QUADRIPARTITE

STANDARDIZATION

AGREEMENT 909

EDITION 1

AMERICAN

BRITISH

CANADIAN

AUSTRALIAN

QSTAG 909

INTRODUCTION

1. Important lessons from history show that combat stress reactions are an inevitable consequence of warfare and that all individuals are susceptible. Effective leadership, group solidarity, high morale, and realistic training produce considerable buffering against combat stress. In addition, many individuals incapacitated by combat stress, if managed correctly, can quickly recover and return to useful function with a minimum risk of relapse.

DEFINITIONS

2. Combat Stress Reaction (CSR) is a term which encompasses an array of reversible effects caused by the stressors of combat and refers to the temporary psychological upset causing an inability to function normally (normal function includes ability to engage the enemy and survive). CSR encompasses the terms Battle Fatigue, Battle Shock, and Critical Incident Stress as well as older terms such as Shell Shock, War Neurosis, Neuropsychiatric (NP), Not Yet Diagnosed (NYD) (Nervous), and Combat Exhaustion. The incidence of CSR is related to many factors including the length, type and intensity of battle.

3. Combat stress reaction is a normal reaction to a very abnormal situation and does not constitute a psychiatric illness although incorrectly managed may become one. It should also be noted that CSR may present as depression, neurosis or psychosis. The practical definition of a psychiatric patient is, therefore, considered to be a CSR casualty who has exceeded the arbitrary 7 day limit for treatment.

4. Stress management refers to assistance given at all levels and includes the application of good leadership by unit personnel to reduce or cope with combat stressors and facilitate recovery in those soldiers exhibiting early signs of CSR as well as specific therapy given to the more serious CRS cases by appropriately trained health care workers.

PREVENTION AND EARLY RECOGNITION

5. Commanders at all levels, and their medical advisors, must work together in order to prevent stress reaction casualties. While an attempt should be made through a personnel screening process to prevent soldiers who are overly susceptible to stress reaction disorders from being sent to a theatre of operations, such action is, at best, only a partial solution. There are a number of positive preventive measures that can minimize the incidence of combat stress reaction.

6. Every effort should be made, for example, to develop unit and sub-unit cohesion, with emphasis being placed on group identification and integration, a sense of individual confidence and permanency, strong horizontal and vertical communication, morale, faith in leadership and a common trust among members of the unit. Prevention also calls for a strong social support system that emphasizes family security and well being. Patriotism and love of country should be fostered and individuals must understand and identify with national aims and objectives.

7. The importance of hard realistic training which incorporates, where feasible, the expected intensity, duration and conditions of future operations cannot be overemphasised. By developing high levels of competence and by familiarizing soldiers with the real capacity and capability of the enemy in terms of his tactics, technology, weapons effects, strengths and weaknesses, the more insidious aspects of fear- that of the unknown - can be minimized. Soldiers must be made aware of the effects of stress and must learn that they can overcome the effects of stress. Leaders at all levels must be made aware that proper nutrition, enforced water and sleep discipline, personal hygiene and physical fitness are important means of reducing combat stressors.

8. In order to fulfil their responsibilities, all leaders - especially those at the junior level - must become well versed in and understand the types of stress reactions which they will encounter, the warning signs of impending breakdown and the steps to take to either pre-empt or cope with this particular type of casualty. They must also be conversant with the measures available before and after battle to minimize the effects of combat stress, and to minimize the occurrence of Post-Traumatic Stress Disorder.

PRINCIPLES OF COMBAT STRESS REACTION CASUALTY MANAGEMENT

9. The principles of management for personnel suffering from combat stress have been well validated since WWI. So essential have these principles been in obtaining satisfactory results that they may be considered critical factors. These principles are:

a. Immediacy. Symptoms of combat stress must be recognized and dealt with as soon as they appear because the longer proper management is delayed the more resistant symptoms are to change. Early management follows the principles of good leadership and should take place in the soldiers unit. More serious CSR cases may require early treatment by appropriately trained health care personnel. The key to early remedy provides the individual at least temporary relief from the stress of engagement and includes sleep, replenishment of food and water, personal hygiene and words of encouragement and understanding by his leaders;

b. Proximity. The further away from the battle a soldier is evacuated, the less likely he is to return to duty. He must be kept as close to the scene of combat as practical to benefit from the invaluable support of unit and comrades, but he must perceive his location to be safe from immediate attack. Management outside the soldiers unit should take place at a central location in a military milieu rather than in a medical treatment facility. This will maximize the suggestible individual maintaining his military image and minimize his identifying as a patient. Proximity also minimizes transportation problems and decreases the malingering that might be encouraged if individuals are being evacuated some distance from the battlefield;

c. Expectancy. From the beginning, it is important that the soldier suffering from CSR be reassured that he is experiencing a normal reaction to an abnormal situation, and after rest he will be returning to his unit. This expectation, assisted by the repetitious firm suggestions that he will rapidly improve and be ready to rejoin his combat unit, takes advantage of the suggestible state of the individual, and is extremely important to his recovery; and

d. Simplicity. Keeping to short and simple methods is also important. Management should be brief and generally last not longer than four days within the Division, or seven days in all. Providing the individual with rest, food, a chance to clean up, and the opportunity to talk about his experience with an understanding group or listener will hasten recovery. The soldier should be assigned simple meaningful military tasks, be involved in a physical exercise regime and be supervised in a structured environment by leaders who clearly understand that the goal is to return him to duty and not make him into a patient.

OPERATING PROCEDURES

10. For the management of CSR cases, the following operating procedures apply:

a. As it may be difficult or impossible at first to differentiate psychiatric from CSR cases, all psychological cases who do not present a danger to themselves or others should initially be managed as combat stress cases. Eventually, unresponsive CSR cases and those who turn out to be psychiatric cases will return to the medical evacuation chain;

b. First Line:

(1) Because it is difficult to predict which CSR cases will recover quickly, all should be held within unit lines where possible for up to 48 hours following which those not recovering will be evacuated. Although holding CSR cases at section or platoon level may for tactical reasons be impractical, many individuals exhibiting CSR can be assisted by Officers and Non Commissioned Members in company lines. The more serious would need assessment by Medical Assistants and possibly the Unit Medical Officer in order to diagnose physical illness which would require evacuation via the medical chain.

(2) CSR cases could be held at the A2/B echelon (ie company/unit administrative-logistic echelon) where they would receive, under direction of unit personnel, rest and short periods of meaningful work followed by return to duty. Brigade/Divisional Combat Stress Management Teams would visit unit holding areas to provide assistance to unit personnel and to prescribe treatment when required. The team will also advise on the evacuation of cases not responding to management at unit level.

(3) Only during operations involving considerable mobility where unit holding may not be possible, would evacuation directly to second line be required.

c. Second Lines:

(1) Those cases not responding to unit management, or who are evacuated for tactical reasons, would be further managed in the Brigade/Divisional Stress Recovery Centre (SRC) under the direction of mental health care trained personnel which may include one of more psychiatrist, medical officer, clinical psychologist, social services officer, mental health nurse, occupational therapist and medical assistant.

(2) At this level management measures continue to include rest, food, warmth, a shower and change of clothing, followed by meaningful work, exercise, reassurance and an opportunity to talk about recent experiences. Reinforcing the idea that the patient can expect a rapid return to duty will enhance recover. CSR patients not recovering in 48-72 hours and psychiatric patients would be evacuated to the corps rear area;

(3) SRCs would normally be located within the Divisional Administrative Area (DAA), and may be deployed for example, separate from, but situated in location with and share the administrative facilities of the Division Medical Station (DMS) within the DAA; and

d. Third Line:

(1) CSR patients would continue to be managed outside the regular medical/surgical treatment facilities. Whereas psychiatric patients would receive care in a psychiatric ward of a hospital, CSR patients would be held in the SRC. These centres would treat cases occurring in the corps rear area and would continue management of CSR patients evacuated from the Divisional SRC. It is envisioned that two such units would be required (in addition to divisional entitlement) and would collocate with the Corps Reinforcement Holding Unit (RHU).

(2) Corps SRCs would hold those patients who may be able to return to duty within 5-7 days. Treatment would continue to actively reinforce the expectation that there would be a significant rate of return to duty. Recovered patients would be discharged into the RHU for reassignment. Patients not recovered at this level may require medical/psychiatric therapy in the Corps area or further evacuation to a theatre base or to home nation.

e. Evacuation:

(1) Although CSR cases can be evacuated by any available means, considerable effort would be made to prevent these personnel being identified as either sick or injured patients. Therefore whenever possible:

(a) Standard Military Pattern vehicles should be used in preference to ambulances, particularly at first line, to reinforce the fact that CSR cases are not likely to be evacuated out of theatre, and to prevent CSR cases affecting the evacuation and treatment of other patients (ie: by overcrowding the medical evacuation chain);

(b) Evacuation of CSR cases should also take place directly between SRCs thus avoiding CSR cases being mixed with patients within major medical facilities; and

(c) Air evacuation should be reserved for the high priority patients and not be used to evacuate CSR cases who would normally be assigned a Priority 3 category.

(2) A diagram of the chain of evacuation is at Annex A.

f. Documentation:

(1) When the CSR case enters or returns to the patient evacuation and treatment chain, normal medical documentation in accordance with QSTAG 470 will apply. Divisional and Corps SRCs are considered, for documentation purposes, medical treatment facilities.

(2) Regular unit administrative documentation procedures will apply to those CSR cases held and managed by unit personnel within unit lines but outside the patient evacuation chain.

ANNEX A

TO QSTAG 909