Military Confronts Combat Stress at Front Lines

Everyone in a combat zone experiences some degree of stress, Army Maj. Dara Josiah-Howze, a psychiatrist with the 55th Medical Company (Combat Stress Control) in Baghdad told the American Forces Press Service. "You have a normal person in an abnormal environment, and you're exposing them to abnormal situations."

When the Iraq operation began two years ago, the biggest source of stress was the combat operations, she said. Now it's the more elusive threats-improvised explosive devices, vehicle-borne IEDs and suicide bombers, among them.

Symptoms run the gamut, Josiah-Howze said, from eating and sleeping disorders to irritability or anxiousness. Some people startle easily; others demonstrate low energy levels or wake up with nightmares. Others have trouble maintaining focus or following through on a project or just feel generally down, she said.

Army Col. Thomas Burke, DoD director of mental health policy in Washington, said troops have experienced these symptoms throughout American military history. During the Civil War, they were called "nostalgia" or "soldier's heart," he said. During World War I, the affliction was "shell shock" and during World War II, "combat fatigue" or "battle fatigue."

Today, these symptoms are called "combat and operational stress reactions," the result of the extreme stress troops are exposed to in combat as well as the unpredictable counterinsurgency operations currently taking place in Iraq.

Sleep deprivation during extended operations, exposure to noise, heat or smoke and the danger of being hurt or killed or seeing others get hurt or killed, "all take a toll on a person's mental state," Burke said.

But this doesn't mean affected troops are mentally ill, Burke stressed. "What they are experiencing is a normal human reaction to an abnormal situation," he said.

And experience and research proves that the best way to treat these troops is to offer care as close to their units as possible, rather than "labeling them as broken" and evacuating them from the region. The latter approach actually puts them at higher risk of developing longer-term problems, Burke said.

"The whole approach to mental health is different than it once was," he said. "We're not pulling people out of line and sending them back to the states. Now the philosophy is to treat these symptoms early, treat them far forward, treat them aggressively, and get these soldiers back to their jobs."

This proactive, preventive approach to treatment keeps troops as close to their unit as possible so their friends and chain of command can maintain contact with them until they return to duty. And the treatment offered is relatively simple: sleep, rest and workshops rather than elaborate psychoanalyst techniques and procedures, Burke said.

"We refer to it as PIES," he explained. "Proximity, as close to the unit as possible. Immediacy, providing treatment now, not evacuating them to the rear and treating them in a week. Expectation, maintaining the assumption that they will return to duty. And simplicity, keeping the treatment simple."

Combat stress control teams are fanned out throughout Iraq to provide mental healthcare to servicemembers experiencing combat and operational stress reactions, and to help prevent others from developing them. In addition, behavioral health teams are embedded in units in Iraq as well as Afghanistan.

Much of the mobile teams' focus is on prevention. They educate servicemembers and their chains of command about symptoms of combat and operational stress reactions, self-help techniques and exercises they can use to counter these reactions, and professional services available to help them.

Troops who request it or appear to need extra help are typically referred for "restorative care," Josiah-Howze explained. This care, offered at fixed locations, is generally limited to 72 hours and includes more intensive stress and anger management, relaxation training and counseling through individual and group sessions.

During their unit visits, combat stress teams emphasize that nobody is immune to combat stress, regardless of their rank or position in the unit. "It affects everyone," said Josiah-Howze. "We've treated everyone from the single teenager to senior officers."

Josiah-Howze said she's convinced that treating combat stress quickly and in the environment can help prevent the condition from evolving into more serious acute stress or post-traumatic stress disorders.

"Through the years, the military has realized that if you wait too long (to provide care), it can have negative effects," she said. "The best way to deal with the issue is to keep (the affected troops) in the environment and to address the problem then and there."

This approach will likely reduce the number of soldiers who will need Veterans Affairs Department mental health services later on, she said, and has the immediate advantage of keeping military units intact during their operations.

Our motto is to "Conserve the Fighting Spirit," Josiah-Howze said. "We're not here to remove soldiers," Josiah-Howze said. "We're here to help them with the problems they're having so they can return to their units and keep fighting."