1Combat Operational Stress Control (COSC): An Integral Part of Force Health Protection CDR Meena Vythilingam, M.D.Deputy Director,Psychological Health Strategic OperationsOffice of Deputy Assistant Secretary of Defense forForce Health Protection & Readiness ProgramsThanksHonor to present at the plenary in front of an august audienceParticular 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 ServicesMost 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!
2Force Health Protection and Readiness Deputy Secretary of DefenseUndersecretary of Defense(Personnel and Readiness)Assistant Secretary of Defense(Command, Control, Communications, and Intelligence)Army Medical ServiceSecretary of the ArmyArmy Surgeon GeneralForce Health Protection and Readiness: Psych HealthLt Col Ritschard- DirectorCDR Vythilingam-DeputyLCDR Frazer, Dr. Carty- XO,Dr. Davison, Dr. Paris,Ms. Fraine, Ms DekleMs BerryAssistant Secretary of Defense(Health Affairs)Army Medical FacilitiesBureau of Medicine and SurgerySecretary of the NavyLocated in an office conveniently named after 2 of the most important topics of this conference;Force Health protection and readiness- green zoneLocated in the Office in the Asst Sec Def – Health affairs; help shape policy, mental health surveillanceGreat team of psychologists, I am the only psychiatristHow are we different from the DCoENavy Surgeon GeneralNavy Medical FacilitiesAir Force Medical ServiceSecretary of the Air ForceAir Force Surgeon GeneralAir Force Medical Facilities
3Psychological Health Strategic Ops Improve – Protect – ConserveHealth & Resilience of Service membersOptimal mission performanceOur MAIN MISSION is to improve and protect the Psychological HEALTH Of the war fighter who is the most valuable asset we haveFull 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 optimallyWe 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
4COSC and Force Health Protection Future of war fighting is joint operations;greatest challenge:meeting the joint medical needs of joint operations, andworking 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 opsTo 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 cyclei.e COSC is not just treating ASD and PTSD in-theater- lots of stuff that needs to be done LEFT OF THE BOOMstrengthen before deployment,prevent protect during deployment andWhat 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 workSo 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 pillarsAnd this is what happenedHealth & 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
5COSC Alphabet Soup Explosion 6 Rs: Reassure, Rest, Replenish, Restore confidence Return to duty, Remind4 Cs: Check, Control, Connect, Confidence3 Cs: Commitment, Control, Challenge7 Cs: Check, Coordinate, Cover, Calm, Connect, Competence, ConfidencePIES: Proximity, Immediacy, Expectation, SimplicityStrengthen, Mitigate, Identify, Treat, ReintegrateBICEPS: Brevity, Immediacy, Contact/Centrality, Expectancy,Proximity,SimplicityAnd 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 NavyAnd 6 Rs ArmyHow do we know if 7Cs are better than 6 Rs- going back to the psych tech imagine her trying to communicate with her colleaguesPersonally, I would propose that PIES are definitely better than BICEPSPREVENT: Privacy, Relaxation, Encourage, Video Games, Educate, Normal duties, Three hots and a cotBATTLEMIND: Buddies (cohesion), Accountability, Targeted aggression, Tactical awareness, Lethally armed, Emotional control, Mission operational security, Individual responsibility, Nondefensive (combat) driving, Discipline and ordering3 Cs: Combat readiness, Combat response, Combat responsibility
6Making Sense of the Alphabet Soup: Merging Navy/MC Model with IOM Approach UniversalEntire populationSelectiveSubset exposed to potentially traumatic eventTarget ConditionASD / PTSDImplications for early detection and treatmentComplicationsImplications for Maintenance & RehabWanted to make sense of the alphabet soupTried to combine 2 concepts here-IOM modelStress continuumWalk you through the IOM approach:Universal – equivalent of mental push ups and sits up and 2 mile runSelective- intervene is a select subset of those at risk- eg. GTMO guards- CAPT Laraway spoke about this programIndicated- intervention when it is indicated, but still sub-clinical symptoms, not yet clinical- COSFA trainingRed is traditional treatmentAll 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 medicsEarly identification- COSREarly interventionPrevention/mitigation- orange going on to reRed is already too lateAdvantages 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 SubpopulationIs this an appropriate subpopulation?Issues – Selected or Indicated or both?Setting and AccessWhere to go, Who to partner with?What types of Prevention Approaches might we considerWho 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 PreventionIndicatedExhibiting sub-clinical symptoms
7Universal Selective Indicated Reintegration Army Navy Marine Corp CSF (Institutional Resilience Training (IRT) and surveillance through the GAT)Leader lead AARTEMEvent/TimeBPD’sBICEPS6 RsDeployment Cycle SupportOp. Resilience TrainingWarrior Adventure QuestNavyStrengthen (unit cohesion, leadership, tough realistic training)AARMitigateIdentifyDetainee opsCOSFAReintegrateMarine CorpWarrior Preparation Program; IITAAR (without outsiders)Post treatment: Confidence, Connection, CompetencePost deployment:Warrior transition Program 1, and 2Air ForceAirman Resiliency TrainingNIMH recsAF Mortuary Affairs Resiliency ProgramVA DoD CPGsDeployment transition center – (Third Location Decompression)Very busy slide – let’s look at general concepts across Services, and look for evidence based studiesUniversal prevention: all Services are paying attention and doing something for strengthening;Revamped Battlemind with a new name/ bottleMarine corps strengthening programs: Mojave Viper; Infantry Immersion trainer; FamiliesSelective prevention- high risk groups after PTE:Good news- no CIDRLLAR –difference between army and marinesMitigate- Reduce the force and intensity of the stressor- lessens the impact of the stressor; Mitigate (eliminate stress, replenish “leaky bucket”)Post trauma social supportIndicated prevention:Acronyms land- head to head comparison of what is betterReintegrationWarrior Adventure Quest (WAQ)
8Services Agreement: Force Preservation Early Identification Stigma Vulnerability FactorsLong-TermOutcomesPsychSuicideHomicide/violencePTSD, depressionOccupational• Impaired/deviantperformance• Involuntaryseparation/AttritionExcessivemedical careSocial• Aggression/withdrawal/avoidanceFamily• Marital discord• Hostility/violenceEmbedded Support Service• COSC services• Behavioral health care• ChaplainConsultation and educationPeer educationProtective FactorsLeadershipUnit Cohesion (horizontal/vertical)• MentoringFamily supportTough realistic trainingBarriers• Access to CareStigmaOutreachStressors• Environmental• Physiological• Cognitive• EmotionalEarly IdentificationOccupationalDemandsEveryone is working fast and furiously towards the same short term and long term goals- army 2009 COSC manual for leadersI.e.. keep SM in the fight and have them adjust well when they are back homeCOSC is a leadership responsibility; leaders need support: Leadership consultation, EducationCare 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 expertEarly 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
9COSC – Service Differences & Challenges Service practicesWhich program “measured results?”Universal preventionIs there a bullet proof vest for the mind and soul?Positive Psychology vs.. Strengthening / educationSelective preventionBetter predictors, e.g. pulse and better treatmentsIndicated preventionCOSFA vs.. BICEPSReintegrationCyprus vs.. BattlemindCan 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 homePublished studies of efficacy- Adler et al Battlemind debriefing after deployment- 4 months follow upBrain armorbullet proof vest for the mind?Strengthen vs. stress mitigationPrevent cognitive impairment during stressBetter sleep in a combat settingCognitive reappraisal techniques
10Do We Really Need a DoD COSC Policy? Most effective, affordable approach to keep the Service member in the fight or reintegrateComplex, continuing, urgent problemMultiple Service programs and evaluations rolled outLimited published evidence of what worksSolving complex problems need innovative solutionsJoint Service COSC ProgramService COSC reps will meet to share data, practices, and coordinate COSC programsSharing program evaluation results is keye.g. OSCARImpartial facilitatorWhat’s in it for you?How is the DoD going to make a difference in the lives of your sailor and marinesSgt Michael Blair- remember what helped him the most- 2 things- one was the ACEP program in WRAMC- army sports psychology programI’m sure that every Marine leader in this room wants the best, most effective, and affordable approach to ……Why do we need a COSCThe problems are complexEach service is trying their approach to find a solutionVery little evidence to confirm what works, but several programs and program evaluation being rolled out as we speakInnovative solutionsInnovation is in the interface eg. Marine Resiliency StudyInnovation is also in Services coming togetherNeed a central mechanism to communicate, share what works, what doesn’t work,Services don’t have the opportunityHere 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?
11Do We Really Need a DoD COSC Policy? Contd.. Program evaluation, common metricsFocus on end-state goalsUpdate COSC DoDIDoD COSC Directive- 1999Outdated - Explosion of new programs and research sinceNeed for coordination among Service COSC efforts
12Ensure future fighting force benefits from lessons learned THANK YOU!Ensure future fighting forcebenefits from lessons learnedDefine leadership responsibilitiesFocus on both the Unit and individualPreserve Service integrity
14Learning From Others- TRIM Model Site Management Strategies0 hrsSocial Support and CohesivenessSupport and MonitoringEducationPlanning PhasePlanning MeetingIdentification of groups and individuals (Targeting)Formulating the management strategy0-24 hrsAssessment 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 hrsonwardsSupport and MonitoringSupport by Trained Stress RespondersMonitoring and Management by Commanders and BuddiesBriefing meeting – (Soon after the event when troops are accessible)Early Referral for Specialist Help if RequiredOne Month Follow-Up and Referred for Specialist Help if Required
15TRIM Risk Factors for Psychological Disorders 1. Perceives that they were out of control during the event2. Perceives that their life was threatened during the event3. Blames others for what happened4. Reports shame/guilt about their behaviour during the event5. Experienced acute stress following the event6. Been exposed to substantial stress since the event7. Had problems with day to day activities since the event8. Been involved in previous traumatic events9. Poor social support, (family, friends, unit support)10. Drinking alcohol excessively to cope with distress
16DoDD 6490.5 Combat Stress Control (CSC) Programs Published in February 23, 1999Certified Current as of November 24, 2003In 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 responsibilitytraining was uneven in combat operational stress prevention, identification and treatment among the ServicesCurrently under revision
17Force Health Protection Protection: Shield from danger, injury, destruction, or damage; to prevent harmWho 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 obviousThe 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
18The Continuum of Care Protractor Different levels of prevention are distinguished by the level of riskof disorder/distress in various populations groups targeted.
19Role of COSC in Joint Force Health Protection Operational Environment 6 functional area capabilities:Joint Human Performance EnhancementJoint Health Surveillance, Intelligence, and Preventive MedicineJoint Casualty ManagementJoint Patient MovementJoint Medical Logistics and InfrastructureJoint Theater Medical Command and Control (and Information Systems)
20Combat Stress Behaviors (FM 4-02.51) What do Services Agree On? Army Frame WorkWhat else do they agree on?Frame work- combat and operational both keyRange of symptoms- color schemeNot 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 traumaAll 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 )UNCLASSIFIED20
21Do 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 PreservationDiagnoses 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 diagnosesRecent sharp increase only in evacuation rates of patients with psychiatric diagnosesDecreased probability of return to duty:psychiatric disordermedical disorder with psychiatric comorbidityWhat 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 COSCThe problems are complexEach service is trying their approach to find a solutionVery little evidence to confirm what works, but several programs and program evaluation being rolled out as we speakNeed a central mechanism to communicate, share what works, what doesn’t work,Services don’t have the opportunity
22Services Agree On: Specifics Universal Prevention:EducationTough realistic trainingStress reduction techniquesSelectiveNeed for Traumatic Event Management following a potentially traumatic eventLeader lead After Action ReviewsIndicatedEarly identification and simple intervention starts with peers- “warriors take care of each other”, soldier peer mentorsOrange zone/COSR should be managed in the unitOrange zone/ COSR should not be medicalizedpeer-driven psychological risk management and support system withmilitary personnel and units to provide the earliest possible identification, mediation, and referral forFamily, operational, and combat and operational environment-related BH and stress management.PTE:—Direct exposure or personal experience of an event that involves actualor threatened death or serious injury, or other threat to one’s physical integrity; or learning aboutunexpected or violent death, serious harm, or threat of death or injury experienced by a family member orother close associate.
23Service DifferencesFrame work: Stress injury model or positive psychology?What is the most effective approach?:Embedded providers / roving COSC unitsSelective: insider or outsider for AARIndicated: COSFA vs. BICEPSReintegration: Cyprus vs. BattlemindIn-theater assessment of unit and individual Service memberpeer-driven psychological risk management and support system withmilitary personnel and units to provide the earliest possible identification, mediation, and referral forFamily, operational, and combat and operational environment-related BH and stress management.PTE:—Direct exposure or personal experience of an event that involves actualor threatened death or serious injury, or other threat to one’s physical integrity; or learning aboutunexpected or violent death, serious harm, or threat of death or injury experienced by a family member orother close associate.