Combat Stress and the Modern Warfighter

This is an article I wrote for a US Special Operations Forces (SOF) training program in 2001, shortly after the beginning of US military action in Afghanistan. Though much has happened in terms of military conflict since those heady days, I believe the the fundamental tenets of men in battle have not changed and that the themes I have drawn out in the article remain just as true today. I have therefore posted it as a blog, in almost its original form.

COMBAT STRESS AND THE MODERN WARFIGHTER

“What battles have in common is human: the behaviour of men struggling to reconcile their instinct for self-preservation, their sense of honour and the achievement of some aim over which other men are ready to kill them. The study of battle is therefore always the study of fear and usually of courage; always of leadership, usually of obedience; always of compulsion, sometimes of insubordination; always of anxiety, sometimes of elation or catharsis; always of uncertainty and doubt, misinformation and misapprehension, usually also of faith and sometimes of vision; always of violence, sometimes of cruelty, self-sacrifice, compassion; above all, it is always a study of solidarity and usually also of disintegration – for it is towards the disintegration of human groups that battle is intended.”- John Keegan, Face of Battle

“ Ninety-five percent of American casualties in wars throughout this century came from "close-combat" units -- aircrews, infantry and armor. So to protect these troops, America needs to take a closer look at how to prepare them for battle”.
This was how the eminently sensible and recently retired Commandant of the US Army War College, MG Robert Scales, began his address to a DOD conference on combat stress a couple of years ago. At the same meeting, Mark Bowden, the author of Blackhawk Down, told the group "stress seems too polite a term for what those men went through. I think 'terror' is a more correct terminology," he said. "I doubt that anything could fully prepare someone for being in that kind of a situation. … the word 'stress' seems too polite a term for it." Bowden explained. "(In combat,) you face a level of terror that no training exercise can really prepare you for.”

I confess to being disturbed by Bowden’s address. He seemed to suggest that all battle is so terrible no man can be adequately prepared; all will be in some way psychologically damaged by it and all will need expert help to fully recover. This is a message supported by a well-meaning industry of contemporary mental health experts. Implicit in this theory is that the modern warfighter, though generally physically stronger and healthier than his forefather, is not as psychologically robust or suited to the rigors of conflict. I do not accept this premise. My experience has been that many men who endured terrible battles never have felt the need to seek out mental healthcare. (Others, whose exposure to the stress of war has been minimal, have spent years on a couch.) I will accept that in many ways the tempo and intensity created by modern weapons systems and the scope for unfamiliar threats, particularly urban and counter-insurgency operations, are increasing the “friction’ of war and putting new and greater demands on our warfighters. But I am not convinced that urban conflict produces markedly greater incidence of combat stress than combat in other environments. It is the intensity of combat and the weapons used that most affects rates of stress casualties. I also know that many of the young men and women I have met in recent years, have shown just as much “fighting spirit” as their forefathers.

"I am content that the opinion that ‘the problem of the psychiatric casualty is much too serious to be left to doctors’ be attributed to me. Soldiers, unable to get bogged down in the morass of diagnosis and treatment, might be persuaded to concentrate on prevention in which doctors have achieved little success " - Maj Gen FW Richardson L/RAMC 1978

I have argued often that man is more important in war than technology and debated the costs and difficulties of recruiting, training and replacing military people as against machines. It is clear to me there is a deliberate shift in modern military healthcare towards the prevention of illness and injury and away from fixing broken bodies. This ethos should also extend to mental health, in peace and conflict. In the context of readiness we must examine more closely what can be done to prevent, or at least limit the worst psychological effects of armed conflict rather than plan for the inevitability of attempting to fix damaged minds and broken spirits.

I have reservations about the current doctrine, which leans heavily on the medical services and particularly on mental healthcare professionals. It argues from a basis that all will succumb. To suggest that the modern warfighter has no defenses against the psychological impact of conflict seems to set him or her up for failure. Moreover, there appears to be little understanding as to what point education and awareness cross into the realm of over-awareness and expectation of, or justification for failure. “Preventive” measures emphasize the psychological and emotional limitations of the individual warfighter and need for early recognition of breakdown. Its center of gravity and resources lie with the Critical Incident Response Team, a necessary and valuable tool but orientated to mitigation rather than prevention. I am not sure I would go as far as one WWII military physician who thought “ psychiatrists were incompetent to judge normal men because their experience is mainly with abnormal ones. I do, however, agree with Major General Richardson, this subject is first and foremost the province of the warfighter. It is an issue of leadership, selection and training and far too important to be left to health professionals of any hue. Having hopefully stirred up an entire medical MOS, I intend to risk their further derision by reverting to some old-fashioned concepts and language to reinforce my argument.


Courage is the essential quality of the warfighter. As it was at Midway and Mogadishu, so it is in Afghanistan and Iraq and other conflicts in the future. It enabled SOF sergeants to storm bunkers in Afghanistan and will permit the young E3 to face up to an angry crowd in Kabul tomorrow. Courage manifests itself in two forms, physical and moral. We tend to emphasize the physical but the moral is often more important, particularly for leaders, yet it is rare a commodity. Many of the criticisms voiced by junior officers and enlisted about their senior leadership tin recent years, concern the need for moral courage. “Moral courage is the most valuable and usually the most absent characteristic in men” – General George Patton.

Physical courage is present in most men and women and it can be enhanced and eroded by a host of external factors. In the final analysis, courage comes down to the power of individual mind over body. Churchill’s personal physician, Lord Moran, in his famous thesis on the First World War defines it as “ a moral quality, it is not a chance gift of nature like an aptitude for games. It is a cold choice between two alternatives; it is a fixed resolve not to quit, an act of renunciation, which must be made not once, but many times by the power of will. Courage is will power” .

In attempting to depict and understand what causes men to succumb to the stress of conflict, there few who have described it more succinctly than Moran “men only have a certain amount of courage in the bank and that the call on the bank may only be a daily drain or it might a sudden draught which threatens to close the account” The key questions are what factors cause this daily or sudden drain and how can the effects be prevented or mitigated.

“Fear is the common bond between fighting men”. – Richard Holmes. The Firing Line
The major drain on a man’s bank of courage is fear; it manifests itself in many forms and is a perfectly natural and defensive reaction to threat or danger. I would argue that Bowden’s use of the word terror is hyperbole. Terror connotes a state beyond control. I don’t think that those he wrote about were ever at point where they lost self-control. In conflict, fear varies in proportion to real or imagined danger. Most warfighters overcome fear by effort of will and the support of others. Recognizing, understanding and controlling individual fear is an essential part of combat stress reduction. Education and training to achieve this is a subtle and difficult challenge. It is however, not the province of mental healthcare professionals, often with no combat experience, to lecture to warfighters about fear in the abstract. This task is a key leadership responsibility and cannot be abrogated to or assumed by the medics. Certain circumstances magnify fear and increase the drain on the bank. I would put the following factors on my list:

Failure. In nearly all men and women, the fear of failing is a deep instinctive force. In some, this fear that they will fail in combat and let their friends down is a real and disabling stress that must be managed by the leader. For many, the fear of failing will drive them to actions that they would not otherwise consider and has driven men to great acts of heroism. The interplay between courage and fear of failure is complex but they appear essential elements of the “fighting spirit”.

The Unknown. The downside of the human imagination is that it is difficult to control. For the warfighter it is at times an essential tool, enabling him to out-think the enemy. At others, it can plague him with doubts and fears to the point of breakdown. This is particularly so when he or she is faced with something new. Fear of the unknown is most marked when a warfighter is alone and especially at night – modern conflict relies increasingly on warfighters operating alone and at night. This requires psychologically robust individuals who are, above all else, well trained.
“What a man has not seen, he always expects will be greater than it really is” - Onasander 1st Century AD

The Unexpected
It is of first importance that the soldier high or low should not have to encounter in war things which seen for the first time set him in terror or perplexity. – Clausewitz
Surprise is a principal of war. Although good training will lessen the chance of a warfighter being presented with something he has not expected, it is highly unlikely that he will never be surprised. History is replete with examples of what happens when warfighters meet the unexpected: their will crumbles. The key lies deeper than learning the enemy’s weapons and tactics. It requires inculcating upon individual warfighters the need to act on their initiative when faced with something unforeseen. This is a principle that SOF have long adhered to and probably what sets them apart from the average warfighter.
Anyone who has been in combat will tell you it is a very noisy affair. War is about destroying the enemy’s will. Noise is very effective in that it limits the ability to think or act. Even at the battle of Agincourt fought between the English and French in the early 15th Century, before the days of gunpowder, the sound of 5000 arrows every ten seconds and the shrieks of dying horses and men were terrible. Being on the receiving end of a dozen modern 155mm artillery rounds is stunning.
Widespread death and destruction in many cases does not affect the individual warfighter as much as the loss of one member of his immediate group. There is little that can be done to prepare the warfighter except meeting and talking with people who have endured and survived. The physical effects of combat serve to increase the drain on the bank of courage. Fatigue, thirst, hunger, disease and above all the climate can reduce the physical state of a warfighter so quickly his “fighting spirit” is broken. Providing logistic support for the warfighter to insulate him or her from the worst is a vital task, but in the final analysis some degree of “combat acclimatization” is essential.

In the face of these challenges, preventing or at least mitigating the worst effects of combat - the draining of the bank of courage - seems more than a little daunting. I offer only three issues for discussion though I know there are many more.

Trust
"His majesty made you a major because he believed that you would know when not to obey his orders."- Prince Frederick Charles
Trust is the basic building block of leadership and vital tool in overcoming the stress of combat. It is a two-way contract, the leader trusts his subordinates and they in turn trust him; it will not succeed in the long-term as a one-way function. It is most powerful when a leader shows complete trust in his or her subordinates. The strength of the German Wehrmacht in WWII lay in the concept of Auftragstaktik. It epitomizes the precept of trusting subordinates. In simple terms it provided leaders at every level with a “commander’s intent”(what had to be achieved and broadly, how) and relied on individual initiative to deal with the unexpected as it arose.
This very successful way of fighting requires an ethos of risk-taking and devolution of responsibility. It is an essential skill in the very complex environment of Counter-Insuregency Operations where often decisions of tactical and even strategic impact have to be taken at the squad level – what the British call “the Corporal’s War”. The contemporary US military is in general a politicized, risk-averse organization, shaped by doctrinaire field manuals on every conceivable subject and, through the medium of modern IT, over-controlled from the top down. It is highly unlikely that the freethinking, risk-taking, confident young E3 or lieutenant will blossom in this environment. SOF, who pride themselves in the practice of freethinking must strive to maintain independence of thought and action at every level.

Training
“Training had come to an end. There had been twenty-two months of it, more or less continuous. The men were as hardened physically as it was possible for humans to be”. 'Band of Brothers', Stephen Ambrose

There are two generally accepted verities in combat stress management. First, although personnel selection methods can weed out those manifestly unsuited for combat, selection is notoriously unreliable. Second, even the best prepared, equipped and motivated warfighters will eventually ‘empty their bank of courage” if they are subjected to enough stress. (Studies carried out in WWII showed that after 90 days of continuous combat even the best fighters began to deteriorate rapidly). Training therefore has two vital functions in combat stress reduction. It acts as a continuous selection system to further weed out the unsuitable; and it prepares the remainder, mentally and physically, for the demands of combat. But training is only of any value if it is realistic. Within the limits of reasonable safety, it must be both physically and psychologically demanding. It must train and test the individual but also, perhaps more importantly it must test the group or team. Good training will always impact the team and make it stronger. Lack of training and poor preparedness will bring disaster. In his book Band of Brothers Stephen Ambrose describes how the men of Easy Company the 506th, who jumped behind Omaha Beach on DDay were at their peak and almost invincible. In their twenty-two months of training their battalion had gone through 5000 enlisted soldiers to produce 1500 fit for battle. Compare them to the US Army only eight years later in Korea. T. R. Fehrenbach writes, “ the Army of 1950 was physically untrained for combat tasks, emotionally unprepared for its stresses. They had to learn in the hardest school there was, that it was a soldier’s lot to suffer and that his destiny may be to die. They were learning something that they had not been told: that in the world are tigers”. Whatever else the current operations in Afghanistan produces in terms of attrition of the enemy, it is the finest training available.

Teams
“They knew and trusted each other…they made the best friends they had ever had or would ever have. They were prepared to die for each other, more importantly, they were prepared to kill for each other”. - Band of Brothers

History shows that the strongest motivation for enduring combat is the bond formed among the members of a squad or the crew of a weapon system or aircraft. Simply put, warfighters fight because of the other members of their small unit. Most warfighters value honor and reputation more than their lives, because life among comrades whom a
warfighter has failed seems lonely and worthless. The cohesion found in small teams provides shelter from the horrors of battle and enables warfighters to persevere in combat. The team provides the individual with security, the belief that that danger can be overcome, a coping mechanism to deal with the trauma of death and killing and a sense that what the team is doing has meaning. J. Glenn Gray, in his book 'The Warriors', described the real value of the team as both the essence of combat and the key to mitigating stress. “Soldiers have died more or less willingly, not for country or honor, or religious faith or other abstract good but because by fleeing their post and rescuing themselves they would expose their companions to great danger. Such loyalty to the group is the essence of fighting morale”.

Conclusion
I believe there is an urgent need to re-examine the way we deal with the stress of modern combat. The issue is not that contemporary operations will necessarily increase the incidence of stress, it is the way we are planning to deal with the issue. It is dangerous predicate our thinking on the expectation that the modern battlefield will be so overwhelming all will succumb and that the medics will be required to mend huge numbers of broken minds and shattered spirits. There is a clear role for the medic in managing combat stress but it should not be the first line of attack. I believe today’s warfighters are just as robust as their forefathers. With the right training and leadership they will equip themselves every bit as well. The key will be how much we trust them, how well we train them and above all, bonding them together in teams and taking every possible measure to keep them together.