Combat and Operational Stress Control in Iraq: Extreme Occupational & Organizational Psychiatry

2. 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

3. 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

4. Historical Roots: Shell Shock to PTSD

5. 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

6. 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

7. Historical Roots: Civil War • Psychiatric Syndromes • Nostalgia • Soldier’s Heart • Stephen Crane: Red Badge of Courage • Gatling gun invented

8. 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

9. 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 mentaldisorders; • Led to creation of Veterans Administration

10. Historical Roots WWII: • Lessons forgotten between the wars • Salmon’s “PIE” Principles • re-learned and re-developed • Effectively implemented • Battle of Okinawa • High combat stress casualty rates • Evacuation to CRTS

11. 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

12. Important Historical Roots and Influences Cont. • 1944 Coconut Grove Fire • Lindemann’s observations from of grief reactions • “modern era” of crisis intervention • 1963/64 Caplan’s 3 tiers of preventive psychiatry • primary-, secondary-, and tertiary prevention implemented in Community Mental Health System

13. 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; Mitchell’s CISD formulated • 1980: Formal recognition of PTSD in DSM-III • “legitimizes” examination of crisis and traumatic events as threats to long-term health

14. Historical Evidence: Vietnam • Criteria for PTSD formulated in 1980 • NationalVietnam 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

15. 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

16. 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

17. 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

18. Roots and Influences • 9/11 • 2002-Present Afghanistan Operation Enduring Freedom • 2003-Present Iraq Operation Iraqi Freedom

19. 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

20. Combat and Operational Stress Control in the US Military

21. Combat and Operational Stress Control in the US military • Army • Navy

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

23. 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

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

25. CSC Functions • Briefing • Educating • Teaching • Facilitating Debriefings • Leading Debriefings • Assessment

26. 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

27. USMC Combat Organization 101

28. Surgical Company Combat Stress Team • General Area Support • Manning • Psychiatrist • Psychologist • 2 Psychiatric Technicians

29. 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

30. Combat Psychiatry as a Model for Organizational Psychiatry

31. I MEF Psychiatrist What it is and what we did in Iraq recently.

32. 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

33. 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

34. 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

35. 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.

36. Pt focused Focus on function What treatments work and what don’t? 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 Help The Stressed

37. 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

38. 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

39. Questions?Discussion?