1. 19 Sept 2005 UNCLASSIFIED 1 of 23 CDR John Kennedy, MC, USN HQMC Health Services Combat/Operational Stress, Behavioral Healthcare, and the PDHRA Photo of Marines in Humvee about to depart on convoy

2. 19 Sept 2005 UNCLASSIFIED 2 of 23 Overview The Problem OSCAR Findings From EFCAT Mission & IG Assist Visit PDHRA The Way Ahead

3. 19 Sept 2005 UNCLASSIFIED 3 of 23 The Problem High incidence of stress and bona fide psychiatric illness in the wake of deployment Stigma interferes with seeking care Inadequate mental health capacity at MTF’s serving Marines Inadequate HQMC coordination, doctrine

4. 19 Sept 2005 UNCLASSIFIED 4 of 23 OSCAR: Original Timeline Month12-6024 Data Collection and Analysis MROC Decision Point MarDiv (X3) PilotIPT Jan 04 MROC Interim Brief Jun 03 Full OSCAR Implementation: All billets defined by IPT filled. MROC Approval Jan 06

5. 19 Sept 2005 UNCLASSIFIED 5 of 23 OSCAR: Actual Timeline 12024 Data Collection/Analysis Decision Point IPT Interim Brief Jun 03 Stepwise OSCAR Implementation MROC Approval ? “Formal” Pilot Study MROC Comeback Jun 04 Existing Division Psychiatrist, HM Psych Tech BUMED Psych Providers 2MARDIV SNCO’s Jan 04 Other SNCO’s Chaplains ? Jun 05

6. 19 Sept 2005 UNCLASSIFIED 6 of 23 OSCAR Validation Partial implementation is already showing results. Preliminary data show: –Lower med-evac rate for GCE versus FSSG and ACE in theater (data on next slide) –Within-unit support transcends stigma –Battalion commanders have greater trust & confidence in their “embedded” psych experts Psych augmentees deployed with Medical BN’s are being employed in an “OSCAR-like” fashion CNA to study OSCAR outcomes & its potential applicability to the reserves

7. 19 Sept 2005 UNCLASSIFIED 7 of 23 Findings from EFCAT mission and IG Assist Visit Mental health/chaplain cooperation better now Commanders like & trust OSCAR MAP personnel ignorant of particular role of battlefield stress management Ambiguous policy guidance from HQMC leading to variations in execution USMC leaders want a “wrap-around” approach Need/desire to push stress management “downward” to the platoon level

8. 19 Sept 2005 UNCLASSIFIED 8 of 23 Post-Deployment Health Reassessment (PDHRA) Post-DHA misses people in need –Underreporting –Delayed emergence of symptoms Reassess Post-DHA completers at the 3-6 month mark –If deployed prior to March 04, optional, passive –If deployed after March 04, required, active All-electronic AMSA is data repository

9. 19 Sept 2005 UNCLASSIFIED 9 of 23 PDHRA Implementation Issues Difficult notification process; ownership unclear Delays in funding to NEHC for ePDHRA “Road show” needed to survey drilling reservists Results of I MEF pilot –Time-consuming for providers & Marines Screening of all Marines back from OIF will take many months Expect over 1000 psych consults which will overwhelm clinics –Recommend a PDHRA administration team and significant augmentation of hospital mental health clinic –Web-based administration essential

10. 19 Sept 2005 UNCLASSIFIED 10 of 23 Next Steps Hire, train PDHRA program managers Decide on next steps in implementation –Larger pilot –Navy- and Marine Corps-wide Calculate new estimates for roll-out date(s) Work with ASD/HA to hire –“Road show” screening personnel –More mental health staff

11. 19 Sept 2005 UNCLASSIFIED 11 of 23 Way Ahead OSCAR –CNA study –Review feasibility of filling SNCO and Chaplain billets –Consider applicability of concept for other MSC’s, Reserve New Combat/Operational Stress Control Section at HQMC (M&RA) –CAPT Nash to lead –Multidisciplinary COSC Advisory Board –Mission: develop a wrap-around stress management program incorporating OSCAR, Warrior Transition, MCCS, MTF mental health Navy Medicine COSC Advisory Board TECOM’s mentorship program

12. 19 Sept 2005 UNCLASSIFIED 12 of 23 Questions? Comments? Photo of 3/24 BN HQ

13. 19 Sept 2005 UNCLASSIFIED 13 of 23 Back-Up Slides: The Problem

14. 19 Sept 2005 UNCLASSIFIED 14 of 23 The Issues 15% of Marines back from OIF-I met screening criteria for disabling depression, anxiety, and/or PTSD Post-deployment stress associated with –Family disruption, separation, divorce, domestic violence –Accidents, misconduct, suicide (up 28%) –Administrative Separation, Physical Disability Recruitment/retention an emerging issue

15. 19 Sept 2005 UNCLASSIFIED 15 of 23 Photo of front of Chapel with sign about CSC in the rear Photo of hallway outside Bravo Surgical Co Combat Stress Control office Stigma, Poor Access to Care

16. 19 Sept 2005 UNCLASSIFIED 16 of 23 Mental Health Visits at NH CPen

17. 19 Sept 2005 UNCLASSIFIED 17 of 23 COSC doctrine: feast or famine –Army: 281 page field manual –USMC: reference publication and local TTP’s

18. 19 Sept 2005 UNCLASSIFIED 18 of 23 Warrior Transition Chaplain-centric program in OIF-I & II Working Group to Update It –Collaboration: line, chaplains, and mental health –Three-stage educational effort Mental health and core group of Chaplains to unit chaplains Unit chaplains to small unit leaders Small unit leaders to rank and file Marines –Three phases Warrior Preparation Warrior Sustainment Warrior Return

19. 19 Sept 2005 UNCLASSIFIED 19 of 23 Stress Patterns Amongst Expeditionary Warfighters Pathological Optimum for Combat Normal Range Stress Level Combat Field OperationsGarrison Psychiatric illness Misconduct Problematic if persists Ideal Typical

20. 19 Sept 2005 UNCLASSIFIED 20 of 23 Various Approaches to Stress Prevention/Management Character Development –Toughness; force of will –Inadequate; stigmatizes those with problems Education –Teach accurate expectations and self-care –Inadequate Peer-to-Peer Support/Mentoring –Ubiquitous; credible –May exceed skill set; problems if “peer” is traumatized also

21. 19 Sept 2005 UNCLASSIFIED 21 of 23 Various Approaches to Stress Prevention/Management Pastoral Care –Memorial services; individual/group teaching, counseling –Cultural divide, often exceeds typical skill set Psychological Debriefing –Review event(s) and emotionally ventilate –May not work; counterproductive if re-traumatization likely; may interfere with chain of command Medical Model –Diagnose and treat individuals who are abnormal –Inadequate prevention; cultural divide; inadequate access to care; stigma

22. 19 Sept 2005 UNCLASSIFIED 22 of 23 Air Force Approach Efforts are not deployment- or incident-focused –Short deployments; only 1% of force in direct combat; minimal PTSD –Well-demarcated incidents, mostly aircraft mishaps –No need for organic mental health or chaplains Instead, uses a systematic community effort Each organizational level of the USAF features two coordinating bodies: –Community Action Information Board (CAIB) –Integrated Delivery System (IDS)

23. 19 Sept 2005 UNCLASSIFIED 23 of 23 Air Force Approach Leadership roles in event of an incident –Lead, intervene, seek assistance from base resources –Guidance provided by online Leader’s Guide To Personnel In Distress –30 hours of stress management education (classroom, online) annually for leaders and rank- and-file Stress Management Provider Roles –Mental health teams intervene/deploy if requested –No longer conducting psychological debriefings

24. 19 Sept 2005 UNCLASSIFIED 24 of 23 USAF versus USMC Agencies and services are coordinated better – at both the headquarters and installation levels Doctrine is more extensive; guidance for leaders is clearer USAF has approx 50% more mental health personnel than USN/USMC USAF has less integration of stress management providers with warfighters

25. 19 Sept 2005 UNCLASSIFIED 25 of 23 Validation & Incorporation Into USMC Early/Expeditionary Intervention Self- and Buddy-Aid –Lessons from psychological debriefing –Role of USMC training continuum Leadership Increased role of line corpsmen, BAS –Requires training Increased effectiveness of chaplains –Training, collaboration with mental health Avoidance of mental health stigma by… –“Embedding” mental health, e.g. the OSCAR program –Use of Marine SNCO’s as part of stress teams

26. 19 Sept 2005 UNCLASSIFIED 26 of 23 Validation & Incorporation Into USMC Ongoing and Post-Deployment Organizational improvements –Wrap-around doctrine –USMC champion at HQMC –HQMC and installation coordinating bodies Unit cohesion as primary method Community health approach in support of small unit leadership Consider increased footprint of well-trained organic mental health

27. 19 Sept 2005 UNCLASSIFIED 27 of 23 Back-Up Slides: OSCAR

28. 19 Sept 2005 UNCLASSIFIED 28 of 23 Mental Health Support in USMC (Pre-OSCAR) FMF (Active, x3) Division -1 Psychiatrist -1 Enlisted Psych Tech Force Service Support Group -None organic -CSC platoon (augmentees) 1 Psychiatrist 2 psychologists 3 psych techs Wing -None organic MTF, MC Base MH Services Civilian model -Poorly coordinated -Not operationally trained -Non-deployable -Liaison/accountability to operating forces variable -Access problems/stigma Limited effectiveness FSSG MED BN Community Counseling Center Div Psych CREDO Mental Health Substance Abuse SemperFit Pastoral Counseling SACO/ FAPO Alcohol Treatment Facility

29. 19 Sept 2005 UNCLASSIFIED 29 of 23 Putting the Pieces Together Multidisciplinary Early, coordinated intervention Accountable to operating forces Supports all phases of deployment Div Psych SNCOs Command Liaisons Chaplain HM Psych Tech Prevention Early Intervention Restoration MH Professionals

30. 19 Sept 2005 UNCLASSIFIED 30 of 23 OSCAR Pilot Expanded stress management capability at each active MARDIV PositionSource 1 PsychiatristExisting Div Billet 1 HM Psych TechExisting Div Billet 1 Add’l PsychiatristBUMED 1 Psychologist (I, II MEF)BUMED 1 ChaplainDivision 4 SNCO’sDivision

31. 19 Sept 2005 UNCLASSIFIED 31 of 23 Current OSCAR Billet Status *Pre-OSCAR T/O Key Filled – In Garrison Filled – Deployed Unfilled No billet for pilot MARDIV Position 1 st 2 nd 3 rd Psychiatrist/ Team Leader* HM Psych Tech* Additional Psychiatrist Clinical Psychologist Chaplain Staff NCO

32. 19 Sept 2005 UNCLASSIFIED 32 of 23 Disposition of Marines Receiving Mental Health Evaluations During OIF-II 4% Referral Rate 5% 99% Return to Duty Rate 95% Personnel Deployed* 1MARDIV 1FSSG/3MAW 12,000 11,000 *Approx personnel deployed at any given time. (Source: 1MARDIV Psychiatrist)

33. 19 Sept 2005 UNCLASSIFIED 33 of 23 Back-Up Slides: EFCAT & IG Findings

34. 19 Sept 2005 UNCLASSIFIED 34 of 23 Findings From EFCAT Mission: Factors Contributing to Success GCE leaders pleased with organic MH with emphasis on… –Resiliency –Forward treatment B CSC Platoon’s support to B Surgical Company medical personnel Collaboration with chaplains at all levels

35. 19 Sept 2005 UNCLASSIFIED 35 of 23 Findings From EFCAT Mission: Factors Hindering Success MAP personnel felt inadequately trained in COSC Conflicting clinical approaches: –Non-medical model: no patient role, COSR label versus –Medical model: patient role, DSM-IV diagnosis Presence of psychiatric technicians at ostensibly non-clinical Regimental Recuperation Center Ambiguity of MH and chaplain roles in warrior transition program

36. 19 Sept 2005 UNCLASSIFIED 36 of 23 Findings From EFCAT Mission: Areas for Further Study Is there value in organic MH assets at Wing? Group? Would MH assets on the CSC Platoon T/O be better able to help Marines by… –Roving more to GCE units (as Army CSC Platoons do?) or… –Being shifted to augment MH assets already “embedded” within the GCE? Is an RRC a good idea? Better at the BN level? Can more be done to empower forward, non-MH assets to provide stress management? –MO’s and corpsmen –Small unit leaders; peers

37. 19 Sept 2005 UNCLASSIFIED 37 of 23 Peer-to-Peer Programs Being Proposed/Probed By Line Marines Historically, this has been the cornerstone of warfighters’ stress management, but it is under-appreciated A peer counseling program is in use today by the Royal Marines, and is being looked at by LtGen Mattis Example from MAG 41 (reserve unit) Obvious benefits –High access, low stigma –High trust and credibility –Timely Potential role for mental health Help train small unit leaders and peer counselors –Availability for referrals (direct or via primary care) Problem: overlaps with plan for new Warrior Transition

38. 19 Sept 2005 UNCLASSIFIED 38 of 23 Line Leadership’s Desire for “Wrap-around” Approach Current situation –Many players using many approaches –Minimal doctrine –Perception of inadequate services, poorly coordinated Dr. Grant, a civilian psychologist has proposed to pull it all together; it is being given a close look

39. 19 Sept 2005 UNCLASSIFIED 39 of 23 Back-Up Slides: PDHRA