NATO RESEARCH STUDY GROUP ON PSYCHOLOGICAL SUPPORT 

	A. David Mangelsdorff, Ph.D., M.P.H.
	Center for Healthcare Education and Studies
	U.S. Army Medical Department Center and School
	Fort Sam Houston, Texas 78234‑6135
United States of America

Developing psychological support for military personnel is an issue of concern to the United States and its North Atlantic Treaty Organization (NATO) allies.  As the military establishments of the NATO nations undergo significant downsizing and changes in missions, new policies need to be developed to provide support for personnel.  The primary function of the armed forces is to maintain national security.  Service in the armed forces involves carrying out missions and training under a variety of stressful circumstances, to include combat.  The training and preparation of military personnel to perform their missions is crucial.

Psychological support deals with the improvement of the psychological situation of the soldier and military group with consideration for the improvement of the combat readiness of soldiers.  Psychological support concentrates on management of stress reactions and the respective preparatory measures including appropriate training.    

In 1984, a NATO Research Study Group on Psychological Fitness was formed to develop adequate selection and training procedures to prepare soldiers to carry out their military tasks.  The procedures used examined the methods of measuring psychological fitness, selection procedures, training required, job analysis assessing stress on operators, job related performance, and highly stressing military functions.  Reports detailed the components of combat stress, the structure of a psychological fitness test for NATO personnel, the development of an Exploratory Group on decision-making and problem-solving under difficult military circumstances, and methods which contribute to combat readiness.   

In 1989, a NATO Research Study Group on Psychological Support was established.  The goals of the NATO Research Study Group on Psychological Support were to develop modules for promoting self help and buddy aid, develop interventions for military leaders which promote psychological support, develop curricula and course objectives for basic training programs to provide psychological support, develop occupational stress and health promotion components as part of workplace stress management, and develop mechanisms for promoting organizational change for psychological support.  This presentation reviews the recommendations made by the Research Study Group.  The recommendations include self help, buddy aid techniques, and guiding principles for psychological support by leaders.

	SELF HELP AND BUDDY AID TECHNIQUES

The primary focus of the techniques is their use for managing (preventing, reducing, or treating) combat and operational stress reactions and optimizing the effectiveness of the soldier. They may also be used in other stressful situations (e.g. realistic military training, accidents, civil disaster situations, and United Nations missions in crisis areas) as the relevant intervention techniques are much the same.  

The use of, experience with, and knowledge about the various techniques are different in the countries participating in the Research Study Group.  The techniques are recommended for introduction in military training in NATO forces.  Their use - alone or in combination - will depend on the situation the soldier is in (e.g. whether it is before, during, or after combat).  It must be kept in mind that different techniques have different aims and effects; some are recommended for calming down a soldier who is upset (e.g. breathing regulation, progressive relaxation); other techniques are for arousal in a passive and depressed soldier (e.g. self-motivation, meaningful physical activities).  Well known common sense items/advice are included.  A technique is defined as: any means/measure aimed at enhancing the military performance as well as the general well being of the soldier (i.e. measures that have great psychological impact on his/her functioning and might easily be forgotten or neglected when the person is under extreme stress).  Techniques are strategies that have proven to be useful in coping with stress in different situations.  A general result from most of the suggested techniques is that the locus of attention is drawn away from the stressors, threats, and fears, toward more constructive thinking and acting.

The Self Help Techniques include: 1) breathing regulation, 2) progressive relaxation, 3) autogenous training, 4) self motivation, 5) imagery, 6) self talk, 7) mental rehearsal, 8) stress inoculation, 9) abreaction, and 10) bodily care.   Several applications can be used for the individual or as buddy aid techniques.  These include: 1) meaningful physical activities, 2) focusing on the mission, 3) information about stress, and 4) ventilation of emotions.  The Buddy Aid techniques are: 1) peer feedback, 2) building of social networks, and 3) encouragement of humor.  

The techniques must be introduced and rehearsed as part of basic training.  They are likely to be of limited use, if only applied when critical events occur.  The techniques should be regarded as part of psychological support measures for all levels in the military organization.

	PRINCIPLES FOR PSYCHOLOGICAL SUPPORT BY MILITARY LEADERS

The main task of the leader is to lead the unit, to know and apply principles of good leadership, and most importantly to carry out his/her decision making functions.  If the leader performs these functions well, he thereby maintains unit morale, and makes his most important contribution to the psychological support of his personnel.  Indeed, scientific study as early as World War II showed, for United States troops in the Pacific theater, that confidence in immediate leadership was the single most powerful influence on morale. 

The leader should have a thorough knowledge of what personnel have been taught about coping with stress, of possible stressors, stress reactions, and principles and techniques which may be used to provide psychological support.  Most important, the leader must accept that stress is a factor which must be taken into account when planning and executing operational tasks.  He must recognize that combat stress reactions (CSR) and fatigue may affect the efficiency of his unit, just as do physical casualties.  

Consideration of possible types of stress reactions and possible leader interventions leads to the conclusion that no general principles of Psychological Support can be stipulated, as particular stress reactions will be determined by the personality of the individual soldier, by the perception of the threat, by the individual's feeling of involvement and ability to cope, by the level of group cohesion, by the type and magnitude of the stressor, by the level of training and experience of personnel, by prior information on what to expect, and so on.  The leader, therefore, has to decide on the form of his intervention, if any, in each case.

Psychological Support should come from within the individual himself (self help) or be administered by his peers in the unit (buddy aid).  The leader must recognize that his second most important contribution to the psychological well-being of his subordinates is to ensure that interpersonal relationships in his unit give the greatest possible scope for self help and buddy aid.  One important factor in this respect is that of general attitudes.  For example, it is obviously not enough for stress reactions and combat fatigue to be accepted by leaders as legitimate reasons for performance deficiencies, if they are not also accepted by a soldier's peers.  

Whereas these Guidelines are not concerned with leadership as such, it is clear from the foregoing discussion that a review of aspects of leadership behavior and their positive or negative effects on personnel and task performance would constitute a detailed indication of possible leader impact on Psychological Support.  In general, two sets of personal qualities and skills are important.

Military leaders in all NATO forces go through selection procedures.  Basically, the selection procedures attempt to identify qualities such as stress resistance and stamina, determination and goal orientation, decision making ability, social adaptability, and many other characteristics.  Subsequent training and exercises help to strengthen these qualities and skills.

Leaders must have a good standard of general education, and be trained in their technical as well as tactical skills.  If their training is not of the highest standard, the confidence of subordinates is at risk.  Loss of confidence and feelings of insecurity in subordinates create stress and lack of discipline.

Given that leaders are selected and trained to high standards in these two sets of skills and personal qualities, they will almost certainly adhere to the following basic principles of Psychological Support for subordinates by leaders, for these principles are all aspects of the traditional concepts of effective military leadership.

	GUIDING PRINCIPLES

Know Self, Know Subordinates.  A good leader must know himself well.  He must be aware of both his strengths and his weaknesses, of how he is likely to react under various types of stress, including lack of sleep and other deprivation conditions.  Only then will he have the psychological resources necessary to deal with the many and sudden demands that may arise.  

He must know his subordinates well: their standards of education and training, and their backgrounds - personal as well as military.  More specifically, he should know if particular stressors are more likely to affect some personnel rather than others (e.g. newly married, newly born child, death in the family, alcohol problems, etc.).  Only then will he understand and be able to select the appropriate intervention(s) for the unit as well as for the individual soldier.  

In effective units, soldiers know themselves and each other, care about each other, share mutual trust, respect, confidence and understanding, and work as a disciplined team.  The leader needs to know the capabilities and limitations of the unit in these respects.

Meet Basic Needs (Food, Drink, Sleep, Shelter, Physical Security).  Although the armed services are trained to survive and fight under various forms of hardship, there are obviously limits to the capacity to sustain performance if these basic needs are not met.  

Ensure Adequate and Timely Communication.  This covers a wide range of vertically and horizontally oriented interpersonal interaction.  Exchange of specific, relevant information, such as the issuing of orders and instructions is naturally essential; and feedback from subordinate leaders is required, to ensure that the command chain is functioning properly.  The purpose of particular tasks must always be explained.  

The importance of an effective mail system cannot be over-emphasized, and if possible, opportunities for telephonic and other methods of communication should also be made available.  In this connection, however, personnel may need to be told that they cannot solve family problems from the battlefield.  They need to be given assurance that the situation at home is under control; especially, knowledge of family support measures needs to be kept up to date.  

On the other hand, fighting personnel must understand that some of their experiences are not suitable for communication to persons who have no possibility of understanding the situation.  One way which may be recommended of verbalizing experiences and feelings related to the battlefield is to keep a diary, bearing in mind security aspects.  Immediate tension relief, however, will most effectively be achieved by talking between comrades (buddies).

Maintain Discipline and Performance Standards.  For good morale, personnel must be well trained and disciplined.  The leader needs to be aware of potential deterioration in performance standards and discipline in difficult situations.  He must not accept compromise, and should explain the consequences of doing so.  He must, therefore, have a clear conception of the performance standards required, and provide directions accordingly.  He will set realistic goals, plan, make decisions and solve problems, supervise, evaluate, teach and counsel his subordinates and arrange for appropriate training.  Above all, the leader must be fair and consistent in his application of rules and regulations to all members of the unit.  Where appropriate, whether in or out of combat, the good leader leads by example.

Monitor and Promote Cohesion and Teamwork.  Group cohesion reflects the commitment of personnel to each other, the bonding between each other, and between leaders and subordinates, which affects their willingness to fight and sacrifice personal safety.  Strong cohesion increases confidence, morale, courage and will to fight.  It tends to develop naturally through meaningful, goal-oriented teamwork.  In order to promote cohesion, personnel should be given opportunities to meet and talk (verbalize their thoughts and feelings).  The leader himself also needs to do this.  

From time to time, personnel may have to be replaced for various reasons.  When this happens, it is important that new members should be integrated into the group as soon as possible, and the leader should get to know them quickly.  

Conduct Post-operational De-briefings.  As a general rule, there should be a general review at the end of each day's activities, and the next day's programma should be previewed.  After action, a tactical unit debriefing should be carried out in order to provide realistic and cohesive information on what has happened.  In this way, a common, structured understanding of, and commitment to, the unit's tactical missions will be maintained.  

Beyond this, critical incidents should be discussed, and opportunity provided for individual emotional defusing.  Each unit member should be allowed to report his experience, express his feelings about it, and try to learn from it.  As far as possible, all members' self-respect should be maintained by assurance by the leader that their performance was good.

Ensure Recuperation and Diversion.  When possible, all personnel - including leaders - should have the opportunity to rest and recuperate.  Preferably, such periods should be spent in "peaceful" surroundings; for example, the unit should be withdrawn, as a whole, from the front line or, even better, after longer front-line operations, personnel should be given leave.  

Waiting to go into action can be extremely stressful; even more stressful may be those occasions when personnel, keyed up for action, have to stand down temporarily, for example because of unfavorable weather conditions.  Although continued training and preparation are essential, if circumstances and the tactical situation permit, this time may be used for letter-writing, reading, playing cards, sport, or other forms of diversion.  If appropriate, talk of personal plans for the future can be very effective in diverting attention from the stresses of combat.

Know Basic Warning Signs and Relevant Techniques.  The leader must know the basic warning signs of CSR, and the relevant techniques for prevention and coping.  The leader is responsible, primarily, for the accomplishment of the mission.  To achieve this objective he must maintain the psychological and physical fitness and cohesion of his unit, but he will become directly involved in providing PS only if time and the situation permit. More generally, he will encourage self-help and buddy aid.

Apply Acknowledged Stress Management Principles.  The leader is expected to play his part in applying, particularly, the accepted Proximity, Immediacy, Expectancy (PIE) stress management principles.  Thus, he should keep personnel who appear to be suffering from CSR as close to their unit as possible.  Experience has clearly demonstrated that the farther away a soldier is taken from his primary unit, the more difficult it is for him to be returned to normal duty.  

When the unit is in action, suspected mild cases of CSR should be kept as close to the action as possible, thus reinforcing their identity as fighting troops and not casualties.  Self-help and buddy aid should be initiated immediately.  Personnel with CSR symptoms should not be left unemployed; they should be helped to cope as early as possible.  

Soldiers should be aware that they are expected to behave as soldiers.  If a man has to be relieved temporarily from combat duties, whether he stays with the unit or is taken to a rear echelon, he should keep his uniform, personal equipment and weapon (unless his behavior seems unstable enough to make it advisable to disarm him).  In general, even if temporarily unable to participate in combat, he will still be able to attend to his personal hygiene, his equipment and his weapon, and the leader must ensure that, as a minimum, these demands are met.  This helps to build up the individual's self-respect as a human being and as a soldier, and to ensure that he is combat-ready when mentally recuperated.  

If the individual's CSR symptoms do not improve after brief rest (usually about 2 days), the leader will need to refer him for medical consultation.  If further rest does not improve his condition, additional professional support may be required.

Seek Specialist Assistance When Necessary.  Medical or psychiatric diagnosis is not a task for the leader.  "Combat stress" is simply a label, which is accepted by all (officers, NCOs and private soldiers), and for practical purposes it can be sub-divided into three degrees of severity: mild, moderate and severe.  

Personnel with mild symptoms may be relatively ineffective, but do not constitute a risk to themselves or others, and therefore may be allowed to remain in their primary unit.  Those with moderate combat stress should not remain in the primary unit, but should be removed from the immediate combat zone for temporary rest and recuperation, although they do not need medical assessment, e.g. to rule out physical causes of their symptoms.  

Personnel with severe combat stress need to be referred to a physician or a mental health officer for assessment and treatment.  Their symptoms may sometimes have physical causes, and they are too disruptive or dangerous to remain without medical treatment.

In Summary.  The most essential leader contributions to psychological support are:

(1)  Maintain a high standard of leadership; observe especially  those aspects discussed in the preceding paragraphs.
(2)  Have a thorough knowledge of the training given to personnel with regard to stressors, reactions and coping.
(3)  Apply this knowledge to oneself.
(4)  Ensure opportunities for self-help and buddy aid.
(5)  Monitor behavior, and know when to seek specialist  assistance, and especially how to recognize signs of severe CSR.  

	SITUATIONS

The different techniques are useful for a variety of situations and conditions.  The situations considered include peacetime, humanitarian help, peace keeping, and peace enforcement operations.

The most common stressors for peacetime situations include the stress of the military lifestyle, reunions following operations, dual role stress as more service members may be married to other service members, organizational stressors such as right-sizing or down-sizing, budget cuts, work overload, and reserve-active force mixes.  

The stressors during humanitarian help, peace keeping, and peace enforcement operations are described during the preparation, deployment, and post-deployment phases.  While the threats and risks are generally low, the factors of uncertainty and duration of deployments becoming critical components.  Adequate training and education help to diminish the stressful effects. 

The psychological support techniques are simple, practical, and effective if used appropriately.  The relevance for various personnel categories and functions must be considered before training and application of the techniques.  The self help and buddy aid techniques should be regarded as part of psychological support measures taken at all levels in the military organization.