Combat stress - American view

May 30, 2005: It’s no secret that combat casualties have been lower in Iraq than in any other American war, even after adjusting for the number of troops and the amount of combat endured. It’s been more difficult to determine if combat fatigue casualties have been lower as well. Unlike physical wounds, combat fatigue is largely invisible. Unless a soldier becomes catatonic, or otherwise incapable of fighting, it’s hard to tell who has combat fatigue, and to what degree. This is because combat stress, for most people, is just another form of stress. Troops who have been through a lot of combat have, for centuries, been described with terms like “battle weary.” For thousand of years, insightful commanders could recognize this, and do something to “raise morale.”

In the last century, combat fatigue has been studied intensively, and techniques have been developed to detect it, and deal with it. There were compelling reasons for this, mainly because the intense combat of the World Wars (1914-45) often created situations where half, or more, of the wounded were down because of combat fatigue.

Treatment methods, which are best applied quickly, and within the soldiers unit, were eventually encapsulated in two easy to remember terms; “The Four Rs” and PIES. The Four Rs were Reassurance of a quick recovery (from a trusted NCO or officer), Respite (from combat, for a few hours or days, depending on how fatigued the soldier is), Replenishment (physical comfort, which could be anything from a cold drink of water, to a meal, relief from extreme cold or heat, or just an opportunity to get some sleep), and Restoration of perspective and confidence through having someone the soldier knows talk to him, followed by gradual resumption of work (usually some training, which troops in combat zones continue to do, but any regular military activity will do.) The PIES represents further guidance on how to implement the four Rs. PIES stands for, Proximity (implement treatment on the spot, within the soldiers unit, if possible), Immediacy (begin treatment as soon as possible once combat fatigue has been detected), Expectancy (assure the soldier that the treatment will work, which is something most troops are eager to hear), and Simplicity (don’t get complicated, simple treatment methods are the most effective.)

Getting NCOs, officers, and the troops themselves, to recognize the symptoms, and implement treatment quickly, is the most important thing. While civilians, and the media, make a big deal out of combat fatigue, the troops who have been in combat tend to recognize it as an occupational hazard. Everyone gets a a taste of it if you've been in combat. The term “combat fatigue” is not much used by the troops themselves. But you will hear an NCO tell an officer things like “a couple of my guys need a break.” This is understood to mean, “some of my guys have a touch of combat fatigue and we better do something right now if we want to prevent it from getting worse.” If there’s not a life and death (every man with a gun is needed) situation, the troops in question will get a break. A sergeant or NCO will then do the Four Rs and PIES drill as needed.

For thousands of years, there have been efforts made to determine if men were able, or not able, to deal with combat stress. This selection process was part of training, which was deliberately stressful. If a recruit developed combat fatigue symptoms during training (and some do), because of inability to handle stress, he was usually sent away. A knowledgeable commander knew that a soldier who would “break” under the stress of combat was worse than useless. Since World War II, it’s also been found that recruits who had chaotic home life, and didn’t graduate from high school, were more prone to coming down with combat fatigue.

It was also found that more realistic training, and lots of it, also reduced combat stress. This, because of Iraq, has led to major changes in how American troops are trained. Non-combat troops, who often found themselves under fire in Iraq, now get a lot more combat training. This has reduced the combat fatigue rates for non-combat troops, although they are still higher than for combat troops. This occurred because the kind of action that usually causes the most combat fatigue for combat troops (getting shelled for long periods of time, and being in passive situations), is not encountered much in Iraq. American troops are usually actively patrolling or carrying out raids. This type of duty does not trigger a lot of combat fatigue. But the non-combat troops, just driving down the road in a convoy, and trying to avoid trouble, are actually in a more stressful situation. Combat troops were selected and trained to go looking for a fight, and that is not nearly as stressful as is just waiting to be ambushed.

It’s still difficult measuring the incidence of combat fatigue. As you look for it harder, and with better tools, you find more of it. But the kind of combat fatigue that makes a soldier worthless on the battlefield, and a danger to himself, has grown much more rare. During World War II, sometimes half the wounded would be combat fatigue cases. That’s now down to a few percent, with many more being detected and treated before they get bad enough to be sent to the rear.

Combat will always be stressful, but there's no reason the stress can't be treated as quickly as a physical wound.
A question arises in my mind.
The German army of both 14-18 and 39-45, was very heavily engaged on muli fronts.
Elite units 'Seemed' to have spent a disproponate time engade in combat operations.
From El Alelamin on the German army fought in an arena of Air inferiority.
They must have had unbeilvable problems with combat stress, how did they cope ?
Have their lessons been learned ?
I know that the German military in WW2 issued generous liqour (Schnapps) rations to the men. Also stuff like Pervitin (Methamphetamine, speed) was widely issued to the troops.

They also encouraged the men to use hookers.

But then again, the severe cases they called "cowards" and put them up against a wall.
For a very thorough analysis of the subject Ben Shepherd has written an excellent book "A War of Nerves: Soldiers and Psychiatrists 1914 - 1994" It also deals with the various issues raised above. As a non-medic I found it very compelling.
stoatman said:
They also encouraged the men to use hookers.

But then again, the severe cases they called "cowards" and put them up against a wall.
In WW2 yes, but in WW1, the number of German soldiers being executed as cowards or deserters was much lower (AFAIK less than 50) than the numbers executed by the British and French Forces (in both cases several hundreds).

Schnappas, drugs, Hookers Where do I sign on.
No I do agree that sum of the above would help but I do beleive that there must be a more deep underlining reason as to why Fritz fought on. Disipline was always said to have been strong, going back to Iron Fritz sewing 'missing' buttons on troops skin.
I can't remember reading of mutinies following big defeats. I do seem to have heard that in 'combat' situation officers of General rank could order immediate on the spot execution, Bayerlerin in the Desert Fox ?

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