Navy Operational Stress Control Paul S. Hammer CAPT, MC, USN Director, Naval Center for Combat & Operational Stress Control

Background Hidden costs of war Commissions on Care for Wounded Warriors Overhauling the system of care –Access to care –Quality of care –Transition and Coordination of care –Screening and Surveillance –Promote Resilience NCCOSC one of a number of BUMED initiatives from PH/TBI Funding

Naval Center for Combat & Operational Stress Control Established to achieve vision of robust Psychological Health –Enhance resilience –Promote best practices Navy – Marine Corps Context –A uniquely diverse military culture Challenge –Responsive to small tactical units –Support peer and unit leaders –Be Evidenced-based –Culturally informed

Mission The mission of the NCCOSC is to improve the Psychological Health of Navy and Marine Corps forces through programs that aid research, educate service members, build resilience and promote best practices in the treatment of Post-traumatic Stress Disorder and Traumatic Brain Injury.

Key Points of OSC Program Stress as a continuum –If we only look at stress illnesses, like PTSD, then we miss early stress reactions and stress injuries that are most amenable to intervention Four sources of stress injury. –Trauma is not the only harmful exposure –Must account for fatigue, loss, and moral conflict Good leaders are the best medicine –Leaders actions to Strengthen, Mitigate, Identify, Treat, and Reintegrate One size does not fit all –Not everyone is equally affected by any given event and not everyone needs something to “feel better” Training and context matter –The best stress inoculation is realistic training that combines stress first-aid practice with other intense training strategies

READY READY (Green) REACTING (Yellow) INJURED (Orange) ILL (Red) Distress or impairment Mild and temporary Anxious, irritable, or sad Physical or behavioral changes More severe or persistent distress or impairment May leave lasting memories, reactions, and expectations Stress injuries that don’t heal without help Symptoms that persist, get worse, or initially get better and then return worse Caregiver Responsibility Caregiver Responsibility Unit Leader Responsibility Unit Leader Responsibility Good to go Well trained Prepared Fit and focused Cohesive units & ready families Individual, Shipmate, Family Responsibility Stressor

Many Causes vs Only Four: Yellow Zone Reactions vs Orange Zone Injuries Hard work Physical injuries Minor illnesses Peer conflicts Conflicts with boss Boredom Relationship problems Relationship problems Money problems Loss of privacy Harsh weather Family separation Loss of possessions Legal problems Lack of sleep Yellow Zone Stress Wear-and- tear Moral injury Loss Life threat Orange Zone Stress

Life Threat A traumatic injury Due to an experience of death provoking terror, horror, or helplessness LossLoss A grief injury Due to the loss of cherished people, things, or parts of oneself Wear & Tear A fatigue injury Due to the accumulation of stress from all sources over time without sufficient rest and recovery Intense or Prolonged Combat or Operational Stress Intense or Prolonged Combat or Operational Stress Inner Conflict A moral injury Due to behaviors or the witnessing of behaviors that violate moral values

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Core Leader Functions Leaders must build resilience in their Sailors and Marines

OSC Core Leader Functions Strengthen –Create confidence / forewarn –Expose to realistic stress in training –Foster unit cohesion Mitigate –Remove unnecessary stressors –Ensure adequate sleep and rest –After-Action Reviews (AARs) in small groups Identify –Know crew stress load –Recognize reactions, injuries, illnesses Treat –Rest and Restoration (24-72 hours) –Chaplain –Medical Reintegrate –Keep with unit if at all possible –Expect return to full duty –Don’t allow retribution or harassment –Communicate with treating professionals (both ways)

Unclassified16 Operational Stress Control Stress as a continuum, not just PTSD Good leaders are the best medicine One size does not fit all Not everyone is equally affected by any given event and not everyone needs something to “feel better” Training and context matter The best stress inoculation is realistic training that combines stress first-aid practice with other intense training strategies Four sources of stress injury. Trauma is not the only harmful exposure Must account for fatigue, loss, and moral conflict Five Core Leader Functions Strengthen – Create confidence, increase cohesion Mitigate – Remove unnecessary stressors Identify – know the load, identify stress injuries early Treat – actively support treatment Reintegrate – communicate with providers, support return to duty