1. Combat Operational Stress Control (COSC): An Integral Part of Force Health Protection
CDR Meena Vythilingam, M.D.
Deputy Director,
Psychological Health Strategic Operations
Office of Deputy Assistant Secretary of Defense for
Force Health Protection & Readiness Programs
Thanks
Honor to present at the plenary in front of an august audience
Particular pleasure to have my first psychiatry professor back in 1993 during my residency at Yale Dr Southwick in the audience-
COSC from the DoD perspective- briefly talk about COSC programs across Services
Most importantly I’m going to talk about what’s in it for you? – it’s the last few hours of the conference,
although I am from the DoD, we are really here to help!

2. Force Health Protection and Readiness
Deputy Secretary of Defense
Undersecretary of Defense
(Personnel and Readiness)
Assistant Secretary of Defense
(Command, Control, Communications, and Intelligence)
Army Medical Service
Secretary of the Army
Army Surgeon General
Force Health Protection and Readiness: Psych Health
Lt Col Ritschard- Director
CDR Vythilingam-Deputy
LCDR Frazer, Dr. Carty- XO,
Dr. Davison, Dr. Paris,
Ms. Fraine, Ms Dekle
Ms Berry
Assistant Secretary of Defense
(Health Affairs)
Army Medical Facilities
Bureau of Medicine and Surgery
Secretary of the Navy
Located in an office conveniently named after 2 of the most important topics of this conference;
Force Health protection and readiness- green zone
Located in the Office in the Asst Sec Def – Health affairs; help shape policy, mental health surveillance
Great team of psychologists, I am the only psychiatrist
How are we different from the DCoE
Navy Surgeon General
Navy Medical Facilities
Air Force Medical Service
Secretary of the Air Force
Air Force Surgeon General
Air Force Medical Facilities

3. Psychological Health Strategic Ops
Improve – Protect – Conserve
Health & Resilience of Service members
Optimal mission performance
Our MAIN MISSION is to improve and protect the Psychological HEALTH Of the war fighter who is the most valuable asset we have
Full spectrum of What ever it takes to improve health and resilience of service members:- policies, surveillance, quality assurance, evaluation, resources , logistics,
The ULTIMATE GOAL is to ensure that every soldiers, sailors, airmen, marines in the fight and coastie can perform every mission optimally
We work equally hard for all Services to ensure that they can focus on their individual mission, although currently we are working closely with the Marines. 3

4. COSC and Force Health Protection
Future of war fighting is joint operations;
greatest challenge:
meeting the joint medical needs of joint operations, and
working in a joint manner shoulder to shoulder with other Services exemplified by our chief Navy psych tech who showed up at Ft Drum,
The Services got together with the DoD and came up with the Joint force health protection Con ops
To protect the force and enhance the mission through three equally important and interrelated pillars across deployment cycle:
Goes beyond the traditional role for medicine to stress the importance of prevention and protection.
It’s easy to see how COSC is crucial for force protection and readiness,
COSC also fits in the JFHP conops- also has 3 pillars- things to do across the deployment cycle
i.e COSC is not just treating ASD and PTSD in-theater- lots of stuff that needs to be done LEFT OF THE BOOM
strengthen before deployment,
prevent protect during deployment and
What is prevention and protection in the COSC context-
What are we preventing? Orange/red zone, in theater and back home, and prevent suicides, violence, homicides, ptsd when return, reintegration into civilian life;
SM can love and work
So we contacted the Services, got their updated COSC doctrines (Draft Doctrine from Navy/MC and leader COSC manual from Army 2009) and said let’s look through them and figure out what they are doing in each of these three pillars
And this is what happened
Health & Fit Force – necessary precondition for mil success in joint ops.
Prevention & Protection – direct impact on requirements for health restoration. Sustain health and prevention of diseases and non-battle injuries essential.
Medical & Rehabilitative Care – More agile and responsive health care in-theater,
Joint Force Health Protection Strategy 2007

5. COSC Alphabet Soup Explosion
6 Rs: Reassure, Rest, Replenish, Restore confidence Return to duty, Remind
4 Cs: Check, Control, Connect, Confidence
3 Cs: Commitment, Control, Challenge
7 Cs: Check, Coordinate, Cover, Calm, Connect, Competence, Confidence
PIES: Proximity, Immediacy, Expectation, Simplicity
Strengthen, Mitigate, Identify, Treat, Reintegrate
BICEPS: Brevity, Immediacy, Contact/Centrality, Expectancy,Proximity,Simplicity
And here is what we ran into When we reviewed the doctrines (only Service member)
imagine what would have happened if I had included all the family programs;
For eg. We found the Read out 7C Navy
And 6 Rs Army
How do we know if 7Cs are better than 6 Rs- going back to the psych tech imagine her trying to communicate with her colleagues
Personally, I would propose that PIES are definitely better than BICEPS
PREVENT: Privacy, Relaxation, Encourage, Video Games, Educate, Normal duties, Three hots and a cot
BATTLEMIND: Buddies (cohesion), Accountability, Targeted aggression, Tactical awareness, Lethally armed, Emotional control, Mission operational security, Individual responsibility, Nondefensive (combat) driving, Discipline and ordering
3 Cs: Combat readiness, Combat response, Combat responsibility

6. Making Sense of the Alphabet Soup: Merging Navy/MC Model with IOM Approach
Universal
Entire population
Selective
Subset exposed to potentially traumatic event
Target Condition
ASD / PTSD
Implications for early detection and treatment
Complications
Implications for Maintenance & Rehab
Wanted to make sense of the alphabet soup
Tried to combine 2 concepts here-
IOM model
Stress continuum
Walk you through the IOM approach:
Universal – equivalent of mental push ups and sits up and 2 mile run
Selective- intervene is a select subset of those at risk- eg. GTMO guards- CAPT Laraway spoke about this program
Indicated- intervention when it is indicated, but still sub-clinical symptoms, not yet clinical- COSFA training
Red is traditional treatment
All colors are important when it comes to COSC, but what is most important is . Research shows that Orange predisposes to red:
Key here is we have an incredible WINDOW OF OPPORTUNITY to preventing Orange Red transition;
this window of opportunity shared by the line and medics
Early identification- COSR
Early intervention
Prevention/mitigation- orange going on to re
Red is already too late
Advantages of IOM model:
Breaks from a causality model of use.
‘Spectrum of Intervention’ model places great emphasis on the importance of prevention.
Introduces concept of risk management – importance in knowing proportion of population at risk in turn means most appropriate prevention strategies can be used.
In turn, this sets up potential for strong evaluation results.
Identification of Subpopulation
Is this an appropriate subpopulation?
Issues – Selected or Indicated or both?
Setting and Access
Where to go, Who to partner with?
What types of Prevention Approaches might we consider
Who should we target?
What approaches should we consider?
Primary prevention measures fall into two categories.
1. The first category includes actions to protect against disease and disability, such as getting immunizations, ensuring the supply of safe drinking water, applying dental sealants to prevent tooth decay, and guarding against accidents.
General action to promote health is the other category of primary prevention measures. Health promotion includes the basic activities of a healthy lifestyle: good nutrition and hygiene, adequate exercise and rest, and avoidance of environmental and health risks.
Secondary prevention: The goal of secondary prevention is to identify and detect disease in its earliest stages, before noticeable symptoms develop, when it is most likely to be treated successfully. With early detection and diagnosis, it may be possible to cure a disease, slow its progression, prevent or minimize complications, and limit disability.
Tertiary prevention: Tertiary prevention programs aim to improve the quality of life for people with various diseases by limiting complications and disabilities, reducing the severity and progression of disease, and providing rehabilitation (therapy to restore functionality and self-sufficiency). Unlike primary and secondary prevention, tertiary prevention involves actual treatment for the disease and is conducted primarily by health care practitioners, rather than public health agencies. Read more: Prevention of Disease - Tertiary Prevention Read more: Prevention of Disease - Primary Prevention
Indicated
Exhibiting sub-clinical symptoms

7. Universal Selective Indicated Reintegration Army Navy Marine Corp
CSF (Institutional Resilience Training (IRT) and surveillance through the GAT)
Leader lead AAR
TEM
Event/Time
BPD’s
BICEPS
6 Rs
Deployment Cycle Support
Op. Resilience Training
Warrior Adventure Quest
Navy
Strengthen (unit cohesion, leadership, tough realistic training)
AAR
Mitigate
Identify
Detainee ops
COSFA
Reintegrate
Marine Corp
Warrior Preparation Program; IIT
AAR (without outsiders)
Post treatment: Confidence, Connection, Competence
Post deployment:Warrior transition Program 1, and 2
Air Force
Airman Resiliency Training
NIMH recs
AF Mortuary Affairs Resiliency Program
VA DoD CPGs
Deployment transition center – (Third Location Decompression)
Very busy slide – let’s look at general concepts across Services, and look for evidence based studies
Universal prevention: all Services are paying attention and doing something for strengthening;
Revamped Battlemind with a new name/ bottle
Marine corps strengthening programs: Mojave Viper; Infantry Immersion trainer; Families
Selective prevention- high risk groups after PTE:
Good news- no CIDR
LLAR –difference between army and marines
Mitigate- Reduce the force and intensity of the stressor- lessens the impact of the stressor; Mitigate (eliminate stress, replenish “leaky bucket”)
Post trauma social support
Indicated prevention:
Acronyms land- head to head comparison of what is better
Reintegration
Warrior Adventure Quest (WAQ)

8. Services Agreement: Force Preservation Early Identification Stigma
Vulnerability Factors
Long-Term
Outcomes
Psych
Suicide
Homicide/violence
PTSD, depression
Occupational
• Impaired/
deviant
performance
• Involuntary
separation/
Attrition
Excessive
medical care
Social
• Aggression/
withdrawal/
avoidance
Family
• Marital discord
• Hostility/violence
Embedded Support Service
• COSC services
• Behavioral health care
• Chaplain
Consultation and education
Peer education
Protective Factors
Leadership
Unit Cohesion (horizontal/vertical)
• Mentoring
Family support
Tough realistic training
Barriers
• Access to Care
Stigma
Outreach
Stressors
• Environmental
• Physiological
• Cognitive
• Emotional
Early Identification
Occupational
Demands
Everyone is working fast and furiously towards the same short term and long term goals- army 2009 COSC manual for leaders
I.e.. keep SM in the fight and have them adjust well when they are back home
COSC is a leadership responsibility; leaders need support: Leadership consultation, Education
Care of the individual SM is just as important as paying attention to the unit and the family (surveillance, morale, cohesion..)
Stigma is alive and well Nobody wants to go to a shrink and wants to know that I went to a shrink-
Assets should be embedded at the unit: chaplain, peer mentors, organic beh. health expert
Early identification and simple intervention starts with peers- “warriors take care of each other”, soldier peer mentors;
army even has a section of CONTINUUM OF COMBAT AND OPERATIONAL STRESS REACTIONS which lists the mild and severe stress reactions

9. COSC – Service Differences & Challenges
Service practices
Which program “measured results?”
Universal prevention
Is there a bullet proof vest for the mind and soul?
Positive Psychology vs.. Strengthening / education
Selective prevention
Better predictors, e.g. pulse and better treatments
Indicated prevention
COSFA vs.. BICEPS
Reintegration
Cyprus vs.. Battlemind
Can we tell the line leaders, I have the best prevention strategy for you?
If you do this, you can keep your men healthy and in the fight while deployed and able to love and work, healthy while at home
Published studies of efficacy- Adler et al Battlemind debriefing after deployment- 4 months follow up
Brain armor
bullet proof vest for the mind?
Strengthen vs. stress mitigation
Prevent cognitive impairment during stress
Better sleep in a combat setting
Cognitive reappraisal techniques

10. Do We Really Need a DoD COSC Policy?
Most effective, affordable approach to keep the Service member in the fight or reintegrate
Complex, continuing, urgent problem
Multiple Service programs and evaluations rolled out
Limited published evidence of what works
Solving complex problems need innovative solutions
Joint Service COSC Program
Service COSC reps will meet to share data, practices, and coordinate COSC programs
Sharing program evaluation results is key
e.g. OSCAR
Impartial facilitator
What’s in it for you?
How is the DoD going to make a difference in the lives of your sailor and marines
Sgt Michael Blair- remember what helped him the most- 2 things- one was the ACEP program in WRAMC- army sports psychology program
I’m sure that every Marine leader in this room wants the best, most effective, and affordable approach to ……
Why do we need a COSC
The problems are complex
Each service is trying their approach to find a solution
Very little evidence to confirm what works, but several programs and program evaluation being rolled out as we speak
Innovative solutions
Innovation is in the interface eg. Marine Resiliency Study
Innovation is also in Services coming together
Need a central mechanism to communicate, share what works, what doesn’t work,
Services don’t have the opportunity
Here is an example of how it might work: If OSCAR works for the Marines, then the DoD could request the Army to evaluate is the OSCAR model works for them instead of the COSC teams-; if OSCAR does not work for Army, then need to know why it works for marines?

11. Do We Really Need a DoD COSC Policy? Contd..
Program evaluation, common metrics
Focus on end-state goals
Update COSC DoDI
DoD COSC Directive- 1999
Outdated - Explosion of new programs and research since
Need for coordination among Service COSC efforts

12. Ensure future fighting force benefits from lessons learned
THANK YOU!
Ensure future fighting force
benefits from lessons learned
Define leadership responsibilities
Focus on both the Unit and individual
Preserve Service integrity

13. Back up slides:

14. Learning From Others- TRIM Model
Site Management Strategies
0 hrs
Social Support and Cohesiveness
Support and Monitoring
Education
Planning Phase
Planning Meeting
Identification of groups and individuals (Targeting)
Formulating the management strategy
0-24 hrs
Assessment of Risk (BDA model)
Individual – (Group intervention ruled out)
Small Group (<8) (Natural grouping or localized incident)
Briefing Meeting – (Soon after the event when troops are accessible)
72 hrs
onwards
Support and Monitoring
Support by Trained Stress Responders
Monitoring and Management by Commanders and Buddies
Briefing meeting – (Soon after the event when troops are accessible)
Early Referral for Specialist Help if Required
One Month Follow-Up and Referred for Specialist Help if Required

15. TRIM Risk Factors for Psychological Disorders
1. Perceives that they were out of control during the event
2. Perceives that their life was threatened during the event
3. Blames others for what happened
4. Reports shame/guilt about their behaviour during the event
5. Experienced acute stress following the event
6. Been exposed to substantial stress since the event
7. Had problems with day to day activities since the event
8. Been involved in previous traumatic events
9. Poor social support, (family, friends, unit support)
10. Drinking alcohol excessively to cope with distress

16. DoDD 6490.5 Combat Stress Control (CSC) Programs
Published in February 23, 1999
Certified Current as of November 24, 2003
In written in response to DoD IG Audit which found:
military training in combat stress control and management was not being adequately provided by all Services to all ranks and levels of responsibility
training was uneven in combat operational stress prevention, identification and treatment among the Services
Currently under revision

17. Force Health Protection
Protection: Shield from danger, injury, destruction, or damage; to prevent harm
Who are we protecting: Humans- the most valuable weapons system. “I am the weapon system; everything else is a tool”
Force Health Protection: Strategy that protects the health of all Service members.
Why is this important: So that all war fighters and support personnel are effective and can function. i.e. READY to conduct assigned missions and operations.
-State the obvious
The human being is the prime resource and key enabler of all war fighting systems.
HUMAN: the most valuable weapons system. To keep that human resource fit and ready , the DoD requires a robust health readiness capability

18. The Continuum of Care Protractor
Different levels of prevention are distinguished by the level of risk
of disorder/distress in various populations groups targeted.

19. Role of COSC in Joint Force Health Protection Operational Environment
6 functional area capabilities:
Joint Human Performance Enhancement
Joint Health Surveillance, Intelligence, and Preventive Medicine
Joint Casualty Management
Joint Patient Movement
Joint Medical Logistics and Infrastructure
Joint Theater Medical Command and Control (and Information Systems)

20. Combat Stress Behaviors (FM 4-02.51)
What do Services Agree On? Army Frame Work
What else do they agree on?
Frame work- combat and operational both key
Range of symptoms- color scheme
Not medicalizing it -
Lets talk about PTSD first………Here are some key terms. PTSD is actually a product of Combat and Operational Stress, which is a normal part of the Soldier experience. Every Soldier is exposed to combat and operational stress, it is the military experience, it is part of what we do. Serving in the Global War on Terror places additional stress on every Soldier and Family.
Because of the unique nature or our business, the profession of arms, Soldiers can be exposed to significant or even multiple potentially traumatic events. Potentially Traumatic Events, or PTEs is an event or events that cause individuals or groups to experience intense feelings of terror, horror, helplessness, and/or hopelessness. It is an experience that is perceived as a threat to one's safety or to the stability of one's world. Examples of PTEs include IED, firefight, death of a buddy, or other trauma
All Soldiers will react to the PTEs they are exposed to, most will successfully grow from those experiences and continue to serve. Some Soldiers may have difficulty transitioning through the PTE experience. While in the process of continued service, such as deployed, they may experience what we call Combat and Operational Stress Reactions or COSR. COSR is nothing more than the broad group of physical, mental and emotional signs that result from combat and operational stress. Remember, it is the reactions you may have while still engaged in doing your job, an example would be what you experience while still deployed during an OIF rotation.
These events will place strain on Soldier and unit. But I want to be clear, not everyone will be unable to deal with the effects of combat and operational stress or PTEs….in fact, most Soldiers do just fine. They experience something we call PTG or Post Traumatic Growth. PTG is a Soldier’s ability to adjust positively after traumatic experiences. It may include changes in personal strength, spirituality, relationships with others, and an increased ability to appreciate life.
Long Term Stress Reactions are a normal result from the military experience, to include serving in a combat environment. Both the good and bad experiences faced by a combat warrior will follow for a lifetime. Many warriors will come back better leaders, fathers, mothers, often more resilient, not taking life for granted as they may have before due to their ability to adapt and overcome. These adaptive stress reactions are positive. Not all intense combat experiences are negative.
However, Post Traumatic Stress Disorder, or PTSD, is a condition which may develop after someone has experienced a life-threatening situation during combat. It is a diagnosable psychiatric condition, but it does not mean a Soldier cannot live a fulfilling life. With treatment and support it is possible for Post Traumatic Growth to occur when a PTSD diagnosis exists. We will spend more time talking about the specifics of PTSD later on.
Combat Stress Behaviors (FM )
UNCLASSIFIED 20

21. Do We Really Need a DoD COSC Policy
Do We Really Need a DoD COSC Policy? Sharp Increases in Med Evacs Due to Psychiatric conditions: Effects on Force Preservation
Diagnoses and factors associated with medical evacuation and return to duty for service members participating in OIF and OEF: a prospective cohort study. (Cohen et al Lancet 2010)
Jan 04- Dec 07: 34,006 Service Members evacuated from OIF and OEF
~10% of evacuation due to psychiatric diagnoses
Recent sharp increase only in evacuation rates of patients with psychiatric diagnoses
Decreased probability of return to duty:
psychiatric disorder
medical disorder with psychiatric comorbidity
What is the true denominator - Rates of COSR in theater?
Here is an example of how it might work: If OSCAR works for the Marines, then the DoD could request the Army to evaluate is the OSCAR model works for them instead of the COSC teams-; if OSCAR does not work for Army, then need to know why it works for marines?
Why do we need a COSC
The problems are complex
Each service is trying their approach to find a solution
Very little evidence to confirm what works, but several programs and program evaluation being rolled out as we speak
Need a central mechanism to communicate, share what works, what doesn’t work,
Services don’t have the opportunity

22. Services Agree On: Specifics
Universal Prevention:
Education
Tough realistic training
Stress reduction techniques
Selective
Need for Traumatic Event Management following a potentially traumatic event
Leader lead After Action Reviews
Indicated
Early identification and simple intervention starts with peers- “warriors take care of each other”, soldier peer mentors
Orange zone/COSR should be managed in the unit
Orange zone/ COSR should not be medicalized
peer-driven psychological risk management and support system with
military personnel and units to provide the earliest possible identification, mediation, and referral for
Family, operational, and combat and operational environment-related BH and stress management.
PTE:—Direct exposure or personal experience of an event that involves actual
or threatened death or serious injury, or other threat to one’s physical integrity; or learning about
unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or
other close associate.

23. Service Differences
Frame work: Stress injury model or positive psychology?
What is the most effective approach?:
Embedded providers / roving COSC units
Selective: insider or outsider for AAR
Indicated: COSFA vs. BICEPS
Reintegration: Cyprus vs. Battlemind
In-theater assessment of unit and individual Service member
peer-driven psychological risk management and support system with
military personnel and units to provide the earliest possible identification, mediation, and referral for
Family, operational, and combat and operational environment-related BH and stress management.
PTE:—Direct exposure or personal experience of an event that involves actual
or threatened death or serious injury, or other threat to one’s physical integrity; or learning about
unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or
other close associate.