1. The Okinawa Experience: USNH Okinawa's Caregiver Occupational Stress Control Program

2. Objectives Participants will be able to:
Describe the major components of Navy Medicine’s Caregiver Occupational Stress Control (CgOSC)
State how USNH Okinawa launched the CgOSC program
Describe an assessment tool to gain identification the commands stress level
Describe USNH Okinawa’s CgOSC Team’s Trials, Tribulations and Triumphs

3. Navy and Marine Corps Maritime Combat and Operational Stress Control Doctrine
The Secretary of the Navy directs the establishment of processes that builds resilient Sailors and Marines, conserves those who are temporarily non-mission ready, and decreases stigma. That process is an integrated Maritime Combat and Operational Stress Control Program based on the stress continuum model.
The Commandant of the Marine Corps and the Chief of Naval Operations integrate C/OSC principles into leadership and operational training programs.
Navy Medicine and Chaplain Corps must both integrate the C/OSC principles as it applies to their personnel and stand shoulder to shoulder to provide support to the Navy and Marine Corps line efforts.

4. Stress Injury Continuum
Stress Continuum Model
Stressor
Stress Injury Continuum
READY (Green)
REACTING (Yellow)
INJURED (Orange)
ILL (Red)
Good to go
Well trained
Prepared
Fit and focused
Cohesive units & ready families
Distress or impairment
Mild and transient
Anxious, irritable, or sad
Behavior change
More severe or persistent distress or impairment
Leaves lasting memories, reactions, and expectations
Stress injuries that don’t heal without help
Symptoms persist for >60 days, get worse, or initially get better and then return worse
The Stress Injury Continuum Model was developed by the USMC/Navy Medicine COSC team. The continuum is an evidenced-based and evidence-informed model that is congruent with the Navy/Marine Corps culture. The continuum has four stages: Ready, Reacting, Injured, and Ill. This model highlights the shared responsibility that all of us share for force protection and force conservation. The bottom of the model reflects relative responsibility gradients of leaders, Sailors, and Caregivers.
Ready:
Readiness is a leadership responsibility that leverages realistic training and group cohesion to form resilience to the challenges and strains of military service.
Effective military training and good leadership that uses sound psychological health strategies is the foundation for stress inoculation and rapid resetting after significant stress exposure.
Reacting:
It is important to note that 100% of people faced with a stressful stimuli will react to that stimuli. How they respond will depend on how prepared they are for the stressor and how they interpret the stressor.
The vast majority of Sailors will use their stress reaction to build their life experience and increase the resources in their coping toolbox.
Injured
Some Sailors will be impacted in a way that decreases their mission effectiveness.
For most, they are temporarily non-mission ready and usually benefit from appropriate involvement of leaders and caregivers to augment social support and coping resources.
Ill
A small number (15% PTSD, 25% includes substance abuse other disorders) will develop a stress related illness and require 6-12 months to be mission ready or to be transitioned out of the service.
Use sprained ankle metaphor or holding a pitcher of water metaphor.
Goal is to facilitate a way back to readiness
Unit Leader
Responsibility
Individual, Shipmate, Family Responsibility
Caregiver
Responsibility

5. 7 C’s of Stress First-Aid
Navy and MC COSC
7 C’s of Stress First-Aid
March 2010
Combat and Operational Stress First Aid was originally developed for those in high risk situations. Its goal is to intervene early in the Yellow and Orange zones to prevent moving into the Orange or Red zones.
Similar to other first responder training, COSFA outlines the practical things you can do to help a Shipmate, or yourself, to move towards Green after a particularly stressful or traumatic event. This model can be used for many operational and personal situations where there is wear and tear, loss, or inner conflict.
Check: When you see behavior change in a shipmate the first thing you do is check in with them and see if they are OK. Similar to basic life support (assess, look, listen, act). If the “Check” is OK go to the next step. If not OK, act and then Coordinate.
Coordinate: Get Help, engage leaders, shipmates, social resources, or caregivers to make sure that a shipmate has the best resources and opportunities to be mission ready. Check and Coordinate are necessary and often repeated actions of looking out for one another before and after stressful events and occur with each of the COSFA actions.
Cover: Get safe — Get out of danger as soon as practical, and stay surrounded by trusted Shipmates or family members (not alone)
4. Calm down, take slow deep breaths — Slow down your heart rate as soon as you can after excessive stress
Sleep — Often 1-2 nights sleep are enough to recover (tell the doc if you’re having trouble sleeping)
5. Connect with others: Talk with trusted peers, leaders, or care-givers about what happened — Talking helps you make sense out of it. Shipmates help each other to stay part of the team.
Avoid blaming – Focus on what you can do now and in the future.
6. Competence – Make sure you and your shipmates have the skills and knowledge needed to achieve the mission or address life stressors. (What has been learned from this life lesson?)
Confidence - Taking the above steps will help you to gradually get back into the routine and rebuild confidence and trust in yourself and others.
Some stress reactions can be delayed or reappear weeks to months later. Continue to check and coordinate as shipmates return to mission and personal readiness.
Remember: Get help from a chaplain, counselor, or medical officer — If you can’t stop thinking about a bad experience or symptoms don’t improve
USCG CHC Conference 5

6. Caregiver Occupational Stress Control Overview
To enhance the resilience of caregivers to the psychological demands of exposure to trauma, wear and tear, loss, and inner conflict
“Caregiver” in this context are medical personnel, religious ministry teams, and family service professionals
3 Core Objectives
Early recognition of caregivers in distress
Peer support and action
Engaging in early help as needed
Program components
Navy Medicine wide MTF awareness training
MTF Training Team Development
Caregiver multimedia resources for individual and team training
Navy Medicine wide caregiver occupational stress assessment
Leader Action
Use the five core leader function in the Maritime COSC Doctrine
Assess the environment of care
The Caregiver and Occupational Stress Control (Caregiver OSC) program was designed to enhance the resilience of caregivers to the psychological demands of exposure to trauma, wear and tear, loss, and inner conflict associated with the therapeutic use of self.
The concept of “caregiver” in this context refers to medical personnel (from Corpsmen to physicians), clinically and non-clinically trained Chaplains, religious program specialists, and family service professionals.
There are three core objectives in the program are early recognition of caregivers in distress, breaking the code of silence related to occupational stress reactions and injuries, and engaging caregivers in early help as needed to maintain mission and personal readiness. 6

7. Background September 2008 January 2009 March 2009 April 2009
Initiated Command Orientation Briefs
January 2009
Presented CgOC to Directors
March 2009
Command CgOSC training (700 staff)
Team training (21 members)
April 2009
First CgOSC Team Meeting Discussion:
Create web page
Develop ways to identify team / Marketing
Measure outcomes
I want to start by providing some background of how we started:
After the COSC conference in August 08, I felt it was important for us to understand what the Stress Injury Model (what is was called at that time) so that we would be able to understand that being in the “orange” did not mean someone was jaundiced. Therefore, I gained a slot in Command Orientation to talk about COSC.
In January 09, after the first CgOSC training, a brief was held for the Board of Directors, primarily to prepare them for the training that occurred in March that same year. Captain Westphal provided the training to 700 out of 1100 of our personnel. He also provided Team Training to 21 members – majority not in MH or Pastoral care field.
April 09 marked the first team meeting and our brain storming session generated really great ideas to include Create web page, ways to identify team, gaining visibility through Marketing, and finally finding a way to Measure our interventions.

8. Trials Internal Web Page Command Stress Assessment Self-care manual
Team members and contact numbers
External Links
Command Stress Assessment
From this we created an Internal Web Page that includes the Self-care manual (Figley, Figley), Contact numbers for the team and we added External Links such as the COSC web page.
We also created a Command Stress Assessment tool we call our “Stress-O-Meter” so that we would be able to gain a better understanding of the commands stress level, and based on this, gear our training or interventions.

9. Stress Injury Continuum
Assess Your Stress Level Based on the Stress Injury Continuum
Your participation in this assessment is confidential and completely voluntary. The results of this assessment will assist in understanding caregiver occupational stress level at USNH Okinawa for development of projects to increase resiliency.
If you would like to decline click here. For more information on staying "green", self-assessment and self-care click here.  (After opening the file, to read the  presentation notes put your cursor over  this symbol        on the top left of each slide.)
Today I feel:
Stress Injury Continuum ○
 READY (Green)
REACTING (Yellow)
INJURED (Orange)
  ILL (Red)
• Calm and Steady
• Confident, Competent,
&  Prepared
• I have a good sense of
Humor
• Fit and focused
• At peace and Spiritually
  Healthy
• My personal/social life
  is good
• My unit is positive and
  Cohesive
• There is a good order
  and discipline
• I have a clear sense of
  my mission
• Mildly Distressed or
  impaired
• Anxious, Irritable, Worried
• Grouchy, Mean, or Short-
  tempered
• I have some trouble
  sleeping
• I'm eating too much or
  too little
• I have difficulty
  concentrating
• Like being left alone,
  apathetic, and/or lack of
  interest
• Negative/pessimistic
• I find myself cutting
  corners on the job
• My unit's morale is
  negative and falling
• There are minor discipline
  problems
• There is an increase in
  alcohol related incidents
• More severe or persistent
  distress/impairment
• Serious suicidal or
  homicidal thoughts
• I have no control
• Can’t fall or stay asleep
• I have been having
  recurrent vivid nightmares
• Intense guilt or shame
• I’m experiencing panic
  attacks or rage
• The inability to enjoy
  activities
• Disruption of moral values
• My unit/command with
  low morale/divided staff
• There are significant
  discipline problems
  alcohol/drug incidents
• I have been experiencing
  symptoms in the orange
  for more than 60 days
• I have been diagnosed
  with or have a history of:   - PTSD   - Depression   - Anxiety   - Substance Abuse
  And I have not been seen
  recently for any of the
  above.
• I have been feeling suicidal
  or homicidal with a plan
All stress Illnesses MUST be
referred to Medical for
evaluation Contact your: Chaplain and/or Medical Provider
The team thought that the Stress Continuum Model would be the best way to 1) market our team and 2) provide us with an assessment tool.
This screen pops up on the same date each month upon initial log-in to the intranet.
This page was approved by the XO/CO, and created by our IT department.
There is a submit button below the model
There is an option to decline and an option to learn more about the Stress Continuum Model.
Should they choose to learn more about this…..

10. Healthy: The Ready Green Zone
READY Sailors
Calm and steady
Confident and competent
Getting the job done
Sense of humor
Sleeping enough
Eating the right amount
Working out, staying fit
Playing well and often
Active socially
Being at peace with oneself
Healthy spirituality
…They will see this power point presentation, that talks about each area of the Stress continuum model identifying what sailors, families and commands look like. This is the presentation you will find in NKO.

11. Stress Injury Continuum
Assess Your Stress Level Based on the Stress Injury Continuum
Your participation in this assessment is confidential and completely voluntary. The results of this assessment will assist in understanding caregiver occupational stress level at USNH Okinawa for development of projects to increase resiliency.
If you would like to decline click here. For more information on staying "green", self-assessment and self-care click here.  (After opening the file, to read the  presentation notes put your cursor over  this symbol        on the top left of each slide.)
Today I feel:
Stress Injury Continuum ○
INJURED (Orange)
  ILL (Red)
• More severe or persistent
  distress/impairment
• Serious suicidal or
  homicidal thoughts
• I have no control
• Can’t fall or stay asleep
• I have been having
  recurrent vivid nightmares
• Intense guilt or shame
• I’m experiencing panic
  attacks or rage
• The inability to enjoy
  activities
• Disruption of moral values
• My unit/command with
  low morale/divided staff
• There are significant
  discipline problems
  alcohol/drug incidents
• I have been experiencing
  symptoms in the orange
  for more than 60 days
• I have been diagnosed
  with or have a history of:   - PTSD   - Depression   - Anxiety   - Substance Abuse
  And I have not been seen
  recently for any of the
  above.
• I have been feeling suicidal
  or homicidal with a plan
All stress Illnesses MUST be
referred to Medical for
evaluation Contact your: Chaplain and/or Medical Provider
If they click on the Orange and Red….

12. Resources
Please contact:     A. your LPO     B. your DIVO     C. Strategies for getting back to the Green     D. Occupational Stress Control (OSC) Team Members:     E. Self Care Plan
This will pop-up at the bottom. This provides the member resources such as contacting their chain of command or one of the CgOSC team members, and the Self-Care Plan.
If they wanted to contact a team member……

13. Resources Where To Get Help – USNH Okinawa
USNH Okinawa has a Caregiver Occupational Stress Control (CgOSC) Team. Please feel free to contact any of the following members:
HM3 Finney, Serena (Neurology) Ms. Christine Bruce (Depl. Health)
HM2 Santell, Aida (ER) LTJG Bernard, Candace (3S)
HM2 Crawford, April (Urology) LTJG Lopez, Jacqueline (3S)
HM2 Murphy, Stephen (Pharmacy) LTJG Tomblin, Nicky (3E)
CS1 Thompson, Jeremiah (ITD) LT Brenner, Danyell (LCSW)
LT Van Dyke, John (Chaplain)
LCDR Ravelo, Samuel (Chap)
LCDR Fisak, Jean (3S)
The CgOSC team has a link on SharePoint where you can find the Self-Assessment and Self-Care Plan Workbook (Figley and Figley).
For unit or individual training, please contact any of the CgOSC Team members.
Thank you for your time.
They would be directed to the intranet and this will come up.

14. Stress Injury Continuum
Assess Your Stress Level Based on the Stress Injury Continuum
Your participation in this assessment is confidential and completely voluntary. The results of this assessment will assist in understanding caregiver occupational stress level at USNH Okinawa for development of projects to increase resiliency.
If you would like to decline click here. For more information on staying "green", self-assessment and self-care click here.  (After opening the file, to read the  presentation notes put your cursor over  this symbol        on the top left of each slide.)
Today I feel:
Stress Injury Continuum ○
 READY (Green)
REACTING (Yellow)
INJURED (Orange)
  ILL (Red)
• Calm and Steady
• Confident, Competent,
&  Prepared
• I have a good sense of
Humor
• Fit and focused
• At peace and Spiritually
  Healthy
• My personal/social life
  is good
• My unit is positive and
  Cohesive
• There is a good order
  and discipline
• I have a clear sense of
  my mission
• Mildly Distressed or
  impaired
• Anxious, Irritable, Worried
• Grouchy, Mean, or Short-
  tempered
• I have some trouble
  sleeping
• I'm eating too much or
  too little
• I have difficulty
  concentrating
• Like being left alone,
  apathetic, and/or lack of
  interest
• Negative/pessimistic
• I find myself cutting
  corners on the job
• My unit's morale is
  negative and falling
• There are minor discipline
  problems
• There is an increase in
  alcohol related incidents
• More severe or persistent
  distress/impairment
• Serious suicidal or
  homicidal thoughts
• I have no control
• Can’t fall or stay asleep
• I have been having
  recurrent vivid nightmares
• Intense guilt or shame
• I’m experiencing panic
  attacks or rage
• The inability to enjoy
  activities
• Disruption of moral values
• My unit/command with
  low morale/divided staff
• There are significant
  discipline problems
  alcohol/drug incidents
• I have been experiencing
  symptoms in the orange
  for more than 60 days
• I have been diagnosed
  with or have a history of:   - PTSD   - Depression   - Anxiety   - Substance Abuse
  And I have not been seen
  recently for any of the
  above.
• I have been feeling suicidal
  or homicidal with a plan
All stress Illnesses MUST be
referred to Medical for
evaluation Contact your: Chaplain and/or Medical Provider
There were several inquiries about us contacting members, should they choose to be contacted so we added a link for this.
And since privacy is a huge concern…no matter what color a member chooses, this will pop-up

15. Would you like to be contacted by a CgOSC team member? Click here
Resource
  Would you like to be contacted by a CgOSC team member? Click here            
Copy
Thank you for your time!
This was loaded last October.
If a member wants to be contacted, they click here…
*Updated and added to monthly assessment 14 October 2009

16. Resource
Please enter your name, address, and/or phone number and a CgOSC team member will contact you.
Name: __________________   __________________ Phone: __________________
And will get this screen.
This will then be ed to only one team member, in our case the team leader, who will contact the person then either send someone from the team to speak to them (after gaining their permission) or will have interaction with the team member directly. We explain that what is discussed will not be documented unless there is reason to (example safety risk). The team members not in the MH field will then refer to the team leader who will refer appropriately.
For training purposes, these interactions' are discussed in our monthly meetings.
To date we have had 14 contacts (11 actual) 6 Civilians
2 Corpsman
3 Officers
3 Unk
The interactions we have had were no more than twice per person (this includes final f/u) and most concerns were about relationships

17. Data from Stress Assessment (2009)
Data Collection Period:
27 May to 26 June
Total Responses: 593
Color
Percentage
Red
5.06
Orange
6.58
Yellow 202
34.06
Green
48.40
Declined 35
5.90
Data Collection Period:
27 June to 26 July
Total Responses: 342
Color
Percentage
Red
6.73
Orange 17
4.97
Yellow 101
29.53
Green 168
49.12
Declined 33
9.65
Data Collection Period:
27 July to 26 August
Total Responses: 391
Color
Percentage
Red
7.16
Orange
7.67
Yellow
33.50
Green
41.69
Declined 39
9.97
The data gathered from all of this was tallied in this manner.
In the first month just over 50% of the command responded.
The month afterwards we averaged just over 350 responses.

18. Data from Stress Assessment (2009)
Data Collection Period:
27 August to 26 September
Total Responses: 344
Color
Percentage
Red
5.52
Orange
5.23
Yellow
33.43
Green
45.64
Declined 35
10.17
Data Collection Period:
27 September to 26 October
Total Responses: 361
Color
Percentage
Red
7.76
Orange 14
3.88
Yellow 117
32.41
Green
45.43
Declined 38
10.53
Data Collection Period:
27 October to 27 November
Total Responses: 340
Color
Percentage
Red
7.65
Orange
5.00
Yellow
30.29
Green
50.59
Declined
6.47

19. Data from Stress Assessment (09-10)
Data Collection Period:
27 November to 26 December
Total Responses: 349
Color
Percentage
Red
7.45
Orange
2.58
Yellow
30.37
Green
52.15
Declined
Data Collection Period:
27 December to 31 January 2010
Total Responses: 353
Color
Percentage
Red
5.95
Orange 15
4.25
Yellow 109
30.88
Green
50.71
Declined 29
8.22
Data Collection Period:
February 2010
Total Responses: 202
Color
Percentage
Red
7.43
Orange
4.46
Yellow
26.73
Green
52.97
Declined
8.42

20. Data from Stress Assessment (2010)
Data Collection Period:
March 2010
Total Responses: 349
Color
Percentage
Red
6.88
Orange
5.44
Yellow
30.95
Green
50.72
Declined 21
6.02
Data Collection Period:
April 2010
Total Responses: 298
Color
Percentage
Red
5.70
Orange 11
3.69
Yellow
26.85
Green
57.38
Declined 19
6.38
Data Collection Period:
May 2010 (01-14)
Total Responses:
Color
Percentage
Red
Orange
Yellow
Green
Declined

21. Combined Data: June 2009 - April 2010
This is the combined 11 month data.
The blue indicates folks who declined. The numbers in the center indicates the number of responses in each zone.
As you can see most responded in the green and yellow, with green averaging 175 or 49%, Yellow 111 or 31%, Orange 18 or 5%, and Red 26 responses or 7%
Extra Info:
29 Declined or 8%

22. Directorate Stress-O-Meter

23. Directorate Stress-O-Meter
There was a Division Officer Course earlier this year and COSC was presented. One question posed was can the responses be broken down to departments so that they can gauge their departments stress level. I suggested that we start with breaking it down by directorates.

24. Directorate Stress-O-Meter

25. Directorate Stress-O-Meter

26. Directorate Stress-O-Meter
So far we have some data and this graph shows red zones by directorate.

27. Directorate Stress-O-Meter

28. Tribulations Big Picture Down in the Trenches High OPTEMPO Retribution
False Positive Responses
Concern for Privacy
So, some of the hurdles we faced during implementation of CgOSC was the OPTEMPO was high (we perceive it to be worse overseas) and there was no time to incorporate unit assessments or training. We have asked several departments to allow us to provide unit assessments and go over some items in the self-care manual but either we not provided enough time or they declined as they were “fine” and did not need the training.
There was a perception of retribution if they spoke out and of course the stigma of seeking counseling.
Regarding the stress assessment, there may be false positives at either end of the stress continuum. I have heard conversations about joking they were in the red to see what would happen, or answering red because of being frustrated at an isolated incident.
Then there is always the concern for privacy. I think however that staff has gotten that we can’t identify who they are especially since we added the 2nd link that asking if they would like to be contacted.

29. Tribulations Slower initiating assessments/ training:
Little time for team to allocate time to the CgOSC program
Limited Mental Health Assets
Other tribulations includes the team’s perception that we were slow in initiating self-care assessments and training based on the reasons discussed previously.
And with limited MH assets available to respond to the increased volume we needed more folks onboard to provide pre-clinical assessment and intervention can augment the supports system needs to be on the ready.
This is a great leadership tool!

30. Triumphs Strong Command Support Intensive Marketing Strategies
Incorporated “OSCAR” into the Customer Relations Program
Continued Command Orientation Briefs; April - COSFA Continuous and Primary Aid training
We have been successful in that the command has given us full autonomy of how we want to navigate COSC and COSFA.
We have been doing intensive marketing strategies to promote COSC and COSFA by having the SCM pop up monthly and by placing large Stress Continuum Model posters in staff lounges and smaller 8x10 COSFA or Stress Continuum Model posters in staff bathrooms.
We have incorporated OSCAR communication in Customer Relations and talking about where we can place COSC/COSFA in Team STEPPS.
We have continued monthly with Command Orientation Briefs (this so far is the best way to recruit team members) and just last month this changed and we were provided a good chunk of time for COSFA Continuous and Primary Aid training.
We have also done 2 COSFA sessions (16 staff) and trained 2 departments in COSFA Continuous and Primary Aid.
And I’m excited to share that after an update brief to the BOD last week, they allowed us 2 hours of their meeting time for COSFA Continuous and Primary Aid training.

31. Feedback What CgOSC activities are taking place at your command?
Are there any data collection activities?
Others
I have talked about Okinawa’s Caregiver OSC program and an assessment tool or Stress-O-Meter to gauge how the command is doing based on the Stress Continuum Model, as well as our Trials, Tribulations and Triumphs.
I’d love to hear what your command is doing and if there are any type of data collection.

32. Questions or Comments