Combat and Operational Stress Control in Iraq: Extreme Occupational

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Combat and Operational Stress Control in Iraq
Extreme Occupational Organizational Psychiatry

• Paul S. Hammer, MD
• Commander, Medical Corps, US Navy
• Division Psychiatrist
• 1st Marine Division

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Agenda

• Overview of Combat and Operational Stress Control
  Doctrine in the US military.
• Brief Overview of how COSC concepts are practiced
  today
• Development and Role of the Marine Expeditionary
  Force Psychiatrist
• Combat Psychiatry as a model for Occupational
  and Organizational Psychiatry

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Historical Roots Shell Shock to PTSD
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Thoughts to Consider

• Combat Stress is not new
• History and Literature have examined the behavior
  of men in battle for millennia.
• Iliad Achilles mutilates Hector
• Odyssey Metaphorical long trip home for Odysseus
• Thucydides Peloponnesian War
• Arthurian Legend
• El Cid
• Roland

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What Is New

• Better understanding of the nature of stress
• Less emphasis on character and weakness
• More emphasis on common biological/physiological
  events
• Separating cowardice from stress-this question
  needs to be addressed
• Ability to survive in battle
• Vietnam first war where combat casualties
  outnumbered NBDI
• Better body armor
• The nature of warfare
• Efficient weapons
• Ability to kill large numbers with minimal effort

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Historical Roots Civil War

• Psychiatric Syndromes
• Nostalgia
• Soldiers Heart
• Stephen Crane Red Badge of Courage
• Gatling gun invented

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Historical Roots World War I

• Shell Shock
• 1st empirical evidence that early intervention
  reduces chronic psychiatric morbidity
• Thomas Salmon develops PIES Principles
• Proximity
• Immediacy
• Expectancy
• Simplicity

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After Effects from WWI Shell Shock

• Britain
• 200,000 Vets being treated and drawing pensions
• 40,000 for War Neurosis
• U.S.
• 38 of all hospitalized veterans in 1919 had
  mental disorders
• Led to creation of Veterans Administration

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Historical Roots WWII

• Lessons forgotten between the wars
• Salmons PIE Principles
• re-learned and re-developed
• Effectively implemented
• Battle of Okinawa
• High combat stress casualty rates
• Evacuation to CRTS

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Historical Evidence WWII

• The British numbers
• By 1945 43,600 were receiving disability
  pensions from the British Army for mental
  disorders
• The U.S. numbers
• By 1945 50,662 still hospitalized in VA medical
  centers for psych reasons
• By 1947 286,000 getting VA disability pensions
  for mental disorders
• By 1951 Only 67 of them had achieved a
  satisfactory occupational and family adjustment
• By 1972 44,000 WW-II combat stress patients were
  still occupying beds in VA hospitals

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Important Historical Roots and Influences Cont.

• 1944 Coconut Grove Fire
• Lindemanns observations from of grief reactions
• modern era of crisis intervention
• 1963/64 Caplans 3 tiers of preventive psychiatry
  
• primary-, secondary-, and tertiary prevention
  implemented in Community Mental Health System

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Development of Crisis Intervention

• 1960s/70s Crisis intervention principles
  applied to reduction of hospitalizations of
  potentially chronic
• 1974 Early work on crisis and stress in
  emergency services personnel Mitchells CISD
  formulated
• 1980 Formal recognition of PTSD in DSM-III
• legitimizes examination of crisis and traumatic
  events as threats to long-term health

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Historical Evidence Vietnam

• Criteria for PTSD formulated in 1980
• National Vietnam Veterans Readjustment Study
  (NVVRS) in the late 1980's
• More than 70 of VN combat vets had at least one
  persistent symptom of PTSD
• 35 of total met the full diagnostic criteria for
  the disorder
• Other estimates of PTSD in VN vets range from
  VA's official 15 (450,000) to 1.5 million

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Disaster Mental Health Intervention

• 1982 Air Florida 90 Crash Wash. DC
• 1st mass use of CISD
• psych support for emergency response personnel
• 1986 Violence in the workplace
• deaths of 13 postal workers on the job

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History, Roots and Influences

• Yom Kippur War
• Oct 1973
• Israelis completely surprised
• Rushed in unprepared reserves
• High combat stress casualties
• MOOTW
• 1994 Rwanda Massacres
• Canadian Peacekeepers had insufficient troops and
  restrictive mandate

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Roots and Influences, continued

• 2000 Mass casualty shooting at Columbine H.S.
  leads to re-exam of youth/school violence issues
• 2000 Increased international concern for
  terrorism (e.g., USS COLE incident), including
  nuke, bio, and chem terrorism

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Roots and Influences

• 9/11
• 2002-Present Afghanistan Operation Enduring
  Freedom
• 2003-Present Iraq Operation Iraqi Freedom

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Current Situation

• Nature of warfare has changed
• Sustained combat operations now different
• Evolution of knowledge base regarding stress and
  stress syndromes
• Evolution of Interventions and Therapies
• Troops need help
• Maintain ability to function and perform duties
• Treat wounds when they occur
• Stigma, barriers and misconceptions still exist

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Combat and Operational Stress Control in the US
Military
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Combat and Operational Stress Control in the US
military

• Army
• Navy

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Army CSC Doctrine

• Mission of US Army
• Mission of Army Medical Dept.
• Mission of Army Mental Health/Combat Stress
  Control

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Army MH Teams

• Division Psychiatry
• Organic to Division Units
• Staffed by Mental Health Professionals
• Treatment and Prevention Missions
• Combat Stress Control Companies
• Subordinate Unit of Combat Support Hospital
• Area support to units
• Prevention Teams
• Treatment Teams
• Recuperation Centers

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Doctrinal Principles

• Conserve the fighting force
• Preventive Interventions
• Early Treatment
• Early Return to Duty
• Communication and Liaison with commands
• Appropriate distribution of personnel

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CSC Functions

• Briefing
• Educating
• Teaching
• Facilitating Debriefings
• Leading Debriefings
• Assessment

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US Navy-Marine Corps CSC Doctrine

• Navy Medicine relationship with Marine Corps
• Principles essentially identical to Army
• Less emphasis on Debriefings
• Two Major Segments
• CSC Teams in Surgical Companies
• Division Psychiatry/OSCAR Program

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USMC Combat Organization 101
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Surgical Company Combat Stress Team

• General Area Support
• Manning
• Psychiatrist
• Psychologist
• 2 Psychiatric Technicians

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Brief Overview of how COSC concepts are practiced
today

• Army CSC Companies
• Prevention Teams
• Treatment Teams
• Navy-Marine Corps OSCAR Teams
• Embedding MH within Regimental Combat Teams

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Combat Psychiatry as a Model for Organizational
Psychiatry
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I MEF Psychiatrist

• What it is and what we did in Iraq recently.

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Development and Role of the Marine Expeditionary
Force Psychiatrist

• Problem of individual vs. unified approaches
• Inconsistent application with providers
• Need to reinvigorate the concept of Division
  Psychiatrist
• Need for someone to oversee the system
• Professional supervision
• Drive outreach effort

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Organizational Role of Force Psychiatrist

• Develop the System
• Strategic Focus
• Develop consistency
• Collect Data
• Informed Decisions
• Mentor MH Professionals
• Teach less experienced MH prof
• Fold into system
• Influence the culture
• Care
• Help the stressed
• Actual nuts and bolts of what we do.

System
Mentor
Care
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Develop and Monitor the system

• Concept of a System
• Combat theater different from garrison
• Coherent Theory and practice
• Working together vs. individually
• Outreach Effort
• Not bringing the clinic to the sand!
• 50 of time doing this.
• Need for Data
• Targeting services to affected populations
• Combat Trauma Record (CTR) for Psych

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Mentoring MH Professionals in Combat Psychiatry

• Team members
• Psychiatric Technicians
• Psychologists
• Psychiatrists
• Many with little or no experience in Operational
  Environment
• Tendency is to fall back to the familiar and
  comfortable
• Outreach doomed unless it is accountable to
  someone above.

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Help The Stressed

• Pt focused
• Focus on function
• What treatments work and what dont?
• How do we get treatment to those who need it?
• Skill in Disposition
• Medevac
• Maintain in Theater

• Competencies
• Diagnoses
• PTSD
• Anxiety
• Depression
• Psychotherapy
• Cognitive
• Psychodynamic
• Brief
• Interpersonal
• Medications

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Combat Psychiatry as Model

• Focus on function
• Crucial need to function
• Consequences of failure to function
• Balancing stress exposure with functional loss
• Maintaining function vs. psychopathology and
  treatment
• Resilience in the face of extreme stress
• Fostering resilience in vivo
• Bolstering resilience deficiencies

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Future Directions

• Comprehensive Combat Mental Health System
  Initiative in I MEF
• Dynamic Combat and Operational Stress Control
  (COSC) System Revision
• PAO Piece
• Individual-Unit-Leader Training
• Fostering Culture Change

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Questions?Discussion?
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