3/G3, S4/ field.
G4, and, G5 when appropriate. The staff chap-
lains (unit ministry teams), JAG, and Provost Sends CSC augmentation
Marshal and MP units are also important sources teams or personnel to reinforce the forward units
of information. that have the greatest need.
b. The level of detail of the CSC esti-
mate depends upon which echelon is preparing NOTE
it.
The medical group and medical brigade
(1) The division mental health sec- headquarters will have a small mental
tion works with the division surgeon and the health staff section to help coordinate
PVNTMED section. The division mental health these activities.
section is concerned with brigades which are
likely to have the most BF cases or other combat c. The primary objective of the CSC
stress and NP problems. This may determine estimate is—
how many assets are pre-positioned and at which
BSAs. Within the brigades (and in the DISCOM), To predict where and when
the division mental health section may need to the greatest need is likely to arise among the sup-
identify specific battalions, companies, and pla- ported units.
toons in order to focus preventive consultation or
reconstitution support activities. To initiate preventive
efforts early.
(2) The CSC units which provide
backup support and reconditioning in the corps To develop contingency
are concerned with divisions, separate brigades/ plans so that limited resources can be allocated
regiments, and other corps units which are likely and prepared for their reallocation as needed.

B-1
FM 8-51

(1) Quantification of the projected can be applied to estimating the potential for
restoration and reconditioning caseloads will not substance misuse/abuse patients and other mis-
be precise. Absolute values should not be given conduct stress behaviors compared with their
too much weight. However, quantification pro- normal rates of occurrence in the troop popula-
vides a useful analytical tool for estimating rela- tion.
tive risk. The historical ratios of the incidence of
BF casualties to the incidence of WIAs provide a (7) The protective (Positive ) and
baseline for estimates in future operations. risk (Negative) factors for misconduct stress
behaviors in paragraph B-3 will be similarly
(2) This analysis is most valid designated, but with a letter "m" (for "miscon-
when applied to specific units in a specific combat duct”) after the parenthesis. Each factor will be
operation. It is less precise when applied to identified as either Positive or Negative.
larger, composite units. The analyst must esti-
mate what percentage of subunits of different
types (combat, CS, and CSS) will encounter parti- B-2. Estimating Battle Fatigue Casualty
cularly negative factors (stressors). He must also Work Load
estimate what percentage will be protected by
beneficial protective factors. a. Protective Factors. The following
protective (Positive) factors reduce BF casualties
(3) The prediction for the incidence relative to WIA:
of WIA requiring hospitalization in the CHS esti-
mate provides a starting point. In moderate to (1) High unit cohesion (Positive).
heavy conventional fighting (mid-intensity con- Troops and their leaders have trained together
flict), the CSC planner can begin with the average (and, ideally, have been in successful combat)
ratio of one BF casualty for five WIA (1:5). Then with little continual turnover of personnel. For
he can examine the nature of the mission for each example. Operational Readiness Training comp-
of the specific units involved and use protective anies and battalions are presumed to have high
(Positive) and risk (Negative) factors to judge unit cohesion provided the leaders have had time
whether 1:5 is likely to be an overestimate or an and training to develop “vertical cohesion” with
underestimate. positive factors (5) and (6), below.
(4) For discussion later in this
appendix (paragraph B-2), the protective and risk (2) History of very tough, realistic
factors for BF are referred to by their parenthetic training (for example, militarily sound and dan-
subparagraph numbers and are identified as gerous preparation to prepare troops for war)
either (Positive ) or (Negative). (Positive). Successful combat with few casualties
is good training. Airborne and Ranger train-
(5) Each of these factors could be ing and realistic live-fire exercises (both small
given a numerical weight (0, +1, +2 for positive arms and artillery) also help to "battle proof"
factors; 0, -1, -2 for negative factors). The factor soldiers.
scores are added algebraically to give a rough
total score. The weight must be based on subjec- (3) Unit leaders and medical per-
tive expert judgment and experience. sonnel are trained to recognize BF (Positive).
They can manage DUTY and REST cases at unit
(6) The same analyzing process level and reintegrate recovered HOLD and REFER
used to estimate BF casualties in relation to WIAs cases back into units.

B-2
FM 8-51

(4) Units are withdrawn from com- questionnaire surveys of unit cohesion and
bat periodically to rest, refit (reconstitute if nec- morale, such as the Unit Climate Profile found in
essary), and absorb new replacements (Positive). DA Pam 600-69.
Replacements arrive and are integrated as cohe-
sive teams, not as individual soldiers. (2) Many leaders and soldiers want
to believe that their unit is elite and will have far
(5) Leaders demonstrate compe- fewer than one BF casualty for ten WIA, even in
tence, courage, and commitment (Positive). Lead- the most intensive battles. The CSC planner
ers care for their soldiers and make provisions should not discourage this belief since it may be a
for physical and mental well-being as the tactical necessary first step toward becoming true. How-
situation permits. Noncommissioned officers ever, the CSC estimator should not make plans
know and are given responsibility for sergeant’s on the strength of the belief alone. Remember,
business (taking care of their troops). Command CSC expertise is managed wisely if it is far for-
also shows concern for soldiers’ families. ward, assisting command in proactive prevention
rather than reactive treatment of BF casualties.
(6) Leaders keep troops informed
of commander’s intent and the objectives of the (3) Even if tough realistic training,
operation and the war (Positive). If necessary, high cohesion, and fine leadership can be inde-
they focus the soldiers’ appraisal of the situational pendently verified (as with unit survey question-
stressors to maintain positive coping. naires), the BF casualty estimate should not be
too much less than the average until the unit has
(7) Victorious pursuit of a retreat- proved itself in successful combat. Even then,
ing enemy (Positive). This reduces BF casualties estimates should continue to consider the poten-
but may release misconduct stress behaviors un- tial negative impact of cumulative attrition, new
less command retains tight control. replacements, and other adverse factors which
may eventually overcome the positive factors.
(8) Hasty withdrawal (Positive).
During hasty withdrawals, few BF casualties (4) Positive factors (8) and (9),
enter medical channels. However, BF soldiers above, are, of course, not truly “Positive. "While
may be lost as KIA, missing in action (MIA), or they decrease the expected requirement to evac-
captured instead of becoming medical patients, uate BF casualties for treatment, they indicate a
and other soldiers who are stressed may desert need to redouble efforts for prevention of mis-
or surrender. conduct stress behavior. Positive factor (7), above,
also should alert command to the need to main-
(9) Beleaguered friendly unit which tain firm control to prevent misconduct stress
cannot evacuate any (or only the most severely behavior.
wounded) casualties (Positive). Here, too, some
soldiers may be combat ineffective due to BF or c. Risk Factors. Increases in the
go AWOL without becoming medical patients. following risk (Negative ) factors add to the pro-
portion of BF casualties in relation to WIA:
b. Assessment of the Positiue Protective
Factors. (1) Combat intensity—indicated
by the rate of KIA and WIA (percent of battle
(1) Positive factors (1) through casualties [out of the total troops engaged] per
(6), above, can be assessed using standard hour or day) (Negative).

B-3
FM 8-51

(2) Duration of continuous opera- are very strong and comfortable, complacency
tions—the number of days which the troops (small may be a problem) (Negative).
units) have been in action without respite, espe-
cially if there is little opportunity for sleep (Nega- (9) Attacking repeatedly over the
tive ). The operation may begin well before the same ground against a stubborn, strong defense
actual shooting. Preparation time and rapid de- (Negative).
ployment (jet lag) effects should also be con-
sidered. (10) Casualties among armor or
mounted infantry crews, such as when armor must
(3) Cumulative combat duration— operate in highly restrictive terrain (Negative).
the total number of days (cumulated over days,
weeks, months) in which the small units (platoons, (11) Casualties from mines or booby
companies) have suffered casualties (Negative). traps (Negative).
(4) Sudden transition to the horrors (12) Extent and intensity of the rear
of war—many new troops with no prior combat battle (Negative). The introduction of CS/CSS
experience being confronted with surprise attack soldier to the stress of battle when attacked.
or new weapons of mass destruction (Negative). These soldiers are confronted with dangers and
horrors of war for which they may not have been
(5) Extent to which the troops are adequately trained or mentally prepared.
subjected to artillery and air attack (with some
allowance for the strength of their defensive forti- (13) Failure of expected support,
fication, dispersion, and concealment) (Negative). such as fire support, reinforcement, or relief;
This is especially true if they involve sudden mass inadequate resupply; inadequate CHS support
devastation. (Negative).
(6) Casualties from friendly fire (14) High personnel turbulence, re-
(including direct fire, artillery, and air attack) sulting in low unit cohesion and inadequate unit
(Negative). This, of course, is not part of the plan tactical training (Negative).
of operation but is a special hazard of the fast-
moving battle. When such incidents are reported, (15) Loss of confidence in leaders,
CSC teams should respond immediately. in supporting or allied units, and in equipment
as compared to the enemy’s (Negative).
(7) High NBC threat—a state of
alertness requiring periods in MOPP Levels 1 (16) Popular opposition to the war
through 4, frequent false alarms, and concerns at home; lack of understanding or belief in the
and rumors about escalation (Negative). Actual justness of the effort (Negative).
NBC use: What type agents? (Persistent con-
tamination? Potential for contagion?) What (17) Families left unprepared by
casualties? What are the implications for in- rapid mobilization and deployment (Negative).
creased MOPP levels, rumors, concerns of escala- Lack of a believable plan for evacuating families
tion, and worries about home? from the theater; lack of plans for keeping them
secure under a reliable authority if they cannot
(8) Being on the defensive, espe- be evacuated. This can also contribute to
cially in static positions (unless the fortifications misconduct stress behaviors, especially AWOL.

B-4
FM8-51

(18) Home front worries (Negative). and emphasizes adherence to the Law of Land
Lack of visible command program for ensuring Warfare, United States Code of Military Justice,
support to Army families. and tolerance for cultural differences (Positive).
(19) Inadequate water available for (2)m History of tough and realistic
drinking (Negative ). training is positive if it includes faithful adher-
ence to rules of engagement which support the
(20) Adverse weather, especially Law of Land Warfare and cultural issues (Positive).
cold-wet; any harsh climate if troops are not
properly trained, equipped, and acclimatized (3)m Unit leaders, medical person-
(Negative). nel, and chaplains are trained to recognize BF
and early warning signs of misconduct stress
(21) Unfamiliar, rugged terrain (jun- (Positive).
gle, desert, mountain, or urban) if troops are not
specifically trained and equipped (Negative). (4)m Units are withdrawn from
combat periodically to rest, refit (reconstitute, if
(22) High prevalence of endemic necessary), and absorb new replacements who
minor illnesses, especially if this reflects inade- arrive and are integrated as cohesive teams, not
quate command emphasis on self-aid and buddy individuals (Positive).
aid preventive measures (Negative).
(5)m Leaders have demonstrated
(23) Last operation before units (or competence, courage, candor, and commitment
many soldiers in them) rotate home, or if the war (Positive). Leaders show caring for the soldiers
is perceived as already won, lost, or in final stages and make provisions for their physical, mental,
of negotiation (Negative). and spiritual well-being as the tactical situation
permits.
(24) Many civilian women and chil-
dren casualties resulted from the fighting (Nega- (6)m Leaders keep troops informed
tive). This may be a stronger factor in brief of the objectives of the operations and war (includ-
OOTW (conflict) than in war where the magni- ing psychological operations and diplomatic,
tude of the horror and the preoccupation with political, and moral objectives) (Positive). They
personal and unit survival may quickly harden focus the soldiers’ appraisal of the situation to
soldiers to these casualties. maintain positive coping against the temptations
to misconduct stress behaviors.
B-3. Estimating Substance Abuse and
Misconduct Stress Behaviors NOTE
a. Protective Factors. Positive Factors These preventive factors will protect
(1) through (6), above, reduce alcohol/drug misuse only if leaders and troops maintain and
and other misconduct stress behaviors (Positive). enforce a unit’s self-image that regards
They can also become misconduct behaviors as the misconduct behaviors as unaccept-
shown in (b), below. able. If this unit’s self-image is lacking,
these factors may even contribute to
(l)m High unit cohesion is positive substance abuse and violations of the
if the unit’s "identity" forbids abuse of substances laws of war.

B-5
FM 8-51

b. Risk (Negative) Factors Which (8)m Hasty withdrawal. Here,
Increase Substance Misuse and Other Harmful too, soldiers may loot or abuse substances “to keep
Combat Stress Behauiors. them from falling into enemy hands” (Negative).
Rape, murder, and other reprisal atrocities
(1)m Permissive attitude and avail- (criminal acts) can occur if retreating troops feel
ability and use of drugs in the TO and also in the hindered by EPWs, or if the civilians being left
US civilian community, especially around posts/ behind are hostile. Leaders must not encourage
garrison areas and in the regions and age groups too zealous a scorched-earth policy. This means
from which recruits are drawn (Negative). that only those items except medical that would
be of potential use to the enemy are destroyed. If
(2)m Inadequate enforcement of leaders lose tight control, overstressed soldiers
the unit’s ADAPCP before deployment in iden- may desert or surrender.
tifying and treating (or discharging) misusers
(Negative). (9)m Beleaguered units which
cannot evacuate any (or only the most severely
(3) Availability and distribution wounded) casualties. Here, too, some soldiers
networks (both legal and illegal) for alcohol and may commit misconduct stress behaviors due to
different types of- drugs in the theater (Negative). BF or go AWOL without becoming medical pa-
Some drugs are more available and cheaper in tients (Negative).
some foreign countries or regions.
(10)m Commission of atrocities by
(4)m Unsupervised use of amphet- the enemy, especially if against US personnel but
amines and other strong stimulants to remain also if against local civilians (Negative).
awake in continuous operations (Negative). This (ll)m Racial and ethnic tension in
can produce dangerous (usually temporary) the civilian world and in the Army (Negative).
neuropsychiatric illness. Also, it may lead to Major cultural and physical/racial differences
dependency and addiction in originally well- between US and the local population,
intentioned, good soldiers, including leaders.
(12)m Local civilian population
(5)m Boredom and monotonous perceived as hostile, untrustworthy, or “sub-
duties, especially if combined with chronic frus- human” (Negative). This is more likely to result
tration and tension (Negative). when soldiers have little knowledge or under-
standing of cultural differences.
(6)m High threat of nerve agent use
with false alarms that result in self-admin- (13)m Failure of expected support,
istration of atropine causing mental symptoms such as reinforcement or relief; inadequate re-
and perhaps temporary psychosis (Negative). supply; inadequate CHS (Negative). Soldiers who
feel abandoned and on their own may resort to
(7)m Victorious pursuit of a re- illegal measures to get what they think they need.
treating enemy. This reduces BF casualties, but Combat soldiers naturally tend to feel “entitled to
may not inhibit commission of atrocities (the claim what they have earned,” and this may lead
criminal acts of killing of EPWs, raping, looting) to looting and worse.
or alcohol/drug misuse (as supplies are “liberat-
ed”) unless command retains tight moral control (14)m High personnel turbulence,
(Negative), lack of unit cohesion, especially “vertical cohesion”

B-6
FM 8-51

between leaders and troops (Negative). A (17)m Lack of a believable plan for
“substance-of-choice” can become a “ticket” for protecting families in the theater, either by
inclusion into a group. evacuating them or keeping them secure under
reliable authority (Negative). Some soldiers may
(15)m Loss of confidence in leaders, go AWOL to stay with them.
in supporting or allied units, and in equipment c. Estimate of Substance Abuse and
as compared to the enemy’s (Negative). These Misconduct Stress Behavior. The purpose of this
produce the same effects as negative factors estimate of potential substance misuse and other
(13)m, above, and (16)m, below. misconduct stress behaviors is the same as for
the estimate of BF casualties. It is to predict
(16)m Popular opposition to the when and where (in which units) problems are
war at home; lack of understanding or belief in most likely to occur so that preventive actions
the justness of the effort (Negative). Some can be focused. Also, provisions can be made for
soldiers will find this an excuse to desert or refuse the medical/psychiatric treatment of substance
lawful orders. Others who continue to do their abuse cases in the TO. The CSC estimator must
duty may show their resentment by lashing out work closely with the JAG staff, MP, and the
at the local population or by using drugs and chain of command to compare the projections with
alcohol. what is actually being found.

Section II. THE COMBAT STRESS CONTROL PLAN

B-4. Format to satisfy those requirements will be influenced
by the factors listed below:
The format for the CSC plan is the standard
outline (see FM 8-55). The CSC planner must (1) The nature, mobility, and in-
analyze the operations order and CHS estimate tensity of combat operations which influence the
for direct or implied CSC missions. He must number of BF soldiers; the severity of symptoms;
assess the available CSC resources and analyze and the feasibility of resting cases in or near their
alternative ways of using them to accomplish the units.
missions. Frequently, it is necessary to prioritize
the missions and recommend to higher command (2) The type of threat force, espe-
which of the alternate courses should be taken. cially the threat to CSC activities themselves. For
example, the likelihood of air and artillery attack;
the security of “rear areas” for rest; the electronic
B-5. Combat Stress Control Planning warfare threat and target detection capability
Considerations in Deployment and for concentrations of troops; and the NBC and
Conflict directed-energy threat.
a. The requirements for each of the (3) The availability of other health
CSC program functions (consultation, reconstitu- service units on which the CSC elements can rely
tion support, NP triage, restoration, recondition- for local logistical/administrative support and for
ing, and stabilization) and the ability of CSC units patient transportation or evacuation.

B-7
FM 8-51

(4) The geographical AO, terrain, division mental health section must be reinforced
and climatic conditions which limit mobility of if cases are to be restored in the BSA and DSA.
CSC units and require additional shelter for pa-
tients. d. Small CSC teams must be pushed
forward to reinforce the maneuver BSA well
(5) The disease, drug, alcohol, and before the fighting starts. Although BF casualties
environmental hazards of the region which will not be evenly distributed among all brigades,
threaten resting BF cases and produce other those cases which occur must be evaluated and
preventable nonbattle injuries which, histori- treated immediately at that level.
cally, resulted from there being a complication
of BF. (1) At critical times, this will be
under mass casualty conditions. Other logistical
b. The CSC planner must determine requirements and enemy activity may make it
the actual strengths of the CSC resources in impossible to respond quickly with CSC personnel
organic unit mental health sections and spe- once the battle has begun. Any newly arriving
cialized units. They may not be at the authorized CSC personnel who join a new unit under such
levels for personnel or equipment. The level of circumstances will take critical hours to days to
training, degree of familiarity, and cohesion with become efficient.
the supported units must be assessed. (2) The purpose of these CSC
"preventive” teams is NOT to hold BF casualties
for treatment in the highly fluid BSA. Their
B-6. Combat Stress Control Planning purpose is to prevent the evacuation of DUTY
Considerations for War and REST BF casualties who could remain with
their units. These teams also ensure correct
a. The more intense the combat, the initiation of treatment and evacuation of the refer
higher the rate of WIA and the higher the ratio of cases to the division fatigue center in the DSA. If
BF casualties to WIAs. If the WIA rate doubles circumstances allow, they could hold a small
there will be four times as many BF cases re- number for overnight observation/restoration.
quiring treatment. Furthermore, high-intensity
combat causes a shift towards more severe sym- (3) Combat stress control teams
ptoms and slower recovery. which are with a brigade not in action will use
this time productively in consultation activities.
b. The CSC organization must achieve These activities will reduce the incidence of stress
a balance between pre-positioning elements far casualties and better enable the unit to treat its
forward and having other elements further to the cases far forward when the time comes.
rear that can take the overflow of cases and be
redeployed to areas of special need. e. Combat stress control elements in
the DSA provide NP triage and prevent any
c. In Army operations, each maneuver unnecessary evacuation. They staff the division
brigade covers a larger and more fluid area and fatigue center which assures 2- to 3-days restora-
has greater firepower and responsibility than did tion within the division. They provide preventive
a WWII division. Winning the first battle will be consultation and reconstitution support through-
critical and can be accomplished only by recon- out the division rear. They can send personnel,
stitution of attrited units and rapid return of tents, and supplies forward to reinforce the teams
temporarily disabled soldiers to their units. The at the BSA.

B-8
FM 8-51

f. Combat stress control elements in with vehicle and preestablished contacts are al-
the corps area must provide the back-up "safety ready at the destination expecting to be re-
net” to catch the overflow from hard-pressed divi- inforced.
sions, as well as providing reconstitution support
to units which are withdrawn from battle and i. If the division mental health section
preventing and treating local rear-area BF cases. or CSC unit is given the mission to support a
Those in the corps area can be transferred separate brigade or ACR, it is important to estab-
laterally within the corps or temporarily sent lish contact and send a liaison officer or NCO to
forward to divisions which are in greatest need. its medical company as early as possible before
With somewhat greater difficulty, these assets the battle.
can be transferred from one corps to another.
g. Combat stress control teams need NOTE
100 percent ground mobility and communications
capability to function in their local areas. They Because of their unique missions,
need a small vehicle to visit the units in the BSA, armored cavalry units have special
DSA, or corps support area and to deploy to need for consultation, preventive
reconstitution sites with other CS/CSS teams. education, and staff planning.
Combat stress control teams should not wonder
around the battlefield alone. When they move Because of their elite self-image, it is important
outside the defensive areas, they should be in that the liaison is someone who has trained with
convoy with other CSS vehicles or be provided the unit and is known by personnel. In some
security by the echelon commander. scenarios, cavalry units suffer extreme attrition
in the first days of continuous operations, yet they
h. Combat stress control units provide are cited as prime candidates for reconstitution
the expertise of their personnel with little require- to return the survivors quickly to battle.
ment for heavy equipment. Therefore, if time,
distance, or the tactical situation prevents a CSC j. Combat stress control support is in-
element from traveling by ground to reinforce expensive and offers great potential pay-off in
another CSC element which is already in place, RTD soldiers at critical times and places in the
the key personnel and light specialized equipment battle and for reconstitution support after the
can be moved by air. battle.
(1) If not required to treat BF
NOTE casualties and attrited units, the same few per-
sonnel will be active in consultation to unit
Combat stress control personnel can be leaders. This preventive consultation could re-
sent forward in air ambulances that are duce BF and improve the potential RTD of unit
going to the forward medical companies members if anyone should become a BF casualty.
to evacuate the wounded.
(2) Combat stress control assets
also assist with treatment of other WIA and DNBI
Additional supplies, equipment, and vehicles can cases who have rapid RTD potential. Many of
follow as sling-loaded or air-droppable cargos. these will also have severe BF symptoms which
The key requirement is that a familiar CSC team require treatment.

B-9
FM 8-51

(3) Finally, CSC personnel have a (1) This zero-day evacuation policy
crucial role in preventing PTSD in troops may continue for the duration of a brief operation
(including those who did not become casualties) or until formal medical-holding facilities can be
by assisting command with after-action de- deployed behind the forward area surgical teams.
briefings.
(2) Early deploying medical per-
sonnel, as well as CSC planners and treaters,
B-7. Combat Stress Control Planning must make a concerted effort to encourage units
Considerations in Operations Other to keep soldiers with DUTY BF in small units
Than War and to keep REST cases in their own CSS
elements for a day or two of light duty, then
a. In OOTW, the total requirement for return them to full duty.
CSC support is significantly less than in war.
There is less need to pre-position CSC elements (3) If at all possible, the plan
far forward except during specific operations should also hold BF casualties at the forward
which approach war. medical facilities for 1 to 3 days of restoration as
an exception to the usual evacuation policy. This
(1) The total ratio of BF cases to holding can be done under very austere conditions
WIA cases may still be high, but the average and need not add significant additional logistical
number of WIA cases is less than two per burden to the system. Failure to provide such
thousand per day, so there are fewer cases. Most inexpensive, proximate treatment will greatly
BF cases can be managed in their units as DUTY increased chronic psychiatric disability among
or REST cases. soldiers.
(2) Few of the cases are HOLD or c. In OOTW, while the need for res-
REFER casualties who need to be held under toration of BF casualties is less than during war,
medical observation, so the BF casualty: WIA the incidence of misconduct stress behaviors in-
ratio is usually less than 1:10. However, rela- creases, specifically—
tively more of those who are casualties will need
stabilization on a hospital ward. Behavior disorders, including
indiscipline and violations of the Law of Land
(3) Reconstitution support is still Warfare and the UCMJ.
important for units following battle, but the
units will usually be small (squad, platoon, Drug and alcohol abuse.
company).
Other disorders of boredom and
b. Contingency operations pose special loneliness.
problems if they involve rapid deployment to an
undeveloped theater.The CHS plan for care of There is still a need for a reconditioning program
all wounded and sick who cannot return imme- in the corps to salvage those cases who do not
diately to full duty may be to evacuate them as improve in the divisions. In conflict, it may be
quickly as possible to the nearest COMMZ- or practical to increase the evacuation policy for
CONUS-based MTFs. The tendency will be to these cases, extending the policy from 7, 14, or 30
err on the side of caution and evacuate anyone days; this maximizes RTD and minimizes the
whose status is in doubt. development of an evacuation syndrome, where

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FM8-51

stress symptoms, misbehavior, or drug and returns and in combined sessions after the return.
alcohol misuse become a “ticket home.” The debriefings should also address—
Increasing the length of stay increases the
reconditioning program census. The preventive How the service member, spouse,
consultation programs remain important for children, and society may have changed.
corps-level CSS units with no mental health
sections. How to cope with those changes
positively.
d. Conflict requires rigorous preventive
programs and after-action debriefings to minimize Welcome home ceremonies and memorial services
subsequent PTSD. These are especially impor- provide a sense of completion and closure.
tant because of the ambiguous and often vicious
aspects of enemy tactics and their effects on our
soldiers. B-9. Combat Stress Control Planning Con-
siderations in Peacetime
B-8. Considerations When Units or Indi- a. To be effective, CSC must form a
vidual Soldiers Redeploy Home (After continuum with the Army mental health services.
Military Operations) The peacetime utilization and training of mental
health personnel must prepare them for their
a. Unit mental health personnel and mobilization missions and develop strong unit
supporting mental health/CSC units assist cohesion among themselves and with supported
leaders in preparing soldiers for the transition units. Future operations may leave little time for
back to garrison or civilian life. A period of on-the-job-training or to develop familiarity and
several days should be scheduled for memorial cohesion before the crucial battle starts.
ceremonies, group debriefings, and discussions
of— b. Army Regulation 40-216 states that
patient care duties must not interfere with the
What has happened in combat, division mental health section’s training with its
especially working through painful memories. division.
What to expect in the soldiers’ c. Echelon III psychiatric and mental
own reactions on returning to peacetime. health personnel who will provide CSC support
should have peacetime duties which bring them
How family and society may into close working relationships with the organic
have changed since deployment and how to deal mental health sections, chaplains, line command-
with these changes constructively. ers, and NCOs of the units they will support in
war.
b. More intensive programs are sched-
uled for individuals or units with prolonged in- (1) Active Component CSC person-
tensive combat or other adverse experiences. nel should be assigned to MEDDACs. They will
Coordination with the rear detachment and work in the following areas:
family support groups is required to schedule
similar education briefings and working-through Community mental health/
sessions at the home station, both before the unit community counseling centers.

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FM 8-51

Drug and alcohol abuse some headquarters, the CSC planner may give
prevention and control programs. the briefing. In others, it may be given by the
unit surgeon as part of the overall CHS plan.
Family advocacy and ex-
ceptional family member programs. b. In any case, the CSC briefing must
be short and simple. The senior commander does
The CSC personnel should be working at the posts not need all the details which went into the
or garrisons of the Active Component divisions, analysis (although those details should be avail-
brigade, regiments, and corps units they will able, if asked for). The commander needs to know
support during war and OOTW. They should the “bottom line.” What will it cost? What is the
also participate with those units in field training return, especially in reduced casualties and rapid
exercises. RTD? What is the risk if it is not done?
(2) Reserve Component CSC per- c. Many commanders are highly
sonnel should train with units they will support knowledgeable about the nature and importance
on mobilization. They should also use available of combat stress reactions and home front issues.
training time to establish and implement CSC However, many others are not. The CSC briefing
programs in those units. may have to overcome the prejudice that mental
health (CSC) interventions are things that pam-
per the troops and ruin them for combat or just
B-10. Briefing the Combat Stress Control burden the unit with weaklings who would be
Plan better purged from the Army.
a. Depending on the echelon, the CSC d. Educating the senior commander,
plan may be briefed to a senior medical using language he knows and understands, is the
commander or line commander for approval. In first essential step of CSC.

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APPENDIX C

MENTAL HEALTH PERSONNEL IN MILITARY POLICE
CONFINEMENT FACILITY TEAMS
C-1. Confinement Facility Teams C-2. Teams LA, LB, LC, and LD
Military Police Confinement Facility Teams LA Teams LA, LB, LC, and LD (administrative
through LF have the mission to provide com- overhead teams) are designed to provide admin-
mand, staff planning, and administrative and istration for facilities of 50, 150, 300, and 450
logistical support to a confinement facility for prisoners, respectively. They contain mental
military prisoners. The guards for the facility health officers, NCOs, and enlisted personnel as
are provided by an MP Guard Company (TOE shown in Table C-1. The medical specialists
19667L000); one squad is sufficient to guard 50 (MOS 91B) shown are also listed as being part of
prisoners. the TOE section for mental hygiene.

C-3. Mental Health Personnel hygiene activities; conducts prisoners’ counseling
functions; performs prisoner evaluations; assists
The duties of the mental health and medical in the development of training programs; and
personnel are listed below: supervises the behavioral science specialist. He
is responsible for monitoring the correctional
a. Social Work Officer, MAJ, AOC treatment program for the prisoners. Each pris-
73A67. The social work officer directs mental oner is evaluated and a correctional treatment

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FM 8-51

program is devised with continuous reevaluation c. Behavioral Sciences Noncommiss-
as additional information becomes available. ioned Officers and Specialists. The behavioral
The following aspects of correctional treatment science specialists help prisoners adjust to
are considered and closely monitored: employ- the confinement environment, learn problem-
ment, training, education, medical condition, solving techniques, and develop productive and
religious participation, off-duty activities, and acceptable behavior. They meet with the pris-
family and financial problems. The social work oner within 48 hours of in-processing, complete
officer identifies prisoners who need psychiat- necessary records, and initiate a follow-up plan.
ric evaluation and refers them to the clinical They provide advice concerning the prisoners’
psychologist. record, conduct, attitude, and progress. They
make recommendations concerning clemency,
b. Clinical Psychologist, CPT, AOC parole, restoration, custody, and job assignments.
73B67. The clinical psychologist applies psy-
chological principles through direct patient d. Emergency Treatment Noncommis-
services to help prisoners adjust to the sioned Officer and Medical Specialist. They
confinement environment; evaluates emotional provide routine sick call and emergency treat-
disturbances and mental and behavioral dis- ment to prisoners. They coordinate CHS for
orders; and promotes effective mental health. medical activities beyond their capabilities.

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APPENDIX D

THE GENEVA CONVENTIONS AND COMBAT
STRESS-RELATED CASUALTIES
D-1. Special Relevance to Medical Combat d. The CSC commander and the chain
Stress Control of command will have to decide whether—

a. This appendix reviews the relation- (1) TO risk the loss of protected
ship of the Geneva Conventions to CSC and status of specific personnel, activities, or facilities
treatment of combat stress-related casualties. in the CSC program by having them strictly
adhere to the nonpatient treatment principles
b. The provisions of the Geneva Con- and operate the CSC unit as a truly nonmedical
ventions afford the wounded and sick, medical activity.
personnel, and medical units protected status.
The time-proven principles of treating BF (2) To accept the possible loss of
casualties is to treat them as soldiers, not as protected status by not marking the unit as
patients. The BF casualties are treated in a medical or by camouflaging the unit. Even if the
nonpatient care tactical setting. This arguably unit is in technical compliance with the GWS,
creates a clear tension, perhaps even a contra- protection status may be lost.
diction.
(3) To seek the full benefit of pro-
c. The issue of the right to Geneva tected status by limiting the application of the
Conventions protection depends not upon what treatment principles and instead operating the
the CSC treater tells the BF soldier but rather on CSC unit as a visibly obvious medical facility.
several issues: This is done at perhaps the price of some
reduction in therapeutic effectiveness.
(1) Does the BF soldier’s behavior e. Whether the CSC activity is oper-
and duty status, in fact, meet the standards set ated as either a visibly obvious medical facility or
by Geneva Convention for the Amelioration of the is camouflaged, CSC personnel and soldiers being
Condition of Wounded and Sick in Armed Forces treated must adhere to the provisions of the GWS.
in the Field (GWS)? A patient who meets these This is required for them to maintain their
standards is considered a privileged patient, that protected status and the protected status for other
is, one who is not contributing to the combat medical units with which they are associated.
efforts by virtue of disability.
f. The remainder of this appendix will
(2) Does the CSC staff’s behavior discuss special considerations for CSC activities
conform to the GWS standard as personnel who and the application of these options based on the
are solely engaged in the care of the sick and definitive Geneva Conventions information found
wounded? in FM 8-10.
(3) Does the physical appearance
of the CSC personnel, tents, vehicles, and so forth, D-2. Special Considerations for Medical
sufficiently identify them as medical and entitled Combat Stress Control Activities
to GWS protection for this to be more than a moot
point on the dispersed, fast-moving, long-range a. We will now reconsider the three
battlefield? questions raised in paragraph B-1(c) relating to

D-1
FM 8-51

whether CSC activities are entitled to Geneva Providing perimeter
Conventions protection. and air guard security for the medical unit only,
not for the total base cluster.
b. Issue #1: Do the battle-fatigued
soldiers comply with the GWS criteria for (b) Round trip prerecovery
patients? visits to the unit are theoretically allowed, pro-
vided the visitors perform no combat-relevant
work but only assist the CSC personnel in their
(1) DUTY and REST cases of BF rounds.
are clearly still combat soldiers and are not
entitled to GWS status. They are still solely on c. Issue #2: Does the CSC staff comply
their own unit’s rolls. They can, therefore, with the GWS criteria for protected medical
perform any soldierly task, including offensive personnel? That depends on what they do or do
operations, without losing a protected status not do.
which they do not have. The treatment principle
of treating them as soldiers is fully satisfied. (1) To retain personal entitlement
to Geneva Conventions privilege, CSC personnel,
(2) HOLD and REFER BF cases like medics, PVNTMED teams, and battalion aid
may be told that they are “soldiers, not patients,” stations, must—
but they are, in fact, medical patients. They are
absent from their units because of a temporary (a) Not use weapons except to
disability that makes them unable to do their defend themselves and their patients when that
combat duties. They are receiving medical care defense is made necessary by enemy attack
and are under the control of medical personnel/ specifically directed at the medical facility.
units. As long as they are not set to performing
tasks which contribute to the war effort, they fully (b) Not transport weapons or
meet the vague GWS criteria for a “sick and ammunition (except for the permissible personal
wounded” patient. small arms), nonmedical equipment, or combat-
effective (nonpatient) troops.
(3) To stay within the letter of
the Geneva Conventions rules, the following (c) Not transport DUTY or
limitations apply: REST BF cases or fully recovered BF casualties
back to their units in CSC (medical) vehicles.
(a) Recovering BF casualty Instead, call the unit to come for them.
perform work projects only at and for medical
units; for example— (d) Not initiate offensive ac-
tions against the enemy.
Filling sandbags and (e) Not engage in labor which
digging trenches for the medical unit’s own directly supports combat operations (as distinct
protection only. from protecting or restoring health).
Moving medical sup- (2) If CSC personnel are rumored
plies, maintaining medical vehicles, and helping to do the above, that may endanger the Geneva
in the medical mess facility and laundry. Conventions status for all CSC personnel, if the

D-2
FM 8-51

captors identify them specifically as CSC rather However, they do not confer immunity from
than simply as medical personnel. attack to the legitimate target with which they
are collocated, so they have no grounds for
d. Issue #3: Does the physical ap- complaint if they suffer casualties.
pearance of the CSC element sufficiently identify
it as medical for it to benefit from theoretical (2) Combat stress control activities
privileged status? Combat stress control activities which are functioning as or with medical units,
can be divided into— but under tactical circumstances where they are
using camouflage, light discipline, perimeter
(1) Combat stress control activities watch, and not showing the distinctive emblem
which take place in nonmedical units. Examples (red cross). Examples are—
are—
Combat stress control team
A CSC consulting team in tents/vehicles at a FSMC, under camouflage.
its truck, visiting a line unit.
The division fatigue cen-
A CSC reconstitution ter or a corps reconditioning center, separated
support team camped at the reconstitution site. somewhat from its supporting medical company
or CSH, and camouflaged.
A CSC reconditioning
“cell” (team) attached to a corps CSS unit, (a) Although the fatigue or
providing ongoing treatment to the “REST BF reconditioning centers technically are “holding
casualty” who are performing limited therapeutic patients,” the tactical setting supports the
duty at that unit. therapeutic message that they are still soldiers
receiving temporary rest and performing for a
(a) The BF soldiers are, in tactical medical unit, not a hospital.”
fact, “soldiers” on DUTY status (however limited)
and not “patients.” The BF casualty could (b) The CSC personnel would
perform work details for CS, CSS, and combat not be legitimate targets and, if captured, would
units in the vicinity under directions from those still have the status of “retained personnel,”
units (not CSC personnel). This includes pulling provided they did not violate the limitation on
perimeter defense duty. They could be trans- medical noncombatants.
ported to and from work details in nonmedical
vehicles. (c) They have little grounds
to complain, however, if a fast-moving or distant
(b) In this situation, the CSC enemy fails to recognize their protected status.
unit provides the best “military tactical” thera-
peutic setting for the “REST” BF cases. The CSS (3) Combat stress control activities
vehicle, tents, and personnel themselves are not which are collocated with medical units showing
a legitimate target and, if captured, would still be the red cross (as red on white and not under
eligible for the Geneva Contentions status of camouflage). Example: A corps reconditioning
“retained personnel” rather than “prisoners of center which is intermixed with a CSH or medical
war,” provided they (collectively) have adhered to holding company and well separated from any
the rules for being medical noncombatants. nonmedical units.

D-3
FM 8-51

(a) To avoid possibly creating recovering and recovered BF casualties to their
an appearance which might compromise the units.
Geneva status of the other medical units which
are under the red cross, the CSC units should (4) Combat stress control per-
show the red cross on all their tents and refrain sonnel could, when necessary, contribute directly
from using camouflage. to the general defense.
(b) In this case, the BF (5) They should still respect the
soldiers can still be told that they are not Geneva status of enemy medical units which
“patients” but rather are on temporary fatigue or are identified as such and of enemy sick and
reconditioning duty. This duty is with the CSC wounded.
unit as temporary medical soldiers. They could
be provided with the armbands showing the small f. Combat Stress Control and Geneva
distinctive emblem which is given to litter bearers Prisoners of War (GPW).
or other soldiers who are temporarily detailed to
medical duties. (1) Prisoners of war will not nor-
mally be brought to the attention of CSC elements
(c) Everyone must, of course, at forward medical facilities unless they also have
comply fully with the Geneva Conventions either wounds or disease, obvious signs of major
restrictions. NP disorders, or BF symptoms which resemble
one of the above.
(d) Because of the substantial
loss of military tactical atmosphere, this (a.) In WWI, it was noted that
alternative is less desirable than locating slightly POW and EPW rarely showed dramatic “shell
further away, closer to the nonmedical CSS units, shock” symptoms. As with the wounded, there is
and erecting camouflage. Issuing the armbands a natural (if relative) relief from anxiety that
may still be helpful. The CSC personnel would comes from being relieved of the responsibility
also wear them in these situations. and danger of combat. Just being alive (having
had your willingness to surrender be accepted)
e. In a conflict where the enemy does and having someone else make all decisions about
not respect the Geneva Conventions, the chain where you go and what you receive is a big relief.
of command may decide that CSC activities will
forego the claim to Geneva Conventions pro- (b) It is also probable that
tection altogether. language barriers and lack of concern for EPW
“feelings” have left many psychiatric problems
(1) The distinctive emblem would among EPW unreported. Probable symptoms
not be shown at all. include:

(2) Recovering BF casualty could Anxiety over how
perform any military tasks they are capable of, they will be treated.
under direct supervision of CSC personnel.
Shame, guilt, and
(3) Combat stress control vehicles depression at having failed their country by being
could, if available, transport DUTY, REST, and captured (or “voluntarily” surrendered).

D-4
FM 8-51

Post-traumatic stress Army MP personnel and any allied or coalition
disorders related to the deaths of comrades, close personnel working at the confinement facility.
calls with death, and horrible sights seen.
Advise regarding the
Major psychiatric ill- stressors and stress manifestation of the prisoners
ness. and how to best control them.
(2) If EPW are brought to CSC Individual evaluation and
personnel for evaluation or are encountered by intervention for guards or prisoners when in-
CSC, mental health section, or NP ward and dicated.
consultation service personnel in the course of
their consultation mission, the GPW requires (4) If CSC personnel are them-
that— selves taken prisoner and are granted “retained
personnel” status, they will—
(a) The EPW receive the
same stabilization for major, potentially life- or Provide NP/mental health
function-threatening mental illness as friendly support to the POW.
soldiers receive. This will normally be provided
on the NP ward of hospitals, with guards pro- Provide life-saving assis-
viding security as needed. Physical restraints tance, as requested, to enemy personnel.
can be used as needed, provided routine nursing
care is protecting against injury and unnecessary Remain true to the code
discomfort. of conduct for POW and not provide other aid,
comfort, assistance, or propaganda to the enemy.
(b) Treatment of EPW with
adjustment disorders or PTSD symptoms will, of
course, not aim to return them to combat duty D-3. The Law of War
but rather to help them adjust to their status
as prisoners and minimize life-long disability The conduct of armed hostilities on land is regu-
following repatriation. lated by the law of land warfare. This body of
law is inspired by the desire to diminish the evils
(c) Combat stress control/ of war by: protecting both combatants and
mental health personnel will not provide direct noncombatants from unnecessary suffering;
assistance to prisoner interrogation. This is the safeguarding certain fundamental human rights
responsibility of military intelligence personnel. of persons who fall into the hands of the enemy,
Combat stress control involvement could jeop- particularly prisoners of war, the wounded and
ardize Geneva-protected status. civilians; and facilitating the restoration of peace.
The law of war places limits on the exercise of a
(3) Combat stress control units belligerent’s power in the interest of furthering
should provide routine mental health consulta- that desire. It requires that belligerents refrain
tion to EPW confinement facilities. This should from employing any kind or degree of violence
include— which is not actually necessary for military
purposes, and that they conduct hostilities with
Stress control advise to regard for the principles of humanity and
the command regarding the stressors of US chivalry.

D-5
FM 8-51

a. Sources of the Law of War. The law wounded or who is sick, and for that reason is
of war is derived from two principal sources: out of combat, is from that moment protected.
treaties (or conventions), such as the Hague and Friend or foe must be tended with the same care.
Geneva Conventions; and customs, practices From this principle, numerous obligations are
which by common consent and long established, imposed upon parties to a conflict.
uniform adherence have taken on the force of law
(see FM 27-10). Under the Constitution of the a. Protection and Care. Article 12 of
United States, treaties constitute part of the the GWS imposes several specific obligations
supreme “Law of the Land” and thus must be regarding the protection and care of the wounded
observed by both military and civilian personnel. and sick.
The unwritten or customary law of war is also
part of the law of the United States and is binding (1) The first paragraph of Article
upon the United States, citizens of the United 12, GWS, states "Members of the armed forces
States, and other persons serving this country and other persons mentioned in the following
(see DA Pam 27-l). Article, who are wounded or sick, shall be
b. The Geneva Conventions. The respected and protected in all circumstances.”
United States is a party to numerous conventions
and treaties pertinent to warfare on land. (a) The word “respect” means
Collectively, these treaties are often referred “to spare, not to attack,” whereas “protect” means
to as the Hague and Geneva Conventions. “to come to someone’s defense, to lend help and
Whereas it may generally be said that the Hague support.” These words make it unlawful to
Convention concerns the methods and means attack, kill, ill-treat, or in any way harm a fallen
of warfare, the Geneva Conventions concern and unarmed enemy soldier while at the same
the victims of war or armed conflict. The Geneva time imposing an obligation to come to his aid
Conventions are four separate international and give him such care as his condition requires.
treaties, signed in 1949, and are respectively
entitled: “Geneva Convention for the Amelio- (b) This obligation is appli-
ration of the Condition of the Wounded and cable “in all circumstances.” The wounded and
Sick in Armed Forces in the Field”; “Geneva sick are to be respected just as much when they
Convention for the Amelioration of the Condi- are with their own army or in no-man’s-land as
tion of Wounded, Sick and Shipwrecked Members when they have fallen into the hands of the
of Armed Forces at Sea” (GWS Sea); “Geneva enemy.
Convention Relative to the Treatment of
Prisoners of War”; and “Geneva Convention (c) Combatants, as well as
Relative to the Protection of Civilian Persons noncombatants, are required to respect the
in Time of War” (GC). The Conventions, with wounded. The obligation also applies to civilians,
amendments, are extremely detailed and contain in regard to whom Article 18 specifically states:
many provisions which are tied directly to the “The civilian population shall respect these
CHS mission. wounded and sick, and in particular abstain from
offering them violence.”
D-4. Protection of the Wounded and Sick
(d) The GWS does not define
The essential and dominant idea of the GWS is what is meant by “wounded or sick”; nor has there
that the person of the soldier who has been ever been any definition of the degree of severity

11-6
FM8-51

of a wound or a sickness entitling the wounded or (b) The wounded and sick
sick combatant to respect. Any definition would shall not be made the subjects of biological,
necessarily be restrictive in character and would scientific, or medical experiments of any kind
thereby open the door to misinterpretation and which are not justified on medical grounds and
abuse. The meaning of the words “wounded and dictated by a desire to improve their condition.
sick” is thus a matter of common sense and good
faith. It is the act of falling or laying down of (c) The wounded and sick
arms because of a wound or sickness which shall not willfully be left without medical
constitutes the claim to protection. Only the assistance; conditions exposing them to contagion
soldier who is himself seeking to kill may be or infection shall not be created.
killed.
(3) The only reasons which can
(e) The benefits afforded the justify prioritized treatment are reasons of
wounded and sick extend not only to members of medical urgency. This is the only justified
the armed forces but to other categories of persons exception to the principle of equality of treatment
as well, classes of whom are specified in Article of the wounded. For example, this means that
13, GWS. Even though a wounded person is not EPW who are triaged as “immediate” must be
in one of the categories enumerated in the Article, cared for before our own wounded who have been
we still must respect and protect that person. triaged as “delayed”.
There is a universal principle which says that
any wounded or sick person is entitled to respect (4) Paragraph 5 of Article 12,
and humane treatment and the care which his GWS, provides that, if we must abandon wounded
condition requires. Wounded and sick civilians or sick, we have a moral obligation to, “as far as
have the benefit of the safeguards of the Geneva military considerations permit,” leave medical
Conventions. supplies and personnel to assist in their care.
This provision is not related to the absolute
(2) The second paragraph of obligation imposed by paragraph 2 to care for the
Article 12, GWS, provides that the wounded and wounded. A belligerent can never refuse to care
sick “. . . shall be treated humanely and cared for for enemy wounded he has captured because
by the Party to the conflict in whose power they adversary has abandoned them without medical
may be, without any adverse distinction found on personnel and equipment.
sex, race, nationality, religion, political opinions,
or other similar criteria. . . .“ b. Enemy Wounded and Sick. The
protections accorded the wounded and sick apply
(a) Adverse distinctions of to friend and foe alike without distinction.
any kind are prohibited. Nothing can justify a Certain provisions of the GWS, however,
belligerent into making any adverse distinction specifically concern enemy wounded and sick.
between wounded or sick who require his There are two provisions in the GPW which also
attention, whether they be friend or foe. Both apply to enemy wounded or sick because they
are equal in their claims to protection, respect, generally apply to POW.
and care. The foregoing is not intended to
prohibit concessions, particularly with respect to (1) Article 14 of the GWS states
food, clothing, and shelter, which acknowledge that persons who are wounded and then cap-
the different habits and background of the tured have the status of POW. However, that
wounded and sick. wounded soldier also needs treatment. Therefore,

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FM 8-51

a wounded soldier who falls into the hands of persons exposed to grave danger, and to protect
an enemy who is a party to the GWS and the them against pillage and ill-treatment [emphasis
GPW will enjoy protection under both Conven- added].”
tions until his recovery. The GWS will take
precedence over the GPW where the two overlap. (a) The "protection and re-
spect” to which wounded and sick enemy civilians
(2) Article 16 of the GWS requires are entitled is the same as that accorded to
the tabulation and sending of information re- wounded and sick enemy military personnel.
garding enemy wounded, sick, or dead.
(b) While Article 15 of the
c. Search For and Collect Casualties. GWS requires parties to a conflict to search for
Article 15 of the GWS imposes a duty on com- and collect the dead and the wounded and sick
batants to search for and collect the dead and members of the armed forces. Article 16 of the
wounded and sick as soon as circumstances Geneva Conventions states that the parties must
permit. It is left to the tactical commander to “facilitate the steps taken” in regard to civilians.
judge what is possible and to decide to commit This recognizes the fact that saving civilians is
his medical personnel to this efforts. If circum- the responsibility of the civilian authorities rather
stances permit, an armistice or suspension of than that of the military. The military is not
fire should be arranged to permit this effort. required to provide injured civilians with medical
care in a CZ. However, if we start providing
d.. Assistance of the Civilian Popu- treatment, we are bound by the provisions of the
lation. Article 18, GWS, is the only one therein GWS. Provisions for treating civilians (enemy or
which addresses the civilian population. It allows friendly) will be addressed in COMMZ regula-
a belligerent to ask the civilian to collect and care tions.
for wounded or sick of whatever nationality. This
provision does not relieve the military authorities (2) In occupied territories, the
of their responsibility to give both physical and Occupying Power must accord the inhabitants
moral care to the wounded and sick. The GWS numerous protections as required by the Geneva
also reminds the civilian population that they Conventions. The provisions relevant to medical
must respect the wounded and sick and must not care include—
injure them.
The requirement to bring
e. Enemy Civilian Wounded and Sick. in medical supplies for the population if the
Certain provisions of the Geneva Conventions are resources of the occupied territory are inadequate.
relevant to the CHS mission.
A prohibition on requisi-
(1) Article 16 of the Geneva Con- tioning medical supplies unless the requirements
ventions provides that enemy civilians who are of the civilian population have been taken into
“wounded and sick, as well as the infirm, account.
and expectant mothers, shall be the object of
particular protection and respect,” The Article The responsibility of
also requires that, “As far as military consider- ensuring and maintaining, with the cooperation
ations allow, each Party to the conflict shall of national and local authorities, the medical and
facilitate the steps taken to search for the killed hospital establishments and services, public
and wounded [civilians], to assist . . . other health, and hygiene in the occupied territory.

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The requirement that environment. Normally, this is facilitated by
medical personnel of all categories be allowed to medical personnel wearing an arm band bearing
carry out their duties. the distinctive emblem (a red cross or red crescent
on a white ground) or by their employment in a
A prohibition on requi- medical unit, establishment, or vehicle (including
sitioning civilian hospitals on other than a medical aircraft and hospital ships) that displays
temporary basis and then only in cases of urgent the distinctive emblem. Persons protected by
necessity for the care of military wounded and Article 25 may wear an arm band bearing a
sick and after suitable arrangements have been miniature distinctive emblem only while exe-
made for the civilian patients. cuting medical duties.
The requirement to pro- (2) The second protection provided
vide adequate medical treatment to detained by the GWS pertains to medical personnel who
persons. fall into the hands of the enemy. Article 24
personnel are entitled to “retained person” status.
The requirement to pro- They are not deemed to be POW, but other-
vide adequate medical care in internment camps. wise benefit from the protection of the 1949
Geneva Convention Relative to the Treatment of
Prisoners of War. They are authorized to carry
D-5. Protection and Identification of out medical duties only, and according to Article
Medical Personnel 28, GWS, “shall be retained only in so far as
the state of health . . . and the number of pris-
Article 24 of the GWS provides special protection oners of war require.” Article 25 personnel are
for “Medical personnel exclusively engaged in the POW, but shall be employed on their medical
search for, or the collection, transport, or duties in so far as the need arises. They may
treatment of the wounded or sick, or in the be held until a general repatriation of POW is
prevention of disease, [and] staff exclusively accomplished upon the cessation of hostilities.
engaged in the administration of medical units
and establishments . . . [emphasis added].” Article b. Specific Cases. Some medical per-
25 provides limited protection for “Members of sonnel may fall into each of the categories
the armed forces specially trained for employ- identified in Articles 24 and 25, depending on
ment, should the need arise, as hospital orderlies, their duties at the time.
nurses, or auxiliary stretcher-bearers, in the
search for or the collection, transport, or (1) While only Article 25 refers to
treatment of the wounded and sick . . . if they nurses, nurses are Article 24 personnel if they
are carrying out those duties at the time when meet the “exclusively engaged” criteria of that
they come into contact with the enemy or fall into Article.
his hands [emphasis added].”
(2) The AMEDD officers and non-
a. Protections. There are two forms of commissioned officers serving in positions that
protection, and they are separate and distinct. do not meet the “exclusively engaged” criteria of
Article 24 are not entitled to its protection but,
(1) The first is protection from under Article 25, are entitled to protection from
intentional attack if medical personnel are intentional attack during those in which they are
identifiable as such by an enemy in a combat performing medical support functions. Examples

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of medical personnel who would not meet the c. Identification Cards and Arm
“exclusively engaged” criteria of Article 24 are— Bands. Medical personnel who meet the “exclu-
sively engaged” criteria of Article 24, GWS, are
(a) The AMEDD officers serv- entitled to wear an arm band bearing the
ing as commanders of FSBs with responsibility distinctive emblem of the red cross and carry the
for base/base cluster defense as well as command medical personnel identification card authorized
and control of medical and nonmedical units. in Article 40, GWS (in the US armed services,
DD Form 1934). Article 25 personnel and medical
(b) The AMEDD officers and personnel serving in positions that do not meet
noncommissioned officers serving in staff posi- the “exclusively engaged” criteria of Article 24
tions within the FSB with responsibility for are not entitled to carry the medical personnel
planning and supervising the logistics support for identification card or wear the distinctive emblem
a combat maneuver brigade. arm band. Such personnel carry a standard
military identification card (DD Form 2A) and
(c) A medical company com- under Article 25, may wear an arm band bearing
mander, a physician, or the executive officer, an a miniature distinctive emblem when executing
MS officer, detailed as convoy march unit medical duties.
commander with responsibility for medical and
nonmedical unit routes of march, convey control,
defense, and repulsing attacks. D-6. Protection and Identification of
Medical Units and Establishments,
(d) Medical Service officers Buildings and Material, and MedicaI
and other Army officers and warrant officers who Transports
are qualified helicopter pilots but who are not
permanently assigned to a dedicated medical a. Protection. There are two separate
aviation unit. These officers devote part of their and distinct forms of protection.
time to flying medical evacuation missions but
primarily fly helicopters not bearing red cross (1) The first is protection from in-
markings on standard combat missions. tentional attack if medical units, establishments,
or transports are identifiable as such by an en-
(e) The GWS does not pre- emy in a combat environment. Normally, this is
clude the use of AMEDD personnel in perimeter facilitated by medical units or establishments
defense of nonmedical units. While manning the flying a white flag with a red cross and by
perimeter defense of nonmedical units, AMEDD marking buildings and transport vehicles with
personnel would forfeit their special protected the emblem.
status under Article 24 of the GWS. They would
be subject to being intentionally attacked, and if (a) It follows that if we
captured, would be POW and not necessarily cannot attack recognizable medical units, estab-
allowed to perform any medical duties. If they lishments, or transports, we should allow them
had returned to their medical duties, they would to continue to give treatment to the wounded in
possibly be entitled to the protection of Article their care, as long as this is necessary.
25, GWS. That is, if identifiable as performing
medical duties, they would not be subject to (b) All vehicles employed ex-
intentional attack, and if captured, would be clusively on medical transport work are protected
allowed to perform medical duties as needed. on the field of battle. Vehicles being used for

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both military and medical purposes, such as (b) Generally the buildings,
ambulances being used to move wounded material, and stores of fixed medical establish-
personnel during an evacuation and carrying ments will continue to be used to treat wounded
retreating belligerents as well, are not entitled to and sick. However, after provision is made to
protection. care for remaining patients, tactical commanders
may make other use of them. All distinctive
(c) Medical aircraft, like markings must be removed if the buildings are to
medical transports, are protected from inten- be used for other than medical purposes.
tional attack but with a major difference: They
are protected only “while flying at heights, times (c) The material and stores of
and routes specifically agreed upon between the fixed establishments and mobile medical units are
belligerents concerned.” Article 36, GWS. Such not to be intentionally destroyed, even to prevent
agreements may be made for each case or may be them from falling into enemy hands. The actual
of a general nature, concluded for the duration of buildings may in certain extreme cases have to
hostilities. If there is no agreement, belligerents be destroyed for tactical reasons.
will be able to use medical aircraft only at their
own risk and peril. (d) Medical transport which
falls into enemy hands may be used for any
purpose once the medical care of the wounded
(d) The second paragraph of and sick they contain is otherwise provided for.
Article 19 imposes an obligation upon belligerents The caveat as to removal of distinctive marking
to “ensure that the said medical establishments applies here also.
and units are, as far as possible, situated in such
a manner that attacks against military objectives
cannot imperil their safety. ” Hospitals should be (e) Medical aircraft are sup-
sited alone, as far as possible from military posed to obey a summons to land for inspection.
objectives. The unintentional bombardment of a If it is performing its medical mission, it is
medical establish or unit due to its presence supposed to be released to continue its flight. If
among or proximity to valid military objectives examination reveals that an act “harmful to the
is a violation of the GWS. Legal protection is enemy” (such as if the aircraft is carrying
certainly valuable but it is more valuable when munitions) has been committed, it loses the
accompanied by practical safeguards. protections of the Conventions and may be seized.
If a medical aircraft makes an involuntary
landing, all aboard, except the medical personnel,
(2) The second protection provided will be POW. A medical aircraft refusing a
by the GWS pertains to medical units, estab- summons to land is a fair target.
lishments, material, and transports which fall
into the hands of the enemy. b. Identification. The GWS contains
several provisions regarding the use of the red
(a) Captured mobile medical cross emblem on medical units, establishments,
unit material is to be used first to treat the and transports (the identification of medical
patients in the captured unit. If there are no personnel has been previously discussed in
patients in the unit, or when those who were paragraph D-5).
there have been moved, the material is to be used
for the treatment of other wounded and sick (1) Article 39 of the GWS reads as
persons. follows: "Under the direction of the competent

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military authority, the emblem shall be displayed (a) "The distinctive flag of
on the flags, armlets, and on all equipment the Convention shall be hoisted only over such
employed in the Medical Service. ” medical units and establishments as are entitled
to be respected under the Convention, and only
(a) There is no obligation on with the consent of the military authorities,”
a belligerent to mark his units with the emblem. paragraph 1, Article 42, GWS. Although the
Sometimes a commander (generally no lower than Convention does not define “the distinctive flag
a brigade commander for US forces) may order of the Convention,” what is meant is a white flag
the camouflage of his medical units in order to with a red cross in its center. Also, the word
conceal the presence or real strength of his “flag” must be taken in its broadest sense. Hos-
forces. The enemy must respect a medical unit pitals are often marked by one or several red
if he knows of its presence, even one which is cross emblems painted on the roof. Finally, the
camouflaged or not marked. The absence of a military authority must consent to the use of the
visible red cross emblem, however, coupled with flag (Article 39) and must ensure that the flag is
a lack of knowledge on the part of the enemy as used only on buildings entitled to protection.
to the unit’s protected status, may render that
unit’s protection valueless. (b) "In mobile units, as in
fixed establishments, [the distinctive flag] may
(b) The distinctive emblem is be accompanied by the national flag of the Party
not a red cross alone: it is a red cross on white to the conflict to which the units or establishment
ground. Should there be some good reason, how- belongs,” paragraph 2, Article 42, GWS. This
ever, why an object protected by the Conventions provision makes it optional to fly the national
can be marked only with a red cross without a flag with the red cross flag. On a battlefield, the
white ground, belligerents may not make the fact national flag is a symbol of belligerency and is
that it is so marked a pretext for refusing to therefore likely to provoke attack.
respect it.
(c) Some countries use the D-7. Loss of Protection of Medical Units
red crescent or the red lion and sun on a white and Establishments
ground in place of the red cross. Those emblems
are recognized as authorized exceptions under Medical assets lose their protected status by com-
Article 38, GWS. mitting acts "harmful to the enemy,” Article 21,
GWS. If such an act occurs, a warning must be
(d) The initial phrase of Arti- given to the offending unit and a reasonable time
cle 39 shows that it is the military commander allowed to cease such activity.
who controls the emblem and can give or withhold
permission to use it; moreover, he alone can order a. Acts Harmful to the Enemy. The
a medical unit to be camouflaged. He is at all phrase “acts harmful to the enemy” is not defined
times responsible for the use made of the emblem in the Conventions but should be considered to
and must see that it is not improperly used by include acts the purpose or effects of which are to
the troops or by individuals. harm the enemy, by facilitating or impeding
military operations. Such harmful acts would
(2) Article 42 of the GWS specifi- include the use of a hospital as a shelter for able-
cally addresses the marking of medical units and bodied combatants, as an arms or ammunition
establishments: dump, or as a military observation post. Another

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instance would be the deliberate siting of a "(5) That the humanitarian activi-
medical unit in a position where it would impede ties of medical units and establishments or of
an enemy attack. their personnel extend to the care of civilian
wounded or sick. ”
b. Warning and Time Limit. The
enemy has to warn the unit to put an end to the b. These five conditions are not to be
harmful acts and must fix a time limit, at the regarded as acts harmful to the enemy. These
conclusion of which he may open fire or attack are particular cases where a medical unit retains
if the warning has not been complied with. The its character as such and its right to immunity,
phrase “in all appropriate cases” recognizes that in spite of certain appearances which might have
there might obviously be cases where a time led to the contrary conclusion or at least created
limit could not be allowed. A body of troops some doubt.
approaching a hospital and met by heavy fire from
every window would return fire immediately. c. A medical unit is granted a privi-
leged status under the laws of war. This status is
based on the view that medical personnel are not
D-8. Conditions Not Compromising Medi- combatants and that their role in the combat area
cal Units and Establishments of is exclusively a humanitarian one. In recognition
Protection of the necessity of self-defense, however, medical
personnel may be armed for their own defense or
a. Article 22 of the GWS reads as for the protection of wounded and sick under
follows: “The following conditions shall not be their charge. To retain this “privileged status,”
considered as depriving a medical unit or es- they must refrain from all aggressive action and
tablishment of the protection guaranteed by may employ their weapons only if attacked in
Article 19: violation of the Conventions. They may not
employ arms against enemy forces acting in
"(1) That the personnel of the unit conformity with the laws of war and may not use
or establishment are armed, and that they use force to prevent the capture of their unit by the
the arms in their own defense, or in that of the enemy. (It is, on the other hand, perfectly
wounded and sick in their charge. legitimate for a medical unit to withdraw in the
face of the enemy.) Medical personnel who use
"(2) That in the absence of armed their arms in circumstances not justified by the
orderlies, the unit or establishment is protected law of war expose themselves to penalties for
by a picket or by sentries or by an escort. violation of the law of war and, provided they
have been given due warning to cease such acts,
"(3) That small arms and ammu- may also forfeit the protection of the medical unit
nition taken from the wounded and sick and not or establishment which they are protecting.
yet handed to the proper service, [sic] are found
in the unit or establishment. (1) Medical personnel may carry
only small arms, such as rifles or pistols or autho-
"(4) That personnel and materiel of rized substitutes.
the veterinary service are found in the unit or
establishment, without forming an integral part (2) The presence of machine guns,
thereof. grenade launchers, booby traps, hand grenades.

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light antitank weapons, or mines in or around a fact of their presence with a medical unit will
medical unit or establishment would seriously shelter them from attack. In case of capture,
jeopardize its entitlement to privileged status they will be POW.
under the GWS. The deliberate arming of a
medical unit with such items could constitute an e. Wounded arriving in a medical unit
act harmful to the enemy and cause the medical may still be in possession of small arms and
unit to lose its protection regardless of the location ammunition, which will be taken from them and
of the medical unit. See the previous discussion handed to authorities outside the medical unit.
of loss of protection of medical units. Should a unit be visited by the enemy before it is
able to get rid of these arms, their presence is not
d. Guarding of medical units, as a rule, of itself cause for denying the protection to be
is performed by its own personnel. However, it accorded the medical unit under the GWS.
will not lose its protected status if the guard is
performed by a number of armed soldiers. The f. The presence with a medical unit of
military guard attached to a medical unit may personnel and material of the Veterinary Corps
use its weapons, just as armed orderlies may, in is authorized, even where they do not form an
order to ensure the protection of the unit. But, integral part of such unit.
as in the case of orderlies, the soldiers may act
only in a purely defensive manner and may not g. Establishments protected by the
oppose the occupation or control of the unit by an GWS may take in civilians as well as military
enemy who is respecting the unit’s privileged wounded and sick without jeopardizing their
status. The status of such soldiers is that of privileged status. This clause merely sanctions
ordinary members of the armed forces. The mere what is actually done in practice.

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«APPENDIX E

MEDICAL REENGINEERING INITIATIVE FOR MENTAL
HEALTH AND COMBAT STRESS CONTROL ELEMENTS
IN THE THEATER OF OPERATIONS

Section I. OVERVIEW OF CHANGES

E-1. Unit Mental Health Sections

a. Divisions.

(1) Comparison. The Medical Force 2000 (MF2K) had a consolidated division mental
health section assigned to the MSMC of the MSB. The division mental health section was staffed with a
psychiatrist, a social work officer, a clinical psychologist, and enlisted mental health specialists. Doctrine
for MF2K specified that the division mental health section send a mental health officer/NCO team to each
maneuver brigade upon deployment. The MRI decentralized the division mental health section, making a
behavioral science officer and a mental health specialist organic to each FSMC. Under the MRI, the
psychiatrist and the NCOIC remain in the MSMC and will continue to have staff responsibilities to the
division surgeon. The psychiatrist and the NCOIC provide mobile consultation in the division rear, tech-
nical supervision to the brigade-level sections and medical personnel, and clinical expertise at the MSMC.

(2) Implications. Division assignment policy, not TOE structure, must ensure that the FSB
medical companies supporting the three maneuver brigades receive one social work officer and one clinical
psychologist as brigade mental health officers. The third brigade can receive either AOC. Doctrine and
policy must ensure that the division psychiatrist, the mental health NCOIC, the brigade behavioral science
officers, and the mental health specialists continue to function in an integrated and coordinated CSC
program. This ensures that all three mental health disciplines/expertise are available throughout the
division. This is facilitated in garrison where all division mental health assets will work together and
provide clinical care for division soldiers and their families. On deployment, division mental health
personnel will continue to work together using telecommunication, electronic transmission, and automated
data processing (“telemedicine”).

b. Area Support Medical Battalion.

(1) Comparison. The MF2K had a centralized mental health section assigned to the
headquarters and support company. This section was similar to the division mental health section except it
only had two officers (a psychiatrist and a social worker). The reorganization of the ASMB under MRI
replaces the headquarters and support company with a headquarters detachment. The headquarters
detachment provides C2 for the battalion. Under this MRI design, the headquarters detachment can locate
with any of its four ASMCs. Each ASMC will have a behavioral science officer and a mental health
specialist assigned. The behavioral science officer position may be filled with either a social worker or a
clinical psychologist. The ASMC mental health section provides mobile support to all units in its area of
responsibility, as well as clinical expertise for the ASMCs. Assigned to the ASMB headquarters detachment
is a psychiatrist and two mental health specialists. The psychiatrist continues to provide staff advice to the
battalion headquarters and technical supervision and clinical expertise for all the ASMCs (mental health
sections). All of the enlisted mental health specialists assigned to the battalion are E-4 or below.

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(2) Implications. When deployed, the ASMB psychiatrist and the ASMC behavioral science
officers may not have the opportunity for close contact depending on the ASMB’s mission and the size of the
AO. All ASMB mental health sections must be proactive by providing consultation and by teaching stress
reduction techniques. Battalion medical personnel must understand the principles of CSC prevention,
treatment, and the different medical/surgical diagnoses that must be ruled out. The absence of mental health
NCOs in the battalion to supervise and mentor the enlisted mental health specialists makes it essential that
each section’s behavioral science officer and mental health specialist work together in peacetime. They
should work together in a field training environment as well as a clinical environment in garrison. All the
mental health personnel assigned to the battalion must learn to make good use of telemedicine among
themselves and with supported units.

c. Armored Cavalry Regiment and Separate Brigades.

(1) Comparison. In MF2K, the ACR had no organic mental health personnel. Separate
brigades had only enlisted mental health personnel in their medical company. The MRI gives these units a
mental health section which is the same as those found in division medical companies. The behavioral
science officer (AOC 67D00) assigned to the ACR or separate brigade FSMCs may be either a social worker
or a clinical psychologist.

(2) Implications. These mental health sections will receive technical training and supervision
from a psychiatrist only when they come under the operational control of a division or are located in the
corps under the ASMB psychiatrist’s area of responsibility. The behavioral science officer assigned to the
ACR should actively seek out training assistance from the ASMB or the division psychiatrist. He should
seek this assistance to ensure that regiment/brigade mental health and other medical personnel are fully
trained in the medical aspects of CSC triage and stabilization.

E-2. Combat Stress Control Units

a. Medical Detachment, Combat Stress Control.

(1) Comparison. In MF2K, the 23-person CSC detachment was designed to be the corps-
level package to augment the organic mental health section of a division during war. Although highly mobile
and designed to break up into widely dispersed teams, the detachment was totally dependent on the division
and/or its higher medical headquarters for administrative and logistical support. Assigned to the headquarters
section was a psychiatrist who was also a full-time clinician in one of the forward-deployed teams and an
NCOIC with a clinical rather than an administrative background. A light-wheeled vehicle mechanic was
added later. Since the first CSC detachment was activated, these units have provided CSC support to their
home posts. They have supported field training exercises while concurrently deploying teams or entire
detachments on 5- to 12-month rotations to Somalia, Haiti, Guantanamo (Cuba), Bosnia, and Hungary.
These missions demonstrated the need for additional clinical and headquarters personnel to conduct highly
flexible, split-based operations. In MRI, the CSC detachment increases to 43 persons (without increasing
total CSC personnel in the corps) by transferring from the CSC companies some of the corps-level CSC
mission support requirements and the assets to accomplish them. Each CSC detachment gains one 4-person
CSC preventive team (for a total of four), one 10-person CSC fitness team (for a total of two), and five new
headquarters personnel.

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(2) Implications. The MRI CSC detachment retains the mission of providing direct support
to a division’s maneuver brigades and general/reinforcing support to the DSA, including corps units in those
areas. In addition, the detachment now augments area support in the corps immediately behind the division.
It can provide reconstitution support for a brigade- or smaller-sized unit; it can conduct the corps-level
reconditioning program, when needed, for the division and corps slice. The bill payer is a reduced number
of CSC companies and detachments in the force structure. The detachment must function with its elements
widely dispersed, some working in and for the supported division and others working in the corps for the
medical group/brigade. The CSC detachment headquarters must coordinate these CSC support operations.
In the corps, the MRI CSH no longer has a 15-person NP ward and consultation service. Under MRI, it has
a small 4-person NP consultation section (psychiatrist, psychiatric nurse, two mental health specialists) to
provide psychiatric stabilization on medical wards; to provide triage and outpatient psychiatry; and to
provide stress control support (including debriefings) for all the hospital patients and staff. The CSC
detachment will have an increased requirement to provide CSC support at the CSHs. Under some
circumstances, the CSC detachment may be required to provide a CSC fitness team to conduct ward-level
stabilization, in addition to other higher priority CSC mission requirements.

b. Medical Company, Combat Stress Control.

(1) Comparison. In MF2K major regional conflicts, the 85-person CSC companies had
responsibility for all CSC support in the corps area, plus major responsibility for supporting and reinforcing
the CSC detachments. The detachments were usually entirely within the division areas, although “spare
teams” might come under the CSC company’s C2 for reallocation to areas of special need. There was no
CSC unit allocation to support the COMMZ. In the COMMZ, the field hospital’s 15-person NP ward, OT,
and psychology personnel provided the required Level 4 reconditioning. The general hospital’s NP ward
personnel provided NP stabilization or detoxification to assure safe air evacuation of psychiatric patients or
RTD for recovered patients. The MF2K COMMZ hospitals could reinforce the COMMZ ASMB’s mental
health section in the event of serious rear battle or disaster. Under the MRI, the hospitals retain only the
4-person NP consultation section. While the MRI CSC detachments take over the forward corps and Level 3
reconditioning mission, the one remaining CSC company is still responsible for the corps rear and has
additional mission responsibilities for the echelons above corps (COMMZ). Each remaining CSC company,
therefore, increases to 88 persons with the gain of two 4-person CSC preventive teams and the retention of
its four CSC fitness teams (previously labeled restoration teams in MF2K). Each CSC company loses five
2½- or 5-ton trucks from its CSC fitness and headquarters sections, plus three maintenance personnel. The
trucks and maintenance personnel were lost because of Armywide rules for vehicles in rear area units. Two
more of the headquarters section’s personnel were also deleted. The CSC company loses 50 percent of its
weapons for self-defense.

(2) Implications. The CSC company still has a high-mobility multipurpose wheeled vehicle
with trailer for each preventive and fitness team and the commander to perform daily consultation missions.
It is dependent on other units to move its large tents and cots. This could be time-urgent in some
reconstitution support missions. The CSC company should use the one remaining large truck in its
headquarters to practice load planning and to develop loading plans for unit equipment being transported by
other units. All the CSC sections could use this vehicle for training and familiarization of loading plans
which would enhance their movement operations. The CSC company still provides CSC preventive teams
for direct support of corps-level brigades (National Guard enhanced readiness brigades, ACRs, field artillery,

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aviation, combat engineers, military police, and so forth) which may deploy as far forward as the divisions’
brigades. The company augments the ASMB/ASMC mental health mission in the corps rear and provides
routine support to brigade-sized units refitting in or transitioning through the corps. The company must
remain able to assemble task-organized elements quickly to provide reconstitution support for a division- or
smaller-sized unit. If Level 4 reconditioning is indicated after several weeks of intensive battle, the CSC
company can provide a CSC fitness team and perhaps a CSC preventive team. One inpatient NP ward in the
theater may be judged more efficient to stabilize psychiatric patients for air evacuation at a time of heavy
casualties. This would prevent their presence from disrupting the functions of the busy medical/surgical
wards. This capability could be achieved by attaching at least one CSC fitness team to a hospital. However,
this should only be a temporary measure because the fitness team will have other CSC support requirements.
The capability of staffing a psychiatric ward, which is no longer organic to any deploying MRI hospital, can
also be required in stability operations and support operations, as it was at Guantanamo for 11 months.
Finally, a new mission for the CSC company and hospital NP personnel is the DOD (Health Affairs)
requirement to screen all US soldiers for mental health problems prior to redeployment from a TO. This can
require brief interviews of up to 20 percent of the redeploying population.

c. Medical Companies and Detachments, Combat Stress Control.

(1) Comparison.

(a) In MF2K, the command positions were officially open only to psychiatrists, although
exceptions were made in practice. In MRI, the TOE specifies that command is now open to “best qualified”
officers of the other mental health disciplines (65A, 66C, 73A, 73B) as well as the psychiatrists (60W).
This is in keeping with the general trend within the Army Medical Department. Number constraints still
require the commander of the CSC detachment to be dual-hatted as a practicing clinician in one of the
teams.

(b) In MF2K, psychiatrists were in the preventive section, usually deployed further
forward, while clinical psychologists were in the restoration (now fitness) section, usually employed further
to the rear. The commander could transfer personnel between sections to meet mission needs. In MRI, the
clinical psychologists are in the preventive section and the psychiatrists are in the fitness section. This
results in a net decrease in psychiatrists and a larger proportional increase in psychologists.

(2) Implications. The switching of the psychiatry and psychology positions was made as an
“economy of force measure,” rather than because of any change in the mission demands at each echelon. It
is projected that the Army will not have sufficient psychiatrists to fill all CSC unit positions. The CSC
mission still recognizes the FSMC as the key point for making the differential triage between combat stress/
BF cases and similar-appearing patients with significant medical or surgical conditions. Putting triage
expertise as far forward as feasible is especially important in chemical warfare scenarios or on a widely
dispersed and mobile high-technology battlefield. The psychiatrists in the CSC units must now make special
effort to train the psychologists and social workers in the preventive section on basic physical/neurological
examinations and to convey relevant findings or suspicions to the physicians and physician assistants. The
psychiatrists must use telemedicine to support their forward deployed CSC preventive teams and must be
prepared to deploy forward themselves when needed. The division psychiatrists must increase training to all

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C 1, FM 8-51

the forward-deployed physicians and physician assistants, as well as the brigade behavioral science officers,
as there will be fewer psychiatrists forward to assist in combat NP triage.

Section II. UNIT MENTAL HEALTH SECTIONS IN THE
THEATER OF OPERATIONS
E-3. Location and Assignment of Unit Mental Health Sections

Mental health sections are located in the divisions, the corps, and echelons above corps. In the divisions, a
mental health section is assigned to each medical company. In the corps and echelons above corps, mental
health sections are assigned to each of the ASMCs. In ACRs and separate brigades, they are assigned to the
medical company.

E-4. Utilization in Garrison

In garrison, mental health personnel assigned to the division or brigade units should be employed as mental
health care providers. They should provide their consultation skills and specialty clinical expertise to
division personnel and their families. When the medical company and its supported units deploy on training
exercises or are in the field, assigned mental health personnel will deploy with them to provide CSC training
and support. In addition, they will train to perfect their own technical and tactical skills. In garrison,
referrals to the hospital or its clinics should be reduced. This is accomplished by having each of the mental
health sections working closely with units leaders and chaplains as consultants. In this capacity, they can
provide intervention and teach stress management. They can evaluate and treat distressed soldiers at their
duty stations or unit areas. However, the mental health sections of the division must continue to operate a
consolidated division mental health activity in which all division mental health officers and enlisted personnel
work together. The consolidated division mental health activity ensures that case management of problem
soldiers/patients receive the benefit of all three mental health disciplines (psychiatrist, psychologist, and
social worker) represented in the division for diagnosis, treatment, and referral. The consolidated division
mental health activity provides the environment for cross training and building of team cohesion.
Additionally, enlisted mental health personnel receive multidisciplinary training and supervision. All three
mental health disciplines contribute fully in operational planning and in the division preventive psychiatry
program, to include family support group development, drug and alcohol prevention and control, and
personnel reliability screening. On some posts, the division mental health assets may augment table of
distribution and allowances personnel in the Community Mental Health Activity. This would be the usual
mode for the behavioral science officers and mental health specialists/mental health sections of the ASMB
and companies of ACRs or separate brigades.

NOTE

In accordance with AR 40-216, clinical responsibilities in garrison
must not interfere with participation in field exercises, deployment
exercises, and maintenance of combat readiness.

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E-5. Division Mental Health Sections

One CSC/mental health section as stated above is organic to each medical company assigned to the division.
The medical companies are a DISCOM asset (see FMs 8-10-1, 8-10-3, and 63-21). The FSMCs are units
assigned to the FSBs which support the maneuver brigades. The MSMC in the MSB is located in the
DSA.

NOTE

The responsibilities of the division mental health section extends to all
division elements and provides a mental health/CSC presence at the
combat maneuver brigades.

The mental health sections are the medical elements in the division with the primary responsibility for
assisting the command with controlling combat stress. Combat stress is controlled through sound leadership,
assisted by CSC training, consultation, and restoration programs conducted by these sections. Division and
brigade mental health sections enhance unit effectiveness and minimize losses due to BF, misconduct stress
behaviors, and NP disorders. All mental health sections assigned or attached to the division work under the
technical control and direction of the division psychiatrist. The division psychiatrist, acting for the division
surgeon, has staff responsibility for establishing policy and guidance for the prevention, diagnosis, treatment,
and management of NP, BF, and misconduct stress behavior cases within the division AO. He also has
technical responsibility for the psychological aspect of surety programs. The staff of the division mental
health sections provides training to unit leaders and their staffs, chaplains, medical personnel, and troops.
The staff monitors morale, cohesion, and mental fitness of supported units. Other responsibilities for the
mental health sections located in divisions include—

• Monitoring indicators of dysfunctional stress in units.

• Evaluating NP, BF, and misconduct stress behavior cases.

• Providing consultation and triage as requested for medical/surgical patients exhibiting signs of
combat stress or NP disorders.

• Supervising selective short-term restoration for HOLD category BF casualties (1 to 3 days).

• Coordinating support activities of attached corps-level CSC elements.

The division psychiatrist normally uses the DSA clearing station as a base of operations. A behavioral
science officer (AOC 67D00) is assigned to each medical company except those which have the psychiatrist
assigned. Each behavioral science officer assigned to a FSMC is designated as the brigade behavioral
science health officer. The mental health specialist (MOS 91X00) assigned to each FSMC is designated as
brigade CSC coordinator. The division psychiatrist oversees the activities of all mental health sections in the
division and provides consultation, as necessary.

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a. Mental Health/Combat Stress Control Support. The division psychiatrist provides input to the
division surgeon on CSC-related matters. He works with the division medical plans and operations
personnel to monitor and prioritize mental health support missions in accordance with the division CHS
OPLANs or OPORDs. Coordination for mental health personnel augmentation is accomplished through the
division surgeon.

b. Mental Health Sections. When the brigades are tactically deployed, the mental health sections
use the division clearing stations operated by the FSMCs as the center of their operations but are mobile
throughout the AO. The section’s priority functions are to sustain combat effectiveness, prevent unnecessary
evacuations, and to coordinate RTD, not to treat cases. The mental health section provides technical
supervision for the attached CSC preventive team from the corps CSC detachment. Through the brigade
surgeons, this section keeps abreast of the tactical situation and plans and projects requirements for CSC
support when units are pulled back for rest and recuperation.

c. Division Mental Health Staff Activities. Mental health sections will coordinate their activities
with the division psychiatrist. The division psychiatrist synchronizes mental health/CSC activities for the
division’s prevention, training, and treatment responsibilities. Behavioral science officers using their
multidisciplinary mental health professional expertise will—

• Supervise and train the mental health specialists.

• Provide mental health/CSC staff input to the commands within the division AO.

• Guarantee clinical evaluation and supervision of treatment for all NP and problematic BF
cases before they leave the division.

• Maintain communications and unity of efforts for the division and brigades.

• Provide points of contact to integrate reinforcing CSC teams throughout the division.

(1) Psychiatrist. The division psychiatrist (MAJ, MC, AOC 60W00) is the officer responsible
for overseeing the division mental health program. The psychiatrist is also a working physician who applies
the knowledge and principles of psychiatry and medicine in the treatment of all patients. He examines,
diagnoses, and treats, or recommends courses of treatment for personnel suffering from emotional or mental
illness, situational maladjustment, BF (combat stress reactions), and misconduct stress behaviors. His
specific functions include—

• Directing the division’s mental health (combat mental fitness) program.

• Being a staff consultant for the division surgeon on matters having psychiatric
aspects, which include—

• The personnel reliability program.

• Security clearances.

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• Alcohol and drug abuse prevention and control programs.

• Planning CSC support for supported units.

• Conducting mental health/CSC operations.

• Providing staff consultation for the MSMC commander and for supported
commands within the division.

• Being responsible for assuring the diagnosis, treatment, restoration, and
disposition of all NP and problematic BF cases.

• Participating in the diagnosis and treatment of the sick, injured, and wounded,
especially those who can RTD quickly.

• Providing consultation and training to physicians, physicians assistants, unit
leaders, chaplains, and other medical personnel regarding diagnosis, treatment, and management of BF,
misconduct stress behavior, and NP disorders.

• Prescribing treatment and disposition for soldiers with NP conditions.

• Providing supervision and training of assigned and attached mental health
personnel.

(2) Behavioral science officer. A behavioral science officer (CPT, AOC 67D00) is assigned
to the mental health section of each FSMC. He serves as brigade behavioral science officer for the
supported brigade and the BSA. The behavioral science officer participates in staff planning to represent
and coordinate mental health/CSC activities throughout the brigade. The behavioral science officer is
especially concerned with assisting and training—

• Small unit leaders.

• Unit ministry teams.

• Battalion medical platoons.

• Patient-holding squad and treatment squad personnel of the FSMC.

The behavioral science officer provides training and advice in the control of stressors, the promotion of posi-
tive combat stress behaviors, and the identification, handling, and management of misconduct stress behavior
and BF soldiers. He coordinates training and support to the brigade through the FSMC commander and
division psychiatrist. He collects and records social and psychological data and counsels personnel with per-
sonal, behavioral, or psychological problems. The general duties of the behavioral science officer include—

• Assisting in a wide range of psychological and social services.

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• Compiling caseload data.

• Providing counseling to soldiers experiencing emotional or social problems.

• Referring soldiers to specific mental health officers, physicians, or agencies when
indicated.

• Assisting with group debriefings, counseling, and therapy sessions, and leading group
discussions.

• Providing individual case consultation to commanders, NCOs, chaplains, battalion
surgeons, and physician assistants within the supported brigade.

• Collecting information from units regarding unit cohesion and morale which
include—

• Obtaining data on disciplinary actions.

• Collecting information with questionnaires.

• Conducting structured interviews.

• Collecting information on individual BF cases pertaining to the prior effective-
ness of the soldier, precipitating factors causing the soldier to have BF, and the soldier’s RTD potential.

NOTE

Behavioral science officer positions, AOC 67D00, may be filled by a
clinical psychologist, AOC 73B67, or a social work officer, AOC
73A67.

(3) Clinical psychologist. The clinical psychologist (CPT, MS, AOC 73B67) assists in the
development, management, and supervision of the division’s mental health (combat mental fitness) program.
His specialty responsibilities apply to the knowledge and principles of psychology, to include—

• Evaluating the psychological functioning of soldiers.

• Conducting surveys and evaluating data to assess unit cohesion and other factors
related to prediction and prevention of both BF casualties and misconduct stress behaviors.

• Performing psychological and neuropsychological testing to evaluate psychological
problems and psychiatric and organic mental disorders, and to screen misconduct stress behaviors and
unsuitable soldiers.

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• Apprising unit leaders, primary care physicians, and other clinical personnel
regarding the assessment of individual and unit mental health fitness programs.

• Providing consultation for unit commanders and CSC/mental health personnel
working at the brigade level regarding problem cases.

• Counseling and providing therapy or referral for soldiers with psychological
problems.

• Serving as the brigade mental health officer for one maneuver brigade (normally
teamed with a behavioral science NCO).

(4) Social work officer. The social work officer (CPT, MS, AOC 73A67) assists in the
development, management, and supervision of the division’s mental health (combat mental fitness) program.
He applies the mental health principles and his knowledge of social work in the performance of his duties.
His responsibilities include—

• Evaluating the social integration of BF and misconduct stress behavior soldiers in
their units and families.

• Coordinating and ensuring the RTD of recovered stress casualties and their
reintegration into their original or new units.

• Identifying and resolving organizational and social environmental factors which
interfere with combat readiness.

• Ensuring support for soldiers and their families from Army and civilian community
support agencies.

• Apprising unit leaders, primary care physicians, and other clinical personnel of
available social service resources.

• Providing consultation to unit commanders and to division mental health section
personnel regarding problem cases.

• Counseling and providing therapy or referral for soldiers with emotional disorders
and psychological problems.

• Serving as brigade behavioral science officer for one maneuver brigade as a member
of the mental health section of the FSMC.

(5) Senior mental health noncommissioned officer. The mental health NCO (E-7, MOS
91X40) is located with the division psychiatrist in the DSA. This senior NCO assists the division psychiatrist
with the accomplishment of his duties. He is the CSC coordinator for the DSA. His specific duties
include—

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• Keeping the division psychiatrist informed on the status of the mental health sections
and on the mental fitness of soldiers supported in the DSA.

• Monitoring, facilitating, and coordinating training activities of the division mental
health personnel.

• Monitoring and coordinating situation reports from division mental health sections.

• Coordinating with the supporting CSC medical detachment for additional mental
health support, as required.

• Supervising restoration of BF casualties in the DSA.

• Conducting classes on selected mental health topics for senior NCOs within the
division.

(6) Mental health specialist. The mental health specialist (E-4, MOS 91X10) is assigned to
the mental health section of each FSMC. He works under the supervision of the behavioral science officer.
The mental health specialist assists the behavioral science officer with the accomplishment of his duties.
The mental health specialist is the CSC coordinator for the supported maneuver brigade and the BSA. His
specific duties include—

• Keeping the behavioral science officer informed on the status and mental fitness of
soldiers in the supported brigade and in the BSA.

• Assisting the behavioral science officer with facilitating and coordinating training
activities of the ASMB mental health personnel.

E-6. Area Support Medical Battalion Mental Health Sections

The ASMB’s mental health sections are the medical elements with primary responsibility for assisting units
in the corps support area to control combat stress. As in the division, combat stress is controlled through
vigorous prevention, consultation, and restoration programs. These programs are designed to maximize the
RTD rate of BF soldiers by identifying combat stress reactions and providing rest/restoration within or near
their unit areas. Also, the prevention of post-traumatic stress disorders is an important objective in both
division and corps CSC programs. Under the direction of the ASMB psychiatrist, the mental health sections
provide mental health/CSC services throughout the ASMB’s AO. The battalion mental health sections are
assigned to the headquarters and headquarters detachment of the ASMB. Also, each ASMC has a mental
health section. The battalion psychiatrist has staff responsibility for establishing policy and guidance for the
prevention, diagnosis, and management of NP, BF, and misconduct stress behavior cases seen by ASMB
physicians and the mental health sections. He also has technical responsibility for the psychological aspect
of surety programs. He provides and oversees mental health and stress control training for unit leaders and
their staffs, chaplains, medical personnel, and troops. Through the battalion and company mental health
sections, the battalion psychiatrist monitors morale, cohesion, and mental fitness of supported units. He has

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technical control over all mental health personnel assigned to the ASMB and provides guidance as required
for the successful accomplishment of their responsibilities. These responsibilities include—

• Providing command consultation and making recommendations for reducing stressors.

• Evaluating NP, BF, and misconduct stress behavior cases.

• Providing consultation and triage, as requested, for patients exhibiting signs of combat stress
reactions or mental disorders.

• Providing selective short-term restoration for HOLD category BF cases.

• Coordinating support activities with the medical company and detachment and CSC elements,
when attached or in support of the ASMB.

a. Mental Health Support. The ASMB S3 and battalion mental health sections monitor and
prioritize mental health support missions in coordination with the MEDCOM/brigade headquarters.

b. Battalion Mental Health Section Staff. The ASMB mental health section is staffed as shown in
Figure E-1. The dispersion of multidisciplinary mental health professionals throughout the battalion ensures
that expertise is present to—

• Train and supervise the mental health specialists.

• Provide staff input to supported commands.

• Provide clinical evaluation and appropriate treatment or referral for all NP and problematic
BF cases.

• Provide a mental health professional for interface with supported brigades, groups, and
corps resources.

• Provide rapid assistance with critical incident/events debriefing for the ASMB’s area of
responsibility.

MENTAL HEALTH SECTION STAFF

Psychiatrist (MAJ, AOC 60W00)
Mental Health Specialist (E-4, MOS 91X10)
Mental Health Specialist (E-3, MOS 91X10)

Figure E-1. Area support medical battalion mental health section.

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(1) Psychiatrist. The psychiatrist (MAJ, MC, AOC 60W00) is the section leader. The
psychiatrist is also a working physician who applies the knowledge and principles of psychiatry and medicine
in the treatment of all patients. He examines, diagnoses, and treats, or recommends courses of treatment for
personnel suffering from emotional or mental illness, situational maladjustment, combat stress reaction, BF,
and misconduct stress behaviors. His areas of responsibility include—

• Implementing CSC support according to the battalion’s area CHS plan.

• Coordinating and conducting mental health/CSC operations.

• Providing staff consultation for the ASMB commander and for supported commands
within the supported AO. This includes the personnel reliability program, security clearances, and
ADAPCPs.

• Training and mentoring ASMC medical and mental health personnel in neurological
and mental status examinations and differential diagnosis of stress and psychiatric disorders from general
medical/surgical conditions.

• Diagnosing, treating, and determining disposition of NP, BF, and misconduct stress
behavior cases.

• Participating in the diagnosis and treatment of the sick, injured, and wounded,
especially of those who can RTD quickly.

• Providing consultation and training to unit leaders, chaplains, and medical personnel
regarding identification and management of BF (combat stress reaction), misconduct stress behaviors, and
NP disorders.

• Providing therapy or referral for soldiers with NP conditions.

• Providing supervision and training of assigned and attached mental health and CSC
personnel.

• Coordinating with the supporting CSC medical detachment for additional mental
health support as required.

(2) Mental health specialists. The mental health specialists (E-4 and E-3, MOS 91X10) are
located with the ASMB psychiatrist at the ASMB headquarters. These mental health specialists assist the
ASMB psychiatrist with the accomplishment of his duties. They may perform as CSC coordinators for
selected units in the corps support area. Their specific duties include—

• Keeping the ASMB psychiatrist informed on the status of the mental health sections
and on the mental fitness of soldiers supported in the corps support area.

• Assisting the psychiatrist with facilitating, and coordinating training activities of the
ASMB mental health personnel.

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• Monitoring and coordinating situation reports from ASMC mental health sections.

• Conducting initial screening evaluations of patients.

c. Area Support Medical Company Mental Health Section. Each ASMC mental health staff
consists of a behavioral science officer and a mental health specialist (Figure E-2). The mental health
specialist assists the behavioral science officer with the accomplishment of his duties. The behavioral
science officer participates in staff planning to represent and coordinate mental health/CSC activities
throughout the AO. The behavioral science officer and mental health specialist are especially concerned
with assisting and training—

• Small unit leaders.

• Unit ministry teams and staff chaplains.

• Battalion medical platoons.

• Patient-holding squad and treatment squad personnel of the ASMC.

AREA SUPPORT MEDICAL COMPANY
MENTAL HEALTH SECTION STAFF

Behavioral Science Officer (CPT, AOC 67D00)
Mental Health Specialist (E-3, MOS 91X10)

Figure E-2. Area support medical company mental health section.

The ASMC mental health section provides training and advice in the control of stressors, the promotion of
positive combat stress behaviors, and the identification, handling, and management of misconduct stress
behavior and BF soldiers. It coordinates CSC training for supported units through the ASMC commander
and battalion psychiatrist, as required. The section collects and records social and psychological data and
counsels personnel with personal, behavioral, or psychological problems. General duties for personnel
assigned to this section include—

• Assisting in a wide range of psychological and social services.

• Providing classes in stress control.

• Compiling caseload data.

• Providing counseling to soldiers experiencing emotional or social problems.

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• Referring soldiers to specific hospital NP services or CSC unit facilities, physicians, or
agencies when indicated.

• Conducting or facilitating group debriefings, counseling, and therapy sessions, and leading
group discussions.

• Providing individual case consultation to commanders, NCOs, chaplains, battalion
surgeons, and physician assistants within the supported AO.

• Collecting information from units regarding unit cohesion and morale which include—

• Obtaining data on disciplinary actions.

• Collecting information with questionnaires.

• Conducting structured interviews.

• Collecting information on individual BF cases pertaining to the prior effectiveness
of the soldier, precipitating factors causing the soldier to have BF, and the soldier’s RTD potential.

The company mental health section uses the ASMC clearing station as the center for its operations but is
mobile throughout the AO. The section’s priority functions are to promote positive stress behaviors, prevent
unnecessary evacuations, and coordinate RTD, not to treat cases. Through the ASMC commander, the
section keeps abreast of the tactical situation and plans and projects requirements for CSC support when
units are pulled back for rest and recuperation.

E-7. Mental Health Personnel in the Armored Cavalry Regiments and Separate Brigades

In the ACRs, active components, and National Guard-enhanced separate brigades, both light and heavy,
mental health personnel are assigned to the medical company, separate brigade. A behavioral science officer
and a mental health specialist are assigned to the mental health section of each FSMC. They serve as the
behavioral science officer and CSC coordinator for the brigade and the BSA. Their duties and responsibilities
are the same as described for the division FSMC mental health section described above. They receive
technical supervision from the division psychiatrist, when attached to a division, or from the ASMB
psychiatrist in their units’ AO in the corps and echelons above corps.

Section III. COMBAT STRESS CONTROL COMPANY

E-8. Medical Company, Combat Stress Control (TOE 08467A000)

The CSC medical company is employed in the corps and echelons above corps. The basis of allocation is
one CSC medical company per corps or theater. The CSC medical company is task-organized, METT-T

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dependent for stability operations and support operations. Medical company, CSC, TOE 08467A000 replaces
Medical Company, CSC, TOE 08467L000.

a. Mission. A CSC medical company provides comprehensive preventive and treatment services
to a corps and echelons above corps during war. It provides this support to all services on an area support
basis. The CSC medical company provides direct support to separate maneuver brigades or CS brigades, as
needed. It reinforces or reconstitutes other CSC assets in the corps or divisions as needed. The CSC
medical company provides CSC/mental health services to indigenous populations as directed in stability
operations or support operations, to include domestic support operations, humanitarian assistance, disaster
relief, and peace support operations. The comprehensive support provided by the CSC medical company
entails all of the six CSC functional mission areas. The CSC functional missions areas are discussed in
Chapter 1.

b. Capabilities. At TOE Level 1, the CSC medical company provides—

• Advice, planning, and coordination for CSC to commanders.

• Combat stress control reconstitution support for units up to division size.

• Preventive and CSC fitness teams (4 to 10 personnel) for consultation, treatment services,
and reconstitution support for up to battalion-sized organizations.

• Restoration or reconditioning programs for up to 50 soldiers per CSC fitness team on an
area basis.

• Deployment of CSC elements to forward areas for support of contingency operations.

c. Assignment. The Medical Company, CSC (TOE 08467A000) is assigned to a corps or
theater MEDCOM. Elements of this TOE may be further attached to a corps medical brigade or to an
ASMB.

d. Organization. The CSC medical company is organized into a headquarters section, a preventive
section, and a CSC fitness section. The company is dependent on appropriate elements of the MEDCOM or
medical brigade for administrative and medical logistical support, medical regulating, BF casualty delivery,
and medical evacuation. The company is dependent on appropriate elements of the corps or COMMZ for
finance, legal, personnel and administrative services, food service, supply and field services, supplemental
transportation, and local security support services. When CSC medical company elements or teams are
deployed to division areas, they are dependent on the division medical companies (such as the MSB medical
company or the FSB medical company) for patient accounting, transportation, food service, and field
service support.

e. Employment. The CSC medical company is employed in all intensities of conflict when a
corps with two or more divisions is deployed. Task-organized CSC elements are deployed for division-size
combat operations, stability operations and support operations, and other contingency operations which are
METT-T dependent.

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(1) The CSC preventive and CSC fitness sections together provide all five mental health
disciplines. These resources are flexibly task-organized in a variety of combinations to meet the fluid CSC
threat at different phases in the operations. Personnel may be quickly cross-attached from one section to
another to accommodate the shifting work load and to provide reconstitution support packages.

(2) The CSC preventive and CSC fitness sections both organize into teams. Combat stress
control preventive or CSC fitness teams deployed forward of the corps boundaries in support of tactical
operations come under operational control of the CHS operations element in the supported units. These
teams will also come under technical control of the division or brigade CSC teams.

(3) One or more of the CSC medical company’s eight CSC preventive teams may locate at
the FSMC when deployed in direct support of separate brigades or ACRs.

(4) One or more of the four (10-person) CSC fitness teams may reinforce ASMCs which are
deployed to locations throughout the corps and echelon above corps. These teams provide a basis for CSC
prevention and intervention. The teams may conduct restoration programs at the ASMCs, as required.
These teams may also be deployed forward to provide temporary augmentation/reinforcement, as required.

(5) Based on work load, one or more of the four CSC fitness teams, plus one or more CSC
preventive teams, locate with a echelon above corps hospital where they conduct Level 4 CSC reconditioning
programs, as required. A hospital located in the corps rear or the COMMZ is the best location to conduct
the theater CSC reconditioning program. When deployed with a hospital, these teams provide mobile
consultation in the vicinity of the hospital. These teams are also prepared to restrict reconditioning
programs and deploy forward in support of higher priority missions on very short notice. These teams can
also augment hospital NP services by staffing a temporary NP ward.

(6) The CSC medical company is divisible into four functionally emulative increments for
split-based operations, stability operations and support operations, as assigned.

(7) Nonstandard task elements for specific missions can be organized using any combination
of the CSC preventive section and CSC fitness section personnel to meet specific mental health needs. For
stability operations and support operations, the minimum is an officer/NCO team to supplement a brigade
CSC team or a CSC preventive module/team of two officers, one NCO, and one enlisted. These modules
may be augmented with personnel from the CSC fitness section to add additional specialty expertise.

E-9. Headquarters Section

The headquarters section provides C2 and unit-level administrative and maintenance support to its sub-
ordinate sections when they are collocated with the company. The headquarters section may also provide
assistance to detached elements by making site visits if the elements are within a feasible distance for
ground transportation. The CSC medical company elements normally deploy with limited maintenance
capability. When these CSC elements deploy, they are dependent on the supported units for patient
accounting, transportation, food service, and field services. The personnel assigned to the headquarters
section includes a—

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• Company commander.

• Chaplain.

• Medical operations officer.

• First sergeant.

• Mental health NCO.

• Supply sergeant.

• Patient administrative NCO.

• Nuclear, biological, and chemical NCO.

• Decontamination specialist.

• Personnel administrative specialist/unit clerk.

• Administrative specialist.

• Unit supply specialist/armorer.

• Patient administrative specialist.

• Light-wheeled vehicle mechanic.

• Power generation equipment repairman.

• Cook.

Personnel from the headquarters section are deployed with teams or task-organized CSC elements, as
required.

a. Company Commander. The company commander, a psychiatrist or other clinical officer (LTC,
MC/MS/AN/SP, AOC 60W00/73A67/73B67/66CTT/65A00) performs normal C2 and supervisory
functions. The commander is also responsible for the training, discipline, billeting, and security of the
company. He provides daily reports to his higher headquarters as established by the TSOPs and corps
reporting procedures. He serves as the NP consultant on the staff of the medical group. As a psychiatrist,
he coordinates with command and unit physicians regarding care and disposition of BF casualties and NP
patients. He exercises clinical supervision over all treatment provided by the CSC sections and detachments.
He performs physical and mental status evaluations in emergency or command evaluation situations; this
includes diagnosing, prescribing initial treatment, and determining disposition. The commander interfaces
with higher and supported headquarters and with supported CSC medical detachments, ASMB mental

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health sections, and division mental health sections. He keeps informed on CSC operations through daily
reports and by frequent visits to task-organized CSC elements deployed from his company.

b. Chaplain. The chaplain (CPT, CH, AOC 56A00) provides religious/ethical education and
perspective to the dispersed sections for the prevention and treatment of BF and misconduct stress behaviors.
He interfaces CSC activities with unit ministry teams in maneuver units, with hospital chaplains, and with
staff chaplains at each headquarters level. The chaplain usually accompanies the CSC medical company
commander when he visits supported units and task-organized CSC elements deployed in support of those
units. The chaplain has a chaplain’s kit to conduct services but is without a chaplain’s assistant. The
chaplain’s primary role is to aid other chaplains and CSC personnel in preventing stress control and in
working with BF casualties and misconduct stress behaviors. In addition to his coordination, liaison, and
training duties, he provides religious support to BF casualties and to staff as available time and support
requirements permit.

c. Medical Operations Officer. The medical operations officer (CPT, MS, AOC 70B67) is the
principal assistant to the company commander on all matters pertaining to the tactical employment of
company assets. He is responsible for overseeing operations and administrative, supply, and maintenance
activities within the company. His responsibilities also include—

• Coordinating administrative activities with the staff of the higher medical headquarters.

• Ensuring unit operations and communications security.

• Keeping the commander current on the corps’ and supported divisions’ tactical situations.

• Assisting the commander with development of CSC support estimates and plans.

• Planning and scheduling unit training activities.

• Coordinating movement orders and logistical support for deployed company elements.

d. First Sergeant. The first sergeant (E8, MOS 91B5M) serves as the principal enlisted assistant
to the company commander. He manages the administrative activities of the CP. He supervises the
company activities of the unit clerk and maintains liaison between the commander and assigned NCO. He
provides guidance to enlisted members of the company and represents them to the commander. He plans,
coordinates, supervises, and participates in activities pertaining to organization, training, and combat
operations for the company. He assists the company commander in the performance of his duties. The first
sergeant also assists the medical operations officer and performs the duties of an operations NCO.

e. Mental Health Noncommissioned Officer. The mental health NCO (E7, MOS 91X40) assists
the commander and chaplain as required. He performs surveys and collects information on stress and
stressors in supported units. He also checks the status of recovered stress casualties.

f. Supply Sergeant. The supply sergeant (E-6, MOS 92Y30) requests, receives, stores,
safeguards, and issues general supplies. He determines methods of obtaining relief from responsibility for

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lost, damaged, and destroyed supply items. He maintains the company supply records, supervises unit
supply operations, and maintains accountability for all equipment organic to the company.

g. Patient Administration Noncommissioned Officer. The patient administration NCO (E-5, MOS
71G20) is responsible for managing patient statistics of all BF casualties seen by the company element. He
is normally located with the company headquarters but makes visits to task-organized CSC elements as
required to ensure company elements are complying with patient administrative requirements. He is
responsible for forwarding the Medical Summary Report (RCS Med-302 [R3]) in accordance with AR 40-
400 and ensures that all BF casualty accountability and status reports are forwarded as directed by higher
headquarters. He initiates the FMC (DD Form 1380) on all BF casualties seen for consultation and medical
treatment and those placed in the center for restoration or reconditioning programs. He ensures that all
restoration and reconditioning centers maintain the Daily Disposition Log. He supervises subordinate
patient administrative specialists. He coordinates transportation and evacuation, as required, for BF casualties
sent rearward for additional restoration or reconditioning and for recovered BF casualties returning to their
units.

h. Nuclear, Biological, and Chemical Noncommissioned Officer. The NBC NCO (E-5, MOS
54B20) coordinates NBC defense operations for the company. He supervises the training that pertains to
procedures and techniques of NBC defense. The NBC NCO predicts the effects of weather and terrain on
chemical operations. His responsibilities also include preparing predictions on nuclear fallout and on NBC
downwind hazards. He prepares and evaluates NBC reports and computes expected radiation effects
affecting personnel, equipment, and operations. This NBC NCO is the technical advisor to the unit
commander on matters pertaining to NBC functions. He provides expertise and training in the operation and
maintenance of NBC equipment. He supervises decontamination of unit equipment, supplies, and personnel
(not patients). At a time of heavy caseloads (unless the unit is in an active NBC environment), the NBC
NCO may serve as a squad leader for up to ten BF casualties in reconditioning or restoration.

i. Decontamination Specialist. The decontamination specialist (E-4, MOS 54B10) assists the
NBC NCO with the accomplishment of his duties. The decontamination specialist
may serve as squad leader for up to ten BF casualties in reconditioning or restoration.

j. Personnel Administrative Specialist/Unit Clerk. The unit clerk (E4, MOS 75B10) provides
and coordinates personnel and administrative support to company personnel and maintains unit admin-
istrative records. He advises the commander and coordinates personnel actions for recovering BF casualties
or RTD soldiers that require other administrative actions. He prepares and processes recommenda-
tions for awards and decorations and arranges for awards ceremony. For complete description of duties, see
AR 611-201.

k. Administrative Specialist. The administrative specialist (E-4, MOS 71L10) prepares military
and nonmilitary correspondence in draft and final copy. He employs basic principles of English composition
and grammar in preparing correspondence. He prepares registered or certified mail for dispatch. He
opens, sorts, routes, and delivers incoming correspondence and messages. He prepares suspense control
documents and maintains suspense files. The administrative specialist prepares and maintains functional
files according to Modern Army Record-keeping System. He receives publications and establishes and
maintains the publications library. He requisitions and stocks blank forms.

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l. Unit Supply Specialist/Armorer. The unit supply specialist/armorer (E-4, MOS 92Y10)
performs duties involving general supply, including inventorying, requisitioning, distribution, and storage.
He assists the supply sergeant with the accomplishment of his duties. In addition to general supply duties,
the supply specialist maintains the weapons storage area, issues and receives munitions, and performs small
arms unit maintenance. He assists the supply sergeant with general supply activities and operates the
vehicle assigned to the supply element.

m. Patient Administration Specialist. The patient administration specialist (E-4, MOS 71G10)
participates in the in-processing of BF casualties into restoration and reconditioning centers. He is
responsible for initiating reports and forms identified in the preceding paragraph. He maintains the Daily
Disposition Log. When deployed with a CSC fitness team or task-organized CSC elements, he works with
the patient administration section of the medical unit to which the task-organized CSC element or CSC
fitness team is attached. Through the patient administration section of the unit they are attached to, they
coordinate BF casualty evacuation and transportation requirements. He maintains his assigned vehicles and
operates company radios. He coordinates the disposition of BF casualties through supporting unit
communications assets. Patient administration specialists deploy with CSC fitness teams or task-organized
CSC elements.

n. Light-Wheeled Vehicle Mechanic. The light-wheeled vehicle mechanic (E-4, MOS 63B10)
performs organizational maintenance, PMCS, and repairs on gasoline and diesel-fueled, light-wheeled
vehicles. Light-wheeled vehicles include prime movers designated as 5 tons or less and their trailers and
associated items. Duties of the light-wheeled vehicle mechanic include—

• Diagnosing malfunctions of light-wheeled vehicles and associated items.

• Troubleshooting engine/equipment problems using TMs, TMDE, and other equipment,
as required.

• Applying applicable safety precautions.

• Performing scheduled maintenance and repairs on vehicles and equipment assisted by the
vehicle operator.

• Maintaining and accounting for tools and equipment issued to him.

• Deploying with company element (task-organized CSC element) to provide maintenance
for company or attached vehicles.

• Maintaining and requisitioning repair parts as required.

• Initiating and maintaining records on equipment use, operations, history, maintenance,
modifications, and calibration.

• Requesting, receiving, recording, and storing parts and tools.

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The light-wheeled vehicle mechanic is also responsible for—

• Providing input for the materiel readiness report.

• Assisting in the scheduling of maintenance and repair services.

NOTE

When the light-wheeled vehicle mechanic deploys, he works with the
maintenance section/element of the unit to which the task-organized
CSC element is attached.

o. Power Generation Equipment Repairman. The power generation equipment repairman (E4,
MOS 52D10) performs unit maintenance functions. The major functions and tasks of the repairman
include—

• Applying applicable safety precautions.

• Inspecting equipment, determining category of maintenance and extent of repairs, and
recording results.

• Classifying unserviceable components and assemblages as required.

• Performing PMCS on shop equipment.

• Maintaining and accounting for tools issued.

• Training unit personnel on how to properly operate and perform user maintenance on
assigned generators.

p. Cook. One cook (E3, MOS 92G10) provides food service (tray-pack heating) for the company
when it is assembled. More often, he is deployed with a task-organized CSC element and further attached
with the food service section of the supported medical unit. He also trains CSC personnel on food tasks
which may be used as a part of a CSC restoration or reconditioning program. He may serves as work group
leader for BF casualties performing food service tasks as part of the BF casualty’s treatment.

E-10. Combat Stress Control Preventive Section

Personnel of this section are task-organized to prevent stress, misconduct, and prevent post-traumatic stress
disorders. The CSC preventive section accomplishes this through command consultation, preventive
education, critical events/incidences debriefings, staff planning, case evaluation, and triage, and counseling
intervention at supported unit. Section personnel also supervise and participate in restoration and

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reconditioning programs conducted by Echelon II medical unit and the CSC fitness section. Personnel from
this section may be task-organized with personnel of the CSC fitness section into CSC elements for specific
missions of the company. This section can divide into eight CSC preventive teams. The section (and team)
leader position may be held by any of the officers assigned to the section. The CSC preventive section has
six clinical psychologists, eight social work officers, two behavioral science officers, eight mental health
NCOs, and eight mental health specialists assigned to the section. This section can divide into eight 4-
person CSC preventive teams. Elements of the section may also be task-organized with elements of the
restoration section to form task-organized CSC elements for deployment to conduct CSC operations. The
company commander will appoint the CSC preventive team or task-organized CSC element leaders,
considering rank, professional qualifications, and especially, experience. The preventive section’s
responsibilities include—

• Providing preventive consultation.

• Assisting units with REST category BF cases and RTD of recovered BF casualties.

• Providing NP triage and stabilization as required.

• Supervising restoration of category HOLD BF casualties by medical personnel.

• Providing medical, psychiatric, and social work expertise to restoration and reconditioning
programs.

• Deploying CSC preventive teams to reinforce CSC elements operating in the divisions and
corps areas.

• Providing reconstitution mental health support to physically and mentally exhausted units.

a. Clinical Psychologists. There are six clinical psychologists (MAJ [four], CPT [two], MS,
AOC 73B67) assigned to the section. Their duties include—

• Providing diagnostic expertise for triage.

• Conducting psychological and neuropsychological testing.

• Providing behavioral treatment and counseling.

• Conducting and supervising surveys of unit cohesion, morale, and individual mental
readiness for combat.

• Providing command consultation.

• Supervising subordinate personnel.

• Conducting and supervising critical event debriefings.

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b. Social Work Officers. Eight social work officers (MAJ [four], CPT [four], MS, AOC 73A67)
are assigned to this section. They provide proactive consultation, give individual and group counseling,
supervise restoration/reconditioning, and coordinate RTD of recovered cases. They also provide staff
advice and coordinate Army and civilian social services support. These social work officers may be divided
among several task-organized CSC elements or be utilized as a member of a CSC preventive team. When
deployed as a member of a CSC preventive team or task-organized CSC element, the social work officers’
duties include—

• Evaluating psychosocial (unit and family) functioning of soldiers with BF and misconduct
stress behavior.

• Coordinating and ensuring the return of recovered BF and NP soldiers to duty and their
reintegration into their original or new unit.

• Identifying and resolving organizational and social environmental factors which interfere
with combat readiness.

• Coordinating support for soldiers and their families through Army and civilian community
support agencies, when possible.

• Apprising unit leaders, primary care physicians, and others health care providers of available
social service resources.

• Providing consultation to supported unit commanders and to other mental health/CSC
personnel regarding problem cases.

• Counseling and providing therapy or referral for soldiers with psychological problems.

• Conducting and supervising unit survey interviews and critical event debriefings.

c. Behavioral Science Officers. These two positions (CPT, AOC 67D00) are filled by AOC
73A67 or AOC 73B67. These officers perform the duties of their respective AOC and in the technical and
tactical operations of the section. The behavioral science officers are responsible for direct supervision of
the mental health NCOs and specialists assigned to the section. The behavioral science officers, assisted by
the mental health NCOs, conduct the training activities of the section. They monitor and coordinate
situation reports, conduct classes on stress control, and provide consultation for leaders of supported units.

d. Mental Health Noncommissioned Officers. There are eight mental health NCOs (E-5, MOS
91X20). Two of these NCOs act as assistant section sergeants and assist the behavioral science officers with
the accomplishment of their duties. When deployed as a member of a CSC preventive team or task-
organized element, these NCOs assume the position of team NCOIC and assist the team leader with the
accomplishment of his duties. Their general duties include—

• Providing consultation and stress control education, especially to NCOs and enlisted
personnel.

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• Assisting in a wide range of psychological and social services.

• Compiling caseload data and referring patients to specific mental health officers and
physicians in supporting MTFs.

• Providing counseling to soldiers experiencing emotional or social problems.

• Conducting or assisting with group counseling and debriefing sessions and leading group
discussions.

• Collecting data in unit survey interviews pertaining to unit cohesion, morale, and
individual mental readiness for combat.

• Conducting or assisting in critical event debriefings.

e. Mental Health Specialists. There are eight mental health specialists (E-4, MOS 91X10)
assigned to the section. These specialists assist the mental health officer and NCOs in gathering social and
psychological data to support patient evaluations. Under the supervision of the mental health officer and
NCOs, they provide initial screening of patients suffering emotional or social problems. In addition to their
duties, they operate and maintain assigned vehicles. Under the supervision of the mental health officer, their
specific duties include—

• Serving as team leaders and providing supportive counseling to BF casualties and
misconduct stress behavior cases experiencing emotional or social problems.

• Assisting in the evaluation of BF casualties and misconduct stress behaviors.

• Assessing the mental status (level of functioning capacity) of BF casualties and misconduct
stress behaviors and their need for professional services.

• Collecting data in unit survey interviews.

• Assisting in critical event debriefings.

• Driving and maintaining team vehicles.

E-11. Combat Stress Control Fitness Section

The CSC fitness section has 4 psychiatrists, 4 OT officers, 4 psychiatric/mental health nurses, 8 OT NCOs,
8 mental health NCOs, and 12 mental health specialists assigned to the section. Personnel of this section are
task-organized to provide NP triage, diagnosis, stabilization, and treatment at restoration or reconditioning
centers. Section personnel also deploy to provide mobile consultation and reconstitution support to units in
the vicinity and to reinforce the CSC preventive teams. Section personnel may be task-organized with
members of the CSC preventive section into CSC elements for specific missions. The section personnel can

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augment a deployed CSH to staff a temporary NP ward. This section can divide into four CSC fitness
teams. Elements of this section are sometimes task-organized with elements of the CSC preventive section
to form task-organized CSC elements which operate restoration or reconditioning centers. At these centers,
they provide NP triage, diagnosis, stabilization, treatment, and disposition. Section personnel, as members
of task-organized CSC elements or CSC preventive teams, also deploy routinely to provide preventive
consultation and reconstitution support to units in the corps area. They reinforce and may reconstitute CSC
medical detachment teams in the division support areas.

NOTE

The priority role for all CSC personnel is the prevention of BF and
other stress-related casualties. This is as true for the CSC fitness
section as it is for the CSC preventive section. The section leader
position may be held by any of the officers assigned to the section.
The company commander will appoint the section leader based on
rank, professional qualifications, and experience. This same rationale
is used in selecting leaders for the task-organized CSC elements and
CSC fitness team.

a. Psychiatrists. The psychiatrists (MAJ [two], CPT [two], MC, AOC 60W00) assigned to this
section examine patients and provide consultation. These psychiatrists make neuropsychological and medical
diagnosis and prescribe and provide treatment. They also direct disposition of patients. The senior
psychiatrist assigned to the section performs the duties of section leader and directs the activities of the
section when the section is assembled. Psychiatrists assigned to this section may be deployed in support of
CSC operations with the section, or as members of either a CSC preventive team or a task-organized CSC
element. When deployed as a member of a CSC preventive team or a task-organized CSC element, the
psychiatrists’ duties include—

• Establishing and providing CSC support.

• Providing staff consultation to supported units as required. This includes nuclear surety,
security clearance, and the alcohol and drug abuse preventive programs.

• Being responsible for the diagnosis, treatment, rehabilitation, and disposition of NP and
problematic BF cases.

• Participating in the diagnosis and treatment of the wounded, ill, and injured, especially of
those who can RTD quickly.

• Consulting and providing training to unit leaders and medical personnel regarding
identification and management of NP disorders, BF, and misconduct stress behaviors.

• Providing therapy or referral for soldiers with NP disorders.

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• Providing supervision and training of assigned and attached mental health personnel.

• Conducting and supervising unit survey interviews and critical event debriefings.

b. Occupational Therapy Officers. Four OT officers (MAJ [two], CPT [two], SP, AOC 65A00)
are assigned to the section. They serve as environmental managers using daily living tasks, physical
reconditioning, work, and other activities to counteract combat stress reactions. Preventive treatment
programs include individual work assignments, organized group work projects, common soldier task review,
stress management education, recreation, and physical reconditioning. Their responsibilities include—

• Providing command consultation to leaders regarding work schedules and restorative off-
duty activity programs.

• Assessing and advising on ergonomically sound work practices.

• Performing functional occupational evaluations of BF casualties.

• Performing neuromuscular evaluations, especially upper extremities and hands.

• Assigning BF casualties to physical reconditioning and work groups.

• Overseeing physical reconditioning and work programs for BF casualties.

• Selecting appropriate activities based on a BF casualty’s assessment.

• Evaluating functional work capacity.

• Modifying reconditioning programs, as required.

• Maintaining records of therapy/treatment.

• Reporting status of BF casualties to psychiatrists and staff members on a daily basis, or in
accordance with the TSOPs.

• Conducting unit survey interviews and critical event debriefings.

c. Psychiatric/Mental Health Nurses. The four psychiatric/mental health nurses (MAJ [two],
AOC 66C7T, and CPT [two], AOC 66C00, AN) provide specialized care, as required. They provide care
for all BF, misconduct stress behaviors, and NP casualties, especially those with severe behavioral
disturbances and/or concurrent physical illness or injury. They administer medications according to the
psychiatrist/physician’s orders. The clinical nurse specialists (AOC 66C7T), when properly trained, may
prescribe medications under the supervision of a psychiatrist/physician. In coordination with the psychiatrist,
clinical psychologist, occupational therapist, and other section members, the psychiatric nurses’ responsi-
bilities include—

• Conducting individual and group therapy and stress control education sessions.

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• Providing preventive and command consultation, especially to medical units.

• Assisting with the development of the RTD plan for each case.

• Ensuring the BF casualty’s therapeutic program, as outlined in the RTD plan, is followed.

• Monitoring the BF casualty’s status and recording pertinent case data.

• Conducting nursing reports in accordance with TSOPs to update section members.

• Conducting and supervising unit survey interviews and critical event debriefings.

d. Occupational Therapy Noncommissioned Officers. Eight OT NCOs (E-6 [four], MOS
91L30N3, and E-5 [four], MOS 91L20N3) are assigned to the section. They assist the occupational
therapists with—

• Evaluating functional capacity and supervising physical reconditioning programs.

• Coordinating and setting up work programs with supported and supporting units and
overseeing the work programs.

• Supervising and ensuring appropriate training for subordinate OT specialists and other
mental health personnel.

• Providing BF casualty status updates to the occupational therapists and other staff
members as required.

• Providing direct supervision of BF casualties and squad leaders.

• Assisting with unit survey interviews and critical event debriefings.

• Assisting with the supervision of work programs.

• Assisting with the identification of useful work projects.

• Assisting with organizing activities which facilitate the recovery of the BF casualties.

• Serving as team leader for up to 12 BF casualties.

e. Mental Health Noncommissioned Officers. A total of eight mental health NCOs (E-6 [four],
MOS 91X30, and E-5 [four], MOS 91X20) are assigned to the CSC fitness section. They assist in a wide
range of psychological and social services.

(1) The NCOs, E-6, are assigned as team chiefs of the CSC fitness teams. Their
responsibilities include—

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• Collecting and recording social and psychological data.

• Counseling soldiers with personal, behavioral, or psychological problems.

• Assisting with the management of the section.

• Deploying as members of the CSC preventive team or task-organized CSC elements.

Their general duties include—

• Assisting in a wide range of psychological and social services.

• Assisting with initial screening and assessment of new cases.

• Compiling caseload data and referring BF casualties to mental health officers and
psychiatrists.

• Providing counseling to BF casualties experiencing emotional or social problems.

• Assisting the psychologist with administration of psychological testing.

• Assisting with group counseling and therapy sessions and leading group discussions.

• Assisting with unit survey interviews and critical event debriefings.

(2) Four mental health NCOs (E-5) manage and provide supervision for BF casualty care.
They deploy with either the CSC fitness teams or the task-organized CSC elements to supervise and function
as BF casualty care managers for the restoration and reconditioning centers. Other duties and responsibilities
include—

• Assisting the psychiatric nurses with planning and executing the establishment,
disestablishment, and movement of the reconditioning center.

• Assisting the psychiatric nurses with conducting restoration and reconditioning center
operations and with the administration of medications and supervision of subordinates and BF casualties.

• Providing guidance and training to subordinate mental health specialists and other
BF care providers.

• Providing direct supervision for BF casualties (when assigned as their squad leader)
and monitoring their progress.

f. Mental Health Specialists. Twelve mental health specialists (E-4 [eight] and E-3 [four], MOS
91X10) provide BF casualty care and intervention, as required. These mental health specialists deploy with
either the CSC fitness teams or the task-organized CSC elements. Their duties include—

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• Following the RTD plans for cases placed under their supervision.

• Coordinating with the psychiatric nurses and other staff members on questions pertaining
to the RTD plan.

• Providing direct supervision for BF casualties (as squad leaders) and monitoring their
progress.

• Recording and reporting to the psychiatric nurses and other mental health staff members
on the status and any other pertinent observation of cases assigned to them.

• Assisting with unit survey interviews and critical event debriefings.

• Operating and maintaining assigned vehicles.

Section IV. COMBAT STRESS CONTROL DETACHMENT

E-12. Medical Detachment, Combat Stress Control (TOE 08567AA00)

The CSC medical detachment is a 43-person unit composed of a headquarters, a CSC preventive section
(composed of a maximum of four CSC preventive teams), and a CSC fitness section (composed of two CSC
fitness teams). The modular CSC teams found in the CSC medical detachment are similar to those found in
the CSC medical company. The CSC medical detachment provides CSC planning, consultation, training,
and staff advice to C2 headquarters and the units to which they are assigned regarding—

• Combat and noncombat stressors affecting the troops.

• Mental readiness.

• Morale and cohesion.

• Potential for BF casualties.

The detachment provides NP triage, basic stabilization, and restoration for BF casualties. Under some
circumstances, it may provide reconditioning for NP and alcohol and drug abuse patients. This unit is
dependent on support from appropriate elements of the corps to include—

• Religious support.

• Finance support.

• Legal support.

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• Personnel and administrative support.

• Laundry and bath services.

• Clothing exchange for unit personnel and stress casualty caseload.

• Communications and operations information support.

The detachment is dependent on units to which it is attached for support, to include—

• Food service.

• Water distribution.

• Medical treatment.

• Logistical support, including combat health logistics.

• Patient administration (assisted by its own enlisted patient administration specialist, MOS
71G10).

• Unit maintenance for the detachment’s communications and power generator equipment and
vehicle maintenance (assisted by its own light-wheel vehicle mechanic, MOS 63B10).

a. Mission. The CSC medical detachment provides complete preventive and treatment services
in direct support of the division and corps personnel deployed forward. It also provides CSC support on an
area basis to all services and indigenous population as directed in stability operations or support operations
which include domestic support operations, humanitarian assistance, disaster relief, and peace support
operations. As the tactical situation permits, this detachment can provide all six of the CSC functions
identified.

b. Assignment. The CSC medical detachment is normally assigned to a corps Medical Brigade
(TOE 08432LXX) or a corps MEDCOM (TOE 08611LXX). It may be further attached to a Medical
Company, CSC (TOE 08467A000), an ASMB (TOE 08456A000), or a division medical company.

E-13. Detachment Headquarters

The detachment headquarters section provides C2 for the detachment. The headquarters section is
responsible for planning, coordinating, and implementing CSC support for supported units. Personnel of
the headquarters section provide maintenance, supply and service, and personnel administration support.
The detachment headquarters is composed of the following personnel:

• Detachment commander who also works as a treating clinician with the CSC preventive or
CSC fitness section.

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• Health service administrative assistant.

• Detachment NCOIC.

• Supply sergeant.

• Patient administration specialist.

• Light-wheel vehicle mechanic.

• Personnel administration specialist/unit clerk.

• Cook.

Detachment officers and NCOs from the CSC preventive team and the CSC fitness team may be assigned
additional duties which enhance the overall effectiveness of the headquarters section. Additional duty
responsibilities may include—

• Maintenance.

• Training.

• Security, plans, and operations.

• Nuclear, biological, and chemical defense.

• Supply.

These duties may be rotated to achieve maximum cross-training.

a. Detachment Commander. The detachment commander, a psychiatrist or other clinical officer
(LTC, MC/MS/AN/SP, AOC 60W00/73A67/73B67/66CTT/65A00) performs normal C2 and supervisory
functions, as well as serving as a treating clinician in one of the CSC preventive or CSC fitness teams. He
coordinates with the command surgeon and mental health sections regarding care and disposition of patients.
He exercises clinical supervision over treatment in all the CSC teams. He provides NP expertise to
supported unit headquarters. In conjunction with supported unit headquarters and MTFs, the detachment
commander plans CSC support for the unit’s operations. He deploys the detachment teams separately, or
task organizes personnel across teams as needed to form task-organized CSC elements. He appoints team
leaders based on qualifications by experience as well as by AOCs.

b. Health Service Administrative Assistant. The health service administrative assistant,(1LT, MS,
AOC 70B67) is the principal assistant to the detachment commander on all matters pertaining to the tactical
employment of detachment assets. He is responsible for overseeing operations and administrative, supply,
and maintenance activities within the detachment. His responsibilities also include—

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• Coordinating administrative activities with the staff of the higher medical headquarters.

• Ensuring unit operations and communications security.

• Keeping the commander current on the corps’ and supported divisions’ tactical situations.

• Assisting the commander with development of CSC support estimates and plans.

• Planning and scheduling unit training activities.

• Coordinating movement orders and logistical support for deployed detachment elements.

c. Detachment Noncommissioned Officer in Charge. The detachment NCOIC (E-7, MOS 91X40)
assists the detachment commander in the accomplishment of his duties. He performs administrative duties;
he receives and consolidates reports from deployed detachment elements and forwards them to higher
headquarters. The detachment NCOIC coordinates support for the detachment and for detachment elements
deployed to supported units. He represents the commander at staff meetings and on-site visits to the CSC
teams when the commander is occupied with clinical duties. When the detachment is divided into CSC
preventive and CSC fitness teams or task-organized CSC elements, the NCOIC normally locates with the
CSC fitness team. He supervises the detachment activities of the unit clerk and maintains liaison between
the commander and assigned NCOs. He provides guidance to enlisted members of the detachment and
represents them to the commander. He plans, coordinates, supervises, and participates in activities pertaining
to organization, training, and combat operations for the detachment. He assists the detachment commander
in the performance of his duties. The detachment NCOIC also assists the health service administrative
officer and performs the duties of an operations NCO.

d. Supply Sergeant. The supply sergeant (E-5, MOS 92Y20) requests, receives, inspects, stores,
safeguards, and issues general supplies. He operates unit-level computers. The supply sergeant prepares all
unit/organizational supply documents. He maintains the detachment supply records, supervises unit supply
operations, and maintains accountability for all equipment organic to the detachment. He maintains and
receives small arms and controls weapons and ammunitions in security areas. The supply sergeant is
responsible for scheduling and performing preventive- and organizational-level maintenance on weapons.
The supply sergeant reviews the Unit Material Condition Status Report and annotates changes. He posts
transactions to organizational and installation property books and supporting transaction files. He determines
methods of obtaining relief from responsibility for lost, damaged, and destroyed supply items. The supply
sergeant is responsible for coordinating all supply activities.

e. Patient Administration Specialist. The patient administration specialist (E-4, MOS 71G10) is
responsible for managing patient statistics of all BF casualties seen by the detachment element. His duties
are consistent with those identified above (paragraph E-9m).

f. Light-Wheeled Vehicle Mechanic. The light-wheeled vehicle mechanic (E-4, MOS 63B10)
performs organizational maintenance. His duties are consistent with those identified above (para-
graph E-9n).

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NOTE

When the light-wheeled vehicle mechanic deploys, he works with the
maintenance section/element of the unit to which the task-organized
CSC element is attached.

g. Personnel Administrative Specialist/Unit Clerk. The unit clerk (E4, MOS 75B10) provides and
coordinates personnel and administrative support to company personnel and maintains unit administrative
records. His duties are consistent with those identified above in paragraph E-9j.

h. Cook. One cook (E3, MOS 92G10) provides food service (tray-pack heating) for the
detachment when it is assembled. More often, he is deployed with a task-organized CSC element and
further attached for work with the food service section of the supported medical unit. He also trains CSC
personnel on food tasks which may be used as a part of their CSC restoration or reconditioning program.
He may serves as work group leader for BF casualties performing food service tasks as part of the BF
casualty’s treatment.

E-14. Preventive Section

This section has four clinical psychologists, four social work officers, four mental health NCOs, and four
mental health specialists. This section can divide into four 4-person CSC preventive teams. Three CSC
preventive teams are normally allocated, one each, to the supported division’s maneuver brigades. The
fourth CSC preventive may provide moving support to the aviation brigade, attached brigade-sized units,
corps units in the division AO, or an ASMC in the corps area. When applicable, it combines with a CSC
fitness team to staff the reconditioning program for the supported division and corps units, usually collocated
with a CSH. Combat stress control preventive team leaders are selected by the detachment commander
based on experience as well as on grade and specialty. Elements of the section may also be task-organized
with elements of the CSC fitness team to form task-organized CSC elements for special CSC operations.
The CSC preventive section’s responsibilities include—

• Preventing stress, misconduct stress behaviors, and post-traumatic casualties by providing—

• Command consultation.

• Stress prevention education.

• Debriefings (critical events and after action).

• Staff planning.

• Case evaluation and triage.

• Counseling intervention at supported units.

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• Preventive consultation support to leaders, chaplains, and medical personnel.

• Assisting nonmedical units with REST category BF casualties and the RTD of recovered BF
soldiers.

• Providing NP triage and stabilization.

• Supervising restoration of HOLD category BF casualties by medical personnel and providing
restoration for selected cases.

• Deploying to units to provide reconstitution support.

a. Clinical Psychologists. There are four clinical psychologists (MAJ [two], CPT [two], MS,
AOC 73B67) assigned to the section. Their duties include—

• Providing diagnostic expertise for triage.

• Conducting psychological and neuropsychological testing.

• Providing behavioral treatment and counseling.

• Conducting and supervising surveys of unit cohesion, morale, and individual mental
readiness for combat.

• Providing command consultation.

• Supervising subordinate personnel.

• Conducting and supervising critical event debriefings.

b. Social Work Officers. Four social work officers (MAJ [two], CPT [two], MS, AOC 73A67)
are assigned to this section. These social work officers provide proactive consultation and evaluate
psychosocial functioning and mission context of the supported units. They give individual and group
counseling and debriefings, supervise restoration/reconditioning, and coordinate RTD of recovered cases.
They provide staff advice and coordinate social services agency support. As a member of a CSC preventive
team or other CSC element, in addition to those duties identified above (paragraph E-10b), the social work
officers’ duties include—

• Evaluating soldiers with BF and misconduct stress behavior.

• Supervising subordinate personnel.

c. Mental Health Noncommissioned Officers. There are four mental health NCOs (E-5, MOS
91X20). One of these NCOs acts as the section sergeant and the other three NCOs act as assistant section
sergeants and assist the section sergeant with his duties. Their duties are consistent with those identified

E-35
C 1, FM 8-51

above (paragraph E-10d). They deploy as NCOICs of teams and may be assigned as the team leader for up
to 14 BF casualties in a restoration center. As stated above, the senior mental health NCO (E-5) also
performs as the preventive section sergeant. His duties are the same as those previously identified above
(paragraph E-11e).

d. Mental Health Specialists. There are four mental health specialists (E-4, MOS 91X20)
assigned to the section. These specialists perform those duties previously identified above (paragraph E-
10e). In addition to their duties, they operate and maintain assigned vehicles.

E-15. Combat Stress Control Fitness Section

This section has two psychiatrists, two OT officers, two psychiatric/mental health nurses, four OT NCOs,
four mental health NCOs, and six mental health specialists. The detachment NCOIC (E-7, MOS 91X40) is
located with the CSC fitness section and serves as the senior mental health NCO. The section can divide
into two CSC fitness teams. One team usually collocates with the supported division’s MSMC to provide
mobile CSC support to the DSA and conduct restoration programs, as required. The second CSC fitness
team augments area support to corps units in the division AO and in forward areas of the corps. It can
conduct the corps-level reconditioning program for the supported division and corps units and usually
collocates with a CSH. The CSC fitness team provides staff and equipment for operating a restoration or
reconditioning center. Personnel of this section are task-organized to provide NP triage, diagnosis,
stabilization, and treatment at a restoration or reconditioning center. Section personnel also deploy to
provide mobile consultation and reconstitution support to units in the vicinity and to reinforce the CSC
preventive teams of the detachment. Section personnel may be task-organized with members of the CSC
preventive section into CSC elements for specific missions. The section personnel can augment a deployed
hospital to staff a temporary NP ward. The section (and team) leader’s position may be held by any of the
officers assigned to the section. The commander will base his selection on experience as well as specialty
and grade. The commander, because of his other duties, normally appoints one of the officers assigned to
the section as the section leader.

a. Psychiatrists. The psychiatrists (LTC [one], MAJ [one], MC, AOC 60W00) assigned to this
section examine patients and provide consultation. These psychiatrists make neuropsychological and medical
diagnosis and prescribe and provide treatment. They also direct disposition of patients. The senior
psychiatrist directs the activities of the section when the section is assembled. Psychiatrists assigned to this
section may be deployed in support of CSC operations with the section, or as members of either a CSC
fitness team or a task-organized CSC element. When employed as a member of a CSC fitness team or a
task-organized CSC element, the psychiatrists’ duties include—

• Establishing and providing CSC support.

• Providing staff consultation to supported units as required. This includes nuclear surety,
security clearance, and alcohol and drug abuse preventive programs.

• Being responsible for the diagnosis, treatment, rehabilitation, and disposition of NP and
problematic BF cases.

E-36
C 1, FM 8-51

• Participating in the diagnosis and treatment of the wounded, ill, and injured, especially of
those who can RTD quickly.

• Consulting and providing training to unit leaders and medical personnel regarding
identification and management of NP disorders, BF, and misconduct stress behaviors.

• Providing therapy or referral for soldiers with NP disorders.

• Providing supervision and training of assigned and attached mental health personnel.

• Conducting and supervising unit survey interviews and critical event debriefings.

b. Occupational Therapy Officers. The OT officers (MAJ [one] and CPT [one], SP, AOC
65A00) perform those duties previously identified above (paragraph E-11b).

c. Psychiatric/Mental Health Nurses. The psychiatric/mental health nurses (MAJ [one] and CPT
[one], AN, AOC 66C00) provide specialized nursing care and management of BF casualties. The position
should be filled by clinical nurse specialists (AOC 66C7T). The duties of the psychiatric/mental health
nurses are consistent with those previously identified above (paragraph E-11c).

d. Senior Mental Health Noncommissioned Officer. The senior mental health NCO (E-7, MOS
91X40) is also the detachment NCOIC. He assists the CSC fitness section leader with the accomplishment
of his duties. He provides assistance with the management of technical and tactical operations of the section.
His specific duties include—

• Keeping the section leader informed.

• Monitoring, facilitating, and supervising the training activities of subordinates.

• Monitoring and coordinating situation reports from deployed CSC preventive teams.

• Conducting classes on selected mental health topics for senior NCOs of supported units.

e. Occupational Therapy Noncommissioned Officers. Four OT NCOs (E-6 [two], MOS 91L30N3,
and E-5 [two], MOS 91L20N3) are assigned to the section. The OT NCOs deploy with either CSC fitness
teams or task-organized CSC elements. Their duties are consistent with those listed above (paragraph
E-11d).

f. Mental Health Noncommissioned Officers. A total of four mental health NCOs (E-6 [two],
MOS 91X30, and E-5 [two], MOS 91X20) are assigned to CSC fitness section. They assist in a wide range
of psychological and social services.

(1) The NCOs, E-6, are assigned as team chiefs of the CSC fitness teams. A team chief
deploys with each CSC fitness team to supervise and function as the BF casualty care manager for a
restoration center. The team chief assists with establishment, disestablishment, and movement of the team.

E-37
C 1, FM 8-51

He also assists with conducting restoration and reconditioning center operations. The team chief may provide
direct supervision for up to 12 BF casualties when assigned as their squad leader. The team chief may be
deployed temporarily to reinforce a CSC preventive team. The responsibilities of the team chief include—

• Collecting and recording social and psychological data.

• Counseling soldiers with personal, behavioral, or psychological problems.

• Assisting with the management of the section.

• Deploying as members of CSC preventive team or task-organized CSC elements.

Their general duties include—

• Assisting in a wide range of psychological and social services.

• Assisting with initial screening and assessment of new cases.

• Compiling caseload data and referring BF casualties to specific mental health
officers and psychiatrists.

• Providing counseling to BF casualties experiencing emotional or social problems.

• Assisting the psychologist with administration of psychological testing.

• Assisting with group counseling and therapy sessions and leading group discussions.

• Assisting with unit survey interviews and critical event debriefings.

(2) The two mental health NCOs (E-5) manage and provide supervision for BF casualty care.
They deploy with either CSC fitness teams or task-organized CSC elements to supervise and function as BF
casualty care managers for the restoration and reconditioning centers. Other duties and responsibilities
include—

• Assisting the psychiatric nurses with planning and executing the establishment,
disestablishment, and movement of the reconditioning center.

• Assisting the psychiatric nurses with conducting restoration and reconditioning center
operations and with the administration of medications and supervision of subordinates and BF casualties.

• Providing guidance and training to subordinate mental health specialists and other
BF care providers.

• Providing direct supervision for BF (when assigned as their squad leader) casualties
and monitoring their progress.

E-38
C 1, FM 8-51

g. Mental Health Specialists. Six mental health specialists (E-4 [four] and E-3 [two], MOS
91X10) provide BF casualty care and intervention, as required. These mental health specialists deploy with
either the CSC fitness teams or task-organized CSC elements. In addition to their duties, they operate and
maintain their assigned vehicle. Duties for the mental health specialist include—

• Following the RTD plans for cases placed under their supervision.

• Coordinating with the psychiatric nurses and other staff members on questions pertaining
to the RTD plan.

• Providing direct supervision for BF casualties (as squad leaders) and monitoring their
progress.

• Recording and reporting to the psychiatric nurses and other mental health staff members
on the status and any other pertinent observation of cases assigned to them.

• Assisting with unit survey interviews and critical event debriefings.

• Operating and maintaining assigned vehicles.

E-39
FM 8-51

GLOSSARY

ABBREVIATIONS, ACRONYMS, AND DEFINITIONS

AAR after-action review ASMC area support medical company
ABCA American, British, Canadian, and assign To place units or personnel in an organi-
Australian zation where such placement is relatively
permanent, and/or where such organization
ACR armored cavalry regiment controls, administers, and provides logistical
support to units of personnel for the primary
ADAPCP Alcohol and Drug Abuse Prevention function or a greater portion of the functions
and Control Program of the unit or personnel. (See also attach;
operational command; operational control;
advanced trauma management This is the organic.)
resuscitative and stabilizing medical or surgi- attach The temporary placement of units or
cal treatment provided to patients to save life personnel in an organization. Subject to
or limb and to prepare them for further evac- limitations imposed by the attachment order,
uation without jeopardizing their well-being the commander of the formation, unit, or
or prolonging the state of their condition. organization receiving the attachment will
exercise the same degree of command and
AG adjutant general control as he does over units and personnel
organic to his command. However, the respon-
ambulance exchange point (AXP) A point in an sibility for transfer and promotion of person-
ambulance shuttle system where a patient is nel will normally be retained by the parent
transferred from one ambulance to another formation, unit, or organization. (See also
en route to a medical treatment facility. assign; operational command; operational
control; organic. )
AMEDDC&S Army Medical Department Center
and School AWOL absent without leave

AN Army Nurse Corps AXP See ambulance exchange point.

AO See area of operations. BAS battalion aid station

AOC area of concentration battle fatigue (BF) Also referred to as combat
stress reaction or combat fatigue. Fatigue by
AR Army regulation definition is the distress and impaired per-
formance that comes from doing something
(anything) too hard and/lor too long. The term
area of operations (AO) That portion of an area battle fatigue is applied to any combat stress
of conflict necessary for military operations. reaction which is treated the way all fatigue
Areas of operations are geographical areas is treated, with the four "Rs"--Reassure of
assigned to commanders for which they have normality, Rest (respite from the work ),
responsibility and in which they have authori- Restoration of confidence through talk and
ty to conduct military operations. activities, and Replenish of nutrition, and
hydration, hygiene and a sense of physical
ASMB area support medical battalion well-being.

Glossary-l
FM 8-51

BF See battle fatigue. combat neuropsychiatric triage Is the process
of sorting combat stress-related casualties
brigade support area (BSA) A designated area and neuropsychiatric patients into categories
in which combat service support elements based on how far forward they can be treated.
from division support command and corps In operations other than war, this may be
support command provide logistics support referred to as proximate neuropsychiatric
to a brigade. The brigade support area nor- triage.
mally is located 20 to 25 kilometers behind
the forward edge of the battle area. combat service support (CSS) The support
provided to sustain combat forces, primarily
BSA See brigade support area. in the fields of administration and logistics.
It may include administrative services,
C2 See command and control. chaplain service, civil affairs, food service,
finance, legal service, maintenance, medical
camouflage The use of concealment and disguise service, military police, supply, transpor-
to minimize detection or identification of tation, and other logistical services. The
troops, weapons, equipment, and installa- basic mission of combat service support is to
tions. It includes taking advantage of the develop and maintain maximum combat power
immediate environment as well as using through the support of weapons systems.
natural and artificial materials. combat stress control (CSC) A coordinated
casualty Any person who is lost to his organiza- program for the prevention, triage and
treatment of each echelon of battle fatigue to
tion by reason of having been declared dead, maximize rapid return to duty and minimize
wounded, injured, diseased, interned, cap- misconduct stress reactions and post-trau-
tured, retained, missing in action, beleaguered, matic stress disorders. This program is con-
besieged, or detained. ducted by unit mental health personnel plus
echelon above division combat stress control
CH chaplain units.
CHS See combat health support. combat support (CS) Fire support and opera-
tional assistance provided to combat elements.
clearing station An operating field medical May include artillery, air defense, aviation
facility established by a clearing company or (less air cavalry and attack helicopter), engi-
medical company which provides emergency neer, military police, signal, and electronic
or resuscitative treatment for patients until warfare.
evacuated and definitive treatment for pa-
tients with minor illness, wounds, or injuries. combat trains The portion of unit trains that
provides the combat service support required
combat health support (CHS) This term is used for immediate response to the needs of forward
in current doctrine to include all services tactical elements. At company level, medical
performed, provided, or arranged by the Army recovery and maintenance elements normally
Medical Department to promote, improve, constitute the combat trains. At battalion,
conserve, or restore the mental and/or physical the combat trains normally consist of ammu-
well-being of personnel in the Army and, as nition and POL vehicles, maintenance/recov-
directed, in other services, agencies, and ery vehicles, and crew and the battalion aid
organizations. station. (See also field trains; unit trains. )

Glossary-2
FM 8-51

combat zone (CZ) That area required by combat security, emission security, and physical
forces for the conduct of operations. It is the security of communications security materials
territory forward of the Army rear area and information.
boundary.
communications zone (COMMZ) That rear
command and control (C2) The exercise of area of the theater of operations, behind but
command that is the process through which contiguous to the combat zone, that contains
the activities of military forces are directed, the lines of communication, establishment
coordinated, and controlled to accomplish the for supply and evacuation, and other agencies
mission. This process encompasses the per- required for the immediate support and
sonnel, equipment, communications, facili- maintenance of the field forces.
ties, and procedures necessary to gather and
analyze information, to plan for what is to be COMMZ See communications zone.
done, and to supervise the execution of opera-
tions. concealment The protection from observation.
command post (CP) The principal facility concept of operations A graphic, verbal, or
employed by the commander to command written statement in broad outline that gives
and control combat operations. A command an overall picture of a commander’s assump-
post consists of those coordinating and special tion or intent in regard to an operation or a
staff activities and representatives from series of operations; includes, at a minimum,
supporting Army elements and other services the scheme of maneuver and the fire support
that may be necessary to carry out operations. plan. The concept of operations is embodied
Corps and division headquarters are particu- in campaign plans and operation plans,
larly adaptable to organization by echelon particularly when the plans cover a series of
into a tactical command post, a main command connected operations to be carried out simul-
post, and a rear command post. taneously or in secession. It is described in
sufficient detail for the staff and subordinate
commander’s estimate The procedure whereby commanders to understand what they are to
a commander decides how to best accomplish do and how to fight the battle without further
the assigned mission. It is a thorough consid- instructions.
eration of the mission, enemy, terrain, troops
available, time, weather, and other relevant CONUS continental United States
factors. The commander’s estimate is based
on personal knowledge of the situation and CP See command post.
on staff estimates.
CPT captain
communications security The protection re-
sulting from all measures designed to deny CRC combat reconditioning center
unauthorized persons information of value
that might be derived from the possession CS See combat support.
and study of telecommunications, or to mis-
lead unauthorized person sin their interpreta- CSC See combat stress control.
tion of the results of such possession and
study. Includes cryptosecurity, transmission CSH combat support hospital

Glossary-3
FM 8-51

CSS See combat service support. corps support command elements may be
located in the division support area to provide
CTA common table of allowances direct support backup and general support as
required.
CZ See combat zone.
DMOC division medical operations center
DA Department of the Army
DNBI disease and nonbattle injuries
DA PAM Department of the Army pamphlet
DPCA Deputy for Personnel and Civilian Affairs
DD/DOD Department of Defense
DSA See division support area.
DEPMEDS Deployable Medical Systems
DSM III-R Diagnostic and Statistical Manual of
direct support (1) A mission requiring a force to Mental Disorders, Third Edition, Revised
support another specific force and authorizing
it to answer directly the supported force’s Echelon I (Unit level) First medical care a soldier
request for assistance. (2) In the North receives is provided at this level. This care
Atlantic Treaty Organization, the support includes immediate lifesaving measures,
provided by a unit or formation not attached advanced trauma management, disease pre-
to, nor under command of, the supported unit vention, combat stress control prevention,
or formation, but required to give priority to casualty collection, and evacuation from sup-
the support required by that unit or formation. ported units to supporting medical treatment.
(See also general support.) Echelon I elements are located throughout
the combat and communications zones. These
DISCOM division support command elements include the combat lifesavers, com-
bat medics, and battalion aid station. Some or
displace To leave one position and take another. all of these elements are found in maneuver,
Forces may be displaced laterally to con- combat support, and combat service support
centrate combat power in threatened areas, units. When Echelon I is not present in a
When a unit is advancing, its command post unit, this support is provided to that unit by
must displace forward. Echelon II medical units.
division support area (DSA) An area normally Echelon II Duplicates Echelon I medical care and
located in the division rear, positioned near expands services available by adding dental,
air landing facilities and along the main laboratory, x-ray, and patient-holding capa-
supply route. The division support area bility. Emergency care, advanced trauma
contains the division support command, management, including beginning resuscita-
command post, the headquarters element of tion procedures, is continued. No general
the division support command battalions, anesthesia is available; if necessary, addi-
and those division support command elements tional emergency measures dictated by the
charged with providing backup support to immediate needs are performed. Echelon II
combat service support elements in the units are located in the combat zone brigade
brigade support area and direct support to support area, the corps support area, and the
units located in the division rear.Selected communications zone, Echelon II medical

Glossary-4
FM 8-51

support may be provided by a clearing sta- echelon above corps Army headquarters and
tion; forward support medical company; organizations that provide the interface bet-
medical company, forward support battalion; ween the theater commander (joint or com-
medical company, main support battalion; bined) and the corps for operational matters,
area support medical companies located in and between the continental United States/
the corps area and in the communications host nation and the deployed corps for combat
zone. service support. Operational echelons above
corps may be United States only or allied
Echelon III This echelon of support expands the headquarters, while echelons above corps for
support provided at Echelon II. Casualties combat service support will normally be
who are unable to tolerate and survive move- United States national organizations.
ment over long distances will receive surgical
care in hospitals as close to the division rear echelon of care This is a North Atlantic Treaty
boundary as the tactical situation will allow. Organization term which can be used inter-
Surgical care may be provided within the changeably with the term level of care.
division area under certain operational condi-
tions. Echelon III characterizes the care that echeloned displacement Movement of a unit
is provided by units such as mobile army from one position to another without discon-
surgical hospitals and combat support hospi- tinuing performance of its primary function.
tals. Operational conditions may require Normally, the unit divides into two functional
Echelon III units to locate in offshore support elements (base and advance); while the base
facilities. Third Country support base, or in continues to operate, the advance element
the communications zone. displaces to a new site where, after it becomes
Echelon IV This echelon of care is provided in a operational, it is joined by the base element.
general hospital and field hospital and in
other communications zone-level facilities echelonment An arrangement of personnel and
which are staffed and equipped for general equipment into assault, combat follow up,
and specialized medical and surgical treat- and rear components or group.
ment. The field hospital normally operate sin
the communications zone but may be deployed emergency medical treatment The immediate
to the rear boundaries of the corps, if neces- application of medical procedures to the
sary. This echelon of care provides further wounded, injured, or sick by specially trained
treatment to stabilize those patients requiring medical personnel.
evacuation to continental United States. This
echelon also provides area health service sup- EPW enemy prisoner(s) of war
port to soldiers within the communications
zone. evacuation (1) A combat service support function
which involves the movement of recovered
Echelon V In this echelon of care, the casualty is materiel from a main supply route, mainte-
treated in continental United States-based nance activity collecting point, and mainte-
hospitals, staffed and equipped for the most nance activity to higher levels of maintenance.
definitive care available within the health (2) The process of moving any person who is
service support system. Hospitals in the wounded, injured, or ill to and/or between
continental United States base represent the medical treatment facilities while providing
final level of CHS. en route medical care.

Glossary-5
FM 8-51

evacuation policy A command decision indica- fragmentary order An abbreviated form of an
ting the length in days of the maximum operation order used to make changes in
period of noneffectiveness that patients may mission to units and to inform them of changes
be held within the command for treatment. in the tactical situation.
Patients who, in the opinion of an officiating
medical officer, cannot be returned to duty FSB forward support battalion
status within the period prescribed are
evacuated by the first available means, FSMC forward support medical company
provided the travel involved will not aggravate
their disabilities. FTX field training exercise
G1 Assistant Chief of Staff (Personnel)
F Fahrenheit
G2 Assistant Chief of Staff (Intelligence)
FH field hospital
G3 Assistant Chief of Staff (Operations and Plans)
field trains The combat service support portion
of a unit at company and battalion levels that G4 Assistant Chief of Staff (Logistics)
is not required for immediate support of
combat elements. At company level, supply G5 Assistant Chief of Staff (Civil Affairs)
and mess teams normally are located in the
field trains. A battalion’s field trains may GC Geneva Convention Relative to the Protection
include mess teams, a portion of the supply of Civilian Persons in Time of War, 12
section of the support platoon, and a maint- August 1949
enance element, as well as additional ammu- general support Support that is given to the
nition and POL. Positioning field trains is supported force as a whole and not to any
dependent on such factors as the type of particular subdivision thereof.
friendly operations underway and available
activity in the area. (See also combat trains; GH general hospital
unit trains. )
GP general purpose
FLOT See forward line of own troops.
GPW Geneva Convention Relative to the Treat-
FM field manual ment of Prisoners of War, 12 August 1949

FMC US Field Medical Card, DD Form 1380 GTA graphic training aid
GWS Geneva Convention for the Amelioration of
forward line of own troops (FLOT) A line that the Condition of Wounded and Sick in Armed
indicates the most forward position of friendly Forces in the Field, 12 August 1949
forces in any kind of military operation at a
specific time. The forward line of own troops GWS (Sea) Geneva Convention for the Ameliora-
may be at, beyond, or short of the forward tion of the Condition of Wounded, Sick, and
edge of the battle area, depicting the nonlinear Shipwrecked Members of Armed Forces at
battlefield. Sea, 12 August 1949

Glossary-6
FM 8-51

HHC headquarters and headquarters company medical intelligence That intelligence produced
from the collecting, evaluation, and analysis
HHD headquarters and headquarters detachment of information concerning the medical aspects
of foreign areas which have immediate or
host nation A nation in whose territory the potential impact on policies, plans, and
United States or allied forces are operating or operations.
supporting the battle.
medical treatment facility (MTF) Any facility
host-nation support Civil and military assistance established for the purpose of providing
rendered in peacetime and wartime to allied medical treatment. This includes aid sta-
forces arid organizations located in the host tions, clearing stations, dispensaries, clinics,
nation’s territory. The bases of such assistance and hospitals.
are commitments arising from national agree-
ments concluded among host nation(s), inter- METT-T mission, enemy, terrain, troops, and
national organizations, and nation(s) having time available
forces operating in the host nation’s territory.
mg milligram
HSC headquarters and support company
MIA missing in action
IG inspector general
mobility The percentage of organic equipment
JAG judge advocate general and personnel that can be moved in a single
lift using organic vehicles. It does not include
KIA killed in action patients in the medical treatment facility.

LBE load bearing equipment MOPP mission-oriented protective posture
MOS military occupational specialty
LTC lieutenant colonel
MP military police
MAJ major
MRE meal(s), ready to eat
MASH mobile army surgical hospital
MS Medical Service Corps
MC Medical Corps
MSB main support battalion
MCW minimal care ward
MSMC main support medical company
MEDCOM medical command
MSR main supply route
MEDDAC medical department activity
MTF See medical treatment facility.
medical equipment set(s) Chest{s) containing
medical instruments and supplies designed NBC nuclear, biological, and chemical
for specific table(s) of organization and equip-
ment units or missions. NCO noncommissioned officer

Glossary-7
FM 8-51

NCOIC noncommissioned officer in charge specific missions or tasks that are usually
limited by function, time, or location; to deploy
NP neuropsychiatric units concerned; and to retain or assign
tactical control to those units. It does not of
NYDN not, yet diagnosed "nervous" itself include administrative or logistics
control. In the North Atlantic Treaty Organi-
OPCON See operational control. zation, it does not include authority to assign
separate employment of components of the
operation order (OPORD) A directive issued by units concerned. (See also assign; attach;
a commander to subordinate commanders for operational command.)
effecting the coordinated execution of an
operation, including tactical movement or- operations security All measures taken to
ders. (See also operation plan.) maintain security and achieve tactical sur-
prise. It includes countersurveillance, phy-
operation plan (OPLAN) A plan for a military sical security, signal security, and information
operation. It covers a single operation or security. It also involves the identification
series of connected operations to be carried and elimination or control of indicators which
out simultaneously or in succession. It im- can be exploited by hostile intelligence organi-
plements operations derived from the cam- zations.
paign plan. When the time and/or conditions
under which the plan is to be placed in effect OPLAN See operation plan.
occur, the plan becomes an operations order.
(See also operation order.) OPORD See operation order.

operational command North Atlantic Treaty order A communication written, oral, or by signal
Organization: The authority granted to a that conveys instructions from a superior to
commander to assign missions or tasks to a subordinate. In a broad sense, the term
subordinate commanders, to deploy units, to order and command are synonymous. How-
reassign forces, and to retain or delegate ever, an order implies discretion as to the de-
tails of execution, whereas a command does
operational and/or tactical control as may be not.
deemed necessary. It does not of itself include
responsibility for administration or logistics. organic Assigned to and forming an essential -
May also be used to denote the forces assign- part of a military organization; an element
ed to a commander. Department of Defense: normally shown in the unit’s table of organiza-
The term is synonymous with operational tion and equipment. (See also assign; attach;
control exercised by the commanders of unified operational control.)
and specified commands over assigned forces
in accordance with the National Security Act OT occupational therapy
of 1947, as amended and revised (10 United
States Code 124). (See also operational patient A sick, injured, or wounded person who
control.) receives medical care or treatment from medi-
cally trained (MOS-or AOC-specific) per-
operational control (OPCON) The authority sonnel.
delegated to a commander to direct forces as-
signed so that the commander may accomplish PCP phencyclidine hydrochloride

Glossary-8
FM 8-51

PIES proximity, immediacy, expectancy, and RTD return to duty
simplicity
S1 Adjutant (US Army)
PLL prescribed load list
S2 Intelligence Officer (US Army)
PMCS preventive maintenance checks and ser-
vices S3 Operations and Training Officer (US Army)

POC point of contact S4 Supply Officer (US Army)

PW/POW prisoner(s) of war SOI signal operation instructions

PROFIS professional officer filler system SP Army Medical Specialist Corps

PVNTMED preventive medicine TEMPER tent, extendable, modular, personnel

QSTAG Quadripartite Standardization Agree- theater of operations (TO) That portion of an
ment area of conflict necessary for the conduct of
military operations, either offensive or
rear area The area in the rear of the combat and defensive, to include administration and
logistical support.
forward areas. Combat echelons from the
brigade through the field Army normally TM technical manual
designate a rear area. For any particular
command, that area extending rearward from TMDE test, measurement, and diagnostic equip-
the rear boundary of their next subordinate ment
formations, or units deployed in the main
battle or defense area to their own rear TO See theater of operations.
boundary. It is here that reserve forces of the
echelon are normally located. In addition, TOC tactical operations center
combat support and combat service support
units and activities locate in this area. (See TOE table(s) of organization and equipment
also brigade support area; division support
area.) TSOP tactical standing operating procedure
reconstitution The total process of keeping the TTP tactics, techniques, and procedures
force supplied with various supply classes,
services, replacement personnel, and equip- UCMJ Uniform Code of Military Justice
ment required. This process maintains the
desired level of combat effectiveness and unit trains Combat service support personnel
restores units that are not combat effective to and equipment organic or attached to a force
the desired level through the replacement of that provides supply, evacuation, and mainte-
critical equipment and personnel. Reconstitu- nance services. Unit trains, whether or riot
tion encompasses unit regeneration and echeloned, are under unit control and no
sustaining support. portion of them is released to the control of a

GIossary-9
FM 8-51

higher headquarters. Trains are normally brief, oral, or written message designed to
echeloned into combat and field trains. (See give subordinates time to make necessary
also combat trains; field trains. ) plans and preparations.
US United States WIA wounded in action
WWI World War I
warning order A preliminary notice of an action
or order that is to follow. Usually issued as a WWII World WarII

Glossary-10
C 1, FM 8-51

combat zone (CZ) That area required by combat security, emission security, and physical
forces for the conduct of operations. It is the security of communications security materials
territory forward of the Army rear area and information.
boundary.
communications zone (COMMZ) That rear area
command and control (C2) The exercise of of the theater of operations, behind but
command that is the process through which contiguous to the combat zone, that contains
the activities of military forces are directed, the lines of communication, establishment for
coordinated, and controlled to accomplish the supply and evacuation, and other agencies
mission. This process encompasses the per- required for the immediate support and
sonnel, equipment, communications, facilities, maintenance of the field forces.
and procedures necessary to gather and
analyze information, to plan for what is to be COMMZ See communications zone.
done, and to supervise the execution of
operations. concealment The protection from observation.

command post (CP) The principal facility concept of operations A graphic, verbal, or
employed by the commander to command and written statement in broad outline that gives
control combat operations. A command post an overall picture of a commander’s
consists of those coordinating and special staff assumption or intent in regard to an operation
activities and representatives from supporting or a series of operations; includes, at a
Army elements and other services that may minimum, the scheme of maneuver and the
be necessary to carry out operations. Corps fire support plan. The concept of operations
and division headquarters are particularly is embodied in campaign plans and operation
adaptable to organization by echelon into a plans, particularly when the plans cover a
tactical command post, a main command post, series of connected operations to be carried
and a rear command post. out simultaneously or in secession. It is
described in sufficient detail for the staff and
commander’s estimate The procedure whereby subordinate commanders to understand what
a commander decides how to best accomplish they are to do and how to fight the battle
the assigned mission. It is a thorough without further instructions.
consideration of the mission, enemy, terrain,
troops available, time, weather, and other CONUS continental United States
relevant factors. The commander’s estimate
is based on personal knowledge of the CP See command post.
situation and on staff estimates.
CPT captain
communications security The protection re-
sulting from all measures designed to deny CRC combat reconditioning center
unauthorized persons information of value
that might be derived from the possession CS See combat support.
and study of telecommunications, or to mis-
lead unauthorized persons in their interpreta- «CSA corps support area
tion of the results of such possession and
study. Includes cryptosecurity, transmission CSC See combat stress control.

Glossary-3
C 1, FM 8-51

CSH combat support hospital support area and direct support to units
located in the division rear. Selected corps
CSS See combat service support. support command elements may be located in
the division support area to provide direct
CTA common table of allowances support backup and general support as
required.
CZ See combat zone.
DMOC division medical operations center
DA Department of the Army
DNBI disease and nonbattle injuries
DA PAM Department of the Army pamphlet
«DOD/DD Department of Defense
DD/DOD Department of Defense
DPCA Deputy for Personnel and Civilian Affairs
DEPMEDS Deployable Medical Systems
DSA See division support area.
direct support (1) A mission requiring a force
to support another specific force and DSM III-R Diagnostic and Statistical Manual of
authorizing it to answer directly the supported Mental Disorders, Third Edition, Revised
force’s request for assistance. (2) In the
North Atlantic Treaty Organization, the Echelon I (Unit level) First medical care a
support provided by a unit or formation not soldier receives is provided at this level. This
attached to, nor under command of, the care includes immediate lifesaving measures,
supported unit or formation, but required to advanced trauma management, disease
give priority to the support required by that prevention, combat stress control prevention,
unit or formation. (See also general support.) casualty collection, and evacuation from
supported units to supporting medical
DISCOM division support command treatment. Echelon I elements are located
throughout the combat and communications
displace To leave one position and take another. zones. These elements include the combat
Forces may be displaced laterally to lifesavers, combat medics, and battalion aid
concentrate combat power in threatened areas. station. Some or all of these elements are
When a unit is advancing, its command post found in maneuver, combat support, and
must displace forward. combat service support units. When Echelon
I is not present in a unit, this support is
division support area (DSA) An area normally provided to that unit by Echelon II medical
located in the division rear, positioned near units.
air landing facilities and along the main supply
route. The division support area contains the Echelon II Duplicates Echelon I medical care and
division support command, command post, expands services available by adding dental,
the headquarters element of the division laboratory, x-ray, and patient-holding capa-
support command battalions, and those bility. Emergency care, advanced trauma
division support command elements charged management, including beginning resuscita-
with providing backup support to combat tion procedures, is continued. No general
service support elements in the brigade anesthesia is available; if necessary, additional

Glossary-4
C 1, FM 8-51

emergency measures dictated by the im- hospitals, staffed and equipped for the most
mediate needs are performed. Echelon II definitive care available within the health
units are located in the combat zone brigade service support system. Hospitals in the
support area, the corps support area, and the continental United States base represent the
communications zone. Echelon II medical final level of CHS.
support may be provided by a clearing station;
forward support medical company; medical echelon above corps Army headquarters and
company, forward support battalion; medical organizations that provide the interface
company, main support battalion; area between the theater commander (joint or
support medical companies located in the combined) and the corps for operational
corps area and in the communications zone. matters, and between the continental United
States/host nation and the deployed corps for
Echelon III This echelon of support expands the combat service support. Operational echelons
support provided at Echelon II. Casualties above corps may be United States only or
who are unable to tolerate and survive move- allied headquarters, while echelons above
ment over long distances will receive surgical corps for combat service support will normally
care in hospitals as close to the division rear be United States national organizations.
boundary as the tactical situation will allow.
Surgical care may be provided within the echelon of care This is a North Atlantic Treaty
division area under certain operational condi- Organization term which can be used inter-
tions. Echelon III characterizes the care that changeably with the term level of care.
is provided by units such as mobile army
surgical hospitals and combat support hospi- echeloned displacement Movement of a unit
tals. Operational conditions may require from one position to another without discon-
Echelon III units to locate in offshore support tinuing performance of its primary function.
facilities, Third Country support base, or in Normally, the unit divides into two functional
the communications zone. elements (base and advance); while the base
continues to operate, the advance element
Echelon IV This echelon of care is provided in a displaces to a new site where, after it becomes
general hospital and field hospital and in other operational, it is joined by the base element.
communications zone-level facilities which
are staffed and equipped for general and echelonment An arrangement of personnel and
specialized medical and surgical treatment. equipment into assault, combat follow up, and
The field hospital normally operates in the rear components or group.
communications zone but may be deployed to
the rear boundaries of the corps, if necessary. emergency medical treatment The immediate
This echelon of care provides further treat- application of medical procedures to the
ment to stabilize those patients requiring wounded, injured, or sick by specially trained
evacuation to continental United States. This medical personnel.
echelon also provides area health service
support to soldiers within the communications EPW enemy prisoner(s) of war
zone.
evacuation (1) A combat service support func-
Echelon V In this echelon of care, the casualty tion which involves the movement of
is treated in continental United States-based recovered materiel from a main supply route,

Glossary-5
C 1, FM 8-51

maintenance activity collecting point, and may be at, beyond, or short of the forward
maintenance activity to higher levels of main- edge of the battle area, depicting the nonlinear
tenance. (2) The process of moving any battlefield.
person who is wounded, injured, or ill to and/
or between medical treatment facilities while fragmentary order An abbreviated form of an
providing en route medical care. operation order used to make changes in
mission to units and to inform them of
evacuation policy A command decision indica- changes in the tactical situation.
ting the length in days of the maximum period
of noneffectiveness that patients may be held FSB forward support battalion
within the command for treatment. Patients
who, in the opinion of an officiating medical FSMC forward support medical company
officer, cannot be returned to duty status
within the period prescribed are evacuated by FTX field training exercise
the first available means, provided the travel
involved will not aggravate their disabilities. G1 Assistant Chief of Staff (Personnel)

F Fahrenheit G2 Assistant Chief of Staff (Intelligence)

FH field hospital G3 Assistant Chief of Staff (Operations and Plans)

field trains The combat service support portion G4 Assistant Chief of Staff (Logistics)
of a unit at company and battalion levels that
is not required for immediate support of com- G5 Assistant Chief of Staff (Civil Affairs)
bat elements. At company level, supply and
mess teams normally are located in the field GC Geneva Convention Relative to the Protection
trains. A battalion’s field trains may include of Civilian Persons in Time of War, 12
mess teams, a portion of the supply section of August 1949
the support platoon, and a maintenance
element, as well as additional ammunition and general support Support that is given to the
POL. Positioning field trains is dependent on supported force as a whole and not to any
such factors as the type of friendly operations particular subdivision thereof.
underway and available activity in the area.
(See also combat trains; unit trains.) GH general hospital

FLOT See forward line of own troops. GP general purpose

FM field manual GPW Geneva Convention Relative to the Treat-
ment of Prisoners of War, 12 August 1949
FMC US Field Medical Card, DD Form 1380
GTA graphic training aid
forward line of own troops (FLOT) A line that
indicates the most forward position of friendly GWS Geneva Convention for the Amelioration
forces in any kind of military operation at a of the Condition of Wounded and Sick in
specific time. The forward line of own troops Armed Forces in the Field, 12 August 1949

Glossary-6
C 1, FM 8-51

GWS (Sea) Geneva Convention for the Amelio- MEDDAC medical department activity
ration of the Condition of Wounded, Sick,
and Shipwrecked Members of Armed Forces medical equipment set(s) Chest(s) containing
at Sea, 12 August 1949 medical instruments and supplies designed for
specific table(s) of organization and equip-
HHC headquarters and headquarters company ment units or missions.

HHD headquarters and headquarters detachment medical intelligence That intelligence produced
from the collecting, evaluation, and analysis
host nation A nation in whose territory the of information concerning the medical aspects
United States or allied forces are operating or of foreign areas which have immediate or
supporting the battle. potential impact on policies, plans, and
operations.
host-nation support Civil and military assistance
rendered in peacetime and wartime to allied medical treatment facility (MTF) Any facility
forces and organizations located in the host established for the purpose of providing
nation’s territory. The bases of such assis- medical treatment. This includes aid stations,
tance are commitments arising from national clearing stations, dispensaries, clinics, and
agreements concluded among host nation(s), hospitals.
international organizations, and nation(s) having
forces operating in the host nation’s territory. METT-T mission, enemy, terrain, troops, and
time available
HSC headquarters and support company
«MF2K Medical Force 2000
IG inspector general
mg milligram
JAG judge advocate general
MIA missing in action
KIA killed in action
mobility The percentage of organic equipment
LBE load bearing equipment and personnel that can be moved in a single
lift using organic vehicles. It does not include
«LT lieutenant patients in the medical treatment facility.

LTC lieutenant colonel MOPP mission-oriented protective posture

MAJ major MOS military occupational specialty

MASH mobile army surgical hospital MP military police

MC Medical Corps MRE meal(s), ready to eat

MCW minimal care ward «MRI Medical Reengineering Initiative

MEDCOM medical command MS Medical Service Corps

Glossary-7
C 1, FM 8-51

MSB main support battalion forces assigned to a commander. Department
of Defense: The term is synonymous with
MSMC main support medical company operational control exercised by the com-
manders of unified and specified commands
MSR main supply route over assigned forces in accordance with the
National Security Act of 1947, as amended
MTF See medical treatment facility. and revised (10 United States Code 124).
(See also operational control.)
NBC nuclear, biological, and chemical
operational control (OPCON) The authority
NCO noncommissioned officer delegated to a commander to direct forces
assigned so that the commander may
NCOIC noncommissioned officer in charge accomplish specific missions or tasks that are
usually limited by function, time, or location;
NP neuropsychiatric to deploy units concerned; and to retain or
assign tactical control to those units. It does
NYDN not yet diagnosed “nervous” not of itself include administrative or logistics
control. In the North Atlantic Treaty
OPCON See operational control. Organization, it does not include authority to
assign separate employment of components
operation order (OPORD) A directive issued by of the units concerned. (See also assign;
a commander to subordinate commanders for attach; operational command.)
effecting the coordinated execution of an
operation, including tactical movement operations security All measures taken to
orders. (See also operation plan.) maintain security and achieve tactical
surprise. It includes countersurveillance,
operation plan (OPLAN) A plan for a military physical security, signal security, and
operation. It covers a single operation or information security. It also involves the
series of connected operations to be carried identification and elimination or control of
out simultaneously or in succession. It indicators which can be exploited by hostile
implements operations derived from the intelligence organizations.
campaign plan. When the time and/or
conditions under which the plan is to be OPLAN See operation plan.
placed in effect occur, the plan becomes an
operations order. (See also operation order.) OPORD See operation order.

operational command North Atlantic Treaty order A communication written, oral, or by signal
Organization: The authority granted to a that conveys instructions from a superior to a
commander to assign missions or tasks to subordinate. In a broad sense, the term order
subordinate commanders, to deploy units, to and command are synonymous. However, an
reassign forces, and to retain or delegate order implies discretion as to the details of
operational and/or tactical control as may be execution, whereas a command does not.
deemed necessary. It does not of itself
include responsibility for administration or organic Assigned to and forming an essential part
logistics. May also be used to denote the of a military organization; an element

Glossary-8
C 1, FM 8-51

normally shown in the unit’s table of reconstitution The total process of keeping the
organization and equipment. (See also assign; force supplied with various supply classes,
attach; operational control.) services, replacement personnel, and equip-
ment required. This process maintains the
OT occupational therapy desired level of combat effectiveness and
restores units that are not combat effective to
patient A sick, injured, or wounded person who the desired level through the replacement of
receives medical care or treatment from critical equipment and personnel. Recon-
medically trained (MOS-or AOC-specific) stitution encompasses unit regeneration and
personnel. sustaining support.
PCP phencyclidine hydrochloride RTD return to duty
PIES proximity, immediacy, expectancy, and S1 Adjutant (US Army)
simplicity
S2 Intelligence Officer (US Army)
PLL prescribed load list
S3 Operations and Training Officer (US Army)
PMCS preventive maintenance checks and services

POC point of contact S4 Supply Officer (US Army)

PW/POW prisoner(s) of war SOI signal operation instructions

PROFIS professional officer filler system SP Army Medical Specialist Corps

PVNTMED preventive medicine TEMPER tent, extendable, modular, personnel

QSTAG Quadripartite Standardization Agree- theater of operations (TO) That portion of an
ment area of conflict necessary for the conduct of
military operations, either offensive or defen-
«RCS requirement control symbol sive, to include administration and logistical
support.
rear area The area in the rear of the combat and
forward areas. Combat echelons from the TM technical manual
brigade through the field Army normally
designate a rear area. For any particular TMDE test, measurement, and diagnostic equip-
command, that area extending rearward from ment
the rear boundary of their next subordinate
formations, or units deployed in the main TO See theater of operations.
battle or defense area to their own rear
boundary. It is here that reserve forces of the TOC tactical operations center
echelon are normally located. In addition,
combat support and combat service support TOE table(s) of organization and equipment
units and activities locate in this area. (See also
brigade support area; division support area.) TSOP tactical standing operating procedure

Glossary-9
C 1, FM 8-51

TTP tactics, techniques, and procedures US United States

UCMJ Uniform Code of Military Justice warning order A preliminary notice of an action
or order that is to follow. Usually issued as a
unit trains Combat service support personnel and brief, oral, or written message designed to
equipment organic or attached to a force that give subordinates time to make necessary
provides supply, evacuation, and maintenance plans and preparations.
services. Unit trains, whether or not
echeloned, are under unit control and no WIA wounded in action
portion of them is released to the control of a
higher headquarters. Trains are normally WWI World War I
echeloned into combat and field trains. (See
also combat trains; field trains.) WWII World War II

Glossary-10
FM 8-51

REFERENCES

SOURCES USED DOCUMENTS NEEDED
These are the sources quoted or paraphrased in These documents must be available to the in-
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AR 40-501. Standards of Medical Fitness. 1 July (Reprinted with basic including C1–14.)
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Terms (Short Title: AD). 15 October 1983. *FM 8-10. Health Service Support in a Theater
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June 1986. 1956. (Change 1, July 1976.)

*This source was also used to develop this publication.

References-1
FM 8-51

*FM 63-21. Main Support Battalion. 7 August AR 40-535. Worldwide Aerornedical Evacuation.
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(Consolidated). 1 April 1992. P5059; AFP 161-3. 31 August 1973. (Re-
DD Form 2A. US Armed Forces Identification printed with basic including Cl.)
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Card for Medical and Religious Personnel 09B2P1; AFM 110-7; NAVMC 2500. 18
Who Serve In or Accompany the Armed November 1966.
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CGCOMDTINST 6320.8A. 30 March 1990. (Reprinted with basic including C1-2. )

References-2
FM 8-51

AR 40-3. Medical, Dental, and Veterinary Care. FM 3-5. NBC Decontamination. FMFM 11-100.
15 February 1985. 23 Ju]y 1992.
AR 40-4. Army Medical Department Facilities/ FM 3-50. Smoke Operations. 4 December 1990.
Activities. 1 January 1980. FM 3-100. NBC Defense, Chemical Warfare,
AR 40-5. Preuentiue Medicine. 15 October 1990. Smoke and Flame Operations. FMFM 11-
AR 40-35. Preuentiue Dentistry; 26 March 1989. 2. 23 May 1991.
AR 40-46. Control of Heaith Hazards from Lasers FM 8-21. Health Service Support in the Com-
and Other High Intensity Optical Sources. munications Zone. 1 November 1984.
6 February 1974. (Reprinted with basic FM 8-26. Dental Services. 9 September 1980.
including Cl. ) FM 10-14. Unit Supply Operations (Manual
AR 40-48. Nonphysician Health Care Provider. Procedures). 27 December 1990.
3 December 1984. (Reprinted with basic FM 10-14-1. Commander’s Handbook for Prop-
including Cl. ) erty Accountability at Unit Level. 2 Nov-
AR 71-13. The Department of the Army Equip- ember 1984.
ment Authorization and Usage Program. FM 10-14-2. Guide for the Battalion S4. 30 De-
3 June 1988. cember 1981. (Reprinted with basic
AR 380-40. Policy for Safeguarding and Control- including Cl. )
ling Communications Security (COMSEC) FM 10-23. Basic Doctrine For Army Field
Material (U). 1 June 1982. Feeding. 12 December 1991.
AR 385-10. Army Safety Program. 23 May 1988. FM 10-63. Handling of Deceased Personnel
AR 385-30. Safety Color Code Marking and in a Theater of Operations. A-FM 143-3;
FMFM 4-8. 28 February 1986.
Signs. 15 September 1983. FM 10-63-1. Graves Registration Handbook. 17
AR 385-40. Accident Reporting and Records. 1 July 1986.
April 1987. FM 10-69. Petroleum Supply Point Equipment
AR 385-55. Prevention of Motor Vehicle Acci- and Operations. 22 October 1986.
dents. 12 March 1987. FM 19-1. Military Police Support for the AirLand
AR 600-200. Enlisted Personnel Management Battle. 23 May 1988.
System. 5 July 1984. (Reprinted with FM 19-30. Physical Security. 1 March 1979.
basic including C1-15. ) FM 19-40. Enemy Prisoners of War, Civilian
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System. 30 April 1992. ruary 1976.
AR 611-201. Enlisted Career Management Field FM 20-31. Electronic Power Generation in the
and Military Occupational Specialties. 30 Field. 9 October 1987.
April 1992. FM 21-10-1. Unit Field Sanitation Team. 11
AR 630-5. Leaue and Passes. 1 July 1984. (Re- October 1989.
printed with basic including Cl–1 1.) FM 21-11. First Aid for Soldiers. 27 October
AR 700-138. Army Logistics Readiness and Sus- 1988. (Change 1, August 1989; Change 2,
tainability. 16 June 1993. December 1991. )
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and Retail Maintenance Operations. 27 Operations. 12 December 1991.
September 1991. FM 24-1. Signal Support in the AirLand Battle.
DA Pam 738-750. Functional Users Manual for 15 October 1990.
the Army Maintenance System (TUMS). FM 25-100. Training the Force. 15 November
27 September 1991. 1988.

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FM 8-51

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and Separate Brigade Intelligence and Organizational, Technical, and Logistic
Electronic Warfare (IEW) Operations. 12 Data, Planning Factors (Volume 2). 7 Oc-
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FM 100-15. Corps Operations. September 1989. Washington, DC, 1987.

References-4
C 1, FM 8-51

REFERENCES

SOURCES USED DOCUMENTS NEEDED

These are the sources quoted or paraphrased in this These documents must be available to the intended
publication. users of this publication.

ABCA QSTAG *AR 40-66. Medical Records and Quality Assurance
Administration. 31 January 1985. (Reprinted
909. Principles of Prevention and Management with basic including C1.)
of Combat Stress Reaction, Edition 1. 25 *AR 40-216. Neuropsychiatric and Mental Health.
October 1991. 10 August 1984.
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*AR 635-200. Enlisted Personnel. July 1984.
Army Publications (Reprinted with basic including C1–14.)
*DA Pam 27-1. Treaties Governing Land Warfare.
AR 40-501. Standards of Medical Fitness. 1 July 7 December 1956.
1987. (Reprinted with basic including C1.) *FM 8-10. Health Service Support in a Theater of
AR 310-25. Dictionary of United States Army Operations. 1 March 1991.
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(Reprinted with basic including C1.) niques, and Procedures. 29 December 1994.
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Handbook. 1 October 1986. 10 June 1991.
FM 8-10-4. Medical Platoon Leaders’ Handbook— *FM 8-10-6. Medical Evacuation in a Theater of
Operations—Tactics, Techniques, and Pro-
Tactics, Techniques, and Procedures. 16
cedures. 31 October 1991.
November 1990.
*FM 8-10-8. Medical Intelligence in a Theater of
FM 8-10-24. Area Support Medical Battalion— Operations. 7 July 1989.
Tactics, Techniques, and Procedures. 13 *FM 8-42. Medical Operations in Low Intensity
October 1993. Conflict. 4 December 1990.
FM 63-20. Forward Support Battalion. 26 February *FM 8-50. Prevention and Medical Management of
1990. Laser Injuries. 8 August 1990.
FM 63-21. Main Support Battalion. 7 August 1990. *FM 8-55. Planning for Health Service Support. 15
FM 100-9. Reconstitution. 13 January 1992. February 1985.
FM 100-10. Combat Service Support. 18 February *FM 8-230. Medical Specialist. 24 August 1984.
1988. *FM 21-10. Field Hygiene and Sanitation. 22
FM 101-5-1. Operational Terms and Symbols. 21 November 1988.
October 1985. *FM 22-51. Leaders’ Manual for Combat Stress
GTA 21-3-4. Battle Fatigue, Normal, Common Control. (To be published.)
Signs, What to do for Self and Buddy. June *FM 27-10. The Law of Land Warfare. 18 July
1986. 1956. (Change 1, July 1976.)

*This source was also used to develop this publication.

References-1
C 1, FM 8-51

*FM 63-21. Main Support Battalion. 7 August AR 40-535. Worldwide Aeromedical Evacuation.
1990. AFR 164-5; OPNAVINST 4630.9C; MCO
*FM 100-5. Operations. 14 June 1993. P4630.9A. 1 December 1975. (Reprinted
DA Form 1155. Witness Statement on Individual. with basic including C1.)
1 June 1966. AR 40-538. Property Management During Pa-
DA Form 1156. Casualty Feeder Report. 1 June tient Evacuation. BUMEDINST 6700.2B;
1966. AFR 167-5. 1 June 1980.
DA Form 2404. Equipment Inspection and AR 40-562. Immunizations and Chemoprophy-
Maintenance Worksheet. 1 April 1989. laxis. NAVMEDCOMINST 6230.3; AFR
DA Form 2405. Maintenance Request Register. 161-13; CGCOMDTINST 6230.4D. 7 Oc-
1 April 1962. tober 1988.
DA Form 2407. Maintenance Request. August FM 8-8. Medical Support in Joint Operations.
1988. NAVMED P-5047/AFM 160-20. 1 June
1972. (Reprinted with basic including C1.)
DA Form 2408-9. Equipment Control Record.
FM 8-9. NATO Handbook on the Medical Aspect
1 October 1972.
of NBC Defensive Operations. NAVMED
DA Form 2409. Equipment Maintenance Log
P5059; AFP 161-3. 31 August 1973. (Re-
(Consolidated). 1 April 1992.
printed with basic including C1.)
DD Form 2A. US Armed Forces Identification FM 8-285. Treatment of Chemical Agent Casual-
Card. 1 July 1974. ties and Conventional Military Chemical
DD Form 314. Preventive Maintenance Schedule Injuries. AFM 160-12; NAVMED P-5041.
and Record. December 1953. 28 February 1990.
DD Form 1265. Request for Convoy Clearance. 1 FM 31-11. Doctrine for Amphibious Operations.
January 1959. NWP22(B)/AFM 2-53/LFM-01. 1 August
DD Form 1380. US Field Medical Card. (Books 1967. (Reprinted with basic including
consisting of 20 two-part sets.) 1 June C1–3.)
1962. FM 41-5. Joint Manual for Civil Affairs. OPNAV
DD Form 1934. Geneva Convention Identity 09B2P1; AFM 110-7; NAVMC 2500. 18
Card for Medical and Religious Personnel November 1966.
Who Serve In or Accompany the Armed FM 100-27. US Army/US Air Force Doctrine for
Forces. July 1974. Joint Airborne and Tactical Airlift Opera-
DD Form 2163. Medical Equipment Verification/ tions. AFM 2-50. 31 January 1985. (Re-
Certification. 1 November 1978. printed with basic including C1.)
TB MED 507. Occupational and Environmental
Health Prevention, Treatment, and Control
READINGS RECOMMENDED of Heat Injury. NAVMED P-5052-5/AFP
These readings contain relevant supplemental 160-1. 25 July 1980.
information.
Army Publications
Joint and Multiservice Publications
AR 5-9. Intraservice Support Installation Area
AR 40-350. Medical Regulating To and Within the Coordination. 1 March 1984.
Continental United States. BUMEDINST AR 40-2. Army Medical Treatment Facilities:
6320.1D; AFR 168-11; BMS CIR 75-15; General Administration. 3 March 1978.
CGCOMDTINST 6320.8A. 30 March 1990. (Reprinted with basic including C1–2.)

References-2
FM 8-51

Index-1
FM 8-51

Index-2
FM 8-51

Index-3
FM 8-51

Index-4
FM 8-51

Index-5
FM 8-51

Index-6
FM 8-51

Index-7
FM 8-51

Index-8
FM 8-51

Index-9
FM 8-51

Index-10
FM 8-51
29 SEPTEMBER 1994

By Order of the Secretatary of the Army:

GORDON R. SULLIVAN
General, United States Army
Official: Chief of Staff

Administrative Assistant to the
Secretary of the Army
07166

DISTRIBUTION:
Active Army, USAR, and ARNG: To be distributed in accordance with DA Form 12-1IE, requirements
for FM 8-51, Combat Stress Control in a Theater of Operations, Tactics, Techniques, and Procedures
(Qty rqr block no. 4901).