The Pentagon has issued a directive that intensifies the role of mental health providers in combat zones, a move that boosts the preventive care psychologists are able to provide in the world's military hot zones, where today's stressors are less likely to be caused by violence and casualties than by environmental stressors such as the weather, terrain and living conditions.

The move began with the Army, which has nearly 40 psychologists in its Combat Stress Control (CSC) units. Meanwhile, the Air Force has assigned 35 psychologists to its Mental Health Rapid Response teams. Some of these units are helping service members deal with the chaotic environments they face overseas in places like Bosnia and Kosovo, where mud and rain can cause unsanitary conditions that provoke anxiety, and the sights of extreme poverty can cause stress.

Psychologists are traveling to such military zones to help, and more are expected to be deployed in the future, since the Department of Defense (DoD) issued the Combat Stress Control directive in February 1999. The directive calls for mental health professionals to deliver services on the front lines with physicians. The mental health units typically have a psychologist, social worker and several mental health technicians. Some units have a psychiatrist, psychiatric nurses and occupational therapists.

"The directive represents a significant and positive direction for psychology because it gets psychologists in more real-world settings," says research psychologist Lt. Col. James Griffith, PhD, past-president of APA's Div. 19 (Military). "It allows psychologists to treat more than tertiary symptoms of combat stress reactions and provides a mandate for psychologists to develop and implement buddy and unit supports and organization configurations to prevent the occurrence of such stress reactions."

Of course, the greatest benefit is to military personnel, says Lt. Col. Kevin P. Mulligan, PsyD, chief consultant to the Air Force Surgeon General for clinical psychology. "Rather than waiting for service members with full-blown post-traumatic stress disorder to walk in the door, psychologists are going into the units and doing prevention work to help them before there are problems," Mulligan says.

Frontline treatment

Under the directive, service members are treated for combat stress as close to the operational front as possible instead of being evacuated to a military base in Europe or back to the United States.

"If people are treated on the front lines with the expectation that they will go back to duty, they usually recover," says Lt. Col. E. Cameron Ritchie, MD, a psychiatrist and program director of mental health policy and women's issues in the Office of the Assistant Secretary of Defense (Health Affairs) Clinical and Program Policy at DoD. "But, if we evacuate them away from their unit, their psychiatric symptoms tend to last."

The treatment outlined in the directive is based on six principles:

  • Brevity. Treatment is usually less than 72 hours.

  • Immediacy. Service members receive help as soon as they experience symptoms such as tremors, nightmares and headaches.

  • Centrality. Treatment calls for solders evacuated from the combat zone to be screened at a central location from which they may be returned to duty if departure is deemed inappropriate.

  • Expectancy. Service members are expected to return to active duty.

  • Proximity. Treatment is at the front or as near to it as possible.

  • Simplicity. Basic measures such as rest, food, hygiene and reassurance are provided.

Proximity and immediacy are particularly important, says Ritchie, because the bonds between service members can be weakened when soldiers are evacuated.

Time away from the unit also allows soldiers to rationalize their symptoms. A service member, for instance, may start thinking, "If I'm not sick, then I'm a coward and I abandoned my buddies. I can't accept being a coward, therefore I'm sick."

One way to counter this is to explain that symptoms, such as sleeplessness and depression, are normal reactions to abnormal events and other members of the unit are having similar responses, says Ritchie.

The directive also calls for mental health professionals to provide for critical event debriefings after any exceptionally stressful situation such as the death of a unit member. The debriefing allows members to talk about what happened, correct any misperceptions about the event, discuss lessons learned and find out how to get help if they continue to feel anxious.

For instance, to head off any long-term problems Maj. Erin Wilkinson, PhD, debriefed soldiers after a fatal helicopter crash in Albania killed two service members during training exercises for the Kosovo conflict in 1999. The debriefing helped service members reconcile their feelings of anger, says Wilkinson, commander of the 254th CSC detachment.

"If there's a war, you expect casualties but if it's a training mission, you expect people to come home at night," she says.

She also debriefed the rescue workers who had to clean up the crash site, often handling the body parts of dead soldiers. "We talked about what they saw, what they smelled, what type of job they were doing," she says.

As part of the directive, mental health professionals also offer stress inoculation before service members go overseas. For example, service members going to Kosovo are told to prepare for the smell of urine and dung, and the sight of mass graves and bombed out roofs.

"By preparing them for the trauma in advance, it can lessen their reaction," says Ritchie.

Lessons learned from past wars

The Pentagon's plan is based on lessons learned during World War I, World War II and the Korean War.

"The United States learned the basic principles of combat stress casualty management from its British and French allies before entering World War I," says Col. James W. Stokes, MD, combat stress actions officer, Army Medical Department Center and School. "But we forgot those lessons and relearned them the hard way in World War II."

At the beginning of World War II, the military sent large numbers of soldiers back to the United States as psychological casualties. Given that a tenth to a half of war casualties are psychological, losing that many soldiers seriously hampered the military's ability to fight because there were fewer soldiers able to serve overseas, says Ritchie.

During the Korean War, clinical psychologists served alongside psychiatrists and social workers in every Army division's Mental Health Section, says Stokes. Army, Navy and Air Force psychologists served in the Gulf War and advanced with troops into Kuwait and into Iraq during the ground campaign.

Under today's directive, says Stokes, "we now have recognition at many levels that psychologists and other mental health personnel are important."

The military's data show that 70 to 90 percent of service members are returned to active duty within a few days when CSC units treat them at the front.