Combat and Operational Stress Control Course on International Law and Armed Conflict

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Combat and Operational Stress ControlCourse on
International Law and Armed Conflict

• Elspeth Cameron Ritchie, MD
• Director, Mental Health Policy and Womans Health
  
• Office of the Assistant Secretary for
  Defense/Health Affairs

31 August 1999
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All Wars Produce Stress Reactions

• Physical--tension, jumpiness, upset stomach,
  fatigue, 1000 yard stare
• Mental and Emotional--anxiety, grief, anger, loss
  of confidence
• Misconduct--disobeying orders, AWOL, alcohol and
  drug abuse, malingering

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World War I

• Shell shock--original name used when reactions
  was thought to be organic
• Over evacuation led to chronic psychiatric
  conditions
• Americans (Thomas Salmon) learned from British
  and French
• 3 echelon system of care developed to decrease
  unnecessary evacuations

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World War II

• Lessons forgotten and relearned
• Extensive psychological screening hampered war
  effort
• Over evacuation of soldiers to United States
• Not Yet Diagnosed Nervous
• Battle fatigue treated with PIES
• Fred Hansen in North Africa
• proximity, immediacy, expectancy, simplicity
• Division psychiatrists

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Korea

• Initial high rate of casualties
• 500/1000/annum
• Al Glass becomes Theatre consultant
• Reinstitution of division psychiatrists
• 3 echelon system of care
• Division, Army hospital theater
• Mobile psychiatric detachments developed
• Combat zone vs rear reactions

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Vietnam

• Poor morale and cohesion
• Individual one year rotation policy
• Few classic battle fatigue reactions
• Misconduct
• fragging, massacres
• Drugs and alcohol
• PTSD (post-traumatic stress disorder)

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Desert Storm/Shield

• Persian Gulf Syndrome
• Medically unexplained illnesses
• Common symptoms include rashes, fatigue,
  depression, headaches
• Fears about exposure to chemical agents
• 10 years later, still the focus of extensive
  research

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Operations Other than War (OOTW)

• Somalia, Haiti, Bosnia, Kosovo
• Active mental health interventions
• Combat Stress Control Teams, Division Mental
  Health, Chaplains
• Low combat casualty reaction (CSR) rate
• Common problems of loneliness, depression

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Emotional and Behavioral Problems Related to
Conflict and Deployment

• Battle fatigue
• Misconduct
• Post-traumatic Stress Disorder
• Compassion Fatigue

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Battle Fatigue

• Physical Signs
• tension, jumpiness, cold sweat, upset, diarrhea,
  haunted stare, fatigue, pounding heart
• Mental Signs
• anxious, irritable, difficulty thinking, trouble
  sleeping, anger, grief, loss of confidence in
• self and unit

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Misconduct

• Misconduct behaviors--mutilating, killing,
  desertions, AWOL, alcohol and drug abuse,
  malingering, self-inflicted injuries, etc
• May or may not be related to combat stress
• Criminal behavior must be investigated and
  punished

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Post-Traumatic Stress Disorder

• Extreme traumatic experience
• Clusters of symptoms
• Recurrent and distressing recollections
• Persistent avoidance of stimuli
• Increased arousal and anxiety
• Post-Traumatic Stress Symptoms
• may have symptoms but not meet criteria for
  disorder

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Compassion Fatigue

• Secondary traumatic stress disorder in those who
  treat the traumatized
• Common in first responders, medical personnel

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Background of Combat Stress Control DoD Directive

• General Accounting Office (GAO) Report 1996
• Combat Stress Control DOD Directive 6490.5 signed
  23 Feb 1999
• White House Conference 6 June 1999 emphasized
  Service implementation

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DoD Directive 6490.5 Combat Stress Control

• CSC policies throughout DoD
• Service CSC consultants (5)
• CSC concepts shall be taught to line
• CSC personnel shall train with line

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DoD Directive

• BICEPS (brevity, immediacy, centrality,
  expectancy, proximity, simplicity)
• Separate Combat Stress Reaction (CSR) casualty
  data
• Service specific implementation plans
• each Service has own mission and culture

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Leaders and Operational Stress Conference

• June 20th and 21st 2000 at Ft. McNair
• Emphasis on line participation
• Brought line, religious, and medical communities
  together
• International attendance

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Combat Stress Control Pillars

• Primary--unit morale, cohesion, communication,
  stress inoculation
• Secondary--stress management, critical event
  debriefings, 4 Rs
• Tertiary--treatment, continue expectation of
  return to duty and recovery, military discipline

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Front Line InterventionsLeadership Actions

• Emphasis on unit cohesion, morale and discipline
• Tough realistic training
• Sleep hygiene, 3 hots and a cot
• Stabilize home front
• Stress inoculation
• anticipate exposure to dead bodies, atrocities

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Handling Remains

• The Mission
• What to Expect
• Guidelines on How to Work with Human Remains
• learn about tragedy, look at pictures in advance
• limit exposure to stimuli
• take care of yourself and others
• debriefings

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Front Line Interventions--Chaplains and Medical

• PIES/BICEPS
• Proximity, Immediacy, Expectancy, Simplicity
• Brevity, Centrality
• 4 Rs--rest, reassurance, rehydration, respite
• Stress management classes
• Critical event debriefings (CEDs)/critical
  incident stress debriefings (CISDs)

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Tertiary Treatment

• Clinic/hospital based
• Continue expectation of Return to Duty if
  appropriate
• Individual and group psychotherapy,
  pharmacotherapy

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US Military Assets Army

• Division Mental Health
• Stress Control Detachments
• Chaplains
• Mental Health in Hospitals

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US Military Assets Navy and Marines

• SPRINT Teams (Special Psychiatric Rapid
  Intervention Teams)
• Mental health in hospitals
• Chaplains
• Marines Division psychiatrists

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US Military Assets Air Force

• Critical Incident Stress Management (CISM)
• Mental health in hospitals
• Chaplains
• Extensive emphasis on suicide prevention

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Outstanding Issues

• Effectiveness of debriefings
• Screenings
• Metrics
• Training
• Consistent implementation

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Controversy over Debriefings

• Commonly used now in United States
• Anecdotal stories of effectiveness
• Little empirical data
• Question of re-victimization
• Does not prevent PTSD

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Metrics--Screenings

• Length
• Ease of administration
• Confidentiality
• Resources Needed
• Different instruments under evaluation

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Metrics

• What are you measuring?
• Cases, casualties, evacuations, patients,
  contacts, hospitalizations
• What are baseline rates of CSRs?
• Historical vs. current OOTWs
• How do you measure effectiveness of
  interventions?
• multiple uncontrolled variables
• no control population

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Training

• Who is trained?
• How are they trained?
• How can that be improved?

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Who Needs Training?

• Medical personnel
• Chaplains
• Independent duty corpsman (IDC)
• Commanders
• NCOs
• CINCs

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Where Would Training Occur?

• Medical training
• Service Schools
• Pre-Command Courses
• Sergeants Time
• In the field
• Media (radio, TV, internet)
• Out reach conferences

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Implementation--Service Wide Resources

• Mental Health
• Chaplains
• Physicians
• Command
• Media
• Websites

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Difficulties for Implementation

• Lack of dedicated resources
• Line buy-in
• Stove-piping

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ConclusionCSC

• Combat/Operational Stress Control improves human
  performance and retains service members
• The line needs to support the concept or it
  wont work