Combat and Operational Stress Alan Ogle, Maj, USAF, BSC Military Psychology PSY4990 University of West Florida, Spring 09

Disclaimer: information in this briefing was compiled from multiple sources in the US military medical services. Many have been modified or shortened to fit the educational purpose, format and training time available. Views expressed are those of the author and do not reflect the official policy or position of the United States Air Force, Department of Defense, or the U.S. Government.

3 War Bad news There is a psychiatric cost to sending young men and women to war Really bad news No one is immune Good news Vast majority survive Really good news Resiliency is the norm

The War (OIF/OEF) Deployers: 1.64 million US Service Members Casualties: 4, Air Force Wounded: 32, Air Force Data include dates: 7 Oct 01 – 21 Jun 08

Battlefield

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OIF Combat Experiences U.S. Army 2003 Being attacked or ambushed - 89% Receiving incoming fire - 86% Being shot at - 93% Seeing dead bodies or remains - 95% Knowing someone seriously injured or killed - 86%

Three Signature Injuries of OIF/OEF Extremity amputations 803 (Jul 08) Traumatic Brain Injury 320,000 (Jan 08) Post Traumatic Stress Disorder/ Depression 300, 000 (Jan 08)

OEF/OIF TBI and PTSD Jan, 2008 Traumatic Brain Injury (TBI) 19.5% report experiencing a probable TBI during deployment Estimated 320,000 cases of TBI Total annual costs of the 2776 cases identified by mid-2007 is $ M. Post Traumatic Stress Disorder (PTSD) 18.5% of veterans meet criteria for PTSD or Major Depressive Disorder (MDD) 14% of returning service members currently meet criteria for PTSD Estimated 300,000 cases of PTSD/MDD Estimated societal costs of PTSD/MDD for the 2 years after returning from deployment is $4.0 – 6.2B 35% of OIF veterans access MH services after returning home

Occupational Morbidity (Jan, 2008) (six months following hospitalization) % Army AD members psychiatrically hospitalized left military service 11 – 12% Army AD members hospitalized for non-MH diagnoses left military service Those separated for a MH condition had higher rates of disability than those separated for non- MH medical conditions

Vision: Healthy/Mission Ready Communities Deployment Behavioral Health

13 Combat and Operational Stress Control Combat stress includes all the physiological and emotional stresses encountered as a direct result of the dangers and mission demands of combat Combat and operational stress control may be defined as programs developed and actions taken to prevent, identify, and manage adverse combat and operational stress reactions (COSR) This program optimizes mission performance; conserves the fighting strength; and prevents or minimizes adverse effects of COSR

14 Before Deployment of Forces Preparation of Service Members (SM) and Families Command Stress Management During Deployment Combat and Operational Stress Control (COSC) After Return of Forces Reintegration with Families PDHRA Education: Army Battlemind, AF Landing Gear Treatment Combat & Operational Stress Prevention and Control Home Station Pre- Deployme nt AOR Redeploy ment Reintegrat ion

15 Basics of Stress Management Stress is normal part of life, healthy unless either excessive or individual has less developed stress management resources Sources of potentially excessive stress: Multiple life stressors Deployment and Operational Stress High work stress coupled with poor unit cohesion Isolation from spouse/normal supports Stress Management is balancing stress load and coping resources

16 Healthy Coping Verbal Low energy Head/body aches Sleep problems Tension Behavior Physical Harm self or others Break things Withdraw from others Abuse alcohol Scream Yell Curse Argue Exercise Healthy recreation & Fun Socializing Good nutrition Talk with friends, family, supervisor See a counselor or chaplain Write letters, journal Sleep, Self-care/nurturing Relaxation Skills Medication for: -sleep, depression, anxiety DON’T DO THESEDO THESE SEE MEDIC WHEN NEEDED High Stress Manifests:

17 Deployment Stress Control Good leadership by officers / noncommissioned officers (NCOs) Good equipment, supplies etc. Good unit cohesion, confidence, focus Pre-deployment training: Realistic What to expect What is expected of them Healthy coping strategies Resources for help if needed

18 Care for Families Service members need to know their families are taken care of Needs met—medical, financial, household etc. Ongoing communication-phone, mail, , video Healthy coping by families Unit support of families Family Readiness Groups (FRGs) Sample Training for Soldier and

19 Commanders Officer and Enlisted leaders are the most important in unit stress management program Attending to soldiers needs and concerns Good leadership Sample Leaders

Support During Deployment Trauma Stress Response Teams/Unit Consultation Mental health services in theater Combat Operational Stress Control Units (COSC) Air Force EMED CASF Theater Hospital Post-Deployment Health Assessment

21 COSC Facilities “Armor up, Prevent when you can, Treat when you must”

22 Combat and Operational Stress Control Its goal is to return Soldiers fit for duty expeditiously The purpose of COSC is to promote soldier and unit readiness by― Enhancing adaptive stress reactions Preventing maladaptive stress reactions Assisting soldiers with controlling COSRs Assisting soldiers with behavioral disorders

23 TRIAGE CATEGORIES FOR COSR CASES The following are triage categories that may be used for COSR cases: Help-in-place Rest Hold Refer

24 TRIAGE CATEGORIES FOR COSR CASES HELP-IN-PLACE (HIP) Help-in-place is used to identify those cases that do not have severe COSR or BH disorders They are provided COSC consultation and education, as appropriate, and remain on duty These interactions may occur in any setting Individual identifying information is not retained or documented There is no implicit or explicit therapist-patient or therapist-client relationship in HIP interactions

COSC Principles: BICEPS Brevity--lasts 48 to 72 hours Immediacy--should be instituted as rapidly as possible Centrality--interventions should be in a central location, separate from a medical facility Expectancy—Service members should be given a clear and consistent message that they will return to duty with their unit Proximity--management occurs near the front with close contact maintained between the member and his or her command Simplicity--focus on the practical steps to restore function and health; and not on treatment and psychotherapy

26 Simplicity Use brief and straightforward methods to restore physical well- being and self-confidence Reassure of normality Rest (respite from combat or break from the work) Replenish bodily needs (such as thermal comfort, water, food, hygiene, and sleep) Restore confidence with purposeful activities and contact with his unit Return to duty and reunite soldier with his unit

27 NONPATIENT STATUS To prevent Soldiers with COSR from adopting the patient role, these guidelines should be followed: Keep the Soldier in uniform and hold him responsible for maintaining Soldier standards Keep the Soldier separate from seriously ill or injured patients Avoid giving him medications unless essential to manage sleep Do not evacuate or hospitalize the Soldier unless absolutely necessary Do not diagnose the soldier prematurely Transport the soldier via general-purpose vehicles, not ambulances

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30 Training Topics: Cont Working with special populations Special ops Contractors Door bangers Convoy drivers Flyers

Re-Deployment Support Reintegration /Reunion education Landing Gear Post-Deployment Health Reassessment Mental health services at home station 18 March class presentation: Post Deployment Mental Health Care

Resource Links PDHealth Predeployment information Air Force predeployment prep--family separations guide Army Behavioral Health predeployment information PDHealth Postdeployment information Postdeployment resources Military Spouse postdeployment information