UNITED STATES OF AMERICA
COMBAT STRESS PREVENTION

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

INDIVIDUAL PROTECTION

Recognition of Signs
     The individual soldier must learn to recognize signs of stress in himself.  
The signs are a normal reaction to a situation.  Mental and physical fitness 
are required to assist the individual endure stress.  The common signs of 
stress may be physical or mental (cognitive).  The most common physical signs 
of stress may include tension, jumpiness, dry mouth, cold sweat, pounding 
heart, difficulty breathing, nausea, diarrhea or constipation, frequent 
urination, or fatigue.  The most common mental signs of stress might include 
anxiety, irritability, difficulty paying attention, difficulty thinking, 
inability to concentrate, forgetfulness, disturbed sleeping, grief, anger, 
frustration, guilt, moodiness, nervousness, tension, pessimism, and/or loss of 
confidence.

     Stress may develop slowly. the signs can be recognized. All of the signs 
are normal; they have been felt by some soldiers at some time.  Coping with the 
sources of stress is essential.  

Controlling Stress
     It is easier to cope with stress when there is an optimistic, confident 
feeling than where there is an unsure feeling.  Confidence is the belief that 
the unit can and will accomplish the mission.  If confidence is to exist, all 
soldiers must believe in themselves, their equipment, other unit members, and 
their training.  Above all, they must believe in the competence of their 
leaders.  

     There are a number of measures the individual soldier can employ to 
control stress.  These include building self-confidence, understanding his role 
and his contribution to the unit and to mission success, understanding his 
responsibility to his fellow soldiers and to the unit.  Soldiers must strive to 
continually improve their skills.  Soldiers need to develop realistic 
expectations of what is expected of them and the standards they are to meet. 

     Through training, soldiers build confidence in their equipment.  The 
soldier needs to know and respect his equipment.  Combined with a belief in his 
own competence, confidence in equipment raises total confidence in fighting 
capability.  Confidence is built through acquiring new skills and knowledge 
during training.  Training should be realistic, provide relevance to the 
conditions of the integrated battlefield, provide refresher training and cross 
training, and provide systematic individual and integrated training.

     Confidence in leaders is developed when good leadership is demonstrated.  
The soldier must be able to trust his leaders.  Good leadership convinces 
subordinates that the leader best knows what must be done, how to do it, who 
should do it, and for how long.

     Coping techniques must be learned and practiced.  Each soldier must know 
how to cope long before combat.  The techniques are practiced during realistic 
training.  Stress must be faced and conquered.  Denying sources of stress is an 
unhealthy way of dealing with them.  

     Rigorous physical conditioning raises tolerance to stress.  As a soldier's 
physical condition improves, he feels better about himself, and stress is 
reduced.

     The soldier on an integrated battlefield needs to know how to give himself 
an injection to counteract chemical agents.  Similarly, on the integrated 
battlefield the soldier should know how to use coping techniques to counteract 
stress.  

     No soldier is alone in the battle against stress.  Buddies and unit 
leaders can assist individual soldiers.  Prayer has served many soldiers in 
warding off stress.  Professional mental health personnel are available for 
individuals having troubles dealing with stress or personal problems.  The 
Red Cross can help as well.  It is important to develop individual support 
systems (peers, friends, leaders, experts) for guidance and information.

Coping Techniques
     The individual soldier can reduce his stress by eating adequately, 
replenishing fluids frequently, resting and sleeping as often as possible, 
sharing feelings constructively (ventilation), and preparing mentally by 
planning ahead and rehearsing available courses of action.  Realistic 
expectations must be developed.  The best way to alleviate stress is to take 
appropriate action.

     Coping with stress in oneself means achieving self-control over the stress 
process.  Each technique can be used to fight off stress that is building up.  
All the techniques use relaxation in some way.  The techniques must be 
practiced during training until they become automatic.  The stress coping 
techniques consist basically of deep breathing exercises, muscle tension-
relaxation exercises, and cognitive exercises.

     Deep breathing.  This exercise consists of deep inhaling, which expands 
the abdomen, and thorough exhaling, which tries to push out all the remaining 
oxygen.  Abdominal breathing involves breathing slowly and deeply.

     Muscle tension-relaxation exercises.  The exercises consist of 
concentrating on various muscle groups and limbs, tensing and relaxing them to 
relax the entire body.  Stretch relaxation and muscle relaxation are methods 
for calming the mind and body.  They can be brief or progressive exercises.

     Self-Massage.  Physical massaging of the neck, limbs, muscle groups 
produces sensations of relaxation.

     Self-Suggestion.  The techniques combines self-suggestion and exercise to 
reach deep mental and physical relaxation.  The technique produces feelings of 
heaviness and warmth that slow down the heart rate and regulate the heartbeat.  
There are four aspects of self-suggestion.  They deal with the repetition of 
different kinds of phrases related to relaxation, warmth, imagery, and 
activation.

     _Self-hypnosis or autogenic training._  These involve concentration 
on self directed mental exercises. 

     _Meditation._  Meditation uses aspects of the relaxation and self-suggestion 
techniques.  All forms of meditation require concentration.  Breathing 
meditation focuses attention on breathing, especially during exhaling.

     _Inoculation._  Stressful situations are brought into mind and ways of 
handling them are reviewed.  The stress of the rehearsal situation is weak 
compared to the real situation.  During the rehearsal phase, the ways of 
handling stressful situations are internalized.  The result is a soldier who is 
better able to master stress when the real situation occurs.

     _Imagery._  The technique requires searching the memory for a familiar place 
to relax, feeling the relaxation that accompanied that place, and relaxing.

BUDDY AID

_Signs of Stress in Others_
     Unit members are often the first to recognize when peers are unable to 
perform their tasks.  When soldiers notice some or all of the following signs 
among their buddies, it is important they consider intervening.  The signs of 
stress which may be present include: alcohol, denial, drugs, emotional 
outbursts, excitability, impulsive behavior, inadequate eating or drinking, 
negativism, obsessive behaviors, restlessness, risk taking, smoking, speech 
disorders, or trembling.       

_Intervention Techniques for Buddy Aid_
     A variety of methods can be used to help others relieve their stress.  
Although they can be used alone, they are most effective when used in 
combination.  These methods include ventilation, stress counseling, crisis 
management, and peer feedback.  

     _Ventilation_ (talking it out) requires one soldier being a good listener 
while the other shares his thoughts and feelings.  The listener must be 
genuinely interested in the talker and what the talker has to say.  The 
listener does not interrupt the speaker; the listener attends and shows he is 
paying attention.  The listener needs to facilitate the speaker ventilating 
further.  It requires active listening.

     _Stress counseling_ requires listening skills to help identify the problem, 
recounting ways the soldier has tried to deal with the problem, reviewing 
approaches that have and have not worked for the soldier, and suggesting new 
sources of action for the soldier to try.  The soldier being counseled can 
learn new ways of responding to sources of stress.  Learning ways to 
effectively cope with sources of stress can lead to improved confidence.

     Crisis management is designed provide immediate help when a soldier's 
behavior indicates he is unable to function adequately.  The goals of crisis 
management are to return the soldier to the level of functioning that he 
maintained before the crisis, to help him cope with the sources of stress, and 
to prevent a recurrence.  The crisis manager's functions are to observe and 
calm the soldier if he is emotional, protect him and others from imminent 
danger, collect relevant information, and take appropriate action.  The 
interventions take place at the crisis scene.

     _Peer feedback_ involves two or more soldiers who review and evaluate the 
actions and behaviors of other soldiers who need help in coping.  The peers' 
function is to point out coping strengths and weaknesses in the soldier being 
helped.  The soldier under stress is helped to select more appropriate coping 
techniques.  The evaluators are helped to monitor their own coping techniques 
as a result of discussing somebody else's techniques.

     The techniques are applicable in a variety of settings.  Ventilation, 
stress counseling, and crisis management techniques are most applicable before 
combat and during lulls in battle.   Peer feedback is most appropriate before 
combat occurs or when an opportunity for prolonged rest is available.  The most 
appropriate coping technique to use with a soldier who has an emotional 
outburst in combat is ventilation.  However, stress counseling and crisis 
management can be used as well.

     The objectives of the peer interventions with a soldier in distress are to 
calm the soldier, to protect him from danger, to find out what is going on, and 
to take appropriate action.  If necessary, specific actions should be taken 
which may include seeking additional help from unit leaders or health care 
personnel.