Combat Stress

“ A soldier’s courage must be reborn daily………The most important task of leaders is to understand how to care for and to prepare soldiers before battle, and to use tactics during battle which recognize that courage must be renewed.” – Marshall De Saxe 18th Century

The art of war aims to impose so much pressure on the enemy soldiers that they lose their will to fight. Of course both the opposing parties try to do this and at times accept severe stress themselves in order to inflict greater stress on the enemy. To win the war, combat stress must be controlled …….. to overcome fear in the face of battle.

What is combat stress? Combat stress is a natural result of heavy mental and emotional work, when facing danger in tough conditions. Like Physical fatigue and stress, handling combat stress depends on the level of one’s fitness and training. It can come on quickly or slowly, and it gets better with rest and replenishment. Many soldiers experiencing combat stress still function normally. The following are normal and common signs of combat stress:

Ø Tension head and back ache, trembling, fumbling and jumpiness
Ø Pain in old healed wounds before combat
Ø Pounding heart; rapid breathing
Ø Upset stomach; vomiting; diarrhea; frequent urination
Ø Emptying bowels and bladder at the first sign of danger
Ø Fatigue; weariness; distant and haunted (1,000 yard) stare
Ø Anxiety, worrying, irritability, swearing, complaining
Ø Awakened by bad dreams; grieving; feeling guilty
Ø Anger at own team; losing confidence in self/unit

History of Combat stress.
Combat stress started since man become in conflict with each other. In all wars and battles combat stress is always there. Informally, man felt and experience combat stress, but not after World War I that man made a scientific interpretation and approach to it when the French and the British discovered that if stress casualties were evacuated far to the rear, many became chronic psychiatric cripples. If treated quickly close to their unit, most recovered and returned to duty.

The experience of World War I; however, was easily forgotten between wars. It had to be rediscovered in World War II (WW II) after several disastrous experiences when large number of psychiatric casualties was over-evacuated in the early battles. By late WW II in the European and Mediterranean theaters, all Divisions provide a provision in recognizing and treating combat exhaustion or battle fatigue cases.

In the WWII Mediterranean and European theaters, the average incidence of combat exhaustion casualties was one case requiring medical holding and treatment for every four wounded in action (1:4). On the Gothic line in Italy, the 1st Armored Division suffered 137 combat exhaustion casualties for 250 WIA (1:1.8 ratio). Overall, with the correct tre3atment, 50 to 70 percent returned to combat within three days and most of the remainder returned to useful duty within a few weeks.

In the Battle of Okinawa, the 6th Marine Division suffered 1,289 combat exhaustion casualties out of 2,662 WIA with a ratio of 1:2. Many of these cases were evacuated to Navy ships offshore and few of those cases ever returned to duty.

In the Pacific theater in WWII, all WIAs are found to have neuropsychiatric disorder. They appeared psychotic (bizarrely out of touch with reality). It was found out that the stressors in these cases were combination of isolation, monotony, boredom, chronic discomfort, low-grade illness from environment, fear of disease, injury and surprise attack. In retrospect, it was realized that evacuating this bizarre stress reaction cases home only encouraged more soldiers to “go crazy” when they temporarily reached their limit of tolerance to stress. It would have been better to send them to rest camps close to their units.

It was also shown in WWII that tough training and Esprit de Corps prevented many battle fatigue casualties. Elite units, such as the Rangers and airborne units, had less than one (1) battle fatigue casualty for every ten (10) WIA. This unit cohesiveness prevailed even in combat assaults, such as Normandy and Arnhem, where extremely high casualties were suffered. Unit cohesiveness also prevailed during prolonged fighting like the Battle of the Bulge.

During the Yom Kippur War in 1973, the Israeli experience confirmed the risk of stress casualties in the modern, high-tech and continuous operations (CONOPS) battle. Israeli estimates of stress casualties suggest that large number of Israeli soldiers, including veterans and leaders, became unable to function because of stress. Stress casualties were frequent in Golan Heights fighting in the initial defense of Sinai, and during the re-crossing of the Suez Canal. Since the Israeli defense force had no plans for treatment of these cases, all such cases were evacuated to hospitals in Israel and many of these Israeli soldiers who were evacuated remain psychiatrically disabled today. After the war, the Israeli instituted a model program for leadership and mental health support purposely to prevent and treat battle fatigue cases. However, in 1982 Lebanon invasion, many cases were inadvertently evacuated by helicopters to Israel in the initial haste of the invasion. Few of these cases were able to return to duty while 60 t0 80 percent of those treated in Lebanon did.

Lessons learned from past wars were very well taken in Vietnam. There are a lot of battle fatigue casualties noted especially after the war; however, the percentage of these cases did not exceed 10 percent. The dramatic decrease in percentage was attributed to the sporadic nature of fighting, air and artillery superiority, well-supplied firebases, scheduled rest and recuperation (R&R) and fixed combat tour.

Other behavioral problems related to loneliness and frustration, however were associated with combat stress in Vietnam. Serious incidents of poor discipline occurred, including commission of atrocities at My Lai. (March 1968), combat refusal and even “fragging” (Murder) of leaders. By 1970-1971 when US ground forces were rarely committed to offensive operations, “neuropsychiatric” casualties especially drug and alcohol abuse and addiction became epidemic which accounted 60% of the medical evacuations from the theater. Today those misconduct problems are recognized as having contributed to the incidence of delayed posttraumatic stress disorder (PTSD) in Vietnam veterans.

The Philippine experience
As far as historical records are concerned, the Philippines experienced war and intense battles since Magellan landed in Mactan in 1521. For centuries the Filipinos have fought countless battles against the Spaniards, the Americans and the Japanese to include our participation in the Korean War. For several decades also, we fought the Muslim secessionist movement in Mindanao where our soldiers of several generations fought in the same place and with the same enemy. Likewise, the communist insurgents, which reached its zenith of glory in the mid-80s, weakened in the 90s and held on up to the present, continuously give the Army a stinging pain on the neck. Thousands of soldiers and thousands of officers have participated in thousands of battles that made the Filipino soldiers one of the experienced and battle tested solders in the world. It is just very sad to note however, that after those thousands of battles, our officers and men were overwhelmed by the glory and chaos and apparently did not give a damn to that abhorred thing called combat stress. With the present trend, it is my approximation that Filipino soldiers will still fight the same kind of battles for generations to come and if combat stress is not considered in our doctrine development, our grand, grand children will repeat history and suffer the same fate as ours.

Effects of Combat Stress
A unit is not be capable of performing its mission adequately if soldier resources are depleted because:

● Vigilance deteriorates.
● Determinations and calculations become inaccurate.
● Reports become faulty.
● Decisions become slow and inaccurate.
● Orders are misunderstood/forgotten.
● Weapons are misused/underused.
● Maintenance and preplanning are forgotten.
Controlling combat stress is often the deciding factor-the difference between victory and defeat-in all forms of human conflict. Stressors are a fact of combat and soldiers must face them. It is controlled combat stress (when properly focused by training, unit cohesion, and leadership) that gives soldiers the necessary alertness, strength, and endurance to accomplish their mission. Controlled combat stress can call forth stress reactions of loyalty, selflessness, and disrupts or interferes with accomplishment of the unit mission. Uncontrolled combat stress could impair mission performance and may bring disgrace, disaster, and defeat.

Armies have known for centuries about the positive effects of stress in preparing soldiers for combat. In old-style basic training (prior to 1970), the drill sergeant deliberately made himself more fearsome than death itself so that the trainee would learn to respond automatically, even in a state of terror. That technique is not useful today because modern war requires more small unit cohesion, trust between leaders and those led, and initiative even on the part of the junior enlisted soldier. The modern drill sergeant must, instead, require the trainees to meet difficult (stressful) standards and work with the trainees to assure that they master them. The result is a well-earned sense of confidence in self, comrades, and leaders that can be applied to future demands.

Airborne and air assault training are just intended to teach the skills needed to arrive on a battlefield after jumping from a low-flying aircraft or repelling from a helicopter. Their greater value comes from requiring soldiers to confront and master their extremely strong, instinctive fear of heights under circumstances, which are deliberately stressful at the time. During training, this fear builds self-confidence and a sense of special identity on completion. (In fact, the training itself is not exceedingly dangerous, statistically speaking. However, the possibility of death does exist if you are extremely unlucky or fail to do the task correctly. This can contribute to additional stress).

Ranger school is a clear example of the recognition of the benefits of positive stress. A generic ranger course objective would read: Perform complex and difficult physical and mental task under great pressure, sleep loss, water and food deprivation, and physical fatigue. No one coasts through ranger school. If anyone seems to be coasting through, the trained ranger cadre will increase the demand on that person until he, too, reaches the stage of stress where he realizes he cannot get through it all alone. Ranger school teaches small teams and their rotating leaders how to control stress in all the team members so the team accomplishes the mission. The training gives the individual soldier confidence, but even more, an awareness of how stress works in oneself and others. It teaches stress control, not stress reduction. Often the need for the team and its individual members is to play different mental and physical stressors against each other. This is done by increasing some stressors while decreasing others to keep the team on its mission and to keep individual soldiers from giving up.

To some degree, acclimatization to mental (cognitive/emotional) stressors also shares that “use it or lose it” feature which is true for adaptation to physical stressors. The airborne qualified trooper may experience more unpleasant stress symptoms when jumping after not having jumped for many months. The physician may find the stress unexpectedly higher when performing a potentially risky patient-care procedure that was once so frequently practiced that it had seemed to involve no stress at all but which has not been performed for some time. However, the memory of successfully mastering the stressor in the past usually speeds up the return of adaptation.

Tolerance to mental stressors is increased by successfully facing and mastering similar stressors (just as tolerance to physical stressors is). However, being overwhelmed by emotional or mental stress may temporarily or permanently impair future tolerance (just as exceeding the ability to cope with physical stressors may). Up to a point, mental stress (even uncomfortable mental stress) may increase tolerance to future stress without any current impairment. A higher level may cause temporary overstrain but may heal as strong or stronger that ever with rest and restorative processing. More severe overstrain, however, may permanently weaken tolerance to future mental stress. As with some cases of damage from physical stress, the harm done by mental stress may not be apparent at the time. It may only be apparent later.

Combat Performance and Combat Stress
The Green Soldier During the first time in battle for soldiers, their combat performance is usually lower than it was in pre-combat training. The novice soldiers are also at relatively high risk of being killed or wounded. This is partly because they have not yet learned to identify and respond automatically to the true dangers (such as the specific sounds of incoming artillery or mortar rounds). Under extreme stress, they may experience difficulty with focusing their attention and remembering what they were taught in training. Their ineffectiveness may also be caused by fear-induced fatigue. First-battle soldiers are at high risk of becoming battle fatigue casualties. Soldiers in their first time under fire are likely to experience high anxiety (the stages of alarm). Poor showing on first exposure to real battle can be reduced by providing tough, realistic training (especially battle drills under high stress), but it cannot be totally prevented.

The Experienced Veteran. If the soldier does not become a casualty in the first battle, his combat skills will improve quickly over the next few days. His skills continue to improve gradually over the next weeks until he is good as he can get. An experienced soldier gains confidence in his skill, comrades, and leaders. For him, the stage of alarm is mostly in anticipation. He responds selectively and automatically to the truly dangerous sounds and cues of the battlefield. When the action starts, he immediately achieves the stage of resistance and is remarkable calm as he focuses on his job. However, the veteran is likely to have a considerable rebound of arousal and anxiety when the fight is over. Not all veteran soldiers ever achieve the state of really low fear in action. Some drop to mid levels, yet still perform their duties effectively.

The Overstressed Veteran. If the unit suffers many casualties, however, and the chance of surviving a long war seems poor, the experienced soldier’s combat performance begins to decline. It can occur after 14 to 21 days of cumulative combat or even after only a few days of extremely heavy losses. The overstressed veteran becomes more careful, loses initiative, and may be indecisive when he needs to act quickly. The anxiety pattern of an overstressed soldier doubts his chances of survival – there were too many close calls in the last battle; too many of his friends were killed (slowly over time or quickly). Under such stress, he feels his own skills are slipping, and it is just a matter of time before he, too, will surely be killed or maimed. Unless he is given the opportunity and help to reduce arousal level and regain some hope, he will soon fail.

Anxiety fear and arousal different stages in combat tour.

Combat skills and high stress tolerance are maintained when frequent successful combat actions occur. If losses in the unit remain low, the veteran can maintain his optimal combat skills for many months. If there is a prolonged cease-fire or if the skilled soldier leaves the combat zone on individual R&R, there may be a brief drop in performance on his return to battle. That drop would be accompanied by a return of the anxiety pattern shown by new soldiers but the anxiety is much briefer. This would be like the anxiety felt by the airborne qualified soldier who is making a jump after not having done so for many months. Predictably, the experienced veteran will regain his combat edge quickly upon returning to battle.

Decline of Combat Skills. How quickly performance declines will usually be related to how many casualties have occurred and how close the soldier was to them (both physically and emotionally). The decline may be hastened or slowly by leadership, unit, scenario, and home front factors.

Restoration of Combat skills. Rest and recuperation, preferably with other soldiers in the unit, can substantially restore combat proficiency. Rest would also substantially return the anxiety pattern to that of the experienced veteran. This recuperation can be accomplished with the help of the medical and combat stress control/mental health personnel at a medical restoration or reconditioning facility.

Combat Stress Behaviors
Positive Combat Stress Behavior. Positive combat stress behaviors include the heightened alertness, strength, endurance, and tolerance to discomfort which the fight or flight stress response and the stage of resistance can produce when properly in tune. Examples of positive combat stress behaviors include the strong personal bonding between combat soldiers and the pride and self-identification, which they develop with the combat units history and mission (unit esprit). These together form unit cohesion-the binding force that keeps soldiers together and performing the mission in spite of danger and death. The ultimate positive combat stress behaviors are acts of extreme courage and action involving almost unbelievable strength. They may even involve deliberate self-sacrifice. Positive combat stress behaviors can be brought forth by sound military training (drill), wise personnel policies, and good leadership. The results are behaviors, which are rewarded with praise and perhaps with medals for individual valor and/or unit citations.

Battle Fatigue.

Battle fatigue is also called combat stress reaction or combat fatigue. Those battle fatigue behaviors, which are listed near the top may accompany excellent combat performance and are often found in heroes, too. These are normal, common signs of battle fatigue. Those that follow are listed in descending order to indicate progressively more serious or warning signs. Warning signs deserve immediate attention by the leader, medic, or buddy to prevent potential harm to the soldier, others, or the mission. Warning signs do not necessarily mean the soldier must be relieved of duty or evacuated if they respond quickly to helping actions. However, soldiers may need evaluation at medical treatment facilities to rule out other physical or mental illness. If the symptoms of battle fatigue persist and make the soldier unable to perform duties reliably, then medical treatment facilities, such as clearing station and specialized combat stress control teams, can provide restorative treatment. At this point, the soldier is a battle fatigue casualty. For those cases, prompt treatment close to the soldier’s unit provides the best potential for returning the soldier to duty.

Misconduct Stress Behaviors.
Examples of misconduct stress behaviors range from minor breaches of unit orders or regulations to serious violations of the Uniform Code of Military Justice (UCMJ) and perhaps the Law of Land Warfare. As misconduct stress behaviors, they are most likely to occur in poorly trained, undisciplined soldiers. However, good, even heroic, soldiers under extreme combat stress may commit these misconducts. Misconduct stress behavior can be prevented by stress control measures, but once serious misconduct has occurred, it must be punished to prevent further erosion of discipline. Combat stress, even with heroic combat performance, cannot justify criminal misconduct.

Stressful Environment
We usually undermine the stressful situations our soldiers experience in the field and we rely so much on the native talents of our combat leaders to minimize the damaging effect of combat stress. We tend to push our troops to their limits to project tough and “macho” image without considering that the mere continuous presence of our soldiers to hostile environment, is a very stressful experience and could dwindle performance. Our combat soldiers usually sleep on hammocks not only for months but years. After a stressful combat operation, our soldiers who suppose to relax and rest, returns to his hammock still on alert, embracing his loaded rifle in preparation for possible enemy harassment. His constant visitors are rain, strong winds and storms that usually attempt to snatch away the remaining comforts that his hammock could offer. With a stick of local cigarettes he attempts to warm his body by inhaling all the smoke into his lungs to collect all available heat he could. Using his poncho, he collects water from the rain to have drinking water and extra water to cook their meals. With all the firewood wet he sacrifices his slippers to prime the wet firewood. Without washing his hands in order to conserve potable rainwater, he gormandizes the half cooked rice mixed with canned sardines spread over the banana leaves. As the night falls he receives the password and the guard detail from his team leader and goes back to his priceless hammock, go inside his “Malong” and dream of the comfort, food, warmth, his children and his wife. Tired like hell, he sleeps with his last thoughts lingers on to his “home sweet home”. His precious nights are continuously haunted by bad dreams that keep him awake and uneasy through the rest of the night.

Morning comes and his team leader briefs the team of an upcoming combat operations. They will be confronting hundreds of fully armed enemies. He feels the danger and could see the fear in the eyes of his neophyte teammates. He says a fervent and short prayer and wonders who among his comrades will soon be wrapped with poncho after the operations. He further wonders who of them will be seriously wounded and eventually be amputated. His imagination wanders further to the extreme of possibilities and could imagine the discontented wife abandoning an amputated husband.

Blood and splattered brain is his first sight upon the first burst of fire. Looking the enemy directly on the eyes he empties his magazine on the enemy two meters away from him. Flesh are scattered around as 7.62mm slugs rip and shred the soft enemy body organs while the enemy grasps his last breathe. The conscientious Christian soldier can’t believe he has killed a person and an internal conflict between reality and his religion develops within him. Suddenly he heard one of his comrades shouts harshly for help. He dashes towards his teammate and is shocked to see a comrade soaked with blood with both feet totally disintegrated by the shrapnels of a homemade landmine. He tried hard to offer comforting words that everything would be fine but his buddy knows better - he would not last long. Trying to catch his remaining breaths, and with eyes flickering, the wounded comrade brings out his wallet, gives his address and relays all his last wills, begging him to promise to take care of his wife and children. He is so overwhelmed by the tragic scene and temporarily lost in touch with reality as his comrade dies crying on his arms. He sits still and remains hugging his comrade until the battle dies down and reinforcement comes.

He couldn’t sleep for days thinking of his comrade and ponders on the possibility that it could happen to him soon or in one of the future operations. He even contemplates and doubts the possibility of seeing his family again. In as much as he wanted to go home as soon as possible, he waived his scheduled R&R due to financial constraint and opted to send his cash in hand to his family. As he counted the days, months and years in the field with the same monotonous activities, he is forced to be contented to meet his family only twice a year. Considering his sacrifices, he is even considered luckier for surviving the hostile condition in the field without overt signs of psychological instability. Several of his comrades however, landed on our field hospitals after displaying dangerous signs of combat stress. Our field hospitals usually send combat stress casualties to AFP Medical Center specifically to Ward 24 and 25. After several months however, because of the reputation of the hospital ward that took care of them, instead of feeling better, patients suffered more isolation, indifference, coldness, distrust, mockery and even ridicule from other soldiers and civilians.

Observations and Lamentations
At this point, I can’t help but express some personal regrets for not being endowed with excellent narrative skills to give a clearer and more realistic picture of a stressful combat environment. The situation narrated above is a gross understatement of the stressful combat scenario and how I wish I could do better.

It is my personal observation that few of our combat commanders in the field appreciate combat stress management. They always invoke their overused line, “During our Time”, which discourages new ideas and stagnates our system into traditional way of soldiery. Our soldiers knowing what happened to their comrades after severe combat stress ailment, would usually question the necessity of those sacrifices while their commanders accused them of refusing to fight or lacking aggressiveness in combat. It is quite unfair to our soldiers because it is the commander’s responsibility to renew their courage and prepare our soldiers psychologically and physically for combat.

Looking back in history, it took the Americans a couple of World Wars to figure out the necessity to address combat stress. While it is generally accepted argument that the Philippines is 50 to 100 years behind the US, it is foolish to wait the same length of time to appropriately address combat stress in our own Army. It can’t be denied that Filipino soldiers are considered as one of the seasoned fighters in the world, their gallantry are irrefutable and their tolerance to combat stress is high; however it is an unquestionable fact that our soldiers are just humans having definite limits. According to Ardant Du Picq, a 19th century French Officer and a student of men in battle, “War is fundamentally a contest of wills fought by men, not machines. You can reach into the well of courage only so many times before the well runs dry.” Ardant Du Picq recognized human limitation as well as the need to do something on our soldier’s psychological state to renew their courage and toughness. As early as 18th century, known military officers and thinkers acknowledged the fact that every soldier has his own breaking point. It may differ in intensity among individuals but one thing is definite, everybody has to break somewhere.

Our soldiers could be rated excellent as far as his military service and professionalism are concerned, but we somehow failed to see that these soldiers have wives and children, waiting and expecting a normal father and husband when they come home. After a stressful stint in the field, will these combat stressed soldiers be normal fathers and husbands when they come back to their family? Definitely, only a few combat stressed soldiers go home without abnormalities in actuations, temper and habits. Is the Army contributing to the rampant family collapse in our society? Are these sacrifices purely part of military professionalism or the Army just doesn’t care?

Perhaps, it is time for us to realize that we could never retain quality soldiers in our ranks if we don’t really care for them. Personnel with exceptional talents and skills would rather venture for greener pasture outside the Army than remain inside knowing that the Army doesn’t really care for them. This lamentation is perhaps very timely, as the Army is fast-tracking its doctrines development, to somehow consider combat stress management in the Philippine Army Doctrine.


(Ideas, facts and graphics are lifted from USFM 22-51, Leader’s Manual for Combat Stress Control” at Internet web page http://www.vnh.org/FM22-51/07fm2251.html)