Citation
U.S. Army Medical Department journal

Material Information

Title:
U.S. Army Medical Department journal
Alternate title:
United States Army Medical Department journal
Alternate Title:
AMEDD journal
Running title:
Army Medical Department journal
Abbreviated Title:
U.S. Army Med. Dep. j.
Creator:
United States -- Army Medical Department (1968- )
Place of Publication:
Fort Sam Houston, TX
Publisher:
U.S. Army Medical Department
Publication Date:
Frequency:
Quarterly[<Oct.-Dec. 2001->]
Bimonthly[ FORMER Sept.-Oct. 1994-]
quarterly
regular
Language:
English
Physical Description:
volumes : illustrations ; 28 cm

Subjects

Subjects / Keywords:
Medicine, Military -- Periodicals -- United States ( lcsh )
Military Medicine ( mesh )
Medicine ( mesh )
Medicine, Military ( fast )
United States ( mesh )
United States ( fast )
United States
Genre:
Electronic journals.
Periodicals.
Periodicals. ( fast )
Fulltext.
Government Publications, Federal.
Internet Resources.
serial ( sobekcm )
federal government publication ( marcgt )
periodical ( marcgt )
Electronic journals ( lcsh )
Periodicals ( mesh )
Periodicals ( fast )
Fulltext
Government Publications, Federal
Periodicals
Internet Resources

Notes

Dates or Sequential Designation:
Sept.-Oct. 1994-
General Note:
Title from cover.

Record Information

Source Institution:
University of Florida
Holding Location:
University of Florida
Rights Management:
This item is a work of the U.S. federal government and not subject to copyright pursuant to 17 U.S.C. §105.
Resource Identifier:
32785416 ( OCLC )
98642403 ( LCCN )
1524-0436 ( ISSN )
ocm32785416
Classification:
RC970 .U53 ( lcc )
616.9/8023/05 ( ddc )
W1 JO96 ( nlm )

Related Items

Preceded by:
Journal of the US Army Medical Department.

UFDC Membership

Aggregations:
Digital Military Collection

Downloads

This item is only available as the following downloads:


Full Text

PAGE 1

JulySeptember2008Perspective1MGRussellJ.CzerwCombatDutyinIraqandAfghanistan,MentalHealthProblems7andBarrierstoCareCOLCharlesW.Hoge,MC,USA;COLCarlA.Castro,MS,USA;StephenC.Messer,MA,PhD;etalEffectivenessofCriticalEventDebriefingsDuringOperationIraqiFreedomII18CPTPatrickJ.Pischke,MS,USAR;CPTChristianJ.Hallman,MS,USARAGRDialecticalBehaviorTherapyDeployed:AnAggressiveAlternativeto24TraditionalMentalHealthontheNoncontiguousBattlefieldCPTBrianD.Parrish,MS,USAWarriorResilienceTraininginOperationIraqiFreedom:CombiningRational32EmotiveBehaviorTherapy,Resiliency,andPositivePsychologyMAJThomasJarrett,MS,USABehavioralHealthActivityandWorkloadintheIraqTheaterofOperations39MAJBarronHung,MS,USARemind:AddressingtheRiskofIllegalViolenceinMilitaryOperations43LTCKarenL.Marrs,AN,USATheArmyMedicalDepartmentBehavioralHealthProponency50COLElspethRitchie,MC,USAWhyTeachMentalHealthTopicstoPhysicianAssistantsand52OtherAlliedHealthcareProfessionals?KarenC.Shea,LCSW,DCSW;MaryannPechacek,PsyDDepartmentofDefenseResponsetoPosttraumaticStressDisorder54GerardA.Grace,PhDArmyProviderResiliencyTraining:HealingtheWoundsontheInside57RichardR.Boone,PhD;etalDownRangeandBeyond:PreparingProviderstoSupportWarriorsin60ResolvingProblematicSubstanceUseJosephE.Hallam,MSTheFamilyAdvocacyStaffTrainingProgram63CindiGeeslin,LCSW;JohnHartz,LCSW;MichaelVaughn,LMSWBattlemindTrainingSystem:ArmorforYourMind66MAJ(Ret)JohnM.Orsingher,MS,USA;etalTheArmyMasterofSocialWorkProgram72DexterFreeman,DSW;MAJGraemeBicknell,MS,USA BehavioralandMentalhealthcare:totalwarriorcarecommitment

PAGE 2

LTGEricB.SchoomakerTheSurgeonGeneral Commander,USArmyMedicalCommandMGRussellJ.CzerwCommandingGeneral USArmyMedicalDepartmentCenterandSchool JulySeptember2008 TheArmyMedicalDepartmentCenter&School PB8-08-7/8/9 0819815 GEORGEW.CASEY,JR General,UnitedStatesArmy ChiefofStaff DISTRIBUTION:Special AdministrativeAssistanttothe SecretaryoftheArmy ByOrderoftheSecretaryoftheArmy: Official: JOYCEE.MORROW Onlineissuesofthe AMEDDJournal areavailableathttps://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1 AProfessionalPublication oftheAMEDDCommunity The ArmyMedicalDepartmentJournal [ISSN1524-0436]ispublishedquarterlyfor TheSurgeonGeneralbytheUSArmyMedicalDepartmentCenter&School,ATTN: MCCS-DT,2423FSH-HoodST,FortSamHouston,TX78234-5078. CORRESPONDENCE: Manuscripts,photographs,officialunitrequeststoreceive copies,andunitaddresschangesordeletionsshouldbesenttothe Journal atthe aboveaddress.Telephone:(210)221-6301,DSN471-6301 DISCLAIMER: The Journal presentsclinicalandnonclinicalprofessionalinformation toexpandknowledgeofdomestic&internationalmilitarymedicalissuesand technologicaladvances;promotecollaborativepartnershipsamongServices, components,Corps,andspecialties;conveyclinicalandhealthservicesupport information;andprovideapeer-reviewed,highquality,printmediumtoencourage dialogueconcerninghealthcareinitiatives. Viewsexpressedarethoseoftheauthor(s)anddonotnecessarilyreflectofficialUS ArmyorUSArmyMedicalDepartmentpositions,nordoesthecontentchangeor supersedeinformationinotherArmyPublications.The Journal reservestherighttoedit allmaterialsubmittedforpublication(seeinsidebackcover). CONTENT: Contentofthispublicationisnotcopyrightprotected.Materialmaybe reprintedifcreditisgiventotheauthor(s). OFFICIALDISTRIBUTION: ThispublicationistargetedtoUSArmyMedical Departmentunitsandorganizations,andothermembersofthemedicalcommunity worldwide.

PAGE 3

JulySeptember20081Fromthebeginningoftherecordedhistoryofcampaignsandcombatbetweenorganizedarmies,warsandbattleswereusuallycharacterizedintermsofgloryandpride,focusedonthenobleleadersandtheoutcomes.Soldiersweretheheroesreturningfromsomedistantandunknownplace,withonlythestoriestheytoldtofamilyandfriendsportrayingthegrimrealityoftheactualevents.LipservicewasgiventothesacrificeoftheSoldiers,butthepublicsinterestinthedetailsofconflictswereshort-livedornonexistent.Usuallyonlytheoutcomesframedintermsofthegloryandrighteousnessoftheeffortremainedinanyonesmemory,exceptthoseofthecombatants.TheSoldierswereexpectedtoreturnfromthecampaignsandsimplyresumetheirnormallives,withoutregardtotheirexperiencesortheirmemories.Afterall,tothosewhowerenotthere,combatwasaglamorousenterprise,surroundedbyflags,banners,drummers,andflashyuniforms.ThereisnobetterexampleofthenaivetofthepublicaboutthestarkrealitiesofthebattlefieldthanthatdemonstratedinJuly1861bythewealthyeliteofWashington,DC,includingsomemembersofCongress.AftertheArmyofNortheasternVirginialeftthecapitalwithgreatfanfaretoengagenearbyConfederateforces,newsoftheimpendingbattleatBullRunnearManassas,Virginia,quicklyspreadaroundthecapital.Theprospectofwitnessingsuchaglamorousundertakingbecameafashionableevent.Asthebattlebegan,thehillsidesandmeadowsbehindUnionlineswerepopulatedwithfancycarriagesasfamiliessocializedandspreadtheirpicnicmealstorelaxandenjoythespectacle.Unfortunately,thegrimfactsofwarfarequicklyinterruptedtheirholiday,astheUnionArmywasroutedandtheywereengulfedinthetideoffleeingSoldiers,severelycomplicatingtheretreatintheirpanic.1TheCivilWarhasbeendescribedasthefirstconflictofmodernwarfare.Advancesintechnologyinweapons,communications,andtransportationcombinedwithahigherlevelofsophisticationinstrategyandtacticstomaketheCivilWarthemostlethalconflicttothatpointinhistory.TechnologyalsoallowedMathewBradytodocumentthewarasphotographicimages,somethingthathadneveroccurredbefore.Ofcourse,stifflyposedpicturesofmilitaryleadersandSoldiershadbeenpublished,butBradytookhiscamerasintothebattlefield.Hephotographedthecarnageanddevastationhefoundthere.InSeptember1862,BradywaspresentattheBattleofAntietam,whichincludedthebloodiestsingledayinAmericanmilitaryhistory.Hisexhibitsofthepicturesofthedeadofthatbattlewereashockingrevelationtothepublic.Forthefirsttime,theycouldseetheexperiencesofthemenwholeftthemtogotowar.However,perhapsmoreimportantly,forthefirsttimethepublicatlargehadasenseofhowwarfareaffectedthosewhofought,andreturned.Inpresentingtherealityofwarfare,Bradysphotographschallengedthepopularnotionsthatcombatanddeathonthebattlefieldwerenoble,gloriousundertakings.Duringthisextended,horrificwar,themedicalsciencesbegantorecognizeapsychologicaldisorder,calledbattlefatigue(BF),asadirectresultoftheexperiencesofthebattlefield.Indeed,oneofthemostrespectedphysiciansofhistime,DrOliverWendellHolmes,PerspectiveMajorGeneralRussellJ.Czerw

PAGE 4

2www.cs.amedd.army.mil/references_publications.aspxwhohimselfhadgonetotheAntietambattlefieldtolocatehiswoundedson,commentedonBradysphotographs:Lethimwhowishestoknowwhatthewarislookatthisseriesofillustrations.Thesewrecksofmanhoodthrowntogetherincarelessheapsorrangedinghastlyrowsforburialwerebutaliveyesterday....Manypeoplewouldnotlookthroughthisseries.Many,havingseenitanddreamedofitshorrors,wouldlockitupinsomesecretdrawer.2AsprofoundasHolmescommentsare,theyweredirectedatthereactionsofthosewhoviewedthephotographs.Thesecretdrawerofthecombatveterancontainsmemoriesofnotonlythesightsofbattlefieldcarnage,butalsothesounds,smells,tastes,andpainoftheexperience.Fiftyyearslater,greaterleapsintechnologyandtacticsproducedcarnageatanevengreaterscaleintheFirstWorldWar.Fortunately,increasedknowledgeandsophisticationinmentalhealthcareallowedmilitarymedicinetorecognizeandaddressthepsychologicaltollofsuchhorrificenvironments:WhentheGermanArmyinitiallyintroducedgaswarfare,psychiatrictoWIAratiosinAlliedgroundforcesoftenexceeded2:1;ie,twohystericalreactionsoccurredforeveryonecasualtyduetoactualgasexposures.ThelargenumberofBFcasualtiesproducedandtheinabilitytoevacuateandreplacetheseSoldierspromptedtheAlliestodevelopbasicprinciplesofeffectivetreatment:treatasfarforwardaspossible,treatasquicklyaspossible,andtreatwiththeexpectationthattheSoldierwillrecoverandreturntocombat.3ThelearningprocesscontinuedthroughWorldWarII,Korea,Vietnam,andOperationDesertStorm,andcontinuestodayintheGlobalWaronTerror.TheRANDCenterforMilitaryHealthPolicyResearchhasrecentlyreleasedadetailedreport4fromacomprehensivestudyofthementalandpsychologicalhealthofWarriorsreturningfromcombatdeploymentstoIraqandAfghanistan.TheRANDreportreinforcestheincreasingemphasisthatmilitarymedicineisplacingonthebehavioralandmentalhealthofourWarriors,reflectedintheArmyMedicalDepartmentsincreasedapplicationofresources,changesinstructure,andaggressive,proactiveactionsaddressingprevention,intervention,therapy,andrecovery.ThoseaspectsofoureffortstoaddressthebehavioralandmentalhealthneedsofourWarriorsarefeaturedinthisdedicatedissueoftheAMEDDJournal.WearepleasedtoopenthisissuewithareprintofanarticlefromtheNewEnglandJournalofMedicinewhichpresentswhathasbecomethedefactobaselinestudyofthementalhealthsituationamongWarriorsengagedincombatoperationsinAfghanistanandIraq.In2003,COLCharlesHogeandhisteamofexperiencedresearchersevaluatedthementalhealthconditionsofgroundcombattroopsbothbeforeandafterdeploymentintothecombattheaters.Theirrigidscientificmethod,largesamplesizes,anddetailed,carefuldatareductionandanalysishaveprovidedinvaluableinformationforthosechargedwiththementalhealthcareofourWarriors,bothduringandaftertheirexperiencesinthefluidandunpredictablecombatenvironmentsoftoday.Indeed,thisarticlehasoftenbeenreferencedinotherwritingsonthesetopics.COLHogeetalsetthestageforthearticlesthatfollowinthisveryimportantissueoftheAMEDDJournal.Wearefortunatetohave4articlesinthisissuewhichwerewrittenbyauthorsprovidingbehavioralandmentalhealthcaretoourWarriorsonthegroundinIraq.ThefirstarticleinthiscollectionisbyCPTPatrickPischkeandCPTChristianHallman.Theirexcellentarticledescribestheirexperienceswithcriticaleventdebriefing,atechniquedevelopedtodealwithpsychologicaltrauma,notonlybythemilitaryinacombatenvironment,butalsousedforpolice,firefighters,rescuepersonnel,emergencyroomstaff,andotherswhoexperiencetraumaticevents.Researchandexperienceinpastextendedconflictssolidlysupportthepropositionthatmentalhealthserviceprovidedasquicklyaspossibleafteratraumaticeventiscriticaltopreventionoftheonsetofposttraumaticstressandotheranxietydisorders.Researchalsoshowsthatsuchdisorderscanbecomechronicandmoreresistanttotreatmentwiththepassageoftime.Thearticledetailstheresearch,anddescribestheresultsof38groupcriticaleventdebriefingsadministeredinIraqbetweenMarch2004andJanuary2005.ThedatagatheredbyCPTPischkeandCPTHallmanstronglyvalidatethepresenceofmentalhealthcareresourcesamongfrontlineforces,andtheapplicationofassistancetothoseexperiencingtraumaticeventsasquicklyaspossible.Perspective

PAGE 5

JulySeptember20083THEARMYMEDICALDEPARTMENTJOURNALCPTBrianParrishhascontributedanintriguing,veryinformativearticleabouttheinnovativeadaptationofatreatmentregimendesignedforthosewithborderlinepersonalitydisordertoassistSoldiersinthecombatenvironment.Theintenseemotionswhicharedrivenbythenever-endingpressuresoflifeanddeathdecisionsinaconstantcrisisenvironmentcancausesomeSoldierstoexhibitsomeofthesamepsychologicalliabilitiesasthosewithclassicpersonalitydisorders.CPTParrishsarticledescribestheuseofdialecticalbehaviortherapyasaninterventiontool,designedtokeeptheSoldierfunctioningwithinthedutyenvironmentwhiledealingwiththeissuesthatthreatentheirpsychologicalwell-being.Therapyisavailable24hoursadayataspecificlocation,awellnesscenterlocatedwithinthetroopmedicalfacilitywhichmitigatesthestigmaSoldiersoftenfeelaboutseekingmentalhealthassistance.ThiscreativeapproachtoensuringourWarriorshaveassistancewhereandwhenneededisanotherdemonstrationofthehighlevelofinitiativeandprofessionalismthatisfundamentaltomilitarymedicine.AsimportantasinterventionandtherapyaretothoseSoldierswhoexperiencepsychologicalproblemsinthecombatenvironment,thoseactionsrepresentoneaspectofmentalhealthcaretreatment.Mentalhealthcarealsohasapreventivecareresponsibility.MAJThomasJarrettsarticleisadetailed,carefullyorganizeddiscussionofthedevelopmentandimplementationofWarrior-orientedcombatstresspreventiontrainingtobepresentedin-theater.ThisWarriorResilienceTrainingisdesignedtostrengthenourSoldierspsychologicalresistancetothedeleteriouseffectsoftraumaticevents.Theapproachtothistypeoftrainingcontainsmuchreinforcementintheethics,values,andstandardsthatarereflectedinArmyEthosandArmyValues,aswellasthevariouscodesofconductandrulesthatarepartofprofessionalmilitarydisciplineandcharacter.MAJJarrettdetailsthefoundationsoftheWarriorResilienceTraining,howitisintegratedintothedeploymenttrainingcycle,andtheoverwhelminglypositivefeedbackreceivedfromthosewhoreceiveitin-theater.Obviously,theremotenessandstarkrealityofthecombatdeploymentenvironmentintroducestypesofstressandpressuresunseeninanormalgarrisonsituation,thereforemandatingtheprovisionoffargreaterrangeofbehavioralandmentalhealthcareservicesthanthoserequiredforthetypicalgarrisonclinicalsetting.Theprevious3articlesreflectthediversityandextentofsomeofthoseservices.However,theactivityworkloadmetricsusedinanormalenvironmentarenotdesignedtotrackmuchoftheworkloadofbehavioralandmentalhealthpersonnelonthesedeployments.Withoutsuchdata,therequirementsexperiencedinthatrealworldcannotbequantified.Plannersanddevelopersfororganizations,structure,doctrine,andtraining,justtonameafew,areunabletoaddresstheneedsforongoingsupport,muchlesslooktofuturerequirements.Also,andperhapsmoreimportant,commanderscannotbeprovidedwithreal-timedataabouttheservicesusedbytheirSoldiers.Totheproperlyeducatedleader,suchdataisinvaluableinformationaboutthepsychologicalreadinessofhisorherSoldierstoperformtherequiredmissions.Theleadercanthentakenecessarymeasurestoaddressproblemareasrevealedinthestatistics.Inhisveryinformativearticle,MAJBarronHungdescribestheCombatandOperationalStressControlWorkloadandActivityReportingSystem(COSC-WARS),whichwasimplementedatthebeginningofOperationIraqiFreedominresponsetotheneedforsuchdata.MAJHungpresentsanddiscussesCOSC-WARSdataforthe6-monthperiodJanuarytoJune2008,asanexampleofthetypeofinformationthatisobtained,andtheimplicationsthattheresultshavefortheindividualSoldiersandtheirunits.Thisarticleisasuccinctandvaluablevalidationofthemethodsandsupportservicesdiscussedinthe3precedingarticles,aswellasarevealinglookattheextentanddiversityofthefactorscausingtensionandstressamongourWarriors.Oftheseveraldestructivebehaviorsthatmayresultfrompsychologicalanxietiesinducedbythecombatenvironmentorotherhighstresssituations,noneismoreperniciousthanactsofviolence,includingmurder,againstenemyprisoners,noncombatants,orevenotherUSservicemembers.Althoughextremelyrare,theseincidentsdohappeninourmilitary.Theoccurrenceofsuchactsisnotonlytragicforthevictimandtheperpetrator,butitmayalsohaveseriousramificationsforthesuccessofthemission,andforthemilitaryingeneral.LTCKarenMarrshaswrittenanimportantarticlewhichpresentstheresearch,theories,andfactssurroundingillegalviolenceby

PAGE 6

4www.cs.amedd.army.mil/references_publications.aspxPerspectivemilitarymembers.HerarticledetailsaconceptforanadditiontothecurrentcombatandoperationalstresscontrolactionstodealdirectlywithaSoldiersstateofmind,usuallyinvolvingrevengeandfrustration,which,ifunchecked,canleadtoillegalviolence.Thepotentialforsuchincidentsmaybegreaterthanwethink,asLTCMarrspointsoutthattheDoDMentalHealthAdvisoryTeamVsreport5(2007)foundatroublingattitudeofdisdainanddisrespectforlocalnationalnoncombatantsamongamajorityofdeployedSoldiersandMarines.Asexpertlyexplainedinthearticle,withoutabaselineofrespectforsuchindividuals,theoverwhelmingcombinationofrage,frustration,andrevengehasnocheck,oftenwithtragicresults.LTCMarrspresentstheRemindconceptasaproactiveefforttogiveWarriorsapsychologicaltooltodealwiththeenvironment,thecircumstances,andespeciallytheemotionsencounteredinthecurrentdeployedenvironments.Thisisathoughtful,informativearticleaboutaveryserioussubjectwhichwarrantsthecloseattentionofmilitaryleadersandmentalhealthprofessionals.ThoseprofessionalsprovidingbehavioralandmentalhealthcareservicestoWarriorsandtheirFamiliesarethefrontlinesofassistanceforthoseinneed.Theyarealsotheleadingedgeofanextensivestructureofplanners,researchers,trainingspecialists,andothersupportstaffwhomakeitpossibleforthemtoapplytheirskills,training,anddedicationtotheirwork.TheremainingarticlesinthisissueoftheAMEDDJournalpresentinformationontheleadershipandtrainingprovidedwithinthebehavioralhealthdisciplinesoftheArmyMedicalDepartment.Leadingoffthissection,COLElspethRitchie,thefirstDirectoroftheBehavioralHealthProponencyoftheOfficeofTheSurgeonGeneral,hascontributedanarticledescribingtheestablishmentoftheProponencyinMarch2007.Shediscussesthebackgroundofherposition,andoutlinestheinitiativesthathaveaddressedareasofconcernwithinbehavioralhealthcare,bothexistingandfuture.TheProponencyprovidesabadlyneededfocalpointatthehighestlevelsofArmymedicineforanincreasinglyimportantaspectofSoldierhealthcare.Thelargestobstacleintheprovisionofbehavioralormentalhealthcareservicesistheunwillingnessofthoseneedingassistancetoavailthemselvesoftheservice.Thatunwillingnessmaystemfromfailuretorecognizetheneed(orrejectionoftheidea),butquiteoftenitispresentduetothestigmaassociatedwithmentalhealthcare.Forthisreason,itisimportantformilitaryhealthcareproviders(ie,primarycare,alliedhealthcareprovider)tobeequippedwiththetoolstorecognizeandmanagementalhealthdisorders.Intheirarticle,KarenSheaandDrMaryannPechacekdescribetheimportanceoftheproperlytrainedhealthcareproviderintheactualdeliveryofpsychologicalhealththerapytomanypatientswhowouldotherwiseavoidorrejectit.Theirinterestingarticledetailsthecircumstancesthatmakesuchanarrangementidealformanypatients.MilitaryhealthcareprovidersarecurrentlytaughttheinformationandskillsnecessaryfortheeffectivemanagementofmentalhealthdisorderswithinthemilitaryhealthcaresettingattheAMEDDCenter&School(AMEDDC&S).TheMentalHealthAdvisoryTeamV5reportedthat15.5%ofSoldiersandMarinessurveyedinAfghanistanandIraq(2007)screenedpositiveforacutestress/posttraumaticstressdisorder(PTSD).ThepreviouslymentionedRANDstudysfindings4supportthatstatistic,indicatingthat14%ofservicemembersreturningfromIraqmetthecriteriaforPTSD.Obviously,thisdisorderrepresentsasignificantchallengeformilitarybehavioralhealthcareprofessionals,bothin-theaterandathomegarrisonmedicaltreatmentfacilities.DrGerardGracesarticlepresentstheclinicalbackground,evolution,andimplementationofaPTSDtreatmenttrainingprogramattheAMEDDC&S.ThisimportantarticleclearlydetailsthechallengesandcomplexitiesfacedbythosechargedwithdevelopingthemosteffectiveapproachtotrainingourbehavioralhealthprofessionalstorecognizeandtreatPTSD,nowandintothefuture.JustastheWarriorResilienceTrainingdiscussedbyMAJJarrettinhisarticleisdesignedtoenableSoldiersonthelinetoresistthedeleteriouspsychologicaleffectsoftraumaticcombatevents,somustwebeconcernedwiththepsychologicalfitnessofthecaregiverswhomustdealwiththeaftermathofcombat,thewoundedSoldiersandnoncombatants.Duringperiodsofheavycombatoperations,thestreamofseverelywoundedpeoplecanbenonstop,andthewoundsareoftenhorrificandextensive.Thiscircumstanceplacesextremepressureandstressonthemedicalprofessionalswholabortosavethoselives,sometimescontinuouslyformanyhourswithoutrelief.Intheirwell-writtenarticle,DrRichardBooneandhis

PAGE 7

JulySeptember20085THEARMYMEDICALDEPARTMENTJOURNALcoauthorsdescribetheArmyProviderResiliencyTraining(PRT)Program,developedandimplementedtoaddressthepsychologicalhealthofthosededicatedtosavingandimprovingthelivesofothers.AlthoughthePRTProgramhasbeenaformalpartofArmymedicaltrainingonlysinceJuly2008,theneedwasrecognizedin2001.Sincethen,variousapproachestoprovidinghealthcareprofessionalsthenecessaryknowledgeandtoolshavebeenused,allpartoftheevolutiontothecurrentPRTProgram,whichwillbemandatorytrainingforallAMEDDcaregivers.ThisprogramisoneoftheArmysanswerstotheperpetualquestion,whotakescareofthecaregivers?Throughouthistory,humanshaveusedmoodalteringsubstancesforvariouspurposes,somebeneficial,somedetrimental.Theconcernforsocietyingeneralis,ofcourse,thedetrimentalabuseofsuchsubstances.Thedamagetotheabuserisprofound,butthedangertootherswhoarenotinvolvedinthatpersonsself-destructiveactivityisevenmoretragic.Inthesituationofamilitary,especiallycombat,environment,interdependenceamongallmembersofaunitisadaily,lifeanddeathreality.Anindividualwhosepsychological,andphysical,capabilitiesareimpairedbytheeffectsofalcoholand/ordrugsrepresentsatrulyseriousliabilitytothesafetyoftheothermembersoftheunit.Further,asubstanceabusermayalsobeadirectphysicalthreattootherSoldiers,and/ortohimorherself.JosephHallamhascontributedanimportantarticledescribingthecurrentsituationamongourSoldiersinIraq,andtheAMEDDC&Strainingresourceswhichareaddressingthoseproblems.Therearecurrently6formalcoursesprovidingtrainingtomilitaryMentalHealthSpecialists,HealthcareSpecialists,civiliancounselors,clinicaldirectorsandsupervisors,andphysicians.Theincreasedavailabilityofcounselingservices,bothin-theaterandathomeinstallations,provideshealthcareproviders,commanders,andotherleaderswithadditionalresourcestoassistourWarriorsandtheirFamilieswiththisextremelydifficultpersonalandsocietalproblem.Anotheroftheundesirableconsequencesofthepsychologicalpressures,stresses,anddisordersthataffectSoldiersinacombatenvironmentisthenegativeimpacttheycanhaveontheWarriorsFamilyrelationships.Dissolutionsofmarriagesandfamilybreakupsfollowingreturnfromdeploymentarefartoocommon.Attheextreme,weseethereportsofphysicalabuse,includingthedeathofoneorbothspouses,andsometimeschildren.Thefamilyadvocacyapproachtoaddressthestressesofmilitarylifeonthefamilywasdevelopedinthe1980s.CindiGeeslinandhercoauthorsdescribetheevolutionoftheAMEDDFamilyAdvocacyStaffTrainingCoursewhichdebutedin1985toprepareFamilyAdvocacyProgramstaffmemberstoimplementtheprogramthroughouttheArmy.Theirarticlelaysouthowthecourseisdesigned,andhowithaschangedovertheyearsinadaptationtoDoDrequirementsandinresponsetothelatestresearchintheareasoffamilydynamicsandviolence.Asthefamilyadvocacyapproachhasmatured,newrequirementsandmethodsoftraininghavebeenidentified.Inadditiontothe2-weekbasiccourse,AMEDDC&Snowpresents6advancedcoursestoaddressthespecifictrainingneedsoftheprofessionalstaff.Also,adistancelearningcomponentofthebasiccourseisnearingcompletion.Notonlywillthedistancelearningelementreducetheresidenttrainingrequirementtooneweekwithattendantsavingsintimeandmoney,butitalsoallowsexpansionofcontentinthecourse,aclearbenefittotheSoldiersandtheirFamilieswhoneedhelp.Theenergy,professionalism,andcommitmentofresourcesdescribedinthisarticleclearlyshowthecommitmentoftheArmytothewholeSoldier,whichincludestheFamilyasfullpartnersinservicetoourcountry.Theprevious5articleshavedealtwiththeAMEDDC&Strainingdirectedatthosechargedwithprovidingmentalandbehavioralhealthevaluation,treatment,andcounseling.Arecentlycreated(March2007)organizationwithinAMEDDC&S,theBattlemindTrainingOffice(BTO)hasthemissiontodevelopanddeliverevolving,sophisticated,andmultifacetedpsychologicalresiliencytrainingpackagesaimedattheWarriorsthemselves.Intheirarticle,MAJ(Ret)JohnOrsingerandhiscoauthorschronicletheestablishmentoftheBTOtoaddresstheneedforanorganizationalapproachtothementalpreparationofSoldierstosuccessfullydeployandthentransitionbacktotheirhomelives.TheBattlemindconceptisanextremelyimportantbigpictureapproach,notfocusedexclusivelyonthatperiodaSoldierspendsinthecombattheater.Rather,whenfullyinstituted,BattlemindtrainingwillencompasstheentirecyclethatpreparesaSoldierfordeployment,thedeploymentitself,andthedecompressionthatisnecessaryasaWarriorleavesthecombatenvironment

PAGE 8

6www.cs.amedd.army.mil/references_publications.aspxandundergoesthepsychologicaltransitiontothesafetyandsecurityofnormallife.Bothpre-andpostdeploymenttrainingincludeblockswiththeWarriorsandtheirFamiliestogethertoensureallpartiesarepreparedforthosechangesthatareunavoidable,forboththeWarriorandFamily.Understandably,thedevelopmentofsuchanexpansive,yetintegratedconceptintothenumeroustrainingpackagesnecessaryisamajorundertaking.TheBattlemindTrainingOfficehasbecomethelargestentityintheSoldierandFamilySupportBranchoftheAMEDDC&S.ItsmissionisrecognizedthroughouttheAMEDDandArmyseniorcommandlevelsascriticaltocombatreadinessandeffectiveness,SoldierandFamilysatisfaction,and,ofcourse,retentionofthatinvaluableresource,ourprofessionalWarriors.DrDexterFreemanandMAJGraemeBicknellclosethisissueoftheAMEDDJournalwithanarticlepresentingaexcitingnewprofessionaleducationopportunitywithintheAMEDD.TheAMEDDhasteamedwithFayettevilleStateUniversitytoestablishaMasterofSocialWorkdegreegrantingprogramformilitarymemberswhichispresentedattheAMEDDC&S.Theprogram,whichstarteditsinitialclassinJune2008,addressesacomplicatedproblemwhichhasplaguedArmySocialWorksinceitsestablishmentin1943.Untilnow,itwasnecessaryfortheArmytosourcegraduatesofcivilianinstitutionsforallofitsmilitarysocialworkers.Ofcourse,thosenewSoldiers,althoughwelleducatedintheknowledgeandskillsoftheciviliansocialworkenvironment,hadnoexposuretothemarkedlydifferentenvironmentofthemilitary.Since1945,AMEDDhaspresentedasubprofessionaltrainingprogramtoorientnewsocialworkers,buttheadjustmentperiodonthejobislong,andeffectivenessofservicesissometimesadverselyaffectedasthenewArmysocialworkerbecomesaccustomedtotheunfamiliarworldinwhichheorshemustpracticetheirskills.Afurthercomplicationarosein1998whenfederallawmandatedthatmilitarysocialworkersmustpossessaprofessionallicensetopractice.ThisrequirementextendedtheperiodbetweengraduationandeligibilitytoentertheArmyandpracticebyover2years,furthershrinkingthepoolofpotentialcandidatesastheirinterestinthemilitarywanedduringtheirexposuretoprivatepractice.TheArmy-FayettevilleStateUniversityMasterofSocialWorkprogramisdesignedtosourcestudentsfromwithinthemilitarythuseliminatingtheneedforadjustmentandreorientationandprovideagraduateeducationfromanaccreditedinstitutiontailoredtoourenvironment.Thegraduatethencompletesthesupervisedpractice-examination-licensurephaseatamilitaryfacility,providingtheArmywithamuchneededresourcewhoismoreeffectivefromdayonethanthoseenteringthemilitarydirectlyfromcivilianeducationandpractice.TheprofessionalswithintheAMEDDC&Shaveworkedlongandhardonthisinnovative,desperatelyneededinitiativethatwillhelpensureSoldiersandFamiliesreceivethebestpossiblesupportservicesandcare.Theyaretobecongratulatedontheirsuccess.REFERENCES 1.McPhersonJM.BattleCryofFreedom:TheCivilWarEra.NewYork:OxfordUniversityPress;1988.2.HobartG.MastersofPhotography:MathewBrady.London:Macdonald&Co;1984:7.3.ChermolBH.Woundswithoutscars:treatmentofbattlefatigueintheUSarmedforcesintheSecondWorldWar.MilAff.1985;49(1):9-12.4.TanielianT,JaycoxLH,eds.InvisibleWoundsofWar:PsychologicalandCognitiveInjuries,TheirConsequences,andServicestoAssistRecovery.SantaMonica,CA:RANDCorporation;1998.PublicationMG-720-CCF.Availableat:http://veterans.rand.org.5.MentalHealthAdvisoryTeam(MHAT)V:OperationIraqiFreedom06-08,Iraq;OperationEnduringFreedom8,Afghanistan.Washington,DC:OfficeofTheSurgeonGeneral,USDeptoftheArmy;February14,2008:26.Availableat:http://www.armymedicine.army.mil/reports/mhat/mhat_v/MHAT_V_OIFandOEF-Redacted.pdf.Perspective

PAGE 9

JulySeptember20087BACKGROUNDThecurrentcombatoperationsinIraqandAfghanistanhaveinvolvedUSmilitarypersonnelinmajorgroundcombatandhazardoussecurityduty.Studiesareneededtosystematicallyassessthementalhealthofmembersofthearmedserviceswhohaveparticipatedintheseoperationsandtoinformpolicywithregardtotheoptimaldeliveryofmentalhealthcaretoreturningveterans.METHODSWestudiedmembersof4UScombatinfantryunits(3ArmyunitsandaMarineCorpsunit)usingananony-moussurveythatwasadministeredtothesubjectsei-therbeforetheirdeploymenttoIraq(n=2530)or3to4monthsaftertheirreturnfromcombatdutyinIraqorAfghanistan(n=3671).Theoutcomesincludedmajordepression,generalizedanxiety,andposttraumaticstressdisorder(PTSD),whichwereevaluatedonthebasisofstandardized,self-administeredscreeningin-struments.RESULTSExposuretocombatwassignificantlygreateramongthosewhoweredeployedtoIraqthanamongthosedeployedtoAfghanistan.Thepercentageofstudysub-jectswhoseresponsesmetthescreeningcriteriaformajordepression,generalizedanxiety,orPTSDwassignificantlyhigherafterdutyinIraq(15.6%to17.1%)thanafterdutyinAfghanistan(11.2%)orbe-foredeploymenttoIraq(9.3%);thelargestdifferencewasintherateofPTSD.Ofthosewhoseresponseswerepositiveforamentaldisorder,only23%to40%soughtmentalhealthcare.Thosewhoseresponseswerepositiveforamentaldisorderweretwiceaslikelyasthosewhoseresponseswerenegativetore-portconcernaboutpossiblestigmatizationandotherbarrierstoseekingmentalhealthcare.CONCLUSIONSThisstudyprovidesaninitiallookatthementalhealthofmembersoftheArmyandtheMarineCorpswhowereinvolvedincombatoperationsinIraqandAf-ghanistan.Ourfindingsindicatethatamongthestudygroupstherewasasignificantriskofmentalhealthproblemsandthatthesubjectsreportedimportantbar-rierstoreceivingmentalhealthservices,particularlytheperceptionofstigmaamongthosemostinneedofsuchcare.TherecentmilitaryoperationsinIraqandAfghanistan,whichhaveinvolvedthefirstsustainedgroundcombatundertakenbytheUnitedStatessincethewarinViet-nam,raiseimportantquestionsabouttheeffectoftheexperienceonthementalhealthofmembersofthemilitaryserviceswhohavebeendeployedthere.Re-searchconductedafterothermilitaryconflictshasshownthatdeploymentstressorsandexposuretocom-batresultinconsiderablerisksofmentalhealthprob-CombatDutyinIraqandAfghanistan,MentalHealthProblemsandBarrierstoCareCOLCharlesW.Hoge,MC,USACOLCarlA.Castro,MS,USAStephenC.Messer,MA,PhDMAJDennisMcGurk,MS,USACPTDaveI.Cotting,MS,USARCAPTRobertL.Koffman,MC,USNABSTRACT ThisarticleoriginallyappearedintheNewEnglandJournalofMedicine:NewEnglJMed.2004;351:13-22.Copyright2004MassachusettsMedicalSociety.Reprintedwithpermissionofthepublisher.

PAGE 10

8www.cs.amedd.army.mil/references_publications.aspxSTUDYGROUPSWesummarizeddatafromthefirst,cross-sectionalphaseofalongitudinalstudyoftheeffectofcombatonthementalhealthoftheSoldiersandMarinesde-ployedinOperationIraqiFreedomandinOperationEnduringFreedominAfghanistan.ThreecomparableUSArmyunitswerestudiedwiththeuseofananony-moussurveyadministeredeitherbeforedeploymenttoIraqoraftertheirreturnfromIraqorAfghanistan.Al-thoughnodatafrombeforedeploymentwereavailablefortheMarinesinthestudy,datawerecollectedfromaMarineCorpsunitafteritsreturnfromIraqthatpro-videdabasisforcomparisonwithdataobtainedfromArmySoldiersaftertheirreturnfromIraq.Thestudygroupsincluded2530SoldiersfromanArmyinfantrybrigadeofthe82ndAirborneDivision,whoseresponsestothesurveywereobtainedinJanu-ary2003,oneweekbeforeayear-longdeploymenttoIraq;1962SoldiersfromanArmyinfantrybrigadeofthe82ndAirborneDivision,whoseresponseswereobtainedinMarch2003,aftertheSoldiersreturnfroma6-monthdeploymenttoAfghanistan;894SoldiersfromanArmyinfantrybrigadeofthe3rdInfantryDi-vision,whoseresponseswereobtainedinDecember2003,aftertheirreturnfroman8-monthdeploymenttoIraq;and815Marinesfrom2battalionsunderthecommandofthe1stMarineExpeditionaryForce,whoseresponseswereobtainedinOctoberorNovem-ber2003,aftera6-monthdeploymenttoIraq.The3rdInfantryDivisionandtheMarinebattalionshadspear-headedearlyground-combatoperationsinIraq,inMarchthroughMay2003.Alltheunitswhosemem-bersrespondedtothesurveywerealsoinvolvedinhazardoussecurityduties.Thequestionnairesadminis-teredtoSoldiersandMarinesafterdeploymenttoIraqorAfghanistanwereadministered3to4monthsaftertheirreturntotheUnitedStates.ThisintervalallowedtimeinwhichtheSoldierscompletedleave,madethetransitionbacktogarrisonworkduties,andhadtheopportunitytoseekmedicalormentalhealthtreat-ment,ifneeded.RECRUITMENTANDREPRESENTATIVENESSOFTHESAMPLEUnitleadersassembledtheSoldiersandMarinesneartheirworkplacesatconvenienttimes,andthestudyinvestigatorsthengaveashortrecruitmentbriefingandobtainedwritteninformedconsentonformsthatlems,includingposttraumaticstressdisorder,majordepression,substanceabuse,impairmentinsocialfunctioningandintheabilitytowork,andthein-creaseduseofhealthcareservices.1-8OnestudythatwasconductedjustbeforethemilitaryoperationsinIraqandAfghanistanbeganfoundthatatleast6%ofallUSmilitaryservicemembersonactivedutyreceivetreatmentforamentaldisordereachyear.9GiventheongoingmilitaryoperationsinIraqandAfghanistan,mentaldisordersarelikelytoremainanimportanthealthcareconcernamongthoseservingthere.Manygapsexistintheunderstandingofthefullpsy-chosocialeffectofcombat.Theall-volunteerforcedeployedtoIraqandAfghanistanandthetypeofwar-fareconductedintheseregionsareverydifferentfromthoseinvolvedinpastwars,differencesthathighlighttheneedforstudiesofmembersofthearmedserviceswhoareinvolvedinthecurrentoperations.Moststud-iesthathaveexaminedtheeffectsofcombatonmentalhealthwereconductedamongveteransyearsaftertheirmilitaryservicehadended.1-8Aprobleminthemeth-odsofsuchstudiesisthelongrecallperiodafterexpo-suretocombat.10Veryfewstudieshaveexaminedabroadrangeofmentalhealthoutcomesneartothetimeofsubjectsdeployment.Littleoftheexistingresearchisusefulinguidingpol-icywithregardtohowbesttopromoteaccesstoandthedeliveryofmentalhealthcaretomembersofthearmedservices.Althoughscreeningformentalhealthproblemsisnowroutinebothbeforeandafterdeploy-ment11andisencouragedinprimarycaresettings,12wearenotawareofanystudiesthathaveassessedtheuseofmentalhealthcare,theperceivedneedforsuchcare,andtheperceivedbarrierstotreatmentamongmem-bersofthemilitaryservicesbeforeoraftercombatdeployment.WestudiedtheprevalenceofmentalhealthproblemsamongmembersoftheUSarmedserviceswhowererecruitedfromcomparablecombatunitsbeforeoraftertheirdeploymenttoIraqorAfghanistan.Weidentifiedtheproportionofservicememberswithmentalhealthconcernswhowerenotreceivingcareandthebarrierstheyperceivedtoaccessingandreceivingsuchcare.METHODS CombatDutyinIraqandAfghanistan,MentalHealthProblemsandBarrierstoCare

PAGE 11

JulySeptember20089THEARMYMEDICALDEPARTMENTJOURNALincludedstatementsaboutthepurposeofthesurvey,thevoluntarynatureofparticipation,andthemethodsusedtoensureparticipantsanonymity.Overall,58%oftheSoldiersandMarinesfromtheselectedunitswereavailabletoattendtherecruitmentbriefings(79%oftheSoldiersbeforedeployment,58%oftheSoldiersafterdeploymentinOperationEnduringFreedominAfghanistan,34%oftheSoldiersafterdeploymentinOperationIraqiFreedom,and65%oftheMarinesaf-terdeploymentinOperationIraqiFreedom).Mostofthosewhodidnotattendthebriefingswerenotavail-ablebecauseoftheirrigorousworkandtrainingsched-ules(eg,nighttrainingandpostsecurity).Aresponsewasdefinedascompletionofanypartofthesurvey.TheresponserateamongtheSoldiersandMarineswhowerebriefedwas98%forthe4samplescombined.Theratesofmissingvaluesforindividualitemsinthesurveyweregenerallylessthan15%;2%ofparticipantsdidnotcompletethePTSDmeasures,5%didnotcompletethedepressionandanxietymeas-ures,and7%to8%didnotcompletetheitemsrelatedtotheuseofalcohol.Thehighresponseratewasprobablyowingtotheanonymousnatureofthesurveyandtothefactthatparticipantsweregiventimebytheirunitstocompletethe45-minutesurvey.ThestudywasconductedunderaprotocolapprovedbytheinstitutionalreviewboardoftheWalterReedArmyInstituteofResearch.Toassesswhetherornotoursamplewasrepresenta-tive,wecomparedthedemographiccharacteristicsofrespondentswiththoseofallactive-dutyArmyandMarinepersonneldeployedtoOperationIraqiFree-domandOperationEnduringFreedom,usingtheDe-fenseMedicalSurveillanceSystem.13SURVEYANDMENTALHEALTHOUTCOMESThestudyoutcomeswerefocusedoncurrentsymp-toms(ie,thoseoccurringinthepastmonth)ofamajordepressivedisorder,ageneralizedanxietydisorder,andPTSD.Weused2casedefinitionsforeachdisor-der,abroadscreeningdefinitionthatfollowedcurrentpsychiatricdiagnosticcriteria14butdidnotincludecriteriaforfunctionalimpairmentorforseverity,andastrict(conservative)screeningdefinitionthatrequiredaself-reportofsubstantialfunctionalimpairmentoralargenumberofsymptoms.Majordepressionandgen-eralizedanxietyweremeasuredwiththeuseofthepatienthealthquestionnairedevelopedbySpitzeretal.15-17Forthestrictdefinitiontobemet,therealsohadtobeevidenceofimpairmentinwork,athome,orininterpersonalfunctioningthatwascategorizedasattheverydifficultlevelasmeasuredbythepatienthealthquestionnaire.Thegeneralizedanxietymeasurewasmodifiedslightlytoavoidredundancy;itemsthatper-tainedtoconcentration,fatigue,andsleepdisturbanceweredrawnfromthedepressionmeasure.ThepresenceorabsenceofPTSDwasevaluatedwiththeuseofthe17-itemNationalCenterforPTSDChecklistoftheDepartmentofVeteransAffairs.4,8,18,19Symptomswererelatedtoanystressfulexperience(inthewordingofthespecificstressorversionofthechecklist),sothattheoutcomewouldbeindependentofpredictors(ie,beforeorafterdeployment).Resultswerescoredaspositiveifsubjectsreportedatleastoneintrusionsymptom,3avoidancesymptoms,and2hy-perarousalsymptoms14thatwerecategorizedasatthemoderatelevel,accordingtothePTSDchecklist.Forthestrictdefinitiontobemet,thetotalscorealsohadtobeatleast50onascaleof17to85(withahighernumberindicatingagreaternumberofsymptomsorgreaterseverity),whichisawell-establishedcut-off.4,8,18,19Misuseofalcoholwasmeasuredwiththeuseofa2-questionscreeninginstrument.20Inadditiontothesemeasures,onthesurveypartici-pantswereaskedwhethertheywerecurrentlyexperi-encingstress,emotionalproblems,problemsrelatedtotheuseofalcohol,orfamilyproblemsand,ifso,whethertheleveloftheseproblemswasmild,moder-ate,orsevere;theparticipantswerethenaskedwhethertheywereinterestedinreceivinghelpfortheseproblems.Subjectswerealsoaskedabouttheiruseofprofessionalmentalhealthservicesinthepastmonthorthepastyearandaboutperceivedbarrierstomentalhealthtreatment,particularlystigmatizationasaresultofreceivingsuchtreatment.21Combatexperi-encesweremodifiedfrompreviousscales.22QUALITY-CONTROLPROCEDURESANDANALYSISResponsestothesurveywerescannedwiththeuseofScanToolssoftware(PearsonNCS).Qualitycontrolproceduresidentifiedscanningerrorsinnomorethan0.38%ofthefields(range,0.01%to0.38%).SPSSsoftware(version12.0)wasusedtoconducttheanaly-ses,includingmultiplelogisticregressionthatwasusedtocontrolfordifferencesindemographiccharac-teristicsofmembersofstudygroupsbeforeandafterdeployment.23,24

PAGE 12

10www.cs.amedd.army.mil/references_publications.aspxCombatDutyinIraqandAfghanistan,MentalHealthProblemsandBarrierstoCare Table1.DemographicCharacteristicsofStudyGroupsofSoldiersandMarinesasComparedwithReferenceGroups.*CharacteristicArmyStudyGroupsMarineStudyGroupArmyReferenceGroup(N=61,742)MarineReferenceGroup(N=20,194) BeforeDeploymenttoIraq(N=2530)AfterDeploymenttoAfghanistan(N=1962)AfterDeploymenttoIraq(N=894)AfterDeploymenttoIraq(N=815) Agenumber(%) 1824yr1647(66) 1226 (63) 528 (59) 652 (80) 32,840 (53) 13,824 (69) 2529yr 496 (20) 387 (20) 206 (23) 114 (14) 13,737 (22) 3,174 (16) 3039yr336(13) 316 (16) 147 (16) 41 (5) 12,960 (21) 2,703 (13) 40yrorolder 34 (1) 28 (1) 13 (2) 4 (1) 2,205 (4) 493 (2) Sex Male 2489 (99) 1934 (99) 879 (98) 815 (100) 61,201 (99) 20,090 (99.5) Female26(1) 23 (1) 14 (2) 541 (1) 104 (0.5)RaceorethnicgroupWhite1749(70) 1339 (69) 531 (60) 544 (68) 44,365 (72) 15,344 (76) Black 208 (8) 198 (10) 185 (21) 53 (7) 7,904 (13) 1,213 (6) Hispanic331(13) 254 (13) 102 (12) 141 (18) 6,140 (10) 2,642 (13) Other 195 (8) 141 (7) 67 (8) 63 (8) 3,262 (5) 867 (4) Education High-school graduateorless 1955 (78) 1514 (78) 726 (82) 728 (89) 48561 (79) 16892 (84) Somecollegeorother202(8) 153 (8) 73 (8) 29 (4) 3260 (5) 346 (2) Collegegraduate 339 (14) 277 (14) 85 (10) 54 (7) 8838 (14) 2945 (15) MilitarygradeEnlistedpersonnelE1E41585(63) 1170 (60) 613 (69) 601 (84) 33823 (55) 13744 (68) E5E6 614 (24) 524 (27) 228 (26) 77 (11) 14813 (24) 2850 (14) E7E9116(5) 91 (5) 23 (3) 8 (1) 3819 (6) 607 (3) Officer 200 (8) 168 (8) 30 (3) 26 (4) 9287 (15) 2993 (15) MaritalstatusSingle1142(50)9 08 (52) 355 (46) 455 (63) 32636 (53) 12332 (61) Married 936 (41) 685 (39) 338 (43) 204 (28) 27582 (45) 7499 (37) Other199(9) 168 (9) 85 (11) 65 (9) 1485 (2) 363 (2)*Dataexcludemissingvalues,becausenotallrespondentsansweredeveryquestion.Percentagesmaynotsumto100becauseofrounding.DataforthereferencegroupswereobtainedfromtheDefenseMedicalSurveillanceSystemsdeploymentrostersofArmyandMarinepersonneldeployedinOperationIraqiFreedomandinAfghanistanin2003.Thetotalnumberofpersonsontheserosterswas315,999,ofwhom229,034(72%)wereactive-dutypersonnel;theremaining86,965weremembersoftheReserveandNationalGuard;97,906(31%)hadadesignationofacombat-armsoccupation.Ofthe229,034active-dutyservicemembers,81,936(36%)hadcombat-armsoccupations,including61,742Soldiersand20,194Marinesinthereferencegroups.Highernumbersindicatehighergrades.

PAGE 13

JulySeptember200811THEARMYMEDICALDEPARTMENTJOURNALThedemographiccharacteristicsofparticipantsfromthe3Armyunitsweresimilar.TheMarinesinthestudyweresomewhatyoungerthantheSoldiersinthestudyandlesslikelytobemarried.Thedemographiccharacteristicsofalltheparticipantsinthesurveysampleswereverysimilartothoseofthegeneral,deployed,active-dutyinfantrypopulation,exceptthatofficerswereundersampled,whichresultedinslightlylowerageandrankdistributions(Table1).DataforthereferencepopulationswereobtainedfromtheDefenseMedicalSurveillanceSystemwiththeuseofavailablerostersofArmyandMarinepersonneldeployedtoIraqorAfghanistanin2003(Table1).Amongthe1709SoldiersandMarineswhohadreturnedfromIraq,thereportedratesofcombatexperiencesandfrequencyofcontactwiththeenemyweremuchhigherthanthosereportedbySoldierswhohadreturnedfromAfghanistan(Table2).Only31%ofSoldiersdeployedtoAfghanistanreportedhavingengagedinafirefight,ascomparedwith71%to86%ofSoldiersandMarineswhohadbeendeployedtoIraq.Amongthosewhohadbeeninafirefight,themediannumberoffirefightsduringdeploymentwas2(interquartilerange,1to3)amongthoseinAfghanistan,ascomparedwith5(interquartilerange,2to13;P<0.001byanalysisofvariance)amongSoldiersdeployedtoIraqand5(interquartilerange,3RESULTS Table2.CombatExperiencesReportedbyMembersoftheUSArmyandMarineCorpsafterDeploymenttoIraqorAfghanistan*ExperienceArmyGroupMarineGroup Afghanistan(N=1962)Iraq(N=894)Iraq(N=815) number/totalnumber(%)Beingattackedorambushed1139/1961(58)789/883(89)764/805(95) Receivingincomingartillery,rocket,ormortarfire 1648/1960 (84) 753/872 (86) 740/802 (92) Beingshotatorreceivingsmall-armsfire1302/1962(66)826/886(93)779/805(97) Shootingordirectingfireattheenemy 534/1961 (27) 672/879 (77) 692/800 (87) Beingresponsibleforthedeathofanenemycombatant229/1961(12)414/871(48)511/789(65) Beingresponsibleforthedeathofanoncombatant 17/1961 (1) 116/861 (14) 219/794 (28) Seeingdeadbodiesorhumanremains771/1958(39)832/879(95)759/805(94) Handlingoruncoveringhumanremains 229/1961 (12) 443/881 (50) 455/800 (57) SeeingdeadorseriouslyinjuredAmericans591/1961(30)572/882(65)604/803(75) Knowingsomeoneseriouslyinjuredorkilled 850/1962 (43) 751/878 (86) 693/797 (87) Participatingindeminingoperations314/1962(16)329/867(38)270/787(34) Seeingillorinjuredwomenorchildrenwhomyou wereunabletohelp 907/1961 (46) 604/878 (69) 665/805 (83) Beingwoundedorinjured90/1961(5)119/870(14)75/803(9) Hadaclosecall,wasshotorhit,butprotectivegear savedyou 67/879 (8) 77/805 (10) Hadabuddyshotorhitwhowasnearyou192/880(22)208/797(26) Clearingorsearchinghomesorbuildings 1108/1961 (57) 705/884 (80) 695/805 (86) Engaginginhand-to-handcombat51/1961(3)189/876(22)75/800(9) SavedthelifeofaSoldierorcivilian 125/1961 (6) 183/859 (21) 150/789 (19) *Dataexcludemissingvalues,becausenotallrespondentsansweredeveryquestion.Combatexperiencesarewordedasinthesurvey.Thequestionwasnotincludedinthissurvey.

PAGE 14

12www.cs.amedd.army.mil/references_publications.aspxto10;P<0.001byanalysisofvariance)amongMarinesdeployedtoIraq.SoldiersandMarineswhohadreturnedfromIraqweresignificantlymorelikelytoreportthattheywerecurrentlyexperiencingamentalhealthproblem,toexpressinterestinreceivinghelp,andtousementalhealthservicesthanwereSoldiersreturningfromAfghanistanorthosesurveyedbeforedeployment(Table3).RatesofPTSDweresignificantlyhigheraftercombatdutyinIraqthanbeforedeployment,withsimilaroddsratiosfortheArmyandMarinesamples(Table3).Significantassociationswereobservedformajordepressionandthemisuseofalcohol.Mostoftheseassociationsremainedsignificantaftercontrolfordemographicfactorswiththeuseofmultiplelogisticregression(Table3).Whentheprevalenceratesforanymentaldisorderwereadjustedtomatchthedistributionofofficersandenlistedpersonnelinthereferencepopulations,theresultwaslessthana10%decrease(range,3.5%to9.4%)intheratesshowninTable3accordingtoboththebroadandthestrictdefinitions(datanotshown).Forallgroupsrespondingafterdeployment,therewasastrongreportedrelationbetweencombatexperiences,suchasbeingshotat,handlingdeadbodies,knowingsomeonewhowaskilled,orkillingenemycombatants,andtheprevalenceofPTSD.Forexample,amongSoldiersandMarineswhohadbeendeployedtoIraq,theprevalenceofPTSD(accordingtothestrictdefinition)increasedinalinearmannerwiththenumberoffirefightsduringdeployment:4.5%fornofirefights,9.3%foroneto2firefights,12.7%for3to5firefights,and19.3%formorethan5firefights(chi-squareforlineartrend,49.44;P<0.001).RatesforthosewhohadbeendeployedtoAfghanistanwere4.5%,8.2%,8.3%,and18.9%,respectively(chisquareforlineartrend,31.35;P<0.001).ThepercentageofparticipantswhohadbeendeployedtoIraqwhoreportedbeingwoundedorinjuredwas11.6%ascomparedwithonly4.6%forthosewhohadbeendeployedtoAfghanistan.TheratesofPTSDweresignificantlyassociatedwithhavingbeenwoundedorinjured(oddsratioforthosedeployedtoIraq,3.27;95%confidenceinterval,2.28to4.67;oddsratioforthosedeployedtoAfghanistan,2.49;95%confidenceinterval,1.35to4.40).Ofthosewhoseresponsesmetthescreeningcriteriaforamentaldisorderaccordingtothestrictcasedefinition,only38%to45%indicatedaninterestinreceivinghelp,andonly23%to40%reportedhavingreceivedprofessionalhelpinthepastyear(Table4).Thosewhoseresponsesmetthesescreeningcriteriaweregenerallyabout2timesaslikelyasthosewhoseresponsesdidnottoreportconcernaboutbeingstigmatizedandaboutotherbarrierstoaccessingandreceivingmentalhealthservices(Table5).DISCUSSION WeinvestigatedmentalhealthoutcomesamongSoldiersandMarineswhohadtakenpartintheground-combatoperationsinIraqandAfghanistan.RespondentstooursurveywhohadbeendeployedtoIraqreportedaveryhighlevelofcombatexperiences,withmorethan90%ofthemreportingbeingshotatandahighpercentagereportinghandlingdeadbodies,knowingsomeonewhowasinjuredorkilled,orkillinganenemycombatant(Table2).Closecalls,suchashavingbeensavedfrombeingwoundedbywearingbodyarmor,werenotinfrequent.SoldierswhoservedinAfghanistanreportedlowerbutstillsubstantialratesofsuchexperiencesincombat.Thepercentageofstudysubjectswhoseresponsesmetthescreeningcriteriaformajordepression,PTSD,oralcoholmisusewassignificantlyhigheramongSoldiersafterdeploymentthanbeforedeployment,particularlywithregardtoPTSD.ThelinearrelationshipbetweentheprevalenceofPTSDandthenumberoffirefightsinwhichaSoldierhadbeenengagedwasremarkablysimilaramongSoldiersreturningfromIraqandAfghanistan,suggestingthatdifferencesintheprevalenceaccordingtolocationwerelargelyafunctionofthegreaterfrequencyandintensityofcombatinIraq.TheassociationbetweeninjuryandtheprevalenceofPTSDsupportstheresultsofpreviousstudies.25Thesefindingscanbegeneralizedtogroundcombatunits,whichareestimatedtorepresentaboutaquarterofallArmyandMarinepersonnelparticipatinginOperationIraqiFreedomandOperationEnduringFreedominAfghanistan(whenmembersoftheCombatDutyinIraqandAfghanistan,MentalHealthProblemsandBarrierstoCare

PAGE 15

JulySeptember200813THEARMYMEDICALDEPARTMENTJOURNAL T a b l e 3 P e r c e i v e d M e n t a l H e a l t h P r o b l e m s a n d P e r c e n t a g e o f S u b j e c t s W h o M e t t h e S c r e e n i n g C r i t e r i a f o r M a j o r D e p r e s s i o n G e n e r a l i z e d A n x i e t y P o s t T r a u m a t i c S t r e s s D i s o r d e r a n d A l c o h o l M i s u s e M e n t a l H e a l t h P r o b l e m A r m y S t u d y G r o u p s M a r i n e S t u d y G r o u p B e f o r e D e p l o y m e n t t o I r a q ( N = 2 5 3 0 ) A f t e r D e p l o y m e n t t o A f g h a n i s t a n ( N = 1 9 6 2 ) A f t e r D e p l o y m e n t t o I r a q ( N = 8 9 4 ) A f t e r D e p l o y m e n t t o I r a q ( N = 8 1 5 ) n o / t o t a l n o ( % ) n o / t o t a l n o ( % ) O R ( 9 5 % C I ) n o / t o t a l n o ( % ) O R ( 9 5 % C I ) n o / t o t a l n o ( % ) O R ( 9 5 % C I ) P e r c e i v e d m o d e r a t e o r s e v e r e p r o b l e m 3 2 3 / 2 2 6 1 ( 1 4 3 ) 3 0 3 / 1 7 6 9 ( 1 7 1 ) 1 5 3 / 7 8 4 ( 1 9 5 ) 1 2 3 / 7 2 0 ( 1 7 1 ) C u r r e n t l y i n t e r e s t e d i n r e c e i v i n g p r o f e s s i o n a l h e l p 2 1 1 / 2 2 4 3 ( 9 4 ) 1 8 0 / 1 7 6 9 ( 1 0 2 ) 1 3 1 / 7 8 6 ( 1 6 7 ) 1 0 6 / 7 0 6 ( 1 5 0 ) R e c e i v e d p r o f e s s i o n a l h e l p i n t h e p a s t m o n t h 1 0 8 / 2 2 8 0 ( 4 7 ) 1 1 8 / 1 7 8 0 ( 6 6 ) 9 1 / 7 9 6 ( 1 1 4 ) 7 0 / 7 4 2 ( 9 4 ) D e f i n i t i o n o f m e n t a l d i s o r d e r B r o a d d e f i n i t i o n D e p r e s s i o n a c c o r d i n g t o P H Q 2 7 5 / 2 4 1 8 ( 1 1 4 ) 2 6 7 / 1 8 8 5 ( 1 4 2 ) 1 2 9 ( 1 0 7 1 5 4 ) 1 2 8 / 8 4 0 ( 1 5 2 ) 1 4 0 ( 1 1 2 1 7 6 ) 1 1 4 / 7 7 5 ( 1 4 7 ) 1 3 4 ( 1 0 6 1 7 0 ) A n x i e t y a c c o r d i n g t o P H Q 3 7 5 / 2 4 1 9 ( 1 5 5 ) 3 2 4 / 1 8 8 6 ( 1 7 2 ) 1 1 3 ( 0 9 6 1 3 3 ) 1 4 7 / 8 3 9 ( 1 7 5 ) 1 1 6 ( 0 9 4 1 4 3 ) 1 2 2 / 7 7 6 ( 1 5 7 ) 1 0 2 ( 0 8 1 1 2 7 ) P T S D a c c o r d i n g t o P C L 2 2 6 / 2 4 1 4 ( 9 4 ) 2 2 4 / 1 9 5 6 ( 1 1 5 ) 1 2 5 ( 1 0 3 1 5 2 ) 1 5 9 / 8 8 1 ( 1 8 0 ) 2 1 3 ( 1 7 1 2 6 6 ) 1 6 1 / 8 1 1 ( 1 9 9 ) 2 4 0 ( 1 9 2 2 9 9 ) A n y o f a b o v e 5 2 2 / 2 5 0 0 ( 2 0 9 ) 4 7 9 / 1 9 5 8 ( 2 4 5 ) 1 2 3 ( 1 0 7 1 4 1 ) 2 4 6 / 8 8 2 ( 2 7 9 ) 1 4 7 ( 1 2 3 1 7 5 ) 2 3 7 / 8 1 3 ( 2 9 2 ) 1 5 6 ( 1 3 0 1 8 7 ) S t r i c t d e f i n i t i o n D e p r e s s i o n a c c o r d i n g t o P H Q 1 2 8 / 2 4 1 8 ( 5 3 ) 1 3 0 / 1 8 8 5 ( 6 9 ) 1 3 3 ( 1 0 3 1 7 1 ) 6 6 / 8 4 0 ( 7 9 ) 1 5 3 ( 1 1 2 2 0 8 ) 5 5 / 7 7 5 ( 7 1 ) 1 3 7 ( 0 9 9 1 9 0 ) A n x i e t y a c c o r d i n g t o P H Q 1 5 5 / 2 4 1 9 ( 6 4 ) 1 4 0 / 1 8 8 6 ( 7 4 ) 1 1 7 ( 0 9 2 1 4 8 ) 6 6 / 8 3 9 ( 7 9 ) 1 2 5 ( 0 9 2 1 6 8 ) 5 1 / 7 7 6 ( 6 6 ) 1 0 3 ( 0 7 4 1 4 3 ) P T S D a c c o r d i n g t o P C L 1 2 0 / 2 4 1 4 ( 5 0 ) 1 2 1 / 1 9 5 6 ( 6 2 ) 1 2 6 ( 0 9 7 1 6 4 ) 1 1 4 / 8 8 1 ( 1 2 9 ) 2 8 4 ( 2 1 7 3 7 2 ) 9 9 / 8 1 1 ( 1 2 2 ) 2 6 6 ( 2 0 1 3 5 1 ) A n y o f a b o v e 2 3 3 / 2 5 0 0 ( 9 3 ) 2 2 0 / 1 9 5 8 ( 1 1 2 ) 1 2 3 ( 1 0 1 1 5 0 ) 1 5 1 / 8 8 2 ( 1 7 1 ) 2 0 1 ( 1 6 1 2 5 1 ) 1 2 7 / 8 1 3 ( 1 5 6 ) 1 8 0 ( 1 4 3 2 2 7 ) A l c o h o l m i s u s e H a v e y o u u s e d a l c o h o l m o r e t h a n y o u m e a n t t o ? 4 0 5 / 2 3 5 8 ( 1 7 2 ) 4 5 2 / 1 8 4 4 ( 2 4 5 ) 1 5 7 ( 1 3 5 1 8 2 ) 1 9 8 / 8 1 9 ( 2 4 2 ) 1 5 4 ( 1 2 7 1 8 6 ) 2 6 8 / 7 5 6 ( 3 5 4 ) 2 6 5 ( 2 2 0 3 1 8 ) H a v e y o u f e l t y o u w a n t e d o r n e e d e d t o c u t d o w n o n y o u r d r i n k i n g ? 2 8 9 / 2 3 1 3 ( 1 2 5 ) 3 3 1 / 1 8 2 1 ( 1 8 2 ) 1 5 6 ( 1 3 1 1 8 5 ) 1 6 8 / 8 1 5 ( 2 0 6 ) 1 8 2 ( 1 4 7 2 2 4 ) 2 1 9 / 7 4 4 ( 2 9 4 ) 2 9 2 ( 2 3 9 3 5 7 ) E a c h s t u d y g r o u p w h o r e s p o n d e d a f t e r d e p l o y m e n t w a s c o m p a r e d w i t h t h e g r o u p t h a t r e s p o n d e d b e f o r e d e p l o y m e n t w i t h t h e u s e o f o d d s r a t i o s ( w i t h 9 5 % c o n f i d e n c e i n t e r v a l s ) a n d c h i s q u a r e t e s t i n g D a t a e x c l u d e m i s s i n g v a l u e s b e c a u s e n o t a l l r e s p o n d e n t s a n s w e r e d e v e r y q u e s t i o n O R d e n o t e s o d d s r a t i o C I c o n f i d e n c e i n t e r v a l P H Q p a t i e n t h e a l t h q u e s t i o n n a i r e P T S D p o s t t r a u m a t i c s t r e s s d i s o r d e r a n d P C L t h e N a t i o n a l C e n t e r f o r P o s t T r a u m a t i c S t r e s s D i s o r d e r C h e c k l i s t P < 0 0 1 f o r t h e c o m p a r i s o n o f g r o u p s r e s p o n d i n g a f t e r d e p l o y m e n t w i t h t h e g r o u p r e s p o n d i n g b e f o r e d e p l o y m e n t c a l c u l a t e d w i t h t h e u s e o f t h e c h i s q u a r e t e s t T h e r e s u l t r e m a i n e d s i g n i f i c a n t a f t e r m u l t i p l e l o g i s t i c r e g r e s s i o n w a s u s e d t o c o n t r o l f o r a g e r a n k e d u c a t i o n a l l e v e l m a r i t a l s t a t u s a n d r a c e o r e t h n i c g r o u p P r o f e s s i o n a l h e l p w a s d e f i n e d a s h e l p f r o m a m e n t a l h e a l t h p r o f e s s i o n a l a g e n e r a l m e d i c a l d o c t o r o r a c h a p l a i n o r o t h e r m e m b e r o f t h e c l e r g y i n e i t h e r a m i l i t a r y o r c i v i l i a n t r e a t m e n t s e t t i n g P < 0 0 5 f o r t h e c o m p a r i s o n o f g r o u p s r e s p o n d i n g a f t e r d e p l o y m e n t w i t h t h e g r o u p r e s p o n d i n g b e f o r e d e p l o y m e n t c a l c u l a t e d w i t h t h e u s e o f t h e c h i s q u a r e t e s t

PAGE 16

14www.cs.amedd.army.mil/references_publications.aspxReserveandtheNationalGuardareincluded)andnearly40%ofallactive-dutypersonnel(whenReservistsandmembersoftheNationalGuardarenotincluded).Thedemographiccharacteristicsofthesubjectsinoursamplescloselymirroredthedemographiccharacteristicsofthispopulation.Thesomewhatlowerproportionofofficershadaminimaleffectontheprevalencerates,andpotentialdifferencesindemographicfactorsamongthe4studygroupswerecontrolledforinouranalysiswiththeuseoflogisticregression.OnedemonstrationoftheinternalvalidityofourfindingswastheobservationofsimilarprevalenceratesforcombatexperiencesandmentalhealthoutcomesamongthesubjectsintheArmyandtheMarineCorpswhohadreturnedfromdeploymenttoIraq,despitethedifferentdemographiccharacteristicsofmembersoftheseunitsandtheirdifferentlevelsofavailabilityforrecruitmentintothestudy.Table5.PerceivedBarrierstoSeekingMentalHealthServicesamongAllStudyParticipants(SoldiersandMarines)*PerceivedBarrierRespondentsWhoMetScreeningCriteriaforaMentalDisorder(N=731)RespondentsWhoDidNotMeetScreeningCriteriaforaMentalDisorder(N=5422) number/totalnumber(%)Idonttrustmentalhealthprofessionals.241/641(38)813/4820(17)Idontknowwheretogethelp.143/639(22)303/4780(6)Idonthaveadequatetransportation.117/638(18)279/4770(6)Itisdifficulttoscheduleanappointment.288/638(45)789/4748(17)Therewouldbedifficultygettingtimeoffworkfortreatment.354/643(55)1061/4743(22)Mentalhealthcarecoststoomuchmoney.159/638(25)456/4736(10)Itwouldbetooembarrassing.260/641(41)852/4752(18)Itwouldharmmycareer.319/640(50)1134/4738(24)Membersofmyunitmighthavelessconfidenceinme.377/642(59)1472/4763(31)Myunitleadershipmighttreatmedifferently.403/637(63)1562/4744(33)Myleaderswouldblamemefortheproblem.328/642(51)928/4769(20)Iwouldbeseenasweak.413/640(65)1486/4732(31)Mentalhealthcaredoesntwork.158/638(25)444/4748(9)*Dataexcludemissingvalues,becausenotallrespondentsansweredeveryquestion.Respondentswereaskedtorateeachofthepossibleconcernsthatmightaffectyourdecisiontoreceivementalhealthcounselingorservicesifyoueverhadaproblem.Perceivedbarriersarewordedasonthesurvey.The5possibleresponsesrangedfromstronglydisagreetostronglyagree,withagreeandstronglyagreecombinedasapositiveresponse. CombatDutyinIraqandAfghanistan,MentalHealthProblemsandBarrierstoCare Table4.PerceivedNeedforandUseofMentalHealthServicesamongSoldiersandMarinesWhoseSurveyResponsesMettheScreeningCriteriaforMajorDepression,GeneralizedAnxiety,orPost-TraumaticStressDisorder*OutcomeArmyStudyGroupsMarineStudyGroup BeforeDeploymenttoIraq(N=233)AfterDeploymenttoAfghanistan(N=220)AfterDeploymenttoIraq(N=151)AfterDeploymenttoIraq(N=127) number/totalnumber(%)Need Acknowledgedaproblem 184/215 (86) 156/192 (81) 104/133 (78) 91/106 (86) Interestedinreceivinghelp 85/212 (40) 75/196 (38) 58/134 (43) 47/105 (45) ReceivedprofessionalhelpInpastyear Overall(fromanyprofessional) 61/222 (28) 46/198 (23) 56/140 (40) 33/113 (29) Fromamentalhealthprofessional 33/222 (15) 26/198 (13) 37/138 (27) 24/112 (21) Inpastmonth Overall(fromanyprofessional) 39/218 (18) 34/196 (17) 44/136 (32) 23/112 (21) Fromamentalhealthprofessional 24/218 (11) 25/196 (13) 29/136 (21) 16/111 (14) *Dataexcludemissingvalues,becausenotallrespondentsansweredeveryquestion.Professionalhelpwasdefinedashelpfromamentalhealthprofessional,ageneralmedicaldoctor,orachaplainorothermemberoftheclergy,ineitheramilitaryorciviliantreatmentsetting.

PAGE 17

JulySeptember200815THEARMYMEDICALDEPARTMENTJOURNALThecross-sectionaldesigninvolvingdifferentunitsthatwasusedinourstudyisnotasstrongasalongitudinaldesign.However,thecomparabilityoftheArmysamplesandthesimilarityinoutcomesamongsubjectsintheArmyandMarineunitssurveyedafterdeploymenttoIraqshouldgenerateconfidenceinthecross-sectionalapproach.Anotherlimitationofourstudyisthepotentialselectionbiasresultingfromtheenrollmentprocedures,whichwereinfluencedbythepracticalrealitiesthatresultedfromworkingwithoperationalunits.AlthoughworkschedulesaffectedtheavailabilityofSoldierstotakepartinthesurvey,theeffectisnotlikelytohavebiasedourresults.However,theselectionproceduresdidnotpermittheenrollmentofpersonswhohadbeenseverelywoundedorthosewhomayhavebeenremovedfromtheunitsforotherreasons,suchasmisconduct.Thus,ourestimatesoftheprevalenceofmentaldisordersareconservative,reflectingtheprevalenceamongworking,nondisabledcombatpersonnel.Theperiodimmediatelybeforealongcombatdeploymentmaynotbethebesttimeatwhichtomeasurebaselinelevelsofdistress.Themagnitudeofthedifferencesbetweentheresponsesbeforeandafterdeploymentisparticularlystriking,giventhelikelihoodthatthegrouprespondingbeforedeploymentwasalreadyexperiencinglevelsofstressthatwerehigherthannormal.Thesurveyinstrumentsusedtoscreenformentaldisordersinthisstudyhavebeenvalidatedprimarilyinthesettingsofprimarycareandinclinicalpopulations.Theresultsthereforedonotrepresentdefinitivediagnosesofpersonsinnonclinicalpopulationssuchasourmilitarysamples.However,requiringevidenceoffunctionalimpairmentorahighnumberofsymptoms,aswedid,accordingtothestrictcasedefinitions,increasesthespecificityandpositivepredictivevalueofthesurveymeasures.26,27Thisconservativeapproachsuggestedthatasmanyas9%ofSoldiersmaybeatriskformentaldisordersbeforecombatdeployment,andasmanyas11%to17%maybeatriskforsuchdisorders3to4monthsaftertheirreturnfromcombatdeployment.AlthoughtherearefewpublishedstudiesoftheratesofPTSDamongmilitarypersonnelsoonaftertheirreturnfromcombatduty,studiesofveteransconductedyearsaftertheirserviceendedhaveshownaprevalenceofcurrentPTSDof15%amongVietnamveterans28and2%to10%amongveteransofthefirstGulfWar.4,8RatesofPTSDamongthegeneraladultpopulationintheUnitedStatesare3%to4%,26whicharenotdissimilartothebaselinerateof5%observedinthesampleofSoldiersrespondingtothesurveybeforedeployment.ResearchhasshownthatthemajorityofpersonsinwhomPTSDdevelopsmeetthecriteriaforthediagnosisofthisdisorderwithinthefirst3monthsafterthetraumaticevent.29Inourstudy,administeringthesurveys3to4monthsafterthesubjectshadreturnedfromdeploymentandatleast6monthsaftertheheaviestcombatoperationswasprobablyoptimalforinvestigatingthelong-termriskofmentalhealthproblemsassociatedwithcombat.Wearecontinuingtoexaminethisriskinrepeatedcross-sectionalandlongitudinalassessmentsinvolvingthesameunits.OurfindingsindicatethatasmallpercentageofSoldiersandMarineswhoseresponsesmetthescreeningcriteriaforamentaldisorderreportedthattheyhadreceivedhelpfromanymentalhealthprofessional,afindingthatparallelstheresultsofcivilianstudies.30-32Inthemilitary,thereareuniquefactorsthatcontributetoresistancetoseekingsuchhelp,particularlyconcernabouthowaSoldierwillbeperceivedbypeersandbytheleadership.Concernaboutstigmawasdisproportionatelygreatestamongthosemostinneedofhelpfrommentalhealthservices.SoldiersandMarineswhoseresponseswerescoredaspositiveforamentaldisorderweretwiceaslikelyasthosewhoseresponseswerescoredasnegativetoshowconcernaboutbeingstigmatizedandaboutotherbarrierstomentalhealthcare.Thisfindinghasimmediatepublichealthimplications.Effortstoaddresstheproblemofstigmaandotherbarrierstoseekingmentalhealthcareinthemilitaryshouldtakeintoconsiderationoutreach,education,andchangesinthemodelsofhealthcaredelivery,suchasincreasesintheallocationofmentalhealthservicesinprimarycareclinicsandintheprovisionofconfidentialcounselingbymeansofemployee-assistanceprograms.Screeningformajordepressionisbecomingroutineinmilitaryprimarycaresettings,12butourstudysuggeststhatitshouldbeexpandedtoincludescreeningforPTSD.Manyoftheseconsiderationsarebeingaddressedinnewmilitaryprograms.33Reducingtheperceptionofstigmaandthebarrierstocareamongmilitarypersonnelisapriority

PAGE 18

16www.cs.amedd.army.mil/references_publications.aspxforresearchandapriorityforthepolicymakers,clinicians,andleaderswhoareinvolvedinprovidingcaretothosewhohaveservedinthearmedforces.ACKNOWLEDGEMENT SupportedbytheMilitaryOperationalMedicineResearchProgram,USArmyMedicalResearchandMaterielCommand,FortDetrick,Md.WeareindebtedtotheWalterReedArmyInstituteofResearchLandCombatStudyTeam:LolitaBurrell,PhD;ScottKillgore,PhD;MelbaStetz,PhD;PaulBliese,PhD;OscarCabrera,PhD;AnthonyCox,MSW;TimothyAllison-Aipa,PhD;KarenEaton,MS;GraemeBicknell,MSW;AlexanderVo,PhD;andCharlesMilliken,MD;forsurvey-instrumentdesignanddatacollection;toSpencerCampbell,PhD,forcoordinationofdatacollectionandscientificadvice;toDavidCouchforsupervisingthedata-collectionteams,databasemanagement,scanning,andqualitycontrol;toWandaCookfordesignandproductionofsurveys;toAllisonWhittforsurvey-productionanddata-collectionsupport;toLloydShanklin,JoshuaFejeran,VilnaWilliams,andCrystalRossfordata-collection,quality-assurance,scanning,andfieldsupport;toJenniferAuchterlonieforassistancewithDefenseMedicalSurveillanceSystemanalyses;toAkeiyaBriscoe-Curetonfortravelandadministrativesupport;totheleadershipoftheunitsthatwerestudied,andtoourmedicalandmentalhealthprofessionalcolleaguesatFortBragg,FortStewart,CampLejeune,andCampPendleton;totheWalterReedArmyInstituteofResearchOfficeofResearchManagement;toDavidOrman,MD,psychiatryconsultanttotheArmySurgeonGeneral;GregoryBelenky,MD;andCharlesC.Engel,MD,foradviceandreviewofthestudy;and,mostimportant,totheSoldiersandMarineswhoparticipatedinthestudyfortheirservice.REFERENCES 1.TheCentersforDiseaseControlVietnamExperienceStudyGroup.HealthstatusofVietnamveterans.I.Psychosocialcharacteristics.JAMA.1988;259:2701-2707.2.HelzerJE,RobinsLN,McEvoyL.Posttraumaticstressdisorderinthegeneralpopulation:findingsoftheEpidemiologicCatchmentAreasurvey.NEnglJMed.1987;317:1630-1634.3.JordanBK,SchlengerWE,HoughR,etal.LifetimeandcurrentprevalenceofspecificpsychiatricdisordersamongVietnamveteransandcontrols.ArchGenPsychiatry.1991;48:207-215.4.TheIowaPersianGulfStudyGroup.Self-reportedillnessandhealthstatusamongGulfWarveterans:apopulation-basedstudy.JAMA.1997;277:238-245.5.KesslerRC,SonnegaA,BrometE,HughesM,NelsonCB.PosttraumaticstressdisorderintheNationalComorbiditySurvey.ArchGenPsychiatry.1995;52:1048-1060.6.PrigersonHG,MaciejewskiPK,RosenheckRA.PopulationattributablefractionsofpsychiatricdisordersandbehavioraloutcomesassociatedwithcombatexposuresamongUSmen.AmJPublicHealth.2002;92:59-63.7.PrigersonHG,MaciejewskiPK,RosenheckRA..Combattrauma:traumawithhighestriskofdelayedonsetandunresolvedposttraumaticstressdisordersymptoms,unemployment,andabuseamongmen.JNervMentDis.2001;189:99-108.8.KangHK,NatelsonBH,MahanCM,LeeKY,MurphyFM.Posttraumaticstressdisorderandchronicfatiguesyndrome-likeillnessamongGulfWarveterans:apopulation-basedsurveyof30,000veterans.AmJEpidemiol.2003;157:141-148.9.HogeCW,LesikarSE,GuevaraR,etal.MentaldisordersamongUSmilitarypersonnelinthe1990s:associationwithhighlevelsofhealthcareutilizationandearlymilitaryattrition.AmJPsychiatry.2002;159:1576-1583.10.WesselyS,UnwinC,HotopfM,etal.Stabilityofrecallofmilitaryhazardsovertime:evidencefromthePersianGulfWarof1991.BrJPsychiatry.2003;183:314-322.11.WrightKM,HuffmanAH,AdlerAB,CastroCA.Psychologicalscreeningprogramoverview.MilMed.2002;167:853-861.12.VA/DoDclinicalpracticeguidelineforthemanagementofmajordepressivedisorderinadults.In:Majordepressivedisorder(MDD):clinicalpracticeguidelines.Washington,DC:VeteransHealthAdministration;May2000.Publicationno.10Q-CPG/MDD-00.Availableat:http://www.oqp.med.va.gov/cpg/MDD/MDD_Base.htm.AccessedJune4,2004.13.RubertoneMV,BrundageJF.TheDefenseMedicalSurveillanceSystemandtheDepartmentofDefenseserumrepository:glimpsesofthefutureofpublichealthsurveillance.AmJPublicHealth.2002;92:1900-1904.CombatDutyinIraqandAfghanistan,MentalHealthProblemsandBarrierstoCare

PAGE 19

JulySeptember200817THEARMYMEDICALDEPARTMENTJOURNAL14.DiagnosticandStatisticalManualofMentalDisordersFourthEdition(TextRevision).Washington,DC:AmericanPsychiatricAssociation;1994.15.SpitzerRL,KroenkeK,WilliamsJB.Validationandutilityofaself-reportversionofPRIME-MD:thePHQprimarycarestudy.JAMA.1999;282:1737-1744.16.LoweB,SpitzerRL,GrafeK,etal.Comparativevalidityof3screeningquestionnairesforDSM-IVdepressivedisordersandphysiciansdiagnoses.JAffectDisord.2004;8:131-140.17.HenkelV,MerglR,KohnenR,MaierW,MollerHJ,HegerlU.Identifyingdepressioninprimarycare:acomparisonofdifferentmethodsinaprospectivecohortstudy.BrMedJ.2003;326:200-201.18.BlanchardEB,Jones-AlexanderJ,BuckleyTC,FornerisCA.PsychometricpropertiesofthePTSDChecklist(PCL).BehavResTher.1996;34:669-673.19.WeathersFW,LitzBT,HermanDS,HuskaJA,KeaneTM.ThePTSDchecklist(PCL):reliability,validity,anddiagnosticutility.SanAntonio,Tx:InternationalSocietyofTraumaticStressStudies,October1993.abstract.Availableat:http://www.pdhealth.mil/library/downloads/PCL_sychometrics.doc.AccessedJune4,2004.20.BrownRL,LeonardT,SaundersLA,PapasouliotisO.A2-itemconjointscreenforalcoholandotherdrugproblems.JAmBoardFamPract.2001;14:95-106.21.BrittTW.Thestigmaofpsychologicalproblemsinaworkenvironment:evidencefromthescreeningofservicemembersreturningfromBosnia.JApplSocPsychol.2000;30:1599-1618.22.CastroCA,BienvenuRV,HufmannAH,AdlerAB.SoldierdimensionsandoperationalreadinessinUSArmyforcesdeployedtoKosovo.IntRevArmedForcesMedServ.2000;73:191-200.23.KleinbaumDG,KupperLL,MorgensternH.EpidemiologicResearch:PrinciplesandQuantitativeMethods.Belmont,CA:LifetimeLearning;1982.24.MenardS.AppliedLogisticRegressionAnalysis.2nded.ThousandOaks,CA:SagePublications;2002.25.FriedmanMJ,SchnurrPP,McDonagh-CoyleA.Posttraumaticstressdisorderinthemilitaryveteran.PsychiatrClinNorthAm.1994;17:265-277.26.NarrowWE,RaeDS,RobinsLN,RegierDA.RevisedprevalenceestimatesofmentaldisordersintheUnitedStates:usingaclinicalsignificancecriteriontoreconcile2surveysestimates.ArchGenPsychiatry.2002;59:115-123.27.HogeCW,MesserSC,CastroCA.PentagonemployeesafterSeptember11,2001.PsychiatrServ.2004;55:319-320.28.SchlengerWE,KulkaRA,FairbankJA,etal.TheprevalenceofposttraumaticstressdisorderintheVietnamgeneration:amultimethod,multisourceassessmentofpsychiatricdisorder.JTraumaStress.1992;5:333-363.29.CarlierIVE,LambertsRD,GersonsBPR.Riskfactorsforposttraumaticstresssymptomatologyinpoliceofficers:aprospectiveanalysis.JNervMentDis.1997;185:498-506.30.KesslerRC,BerglundP,DemlerO,etal.Theepidemiologyofmajordepressivedisorder:resultsfromtheNationalComorbiditySurveyReplication(NCS-R).JAMA.2003;289:3095-3105.31.RegierDA,NarrowWE,RaeDS,ManderscheidRW,LockeBZ,GoodwinFK.ThedefactoUSmentalandaddictivedisordersservicesystem:EpidemiologicCatchmentAreaprospective1-yearprevalenceratesofdisordersandservices.ArchGenPsychiatry.1993;50:85-94.32.KesslerRC,McGonagleKA,ZhaoS,etal.Lifetimeand12-monthprevalenceofDSM-III-RpsychiatricdisordersintheUnitedStates:resultsfromtheNationalComorbiditySurvey.ArchGenPsychiatry.1994;51:8-19.33.DeploymentHealthClinicalCenter.Practiceguidelinesdeploymentcyclesupportandclinicians.Availableat:http://www.pdhealth.mil.AccessedJune4,2004.AUTHORS COLHogeisDirector,DivisionofPsychiatryandNeuroscience,WalterReedArmyInstituteofResearch,SilverSpring,Maryland.COLCastroisDirector,MilitaryOperationalMedicineResearchProgram,USArmyMedicalResearchandMaterielCommand,FortDetrick,Maryland.DrMesserisChiefofResearch,DepartmentofPsychiatry,WalterReedArmyMedicalCenter,WashingtonDC.MAJMcGurkisCommander,USArmyMedicalResearchUnit-Europe,Heidelberg,Germany.CPTCottingisanAssistantProfessorintheDepartmentofPsychologyandPhilosophyattheVirginiaMilitaryInstitute,Lexington,Virginia.

PAGE 20

18www.cs.amedd.army.mil/references_publications.aspxINTRODUCTIONPerhapsnothingismorestressfulthantheexperienceofwar.Theverysights,sounds,andsmellsthatoneexperiencesinwarcanhaveaneverlastingimpact,physically,emotionally,andmentally.Sincetheout-breakofthewarinIraq,theArmyhassentnumerousmedicalunitstotheMiddleEasttohelptreatpeoplesufferingfrombothphysicalandpsychologicaltrauma.Specializedmedicalunitscalledcombatstresscontrol(CSC)areusedprimarilytoprovidementalhealthrelatedservicesthroughoutthetheaterofopera-tion.MembersofCSCunitsincludeavarietyofmen-talhealthcareprofessionalssuchaspsychiatrists,psy-chologists,socialworkers,occupationaltherapists,psychiatricnurses,andmentalhealthspecialists.CSCunitsaremainlydeployedtopreservethefightingstrengthoftheArmybytreatingwoundsthatdonotbleed.Theyoftentakeaproactiveapproachbysend-ingsmallteamsaroundtodifferentsitesandofferingavarietyofclassesinthepreventionofbattlefatigue.CSCmembersarealsotrainedtoprovideindividualcounselingandcanevenutilizeanumberofdifferenttherapeutictechniquestohelpeaseanypsychologicalsuffering.Onetechniquethatwasdesignedtohelppeoplehealfrompsychologicaltraumaiscalledacriticaleventdebriefing(CED).MostCSCsusecriticaleventde-briefingsinagroupsettingforanypersonnelwhowereunfortunateenoughtobedirectlyinvolvedinatraumaticevent.TheseCEDswereoftenconductedbydifferentteammembersoftheCSCinnumerousloca-tionsthroughoutthetheaterofoperation.ToattendaCED,onehadtoeitherbeamemberoftheCSCteam,orsomeonewhowasdirectlyinvolvedinsomecapac-itywiththetraumaticevent.Nooneelsewaspermittedtoattend.ChaplainsweresometimesinattendanceaspartoftheCSCteam.LITERATUREREVIEWRecentresearchstudieshaveindicatedtheseverityanddistinctionofmentalhealthaffectsofcombatSoldiersengagedinwartimeoperations.Ithasbeenreportedthatatleast17%ofpostcombatveteranshavedepres-sion,anxiety,orposttraumaticstressdisorder(PTSD).1Hogeetal2reportedintheirstudyofcombatinfantrySoldiersthatthepercentageofstudysubjectswhoseresponsesmetthescreeningcriteriaformajordepres-sion,generalizedanxiety,orPTSDwassignificantlyhigherafterdutyinIraq(15.6%to17.1%)thanafterdutyinAfghanistan(11.2%).A12-memberadvisoryteamsurveyed756SoldiersinIraqandfoundthat87%ofSoldiersreportedhighlevelsofstressovernotknowinghowlongtheywouldbedeployed,71%re-portedhighlevelsofstressregardinglengthofdeploy-ment,57%reportedhighlevelsofstressoversepara-tionfromfamily,and55%reportedhighlevelsofstressoverthelackofprivacyandpersonalspace.3AccordingtotheDiagnosticandStatisticalManualofMentalDisorders,4PTSDandpanicdisorder(PD)areclassifiedasanxietydisorders,whichareinitiallytrig-geredbysomekindoftraumaticeventthathasnotbeentreatedproperly.Literatureaddressestheimpor-tanceofearlymentalhealthtreatmentfollowingatrau-maticevent.AscitedbyVesper,5LitzmentionsthatEffectivenessofCriticalEventDebriefingsDuringOperationIraqiFreedomIICPTPatrickJ.Pischke,MS,USARCPTChristianJ.Hallman,MS,USARAGR ABSTRACTTeammembersofaUSArmymedicalcombatstresscontrolunitprovidedcriticaleventdebriefingsformilitarypersonnelwhoweredirectlyinvolvedinatraumaticeventduringOperationIraqiFreedomII.Eachpersonattendingthedebriefingwasthengivenashort5-questionsurveyimmediatelyfollowingthesession.Outofthe396participantswhocompletedthesurveyquestionnaire,273feltthedebriefinggivenbytheteamwashelpful,97hadnoopinion,and26didnotfeelitwashelpful.ThisparticularcombatstresscontrolteamwaslocatedinTaji,Iraq.ThedatawascollectedfromdebriefingsconductedfromthebeginningofMarch2004tomid-January2005.

PAGE 21

JulySeptember200819thereisevidencethatonceveteransdevelopmilitary-relatedPTSD,thesymptomsremainchronicacrosstheirlifetimeandtheybecomeresistanttotreatmentthathasbeenshowntoworkwithotherformsofchronicPTSD.Oneofthemostcommonlyreportedclinicalproblemsinanxietydisorders,suchasPTSDandPD,aredisturbancesinsleep.6CombatveteranswithPTSDfrequentlyreportsuddenawakeningsfromnightmaresthatcloselyresembletheirmostsalienttraumaticexperience.7PTSDpatientswithcomorbidPDmayexpressadditivesymptomsofcentralfearsys-temdisturbance.8Thus,itisvitallyimportanttopro-videearlyinterventiontoreducechronicimpairmentsinveterans.5SignificantfindingsincludethediscoverythatprovidingSoldierswithimmediatepsychologicalinterventionclosetothefrontlinesincreasethelikeli-hoodoftheirrecoveringsufficientlytoreturntoduty.9PsychologistViktorRazdvevstudiedcombatantsinChechnyaandindicatedthathe,andothers,recognizedthatifyoucangettoapersoninhours,ornolaterthan2to3daysaftersufferingpsychologicaltrauma,youcouldweakenorevenpreventPTSDsonset.10Severalstudieshaveimplicatedthebenefitsderivedfromprovidingmentalhealthservices,suchascriticalincidentstressdebriefings(CISD),toindividualswhohaveexperiencedtraumaticevents.Adebriefingcanbeconductednearthesiteoftheactualevent.11,12An-othercomponentofaCISDisadefusing.Tobemosthelpful,debriefinganddiffusingtechniquesmustbedone24to72hoursaftertheinitialimpactoftheevent.13,14Eidetal15studiedmilitarypersonal(n=9)andcivilianfirefighters(n=9)involvedwithaseverecaraccidentinwhichrescueeffortsplacedtheworkersinharmsway.Thegroupthatreceivedadditionalpsy-chologicaldebriefingsreportedfewerPTSDsymp-toms.15Jenkins16researched34maleand2femaleemergencymedicaltechnicians,paramedics,andfire-fighterswhoworkedatthesiteofamassshooting.Jenkinsreportedthat52%ofthesample(n=15)at-tendedatleastoneCISDwhilethecontrolgroupchoosenottoparticipatewiththeCISD.Itwasfoundthatparticipationwithdebriefingsascorrelatedwithlowerdepressionandanxietyscoresonemonthpost-shooting.Shalevetal17studied39IsraeliSoldiersex-posedtodirectcombatandfoundthedebriefingcorre-latedwithself-reportreductioninanxietysymptomsandimprovementinself-efficacy.BurnsandHarm18studiedemergencynurses(n=682)andfoundthat88%ofthesurveypopulationwhohadparticipatedinde-briefingsfoundthemhelpful.RobinsonandMitchell19studied172emergencyservice,welfare,andhospitalpersonnelinAustraliaandfoundthatmostpersonalwhoreportedsymptomsofstressfollowingatraumaticincidentstatedthatthesesymptomshadbeenreducedasaconsequenceofattendingthedebriefing.Somearticlesandstudiesaddressthebarriersexperi-encedbymilitarypersonaltoreceivementalhealthservices.Totreatcombatstresseffectively,thepri-marybarrierthattheUSArmymustovercomeisthefearofstigmatizationthatSoldiersassociatewithmen-talhealthtreatment.20Friedman21mentionsthatthosereturningfromOperationIraqiFreedomorOperationEnduringFreedomwhoreportedthegreatestnumberormostseveresymptomsweretheleastlikelytoseektreatmentforfearthatitcouldharmtheircareers,causedifficultieswiththeirpeersandwithinunitlead-ership,andbecomeanembarrassmentinthattheywouldbeseenasweak.Hogeetal2reportedintheirstudyofUScombatinfantrySoldiersandMarinesinIraqandAfghanistanthatthosewhoseresponseswerepositiveforamentalhealthdisorder,only23%to40%soughtmentalhealthcare.Ithasbeendeterminedthatatleast60%ofveteransareunlikelytoseekmentalhealthhelpsecondarytothefearofstigmaorlossofcareeradvancementopportunities.1METHODOLOGYThisstudyinvolvedasampleofconvenience(n=396)ofUSmilitarypersonnelwhoattendedaCEDfollow-ingatraumaticevent.TheCEDtechniqueusedinthisstudyisbaseduponthe7-stageCISDMitchellModel.22Datawascollectedfrom38separateCEDsadministeredfromthebeginningofMarch2004throughmidJanuary2005duringOperationIraqiFreedomII.ThedifferentgroupsthatparticipatedintheCEDsrangedinsizefrom2to24participants.EachparticipantexperiencedatraumaticwareventinIraqwhichinvolveddeath,seriousinjury,and/orlifethreateningcircumstances.ThelocationofthestudywastheForwardOperatingBase,CampCooke,Taji,Iraq.Thedatacollectioninstrumentwasa5item(Likertscale)self-surveyformasillustratedinFigure1.Par-ticipantsweregiveninstructionsforcompletionofthesurveyaftertheCED.Surveyformswerecompletedconfidentiallyandconciseidentificationfeatureswereexcludedfromeachsurveyformtoachievetheatomic-ityofeachparticipant.Participationwiththestudywasvoluntary,althoughstronglyencouraged,andtherewasa100%participationrate.

PAGE 22

20www.cs.amedd.army.mil/references_publications.aspxEffectivenessofCriticalEventDebriefingsDuringOperationIraqiFreedomIIFINDINGSQuestion1askediftheparticipantexpectedlong-termnegativeeffectsasaresultofthecriticalevent.Re-sponsesareshowninFigure2:29.55%(n=117)ofthesamplepopulation(n=396)disagreed;26.52%(n=105)indicatednoopinion;22.73%(n=90)stronglydis-agreed;15.91%(n=63)agreed;5.30%(n=21)stronglyagreed.Question2responsesasshowninFigure3:59.34%(n=235)ofparticipantsagreedthattheCEDwashelp-fuland24.49%(n=97)hadnoopinion.9.60%(n=38)ofparticipantsstronglyagreed,while4.55%(n=18)disagreedand2.02%(n=8)ofparticipantsstronglydisagreedthattheCEDwashelpful.Question3askedparticipantsiftheyfelttheCEDwouldhavebeenhelpfulwithin2hoursofthecriticalincident.AsshowninFigure4,32.83%(n=130)ofparticipantsindicatednoopinion,while26.77%(n=106)indicatedtheydisagreed.18.69%(n=74)indi-catedthattheyagreedthattheCEDwouldhavebeenmosthelpfulifconductedwithin2hoursofthecriticalevent.12.12%(n=48)indicatedthattheystronglydis-agreed,while9.60%(n=38)indicatedthattheystronglyagreed.Question4askedparticipantsiftheyfeltafollow-upappointmentwasimportantaftertheCED.36.87%(n=146)ofparticipantsindicatednoopinion,while23.74%(n=94)disagreed.22.98%(n=91)ofpartici-pantsindicatedtheyagreedand11.36%(n=45)stronglydisagreed.5.05%(n=20)ofparticipantsindi901171056321020406080100120140 N u m b e r o f R e s p o n s e sStronglyDisagreeStronglyAgreeDisagreeAgreeNoOpinionFigure2.DistributionofresponsestoQuestion1:Doyoufeelthecriticaleventyouexperiencedwillhavealong-termnegativeimpactonyouractivitiesofdailyliving? 89723538050100150200250 18 N u m b e r o f R e s p o n s e sDisagreeStronglyDisagreeNoOpinionAgreeStronglyAgreeFigure3.DistributionofresponsestoQuestion2:DoyoufeelthisCEDwashelpful? CRITICALEVENTDEBRIEFINGSURVEYTodaysDate:DateofEvent:Gender:Age:Rank:1.Doyoufeelthecriticaleventyouexperiencedwillhavealong-termnegativeimpactonyouractivitiesofdailyliving?(Circleonethatbestapplies)12345StronglyDisagreeDisagreeNoOpinionAgreeAgreeStrongly2.DoyoufeelthisCEDwashelpful?12345StronglyDisagreeDisagreeNoOpinionAgreeAgreeStrongly3.DoyouthinktheCEDwouldhavebeenmosthelpfulifconductedwithin2hoursofthecriticalincident?12345StronglyDisagreeDisagreeNoOpinionAgreeAgreeStrongly4.AftertheCED,doyouthinkafollowupappointmentisimportant?12345StronglyDisagreeDisagreeNoOpinionAgreeAgreeStrongly5.Haveyouhaddifficultytalkingwithothersaboutthecriticalincident?12345StronglyDisagreeDisagreeNoOpinionAgreeWeappreciateyourfeedback.Feelfreetowritecommentsonback.AgreeStrongly Figure1.Theself-surveyformusedtocollectdatatoevaluatetheeffectivenessofcriticaleventdebriefingsfollowingtraumaticcombateventsinandaroundTaji,Iraq(March2004-January2005).

PAGE 23

JulySeptember200821THEARMYMEDICALDEPARTMENTJOURNALcatedthattheyfeltafollow-upappointmentaftertheCEDwasimportant.SeeFigure5.Question5askedparticipantsiftheyhaddifficultytalkingwithothersaboutthecriticalincident.35.61%(n=141)ofparticipantsindicatedtheystronglydis-agreedand31.31%(n=124)indicatedthattheydis-agreed.16.67%(n=66)ofparticipantsindicatednoopinion,11.87%(n=47)indicatedtheyagreedand4.55%(n=18)indicatedthattheystronglyagreed.SeeFigure6.DISCUSSIONQuestion1.Doyoufeelthecriticaleventyouexperi-encedwillhavealong-termnegativeimpactonyouractivitiesofdailyliving?Manyparticipantseitherdis-agreed(29.55%,n=117),orstronglydisagreed(22.73%,n=90).Theseresponsesindicatealevelofself-assessedresilienceamongmilitarypersonnelinacombatzoneinvolvedwithtraumaticevents.Thepar-ticipantswhoagreed,15.91%(n=63),andstronglyagreed,5.30%(n=21),indicatethecohortwithapre-conceptionofenduringfuturedifficulties.Thisap-proximately20%oftheparticipantswhoeitheragreedorstronglyagreedwithQuestion1providesanindica-tionofindividualswhohaveassessedthemselvesassufferinglong-termconsequencesfromthetraumatic,criticaleventtheyexperienced.Question2.DoyoufeelthisCEDwashelpful?Ap-proximately69%(n=273)ofparticipantseitheragreedorstronglyagreedthattheCEDwashelpful.Only2.02%(n=8)ofparticipantsstronglydisagreed,and4.55%(n=18)disagreedthattheCEDwashelpful.Thesefindingsarecongruentwithotherstudiesofthisnatureinwhichthemajorityofparticipantsfeelthatdebriefingsarehelpful.Question3.DoyouthinktheCEDwouldhavebeenmosthelpfulifconductedwithin2hoursofthecriticalincident?Findingsfromquestion3remainedrelativelyproportionatebetweenparticipantswhoagreed,com-paredtothoseparticipantswhodisagreed.Thesefind-ingswouldsupporttheneedforimmediatementalhealthinterventionshortlyafteracriticalevent,aswellasafteracalming-downperiodof48to72hours.ThehighestresponseforthisquestionwastheNoOpinionoptionwhichwasselectedby32.83%(n=130)ofpar-Figure4.DistributionofresponsestoQuestion3:DoyouthinktheCEDwouldhavebeenmosthelpfulifconductedwithin2hoursofthecriticalincident? 481307438106020406080100120140 DisagreeStronglyDisagreeNoOpinionAgreeStronglyAgree N u m b e r o f R e s p o n s e s 45146919420020406080100120140160 N u m b e r o f R e s p o n s e sDisagreeStronglyDisagreeNoOpinionAgreeStronglyAgreeFigure5.DistributionofresponsestoQuestion4:AftertheCED,doyouthinkafollow-upappointmentisimportant? 141664712418020406080100120140160 N u m b e r o f R e s p o n s e sDisagreeStronglyDisagreeNoOpinionAgreeStronglyAgreeFigure6.DistributionofresponsestoQuestion5:Haveyouhaddifficultytalkingwithothersaboutthecriticalincident?

PAGE 24

22www.cs.amedd.army.mil/references_publications.aspxticipants.Approximately28%(n=112)ofthepartici-pantsagreedorstronglyagreedwiththepremiseofthequestion.Thesefindingssupporttheneedforearlyintervention,shortlyafteratraumaticeventhasoc-curred.Question4.AftertheCED,doyouthinkafollow-upappointmentisimportant?Thefindingsfromquestion4remainedrelativelyproportionatebetweenthosepar-ticipantswhoeitheragreedordisagreed.TheAgreeoptionswereselectedby22.98%(n=91)(agree),and11.36%(n=45)(stronglyagree)ofparticipants.ThesefindingsimplicatetheimportanceoftheprovisionofongoingmentalhealthserviceavailabilityaftertheinitialCEDiscompleted.ThefindingsalsoemphasizetheimportanceoftheteachingphaseoftheCEDinwhichSoldierscanobtaininformationconcerningser-viceswhichareavailable.Question5.Haveyouhaddifficultytalkingwithoth-ersaboutthecriticalincident?Themajorityofpartici-pantseitherstronglydisagreed(35.61%,n=141),ordisagreed(31.31%,n=124).Althoughasmallercohortofthesamplepopulationeitheragreed(11.87%,n=47),orstronglyagreed(4.55%,n=18),thefindingswouldsupportthebenefitsofaCEDwhereastruc-turedsettingisavailableforthosewhohavedifficultytalkingaboutthecriticalevent.Self-disclosureandsupportiveinteractionsservetoamelioratethenegativeeffectsofexposuretocombat.23-25CONCLUSIONWithoutadoubtthemostvaluableassetoftheUSmilitaryistheindividualservicemember.Justasmaintenanceiscrucialtoweaponsandequipment,mentalhealthtreatmentavailabilityisvitaltoindividu-alswhohaveexperiencedwartimetrauma.Althoughmentalhealthtreatmentinthemilitaryhasimprovedsignificantlyoverthepastdecades,thedevelopmentandprovisionofmentalhealthservicesinacombatzoneremainsapioneeringfield.HardlessonswerelearnedfromVietnameraveteransregardingconse-quencesassociatedwithnotaddressingthepsychologi-calaspectsofwartimetrauma.Consequently,personalandsocialills,suchasPTSD,relationshipproblems,domesticabuse,employmentinstability,homelessness,andchemicaldependency,areassociatedwithagrow-ingnumberofveteranswhoexperiencedtraumainthecontextofwar.Diminishingbarriersforthereceptionofmentalhealthservicesandprovidingcontinuityofcarearesomeofthechallengesfacedwithupfronttraumatreatmenttoourmilitarypersonnel.Asignifi-cantamountofstigmacontinuestoexistforthoseseekingmentalhealthservices.Thisstudyprovidesvaluableinformationthatindicatestheneedforpsychologicaltreatmentandvalidatesthebenefitsofupfrontmentalhealthservices,specificallyfromCEDs,toourtroopsonthefrontlines.Thetreat-mentofcombatstressandbattlefatigueisaspecial-izedfieldthatreliesonprofessionalswhooftenputthemselvesinharmswaytoadministertheseservicestoourmilitaryservicemembersinhostileregions.Thereisaneedtocontinueresearchintheareathatprimarilyconcentratesontheprovisionofupfront,mentalhealthservicesinacombatzoneandtheimple-mentationofimprovementstotheexistingservicesys-tem.Sadly,thebattlefieldoftentravelsfromforeignlandsbacktotheirlivingroomsinthemindsoftrau-matizedwarveterans.AlthoughprogresshasbeenmadeinmentalhealthservicesintheUSmilitaryovertheyears,itisimperativetoimprovetheseservicessothatnooneisleftbehind.ACKNOWLEDGEMENT TheauthorsthankSSGJenniferAnnDavis,USAR,whoprovidedassistancewiththedatacollectionin-strumentandcollationofthedata.REFERENCES 1.HutchinsonJ,Banks-WilliamsL.Clinicalissuesandtreatmentconsiderationsfornewveterans:SoldiersofthewarsinIraqandAfghanistan.PrimPsychiatr.2006;13(3):66-71.2.HogeCW,CastroCA,MesserSC,McGurkD,CottingDL,KoffmanMD.CombatdutyinIraqandAfghanistan,mentalhealthproblems,andbarrierstocare.NewEnglJMed.2004;351(1):13-22.Note:ThearticleisreprintedinthisissueoftheAMEDDJournal,beginningonpage7.3.JewellL.Armyreleasesfindingsoffirst-everSoldierwell-beingstudyincombatarena.ArmyNewsSer-vice(online).March26,2004.Availableat:http://www4.army.mil/ocpa/read.php?story_id_key=5802.4.DiagnosticandStatisticalManualofMentalDisor-dersFourthEdition(TextRevision).Arlington,VA;AmericanPsychiatricAssociation;2000.EffectivenessofCriticalEventDebriefingsDuringOperationIraqiFreedomII

PAGE 25

JulySeptember200823THEARMYMEDICALDEPARTMENTJOURNAL5.VesperJ.HealingTraumaticStress,PTSD&Grief:Practical&EffectiveTreatmentStrategies.EauClaire,WI:PESI,LLC;2006.6.SheikhJI,WoodwardSH,LeskinGA.Sleepinpost-traumaticstressdisorderandpanic:convergenceanddivergence.DepressAnxiety.2003;18(4):187-197.7.DowBMJr,KelsoeJR,GillinJC.SleepanddreamsinVietnamPTSDanddepression.BiolPsychiatry.1996;39(1):42-50.8.WoodwardSH,LeskinGA,SheikhJI.Sleeprespira-toryconcomitantsofcomorbidpanicandnightmarecomplaintinposttraumaticstressdisorder.DepressAnxiety.2003;18(4):198-204.9.BellJL.Traumaticeventdebriefing:servicedeliverydesignsandtheroleofsocialwork.SocWorker.1995;40(1):36-43.10.ThomasTL,OHaraCP.CombatstressinChechnya:theequalopportunitydisorder.ArmyMedDeptJ.January-March2000:56-58.Availableat:http://www.cs.amedd.army.mil/dasqadownload.aspx?policyid=93.11.DavisJA.Graduateseminarintheforensicsciences:massdisasterpreparationandpsychologicaltrauma;May1992;SanDiego,CA.12.MitchellJT.Criticalincidentstressmanagement.Response.September-October1986:24-25.13.DavisJA.Onsitecriticalincidentstressdebriefingfieldinterviewingtechniquesutilizedintheaftermathofmassdisaster.Trainingseminarforemergencyrespondersandpolicepersonnel;March,1993;SanDiego,CA.14.MitchellJT.Stress:thehistoryandfutureofcriticalincidentstressdebriefings.JEmerMedServ.1988;13:7-52.15.EidJ,JohnsenBH,WeisaethL.Theeffectsofgrouppsychologicaldebriefingonacutestressreactionsfollowingatrafficaccident:aquasi-experimentalapproach.IntJEmergMentHealth.2001;3(3):145-154.16.JenkinsSR.Socialsupportanddebriefingefficacyamongemergencymedicalworkersafteramassshootingincident.JSocBehavPers.1996;11:477-492.17.ShalevAY,PeriT,Rogel-FuchsY,UrsanoRJ,Mar-loweDH.Historicalgroupdebriefingaftercombatexposure.MilMed.1998;163(7):494-498.18.BurnsL,HarmNJ.Emergencynursesperceptionsofcriticalincidentsandstressdebriefing.JEmergNurs.1993;19(5):431-436.19.RobinsonRC,MitchellJT.Evaluationofpsychologi-caldebriefings.JTraumaStress.1993;6(3):367-382.20.ShepardK.Howtostopfightingourselves:removingthestigmaofmentalhealthtreatmentforsoldiers.ArmyMedDeptJ.April-June2007:20-24.21.FriedmanMD.Acknowledgingthepsychiatriccostofwar.NewEnglJMed.2004;351(1):75-77.22.MitchellJT,EverlyGS.CriticalIncidentStressMan-agement(CISM):BasicGroupCrisisIntervention.3rded.EllicottCity,MD:InternationalCriticalInci-dentStressFoundation,Inc;2003.23.BoltonEE,GlennDM,OrsilloS,RoemerL,LitzBT.Therelationshipbetweenself-disclosureandsymp-tomsofposttraumaticstressdisorderinpeacekeepersdeployedtoSomalia.JTraumaStress.2003;16(3):203-210.24.GreenBL,GraceMC,LindyJD,GleserGC,LeonardA.RiskfactorsforPTSDandotherdiagnosisinageneralsampleofVietnamveterans.AmJPsychiatr.1990;147(6):729-733.25.TaftCT,SternAS,KingLA,KingDW.Modelingphysicalhealthandfunctionalhealthstatus:theroleofcombatexposure,posttraumaticstressdisorder,andpersonalresourceattributes.JTraumaStress.1999;12(1):3-23.AUTHORS CPTPischkeisamemberofthe785thMedicalCom-panyCombatStressControl,FortSnelling,Minnesota.CPTHallmaniswiththe3rdMedicalRecruitingBattal-ion,FortKnox,Kentucky.Previouslyhewasassignedto785thMedicalCompanyCombatStressControl,FortSnelling,Minnesota.

PAGE 26

JulySeptember200824INTRODUCTIONSoldiersprotectthenationfromthreatbyplacingthemselvesinharmsway.Theydeservethehighestqualityofweapons,equipment,andtrainingthatwillincreasetheirsurvivalandensurevictory.Innovationsintechnologymustbematchedbyconceptualinnovationsasweconfrontanelusiveandruthlessenemy.Soldiersmustrespondonanoncontiguousbattlefieldtoseeminglyunpredictableviolencewithdecisiveness,judgment,andprofessionalism.Thenoncontiguousbattlefield,whereproximityoftencompromisesintegrity,maybedescribedaslackingfrontlines,orclearboundarieswithenemiesthataredifficulttodistinguishfromnoncombatants.Wehavesuccessfullyadaptedourweaponsandtacticstothethreatspresentedbyterrorism.Nowwearechallengedtoadaptourcognitiveresponsetoenvironmentalthreatsinordertosustainthefightingstrengthofthosewhomwesendtowar.Dialecticalbehaviortherapy,2slightlyadaptedtothecombatzone,hasbeendemonstrated,throughitsimplementationattheWitmerWellnessCenter,tobeaneffectiveinterventionthataddressestheemotionaldysregulation3thatisproducedbytheinvalidatingenvironment4ofthenoncontiguousbattlefield.Theborderlinepersonalitystatesthatdialecticalbehaviortherapywasoriginallydevelopedtotreathasmanysimilaritiestothenoncontiguousbattlefield.Bothproduceamiasmic,anticatharticatmospherethatcreatesdysregulation.ThequalitiesoftheSoldiercohortthatwouldserveonthenoncontiguousbattlefieldmustalsobeconsideredinthecontextofevaluatingthismodality.Soldiersutilizingdialecticalbehaviortherapyskillsimprovedfocusandattention,increasedcomposureincrisis,anddevelopedamorerealisticappraisalofthreat.TheWellnessCenterhassuccessfullyintervenedwithlife-savingsymptomreductionevenasitwasbattle-testedduringthehighestrecordedsuicideratesamongSoldiersinourhistory.5DialecticalBehaviorTherapyDeployed:AnAggressiveAlternativetoTraditionalMentalHealthontheNoncontiguousBattlefieldCPTBrianD.Parrish,MS,USA ABSTRACTThispaperprovidesadescriptionoftheWitmerWellnessCenter,thefirstsuccessfulmilitaryapplicationofdialecticalbehaviortherapyinatheaterofwar.Dialecticalbehaviortherapyisadynamicandprovocativeevidenced-basedmodificationofcognitivebehavioraltreatmentdevelopedbyDrMarshaLinehan*forpatientswithsevereemotionaldysregulation.Oneoftheprimaryconceptsofdialecticalbehaviortherapyisthatself-harmingbehaviorsarelearned,andprovideevidenceofmaladaptivecopingthatisreinforcedinaninvalidatingenvironment.Dialecticalbehaviortherapyrecommendsahierarchyofgoalstoeffectivelyaddressthebehaviorsassociatedwithdysregulation.Chiefamongthesegoalsisreducingriskofviolencetoselforothers.Dialecticalbehaviortherapyisespeciallywell-suitedforthecomplexanddynamicenvironmentofthenoncontiguousbattlefieldwithitschronicthreatofultraviolence,strainofnonresponse,shiftingrulesofengagement,andextendeddurationandfrequencyofcombatdeployments.TheWitmerWellnessCenterprogramusesanintensiveoutpatientorganizationalstructureandminimal,butinnovative,modificationstostandarddialecticalbehaviortherapydesignedtomeetthespecialrequirementsofWarriorsinacombatzone.TheWellnessCenterprogramwasdesignedandimplementedduringOperationIraqiFreedom07-09,atatimeduringthetroopsurgewhensuicideratesamongUSforceshadreachedanunprecedentedlevel. *DrLinehanisaProfessorofPsychology,AdjunctProfessorofPsychiatryandBehavioralSciencesattheUniversityofWashington,andDirectoroftheBehavioralResearchandTherapyClinics,aconsortiumofresearchprojectsdevelopingnewtreatmentsandevaluatingtheirefficacyforseverelydisorderedandmultidiagnosticpopulations.Noncontiguousareasofcombatoperationsdonotshareacommonboundary.1

PAGE 27

JulySeptember200825Militarysubcultures,especiallyinacombatenvironment,areverysimilartothatofpolicesubcultures.6Bothmayproduceaninvalidatingenvironmentover-controllingtheexpressionofemotionsbyitsmembers.Traumaticexperiencesmaybeinvalidated.Inneremotionalexpressionsmaybepunishedbyattributingthem,throughadhominemattacks,toinsanity,weakness,fear,lackofself-discipline,orcompetence.Throughapowerfulgroupprocesswithintensepeerpressureandlittleprivacyavailable,theSoldieristaughttoinvalidatehisownexperiencesandbeliefsinfavoroftheculturesbeliefs.Duetowartimede-escalationandchangingrulesofengagement,theSoldiermaybeunabletoexperienceanycombatabreaction.7Individual,organizational,andenvironmentalfactorscombinewithchronicexposuretothestrainofnonresponsetothreat,resultingindysregulation.Emotionaldysregulationmaybedefinedasanindividualspoorlymodulatedemotionalreactivenessthatexceedstheacceptedornormativerangefortheculture.Individualsmaybemorevulnerabletoemotionaldysregulationbecauseofbiologicalpredispositionorbecausetheyhavehistoryofpreviousexposuretoaninvalidatingenvironment.Maintainingmilitarybearingrequires,bynecessity,anextremelylimitedrangeofacceptableemotiveresponses.Untreateddysregulationproducesamyriadofsymptomsandshiftingmoodsthateffectsperformance,well-being,andmission.AllSoldiers,lackingbehavioraladaptationtothenoncontiguousbattlefield,andwithoutthebenefitofanycognitiverestructuringtotranscendtraumaticeventsandadjusttothechronicexperienceofthreat,arevulnerabletodysregulation.Theeffectsofemotionaldysregulationmaybecumulativeanddevelopmental.8Dialecticalbehaviortherapy,whichwasoriginallydesignedfortreatmentofpersonswithborderlinepersonalitydisorder,9assertsthatindividualswhohaveexperiencedinvalidatingenvironmentsduringchildhoodbecomeextremelyreactivetoemotionalstimulation.Theytendtobehypervigilantandtheirarousallevelescalatesrapidlyandtakesmuchmoretimetorecovertoaculturallyacceptablebaseline.Thisprovidesanexplanationofwhypersonswithborderlinepersonalitydisorderoftenpresentwithextremeemotionalliability,rapidlyshiftingtheiremotions,andlivinglivesthatseemperpetuallyincrisis.Theseindividuals,withpoorlydevelopedboundariesandahistoryofexperiencinginvalidation,arenotequippedtocopewithintenseemotions.Dialecticalbehaviortherapyrecommendsahierarchyofgoalstoeffectivelyaddressthebehaviorsassociatedwithdysregulation.Chiefamongthesegoalsisreducingriskofviolencetoselforothers.Nextarethosebehaviorsthatobstructtherapyinterventions,andfinally,thosebehaviorsthatdiminishtheparticipantsqualityoflife.Soldiers,likelawenforcementofficers,mayexperienceaninvalidatingworkenvironmentthatleavesthemillequippedtocopewiththeintenseemotionsprovokedbytheworkofdistinguishingthegoodguysfromthebadguys.TheseSoldiersmustthennegotiatealargelyunpredictableandviolentenvironmentinwhichtheyare,inessence,operatingaspoliceinacombatzone.THEWELLNESSPROGRAMTheWitmerWellnessCenterfunctionsasanintegratedcomponentwithinthefacilitiesoftheWitmerTroopMedicalClinic.ThisLevelIImedicalfacilitywasdedicatedinthenameofMichelleWitmer,*thefirstfemaleNationalGuardSoldiertobekilledinactioninits367yearhistory.TheWellnessCenterprovidesfullrange,evidenced-based,outpatientcognitivebehaviortreatmentservicesfortheWitmerTroopMedicalClinicandthesurroundingareaofresponsibility.ItsrelativelydiscreetlocationwithinamedicalfacilityprovidesalessstigmatizingopportunityforSoldierswhoareconcernedaboutbeingidentifiedasmentalhealthpatients.TheWellnessCenterprovidesavoluntary,Soldier-centered,harm-reducing,integrative,nongender-specific,wellness-focusedapproachtobehavioralhealthtreatment,emphasizingpersonalresponsibilityforbehavioralhealthinthesamemannerthatSoldiersareheldaccountablefortheirphysicalfitness.TheWellnessCenterprovidesatreatmentplatformthatdeliversintensiveoutpatienttreatmentfeaturingdialecticalbehaviortherapyfortheSoldier,whilemaintainingclosecommunicationwiththeSoldierscommand.WhentheSoldier'sunitisactivelyengagedinatherapeuticallianceontheSoldiersbehalf,anexoskeletalstructureiscreated,thatcan,temporarily,butcritically,filternegativeprojection.Theengagedunitmayprovidesupport,andthepsychological *SPCMichelleM.Witmer,aSoldierinthe32ndMilitaryPoliceCompany,WisconsinNationalGuard,waskilledinactioninBaghdad,Iraq,onApril9,2004.

PAGE 28

26www.cs.amedd.army.mil/references_publications.aspxDialecticalBehaviorTherapyDeployed:AnAggressiveAlternativetoTraditionalMentalHealthontheNoncontiguousBattlefieldsafety,thatisrequiredfortheSoldiertoreducetraumatictransferenceandproductivelyparticipateinbrieftreatmentwiththetherapist.TheprimarytreatmentgoalforallSoldiersparticipatingintheprogramattheWellnessCenteristoimprovetheirperformanceandenhancetheirfunctioning,emphasizingthatitishighlypreferredthattheyremainondutyandfocusedontheirmissionwhileactivelyengagedintherapy.DiligenteffortisappliedtostrengthenmeaningfulsocialsupportwithintheSoldiersunit,ratherthanremovingtheSoldierfromhisbaseofprimarysupport.ManySoldiersfunctionasmembersofteamsorsquadsthataresohighlyintegratedthatitmaybedetrimentaltothecohesionoftheunittoremoveonememberforanyreason,butparticularlyforsomethingasstigmatizingasmentalhealththerapy.Assessmentandoutpatienttherapyservicesareprovided24hoursperday,7daysperweekbyalicensedclinician.TheWellnessCenterdoesnothavespecifiedwalk-inhours.Soldiersreceivetriageservicesandareassessedimmediatelyorscheduledforfurtherevaluationbasedupontheinitialassessment,theindividualneedsoftheSoldier,and/ortheSoldierscommand.TherearenodistinctionsmadebetweenSoldierswhoworkoutsidethewireandwhotravelintoactivecombatareassubjecttoroadsidebombsandambushes,andthosewhoworkinsidethewireandprovidesupportservicesinthecombatzonewhichmayroutinelyplacethematheightenedriskofdeathordismembermentbytheindirectfireofrockets,mortars,ortheoccasionalsniper.Threatisever-presentonthenoncontiguousbattlefield.Sincethetreatmentmodelisnotfocusedonthereductionofpathology,butonthedevelopmentofwellness,theonlySoldiersthatwouldprobablybeinappropriateforinclusionintotheopen-endedcontinuousgroupsarethosewhodemonstrateantisocialorschizoidpersonalitytraitsandthoseindividualswhodonotwanttreatment,oronlyrequestpsychopharmacologicalinterventions.Equally,malingerersandsubstanceabusersarenotattractedtothismodalityduetotheaccountability,rigorousworkinvolved,andacoreobjectiveofhavingaclearmind,freeofallmoodalteringchemicals.GreatemphasisisplacedonprovidingoutstandingcustomerservicethatistimelyandtailoredtotheneedsoftheindividualSoldier.SoldiersthatarenewtotheprogramandthosewhoareestablishedintreatmentintheWellnessprogrammaybeseenonanemergentbasis24hoursperday7daysperweek.EstablishedorganizationaldoctrineanddirectivesandJCAHO*standardsregardingconfidentialityandcarearealwaysmaintainedandeveryeffortismadetopreservetheSoldiersdignitywiththeassumptionthattheSoldierenteredtherapyasacompetentindividual.Soldiersengageintherapywiththeexpectationthattheywillenhancetheirfunctioningandimprovetheirmissioneffectivenesswhileparticipatinginevidence-basedcognitivebehaviortherapy.IndividualandgroupdialecticalbehaviortherapyisfeaturedastheprimaryclinicalmodalityoftheWellnessCenter.AllSoldierswhoparticipateareprovidedwithacomprehensiveassessmentandtreatmentbyalicensedclinician.Missionrequirementsarealwaysconsideredduringthedevelopmentofthetreatmentplan,andtheSoldiersindividualizedprogramismanagedflexiblyaroundmissions,unlesssafetywouldbecompromised.Soldiersmaybeseenforindividualorgrouptherapy,asneeded,inanyconfigurationthatisassessedasmostbeneficialtothehealth,well-being,andmissionoftheSoldier.Dialecticalbehaviortreatmentisnotintellect-dependent.Soldierswhoaretemporarilycognitivelyimpairedbyactivesymptomsareabletousetheskillsonaconcreteleveluntiltheyimprove.Duringthisdeployment,IhavesuccessfullyengagedSoldierswithborderlineintelligence,aswellasofficerswhohadgraduatedfromtheMassachusettsInstituteofTechnologyandtheUSMilitaryAcademy.AllSoldiersareassessedforriskofharmtoselforothersateveryencounter.Contingentuponthelevelofriskpresented,andsubsequenttoacomprehensiveassessmentthatutilizesindividualizedpsychometricevaluationandthe2007JCAHOBasicSuicideAssessmentFiveStepEvaluation.10Soldiersmaybedeterminedtorequiretransfertoahigherlevelofcare.Soldiersassessedasbeingatrisk,butnotrequiringmedicalevacuation,maybeplacedonaCommandInterestProfilethatprovidesspecific *JointCommissiononAccreditationofHealthcareOrganizations

PAGE 29

JulySeptember200827THEARMYMEDICALDEPARTMENTJOURNALrecommendationsforsafelymanagingdirectsupervisionoftheSoldierbytheSoldierscommand.ThisallowstheSoldiertoremainasactivelyinvolvedinhismissionaspossible,whiledevelopingtreatmentskillsthatwillreducerisk.TheSoldiersindividualizedCommandInterestProfilewillspecifyallrecommendationsforenhancedsafetymeasures,limitationstoduty,access,oractivities.TheCommandInterestProfilewillbesignedbyarepresentativeofthecommandwhentheyassumesupervisionoftheSoldierwhowasassessedtobeatrisk,commencingadialoguebetweenthecommandandthelicensedclinicianthatisintegraltothesafemanagementofSoldierswithhighriskbehaviors.CommunicationregardingcasemanagementwiththeSoldierscommandisessentialinthisprocess.Thecommanderoramemberofthechainofcommandisrequested,whenappropriate,totakeanactiveroleinsupportingtheSoldierstreatment.Commandersareusuallywillingtoinvestintime,escorts,andresourcesfortheSoldierwhentheyobservethebehavioralchangesandimprovedfunctioningintheSoldier.Soldierswhoareassessedtobeatriskreceiveintensivelevelsofoutpatienttreatment,formallyagreenottoharmthemselves("contractforsafety"),andarereassessedwithdocumentationintheelectronicmedicalrecordateveryencounterforthelengthoftreatment.WhentheSoldierisassessedasnolongerbeingatriskofharmtoselforothers,theSoldierisformallyrecommendedforremovalfromtheCommandInterestProfilebythebehavioralhealthofficer,inagreementwiththeSoldierandtheSoldierscommand.TheWellnessCenterisstructuredonanintensiveoutpatienttreatmentmodelinwhichtheSoldierisseen,asoftenasneeded,baseduponongoingriskassessment.Typically,Soldiersareseenaminimumoftwiceperweek,withoneindividualsessionof60to90minutesandoneormoreopen-endedcontinuousgroupsessionsof90to120minutes.Soldiersmaybeseenonadailybasis,asneeded,inordertopromoteemotionalself-regulationandreducetheriskofharmtoselforothers.TheWellnessmodelbeginswiththeassumptionofcompetenceintheSoldierbeingtreated.TheSoldierbeingtreatedisalwaysregardedwithrespect,andeveryeffortismadetopreservethedignityofaSoldierinuniform.TheSoldierundertreatmentistypicallycarryingaweaponandammunition.EvenwhentheSoldierissuicidal,theSoldierretainstheweapon,butthatweaponisrenderedinoperable.Pathologyisalwaysdeemphasized.WELLNESSADAPTATIONSTOSTANDARDDIALECTICALBEHAVIORTHERAPYUponareviewoftheliterature,theWellnessCenteristhefirstuseofdialecticalbehaviortherapywithSoldiersinanactivecombatzone.DialecticalbehaviortherapywasminimallyadaptedattheWellnessCenterformilitaryuse.11TheWellnessmodelpromotestreatmentinterventionsthatareverymuchlikephysicaltraining,whereinthepersonseekstoimprovetheirperformance,enhancetheirfunctioning,anddevelopapervasivesenseofwell-beingthrougharigorousexerciseregimethatinvolvesself-disciplineandpersonalaccomplishment.Thelicensedclinician,whoactsastreatmentprovider,oftenactsmorelikeapersonaltrainerthanthemedia-influencedstereotypeofatherapist.Followingtheanalogy,thepersonaltrainerseekstocoachtheathletebyassessingcapabilitiesandform,teachingskills,measuringprogress,developingaclearobjective,andmotivatingthepersontocontinuewiththeirindividualizedprogram.Thepersonaltrainercannotdotheexercisesfortheathlete.Thepersonaltraineremphasizesthequalitiesofaccountabilityandpersonalresponsibilityintheathleteengagedintheprogram.Therefore,weeklyindividualandgrouptherapysessionsarestructuredverymuchliketheindividualandgroupphysicaltrainingsessionsthataresofamiliartoSoldiers.Individualsessionsprovideforintensiveskillbuilding,whilegroupsessionsemphasizecoachingtheapplicationofthoseskillsinrealworldscenarios,includingcombatsituations.AstheSoldiersskillsandgeneralfunctioningincreases,theSoldierisencouragedtocofacilitateandtoleadagroupsessionunderthesupervisionofthelicensedclinicianfacilitator.Soldiers,typically,participateinanindividualsessionandatleastonegroupsessionperweekunlesstheSoldierisonataperingschedule.TheadaptationofusingataperingschedulesupportedSoldierswhohaddevelopedafoundationindialecticalbehaviortherapyandacquiredmostoftheskills,butwhostillrequestedongoingcoachingwithskillsimplementation.Insome

PAGE 30

28www.cs.amedd.army.mil/references_publications.aspxinstances,Soldierswho,duetomissionrequirements,wouldbeunabletocontinuetreatmentinthestandardformatwouldbeprovidedwithatruncatedversionofthefoundationalskills.ThestandarddialecticalbehaviortherapyformathasbeenexpandedandcontractedbasedupontheindividualneedsoftheSoldiers.Individualtreatment,ofanyduration,isonlycommencedsubsequenttothecompletionofacomprehensiveassessment.Theskillslearnedinindividualsessionsfollowthestandarddialecticalbehaviortherapy12formatusing4modulesthatincludemindfulness,interpersonaleffectivenessskills,regulationofemotions,anddistresstolerance.Theskillsareintroducedbaseduponanindividualizedtreatmentplan.Standarddialecticalbehaviorskillsaremodifiedonlyinthesensethatmilitaryanalogiesthatarefamiliarandreadilyaccessibleareusedtorapidlyexplainandfacilitateunderstandingoftheconceptspresentedinthe4modules.Individualtreatmentsessions,groupskillstrainingsessions,andintensivecasemanagementareavailable24hoursperday,andconsultationsessionsareheldwiththeSoldierscommand.Theindividualtreatmentsessions,skillstraininggroup,andconsultationgroupsessionsarescheduledandconducted,asneeded,basedonthecurrentriskassessment.ThegroupskillssessionsareopenonlytoSoldiersthathavebeenassessedandareparticipatinginindividualtreatment.Thegroupskillstrainingsessionsreinforcetheskillsalreadyacquiredinindividualsessionsandemphasizestheapplicationofthoseskills.Soldiersareaffordedmultipleopportunitiestosharetheirexperiencesastheypracticetheirskillsatwork,ininterpersonalrelations,andincombatsituations.ItisoftenhighlymotivatingforSoldierstoheartestimonialsofotherSoldierswhoareabletodescribetheiracquisitionofdialecticalbehavioraltherapyskillsandthefunctionalchangesthathaveoccurredasadirectresultofimplementingthoseskills.Groupskillsessionsareopen-endedandcontinuous.Aspecificdialecticalbehaviortherapyskillishighlightedineachgroupsession.AttheWellnessCenter,alicensedclinicianisavailabletocoachSoldiersthroughcrises24hoursperdayinperson,andbytelephone.TheconsultationsessionsareheldwithrepresentativesoftheSoldierscommandasappropriateandonavoluntarybasiswithasignedconsenttoreleaseinformationtothecommand.Thiscreatesanonadversarialsupportiveforumformediationofgrievancesandpracticeofinterpersonaleffectivenessskillsinwhichvalidationisrolemodeledforthecommandteam.TheseadaptedconsultationsessionsprovideavenueinwhichthecommandmayreceiverecommendationsabouttheirSoldiers,andthelicensedclinicianisbetterabletocoordinatecareandgetfeedbackabouttheSoldiersfunctionalimprovements.DEMOGRAPHICSIthasbeenestimatedthatmorethan5,000behavioralhealthcontactswithmilitarypersonnel,contractors,andotherswillbemadethroughtheWellnessCenteroverthecourseofmycurrentdeployment.Morethan95%ofdocumentedencounterswerewithArmySoldiers,andtheremaining5%wereNavyorAirForcepersonnel,civiliancontractors,thirdcountrynationals,orIraqicivilians.Approximately30%ofthoseSoldierswhomIassessedandtreatedwereconsideredtobeinahighriskcategory.Soldiersthatareassessedasbeingathighrisk,asdefinedhere,wouldrequireaCommandInterestProfileorclinicalrecommendationfordirectsafetysupervision,orwouldhavecurrentorhistoricalsuicidalorhomicidalideationorbehavior,orsignificanthistoryofcriminalviolenceorpsychiatrictreatmentorhospitalization.TheWellnessCenterhaspromotedtheconceptofRemainonDutyratherthanReturntoDuty,workingaroundmissionschedulesandcoachingSoldiers,asmuchaspossible,inplaceandwithoutremovingthemfromanopportunitytousetheirdialecticalbehaviortherapyskills.TheWellnessCentersmottoisremainonduty,andithasmaintainedareturntodutyrateexceeding99%,withonly5medicalevacuationsforSoldierswhorequiredahigherlevelofcare,andzeroincidentsornegativeoutcomesthatresultedfromanytreatmentorprogrammaticprocess.IattributethissuccessinsafelymanagingahighvolumeofSoldiers,manyinahighriskcategory,totheeffectivenessofdialecticalbehavioraltherapyanditsdeliverysystem,theWellnessCenter.ThemajorityofSoldiersthatparticipatedintreatmentwereidentifiedasexperiencingemotionaldysregulation,andnearlyallpatientswereDialecticalBehaviorTherapyDeployed:AnAggressiveAlternativetoTraditionalMentalHealthontheNoncontiguousBattlefield

PAGE 31

JulySeptember200829THEARMYMEDICALDEPARTMENTJOURNALexperiencingsignificantsymptoms.Whiletheavailabledatasupportstheassumptionthatimmediategainsmaybeachievedintermsofsymptomreductionandincreasedsurvivabilitythroughrealisticthreatassessmentandenhancedattention,forsustainabilityofgains,thesecognitivelifestylechangesrequirethesameinstitutionalsupportthatphysicalfitnessreceiveswithintheexistingmilitaryorganizationalstructure.ManyoftheSoldiersseenattheWellnessCenterfortreatmentappeartohaveimpairedcapacitiesforself-regulation,13andsomepresentwithsymptomsandhistorythatwouldbeconsistentwiththediagnosticcriteriaforcomplextraumadisorder,14inthattheirexperienceoftraumainchildhoodisbeingexacerbatedbytheeffectsofenvironmentalinvalidationwhileservinginacombatzone.WemayanticipatethebehavioralhealthneedsofSoldiersinthenextdecadebylookingatthechildrenintheUnitedStatestoday.AccordingtoPerrysresearch,15eachyearmorethan5millionchildrenintheUnitedStatesexperiencesomeextremetraumaticevent.Morethan40%ofthesechildrenwilldevelopsomeformofchronicneuropsychiatricproblemthatcansignificantlyimpairtheiremotional,academic,andsocialfunctioning.Themajorityoftheseneuropsychiatricproblemsareclassifiedasanxietydisorders,withthemostcommonbeingposttraumaticstressdisorder(PTSD).TypicalsignsandsymptomsofPTSDincludeimpulsivity,distractibilityandattentionproblems(duetohypervigilance),dysphoria,emotionalnumbing,socialavoidance,dissociation,sleepproblems,aggressive(oftenreenactment)play,schoolfailure,andregressedordelayeddevelopment.InmoststudiesexaminingthedevelopmentofPTSDfollowingagiventraumaticexperience,twiceasmanychildrensufferfromsignificantposttraumaticsignsorsymptoms,butlackallofthecriterianecessaryforthediagnosisofPTSD.Inthesecases,theclinicianmayidentifytrauma-relatedsymptomsaspartofanotherneuropsychiatricsyndrome.Forexample,hypervigilanceisoftenconsideredanattentionproblemandtraumatizedchildrenwillbediagnosedandtreatedasiftheyhaveattentiondeficithyperactivitydisorder.15TheSoldierswhowerethesechildren,andwhowereabletofunctiontosomedegreepriortodeployment,nowpresent,ofteninacutedistresswithdysregulationofemotionsandbehaviorwhenconfrontedbytherigorofthenoncontiguousbattlefield.Inacomprehensivenationalsurveycompletedin2005,16overthecourseofoneyear,researchersconductedtheDevelopmentalVictimizationSurveytogatherdataonarangeofvictimizationsfrombirthuntiladulthood.Amongthefindings:Justmorethanhalfoftheyouths(530/1000)experiencedaphysicalassault.Thehighestrateofphysicalassaultvictimizationoccurredbetweenages6and12.Onein12(82/1000)oftheyouthsexperiencedsexualvictimization,includingsexualassault(32/1000)andattemptedorcompletedrape(22/1000).Childmaltreatmentwasexperiencebyalittlelessthanoneseventhoftheyouths(138/1000).Thestudydividedmaltreatmentinto5categories(physicalabuse,sexualabuse,emotionalabuse,neglect,andfamilyabduction)ofwhichemotionalabuse(namecallingordenigrationbyanadult)wasmostfrequentinoccurrence.Thehighnumbersofchildrenwhohaveexperiencedinvalidationintheirpredeploymentoriginssupportthecontentionthatwewillbetreatingthemwhentheyreexperienceitundertheaddedstressorsandperceivedthreatthattheymayencounterinacombatzone.Twenty-twopercentofchildreninanationalsamplereported4ormoredifferentkindsofvictimizationinasingleyear.Oncechildrenbecomepolyvictims,theirriskforadditionalvictimizationtendstoremainveryelevated.Polyvictimshaveextremelyhighlevelsoftraumaticstresssymptoms.Theundetectedpresenceofsuchmultiplevictimizationexposureamongresearchsamplesofchildrenidentifiedbecauseofasinglevictimizationtype(victimsofsexualabuseorbullying)maybewhataccountsforaconsiderableportionoftheassociationbetweentheseindividualvictimizationsandtraumaticsymptommeasures.Ifresearchersandpractitionerscanmoreeffectivelyidentifypolyvictimsandthoseonthepathtobecomingpolyvictims,theymightbeabletodirectprevention

PAGE 32

30www.cs.amedd.army.mil/references_publications.aspxresourcestoforestallthemostseriousvictimizationcareersandmostadverselyaffectedchildren.17ManyoftheseadverselyaffectedchildrenmaybeourverybestSoldiers.Universaldestigmatizationtraininginanevidenced-basedtherapydesignedtoreducethesymptomsofcomplexorpolytrauma,would,inallprobability,reducethestrainofnonresponsetothreatandthesenseofinvalidationthatmayresultindysregulation.Thebranchofdevelopmentalvictimologythatstudiestheimpactofvictimizationonchildrenpositsthatchildrenatdifferentstagesofdevelopmentexperienceandcopewithvictimizationindifferentways.Priorresearchintodifferingimpactshasbeennarrowlyfocusedonsexualabuseandposttraumaticstressdisorder.Developmentalvictimologyaddressesamuchbroaderrangeofvictimizations,focusingparticularlyonvictimizationsexperiencedbyamajorityofchildren,suchaspeerorsiblingassaultandtheft.Developmentalvictimologyexploresabroadrangeofpotentialimpactsbeyondthosefallingintherealmofpsychopathology,includingeffectsonpersonality,socialskills,politicalandsocialattitudes.Itfurtherfocusesonhowtheseimpactsarefeltandmanifestedatdifferentstagesofchilddevelopment.18Soldierswhohaveexperiencedtheweightyconsequencesofcomplexorpolytraumaareoftenhighlymotivatedtoengageintrainingwiththeexpectationthattheywillenhancetheirfunctioningandimprovetheirmissioneffectivenessbyparticipatinginevidence-basedcognitivebehaviortherapy.AccordingtothemostrecentinformationavailablefromtheNationalAllianceonMentalIllness,19oneinfouradultsapproximately57.7millionAmericansexperienceamentalhealthdisorderinagivenyear.Onein17liveswithaseriousmentalillness,suchasschizophrenia,majordepression,orbipolardisorder,andaboutonein10childrenhaveaseriousmentaloremotionaldisorder.Anxietydisorders,whichincludepanicdisorder,obsessive-compulsivedisorder,PTSD,generalizedanxietydisorder,andphobias,affectabout18.1%ofadults,anestimated40millionindividuals.Halfofalllifetimecasesofmentalillnessbeginbyage14,threequartersbytheageof24.6years.Despiteeffectivetreatments,therearelongdelays,sometimesdecades,betweenfirstonsetofsymptomsandwhenpeopleseekandreceivetreatment.Fewerthanonethirdofadultsandonehalfofchildrenwithadiagnosablementaldisorderreceiveanymentalhealthservicesinagivenyear.IntheUnitedStates,theannualeconomic,indirectcostofmentalillnessisestimatedtobe$79billion.Mostofthatamount,approximately$63billion,reflectsthelossofproductivityasaresultofillness.19SuicideistheeleventhleadingcauseofdeathintheUnitedStates,andthethirdleadingcauseofdeathfordecedentsinthe10to24yearagegroup.20Morethan90%ofthosewhodiebysuicidehaveadiagnosablementaldisorder.InJuly2007,KaplanetalpublishedtheresultsofanationwidereportwhichindicatedthatmaleveteransaretwiceaslikelytodiebysuicideascomparedwiththeircivilianpeersinthegeneralUSpopulation.21CONCLUSIONSResearchisneededtofurtherdevelopunderstandingofthebehavioralhealthneedsofSoldiers.Thoseneedsaredynamicandhavechanged,notonlybecauseofthedurationandfrequencyofdeployments,butalsobecauseofthequalitiesinherentintheenvironmentofthenoncontiguousbattlefieldandtheSoldiercohortthatwillbeservingthere.Clearly,amoreflexibleandSoldier-centeredmodelofbehavioralhealthcaredeliveryisneededinthemilitary,especiallyintheater.ThesuccessoftheWellnessmodelsupportsanargumentforthedevelopmentofanewparadigmforthetreatmentofSoldiersinwhich,likethebattle-testedwayinwhichSoldiersaretaughttousetheirweaponsinaneffectivemanner,wewillceasetocompartmentalizementalhealth,and,instead,alignbodyandmindinanintegrative,nonstigmatizing,relevantmodeloftreatmentandservicedelivery.ResearchandstatisticalevaluationoftheWellnessCentermodelisneeded.Factoranalysisofeachprogramelementwouldprovideusefulinformation,aswoulddevelopmentofthetheoreticalunderpinningsofthemilitaryadaptationofdialecticalbehavioraltherapy.Althoughgainsmaybeimmediatelyrealizedintermsofsymptomreductionandfunctionalimprovement,theymaynotbepermanentwithoutongoingsocialsupport,preferablyinstitutionalizedwithintheexistingmilitarystructure.Analysisoflong-termgains,maintenanceofprogressmade,andrelapsepreventionshouldbecompleted.Finally,itwillalsobeimportanttomeasurechangesinpostdeploymentDialecticalBehaviorTherapyDeployed:AnAggressiveAlternativetoTraditionalMentalHealthontheNoncontiguousBattlefield

PAGE 33

JulySeptember200831THEARMYMEDICALDEPARTMENTJOURNALrelationshipsandqualityoflifesubsequenttoSoldierslearningdialecticalbehavioraltherapyskills.REFERENCES 1.FieldManual3-0:Operations.Washington,DC:USDeptoftheArmy;February2008:chap5,p5-14.2.LinehanMM.SkillsTrainingManualForTherapyOfBorderlinePersonalityDisorder.NewYork:GuilfordPress;1993.3.DimeffL,KoernerK,LinehanMM.SummaryofResearchonDialecticalBehaviorTherapy.Seattle,WA:BehavioralTech,LLC;2002.4.Cheavens,JS,RoenthalZM,DaughtersSB,NowakJ,KossonD,LynchTR,LeiuezCW.Ananalogueinvestigationoftherelationshipsamongperceivedparentalcriticism,negativeaffect,andborderlinepersonalitydisorderfeatures:theroleofthoughtsuppression.BehavResTher.2005;43(2):257-268.5.MentalHealthAdvisoryTeam(MHAT)V:OperationIraqiFreedom06-08,Iraq;OperationEnduringFreedom8,Afghanistan.Washington,DC:OfficeofTheSurgeonGeneral,USDeptoftheArmy;February14,2008.6.FigleyCR.Policecompassionfatigue(PCF):theory,research,assessment,treatment,andprevention.In:ViolantiJ,PatonD,eds.PoliceTrauma:PsychologicalAftermathofCivilianCombat.Springfield,IL:CharlesC.Thomas;1999:37-53.7.WastellCA.Exposuretotrauma:thelong-termeffectsofsuppressingemotionalreactions.JNervMentDis.2002;190(12):839-845.8.BeaudhaineTP,Gatze-KoppL,MeadHK.Polyvagaltheoryanddevelopmentalpsychopathology.Emotiondysregulationandconductproblemsfrompreschooltoadolescence.BiolPsychol.2007;74:174-189.9.JuddPH,McGlashanTH.DevelopmentalModelofBorderlinePersonalityDisorder:UnderstandingVariationsinCourseandOutcome.Arlington,VA:AmericanPsychiatricPublishing;2003:31.10.JacobsD.AResourceGuideforImplementingtheJointCommissiononAccreditationofHealthcareOrganizations(JCAHO)2007PatientSafetyGoalsonSuicide.Availableat:http://www.naphs.org/Teleconference/documents/ResourceGuide_JCAHOSafetyGoals2007_final.pdf.AccessedSeptember5,2008.11.LinehanM.Commentaryoninnovationsindialecticalbehaviortherapy.CognBehavPract.2000;7:478-481.12.MillerAL,RathusJH,LinehanMM,SwensonCR.DialecticalBehaviorTherapy.NewYork:GuilfordPress;2007:1.13.PynoosR,SteinbergA,PlacentiniJ.Adevelopmentalpsychopathologymodelofchildhoodtraumaticstressandinteractionwithanxietydisorders.BiolPsychiatry.1999;46:1542-1554.14.vanderKolkBA.Developmentaltraumadisorder:towardarationaldiagnosisforchildrenwithcomplextraumahistories.PsychiatricAnnals.2005;35(5):401-402.15.PerryBD.MaltreatedChildren:Experience,BrainDevelopmentandtheNextGeneration.NewYork:W.W.Norton&Company.Inpress.16.FinkelhorD,OrmrodRK,TurnerHA,HambySL.Thevictimizationofchildrenandyouth:acomprehensive,nationalsurvey.ChildMaltreatment.2005;10(1):5-25.17.FinkelhorD,Kendall-TackettKA.Developmentalperspectiveonthechildhoodimpactofcrime,abuseandviolentvictimization.In:CicchettiD,TothS,eds.DevelopmentalPerspectivesonTrauma:Theory,Research,andIntervention.NewYork:UniversityofRochesterPress;1997:1-32.18.FinkelhorD,OrmrodRK,TurnerHA.Polyvictimization:aneglectedcomponentinchildvictimizationtrauma.ChildAbuseNegl.2007;31:7-26.19.NAMIFactSheet.MentalIllness:FactsandNumbers,October2007.NationalAllianceonMentalIllness.Availableat:http://www.nami.org/Template.cfm?Section=About_Mental_Illness&Template=/ContentManagement/ContentDisplay.cfm&contentID=53155.20.FederalInteragencyForumonChildandFamilyStatistics.AmericasChildren:KeyNationalIndicatorsofWell-Being,2005.Washington,DC:FederalInteragencyForumonChildandFamilyStatistics;July2007.Availableat:http://www.childstats.gov/pdf/ac2007/ac_07.pdf.21.KaplanMS,HuguetN,McFarlandB,NewsomJT.Suicideamongmaleveterans:aperspectivepopulation-basedstudy.JEpidemicalCommunityHealth.2007;61(7):619-624.AUTHOR CPTParrishistheBehavioralScienceOfficer,566thMedicalCompany(AreaSupport),62ndMedicalBrigade(TaskForce62),CampLiberty,Iraq.

PAGE 34

32www.cs.amedd.army.mil/references_publications.aspxWarriorResilienceTraininginOperationIraqiFreedom:CombiningRationalEmotiveBehaviorTherapy,Resiliency,andPositivePsychologyMAJThomasJarrett,MS,USA ABSTRACTWarriorResilienceTraining(WRT)isaneducationalclassdesignedtoenhanceWarriorresilience,thriving,andposttraumaticgrowthforSoldiersdeployedinOperationIraqiFreedom.WarriorResilienceTrainingusesrationalemotivebehaviortherapy(REBT),Armyleadershipprinciples,andpositivepsychologyasavehicleforstudentstoapplyresilientphilosophiesderivedfromArmyWarriorEthos,Stoicphilosophy,andthesurvivorandresiliencyliterature.StudentsinWRTaretrainedtofocusuponvirtue,character,andemotionalself-regulationbyconstructingandmaintainingapersonalresiliencyphilosophythatemphasizescriticalthinking,rationality,virtue,andWarriorEthos.Theauthor,anArmylicensedclinicalsocialworker,executivecoach,REBTdoctoralfellow,andformerSpecialForcesnoncommissionedofficer,describeshisinitialexperienceteachingWRTduringOperationIraqiFreedomtocombatmedicsandSoldiersfrom2005to2006,andhisexperienceasaleaderofacombatstresscontrolpreventionteamcurrentlyinIraqofferingmobileWRTclassesin-theater.WarriorResilienceTrainingrationale,curriculum,variants(likeWarriorFamilyResilienceTraining),andfeedbackareincluded,withsuggestionsastohowbehavioralhealthprovidersandcombatstresscontrolteamsmightbetterintegratetheirserviceswithleaders,chaplains,andcommandstobettermarketcombatstressresiliency,reducebarrierstocare,andpromoteforcepreservation.Informalanalysisofclassfeedbackfrom1168respondentsregardingWRTreceptionandutilizationisexamined.FromtheArmyLeadershipManual1:TheWarriorEthosisacomponentofcharacter.ItshapesandguideswhataSoldierdoes.ItislinkedtightlytoArmyvaluessuchaspersonalcourage,loyaltytocomrades,anddedicationtoduty.(page4-51)Beliefsmatterbecausetheyhelppeopleunderstandtheirexperiences.Thoseexperiencesprovideastartpointforwhattodoineverydaysituations.Beliefsareconvictionspeopleholdastrue.Valuesaredeep-seatedpersonalbeliefsthatshapeapersonsbehavior.Valuesandbeliefsarecentraltocharacter.(page4-57)GoodleaderscontroltheiremotionsMaintainingself-controlinspirescalmconfidenceintheteamLeaderswholosetheirself-controlcannotexpectthosethatfollowthemtomaintaintheirs.(page6-20)Self-control,balance,andstabilityalsoassistmakingtherightethicalchoices.Anethicalleadersuccessfullyappliesethicalprinciplestodecisionmakingandretainsself-control.Leaderscannotbeatthemercyofemotion.Itiscriticalforleaderstoremaincalmunderpressureandexpendenergyonthingstheycanpositivelyinfluenceandnotworryaboutthingstheycannotaffect.(page6-22)

PAGE 35

JulySeptember200833WARRIORRESILIENCETRAININGHISTORYANDRATIONALETheMentalHealthAdvisoryTeamIVreport,2releasedinNovemberof2006,indicatedthat17%ofthesurveyedSoldierswhoreportedmediumcombatexposurescreenedpositiveforcombinedmentalhealthproblems,includingdepression,anxiety,andacutestressreactions(posttraumaticstressdisorder(PTSD)),whilepositivescreeningswereindicatedfor30%ofSoldierswithhighcombatexperience.Afull37%ofthoseSoldiersandMarineswhoscreenedpositiveformentalhealthproblemsreportednottrustingmentalhealthprofessionals,fearofstigmatizationorbeingperceivedasweak,andbeingtreateddifferentlyiftheyuseavailableservices.OtherresearchconfirmedpersistentandpervasiveSoldierfearofstigmatizationasabarriertocareforutilizationofbehavioralhealthservices,3despitethepresenceofArmycombatstresscontrolunitsintheaterdesignedspecificallytoprovidepreventionandreducebarriersthroughcombatoperationalstresscontroldoctrine,andpredeploymentcombattraining.4FromNovember2005toJuly2006,Iservedasabehavioralhealthofficerforanareasupportmedicalcompanysupporting30,000to50,000WarriorsatCampLiberty,Iraq.MyexperienceintheaterconfirmedtheMHATIVobservationsfirsthand,includinginstitutionalbias,Soldierresistancetowardbehavioralhealthservices,anddifficultyprovidingsocialworkoutreachduetoanexcessivecaseload.TherewasaneedforaWarrior-oriented,combatstresspreventionclassthatcouldattract,instruct,andpsychologicallyinoculateWarriorsagainstcontinuedcombatoperationalandhomefrontstressors.5Suchaclasswouldneedapsychological,standardizedself-helpsystem,likerationalemotivebehaviortherapy(REBT),6whichIusedintime-limitedinterventionsintheater.AclassappealingtoWarriorswouldalsogainsupportfromtheirleadersifdesignedandmarketedfromacoachingandleadershipresiliencyapproach,focusedonassistingWarriorstoreturnwithhonor,versuscataloguingtheirdeficits.Usinginsightsandphilosophiesderivedfromthesurvivor,resiliency,andprisonerofwarliterature,7Stoicphilosophy(thegenesisofREBT),8ArmyWarriorEthos,andArmyValues,9aWRTeveningclassandaWRTmedictrainingcoursewereinitiatedinDecember2005,atCampLiberty,Iraq.THEORETICALFOUNDATIONSOFWARRIORRESILIENCETRAINING:RATIONALEMOTIVEBEHAVIORTHERAPYDrAlbertEllis,10oftenreferredtoastheGrandfatherofcognitivetherapy,startedthecognitiveandphilosophicalcounselingrevolutionin1955,introducinghistrademarkABCTheoryofEmotionstoassistclientstoidentifyanddisputeirrationalbeliefswhichcreateemotionalsufferingandblockpersonalfulfillment.HeoftenreferencedEpictetus,thewell-knownStoicphilosopher,whosaidmanisnotdisturbedbyevents,buttheviewhetakesofthem.11Thisviewalonepredatedcognitivetherapyby2millennium.REBTresearchershaveproducedhundredsofstudiessupportingtheclinicalutilityofREBTasanevidence-basedpractice.DrEllisvirtuallypioneeredthepsychologyself-helpfield,authoringover80booksonREBTapplications,aswellasaudioandvideotapes,withinternationalREBTcentersworldwidepromotingrationalliving.12Elliscreditedhissystemheavilytohisstudyofphilosophy,especiallyStoicism.6ElliscitedRomanEmperorMarcusAurelius(authorofMeditations13)andEpictetusasbeinghighlyinfluentialinhiscreationofREBT,whichencouragesself-discipline,rationality,andtheadoptionofaresilient,adaptivemindset,despiteexternaladversity.REBTappealsespeciallywelltoWarriors,whoIhavefoundtobeoftensuspectofdependentoroverlyexpressivetherapies,justasStoicismitselfappealedtofamousstudentslikeRomanEmperorMarcusAurelius13andAdmiralJamesStockdale,aseniorNavalaviatorwhocreditedthesystemwithassistinghiminhissurvivalofcaptivityandtortureforover7yearsinNorthVietnamastherankingprisonerofwaramongtheofficers.7REBTnaturallysharessomeprincipleswiththecombatstresscontroldoctrineofBICEPS4(p1-7)aswell:BrevityREBTisatimelimitedapproach.REBTtherapiststrainasifeachsessioncouldbethelast,assistingclientsrapidlyidentifyandreplacemaladaptivebehaviorsandemotions.Immediacyemployeddirectlybycombatstresspreventionteams,andtheSoldiersthemselveswhoreceivetraining.ContactteachingREBTfundamentalstoSoldiersandLeadershiptogether.ExpectancyofrecoveryREBTmaintainsthathumanscanovercometheircurrentissuesandalso

PAGE 36

34www.cs.amedd.army.mil/references_publications.aspxdealeffectivelywithadestructivepast,includingtraumas.ProximityREBTistaughtattheunitleveltoSoldiers,medics,peer-coaches,andleaders,andispracticedintheArmyMedicalDepartmentcourseformentalhealthtechnicians(militaryoccupationalspecialty68X).SimplicitytheABCtheoryiseasilytaught,withclientsrapidlymasteringtheA-B-Cmodel.Itisusedfromschool-agedchildrentoexecutivesinbusiness(rationalemotivebehaviorcoaching).Forexample,afterexperiencinganoxiousa ctivatingevent(A),Soldiersgenerateperceptionsorb eliefs(B)abouttheevent,producingemotionalandbehavioralc onsequences(C).Soldiersaretaughttoidentifyandvigorouslyd ispute(D)thoseirrationalbeliefswhichareirrationalorgoal-thwarting.Themostcommonirrationalprocesses(similartocognitivetherapyscognitivedistortions),whichguaranteearecipeforsufferinginclude:Shoulds/Musts/Demands,Awfulizingor"Catastrophizing,"LowFrustrationTolerance,andSelf/OtherNegativeRatingorBlaming.IconcurwithotherREBTpractitionersthatcontrollingorover-controllingcouldeasilybethefifthREBTIrrationalProcess,andisitselftheantithesisofStoicism.SoldiersrehearsenewEffectiveBeliefsproducingmoremanageableemotions(sorrowandgriefversusdepression,orfrustrationversusrage)andadaptivebehavioralchoicesthatleadtogoalattainmentandWarriorperformance.REBTworksequallywellasatherapeuticinterventionthenself-coachingmodel,whenclientsaretrainedbyaqualifiedREBTtherapistorcoach.VIRTUE,CHARACTER,STOICISM,ANDWARRIORETHOSThefocusofWRTonvirtueandcharacter,asidefromArmyLeadership,1,14isalsosupportedbypositivepsychologicalresearchwhichclassifieduniversalcharacterstrengthsandvirtues.15Seligman,16(whocoinedthetermlearnedoptimism)andPeterson15catalogued6corevirtueswisdom,courage,humanity,justice,temperance,andtranscendencealongwith18supportiveandunderlyingcharacterstrengthswhicharedescribedasmechanismswhichdefineandsupportthesevirtuesinaction.WhereasthefourtheditionofDiagnosticandStatisticalManualofMentalDisorders17andpreviousversionshaveexclusivelyfocuseduponpathology,mentaldisorderclassification,anddiagnoses(includingpersonalitydisorders,formerlyknownascharacterdisorders),thepositivepsychologicalvirtueandstrengths-basedapproach(heraldingbacktoancientphilosophy)usesaresearch-groundedclassificationsystemofwhatisexemplaryinhumans,morallysuperior,andaccepteduniversallyasvirtues.Characterandvirtue-basedcounselingapproacheshaverelevanceforArmyWarriorswholivebysimilarvirtuesandvaluesasinthe7Armyvaluesofloyalty,duty,respect,selflessservice,honor,integrity,andpersonalcourage.OthercodesthatdictatestandardsanddemeanorforWarriorsonandoffthebattlefieldincludetheCodeofConduct,rulesofengagement,theGenevaConvention,andtheNoncommissionedOfficerandRangerCreeds,whichareallaimedtowardsstandardizingethicalbehavior,agreeduponmartialvirtues,andhonorforprofessionalWarriors.1,9PositivepsychologyisanaturalchoiceforWarriorsasitalsofirmlygroundedinAristotelianprinciplesofvirtueandethicalbehavior.JorgensenandNafstad18note:TheAristotelianmodelfocusesonthevirtuousindivid-ualandthoseinnertraits,dispositionsandmotivesthatqualifytheindividualtobevirtuous,virtueofthoughtandvirtueofcharacter:Virtueofthoughtarisesandgrowsmostlyfromteaching;thatiswhyitneedsexperienceandtime.Virtueofcharacterresultsfromhabit(ethos).19theconceptofgoodcharacterconsti-tutes,asshown,oneoftheconceptualcornerstonesofpositivepsychology.STOICISMGreco-RomanStoicism,flourishingfrom300BCtoapproximately450ADandstillinfluentialtoday,isapracticalsystemofphilosophywhichpromotesself-control,personalfortitude,detachment,andcivicresponsibilitythroughmoralexcellence,rationality,andvigorousmanagementofperceptionsandevaluations.Stoiccardinalvirtueswerewisdom,courage,justice,andtemperance,withhumanityandtranscendenceadditionallyrecognizedinmodernpositivepsychology.Well-knownandoftenquotedStoicsincludeEpictetus,11MarcusAurelius,13Seneca,20andCicero.20Sherman21describestheancientandever-presentinfluenceStoicismstillholdsontheWesternWarriormilitarymindset:TheStoicsofferimportantlessonsforthemilitary,and,Iwouldurge,forciviliansaswell.TheygiveguidanceWarriorResilienceTraininginOperationIraqiFreedom:CombiningRationalEmotiveBehaviorTherapy,Resiliency,andPositivePsychology

PAGE 37

JulySeptember200835THEARMYMEDICALDEPARTMENTJOURNALinshapingacharactereducationthattakesseriouslythevaluesofdisciplineandself-mastery,whilerecognizingourdependenceuponothersnotonlyinsmallcommunities,butalsoglobally.21MEDICWARRIORRESILIENCETRAINING,2005-2006Medicswereanaturalchoicetocross-traininWRTcoachingduetotheirdirectdailycontactwithcombatSoldiers.WRTmedicsstudieddoctrinalcombatstresscontrolmaterial,emphasizingcombatstresseducationandpreventionalongwithresiliency,thriving(similartoArmyadaptivestressreaction),andtheposttraumaticgrowthliterature.22ThegoalwastoassistmedicstohelpreduceSoldierbarrierstocare,whilelearningbasicREBTcoachingskillsthatcouldassisttheminservingSoldiersandreducetheirowncompassionfatigue,whichispromotedintheArmyproviderresiliencytraining.23*TheirrolethenwassimilartothecurrentBattlemindmedicorunitbehavioralhealthadvocateswhoreceivementalhealthcrosstrainingasaforcemultiplier.Over8two-hourtrainingsessions,voluntaryWRTcombatmedicstudentslearnedREBTprinciples,appliedtheresiliencyandsurvivorliteraturetoSoldierscenarios,24participatedinpeer-coachtraining(includingevocativeroleplaysrelatedtodeploymentstress),andexaminedArmyValuesandWarriorEthosasasourceofresiliency.TheyalsostudiedStoicprinciplesourcesandcommentariesandfirsthandaccountsofprisonerofwarsurvivorssuchasAdmiralStockdaleandVictorFrankl,7,25whileexaminingotherWarriorcodessuchasJapaneseBushido,whichinfluencedtheArmy7Valuesselectionin1991.WRTmedicsroutinelypracticedevocative,live,REBTcoachingsessionswithaSoldierwhorole-playedhighlydistressed,theater-specificcombatstressandrelationshipissues,includingstrongreluctancetovisitbehavioralhealth.Allmedicsreportedthatthiswasthemostvaluabletrainingtheyreceived.PUBLICWARRIORRESILIENCETRAININGCLASSInadditiontotheWRTmediccourse,apublicWRTclassmet5timesweekly,reviewingbasicREBTself-helpprinciples,resiliencyfundamentals,andWarriorEthosvirtueethics.Each90-minutesessionreviewedthesesamefundamentalsasstudentcompositioncontinuallyvariedduetooperationaldemands.WRTclasseswereofferedat2locations,5timesweekly,alongwithmobileclassversionsofferedforunitssuchasinfantry,militarypolice,explosiveordnancedisposal,andcombatengineeronCampLiberty.Typicalattendanceaveraged6to12Soldiersnightly,withmostreferralshavingbeenmadepersonallybyotherclassmembers.Providers,includingphysicians,physiciansassistants,andchaplains,aswellasotherofficers,alsoattended,contributingtotheongoingresiliencydialogueandgrowth.Thosechaplainswhoattendedwereespeciallysupportiveofanymentalhealthproviderwhospokeopenlyaboutmoralintegrity,virtue,ethics,andcharacterstrength.Iamcurrentlydesigningaresiliencysummitwiththechaplainsintheater.INFORMALOUTCOMES,2005-2006AsWRTwasanoptionalclassratherthananinterventionorformalArmyprogram,anoutcomestudywasnotconducted,thoughitwouldhavebeenvaluable.Personalexitqualitativeinterviewsandmultiplecommandlettersofsupportsuggestedthecoursespopularity.AnarticleintheJune25,2006issueoftheUSArmy4thInfantryDivisionsnews-paper(publishedanddistributedinIraq),TheIvyLeaf,entitledLearningStoicABCs:WarriorresiliencetrainershelpSoldiersmaintainmental,emotionalhealthinIraq,theWRTprogramwasdescribedasavehicleTobettertraincombatmedics,seniornoncommissionedofficersandhighlymotivatedE-4andaboveinWarriororStoicmethodsofcognitivebehavioralpeercounseling...theprogressivesessionsprepareSoldierstobeunitpeeradvocatesforemotionalhealthandresiliency,aswellasthekeyreferralsourceforSoldierswhoneedformalcoun-seling,andaresourceinpotentialemergencies.26AnarticlewithatitlethatincludesStoicismgivestroopsarmorforthesoulappearedintheAtlantaJournal-ConstitutiononMarch29,2006.27WarriorresiliencytrainingpredatedtheFieldManual4-02.51suggestionthatSoldierpeermentors[be]trainedtoprovideCOSC[combatoperationalstresscontrol]help-in-placeassistanceforCOSCinformationtopeers.4(p5-1)Uponredeployment,a4-session,8-hourFamilyreadinessgroupleaderstrainingversionofWRTcalledtheWarriorFamilyResilienceTraining(WFRT)ProgramwasdevelopedforFortDrumSocialWorkServicesandOperationReadyinFebruary2007,andaWRTposterwaspresentedbytheauthoratthe2007ForceHealthProtectionConference.WhileIwasaBehavioralHealthConsultantinthe98thCombat *Seerelatedarticleonpage57.Seerelatedarticleonpage66.

PAGE 38

36www.cs.amedd.army.mil/references_publications.aspxStressControlDetachment,IdrewuponmySpecialForcesbackgroundtohelpdesignanadaptationoftheWRTmedicclass,calledEliteWarriorResilienceTraining(EWRT),inOctober2007forthe1stSpecialForcesGroupSurgeon.A6-partWFRTwasconductedforthe62ndMedicalBrigadeand1stSpecialForcesFamilyReadinessGroupleadersatFortLewisfromMarchtoApril2008.IhavealsopresentedWRTfortheWarriorResilienceProgramattheArmyMedicalDepartment.THEWARRIORRESILIENCETRAININGCLASSTODAYINOPERATIONIRAQIFREEDOMAsofSeptember14,2008,over160WRTclasses,withapproximately4,500participants,havebeenconductedbythe98thCombatStressControl(CSC)Multi-NationalDivisionBaghdadPreventionteaminOperationIraqiFreedom.Thecurrentversion,WarriorResilienceTraining:Thriving,notJustSurvivingThroughYourCombatDeployment,consistsofastandardized,90-minutepresentationwhichreviewscombatoperationalstressreactionstress-inoculationprinciples,resiliency,andposttraumaticgrowthprinciples,WarriorEthos,ArmyValues,andREBTself-coaching,includingaspecialportionwhichrelatestheArmyValuestoFamilyvalues.ThepresentationisdeliveredinaninteractionalfashionusingaPowerPointslideshowornotes,andisalwayscopresentedwithbothofficerandenlistedpreventionteammemberswhenpossible.SoldiersareaskedtoexaminetheirownresiliencyandWarriorphilosophiesregardingfamilyseparation,loss,unitconflict,andcombatoperationalstress.WRTuses(withpermission)resiliencyandthrivingmaterialandself-assessmenttoolsproducedbyAlSiebert.24,28WerecommendthatSoldierscontinuetheirresiliencyself-education,providingonlineresiliencyresourcesproducedbytheArmyBattlemindTrainingOffice,andotherwellknownauthorslikeDaveGrossman,5whotrainedourcombatstresscontrolunitwithhissignatureTheBulletproofMindlecturepriortoourdeployment.FEEDBACKFROMWARRIORRESILIENCETRAININGUseofananonymous,5-questionfeedbackform,shownintheFigure,wasinitiatedonJuly14,2008,withthegoalofimprovingtheWRTclassandgaugingcontentcomprehensionandrelevancy.UnitmembersarevoluntarilysurveyeduponcompletionofaWRTclass.Anoptionalfollow-upcontactisoffered,ifSoldierschoosetoprovideanemailtobecontactedwithin60to90days.AsofSeptember12,2008,datafrom1,168surveyshavebeencollated.ThatdatasuggestssomeverypositivetrendsregardingWRTWarriorResilienceTraininginOperationIraqiFreedom:CombiningRationalEmotiveBehaviorTherapy,Resiliency,andPositivePsychology98thCombatStressControlDetachmentWarriorResilienceTrainingFeedbackFormStronglyDisagreeDisagreeNeutralAgreeStronglyAgree 1.Inowunderstandandcanrecognizeposttraumaticgrowthatleastas wellasIunderstandandrecognizeposttraumaticstressdisorder. [mean=4.13/82.7percentile] 1 2 3 4 5 2.IbelievethatIcanandwillbestrengthenedthroughmydeploymentexperiences,evenwhentheyarenegativeorpainful.[mean=4.27/85.4percentile]12345 3.ComparedtootherArmycombatstress,suicideawareness,orresiliency briefingsIhaveattended(includingBattlemind),Ibelievethistrainingwill bemoreusefulinmanagingdeployment,combat,andreal-lifestressors. [mean=4.17/83.4percentile] 1 2 3 4 5 4.Theinstructor(s)wereprofessionalandeffectiveinconveyingthetraining.[mean=4.60/92.1percentile]12345 5.Ibelievethistrainingwillassistmetobecomemoreresilientandlearnto thriveduringthisdeploymentandwhenIreturnhome. [mean=4.19/83.9percentile] 1 2 3 4 5 RepresentationofthefeedbackformofferedtoparticipantsattheconclusionofWarriorResilienceTrainingclasses,fromJuly14toSeptember12,2008.Theresultsfrom900completedformswerecollated.Themeanscoreandpercentilerankingforeachquestionisshowninthebrackets.Note:Meansroundedtonearesthundredthandpercentiletonearesttenth,usingunadjustedmeans.

PAGE 39

JulySeptember200837THEARMYMEDICALDEPARTMENTJOURNALacceptanceasaclass,andSoldierrecognitionofresiliencyandposttraumaticgrowthasarealpotentialdeploymentoutcome,ratherthancombatoperationalstressreactionsorposttraumaticstressdisorderalone.WrittenfeedbackcommentscollectedfromSoldiersinranksfromPrivatetoColonel,includingalmosteverymilitaryoccupationalskill,routinelysuggestthatWRTisahighlybeneficialcombatstresscontrolclass,rivalingstress,angermanagement,combatstress,orresiliencyclassespreviouslyreceivedintheaterorstateside.RespondentsoftenrecommendthatWRTclassesbetaughtasdoctrine.Fourexamples,usedwithpermission,illustratetypicalfeedback(allfeedbackformsareavailablefromtheauthorforreview):OneofthebestcombatstresscoursesIhaveeverseen,thiscourseshouldbeatthetopofthelistofdeployingunits.StaffSergeant,explosiveordnancedisposal,7/14/08ThesinglemostbeneficialmentalhealthtrainingIhavereceivedin15yearsintheArmy.Thistrainingneedstobedoctrine.PlaceinDVDwithlinkstowebandpushouttoDoD.Commander,explosiveordnancedisposalunit,7/14/06Veryinformative,recommendthisbeapartofpredeploymentandreintegrationtraining.CommandSergeantMajor,commandersconference,8/6/08Allsoldiersshouldgotothistraining.Very,veryhelpful.1stSergeant,commandersconference,8/6/08WARRIORRESILIENCETRAININGANDBATTLEMINDOthertypicalcommentssuggestthatWRTconfirmspersonalphilosophiesregardinghumanresiliencyandpotentialthatSoldiershavelongendorsed,yethadneverbeenconveyedorreinforcedbyArmymentalhealthpractitionerstheexceptionbeingtheChaplainCorps,whichagainisusuallymostsupportiveofWRT.The98thCSCPreventionTeamendorsesandteachesArmyBattlemindasanofficiallysanctionedresiliencyprogram,withempiricalsupportandWarrior,Spouse,andmedicversions.HoweverWRTclassesfocusspecificallyonresilientvirtues,character,andleadershipqualitiesmorethanpsychoeducationorstressinoculationstrategiesnormalizingcombatoperationalstressreactions.ExperienceinIraqhasrevealedthatcompletionofBattlemindtrainingisstillrarelyreportedbySoldiers,whoaredirectlyaskediftheyhavereceivedBattlemindtrainingandareoftenshowntheBattlemindacronym.ItispossiblethatthisvaluabletrainingisoneofmanyclassestowhichbeleagueredSoldiersareexposedpriortotheircombatordeployment-specifictraining.TheBattlemindWarriorresiliencyversionsharessomesimilaritieswiththeWRTproductsfromastressinoculationandWarriorEthosstandpoint,withthetermWarriorresiliencypossiblyhavingbeeninfluencedbyearlierWarriorResilienceTraining.DISCUSSIONWRTprovidesamissingbridgeandalloybetweenWarriorEthos,leadership,ethics,andcurrentArmycombatstressmanagementorresiliencytrainingprograms.Soldiersmustbemadeawareoftheirtremendouscapacitytonotonlyendure,butthrivethroughtheircombatdeploymentexperiencesandhomefrontstressors,andreturnwithhonor.Theyshouldbetrainedtorecognizeandanticipateposttraumaticgrowth,aswellascombatoperationalstressandPTSDsymptoms.MostSoldierswillnotattendsurvival,evasion,resistance,andescapetraining,orbecomeSpecialForcesorRangersoperators,yettheydeserveelitementaltrainingtoendurecombat.Resiliency,rationality,virtue,ethics,andWarriorEthos,groundedinapositivepsychologicalframeworkthataffirmsthehumanspirit,canbeintegratedtogether,taughtto,andmodeledbyourmilitaryleaders,Chaplains,behavioralhealthpractitioners,andtheSoldiersthemselves.ResiliencycanbestrengthenedinArmyFamiliesaswell,whoarealsopartoftheWarriorculture.Ournation,comprisedofvirtuallyeveryraceonearth,representsoneofthemostresilientalloysinhumanhistory.TheUSArmydemandsanexcellenceofcharacterandadvancedresiliencythatmustbecontinuallycultivatedtosustainanall-volunteerforce.ArmyValues,WarriorEthos,andleadershiparecriticalfoundationsofArmyresiliencytrainingthatcanbeskillfullyintegratedintoamodelpromotinginternalcombatstresscontrol.WarriorResilienceTrainingrepresentsapilotstudyofwhatsuchanalloymightproduce.If,asEpicurussaid,Emptyistheargumentofanyphilosopherwhichdoesnotrelieveanyhumansuffering,20thenWRTismakinganeffectiveopeningargumentthatisbothrelievingsufferingandpromotingWarriorresilience,thriving,andrecognitionofposttraumaticgrowthopportunities.

PAGE 40

38www.cs.amedd.army.mil/references_publications.aspxWarriorResilienceTraininginOperationIraqiFreedom:CombiningRationalEmotiveBehaviorTherapy,Resiliency,andPositivePsychologyREFERENCES1.FieldManual6-22:ArmyLeadership:Confident,Competent,andAgile.Washington,DC:USDeptoftheArmy;12October2006.2.MentalHealthAdvisoryTeam(MHAT)IVOperationIraqiFreedom05-07FinalReport.Washington,DC:OfficeofTheSurgeonGeneral,USDeptoftheArmy;November17,2006.Availableat:http://www.armymedicine.army.mil/reports/mhat/mhat_iv/MHAT_IV_Report_17NOV06.pdf.3.HogeCW,CastroCA,MesserSC,McGurkD,CottingDL,KoffmanMD.CombatdutyinIraqandAfghanistan,mentalhealthproblems,andbarrierstocare.NewEnglJMed.2004;351(1):13-22.4.FieldManual4-02-51.CombatandOperationalStressControl.Washington,DC:USDeptoftheArmy;6July2006.5.GrossmanDA,ChristensenLW.OnCombat:ThePsychologyandPhysiologyofDeadlyConflictinWarandPeace.Belleville,IL:PPCTResearchPublications;2004.6.EllisA.ReasonandEmotioninPsychotherapy:AComprehensiveMethodofTreatingHumanDisturbances:RevisedandUpdated.NewYork:LyleStewart/BirchLanePress;1994.7.StockdaleJB.CourageUnderFire:TestingEpictetusDoctrinesinaLaboratoryofHumanBehavior.Stanford,CA:HooverInstitutionPress;1993.8.ShermanN.StoicWarriors:TheAncientPhilosophyBehindtheMilitaryMind.NewYork:OxfordUniversityPress;2005.9.SoldierLifewebpage,GoArmywebsite.LivingtheArmyValues.USDeptoftheArmy.Availableat:http://www.goarmy.com/life/living_the_army_values.jsp.AccessedOctober11,2006.10.BurnsD,VeltenE.TheLivesofAlbertEllis:TheAuthorizedBiography.Tucson,AZ:SeeSharpPress;2006.11.LongAA.Epictetus:AStoicandSocraticGuidetoLife.NewYork:OxfordUniversityPress;2002.12.DavidD,SzentagotaiZ,KallayE,MacaveiB.Asynopsisofrational-emotivebehaviortherapy(REBT);fundamentalandappliedresearch.JRatnl-EmtvCogn-BehavTher.2005;23(3):175-221.13.HadotP,ChaseM.TheInnerCitadel:theMeditationsofMarcusAurelius.Cambridge,MA:HarvardUniversityPress;1998.14.FieldManual22-51:LeadersManualforCombatStressControl.Washington,DC:USDeptoftheArmy;29September1994.15.PetersonC,SeligmanMEP,eds.CharacterStrengthsandVirtues:AHandbookandClassification.NewYork:OxfordUniversityPress;2004.16.SeligmanMEP.LearnedOptimism:HowtoChangeYourMindandYourLife.NewYork:AlfredA.Knopf,Inc;1991.17.DiagnosticandStatisticalManualofMentalDisordersFourthEdition(TextRevision).Washington,DC:AmericanPsychiatricAssociation;1994.18.JorgensenIS,NafstadHE.Positivepsychology:historical,philosophical,andepistemologicalperspectives.In:PetersonC,SeligmanMEP,eds.PositivePsychologyinPractice.NewYork:JohnWiley&Sons;2004:20.19.Aristotle.NicomacheanEthics.CrispR,trans.NewYork:OxfordUniversityPress;2000.20.LongAA,SedleyDN.TheHellenisticPhilosophers.Vol1.Cambridge,England:CambridgeUniversityPress;1987.21.ShermanN.Educatingthestoicwarrior.In:DamonW,ed.BringinginaNewEraofCharacterEducation.Stanford,CA:HooverPress2005.22.CalhounLG,TedeshiRG,eds.HandbookofPosttraumaticGrowth:ResearchandPractice.Mahwah,NJ:LawrenceErlbaumAssociates;2006.23.FigleyCR,ed.CompassionFatigue:SecondaryTraumaticStressDisordersfromTreatingtheTraumatized.NewYork:Brunner/Mazel;1995.24.SiebertA.TheSurvivorPersonality.NewYork:BerkeleyPublishingGroup;1996.25.FranklVE.Man'sSearchforMeaning:AnIntroductiontoLogotherapy.NewYork,NY:PocketBooks,Simon&Schuster;1963.26.MottM.LearningStoicABCs:WarriorresiliencetraininghelpsSoldiersmaintainmental,emotionalhealthinIraq.TheIvyLeaf.2006;1(12):11.27.BasuM.Georgia'sGuard:the48thinIraq:stoicismgivestroops"armorforthesoul".AtlantaJournal-Constitution.March29,2006:F1.28.SiebertA.TheResiliencyAdvantage:MasterChange,ThriveUnderPressure,andBounceBackfromSetbacks.SanFrancisco,CA:Berrett-KoehlerPublishers;2005. AUTHORMAJJarrettisthePreventionTeamOfficer-in-Charge,VictoryBaseCampandMulti-NationalDivision,Baghdad,Iraq.Heisdeployedfromthe98thCombatStressControlDetachment,FortLewis,Washington.

PAGE 41

JulySeptember200839TheservicesthatUSmilitarybehavioralhealthpersonnelprovideinadeployedenvironmentaremuchbroaderthaninstatesideclinicalsettings.BehavioralhealthprovidersandmentalhealthspecialistsinsupportofOperationIraqiFreedom(OIF)conductprevention,consultation,andrestorationactivities,inadditiontooutpatientclinicalservices.Activityworkloadmetricsthatareutilizedinstatesidemilitarybehavioralhealthclinicsdonotaccuratelyaccountformuchoftheworkloadthatbehavioralhealthpersonnelconductondeployment.Consequently,theCombatandOperationalStressControlWorkloadandActivityReportingSystem(COSC-WARS)wasdevelopedandhasbeeninusesincethebeginningofOIF.ThecollectionoftheCOSC-WARSdatahasbeeninconsistentoverthedurationofOIF.TheMentalHealthAdvisoryTeamVReport1recommendedthatCOSC-WARSbereportedthroughouttheIraqtheaterofoperations(ITO).SinceJanuary2008,thetheaterBehavioralHealthConsultantinIraqhasexpandedthecollectionofCOSC-WARSfromthecombatstresscontrol(CSC)units,areasupportmedicalcompanies,andcombatsupporthospitalstoincludetheArmydivisionalbehavioralhealthassets.Thetypesofservices(excludingNavy/Marinebehavioralhealthinformation)providedbyallCSCunitsandotherArmybehavioralhealthassetsfromJanuarytoJune2008aredescribedbelow.COMBATSTRESSPREVENTIONThepreventionactivitiesthatbehavioralhealthpersonnelperformintheITOaretheemphasisoftheCSCTeams.Thefirstoftheseincludewalkabouts,whicharedescribedasoutreachvisitstounitlocationsoraroundtheirareaofoperationforthepurposeoftalkingwithservicememberstogatherinformationonthecurrentstressors,problems,morale,orthestatusofservicemembersortheirunit.Walkabouts,sometimesreferredtostealthmentalhealth,areattheheartofthepreventionactivitiesinthattheseout-of-officecasualcontactsarelessintimidatingthanaclinicalsetting.Theaimistoassessthewell-beingofthetroops,impartsomehelpfulcopingknowledgeorresources,andlendanobjective,caringear.Thesecontacts,whichcouldbeinagrouporone-on-one,appearasanormalconversationatplaceslikethedininghall,recreationareas,livingareas,orevenintransport.Forexample,onementalhealthspecialistwasstuckinaconvoythatwashaltedforseveralhoursoutsidethewire.WhileotherSoldiersinthevehiclewerebecomingagitatedwiththeextendedwait,hestartedaconversationwithsomeofthoseSoldiers,andeventaughtthemsomerelaxationtechniques.HenotedthattheseSoldierscalmeddownandwereabletopassthetimemoreeasily.Duringthefirsthalfof2008,some80,400walkaboutswereconductedintheITO(averageof13,400permonth).Thetotalmayincludemultiplecontactswiththesameindividualsondifferentdays.Asecondcomponentofbehavioralhealthpreventionactivitiesiseducationalclasses,includingclassesonlifeskills,maritalmaintenance,personalgrowth,sexualresponsibility,tobaccocessation,stressmanagement,angercontrol,suicide/violenceBehavioralHealthActivityandWorkloadintheIraqTheaterofOperationsMAJBarronHung,MS,USA ABSTRACTDeployedservicemembersencountergreaterstressorssuchascombat,separationfromnormalsupportgroups,andhighoperationaltempointheIraqtheaterofoperationsthaninastatesidesetting.Consequently,theservicesthatbehavioralhealthpersonnelprovideduringdeploymentincludeawiderbreadthofactivitiesthanaretrackedandprovidedinaUSmilitarymedicaltreatmentfacilitysetting.TheCombatandOperationalStressControlWorkloadandActivityReportingSystemwasdevelopedtotrackthediversebehavioralhealthactivitiesperformedintheater.TheseactivitiesduringtheperiodofJanuarythroughJune2008includedpsychoeducationalclasses(n=3,900),traumaticeventinterventions(n=535),commanddirectedmentalhealthevaluations(n=750),andcasualwalkabout/preventioncontacts(n=80,400).ThesebehavioralhealthtreatmentandpreventionactivitiesperformedintheIraqtheaterofoperationsareacrucialpartofthemedicalsupportprovidedtotroopsinaharshenvironment.Theseactivitiesserveasforcemultipliersandhelpconservethefightingstrengthofcombattroops.

PAGE 42

40www.cs.amedd.army.mil/references_publications.aspxBehavioralHealthActivityandWorkloadintheIraqTheaterofOperationsprevention,substanceabuse,combatstress,andcopingwithdeploymenttransitions.Theseclassesaredesignedtoteachservicememberscopingandproblemsolvingskillstohelpmanagecommonproblemsthattheymayencounterondeployment.Classesareofferedonaregular,recurringbasis,orgivenasneeded.Duringthefirsthalfof2008,atotalof3,900classesweregivenwith45,500participants(7,600permonthaverage).Anothermajorpreventioneffortisinterventionfollowingpotentiallytraumatizingevents.Theseeventsgenerallyinvolveexperiencing,witnessing,orbeingthreatenedwithsignificanthumansuffering,injury,ordeath.Behavioralhealthpersonneloftenprovidesupportthroughdisseminatinginformationabouttypicalreactions,copingskills,andresources.Behavioralhealthpersonnelmayalsoprovideone-on-onesupport,orgroupdefusing/debriefingsessionsasneeded.Thespecificinterventionofferedisbasedonclinicaljudgment,dependingontheseverityoftheeventandtheinputoftheleadersandindividuals.Atotalof535traumaticeventinterventionswereconductedintheITOwith7,600participants(1,270permonthaverage)fromJanuarytoJune2008.Consultationwithcommandersandotherleadersaboutbehavioralhealthissuesisapreventionendeavorthatcanhaveanexponentialimpact.Examplesincludepresentationofanoverviewofavailablebehavioralhealthservices,discussionsofunitmoraleandstress,educationaboutleadershipstrategiestoreducestress,andconsultationsaboutindividualswithbehavioralhealthchallenges.FromJanuarytoJune2008,therewere5,200consultationswithleadersaboutindividualSoldiers,and6,800consultationsaboutotherissues.SomecommandersintheITOareuninformedandleeryoftheservicesandgoalofbehavioralhealthinterventions.Professionalconsultationshaveoftenputthesecommandersconcernsatease,resultingincommanderswhomorereadilydiscusstheirconcernswithbehavioralhealthpersonnel,whichinturnmakesiteasierfortheirtroopstoreceiveservices.Furthermore,unitbehavioralhealthsurveyscanbeusedtoinformcommandersabouttheconcernsandneedsoftheirtroops.Over300unitsweresurveyedwith10,600participantsduringthefirst6monthsof2008.BEHAVIORALHEALTHTREATMENTINTHEITOWithlong-termdeployments,manyservicemembersrequirecombatstresscontrolorbehavioralhealthtreatmentin-theater.Troopswhodevelopmildstressreactionsrelatedtodeploymentaredescribedashavingcombatoperationstressreactions(COSR).ThetermCOSRcanapplytostressreactionsinadeployedmilitaryenvironmentthatarenotadequatelyexplainedbyphysicaldisease,injury,orapreexistingbehavioralhealthdisorder.Thesesymptomsareconsideredtransientreactionstothetraumaticstressofcombatand/orcumulativestressesofmilitaryoperations.ThosewithCOSRarenotreferredtoaspatients,butaredescribedashavingnormalreactionstoanabnormalevent.Thisisdesignedtohelpreducethestigmaassociatedwithbeingamentalhealthpatient.COSRisdistinguishedfrombehavioralhealthdiagnoses(BHD),whichareusuallypreexisting,moreenduring,ormoreseveredisordersasdescribedintheDiagnosticandStatisticalManualofMentalDisorders.2TohelpdistinguishCOSRsymptomconstellationsthatresembleBHDs,thecurrentguidanceisthatadjustmentdisordersorrelational,occupational,andenvironmentalproblems(Vcodes*)duetodeploymentrelatedissuesshouldbeconsideredCOSR.Thesearesymptomsthattypicallyremitshortlyafterreturnfromdeployment.Incontrast,BHDaremoresevereorenduringconditionssuchaspsychosis,majordepression,posttraumaticstressdisorder,bipolardisorder,andsubstanceintoxicationordependence.Ofcourse,themoreseverecaseswereevacuatedfromtheaterforahigherlevelofhealthcare.DuringJanuarytoJune2008therewere10,700newCOSRcases,23,700totalCOSRcontacts,8,160newBHDcases,and25,800totalBHDcontacts.Contactsincludemultipleappointmentswiththesameindividualondifferentdays.Oftheindividualappointments,73%wereforcounselingand27%dealtwithmedicationmanagement.InCOSC-WARS,newCOSRappointmentsarefurtherbrokendownbyprimarystressororcomplaint,thetoptwoofwhicharehome-frontproblemsandcombatexposure(seeTable1).Home-frontproblemsincludeissuesathomesuchasrelationalproblems,problemswithchildren,family *DescribedinthechapterOtherConditionsthatMaybeaFocusofClinicalAttentionintheDiagnosticandStatisticalManualofMentalDisorders.2Thesecodesaredesignedforoccasionswhencircumstancesotherthanadiseaseorinjuryresultinanencounterorarerecordedbyprovidersasproblemsorfactorsthatinfluencecare.

PAGE 43

JulySeptember200841THEARMYMEDICALDEPARTMENTJOURNALillness,andfinancialproblems.ThethirdmostcommonCOSRstressorwasconflictbetweenpeerswithintheunit.Tiedforfourthisconflictwithorbetweenleaders,andmissionrequirements.Thelatterisabroadcategorythatincludescontinuousoperations,fragmentedsleep,frequentharassmentbytheenemywithoutseriouscasualties,littlechancetorelaxandreplenishbecauseoflonghours,poorlivingconditions,poorrecreationalfacilities,poorcommunicationwithhome,longoruncertaintourlength,extensionoftourorstop-loss,etc.ThesixthhighestCOSRstressorisattributedtoapotentiallytraumatizingeventotherthandirectcombat(suchasasuicideinunit,severeaccidents,andexposuretomasssuffering,deadbodies,orgreatdanger).Otherstressorsthataretrackedincludepersonalitytraitsorhabitsthatcausesignificantconflict,andenvironmentalstressorssuchasheat,cold,dryness,wetness,wind,dust,insects,poorhygiene,orminorsubclinicalillnessesthatcanresult(eg,milddehydration,milddiarrhea).Table2displaysthetopbehavioralhealthdiagnosesthatweretreated.Thehighestcategoriesunderotherwerelikelysleepdisordersandadjustmentdisorders.These2categoriesdidnotoriginallyhaveseparatereportinglinesonCOSC-WARS,buttheyappearassuchonthereportformasofJuly2008.Thedispositionofeachappointmentistrackedaswell.Duringthefirst6monthsof2008thevastmajorityofindividualswerereturnedtodutywithoutlimitations(90.8%,n=45,100),followedbyreturnedtodutywithlimitations(4.4%,n=2,185).Only0.67%ofthedispositions(n=335)wereforevacuationsoutoftheater.Theremaining2categorieswereforrest(senttoanonmedicalsupportunit,typicallyfartherfromthefrontlines;3.4%,n=1700),andrefertoahigherlevelofmedicalcareintheater(0.91%,n=450).Over99%ofbehavioralhealthcontactsresultedinservicememberscontinuingtheirtreatmentintheaterorbeingreturnedtofullduty.Alogicalextensionoftheseresultsisthatevacuationratesoutoftheaterforcombatandoperationalstressreactionsandbehavioralhealthdiagnoseswouldhavebeenmuchhigherifbehavioralhealthteamswerenotintheaterprovidinghighquality,broadspectrumcare.Empiricalevidenceindicatesthat,typically,whenservicememberscompletetheircombattourwiththeirunitwhilereceivingbehavioralhealthcareasneeded,theiroverallfunctioningisbetterthanthatdemonstratedbythosewhoarereturnedindividuallytoreceivetreatmentoutoftheater.Often,thehigherlevelofmedicalcarethataservicememberisreferredtoin-theateristherestorationprogram.ThereareseveralrestorationcentersinIraq,whichhostresidentialtreatmentprogramsrangingfrom3daysto7daysinduration.Theprogramgivesparticipantstheopportunitytorestandrecuperate,whilelearningcopingskillsthroughclassesandindividualappointments.Theparticipantsalsoengageinphysicaltraining,artsandcrafts,andotherrecreationalorsocialactivities.Manyoftheseindividualsjustneedalittletimetorechargeand PresidentialauthorityunderTitle10USCode12305tosuspendlawsrelatingtoseparationofanymemberoftheArmedForcesdeterminedessentialtothenationalsecurityoftheUnitedStates.3StressorTotalMonthlyAveragePercent Home-frontproblems 3091 515 29.0Combatexposure215035820.4 Peer/unitconflict 1418 236 13.3Leadershipconflict121120211.3 Missionrequirements 1211 202 11.3NoncombatPTE*469784.0 Personalityproblems 408 68 3.8Environmentalfactors278462.6 Other 440 74 4.2*PotentiallytraumatizingeventTable1.StressorsasreportedinCOSC-WARSfornewcombatandoperationalstressresponsecasesintheIraqtheaterofoperations,JanthroughJun2008. DisorderTotalMonthlyAveragePercent Depression 1389 232 24.0Nicotineproblem100216717.1 Anxiety 928 155 15.8PTSD/ASD72012012.3 Othersubstanceabuseproblems 192 32 3.3Other164027327.9Posttraumaticstressdisorder/acutestressdisorderTable2.LeadingbehavioralhealthdiagnosestreatedintheIraqtheaterofoperationsasreportedinCOSC-WARS,JanthroughJun2008.

PAGE 44

42www.cs.amedd.army.mil/references_publications.aspxBehavioralHealthActivityandWorkloadintheIraqTheaterofOperationsdevelopsomenewcopingtechniques,andthencanreturntotheirunit.Thevastmajorityofthosewhoattendedtherestorationprogramduringthefirst6monthsof2008werereturnedtodutyorcontinuedtreatmentin-theater,onlyabout6%(36of594)oftheparticipantsrequiredevacuationoutoftheater.Otherbehavioralhealth-relatedservicesthatweretrackedinCOSC-WARSfromJanuarytoJune2008includedcommand-directedmentalhealthevaluations(n=750)andotherArmyrequiredmentalhealthscreenings(n=590).Thelatterincludesscreeningsfordrillsergeants,recruiters,andSoldiersrecommendedforadministrativeseparation.BehavioralhealthprovidersintheITOalsoassistwithcognitivescreeningfortroopswithsuspectedconcussions.Of560screened,86demonstratedprobabletransientcognitiveimpairment.SURVEYSAMPLETherecipientsofthesebehavioralhealthservicesintheITOhavegenerallyratedtheserviceshighly,asindicatedinsatisfactionsurveys.Onthesurvey,therecipientsofourbehavioralhealthinterventionsareaskedtoratetheservicesaseitherpoor(1point),fair(2points),good(3points),orexcellent(4points).InaJune2008sampleof126recipients,98%ofthosesurveyedratedtheOverallQualityofCareasgoodorexcellent(Meanscore=3.7).Othersurveyitems(andtherespectivemeanscores)which,bypercentage,wereratedasgoodorexcellent:Serviceshelpedmecopebetter(86%,M=3.4)Personalmannerofthestaff(98%,M=3.7)Groupeducationalclasses(96%,M=3.6)Individualtreatment(94%,M=3.6)Willingnessofstafftoanswermyquestions(98%,M=3.8)CONCLUSIONAllofthebehavioralhealthtreatmentandpreventionactivitiesperformedintheITOarecrucialelementsofthemedicalsupportprovidedtoSoldiersinaharshenvironment.Theseactivitiesserveasforcemultipliersandhelpconservethefightingstrengthofcombattroops.Althoughdefinitivedatahavenotyetbeenpublished,historicalevidenceandhardexperienceshowsthelikelihoodthat,withoutthebreadthanddepthofthebehavioralhealthinterventionsprovidedintheater,thousandsofadditionaltroopswouldhavebeenevacuatedoutoftheater.Theselosseswouldcauseincreasedoperational,physical,andbehavioralhealthstrainonothersintheunit,compoundingtheexistingstrainimposedbycurrentdeploymentstressors.Further,theearlyinterventionsbuildresiliency,likelyhelpingtopreventthesesymptomsfromdevelopingintomoreseveredisordersinthefuture.Iamconfidentthat,eventually,definitivedatawillconclusivelydemonstratethetrueextentofthebenefitsourSoldiersderivefromthebehavioralhealthcareservicesprovidedin-theater.REFERENCE 1.MentalHealthAdvisoryTeam(MHAT)V:OperationIraqiFreedom06-08,Iraq;OperationEnduringFreedom8,Afghanistan.Washington,DC:OfficeofTheSurgeonGeneral,USDeptoftheArmy;February14,2008.Availableat:http://www.armymedicine.army.mil/reports/mhat/mhat_v/MHAT_V_OIFandOEF-Redacted.pdf.2.DiagnosticandStatisticalManualofMentalDisordersFourthEdition(TextRevision).Arlington,VA:AmericanPsychiatricAssociation;2000.3.JointPublication1-02:DoDDictionaryofMilitaryandAssociatedTerms.Washington,DC:JointStaff,USDeptofDefense;March4,2008.Availableat:http://www.dtic.mil/doctrine/jel/new_pubs/jp1_02.pdf.AUTHOR MAJHungistheTheaterPsychologyConsultant,62ndMedicalBrigade(TaskForce62),VictoryBaseComplex,Baghdad,Iraq.

PAGE 45

JulySeptember200843Remind:AddressingtheRiskofIllegalViolenceinMilitaryOperationsLTCKarenL.Marrs,AN,USA PROACTIVEMEASURESADDRESSINGSERIOUSMISCONDUCTAprefacebyCOL(Ret)JamesStokes,MC,USATheRemindconceptisonthecuttingedgeofmethodstodefendservicemembersfromsuccumbingtothecorrosiveeffectsofwarandcommittingcrimesthatendangerthemissionandeventheultimateArmyobjectives.Theconceptofmisconductstressbehaviorsasacategoryalongsidethepositivecombatstressbehaviorsandbattlefatigue(whichisnowcalledcombatandoperationalstressreaction)enteredUSArmyleadershipandmedicaldoctrinein1993withpublicationofFieldManual22-51,Leader'sManualforCombatStressControl,1andFieldManual8-51,CombatStressControlinaTheaterofOperations[nowobsolete].Priortothosemanuals,discussionandtrainingimpliedthatonlypoorSoldiersandsociopathscommittedthemostsevereformofmisconductthedeliberatekillingofsurrenderingenemycombatantsordisarmedprisoners,ofnoncombatants,andevenofotherUSservicemembers(ie,fragging).Thenewmanualsemphasizedthatseriousmisconduct(evenmurder)canbethesecondsideofthedouble-edgedswordofthepositivecombatstressbehaviors.Thosecrimeshavebeencommittedbyheroicservicemembersinexemplaryunitswhenfrictionanddistressbecametoointenseorprolonged,andpositivedisciplineandmissionfocuswerenotactivelyandcontinuouslysustained.Inmodernoperationswithworldwidemediacoverage,asingleatrocitycanprofoundlyunderminetheUnitedStates'objectivesfortheentireconflict,andputallourservicemembersatmorerisk.TheRemindconceptandtheroutineandspecialactionsitcallsforareessentialmeansforleadersandBattleBuddies*tosustainpositivedisciplineandmissionfocusunderextremestressandprovocation.COL(Ret)StokesisrecognizedasoneoftheArmysleadingauthoritiesoncombatoperationalstresscontrol.HeiscurrentlyacontractpsychiatristattheBrookeArmyMedicalCenter,evaluatingveteransstillonactivedutyorontheTemporaryDutyRetirementListforMedical/PhysicalEvaluationBoards. *GenerallydefinedasthepersontowhomaSoldiercanturnintimeofneed,stress,andemotionalhighsandlowswhowillnotturntheSoldieraway,nomatterwhat.ThispersonknowsexactlywhattheSoldierisexperiencingbecauseofexperiencewithsimilarsituationsorconditions,eithercurrent,previous,orboth.OVERVIEWCurrently,actionsemployedforcombatandoperationalstresscontrol(commonlyreferredtoasthe5Rs)include:2(p1-8)ReassuranceofnormalityRestorabreakfromcombatReplenishingbodilyneeds(thermalcomfort,water,food)RestoringSoldierconfidencewithpurposefulactivityandcontactwithhisunitReturntodutyinanefforttodecreasethelikelihoodoflong-termpsychiatricdisabilityandmaintaincombatpowerThisarticleprovidesbackgroundinformationwiththeoryandcontextforRemind,a6thRthatispendingrevisionandinclusioninthenextpublicationofArmyFieldManual4-02.512andFieldManual6-22.5.3Remindisintendedtoprovideguidanceforcliniciansandmilitaryleadersinvolvedincombatoperationstoidentifyandintervenebeforethoughtsofharmingorkillingnoncombatantsresultinmisconductor,asaworstcasescenario,inwarcrimes.TheRemindconceptisbasedonmentalhealthlessonslearnedincombatandareviewofrecentcombat-specificandrelevantcivilianliterature.Ofnote,thetermcombatisreferencedthroughoutthearticle,butRemindmaybeappliedtopeacekeepingorothermilitaryoperationsthatevolveintoviolenceanddeath(eg,tortureanddeathsofUSSoldiersinSomalia4).

PAGE 46

44www.cs.amedd.army.mil/references_publications.aspxRemind:AddressingtheRiskofIllegalViolenceinMilitaryOperationsThe6thRencompassesaddressingunitandindividualriskfactorsandbehaviorsthatprecedemisconductandremindingSoldiersthat,althoughgoodSoldierscommonlyhavevengefulthoughtsinthecontextofintensecombat,actingonthoughtsofrevengeandharmingorkillingnoncombatantsismisconductthatwillbepunished.SoldiersarefurtherRemindedthatresortingtoillegalrevengedishonorsthemandtheirfriends(livinganddead)andhelpstheenemydiscreditthemandwin.Remindstressesthattheultimateobjectiveistoreturnhomewithhonor.Thisarticlealsoaddressesrecommendationsthatclinicianscanoffercommanderstomaintainindividualandunitsafetyandconservecombatpower.Finally,thisarticlediscussestheproposedfutureapplicationandevaluationoftheconceptofRemind.DESCRIPTIONOFTHEPROBLEMArmypolicyandcombatandoperationalstresscontroldoctrineaddresssuicideawarenessandpreventioninbothgarrisonandcombatenvironments.SoldierswhoarenotmentallyillandthreatentoharmorkillothersingarrisonareprocessedinaccordancewiththeUniformCodeofMilitaryJustice.*WhatislackingisaprocesstoaddresscommonthoughtsofvengeancethatareexperiencedbyotherwisegoodSoldiersinthecontextofthekillinganddeathassociatedwithintenseand/orprolongedcombatbeforethesethoughtsresultinmisconduct.AnySoldiersuicideisatragedywithintenseandlastingeffectsontheindividuals,families,andunitsinvolved;butmisconductbyasingleSoldiercanhaveafarwiderrippleeffect.Inadditiontotraumaforvictimsandperpetratorswholaterregretactingonviolentimpulse,awarcrimecarriedoutbyanindividualSoldiercanunderminealltacticaleffortstosolicitthecooperationofthelocalcommunity.Themisconductbehaviorsofafewcanhaveimage-destroyinginternationalandstrategicramificationsthatreverberateforgenerations(eg,MyLai6).WiththeintenseandprolongedconflictsinIraqandAfghanistan,theneedforDepartmentofDefenseapprovedguidancetobehavioralhealthpersonnelisincreasinglyclear.ThefourthiterationoftheMentalHealthAdvisoryTeam(MHATIV)surveyof1,320Soldiersand447MarinesdeployedtoIraqthatwasreleasedinMay2007verifiedthathostilethoughtstowardnoncombatantsareverycommon.7Thesurveyfoundthatonly47%ofSoldiersand38%ofMarinesagreedthatnoncombatantsshouldbetreatedwithrespect.TheMHATIVsurveyalsoreportedthat10%ofSoldiersandMarinesindicatedmistreating(kickingorhitting)noncombatantsordestroyingordamagingpropertyunnecessarily.Inadditiontothisevidenceoflowgrademisconductbehaviors,asignificantnumberofdeployedSoldiersnearly16%of425Soldiersseekingmentalhealthservicesina2006study8endorsedthoughtsofkillingsomeonebesidestheenemywithinthelastmonth.OVERVIEWOFORGANIZATION:ARMYCOMBATANDOPERATIONALSTRESSCONTROLTheArmyrecognizesthedetrimentalphysicalandpsychologicaleffectsofcombatonSoldiersandtheirmissionperformance.9Armycombatstresscontrol(CSC)teamsweredevelopedtoprevent,identify,andmanagecombataswellasoperationalstress.TheCSCteamsaredeployedtomaximizereturntodutyforSoldierswhoaretemporarilyimpairedbystress-relatedconditionsorbehavioraldisorders.FieldManual4-02.512establishestheconfiguration,assignment,andfunctionsofCSCunitsthatarealreadyinplace.TheseteamsareintegraltothecurrentcombatenvironmentandcanactnowusingRemindtodecreasethelikelihoodofmisconductbehaviorsincombat.CONTEXTFORREMINDIndividual,combat/operational,constraint/relief,andsituationalfactorscanallcontributetotheoccurrenceofmisconductduringviolentmilitaryoperations.Individualfactors:Youngmenareathighestriskforcommittinghomicideinciviliansettings.10Mentalillnessorpersonalitydisordersmayalsopredisposeanindividualtoviolence.Training/conditioningandtherecentexperiencesofthepotentialassailant(eg,experiencingthedeathofafriendbyenemyaction)havebeenlinkedwithillegalkillingbehavioronthebattlefield.11Nostudieswerefoundlinkingsubstanceabusewithillegalviolenceincombat,butsubstanceabusehasbeenlinkedtoincreasedcivilianriskforhomicide.10 *TheUniformCodeofMilitaryJustice(UCMJ),afederallaw,5isthejudicialcodewhichpertainstomembersoftheUnitedStatesmilitary.UndertheUCMJ,militarypersonnelcanbecharged,tried,andconvictedofarangeofcrimes,includingbothcommon-lawcrimes(eg,arson)andmilitary-specificcrimes(eg,desertion).

PAGE 47

JulySeptember200845THEARMYMEDICALDEPARTMENTJOURNALCombat/operationalfactorsthatareknowntoincreasestresscasualtiesincludebothahighrateofphysicalwoundinganddeathinbattleandlongerdurationofcombat.9Multipledeployments,unitextensionsintheater,anddecreaseddwelltimeallincreasedurationoftimeincombattoday.Absenceofconstraints/relief:Alackofconstraintsreferstotheabsenceofanyindividual/entitythatmightcounteraSoldiersproclivitytoactonviolentimpulse.ExamplesofconstraintscouldincludeaprincipledBattleBuddy,aplatoonsergeantreinforcingrulesofengagement,orroutineoversightofSoldieractivitiesbythecommand.Highoperationstempo(OPTEMPO),orpaceofactivitywithoutrelieffromintensemilitaryoperationsmayalsocontributetomisconduct.Reliefencompassesanyactivitythatallowsabreakfromintensecombatoroperationalstress,eg,afullnightofsleeporrotationofindividualsorsmallunitsawayfromhighOPTEMPO.ProactiveCSCteamsareinapositiontoprovidereliefbyallowingaSoldiertimetoverbalizethoughtsandfeelings,and/orconstraintintheformofRemindasdetailedbelow.Situationalfactorsrefertothepresenceofaneasilyaccessible(soft)target,weapon(s),andunsupervisedtimetocommitaviolentact.Althoughthepresence(orabsenceinthecaseofconstraints/relief)offactorscanindependentlytriggerillegalviolence,recentcombatexperiencesuggeststhattheinfluenceofmanyvariablessimultaneouslyismorelikelytoresultinhorrificwarcrime.Metaphoricallyspeaking,multiplestormscombineandresultinasystemthatisfarmoredestructivethananyindividualweatherpatternalone.Atrocitiesincombataretheexceptionratherthaneverydayoccurrencesbecausemultiplenegativefactorsrarelyconvergetocreatetheperfectstorm.Thismodel,illustratedatright,explainsthecontextinwhichawarcrimemightoccur;butdoesnotabsolveanindividualofresponsibilityforhisorheractions.Theconstructalsoestablishesmultiplefactorsthatmightbeaddressedtomitigatetheriskofillegalviolenceincombat.Examplesincludeastandardforenlistmentthatscreensoutapplicantswithacriminalhistory,propercommandoversight,breaksinOPTEMPO,etc.RemindisatoolintendedtoassisttheindividualSoldiertomakeethicaldecisionsincircumstancesthatareunimaginableincivilianorgarrisonsettings.TheconceptdovetailswithArmyValuestofacilitateethicalaccomplishmentofacombatmission.SoldiersareinstructedintheArmyValueofRespectfromtheearliestdaysoftheirtraining.Soldiersalsoreceiveinstructioninrulesofengagement(ROE)andtheLawofLandWarfare12beforedeploymenttoacombatzone.InstructionsconcerningROEareupdatedandreiteratedthroughoutdeployment.ThepurposeofRemindistobridgethegapbetweenwhatSoldiersaretaughtaboutethicsandmilitarylaw,andwhattheydointhecontextofthehorrorsofintensecombat.THECONCEPTOFREMINDThefollowingarethekeyconceptsofRemindforbehavioralhealthpersonnel:UScombatpowerisfundamentallycomprisedofSoldierswhoaretrainedandlegallyauthorizedtoengagewithanddestroyenemycombatants.ThedestructionofenemyforcesisconstrainedbyROEthatarebasedupontheLawofLandWarfare.Theserulesgoverningtheuseofmilitaryforcearemuchlikeemployingacontrolledburntoclearaforest.Properlyappliedcombatpowertargetsanddamagesorkillstheenemywithoutinflictingsignificantcollateraldamage.Uncontrolledcombatpower,likeafireoutofbounds,canproducedisastrouseffects.Leadersengagedindirectingviolentmilitaryoperationsareintheunusualpositionofhavingtomanagethisfireofdangerousnesstoothersandkilling.Behavioralhealthpersonnelareinapositiontoconductunitandindividualassessmentsandadvisecombatcommandersonthebestcourseofactiontominimizetheriskofmisconductandpreservecombatpower.IndividualFactorsWARCRIMEAbsenceofConstraints/ReliefSituationCombat/OperationalFactors

PAGE 48

46www.cs.amedd.army.mil/references_publications.aspxThoughtsofkillingorharmingothersingarrisonaremanagedasmisconduct.Thistendency,appliedtocombatactionsdecreasesthelikelihoodthatSoldierswillverbalizetheirforbiddenvengefulthoughts.Thoughtsofkillingorinjuringothersoutsideofestablishedguidelinesmustbeaddressedbeforeanyattemptsatpreventionarepossible.TheRemindconceptisbasedonthepremisethatthoughtsofkillingand/orinjurytoothersoutsideofestablishedROEarebestaddressedasstressreactionsthatcanbeexpectedinthelife-and-deathcontextofcombat.9FigleyandNash9equatetheintensityoffriendshipsformedincombattothestrengthofthematernal-childbond.Assuch,theagonyfollowingthedeathofafriendincombatparallelsthepainamotherfeelsatthedeathofherchild.Toaddtothisintensity,combatdeathsarefrequentlygruesomeandhorrificinnature.HorrificcombatdeathsfrequentlyleadSoldierstofeelvengefulandverbalizeadesiretokillorharmcivilianstheybelievetobeaidingtheenemy,ortowardthoseincommandthattheyholdresponsibleforthedeathsoftheirfriends.Suicideandhomicideratesareknowntoincreaseinciviliansettingsborderingcivilwars,13soSoldiershavingviolentthoughtstowardsthemselvesandnoncombatantsincombatsettingsshouldnotcomeasasurprise.Awartimeincreaseinthoughtsofviolencetoselfandotherscanbeunderstoodonacontinuumofthewell-knownconceptoffightorflight.Theincreaseinstresscreatedbyintensecombatconditionsproducesacorrespondingincreaseinboththefrequencyandintensityof:Thoughtsofescapingaseeminglyhopelesssituationbysuicide(extremeflight)orThoughtsofrevengedirectedatnoncombatants(extremefight)Vengefulthoughtsmayoccurinindividualsorpervadeentireunitsimpactedbyintenseandprolongedcombattrauma.PoorlytrainedandundisciplinedSoldiersareathighestrisk,butproudcohesiveunitsarealsosusceptibleduringtimesofextremecombatstress.ThoughtsofkillingorharmingothersoutsideofROEalonearenotareasontoevacuateindividuals/units,considerthemuntrustworthy,ordoubttheirabilitytocontinuewiththemissionanymorethansuicidalthoughtswithoutintentorplanmerithospitalizationorpermanentstigma.BehavioralHealthprovidersareroutinelyconsultedtoassessforandintervenetodecreasetheriskofsuicide.Inacombatcontext,behavioralhealthprovidersshouldalsoexpecttobeconsultedtoassessforriskofillegalviolence,identifyindividualandunitriskfactorsandbehaviorsthatmayprecedeillegalacts,andemployinterventionstodecreasetheriskofviolentmisconduct.Clinicalscreeningforunitandindividualriskfactorsandindividualbehaviorsthatmayprecedeactsofmisconductshouldincludeassessmentofthefollowingriskfactorsandbehaviors:Unitriskfactorsthatmayprecedeillegalviolenceincombat:MultipleSoldierand/orciviliandeaths,inthesameunit,overashortperiodoftimeHighOPTEMPOwithlittlerespitebetweenengagementsIncreasednumberofdaysincombat(aWWIIstudycitedincreasedvulnerabilityafter60dayswithatleastonefriendlycasualty9)Rapidturnoverofunitleaders(especiallywithvacancycreatedbydeathofanadmired,trustedleader)ManpowershortagesRestrictiveorconfusingROEasevidencedbythemesofpowerlesstofightbackEnemythatisindistinguishablefromciviliantargetsCollectiveperceptionoflackofsupportfromhighercommandRumorsofoverkilloflegitimateenemytargets,eg,mutilationofanenemycombatantwithexcessivefirepowerCombatContextFightFlightMurderHI*CombatandOperationalStressReactionSISuicide *HomicidalideationSuicidalideation Remind:AddressingtheRiskofIllegalViolenceinMilitaryOperations

PAGE 49

JulySeptember200847THEARMYMEDICALDEPARTMENTJOURNALIndividualriskfactorsthatcanbeappliedtoriskassessmentforillegalviolenceinanymilitaryorciviliansettingandrememberedusingtheacronymISAMADGUY:ImpulsiveSocialsupportdeficitAngryaboutincidentMentalillness(eg,bipolarorpsychoticdisorder)Armed/accesstoweaponsDiditbefore(violentcrimewithorwithoutarrest/jailordisciplineundertheUniformCodeofMilitaryJustice)Guiltless(antisocialtraitsorpersonalitydisorder,otherClusterB*disorders)Undertheinfluence(drugand/oralcoholhistory)YoungmaleIndividualMilitary/CombatSpecificRiskFactorsthatmayprecedeillegalviolenceincombat:Individualhassufferedacombatloss(friendwoundedorkilledinaction)Soldierpersonallywitnessedtheinjuryordeathorwasinvolvedinthemedicalevacuationoffriend/unitmemberGruesome,horrificcombatlossIndividualBehaviorsthatmayprecedeillegalviolenceincombat:Soldierverbalizesthoughtsofangertoward/lackofsupportfromhighercommandSoldierverbalizesangertowardandthoughtsoftakingrevengeontheindigenouscivilianpopulationChangeinappearance/behavior:laxmilitarydress/bearinghyperarousalirritability/angryoutburstsmorose/isolativechangesinsleepandappetiteDeliberatecrueltytopeopleoranimalsRisktaking(intentionalnearmissintraffic)SoldierpushingROEtothemaximum,eg,excessive/indiscriminant/nearmisswarningshotsDrugoralcoholuseByscreeningforunitandindividualriskfactorsandindividualbehaviorsthatmightprecedemisconduct,clinicianscanintervenetodecreasethelikelihoodthatthoughtsofkillingorharmtootherswillescalatetouncontrolledviolence.InadditiontoallowingtimefortheSoldiertoverbalizeforbiddenthoughtsandfeelings,cliniciansshouldinquiredirectlywhethertheSoldieristhinkingabouttakingillegalrevenge.BehavioralhealthpersonnelshouldadviseSoldiersthatthinkingaboutillegallyharmingorkillingothersisacommonreactionthatgoodSoldiershaveinresponsetothesadnessandangerthatarepartofcombat,butthattakingactiononillegalthoughtsismisconductthatmustbepunished.Theapplicationofsomecombinationorallofthe5RsofCombatStressControl(Reassure,Rest,Replenish,Restore,andReturn)shouldincludea6thR:Remind.RemindtheSoldier(s)asappropriatebefore,during,andaftercombatthat:1.Youare(an)AmericanSoldier(s)heretocompletealawfulmission.2.AmericanSoldiersbehavehonorablybecauseitistherightthingtodo.3.HarmingorkillingnoncombatantsdishonorsyouandyourfellowSoldiers,livinganddead.4.Steppingdowntorevengehelpstheenemytodiscredityouandyourunit,andwin.5.TheultimateobjectiveistoReturnHomeWithHonor.MostSoldierswhoareprovidedwithanopportunitytoverbalizetheirthoughtsandfeelings,treatedwithreassurance,rest,etc,andremindedoftheirobligationtothemselvesandtheirfriendscanregroupandsafelycontinuethemission.IntheeventofcontinuedthoughtsofkillingorharmingothersoutsideofestablishedROEwithintentandplantoact,ora *Anyofagroupofdisordersinwhichpatternsofperceiving,relatingto,andthinkingaboutone'sselfandone'senvironmentinterferewiththelong-termfunctioningofanindividual,oftenmanifestedindeviantbehaviorandlifestyle.14

PAGE 50

48www.cs.amedd.army.mil/references_publications.aspxcombinationofunitand/orindividualriskfactors/behaviorsthatindicateunacceptablerisk,furtherstepsmustbetakentoconservesafeandeffectivecombatpower.Theclinicianmayrecommendthatthecommand:Increasesupervisionandcontrol.RotatetheSoldier/unitawayfromhighOPTEMPOandheavylosses.Evacuateindividual(s)tothenextlevelofcareifrequired.Unlessthereisimmediatedanger,Soldierswhoaredangeroustoothersbesidestheestablishedenemyshouldnotcontinuetocarryaloadedweapon(thefiringpinoftheweaponmayberemovedtoensuresafetyandpreservedignity).Behavioralhealthpersonnelshouldalso:Consultcommandforcollateralinformation.MaintainclosecontactwithcommandandunitmedicstocheckonthestatusofSoldiersatrisk.Conductfrequentface-to-facereassessments.Briefincomingbehavioralhealthpersonnelonexistingcasesandneedforclosefollow-uptomaintainsafetyandcontinuityofSoldiercare.Offinalnote,clinicianswhoarestationedfarforwardwithSoldiersengagedinintenseongoingcombatoperationswithheavylossesaresubjecttomanyofthesamementalandphysicalstressorsastheSoldierstheytreat.SharingwithSoldiersintheexperienceofdangeranddeathcancreateastrongsenseofidentificationwiththesupportedunit.ThiscohesionisadaptivewhenahighdegreeofCSCteaminvolvementleadsSoldierstofeelcomfortableseekingmentalhealthservices.ThissamesolidaritymaymakeaneutralandobjectivestancedifficulttomaintainintheongoingcontextofSoldierinjuriesanddeaths.CliniciansshouldtakecaretoaddresshowtheirownvengefulthoughtsandfeelingsmaybetransmittedtotheSoldierstheyserve.CSCunitcommandersshouldkeepinclosecontactwithcliniciansstationedatfarforwardareasandconsiderperiodicrotationofindividualsorteamsfromviolentcombatconditionstolessintenseduties.DESIREDOUTCOMEApplicationofRemindcannoteliminateallindividualactsofillegalviolenceanymorethansuicideawarenesstrainingcaneliminateallsuicides.Itcan,however,establishproactiveriskassessmentandinterventionsdesignedtodecreasethelikelihoodofmisconductincombat.THEROADAHEADRemindiscurrentlybeingtaughtintheCombatandOperationalStressControl(COSC)CourseattheAMEDDCenterandSchool,andispendingrevisionandinclusionintoArmyCOSCdoctrine.ThetrainingshouldbeincorporatedintoAMEDDMentalHealthandotherofficerbasiccoursesaswellasthebasicandadvancednoncommissionedofficercoursestodisseminatetheconcepttonewbehavioralhealthprovidersandfutureArmyleaders.Thesuccessofpreventioneffortsingeneral,ortheabsenceofanegativeoutcomeisnotoriouslydifficulttomeasure(eg,towhatextenthasArmySuicideAwarenesstrainingactuallydecreasedSoldiersuicides?).Evenassumingextensivebuyinandpromulgationbyline-unitcommanders,quantifyingthesuccessofRemindwillbedifficultsinceactualwarcrimesare,thankfully,relativelyrare.OnelesswarcrimeattributabletoaUSSoldiercouldbeconsideredsuccess,butbettermeasuresofthefutureimpactofRemindonmisconductincombataredesirable.MentalHealthAdvisoryTeamsurveyshaveaddressedtheimpactofSuicideAwarenesstrainingandmightalsohelptoquantifytheeffectsofRemind.Inparticular,theMHATIVreport7addressedethicsandbattlefieldbehaviorforthefirsttime.Therefore,MHATIVcouldbeabaselineagainstwhichRemindeffortsmaybeevaluatedinfuture,withtheunderstandingthat,evenwithaudiencesaturation,changesinArmyattitudesandculturetaketimesometimesaverylongtimetoberealized.RemindsuggestsanumberofbroaderimplicationsthatshouldalsobeconsideredacrosstheDepartmentofDefense(DoD).Maintainingtheinitiativeandsuccessinmilitaryoperationsrequirescontrolofthecombatenvironment.FailuretoaddresstheconnectionsbetweentheethicalbehaviorofUSforcesincombatandleaderdevelopment,forceprotection,informationoperationsandmedia/publicaffairsacrossthetactical,operational,andstrategicspectrumcouldcedemilitaryandpoliticalinitiativetoouradversaries.SincesuchlossofinitiativecouldmakeUSstrategicobjectivescostlyorevenimpossibletoachieve,effortsRemind:AddressingtheRiskofIllegalViolenceinMilitaryOperations

PAGE 51

JulySeptember200849THEARMYMEDICALDEPARTMENTJOURNALshouldbemadetoadviseallDoDpersonneloftheimportanceoftrainingandexecutingRemindatalllevelsofmilitarydecisionmaking.REFERENCES 1.FieldManual22-51:LeadersManualforCombatStressControl.Washington,DC:USDeptoftheArmy:29September1994.2.FieldManual4-02.51:CombatandOperationalStressControl.Washington,DC:USDeptoftheArmy;6July2006.3.FieldManual6-22.5:CombatStress.Washington,DC:USDeptoftheArmy;23June2000.4.USArmyCenterofMilitaryHistory.TheUnitedStatesArmyinSomalia:1992-1994.Washington,DC:OfficeoftheAdministrativeAssistanttotheSecretaryoftheArmy;2003.CMHPublication70-81-1.5.64Stat.109,10USC,ch47.6.OlsonJS,RobertsR.MyLai,ABriefHistorywithDocuments.NewYork:Macmillan;1998.7.MentalHealthAdvisoryTeam(MHAT)IVOperationIraqiFreedom05-07FinalReport.Washington,DC:OfficeofTheSurgeonGeneral,USDeptoftheArmy;November17,2006.Availableat:http://www.armymedicine.army.mil/reports/mhat/mhat_iv/MHAT_IV_Report_17NOV06.pdf.8.HillJV,JohnsonRC.SuicidalandhomicidalSoldiersindeploymentenvironments.MilMed.2006;171(3):228-232.9.FigleyCR,NashWP,eds.CombatStressInjury:Theory,Research,andManagement.London:RoutledgeMentalHealth;TaylorandFrancisGroup;2006.10.CrandallCS,JostPF,BroidyLM,DadayG,SklarDP.Previousemergencydepartmentuseamonghomicidevictimsandoffenders:acase-controlstudy.AnnEmergMed.2004;44(6):646-655.11.GrossmanD.OnKilling:ThePsychologicalCostofLearningtoKillinWarandSociety.NewYork,NY:BackBayBooks/LittleBrownandCompany;1996.12.FieldManual27.10:TheLawofLandWarfare.Washington,DC:USDeptoftheArmy;18July1956.13.KrugEG,DahlbergLL,MercyJA,ZwiAB,RafaelLozanoR,eds.TheWorldReportonViolenceandHealth.Geneva,Switzerland:WorldHealthOrganization;2002.Availableat:http://www.who.int/violence_injury_prevention/violence/world_report/en/index.html.AccessedApril6,2007.14.TheAmericanHeritageMedicalDictionary.Boston,MA:HoughtonMifflinCompany;2007.AUTHOR LTCMarrsisaPsychiatricMentalHealthNursePractitionerattheUSArmyInstituteofSurgicalResearch,FortSamHouston,Texas. USArmyInstituteofSurgicalResearch

PAGE 52

50www.cs.amedd.army.mil/references_publications.aspxTheBehavioralHealthProponencywascreatedinMarch2007.ItwasmodeledaftertheProponencyforPreventiveMedicine,tobringahostofdifferentdisciplinesandinitiativesunderonecentralorganization.TherewasalsoarecognitionoftheimportanceofdistinctbehavioralhealthrepresentationattheOfficeofTheSurgeonGeneral,sothatthestaffwouldbereadilyavailablewithinthePentagon.TheauthorwasappointedthefirstDirectoroftheBehavioralHealthProponency,havingalreadybeenthePsychiatryConsultanttoTheSurgeonGeneral.TheBehavioralHealthProponencyisnestedwithinHealthPolicyandServices.ItsubsumestheBehavioralHealthDivisionattheArmyMedicalCommand,includingthenewSuicidePreventionOffice.ThereisextensivecoordinationwiththeDivisionofNeuropsychiatryattheWalterReedArmyInstituteofResearch,theSoldierandFamilySupportBranchoftheArmyMedicalDepartment(AMEDD)CenterandSchool,theCenterforHealthPromotionandDiseasePrevention,andtheSuicideRiskandSurveillanceOfficeattheMadiganArmyMedicalCenter.AstheorganizationandfunctionsoftheProponencyhavematured,responsibilitieshavebeencenteredaroundpolicyupdatesinbehavioralhealthcareandtheimplementationoftherecommendationsoftheDepartmentofDefense(DoD)MentalHealthTaskForce.1Theofficeanswersqueriesfromseniormilitaryleadership,DoD,Congress,andthemedia.StaffmembersprovideexpertisetosupporttheArmysWarriorTransitionOffice,DeputyChiefofStaffG-1,andInstallationManagementCommand,aswellastheDefenseCenterofExcellenceandotherrelatedagencies.TheBehavioralHealthProponencyhasimprovedaccesstobehavioralhealthcare.Numerousinitiativeshavefocusedonincreasingthenumberofproviders,thusincreasingthedeliveryofhealthcareservicestoSoldiersandFamilymembers.TheAMEDDhassteadilyincreasedthenumberofproviders.AsaresultofaMemorandumofAgreementbetweenDoDandtheDepartmentofHealthandHumanServices,2theUSPublicHealthServiceisrecruitingproviderstoworkinDoDfacilities.Therearealsomajoreffortstoenhancerecruitingandretentionofuniformedproviders,includingadoublingofthesizeofthepsychologyinternstaff,aretentionbonusforpsychologists,andaneducationalprogramforsocialworkers.SUICIDEPREVENTIONThreecriticallyimportantandhighlypublicizedareashavebeentheincreaseinsuicides,administrativeseparations,andtheincreaseinthenumbersofdiagnosesofposttraumaticstressdisorder(PTSD)andtraumaticbraininjury.TheProponencyhasbeenworkingcloselywiththeArmyG-1,ChaplainCorps,andInstallationCommandtoimprovesurveillance,decreasestigma,andimproveeducationalmaterials,withthegoalofreducingsuicidalbehavior.TheissueshavebeenelevatedtotheseniorArmyleadership,withtheformationofaGeneralOfficerSteeringCommittee,cochairedbytheG-1andTheSurgeonGeneral.ArecentinitiativeistheestablishmentofanepidemiologicalanalysiscellattheArmyCenterforHealthPromotionandDiseasePrevention.ADMINISTRATIVESEPARATIONSNumerousmediastorieshaveallegedthattheArmyhasbeenwrongfullydischargingSoldierssufferingfromPTSD,usingapersonalitydisorderdiagnosis.TheProponencyconductedamajorreviewofdischargerecordsfrom2001to2006.Althoughthereviewersdidnotfindevidenceofmisdiagnosis,theydidfindpoordocumentationinmanycases.Tworelevantpolicieshavebeenissued:ThereviewofallpersonalitydisorderdiagnoseswasmandatedinAugustof2007.EffectiveMay2008,medicalclinicsmustensurethatallSoldiersdischargedunderawidevarietyofadministrativedischargesarescreenedforTheArmyMedicalDepartmentBehavioralHealthProponencyCOLElspethRitchie,MC,USA

PAGE 53

JulySeptember200851traumaticstressdisorderandtraumaticbraininjury.TRAININGRECOGNITIONOFPTSDANDTBINumerouseducationalproductshavebeendevelopedbytheWalterReedArmyInstituteofResearchandtheAMEDDCenterandSchool,undertheBattlemind*rubric.Achain-teachinginitiativeonPTSDandtraumaticbraininjurywaslaunchedinJuly2007.Itfocusedonrecognitionofsignsandsymptoms,andSoldierandleaderactions.Bytheconclusionoftheprograminthefallof2007,over800,000Soldiershadbeentrained.OtherBattlemindproductsarebeingimplementedthroughouttheSoldierslifeanddeploymentcycle.THEFUTUREInadditiontorisingreportsofPTSD,thereareincreasingreportsofbingedrinkingamongreturningveterans.TheProponencyisworkingdiligentlywiththeArmyG-1,theresponsibleagencyfortheArmySubstanceAbuseProgram,toenhanceandupdatetreatmentforalcoholabuseanddependence.Bothintensiveoutpatienttreatmentandresidentialtreatmentforsubstanceabusecapacitymustbeenhancedinourbehavioralhealthsystem.TheTRICAREoutpatientmentalhealth/behavioralhealthbenefithasrecentlybeenenhanced.TheChiefofStaffoftheArmyrequestedaComprehensiveBehavioralHealthStrategyfromtheOfficeofTheSurgeonGeneral.TheAssistantSurgeonGeneralforForceProjectionisleadingtheeffort,whichhasdeterminedthatcomprehensivebehavioralhealthshouldbeapproachedasawhole-lifefitnessstrategy,includingthe6categoriesofwellness(social,spiritual,emotional,family/finance,career,andphysical).Thestrategydevelopmentgrouprecognizestheneedtoincorporateenhancementofcurrenthealth(SoldierandFamily),preventionoffutureproblems,andtreatmentwhenproblemsarise.Thegroupisemphasizinguseofstandardizedmetricstodeterminesuccess,standardizedscreeningandtreatmentmodalities,anduseofevidence-basedclinicalguidelines.TheArmysWholeLifeFitnessStrategywillbeformallyreleasedinthenearfuture.REFERENCES 1.DefenseHealthBoardTaskForceonMentalHealth.AnAchievableVision:ReportoftheDepartmentofDefenseTaskForceonMentalHealth,June2007.FallsChurch,VA:USDeptofDefense;2007.Availableat:http://www.health.mil/dhb/mhtf/MHTF-Report-Final.pdf.AccessedSeptember12,2008.2.OfficeofTheSurgeonGeneral.HHS,DepartmentofDefenseagreementtoincreasementalhealthservicesavailabletoreturningmilitaryservicemembers.USDeptofHealth&HumanServices;June4,2008.NewsRelease.Availableat:http://www.surgeongeneral.gov/news/pressreleases/20080604a.html.AccessedSeptember12,2008.AUTHOR COLRitchieisDirectoroftheBehavioralHealthProponencyintheOfficeofTheSurgeonGeneral,Washington,DC. *Seerelatedarticleonpage66.Chain-teachisamethodofunittraininginwhichdesignatedunitmembersfirstreceivethetraining,afterwhichitistheirresponsibilitytotrainanotherlevelofpersonnel,whointurnwillcontinuetrainingothers.Thetrainingcontinuesinapyramidfashionuntilallpersonnelrequiringsuchtraininghavereceivedit.TRICAREisDoDshealthcareprogramformembersoftheuniformedservices,theirfamilies,andtheirsurvivors.Informationavailableathttp://www.tricare.mil.

PAGE 54

52www.cs.amedd.army.mil/references_publications.aspxAlthoughtherehavebeentremendousadvancesinpharmacologicandpsychotherapeutictreatmentsofmentalhealthandstress-relateddisorders,themilitaryprimarycareproviderandalliedhealthcareprofessionalmayrepresentthemostpotenttreatmentforSoldiersandtheirFamilymemberssufferingfromtheseproblems.Severalfactorsenhancethepoweroftheseproviderstocarryoutpsychotherapeuticinterventions.First,patientstrusttheirprimarycareandalliedhealthcareprovidersandbelievethemcapableofhelpingwithemotionaldifficulties.Manypatientsfeelmorecomfortabletalkingwiththeirprimarycareprovider,occupationaltherapist,orphysicaltherapistratherthananunfamiliarpsychiatristorcounselor.Somepatientsmayperceiveareferraltoamentalhealthspecialistasarejectionbyoneofthoseproviders,andmightfearthestigmaassociatedwithseeingthisspecialist.Asaconsequence,manypatientsmayfailtofollow-throughwithmentalhealthreferrals.Overall,onlyabouthalfoftheoutpatientsreferredforamentalhealthconsultationcompletetheprocess.1AsecondfactorthatputsthemilitaryhealthcareproviderinanadvantageouspositiontoprovidepsychotherapeuticinterventionsisthatSoldiersandtheirFamilymemberstypicallycometothemwithearlysignsofemotionaldistress.Infact,severalstudies1conductedinthegeneralpopulationhaveconcludedthatitistheemotionaldistressthatactivatesthevisittotheprimarycareclinicinupto60%ofcases,evenwhenamedicalillnessispresent.Militaryhealthcareprovidersareintheuniquepositiontointerveneearlyinthecourseofmentalhealthdisorderstopreventmoresignificantmorbidity.TheprovidermayactuallycarryoutprimaryorsecondarypreventioninsomeadjustmentsexperiencedbyourWarriorsandtheirFamilies,suchasaSoldierreturningtothehomeenvironmentfollowingdeployment.Forexample,educatingpatientsinadvanceabouttheemotionalaspectsofthistransitionthisoftenoccurswhenaspousereturnshomeafteradeploymentmayhelpthepatientcopewiththestressorandpreventtheonsetofmoreseriousorpathologicalreactions.Moreover,becausemanypatientsfocustheirdistressontheirhealth,suchprovidersareinafavorablepositiontoaddressthoseconcerns.Thethirdandmostsignificantfactoristhattheprimarycareandalliedhealthcareproviderhastheopportunitytomaintainanongoingrelationshipwithhisorherpatients.Continuityofcareallowsfamiliarity,trust,andconfidencetoexist,whichcanserveasafoundationforbriefinterventionsaswellassupportandencouragementforpatientswhorequirereferralstomentalhealthprofessionals.ItallowsourSoldiersandtheirFamilymemberstoreceivemoreintegratedcarethatincorporatesthebiopsychosocialapproachthatissoessentialtomaintainingtroopreadinessandpeakFamilyfunctioning.Seeingpatientsforbriefvisitsmayenablethehealthcareprofessionaltodealwithoneaspectofthepatientsdifficultyandnotoverloadthepatientwithtoomanypsychologicalissues.Similarly,thehealthcareprofessionalsgoalistoachieveamodestchangeinthepatientsemotionalstate.TherealwaysexiststhepossibilitythattheacuityandcomplexitypresentedbyaSoldierorFamilymemberwillexceedthetimelimitationsandexpertiseoftheprimarycareandalliedhealthcareprovider.Itistheseveryinstancesinwhichaprovidermaydeftlyusetheirrelationshipandcommunicationskillstoachieveasuccessfultransitiontoamentalhealthprofessional,andhence,achieveamoreauspiciousoutcomeforourSoldiersandtheirFamilies.TheobjectiveofthebehavioralhealthcoursescurrentlyofferedattheArmyMedicalDepartmentWhyTeachMentalHealthTopicstoPhysicianAssistantsandOtherAlliedHealthcareProfessionals?KarenC.Shea,LCSW,DCSWMaryannPechacek,PsyD

PAGE 55

JulySeptember200853 (AMEDD)CenterandSchoolistoequipourmilitaryprimarycareandalliedhealthcareproviderswiththeknowledgeandskillsrequiredtorecognizeandmanagementalhealthdisorders.Oneofthechiefchallengesforhealthcareinourcurrentoperatingenvironmentisthepreventionoftheunderdiagnosisofmentalandstress-relateddisorders.Ourexceptionallywell-trainedandcommittedhealthcareprovidersrequiretrainingintheselectedskillsthatenablethemtocollectinformationfrompatientsforthepurposesofscreening,diagnosis,furtherassessment,andoutcomesmonitoring.Theseskillsmayalsohelptoexpeditetheprovisionofinformationtopatientsabouttheirdisordersandmanagementthereof.Theyoftenproveinvaluableindecreasingpatientsresistancetoacceptingamentalhealthdiagnosisandtreatmentbyenablingthepatienttoplayamoreactiveroleintheircare.Theknowledgeandskillsmayalsobeusedtoincreaserecognitionofmentalhealthandstress-relateddisorders,improvedocumentation,andhelporganizecaresothatnothingismissedorforgotten.SpecialSubjects,asmallbutessentialdivisionwithinthePsychologicalHealthsectionoftheSoldierandFamilySupportBranch,AMEDDCenterandSchoolatFortSamHouston,iscurrentlychargedwiththeresponsibilitytoteachtheinformationandskillsnecessaryfortheeffectivemanagementofmentalhealthdisorderswithinthemilitaryhealthcaresetting.ThemissionoftheSpecialSubjectsdivisionistoimpartknowledgeinanacademicsettingaboutmentalhealthtopicsthatwillprovideourproviderswithreadilyavailabletoolsthatarenotapartoftheusualmedicalpracticesetting.Thesetoolscanbeusedtoovercomethebarrierstomentalhealthcarewithamodicumofeffortandexpense,tohelpincreasebothpatientandprovidersatisfactionbyimprovingthecareprovided,and,mostimportantly,toimprovepatientoutcomes.REFERENCE 1.KatzelnikDJ,SimonGE,PearsonSD,etal.Randomizedtrialofadepressionmanagementprograminhighutilizersofmedicalcare.ArchFamMed.2000;9:345-351.AUTHORS MsSheaandDrPechacekareInstructor/WritersintheSpecialSubjectssectionoftheSoldierandFamilySupportBranch,DepartmentofPreventiveHealthServices,AMEDDCenterandSchool,FortSamHouston,Texas. Two-ThousandYardStareApaintingbyTomLea,LifeMagazinecombatartistandcorrespondent,fromtheMarineCorpscampaignfortheislandofPeleliu,September1944.Thisfamouspaintingisknownforitsgraphicaldepictionofthepsychologicalstressinflictedbythehorrorsofextended,totalcombat.ImagecourtesyoftheUSArmyCenterforMilitaryHistory,Washington,DC.

PAGE 56

54www.cs.amedd.army.mil/references_publications.aspxDepartmentofDefenseResponsetoPosttraumaticStressDisorderGerardA.Grace,PhDAreviewofcurrentresearchliteratureclearlypointstothefactthatthecontinuedengagementfortheUSandAlliedForcesinOperationIraqiFreedom(OIF)andOperationEnduringFreedom(OEF)arepresentingsignificantchallengesfortheclinicalandmedicalserviceswithinthemilitarysystem.Thesechallengesaremakingsalientsomesystemicdeficienciesintheconceptualizationandthedeliveryofappropriatehealthcareforthephysically,psychologically,orspirituallytraumatizedWarriorandtheirsignificantlovedones.Conversely,thiscrisishaspushedthemilitarysystemtowardsanewandmoreevolvedhomeostasisasitstretchestoadequatelymeettheholistichealthcareneedsoftheWarriorintheatreandthereturningWarrior.Itisoutofthisstretchingthataposttraumaticstressdisorder(PTSD)trainingprogramformentalhealthprovidershasevolved.ThistrainingprogramisnowinstitutedasanintegralpartofthePsychologicalHealthSectionoftheSoldierandFamilySupportBranch,DepartmentofPreventiveHealthServicesoftheArmyMedicalDepartmentCenterandSchool.ThisarticlerevisitsthedefiningparametersofPTSD,thensummarizesthestateofaffairsonthegroundpertainingtoPTSDandthementalhealthofSoldiersasespousedbytheMentalHealthAdvisoryTeamIVreport.1Finally,thisarticlespeakstotheefficacyofempiricallyvalidatedtreatmentforPTSD,andhow,basedonthisresearch,thePTSDtrainingprogramhasbeenconstituted.Thearticleconcludeswithacommentonsomeresearchinprogressthatcontainstheseedsofmuchhopeforfutureproviders,instructors,andmilitarymenandwomencommittedtoassailthePTSDdragon.AccordingtotheDiagnosticandStatisticalManualofMentalDisorders,2PTSDisdefinedas:A.Exposuretoatraumaticeventwhere,Personexperienced,witnessed,orwasconfrontedwithaneventoreventsthatinvolvedactualorthreateneddeathorseriousinjury.Personsresponseinvolvesintensefear,helplessness,orhorror.B.Traumaticeventispersistentlyreexperiencedthroughoneormoreofthefollowing:recurrentintrusivedistressingrecollections,recurringdistressingdreams,flashbacks,psychologicaldistressinresponsetoreminders,cuedpsychologicalreactivity.C.Persistentavoidanceofstimuliassociatedwiththetraumaandnumbingofgeneralresponsiveness.D.Persistentsymptomsofincreasedarousal,irritability,difficultyfallingasleeporstayingasleep,difficultyconcentrating,hypervigilance,exaggeratedstartleresponse.E.Durationofdisturbanceismorethanonemonthafterthetrauma:AcutePTSD:1through3monthsChronicPTSD:morethan3monthsDelayedonset:morethan6MonthsMENTALHEALTHADVISORYTEAMIVFINDINGSIn2003,theDoDinstitutedaworkingadvisoryteamcalledTheMentalHealthAdvisoryTeam(MHAT).ThepurposeofMHATistoassessthementalhealthandwell-beingofthedeployedforcesservinginIraq,andtoassesstheefficacyofthedeliveryofbehavioralhealthcareduringOIF.Todatetherehasbeenaseriesof4surveysconductedwiththeresultspublished.Thelastpublishedresultswerein2007intheMHAT-IVreport.1*Thepopulationsurveyedconsistedof1,320Soldiersand447Marines.ThefindingsofMHAT-IVconcurwiththeintuitivesenseofconcernedproviders.The2007reportconfirmsa50%increaseoverthelastyearofservicemenandwomenfromOIFandOEFcarryingadiagnosisofPTSD.Thisbringsthetotalof *Sincethisarticlewaswritten,theMHATVreportfordatacollectedduring2007wasreleasedbytheDepartmentoftheArmy.TheEditors

PAGE 57

JulySeptember200855WarriorsafflictedwithPTSDto40,000inthelast5years.TheArmyandMarineCorpscarrythemajorityoftheburdenofthisdiagnosis.ThefollowingisasynopsisoftheMHATIVfindings:NotallSoldiersandMarinesdeployedtoIraqorAfghanistanareatequalriskforscreeningpositiveformentalhealthproblems.Thelevelofcombatisindirectproportiontomentalhealthstatus.ForSoldiers,multipledeployments,deploymentlengthoftime,andFamilyseparationwerepredictiveofhigherincidentsofmentalhealthissues.GoodnoncommissionedofficerleadershipiskeytosustainingSoldierandMarinementalhealthandwell-being.Behavioralhealthprovidersrequireadditionalcombatandoperationalstresstrainingpriortodeployment.OverthreefourthsofSoldiersreportedbeinginsituationswheretheycouldbeinjuredorkilled(firstcriteriaforPTSDdiagnosis).SeventeenpercentofSoldiersscreenedpositiveforAcutestressin-theatre.TheWalterReedArmyInstituteofResearchLandCombatStudyindicatesthattheseratesarelikelytoincreaseandevolveintoChronicPTSD6monthsand12monthspostdeployment.3Thisreportmaynotpresentanycounterintuitiveinformation.Itdoes,however,providegreatclarityinhighlightingtheimmediateneedsoftheSoldierandfellowservicemenandwomen.Theseparticularandsalientneedsinturnspeakloudlytothemilitaryhealthcaredeliverysystem.TheneedsoftheSoldierinrelationtoAcutestressin-theatreandPTSDpostdeploymenthavehighlightedapaucityofmentalhealthresourcestomeetthisburgeoningneed.Thereare2aspectstothisimpoverishedresource:First,havingsufficientmentalhealthprofessionalsavailabletoallowthereturningWarriorefficientaccesstocare.Second,havingsufficientmentalhealthproviderswhoaretrainedinthemosteffectivetreatmentmodalitiesforPTSDcontinuestobeanissue.InresponsetotheMHATreports,theDepartmentofDefense(DoD)directedthatallArmysocialworkers,nursecasemanagers,psychiatriccasemanagers,andnursepractitionersmustbetrainedinevidence-basedtreatmentmodalitiesforPTSD.EMPIRICALFINDINGSONEFFICACYOFTREATMENTFORPOSTTRAUMATICSTRESSDISORDERItisthefoundingpurposeofthePTSDtrainingprogramtoensurethatthebesttraininginallempiricallyverifiedtreatmentsforPTSDismadeavailableforalltargetedproviders.Researchondifferenttreatmentmodalitiesissufficienttoconcludethatnotallmodalitiesoftreatmentinthebodyofpsychologicalliteratureareequallyeffectiveorevenappropriatewhenitcomestothecomplexityofdynamicsinducedbycombattrauma.ThegreatestbodyofresearchhasbeenconductedonProlongedExposureTherapy.OncomparativestudiesacrossthedifferentmodalitiesoftreatmentforPTSD,ProlongedExposureseemstohaveanedgeintermsoflong-termpositiveoutcomes.4CognitiveProcessingTherapy(CPT)hasverysimilaroutcomestoProlongedExposure(PE),withtheconductofextensivecomparativestudiesbytheUniversityofPennsylvania.EyeMovementDesensitizationReprocessing(EMDR)hasmuchanecdotalappraisalasaneffectivetreatmentforPTSD.Whilelackingextensiveresearch,EMDRhasanumberofscientificstudiespublished,verifyingitsefficacyintreatingPTSD.EMDRisespeciallyappealingasamodalityasitrequiresaminimalamountofin-betweensessionorpreparationworkfromthepatient,whereasCPTandPEinvolveastrongcommitmenttoin-betweensessionwork.Therapeuticliteratureispermeatedwiththisproblemofmotivatingclientstotakeresponsibilityforin-betweensessionworkandisassociatedwithahighpercentageofclientattrition.Fromthisperspective,EMDRisefficient,effective,andthusbecomingaprominentmodalityoftreatment.All3modalitiestargettheinformationprocessingmechanismoftraumaticmemories.ThePTSDtrainingprogramhasinstitutedcomprehensivetraininginall3modalitiesoftreatment.TheseminalauthorsofthetheoriesProlongedExposureTherapyandEyeMovementDesensitizingandReprocessingareintegrallypartofthetraining,asinstructorsandsupervisors.Thenumberofproviderstrainedthusfarineachmodality:EyeMovementDesensitizingandReprocessing:68ProlongedExposureTherapy:127CognitiveProcessingTherapy:81

PAGE 58

56www.cs.amedd.army.mil/references_publications.aspxDepartmentofDefenseResponsetoPosttraumaticStressDisorderThefar-reachingvisionofthiseffort,oncethereisasignificantamountofproviderstrained,isthedesignationofacoregroupthatwouldtraintobecometrainersineachmodalityoftreatment.ThiswoulddecreaseDoDsdependenceonoutsourcingforthistrainingandsignificantlyreducetheexpenseassociatedwiththiseffort.RESEARCHANDDEVELOPMENTTheresearchchallengesassociatedwithmentalhealthandthemilitarysystemaredaunting.ThepaucityofquantitativedataaroundAcuteStressDisorderin-theatre,anditsmanagement,ortreatment,andtheeffectivetreatmentofPTSDspecifictocombattraumaisscreamingatanalreadyoverstretchedsystemtoconductmoreresearch.ThemajorityofresearchconductedonPTSDhasbeennormalizedoncivilianpopulationsinresponsetosingletraumaticevents,mostlyinvolvingrapeandmolestation.Thisresearchmaynotalwaysbetransferabletothemilitarypopulationwherecombatisongoingandexposuretorepetitivetraumaisinevitable.ItistheintentionofthePTSDtrainingprogramtodeveloparesearchtoolthatwillproducequantitativedatatotracktheefficacyofeachmodalityoftreatmentforPTSDasitrelatesspecificallytocombattrauma,andthusyieldsignificantinformationthatwilladvancetheknowledgebaseinthisgrowingareaofneed.POSTTRAUMATICSTRESSDISORDERANDBEYONDWithinthebodyofpsychologicalliteratureandmilitarytrainingthereisaperceptibleparadigmshiftawayfrompathologicalcategorizationsandmoretowardsaresiliencyandstrengths-basednarrative.Thisreflectsauniversaldynamicalwaysrecognizedbyancientwisdomtraditions.Theuniversaldynamicwelldocumentedinpsychospiritualliteratureisthatveryoftenpsychological,spiritual,andhumangrowthisusheredinonthethresholdofsomemajorlifetraumaorlife-threateningevent.HereinliestheseedsofhopeforthereturningWarriorwithPTSD.Thechallengeisforhealthcareproviderstobeexcellentlyequipped,sotheycanhelptheWarriortominethegoldfromthesedimentofhisorhersuffering.Itisthisdepartmentsgoaltocreateatrainingcontextwherethiscanbecomearealpossibility.CONCLUSIONWarinIraqandAfghanistancontinuestobepersonal,leavinganexistentialvacuuminthelifeofthecombattraumasurvivor.ThereturningWarriorwithPTSDisnotanisolatedcell,mind,orbody.She/heispartofawidernetworkofrelationshipsand,astheWarriorattemptstosettlebackintoanormalfamilialcontext,thatwholenetworkofrelationshipsisaffectedbythesymptomaticcognitionsandbehaviorsassociatedwithPTSD.Asneverbefore,theDoDhaslookedthisproblemstraightintheeyeandrespondedwithahugecommitmentofresourcestoprovidewhateverittakestolessenoreradicateunnecessarysufferinginthelivesoftheWarriorandtheirlovedones.Asadepartment,itisaprivilegetobepartofasolutiontowhathasbeenaverypainfulprobleminthelivesofgenerationsofmilitaryservicemenandwomen.REFERENCES 1.MentalHealthAdvisoryTeam(MHAT)IVOperationIraqiFreedom05-07FinalReport.Washington,DC:OfficeofTheSurgeonGeneral,USDeptoftheArmy;November17,2006.2.DiagnosticandStatisticalManualofMentalDisordersFourthEdition(TextRevision).Arlington,VA:AmericanPsychiatricAssociation;2000.3.HogeCW,CastroCA,EatonKM.ImpactofCombatDutyinIraqandAfghanistanonFamilyFunctioning:FindingsfromtheWalterReedArmyInstituteofResearchLandCombatStudy,2006.In:HumanDimensionsinMilitaryOperationsMilitaryLeadersStrategiesforAddressingStressandPsychologicalSupport.MeetingProceedingsRTO-MP-HFM-134,Paper5.Neuilly-sur-Seine,France:5-15-6.4.VanEttenML,TaylorS.Comparativeefficacyoftreatmentsofposttraumaticstressdisorder:anempiricalreview.JAmMedAssn.1998;268:633-638.AUTHOR DrGraceisPTSDTrainerandInstructorforthePsychologicalHealthDivisionoftheSoldierandFamilySupportBranch,DeptofPreventiveHealthServices,ArmyMedicalDeptCenterandSchool,FortSamHouston,Texas.HeisresponsibleforArmywidetrainingoflicensedpractitionerswhoprovidedirectcaretoSoldierscarryingadiagnosisofPTSD.

PAGE 59

JulySeptember200857ArmyProviderResiliencyTraining:HealingtheWoundsOntheInsideRichardR.Boone,PhDCherylCamarillo,LCSWLisaLandry,PhDSSGJeromeDeLucia,USAFromIraqsIEDAlley,toWalterReedsIntensiveCareCenter;fromaCombatOperationalStressControlclinicinAfghanistantoBrookeArmyMedicalCentersBurnUnitArmymedicalandbehavioralhealthpersonnelareonthefrontlinesoftrauma-fightingandtraumaexposure.FamedpsychoanalystandHolocaustsurvivorVictorFranklonceremarked,Thatwhichistogivelightmustendureburning.1Perhapsthekeywordinthatwiseremarkisendure.Ifwe,asArmyhealthcareproviders,mustexperienceemotionalandpsychologicalhardshipstobringcaretoothers,howarewetoenduretheburnthatisanecessarycomponentofgivinglight?ToborrowfromarecentArmytelevisionadvertisement:theArmyhaslongexpectedmuchofitsmedicalandbehavioralhealthproviders,and,atlast,thisclassofSoldiercanexpectmorefromtheArmy.Whatfollowsisabriefaccountofhowthatmorehasbecomeavailableandwhatthatmoreactuallyis.ThestoryoftheArmyProviderResiliencyTrainingProgram(PRT)isthestoryofhowwecametorecognizetheneedtoprovidecareforthosewhosejobsandprofessionsaretocareforothers.Itisastorywithmanycontributors,anditisastorythathasevolvedovermanyyears.Finally,itisastoryofacommunityofcaregiverscomingtotermswiththeunpleasantrecognitionthatingivinglightandlifetoothers,theymayintheprocess,beburnedbythedarknessofprofoundillnessandcatastrophicinjury.Hereinliesaparadox:thatthemostvitalmeaningsofferedbylifeareoftenfoundinthemidstofsuffering,andyet,ifsufferingistostrengthenandelevate,itmustberedeemedbypeoplewhoarepowerfulagentsintheirownlives.Theredeemermustbeanagentwithanattitude:anattitudeofdetermination,anattitudeofcourage;anattitudeofhumor;andanattitudethathasasitsbedrockthebeliefthatwewillnever,nevergiveupnomatterthecost.WOUNDSONTHEINSIDEAfewyearsagothetelevisionnetworkHomeBoxOfficepresentedthepowerfuldocumentary,BaghdadER.Thiscriticallyacclaimedshowgaveviewersarealistic,oftenharrowing,glimpseintowhatitcanmeantobeanArmyhealthcareprovider.AsCOLCasperP.JonesIII,theCommanderoftheshowsprimaryfocalpoint,the86thCombatSupportHospital,remarkedatthetime,Youcanlearnaboutwarbywalkingthroughthisfacilitythehorrorsofwhatmancandotomanarevisualizedrighthere.Butwedoourbest,ourlevelbest,tomakesureourpeoplesurviveandmakeitbacktotheirhomes.2WEDOOURBESTThatphrasecaptureswelltheinformalcreedoftheArmyhealthcareprofessional.Itstatesclearlyourprofessionalintent.Moreover,itsuggestsindirectlythatthecircumstanceswhereinwecarryoutourintentareoftenlessthancongenial.Infact,inourtheatersofwarthosecircumstancescanbenearlyasdangerousastheenvironmentsinwhichourpatientsreceivetheirwoundsandinjuries.Beingincloseproximitytothetraumaofourpatients(bothgeographicallyandemotionally),itshouldcomeasnosurprisethatArmyhealthcareproviderscanthemselvesexperiencesomeaspectsoftraumatization.ConsiderthewordsofSPCSaidetLanier,an86thCombatSupportHospitaloperatingroomassistant:Thisishardcore,raw,uncuttrauma,dayafterday,everyday.Evenifyoureluckyenoughnottogohomewithwarwoundsontheoutside,ifyourenotequippedwithcopingskills,youlldefinitelyhavethemontheinside.2

PAGE 60

58www.cs.amedd.army.mil/references_publications.aspxDepartmentofDefenseResponsetoPosttraumaticStressDisorderARMYPROVIDERRESILIENCYTRAINING:THEBEGINNINGSNotlongafterthetragiceventsofSeptember11,2001,andtheinitiationoftheGlobalWaronTerror(GWOT),membersoftheSoldierandFamilySupportBranch(SFSB)oftheArmyMedicalDepartmentCenter&School(AMEDDC&S)begantoconsiderissuesrelatedtotheeffectsoftheconflictonhealthcareproviders.TheyrealizedthenthattheGWOTmightwellbeadifficultandprotractedeffort.Atthattime,theconceptofcareforthecaregivershadalreadyreceivedattentioninsuchareasasgeriatricpsychiatryandbehavioralmedicineasmentalhealthprofessionalshadbeguntoobserveandrespondtothedeleteriouseffectsofprolongedcare-givingonFamilymembersofthechronicallyill,particularlythosewithdementia.Initially,theBranchsinterestincompassionfatigue,secondarytrauma,andcaregiverburnoutresultedinbriefingsprovidedforafewcoursesattheAMEDDC&S.Soon,however,decisionsweremadetoteachPRTprinciplesinallAMEDDC&Scourses,tocreateadistancelearningPRTvideo,andtocreateMobileTrainingTeams(MTT)totakePRTproductsontheroad.Astheseproductsandservicesevolved,twosubtlebuthighlymeaningfulshiftsbegantotakeplaceintheverynatureofArmyPRT.Firstly,asoftenhappenswithArmyinitiatives,theSFSBbegantomilitarizetheterminology.Compassionfatiguebecameproviderfatigueandcaregiversatisfactionbecameproviderresiliency.Partofthischangewasdrivenbyourdesiretomakethetermsmorepalatabletomilitaryaudiences.However,theotherdrivingforce,anextremelywelcomeone,wasthemovementwithinbehavioralhealthawayfromafocusonpsychopathologytooneofpositive,strengths-buildingpsychology.Second,andperhapsevenmoresignificant,itwasagreedthatthemajorpsychologicalassessmentdeviceforthemeasurementofthesevariables,theProfessionalQualityofLifeTest(ProQOL*)wouldbemodifiedtospecificallyandexplicitlyaddresstheuniquestressorsandoperationalcircumstancesfacedbymilitaryhealthcareproviders,aprocessthatiscurrentlyunderway.Atthesametime,primarilyasaresultofthefeedbacktoourMTTmissionsregardingtheextentandseverityofproviderfatigueandsecondarytrauma,theBranchdecidedtodevelopaprogramthatwouldmakePRTavailabletoALLmembersoftheAMEDDcommunity,andtoidentifyandteachspecialPRTtrainersandsupervisorswhowouldbeembeddedwithinmostmilitarymedicaltreatmentfacilitiesandregionaltrainingcommands,andwhosejobitwouldbetoprovideongoingPRTeducation,assessment,andinterventionalactiontomedicaltreatmentfacilityproviders.ARMYPROVIDERRESILIENCYTRAINING:THEGIFTInDecember2007,theSFSBinvitedDrCharlesFigley(founderofthefieldoftraumatology),DrBethStamm(creatoroftheProQOL),andDrAlSiebert(foremostamongresiliencyexperts)totheAMEDDC&StopreviewandcommentontherecentlydevelopedPRTproducts.ThismeetingcoincidedwithdiscussionsbetweentheSFSBandtheArmyMedicalCommands(MEDCOM)BehavioralHealthDepartmentregardingthedevelopmentandexecutionofaproposedAMEDD-widePRTinitiative.Outofthesediscussions,andwiththesupportofTheActingSurgeonGeneral,anArmyMedicalActionPlantaskwasestablishedwhichrequiredassessmentofproviderfatigueandburnout,andtheimplementationofaPRTprogramthatwouldalleviateordecreaseproviderfatigueandburnout.AfternumerousSFSBandMEDCOMmeetingsandbriefings,theprogramwaspresentedtoandapprovedbyTheSurgeonGeneralonJune3,2008.Lessthanonemonthlater,onJuly1,2008,theArmyPRTinitiativewaslaunched.Atpresent,healthcareprovidersfromacrosstheArmyMedicalDepartmentarecompletingPhaseIofthe3phasePRTtrainingsyllabus.Thefirstphaseinvolves *Ascreeninginstrumentwhichmaybeusedtomeasuretheprofessionalqualityoflifeamongmedicalandmentalhealthprofessionalsinanorganization.TheProQOLmeasuresonespotentialforcompassionsatisfaction(ie,thepleasureonederivesfromdoingajobwell),burnout,andcompassionfatigue/secondarytrauma(ie,symptomsdevelopingfromsecondaryexposuretothetraumaticeventsofothers). TheFigleyInstitute,Tallahassee,FL.http://www.figleyinstitute.com/indexMain.htmlInstituteofRuralHealth,IdahoStateUniversity,Pocatello,ID.http://www.isu.edu/irh/index.shtmlTheResiliencyCenter,Portland,OR.http://www.resiliencycenter.com/

PAGE 61

JulySeptember200859THEARMYMEDICALDEPARTMENTJOURNALadministrationoftheProQOLforwhichimmediatefeedbackisgiventotheproviderregardinghiscurrentlevelsofcompassionsatisfaction(thepleasureonehasfromdoingonesworkwell),compassionfatigue(work-relatedstressortrauma),andburnout(afeelingofhopelessnessindealingwithonesoccupationalcircumstances).Thisphasealsohasabrief,butextremelyimportant,PRTvideowhichsetsthestageforonesongoingself-careresponsetotheinevitablechallengestowell-beingbroughtonbydifficultwork.PhaseIIinvolvesadditional,detailededucationintothemarkersofproviderfatigueandthepathwaystoresiliency.DuringPhaseIIthehealthcareproviderdiscusseswithhisorhertrainerthepersonalmeaningoftheProQOLresultsandmapsouttheall-importantself-careplan.Thisplanwillbethefoundationoftheproviderscommitmenttodevelopingapositive,resilientattitudetowardswork,home,andindeedalloflife.Thefinalphase,abirth-monthactivity,involvesProQOLreassessmentand,ifnecessary,afine-tuningorevenredirectionofonesself-careplan.Meanwhile,atanytimebetweentheprogramsphases,PRTtrainerswillbereadilyavailabletoassistindividualswithquestionsorconcernsthatrelatetoproviderfatigue,burnout,ortheself-careplan.Ofcourse,aswithanymandatoryArmytraining,thereisgoingtobesomepush-back,someresistancetoyetanothertrainingmissiontoaccomplishwhenthereissomuchworktobedone.Also,ithastobeacknowledgedthatmakingArmyPRTmandatoryrunscountertotheverynatureofpsychologicalhelp,anenterprisethattendstobelievethatpeoplehavetowanthelpandaskforitbeforeitiseffective.However,itwasdecidedthattheproblemwassufficientlysignificantandtheprogramsufficientlyusefulthatitwould,inthelongrun,besomethingthatwewouldbegladwewererequiredtodo.Itisourhopethatthiswillbetrue,andinkeepingwiththeinteractivenatureoftheprogram,itsuserswillhaveseveralopportunitiestocontributetheiropinionsastothequalityandutilityoftheprogram.Inthemeantime,weareconvincedthatArmyPRT,boththeprogramandthetrainers,arebestunderstoodasagift;agiftfromyourcommandertoyou.Itisagiftoftimeandopportunitytoreflectonyourselfandwhatyoucandotoimprovenotonlyaspectsofyourjobandyourreactionstoit,butalsoyourlifeingeneral.CONCLUSIONThewayahead,awaytowardwhichthePRTSectionoftheSFSBisalreadyengaged,isthewayfromindividualself-caretoorganizationalresiliency.Werealizethattheresiliency-buildinglaborsofeachhealthcareprovider,asnecessaryandsignificantastheymaybe,willnotbearfullfruitiftheorganizationforwhichthatpersonworksisinsensibleandinsensitivetotheissuesofproviderfatigueandburnout.WecontinuetoworkcloselywithcommandersandotherleadersinamutualefforttofindwaysofimprovingthelivesofprovidersthroughouttheArmyMedicalDepartment.Meanwhile,trainersarebeingtrained,andprovidersarebeingassessedandeducated.InthesewaysArmyPRTisbeginningtomakeavailablethecopingskillsaboutwhichSPCLanierspoke.Insodoing,wehopetoseeareductionintheextentthatourbraveandcapablehealthcare-giversarenegativelyaffectedbytheirwoundsontheinside.REFERENCES 1.FranklVE.Man'sSearchforMeaning:AnIntroductiontoLogotherapy.NewYork,NY:PocketBooks,Simon&Schuster;1963:129.2.BaghdadER[transcript].HomeBoxOffice.May21,2006.AUTHORS DrBooneisastaffpsychologistandinstructor,SoldierandFamilySupportBranch,DeptofPreventiveHealthServices,AMEDDC&S,FortSamHouston,Texas.MsCamarilloisaPRTInstructor,Writer,andSubjectMatterExpertintheSoldierandFamilySupportBranch,DeptofPreventiveHealthServices,AMEDDC&S,FortSamHouston,Texas.DrLandryisaPRTInstructorandWriterintheSoldierandFamilySupportBranch,DeptofPreventiveHealthServices,AMEDDC&S,FortSamHouston,Texas.SSGDeLuciaisaPRTInstructor/AdministratorintheSoldierandFamilySupportBranch,DeptofPreventiveHealthServices,AMEDDC&S,FortSamHouston,Texas.

PAGE 62

60www.cs.amedd.army.mil/references_publications.aspxINTRODUCTIONOnSeptember28,1971,TitleV(knownastheHughesamendment)ofPublicLaw92-1291wassignedintoeffect,mandatingthattheArmedForcesprovidesubstanceabuseidentification,treatmentandrehabilitationtoservicemembers.Sincethattime,theinitialconceptforalcoholanddrugtreatmenthasexperiencedmanychangesandchallenges.TheArmySubstanceAbuseProgramisgovernedbyArmyRegulation600-85,2whichdescribestherolesandresponsibilitiesofthecommand,thepreventionandeducationaspects,andthetreatmentlevelsandprograms.LastrevisedinOctober2001,ArmyRegulation600-85doesnotaddresssomeofthecurrentchallengesthatSoldiersandcommandersarefacinginIraqandAfghanistan,northosearisingafterreturntotheirhomedutystations.TheMentalHealthAdvisoryTeamV(MHATV)report3recognizedthatsubstanceabuseisariskfactorforbothdeployedandpostdeploymentSoldierswhoareexperiencinghighstresslevels,symptomsofposttraumaticstressdisorder(PTSD),depression,orotherdifficulties.Aclearneedforsubstanceabuseinterventionandtreatmenthasbeenidentified.Thisarticleexaminescurrentsubstanceuseintheater,discusseshowthishasdevelopedanddescribeshowtheArmyMedicalDepartmentCenterandSchoolsAlcoholandDrugTrainingSectioncontributestoaddressingtheneedsofSoldiers.CURRENTSUBSTANCEUSEANDTREATMENTINTHEATERFromthefirstdayofOperationIraqiFreedom,March19,2003,theUSArmys5thCorpsprohibitedalcoholpossessionintheIraqtheaterofwarwithGeneralOrderNumber1.Unfortunately,articlesinvariouspublicationsandmediamakeitapparentthat,despitethatmandate,alcoholandothersubstancesareavailableandbeingusedbySoldiersintheatertomanagestressandpsychologicalsymptoms.AnarticleinTheArmyTimes4inMarch2008describedinhalantusebySoldiers,sometimesresultingindeath.Aweeklater,anotherarticleintheStars&Stripes5describedalcoholasaweaponofchoiceinsexualassaults.AninternetsearchonsubstanceuseinIraqproducesnumerousarticlesdescribingtheavailabilityanduseofalcoholandotherdrugsbySoldiersduringdeployment.Forexample,publicationsasdiverseastheInternationalHeraldTribune6in2007andTheArkansasDemocrat-Gazette7in2005publishedarticlesaddressingproblemswithalcoholamongUSmilitarypersonnelinIraq.Suchnewsandmagazinearticlesmakeseveralthingsclear.First,alcoholandothersubstancesarenow,andhavebeen,available.Second,Soldiersareusingsubstancesformanydifferentreasons.Third,themajordeterrenteffortsusedbycommandersareunannouncedinspectionsandlegaloradministrativeactionsSoldiersfoundtopossessandusealcoholordrugssubjecttocourtmartialandconfinement.Thereisnomentioninanyofthearticleswereviewedofanytypeoftherapeuticintervention,counseling,ortreatmentbeingprovidedforSoldierswhoareusingalcoholordrugs.ItappearsthatthecurrentapproachistoorderSoldiersnottouse,topunishthemheavilywhentheydo,andnotprovideanytypeofmentalhealthinterventionorsupportwhendrugsoralcoholareinvolved.Therehaslongbeenconflictintheperceptionofalcoholanddruguseasalegalandmoralissueversusabehavioralordiseaseissue.Therearemultiplereasonsthatapersonmightusesubstances.Someofthereasonssupportedbytheresearchare:1.Selfmedication:thereductionofhyperarousalresultingfromconsistentlyhighlevelsofstress.2.Sharedvulnerability:geneticvulnerabilitytosubstanceabuseandotherdisorderswhichincreasethelikelihoodofsubstanceusefollowingatraumaticevent.DownRangeandBeyond:PreparingProviderstoSupportWarriorsinResolvingProblematicSubstanceUseJosephE.Hallam,MS

PAGE 63

JulySeptember2008613.Highrisk:ifhighriskfordevelopingasubstanceabuseproblemexistsbeforeatraumaticevent,theriskbecomesevengreateraftersuchanexperience.4.Susceptibility:whensubstancesareusedasacopingtoolinresponsetosymptoms,thesymptomsareactuallyincreased.Whenanyoracombinationofthesefactorscomeintoplay,theytendtooverrideanyconsiderationsofpotentialconsequencessuchasinspectionsorlegalactions.Prohibitiondoesappeartoworkonashort-termbasis.Howeverduetotheavailabilityofsubstancesandthestressofthehightempoofoperationsinthedeploymentenvironment,long-termprohibitionwithouttherapeuticinterventionrepresentsanunrealisticexpectation.Adeterrencestrategylimitedtoprohibitionandpunishmentisthereforeboundtofail.TheMHATVreport3identifiesseveraltrendsthatfurtherindicateaneedfordrugandalcoholpreventionandcounselingservicesduringextendedoperations.Theassessmentrevealsanoverallrateofalcoholuseduringdeploymentof8%.3(p30)Duringtheirseconddeployment,Soldiersreporttwicetherateofalcoholuse,whilenoncommissionedofficersreporta37%increase.3(p47)Theuseofinhalantswasreportedat3.8%duringdeployment.3(p30)Theseratesofsubstanceusesupporttheconclusionthatthenumberandlengthofdeploymentsarecontributingfactorstoanincreaseinsubstanceuse.CURRENTPROBLEMSANDFORWARDSOLUTIONSThereare2obstaclestoprovidingbettersupportforSoldierswhoareat-riskforusingsubstances.Thefirstisthelackofapolicyforprovidingsubstanceabusetreatmentintheatre.Thesecondistoofewtrainedcareproviderstocounselat-riskSoldiers.AlcoholanddruguseisaknownriskfactorforSoldierssufferingfromanypsychologicaland/oremotionaldifficulty.Policyrecommendationsanddevelopmentarebeyondthescopeofthisarticle.TheMHATVreportaddressesthelackofcareprovidersbyrecommendingthat,priortodeployment,Soldierswithmilitaryoccupationalspecialties(MOS)68X*and68Wreceivetraininginsubstanceabuseandothertypesofcounseling.3(p100)TheconcernaboutcounselortrainingisalsoaddressedintheOTSG/MEDCOMPolicyMemo07-026dated17July2007.8ThismemofocusesontheneedforMentalHealthSpecialiststohaveworkassignmentsthatenablethemtodevelopsufficientcounselingskillstobeproficientwhentheyaredeployed.ThecounselingtrainingofferedbytheAlcoholandDrugTrainingSection(ADTS)isanotherresourcetohelpSoldierswitheitherMOS68XorMOS68Wgainproficiencyinbothindividualandgroupcounselingwithlittlesupervision.Traditionally,theADTSIndividualandGroupCounselingcourseshaveprovidedtrainingtoMOS68XSoldiers,civiliancounselors,andotherSoldiers/civilianswithabackgroundinprovidinghealthcare.ThisincludesmedicsandotherSoldiersassignedtotheArmySubstanceAbuseProgram.Thistraining,alongwithsupervisedworkexperience,providesabaseofcivilianandmilitarycounselorsthathavethenecessaryskillstoeffectivelyprovidecounselingtoSoldiers.ThesebasiccounselingskillscanbeappliedtoprovidecounselingtoSoldierswhoareexperiencingstressduringdeployment,orwhomaybedrinkingorusingdrugstorelievePTSDorothersymptomsofpsychologicaldistress.TheAMEDDsgoalofgreateravailabilityofcounselingservicesin-theaterisaneffortaimedatdirectlydecreasingtheratesofalcoholanddruguseduringdeployments.ALCOHOLANDDRUGTRAININGCOURSESTheADTSattheArmyMedicalDepartmentCenterandSchooliscomprisedofskilledstaffmemberswhoarecommittedtopresentingrelevant,qualitytrainingtosubstanceabusetreatmentproviders.Basedontheconceptoflife-longlearning,thecoursesprovidedbytheADTSareessentialfortheMentalHealthSpecialistandtheHealthcareSpecialist.Thecoursesarealsoasignificantenhancementforcredentialedprovidersatalllevelsofexperiencesincestudentscompletingthecoursesreceivecontinuingeducationunitsrecognizedbyallmajorcertificationandlicensingboards.ADTScoursescurrentlyoffered:TheIndividualCounselingCourse(5H-F4/302-F4):Thisisafastpacedcoursethatincorporatestheorybasedlearningandhands-onlearningwhiletrainingtoimprovetheparticipantscounselingskills.Thiscourseprovidesasmallgroupexperiencewherestudentsimprovetheirskillsthroughpracticeutilizingroleplaywithasimulatedpatient.TheGroupCounselingCourse(5H-F5/302-F5):Themosttalkedaboutofallthetrainingprovidedby *MentalHealthSpecialistHealthcareSpecialist

PAGE 64

62www.cs.amedd.army.mil/references_publications.aspxDownRangeandBeyond:PreparingProviderstoSupportWarriorsinResolvingProblematicSubstanceUseADTS,studentscanimmediatelyusetheskillstheylearnuponreturningtotheirjobs.Throughoutthefirstweek,studentsgetinformationandone-on-onetimewithaninstructortocreateagroupdesignthatwillworkinadeployedenvironmentorattheirhomestations.Thesecondweekofthecourseprovidesapersonalgroupexperiencefortheparticipants.Theexperienceisnotatherapygroup,however,participantsdooftenreportatherapeuticeffect.Participantsaregiventheopportunityforaglimpseintothepowerofgroup,bothasamemberandaleader.Atthemostrecentgroupcourse,theexcitementandreinvigorationofacivilianproviderwasevidentassheindicatedthatshehadbeenstuckwithhowtomoveforwardwiththePTSDgroupshewascurrentlyleading.ThereisnodoubtshewillimplementallthatshehaslearnedtoassistWarriorswiththeirhealing.TheAdvancedCounselingCourse(5H-F10/302/F10):TheAdvancedCounselingCourseisaone-weekresidentialcoursedesignedtoprovidemilitaryandcivilianmentalhealthtechniciansandotherprofessionalswithadvancedtraininginsubstanceabusetreatment.Specialemphasisisgiventotopicsfrequentlyneededforlicenseandcertificationrenewal,includingethics,culturaldiversity,familyviolenceandHIV/AIDS.Expertsfromthefieldareinvitedasfundspermit.TheFamilyCounselingCourse(5H-F7/302-F7):TheADTSstaffmembersareenthusiasticaboutthereinstatementoftheFamilyCounselingCourse.Duetolackoffundinginthepast,theApril2008FamilyCoursewasthefirsttobeconductedinseveralyears.ThisyearsFamilyCourseprovidedessentialtoolstoworkwithWarriorsandtheirfamilieswhoareunderpressureduetoPTSDandsubstanceuse.Thestudentsresponsetothetrainingwasoverwhelminglyfavorable.Becauseofthenumerousrequestsfromtheprovidersinthefield,theADTSstaffisadvocatingforthiscoursetobepresentedannually,ratherthanthecurrentbiennialschedule.TheManagementCounselingCourse(5H-F6):TheArmySubstanceAbuseProgram(ASAP)ManagementCourseislimitedtoASAPclinicaldirectorsorclinicalsupervisorswhohavemorethan50%oftheirdutiesperformingasaclinicaldirector.Thecourseisaone-weekresidentialcoursedesignedtoprovideclinicaldirectorswithcurrenttreatmentstrategies,treatmentdevelopments,researchdatainthesubstanceabusearena,JointCommissiononAccreditationofHealthcareOrganizationsinformation,andupdatesfromtheArmyMedicalCommandandotherappropriatesources.TheClinicalConsultantCourse(5H-F9):ThiscourseisdesignedprimarilyforphysiciansnewlyassignedasclinicalconsultantstotheASAP.Thepracticalrealitiesoftheclinicalconsultantposition,aswellastechnicaltipsandtraps,arediscussedatlength.Experiencedconsultantsalsobenefitbecausethecoursecontentvariesfromyeartoyear.REFERENCES 1.PubLNo.92-129,85Stat361.2.ArmyRegulation600-85:ArmySubstanceAbuseProgram.Washington,DC:USDeptoftheArmy;March24,2006.3.MentalHealthAdvisoryTeam(MHAT)V:OperationIraqiFreedom06-08,Iraq;OperationEnduringFreedom8,Afghanistan.Washington,DC:OfficeofTheSurgeonGeneral,USDeptoftheArmy;February14,2008.4.O'ConnorS.Deathbydust-off:huffing,thesecretwar-zoneepidemic.ArmyTimes.March10,2008:14.5.BurgessL.Report:alcoholaffectsassaultrateinArmy.Stars&Stripes,MideastEdition.March18,2008.Availableat:http://www.stripes.com/article.asp?section=104&article=60775&archive=true.6.VonZielbauerP.InIraq,Americanmilitaryfindsithasanalcoholproblem.InternationalHeraldTribune.March12,2007.Availableat:http://iht.com/articles/2007/03/12/news/alcohol.php.7.SchlesingA.Drugs,boozeeasyforGIstogetinIraq.TheArkansasDemocrat-Gazette.January3,2005.Availableat:http://www.november.org/stayinfo/breaking3/GIDrug.html.8.OTSG/MEDCOMPolicyMemo07-26.Subject:MilitaryOccupationalSpecialty(MOS)68X,MentalHealthSpecialistUtilization.FortSamHouston,Texas:Headquarters,USArmyMedicalCommand;July17,2008. AUTHORMrHallamisCourseManager,AlcoholandDrugTrainingSection,SoldierandFamilySupportBranch,DepartmentofPreventiveHealthServices,AMEDDCenter&School,FortSamHouston,Texas.

PAGE 65

JulySeptember200863TheFamilyAdvocacyStaffTraining(FAST)Coursewasfirstdevelopedinthemid1980sbysocialworkinstructorsandwritersattheBehavioralScienceDivisionoftheAcademyofHealthSciences,ArmyMedicalDepartmentCenterandSchool(AMEDDC&S),FortSamHouston,Texas.ThecoursewascreatedinresponsetoarequestbytheDepartmentoftheArmyfororientationtrainingfornewFamilyAdvocacyProgram(FAP)staffinthefamilyadvocacymission.ThecoursewasdesignedforbothActiveArmyandcivilianpersonnel,andincludedorientationtrainingforprofessional,paraprofessional,andsupportpersonnelin5areas:directservices,administration,evaluation,prevention,andeducation.ThecoursefieldedbytheBehavioralScienceDivisionin1985wasinitially3weeksinlength.Trainingwasprovidedinthefollowingareas:Administrationandmanagement(toincludebudgetmanagement)oftheFAPMarketingofFAPRoleoftheArmyCentralRegistryDevelopmentofprimaryandsecondarypreventionprogramsInvestigationandassessmentofchildandspouseabusereportsOverviewtothemedicalaspectsofchildandspouseabuseRolesandresponsibilitiesofthemembersoftheFamilyAdvocacyCaseManagementTeamFamilyAdvocacyCaseManagementTeamcasedeterminationprocessTreatmentplandevelopmentTosuccessfullycompletethecourse,studentswererequiredtoprepareandpresenta10-minuteinformationbriefingabouttheirroleinthefamilyadvocacyprogramtoaseniorfieldgradeofficerorcivilianequivalentduringthelastweekofthecourse.Inthelate1980s,theFASTcoursewaschangedfroma3-weekDepartmentoftheArmyCoursetobecomethe2-weekDepartmentofDefenseFamilyAdvocacyStaffTrainingCourseconductedbytheAMEDDC&S.Studentsforthis2-weekinterservicecoursewerefromallbranchesofthemilitary(Army,AirForce,Navy,andMarineCorps)witheachserviceresponsibleforselectingtheirrespectivestudentstoattend.Thenumberofparticipantsfromeachbranchofservicewasdeterminedbythesizeoftheirtroopforce,withtheArmyhavingthelargestnumberofstudentslots,followedbytheAirForce,Navy,andMarineCorps.Thenewlydesigned2-weekcoursecontainedinstructionthatamplifiedthemilitaryscommitmenttopreventingspouseandchildabusebyprovidingarangeofessentialservicestostrengthenSoldiersandfamilies.Theimportanceofprovidingvictimsafetyandoffenderaccountabilitycontinuedtobeapartofthetraining.ThecurriculumalsomaintainedafocusontheprimarypurposeoftheFamilyAdvocacyProgram,thepreventionofspouseandchildabuseandneglect.Breakoutsessionsforeachstudenttomeetwiththeirservicerepresentativeabouttheirrespectiveprogramswereincludedinthecurriculum.StudentsalsoreceivedinstructionontheorganizationoftheFAP,toinclude:RolesandresponsibilitiesoftheCaseReviewCommitteeDynamicsofchildandspouseabuseMedicalassessmentofchildabuseandspouseabuseChildsexualabuseProgramimplementationLegalissuesCaseinvestigationRecordsandresourcemanagementThecoursecontinuedtoincludearequirementthatthestudentssuccessfullycompletea10-minuteinformationbriefontheirroleintheFAP.Inthelate1990s,theNavy,MarineCorps,andAirForceoptionedoutofthe2-weekcourse.ThecourseagainbecametheDepartmentoftheArmyFamilyTheFamilyAdvocacyStaffTrainingProgramCindiGeeslin,LCSWJohnHartz,LCSWMichaelVaughn,LMSW

PAGE 66

64www.cs.amedd.army.mil/references_publications.aspxAdvocacyStaffTrainingCourse.Adecisionwasalsomadetodropthe10-minutebriefingasacourserequirement.The2-weekcoursehascontinuedtoevolvetomeettheneedsofthefieldandtoreflectthecurrentresearchinthefieldoffamilyviolence.Forexample,blocksofinstructionwereaddedtoaddresstheissuesofcultureandtheimpactofsubstanceabuseinfamilyviolence.Althoughthecourseisbasicinorientationtothefieldoffamilyviolence,thechangeincoursecontentissuchthatstudentswhoattendedthecourse10yearsagoormoremaybegivenawaivertoattendthecourseagaintobenefitfromthosechanges.DEVELOPMENTOFDISTANCELEARNINGAnotherpendingchangeisthedevelopmentofadistancelearningcomponentthatwillreplaceoneweekofthe2-weekcourse.Aftercompletionofthedistancelearningelement,studentsmayapplytocompletetheone-weekresidentcourse.Thisdistancelearningcomponentisbeingdevelopedtoconserveboththecostoftrainingandthelengthoftimecourseparticipantsmustbeawayfromtheirjobstoattendtraining.Also,thedevelopmentofdistancelearningtrainingallowstheinclusionofadditionalinformationthatcannotbeincludedinthe2-weekcourseduetotimeconstraints.Thefirststepinthedevelopmentofthedistancelearningcomponentwasthedeterminationastowhichcourseswouldbeincludedinthattraining,andwhichcoursesshouldremainintheresidentportionofthecourse.Itwasdeterminedthatblocksofinstructionthatareadministrativeinnature,andthattrainingwhichisrelevanttotheproblemsoffamilyadvocacycouldbeaccomplishedinthedistancelearningcomponentwithoutcompromisingthequalityofthetraining.Forexample,theblockofinstructionthataddressesthetopicofsubstanceabuseandthefamilywasincludedindistancelearningtraining,notbecauseitisnotimportantinaddressingtheissuesofchildandintimatepartnerviolence,butbecauseitisnotaspivotalindevelopingtheaccurateassessmentandtreatmentoffamilyviolence.Trainingintheresidentportionofthecoursewillcontinuetobethatinstructionwhichispivotaltothepreventionandaccurateassessmentandinvestigationoftheproblemsofchildandspouseabuse.Itisanticipatedthatthedistantlearningcomponentwillbeimplementednolaterthanfiscalyear2010.Onceitisfullyimplemented,costssavingsshouldbesubstantial.ThesavingswillallowmoreArmyfamilyadvocacyprofessionalstotakeadvantageofthetrainingwithnocompromiseinthequalityofthecourse.ADVANCEDTRAININGTheFamilyAdvocacyStaffTrainingCoursewasdesignedtoprovideanoverviewoftheissuesoffamilyviolencebyprovidingmembersofthemultidisciplinaryCaseReviewCommittee(CRC)withanunderstandingoftheroleofeachCRCmember.Tothatend,arequirementwasidentifiedtoprovideskill-buildingcoursesforthemembersofthefamilyadvocacyprogramwhohavetheprimaryresponsibilityfortheprevention,education,andtreatmentaspectsoftheprogram.Thisrecognitionledtothedevelopmentof6advancedcoursestoaddressthespecifictrainingneedsofthefamilyadvocacyprofessionalstaff.WiththeexceptionoftheSupervisorsCourse(3days),allcoursesare4daysinlength.Inordertoprovidefamilyadvocacycliniciansandpreventionandeducationproviderswiththemostup-to-datetraining,thecoursecontentunderthebroadertopicheadingischangedeachyeartoreflectthestate-of-the-arttrainingandmostcurrentresearch.ChildAbuseFamilyAdvocacyStaffTrainingCourse:Designedtoassistfamilyadvocacycliniciansandeducatorsinthedevelopmentofskillstoassessandtreattheproblemsofchildabuse.Specifictrainingisprovidedontheprevention,identification,investigation,andtreatmentofchildabuse.Blocksofinstructionincludetrainingonchildabuseriskassessment,familystrengthsandneedsassessment,andinterventionstrategiesforchildrenandfamilies.SpouseAbuseFamilyAdvocacyStaffTrainingCourse:Providesadvancedinstructiononspouseabuseinterventionandtreatmentissues.Blocksofinstructioninthis4daycourseincludeanoverviewtotheproblemsofspouseabuse,aswellastrainingonspouseabuseriskassessment.Riskassessmentisespeciallycritical,asthisassessmentprovidesafoundationonwhichfuturetreatmentisbased.Forexample,riskassessmentinformstheclinicianifcouplestreatmentisanoption,orifthetreatmentshouldbeprovidedingenderspecificgroups.TrainingTheFamilyAdvocacyStaffTrainingProgram

PAGE 67

JulySeptember200865THEARMYMEDICALDEPARTMENTJOURNALisalsoprovidedonvarioustreatmentoptionstoaddresstheproblemscausedbyspouseabuse.Treat-mentapproachesincludetreatmentoptionsforvictims,offenders,andthechildrenwhowitnessviolence.ThePreventionFamilyAdvocacyStaffTrainingCourse:Concentratesonpreventionofabusewithinthefamilybyplanningandimplementingvariousprogramsforspouses,parents,andchildren.Lawenforcementcrimepreventionasitrelatestothepreventionofchildandspouseabuseisalsoincluded.Instructionaddressesthetopicsofprogramplanningandevaluation,budgetmanagement,andthedevelopmentofpreventionprogramsforspouses,parents,andchildren.TheForensicFamilyAdvocacyStaffTrainingCourse:Providesadvancedinstructionontheacquisitionofforensicinterviewingskillsofchildrensothatdetailedstatementscanbeobtainedofeithertheirownabuse,orabusethattheyhavewitnessed.Athoroughstatementwithasmuchdetailedinformationaspossibleisrequiredwheneveranallegationofchildabuseorchildsexualabuseisreceived.Aresearch-basedprotocolthathasbeendemonstratedtoillicitfreenarrativefromchildrenabouttheirexperiencesisusedinthistraining.Smallgroupinstructionwithmultipleopportunitiestopracticetheinterviewprotocolisutilizedasakeymethodofinstruction.Trainingincourtpreparationisalsoincluded.TheMultivictimFamilyAdvocacyStaffTrainingCourse:Designedinrecognitionofthecomplexitiesinmanagingcasesthatincludeallegationsofchildsexualabusethatinvolvethepotentialoflargevictimpools.Frequently,allegationsofthistypeofabuseoccurinDoDsanctionedactivities,whichfurthercomplicatestheassessment,investigation,andmanagementofthesecases.Blocksoftrainingincludeinstructionintheareaofdevelopmentofavictimmatrixtoassistintheidentificationofpotentialvictimstobeinterviewed,legalissuesassociatedwiththeinvestigationofthesecases,andinterviewstrategiesforchildren,whichincludesinformationonmemoryandrecallofevents.TheSupervisoryFamilyAdvocacyStaffTrainingCourse:Threedaysoftrainingforcivilserviceemployeesandsocialworkofficersdesignedtoprovidetraininginthedevelopmentofsupervisoryskills.Thecoursewasdevelopedinrecognitionoftheneedtoprovidetrainingforindividualswhoaresupervisors,butwhohavenopriorexperienceortraininginthismission.Thecoursefocusesonbothclinicalsupervisionandadministrativesupervisoryresponsibilities.Trainingisalsoprovidedtomilitaryinstallationsbymobiletrainingteams(MTTs).Theyprovidea1daytrainingsessionwhichfocusesonteambuildingfortheCRCsandtheinstallationclinicaltreatmentteam.Thefocusofthetrainingiscurrentresearchintheareaofchildabuseandintimatepartnerviolence,aswellasteambuildingactivitiestoassisttheCRCintheirgroupefforts.Sincethemissionoftheadvancedtrainingistoprovideinformationonthemostcurrentresearchinthefieldoffamilyviolence,thesecoursesarecontinuouslyupdatedtoreflecttheneedsofthecliniciansandpreventionandeducationspecialistsservingourSoldiersandtheirFamilies.Anexampleofsuchchangeistheinclusionofaddictioninformationanditsimpactontheproblemsoffamilyadvocacyinoneadvancedcourseeachyear(eitherthespouseorchildabusecourse).Thiscourseisalsomadeavailabletothealcoholandsubstanceabuseclinicalstaff.ThejointtrainingwasimplementedtoprovidecliniciansinbothtreatmentareaswiththebestpossibleclinicalstrategiesinthetreatmentofArmyFamilies.Informationontheimpactofposttraumaticstressdisorderisalsoincludedinthistraining.SUMMARYTheFamilyAdvocacyStaffTrainingCoursehascontinuedtoevolvetoprovidethehighestquality,research-basedtrainingtomeettheneedsofArmyfamilyadvocacyprofessionals.TheBehavioralScienceDivisioniscommittedtoensuringthatthosechargedwithprovidingFamilyadvocacysupportreceivethebesttrainingavailableinprevention,education,andtreatmentforourSoldiersandtheirFamilies.AUTHORS MsGeeslinandMrHartzareFamilyAdvocacyProgramInstructorsandCourseManagersintheSoldierandFamilySupportBranch,DepartmentofPreventiveHealthServices,AMEDDCenter&School,FortSamHouston,Texas.MrVaughnistheFamilyAdvocacyProgramManager,SoldierandFamilySupportBranch,DepartmentofPreventiveHealthServices,AMEDDCenter&School,FortSamHouston,Texas.

PAGE 68

66www.cs.amedd.army.mil/references_publications.aspxINTRODUCTIONFromthetimenewrecruitsentermilitaryservice,theyaredrilledwiththeunderstandingthattoaccomplishthemissiontheymustmaintainandoperateanessentialweaponsystem.ThatessentialweaponsystemisthetrainedandarmedUSArmySoldier.Historically,theinstitutionaldevelopmentoftheUSArmySoldierhasincludedtoughphysicalconditioningcoupledwithrealistictechnicalandtacticaltraining.Thistraditionalapproachtoshapingnewrecruitshasconsistentlyproducedacorpsoftough,confident,flexible,andpreparedWarriorscapableofwinningincombatandwagingsuccessfulmilitaryoperations.BattlemindtrainingaugmentsthisskillsetbybuildingupontheWarriorsprovencombatskillsandmentalfortitudefortrulywecannotsendtheirbodieswherewehavenotpreparedtheirmindstogo.ThetermBattlemindwasoriginallycoinedduringtheearly1990sbyGeneralCrosbySaintwho,atthetime,wastheCommanderofUSArmyEurope.1Herecognizedthattherewasaneedtomentallypreparehistroopstobothdeployandthentransitionbacktotheirhomelifesuccessfully.Battlemind,asitisknowntoday,cametofruitionfollowingtheresearchfindingsoftheLandCombatStudy(2003-2004)spearheadedbyCOLCarlCastroandCOLCharlesHoge.2ThesedetaileddeploymentandsubsequentredeploymentdatawerecollectedandanalyzedbytheirteamattheWalterReedArmyInstituteofResearch(WRAIR).TheneedsidentifiedbytheanalysispavedthewayforthecreationoftheArmyspremierepsychologicalresiliencyprogramBattlemind.TheLandCombatStudyprovidedthestatisticalfoundationfromwhichBattlemindtransformedfromconcepttoapplicationasaviablereadinessenhancingtoolfordeploymentcyclesupporttraining.TheBattlemindTrainingSystemcontinuestodevelopasaprogramundera3-pillarapproachwhichincludesdeployment-relatedtraining,buthasfurtherevolvedintoinstitutionaltraining.BattlemindisnowdefinedasaWarriorsinnerstrengthtofacefear,adversity,andhardshipduringtoughtimeswithconfidenceandresolution.Itisthewilltopersevereandwin.BattlemindtrainingseekstobuilduponaWarriorsprovencombatskills,self-confidence,andmentaltoughnessascriticalaspectsoftheirtraining.TheBattlemindTrainingOffice,locatedattheArmyMedicalDepartment(AMEDD)CenterandSchool,FortSamHouston,Texas,continuestoworkinconjunctionwithWRAIRtodevelopresearch-based,relevant,psychologicalresiliencytrainingthatcanbeimpartedinalanguageandmannertowhichWarriorscanrelate.BATTLEMINDTRAININGOFFICEInMarch2007,theCombatStressActionsOfficewasreorganizedintotheBattlemindTrainingOffice,undertheumbrellaoftheSoldierandFamilySupportBranchattheAMEDDCenter&School.ItistheplatformfromwhichallBattlemindandCombatandOpera-tionalStressControlTrainingisdevelopedandfielded.TheobjectivesofBattlemindtrainingaretomentallyprepareourWarriorsfortherigorsofcombatandothermilitarydeployments;toassistourWarriorsintheirsuccessfultransitionbackhome;toprovideourWarriorswiththeskillstoassisttheirBattleBuddy*totransitionhome;and,finally,toprepareourWarriorstodeployagaininsupportofalltypesofmilitaryBattlemindTrainingSystem:ArmorforYourMindMAJ(Ret)JohnM.Orsingher,MS,USA2LTAndrewT.Lopez,MS,USAR1SG(Ret)MichaelE.Rinehart,USA *DefinedasthepersontowhomaSoldiercanturnintimeofneed,stress,andemotionalhighsandlows,whowillnotturntheSoldieraway,nomatterwhat.ThispersonknowsexactlywhattheSoldierisexperiencingbecauseheorsheiscurrentlygoingthroughasimilarexperienceorhasbeenthroughasimilarexperienceand/orsituationbefore.

PAGE 69

JulySeptember200867operations,includingadditionalcombattours.Theseobjectivesareaccomplishedvia3distinctcyclesofmilitarylife:Life-CycleTraining,Deployment-CycleTraining,andSoldier-SupportTraining.Eachofthesecyclesbuildsfromandcomplementstheothers.Life-CycleTrainingstrivestoeliminatethestigmathatsurroundsthesearchforbehavioralhealthcareandtopromoteresiliencethroughoutaWarriorscareer.Deployment-CycleTrainingprovidesWarriorswiththeskillsnecessarytothriveandadapttothestressorsofdeployment,andthensuccessfullytransitionfromtheextraordinarycircumstancesrelatedtomilitarydeploymentsbacktogarrisonandFamilylife.Finally,Soldier-SupportTrainingaddressestheuniqueneedsandspecificrequirementsofWarriors,theirFamilies,andthemilitarycommunityatlarge.LIFE-CYCLETRAININGBattlemindLife-CycleTraininginstitutionalizesBattlemindprinciplesandconceptsintotheUSArmytrainingandeducationsystem.Atthemostbasiclevel,WarriorsaretrainedhowtomentallypreparethemselvesforalltypesofcontemporarymilitarydeploymentswhilecaringfortheirBattleBuddies.Atthehighestlevel,seniorleaderswilllearnhowtodesignorganizationalmodelswhichpromotegrowth,reducebarrierstobehavioralhealthcare,andenhancetotalunitreadinessforlargetroopelements.Inotherwords,asourWarriorsprogressthroughtheircareers,theywillcontinuetobuildtheirBattlemindskillsinawaythatiscommensuratewiththeirlevelofresponsibility.ItensuresourWarriorsunderstandwhatis,andwhatisnot,withintheirdirectabilitytocontrol.Therearecurrently7BattlemindLife-CycleTrainingproductsinvariousstagesofdevelopment.AllinstitutionalizedBattlemindtrainingproductswillbefieldedbytheendoffiscalyear2009.BasicBattlemindTraining(BBT)isthebuildingblockforalllife-cycletraining.BBTwillbetrainedatBasicCombatTrainingandOneStationUnitTrainingprogramsofinstruction.ThetenetsofBBTincludetrustinleaders,BattleBuddies,andpromotesself-aid/buddy-aidskillswhichincludepeerinterventiontechniquestoensurephysicalandmentalwell-being.Warriorsaretaughttofocustheirthoughts,actions,andresiliencyskillswhileneverlosingsightoftheirduty,values,andtheWarriorEthos,regardlessofthesituationtheymayfindthemselves.BattlemindWarriorResiliency(BWR)isthecorecompetencytrainingforallAMEDDenlistedandofficerpersonnel.BWRiscurrentlybeingtrainedintheAMEDDEnlistedAdvancedIndividualTraining(AIT)andOfficerBasicOfficerLeadershipCourse(BOLC).Thisskills-basedtrainingemphasizesthoseskillslearnedinBBT;additionally,BWRteachesAMEDDpersonnelhowtoidentifyandassistWarriorswhomaybeinneedofbehavioralhealthtreatment.Theprinciplemessagewillbethatpsychologicaltraumaderivedfromcombatoroperationaldeploymentsconsistsofpredictableemotionsthat,whenrecognizedandbroughttolight,arealsotreatable.BWRstrivestoeliminateperceivedstigmashistoricallyassociatedwithWarriorsseekinghelpforbehavioralhealthproblems.BattlemindWarriorResiliencyTransitiontargetsthoseAMEDDenlistedandofficerpersonnelwhocompletedAITandBOLCbeforetheBBTandBWRwereincorporatedintotraining.ThisinstructionincludeselementsofbothBBTandBWR.BattlemindWarriorResiliencyRecertificationensuresestablishedBWRstandardsaremaintainedandvalidatedtotherequiredskillsetsintheexecutionofunit-levelresiliencyprograms.Thismodule,akintocardiopulmonaryresuscitationrecertification,willstrivetoremainadynamictrainingprogramthroughthecontinueduseofrelevantupdatesbasedonfurtherresearchfindings.BattlemindforLeaders(BFL)representsthecontinu-ationofBattlemindLife-CycleTrainingresiliencytrainingthroughtheprofessionalmilitaryeducationsystem.BFLbuildsupontheskillslearnedduringBBTandbeginstoshiftitsfocustoeffectiveleadershiptechniquesanditsdirectrelationshiptoindividualmoraleandtheincidenceofbehavioralhealthissuesinaunit.ThistrainingmeetstherequirementsspecifictojuniorleadersinthegradeofE4(P)toE6aswellasthatofcompanygradeofficers.Targetdeliverywillbetononcommissionedofficers(NCOs)attendingtheWarriorLeadersCourseandtheBasicNoncommissionedOfficerCourse,aswellastoofficersattendingBasicOfficerLeadershipCourseandtheCaptainsCareerCourse.BattlemindforLeadersIntermediate(BFL-I)buildsuponBFLtrainingandextendsitsfocustotheimplementationandmanagementoforganizationalhealthpoliciesatbattalionandsimilarsizedelementsforstaffpositionsandmidgradeleaders.Thistraining

PAGE 70

68www.cs.amedd.army.mil/references_publications.aspxnotonlyaddressesaspectsofWarriorleadership,italsodiscusseseffectivetechniquesofmentoringjuniorleaders.TargeteddeliverywillbeforNCOsattendingAdvancedNoncommissionedOfficersCourse,andtoofficersattendingIntermediateLeaderEducation.BattlemindPrecommandandSeniorLeaders(BSL)representstheculminationofBattlemindLife-CycleTrainingthatstartedwithBFLandBFL-I.BSLwilltargettheinformationandskillsnecessarytobuild,manage,andenforceumbrellaorganizationalpolicieswhichpromoteunitreadinessatbrigadelevelandhigher.ItwillalsomaintainafocusonresiliencyissuesuniqueforseniorNCOsandseniorofficersincommandpositions.BSLwillbetaughtduringprecommandandseniorservicecourses,toincludetheSergeantsMajorAcademyandtheWarCollege.DEPLOYMENT-CYCLETRAININGDeployment-CycleTrainingispartofthereadinessinitiativesponsoredbytheArmyG-1calledtheDeployment-CycleSupportProcess.Battlemindtrainingprovidestargetededucationtobedeliveredatdesignatedtimesthroughoutall7phasesofdeployment(training/preparation,mobilization,deployment,employment,redeployment,postdeployment,andreconstitution).ResponsibilityforthedeliveryofDeployment-CycleSupporttraininghasbeensharedwiththeChaplainsCorpsasdirectedbyArmyDirective2007-02.3Thecombinationofchaplainsandbehavioralhealthprofessionalssignificantlyextendsthecapabilityfordeliveryofthistrainingfordeployingunits.Deployment-CycletrainingmodulesaredesignedtobuilduponexistingWarriorstrengthssuchasmentaltoughness,teamwork,andpsychologicalresiliencyasWarriorspreparetodeployandreturnfromalltypesofmilitaryoperations.ThesetrainingmoduleswereoriginallycreatedanddevelopedbyWRAIRusingdataanalysesfromtheLandCombatStudyandsubsequentMentalHealthAdvisoryTeamfindings.ThefindingsshowedthatWarriorswantedandneededtrainingwhichprovidedthemwithcopingskillsandtechniquesthatcouldbeemployedbefore,during,andafteradifficultdeploymentrotation.TheresultingtraininghelpsWarriorsbyprovidingthemwithconceptsandtoolsdesignedtoreducetheimpactofstressofpotentiallytraumaticevents(PTE)priortoexperiencingtheminadeploymentsetting.Pre-DeploymentBattlemindTrainingPre-DeploymentBattlemindTraining(PDBT)ispackagedintoindividualtrainingforWarriors,leaders,helping-professionals,andmilitarySpouses.Ideally,trainingisdeliveredinplatoon-sizedelementsorworkinggroupsofnomorethan40students.TrainingforSpousesandFamiliesistypicallyconductedbyFamilyReadinessGroupsorrepresentativesatArmyCommunityServicetosimilarsizedgroupsofFamilymembers.Allmodulesprepareeachofthesegroupsforrealitiesspecifictotheirdeploymentexperiences.InpredeploymenttrainingforWarriorsandleaders,theyarepreparedforawiderangeofsensory,psychological,andemotionalstimuliassociatedwithmilitarydeployments.Theleadertrainingmodulesexpandontheeducationbyhighlighting10toughfactsforleaders,suchastheexpectationofandpreparationforinjuriesanddeathsofonesunitmembers,andtounderstandthatdeploymentsplaceatremendousstrainonFamilies.PDBTexpoundsonthe10toughfactsforleaders,andgivesthemsomewaystohelpmitigatethepredictableeffectsonboththemselvesand,especially,unitmembersandtheirFamilies.Predeploymenttrainingforhelping-professionalsdiscusses12toughfactswhichincludeissuessuchasdealingwithburnout,thedeliveryofbadnews,andbreakingdownbarrierstocare.Finally,predeploymenttrainingforSpousesandFamilymembersfillsanextremelyimportant,butsometimesoverlooked,gapinpreparedness.ThetrainingisconductedwiththedeployingWarriorsandtheirrespectiveFamilies.ItprovidesagroupsettingopportunitytodiscusswhatWarriorswillexperienceonthebattlefield,whilealsoprovidingperspectivetotheWarriorsastowhattheSpouseandFamilywillexperiencewhiletheyaredeployed.ItemphasizestheimportanceofcommunicationandunderstandingbetweenFamilymembers.Furthermore,itprovidestheSpouseandFamilywithhomefrontexpectationsregardingthetemporarychangeofroleswithinthehousehold,havingtoweardualhatsasaparent,andwhenandwheretoseekhelpifneededwhiletheWarriorSpouseisaway.TrainingDuringDeploymentDuringthedeployment,Battlemindtrainingfocusesonmanagingthelevelofhealthandunitefficacyinthecontemporaryoperatingenvironment.4Duringadeployment,tragedycantakemanyforms,fromaclosecallunderhostilecircumstances,unitcasualties,BattlemindTrainingSystem:ArmorforYourMind

PAGE 71

JulySeptember200869THEARMYMEDICALDEPARTMENTJOURNALaccidents,orevenfratricide.Anyoftheseincidentscanshatterindividualoruniteffectiveness.Deployment-focusedBattlemindtrainingseekstomitigatetheeffectsofsucheventsbyreinforcingWarriorskills,self-aid/buddy-aid,battlefieldethics,andpreparingWarriorstocontinuetheirmissions.TheseskillsaretrainedtoTraumaticEventManagementpractitionersandreinforcedduringBattlemindPsychologicalDebriefings.TraumaticEventManagement(TEM)trainingplaysanenormousroleinhelpingWarriorsandunitsbounceback.TEMoffersinformationoncombatandoperationalstressreaction,PTE,posttraumaticstressdisorder,long-termstressreaction,andposttraumaticgrowth.TEMalsoteacheshowtofacilitatestructuredgroupdiscussionsforWarriorswhohaveexperiencedasignificantincidentintheater,andhowtomoveonandgrowfromthatexperience.TheTEMprogramwasdesignedtoprovideaconceptualframeworktoprovidetheabilitytoflexiblyapplysupportiveinterventionsinresponsetoaPTE.SuchinterventionsshouldbebasedonathoroughassessmentoftheimpactandlevelofdysfunctionthataspecificorseriesofPTEshavecausedorganizationsorindividuals.TheanalysisofdegradationresultingfromPTEexposureresultsinaseriesofselectiveinterventionsintendedtomaintainunitcohesionandhelpunitsregaincombateffectivenessasefficientlyaspossible.TEMwasdevelopedtoincludeevent-andtime-drivenformatswhichareflexibleandfocusedoneducation,whileallowingparticipantstoexplorepredictablereactionstoextraordinarystimuli.BattlemindPsychologicalDebriefing(BPD)wasdevelopedbyWRAIRafterextensiveresearchwithmilitarypopulations.6Whilethereareseveraldifferentkindsofdebriefingmodels,BPDfocusesontheuniqueaspectsofwhatWarriorsmustdealwithonthemodernbattlefield.BPDtrainingisprovidedtoBehavioralHealthandUnitMinistryassets.Whennecessary,theBPD-trainedTEMpractitionercanleadorfacilitateadebriefingwithagroupwhohasjustexperiencedaPTEwhileservinginthecontemporaryoperatingenvironment.TheBPDformatattemptstohelpWarriorsmakesenseofPTEs,andrestoreasenseofdutyandhonortotheparticipantssothattheycancontinuewiththeirmission.BPDisdifferentfromexistingciviliandebriefingmodelsinthattheSoldierinacombatzonemayberequiredtoenduresimilartraumaticeventsonmultipleoccasions,simplybecauseofthenatureofthework.ThatstandsinstarkcontrasttothenormalcivilianexperiencetheaffectedindividualwilllikelyneverbeexposedtoasimilarPTEagain,andtheoddsofrepeatedexposuresareinfinitesimallysmall.Therefore,theciviliandebriefingmodelhasasitsgoalassistanceandpreparationoftheindividualtorecoverandcontinuewiththerestofhisorhernormallife.PostdeploymentBattlemindTrainingPostdeploymentBattlemindtrainingclosestheloopontrainingforWarriorsandtheirFamiliesinregardstothedeploymentcycle.PartofthefindingsfromtheLandCombatStudyincludearequirementfortraininghowtotransitioncombatskillstohomeskills.WarriorshavedifficultyreintegratingintotheirhomelifeandwiththeirFamiliesonpredictabletimelinesfollowingadeployment.BattlemindITraining(PostdeploymentHealthAssessment)ispresentedtoWarriorswhoareredeploying,orwhohaverecentlyreturnedfromadeployment.Thismodulediscussesnormalhomecomingexpectationsandhowtosuccessfullytransitionfromthecombatzonetothehomezone.Thisone-hourblockofinstructionprovidesself-awarenesstrainingtoWarriors,adaptationskills,andeducationonfindingbehavioralhealthresources.Additionally,itdiscusseshowtomodifydesirablecombatskillswhichhelpedtheWarriortosurvivethedeploymentintoskillsthatwillbeusefulwhenbackwithFamilyandfriends.BattlemindIITraining(PostdeploymentHealthReassessment)iscomplementarytrainingtotheBattlemindImodulepresentedatthe3-to6-monthmarkfollowingadeployment.Itdiscussestheongoingtransitionhomeandhowtoworkthroughproblemswhichcommonlyariseamongcombatveterans.Thetrainingreinforcestheself-aid/buddy-aidconceptandattemptstodispelcommonmythsassociatedwithseekingbehavioralhealthassistance.BattlemindTrainingforSpousesandFamiliesispresentedtoWarriorsandtheirFamiliesinmuchthesamemannerasthepredeploymentversion.Thisblockreviewsmattersdiscussedpriortodeployment,andhelpsFamiliesstartadialogueregardinghowthingshavechangedsincetheWarriorwasfirstdeployed.

PAGE 72

70www.cs.amedd.army.mil/references_publications.aspxBattlemindTrainingSystem:ArmorforYourMindThemajorthemeofthistrainingcentersontheWarriorandSpousebecomingateamagain.DuringaWarriorsdeployment,theFamilyunitmaybegintorelyonexternalsupport,andindividualsmaybecomepersonallyindependent.TheresponsibilityoftheWarriortotransitionhisorhercombatskillsisdiscussed,butthatresponsibilityispairedwiththespousalresponsibilitytotransitionthehomefrontdeploymentskillsaswell.SOLDIER-SUPPORTTRAININGSoldier-SupportTraining(SST)capturestheuniquepopulationsandsubjectsthatLife-CycleandDeployment-Cyclemodulesdonot.SSTwillprovideBattlemindtrainingtoextendedsupportsystems,includingspecializedpopulationssuchasNationalGuardandReserveComponentspecificissues,militaryFamilies,andnetworkhealthproviders.ChaplainTraintheTrainer:ThegoalofthecourseistoteachchaplainsandchaplainassistantshowtoreturntotheirinstallationsandtrainremainingchaplainsandbehavioralhealthassetsintheeffectivepresentationofDeploymentCycleSupportBattlemindTraining.ModulesmandatedbytheArmyG-1include:PredeploymentBattlemindtrainingforLeadersandWarriors,BattlemindI(PostdeploymentHealthAssessmenttraining),BattlemindII(PostdeploymentHealthReassessmentTraining),TraumaticEventManagementtraining,BattlemindPsychologicalDebriefingtraining,andPre/PostdeploymentmodulesforSpousesandFamilies.TheCombatandOperationalStressControl(COSC)Courseisthepremierplatformofdeploymentcentricpreventiontrainingforbehavioralhealthandunitministrypersonnel.Thecourseoffers5daysofdidacticeducationandpracticalexercisesonthelatestCOSCdoctrineandbattlefieldupdates.Inadditiontodoctrinaltraining,studentsalsoreceivebriefingsonrelatedareasincludinganalysisofthemostrecentMentalHealthAssessmentTeamdata,mildtraumaticbraininjury/concussionawareness,theArmyCenterforEnhancedPerformance*EducationModel,BattlefieldEthics,SexualAssaultPreventionIn-TheaterandbriefingsfromtheNavy,AirForce,andMarineCorpsCOSCprofessionals.PriorityofattendanceforthiscoursegoestopersonnelpreparingtodeployoverseasinsupportofOperationsIraqiFreedomandEnduringFreedom.PriorityattendeesalsoincludeAirForcebehavioralhealthpersonnelwhohavebeentaskedtodeployinlieuofArmypersonneltosupportArmymissions.AdvancedmodulesoftheCOSCCourseareindevelopmentandwillhavemorepracticalexercisesandhands-ontrainingwhichfocusonspecifickeyCOSCpreventionandinterventionconcepts.WarriorsinTransition(WT)arethoseWarriorswhoareassignedtoaWarriorTransitionUnit(WTU).TheseWarriorsreceivetreatmentandrehabilitationforinjuriessustainedinthecombattheater.TheBattlemindTrainingOffice(BTO)hasdevelopedtrainingforWTUstaffduringtheWTUResidenceCoursetoincludetraininginSuicideAwarenessandBattlemindResiliencyTraining.TheSpouses,Families,andfriendswhocareforWTswhoarerecoveringfrombothphysicalandpsychologicaltraumaareknownasWTCaregivers.BTOisintheprocessofdevelopingtrainingmodules,videos,andacounselingprogramthatfocusesontheuniqueneedsofWTCaregivers.WEBSITE,INTERACTIVEVIDEOS,ANDMARKETINGAswithanythinginthisworld,informationisessentialinmakingsounddecisionsandkeepingourselvesawareofoursurroundings.ThemarketingofBattlemindisacrucialcomponentinraisingtheawarenessofourWarriors,commanders,Families,andotherorganizationsabouttheproductsandprogramswehaveavailable.TheBTOhasandcontinuestopromoteitsprogramsinseveraldifferentwaysinordertoreachasmanypeopleaspossible.Recently,theBTOlaunchedaninternetportalwhichhasbecometheArmysofficialBattlemindwebsite(http://www.battlemind.army.mil).ItwillbecomeamajorconduitfortheBTOtodispenseinformationandtraining,andwillbearesourceforWarriors,Families,commanders,andbehavioralhealthproviders.MarketingoftheBattlemindlogoanditstenetshavetakentheBTOfromboothsatseveralconferencestothetrainingofAirForcebehavioralhealthprovidersandCanadian,ElSalvadoran,andSlovenianmilitarypersonnel. *TheCenterforEnhancedPerformanceisadepartmentoftheUSMilitaryAcademyPreparatorySchool,WestPoint,NewYork.Informationisavailableathttp://www.usma.edu/USMAPS/pages/academics/cep_home.htm.

PAGE 73

JulySeptember200871THEARMYMEDICALDEPARTMENTJOURNALEducationistheprimaryleveragewehaveinthedevelopmentofawarenessandanunderstandingoftheissuesthatchallengethewoundedWarrior.Technologyasafundamentalmodalityofeducationtodayiseffectiveandreadilyavailable.TheAMEDDBattlemindTrainingOfficebelievesthatthereissignificantvalueincreatingVirtualExperienceImmersiveLearningSimulationsthatwillallowbothwoundedWarriorsandthoseinvolved/investedintheirrecoverytopracticedealingwithissuesincomputer-basedand/orweb-basedexperiences.Suchsimulationsallowpeopletoexploreandunderstandissuesandchallengesinawaythathelpsthemprepareforsuccessfullydealingwiththoseissuesandchallengeswhentheyfacetheminreallife.TheBTOinconcertwithAMEDDTelevisionarecurrentlyworkingonseveralvideoprojectsthatwillbeusedtoeducateWarriorsandFamilymemberstoincludeSuicideAwareness,PosttraumaticStressDisorder,andSeekingBehavioralHealthCare/ReducingStigma.CONCLUSIONAlthoughstillinitsinfancy,theBattlemindTrainingOfficehasbecomethelargesttrainingbranchintheSoldierandFamilySupportBranchattheAMEDDC&S.ThediverseandimportantmissionsofBTOhavebecomeafocalpointwithintheAMEDDandatseniorArmycommandlevels.CampaignsduringOperationsIraqiFreedomandEnduringFreedomhaveshownusthatwemustremainflexibletobeabletomeetmissionobjectives.BTOstrivestobeproactive,flexible,andasforwardthinkingaspossible.RemainingfocusedontheWarriorandtheirFamilyneedsremainsourobjective.PreparingWarriors,leaders,andtheirFamiliesfortheoperationaltempoofourcurrentArmyisofcrucialimportance.ACKNOWLEDGEMENTTheauthorsthankLaurenceHunter,MichaelHagan,CurtisCollins,ValWilson,DuaneMeyer,andToyaTrevinofortheircontributionsandassistanceinthepreparationandreviewofthisarticle.REFERENCES1.SaintCE.BattlemindGuidelinesforBattalionCommanders.Heidelberg,Germany:Headquarters,USArmy,EuropeandSeventhArmy;1992.2.HogeCW,CastroCA,MesserSC,etal.CombatdutyinIraqandAfghanistan,mentalhealthproblems,andbarrierstocare.NEnglJMed.2004;351(1):13-22.Note:ThearticleisreprintedinthisissueoftheAMEDDJournal,beginningonpage7.3.ArmyDirective2007-02.DeploymentCycleSupport(DCS)PolicyGuidance.Washington,DC:USDeptoftheArmy;March26,2007:12-13.Availableat:http://www.army.mil/usapa/epubs/pdf/ad2007_02.pdf.Accessed18August2008.4.Thecontemporaryoperatingenvironmentistheoperationalenvironmentthatexiststodayandfortheclearlyforeseeablefuture.AnoperationalenvironmentisdefinedinDoDJointPublication1-025asacompositeoftheconditions,circumstances,andinfluencesthataffecttheemploymentofmilitaryforcesandbearonthedecisionsoftheunitcommander.5.JointPublication1-02:DoDDictionaryofMilitaryandAssociatedTerms.Washington,DC:JointStaff,USDeptofDefense:July12,2007.Availableat:http://www.dtic.mil/doctrine/jel/new_pubs/jp1_02.pdf.6.AdlerA,CastroC,McGurkD.BattlemindPsychologicalDebriefings.WalterReedArmyInstituteofResearch,USArmyMedicalResearchUnitEurope,Report#2007-001;2007.Availableat:http://www.usamru-e.hqusareur.army.mil/Battlemind%20Psych%20Debriefing%20Procedures%202%20APR%2007.pdf.Accessed18August2008.AUTHORS MAJ(Ret)Orsingher,2LTLopez,and1SG(Ret)RinehartareInstructor/WritersintheBattlemindTrainingOffice,SoldierandFamilySupportBranch,DepartmentofPreventiveHealthServices,AMEDDCenter&School,FortSamHouston,Texas.

PAGE 74

72www.cs.amedd.army.mil/references_publications.aspxINTRODUCTIONFornearlyacentury,civilianuniversitieshaveassumedamajorroleinrecruiting,preparing,andequippingbehavioralscienceprofessionalstoserveinthevariousuniformedservices.ThisisespeciallytrueasitrelatestoArmysocialworkers,whohaveplayedanintegralroleintheArmysattempttoprovidecomprehensivemedicalhealthcaretoSoldiersandmilitaryFamilymemberssincethebirthofArmySocialWorkinNovember1943.1ShortlyafterthecreationoftheArmySocialWorkmilitaryoccupationalspecialty,FortSamHoustondevelopedasubprofessionaltrainingprogramthatwouldhelpmoldandpreparecivilianeducatedsocialworkersforthedifficultmissionthattheyhadchosentopursue.2From1918,theyearinwhichSmithCollegeopenedthedoorsoftheSmithPsychiatricTrainingProgramwiththeexpressedpurposeofeducatingcivilianstoworkassocialworkersinmilitarycommunities,until2008,civilianuniversitieshavehadaclearanddefiniteroleinthedevelopmentofmilitarysocialworkers.Thecivilianuniversitieseducatethem,andtheArmyrefinesthemviamilitaryspecifictraining.However,onFebruary2,2008,thepartnershipbetweenFayettevilleStateUniversity(FSU)andtheArmyMedicalDepartment(AMEDD)changedthiswiththedevelopmentoftheArmy-FayettevilleStateUniversityMasterofSocialWork(MSW)Program.ThisarticleprovidesahistoricalglimpseatthecircumstancesthatledtothedevelopmentofamasterofsocialworkprogramatFortSamHouston.Inaddition,thearticleprovidesanoverviewoftheadmissionstandards,CouncilonSocialWorkEduca-tionconsiderations,andthestepsthattheArmyMedicalDepartmentCenter&School(AMEDDC&S)andFayettevilleStateUniversitytaketoensureconsis-tencythroughclosecollaborationandpartnershipinthecreationoftheprogram.HISTORICALPERSPECTIVEInNovember2006,TheArmySurgeonGeneral,inresponsetoarecognizedshortageofsocialworkofficers,approvedaproposalfortheAMEDDC&StoestablishamasterofsocialworkprogramtoeducateandtrainmilitarysocialworkerstomeetthebehavioralhealthneedsofSoldiersandtheirFamilies.TheplanfortheArmytodevelopagraduate-leveleducationprogramwasoriginallypresentedtoTheSurgeonGeneralbyColonelYvonneTucker-Harris,theSocialWorkConsultanttoTheSurgeonGeneral.3TheWaronTerror,multipledeployments,increasesintheattritionofcompanygradesocialworkofficers,andlicensurerequirementswereadverselyaffectingthesocialworkinventory.Moreover,ithasbecomeincreasinglydifficulttorecruitandretaincompetentandcommittedArmysocialworkers.Thus,itwascleartoArmyleadershipthatmoresocialworkerswereneeded,and,basedupontherealitythatsocialworkersintheArmywereoperatingat75%strength,itwasapparentthattheArmycouldnolongermaintainthestatusquoifitintendstomeetthementalhealthneedsoftheforceinthepresentandyearstocome.Civiliancollegesanduniversitieshavebeenteachingclassesonsocialworkrelatedissuessince1898,andofferinggraduateeducationssince1945.4TheArmyhasbeenrelyinguponcivilianuniversitiestodevelopsocialworkerswhomaybeinterestedinpursuingacareerinthemilitarysince1918.5Assuch,onemightquestionwhy,afterhalfacenturyofrelianceuponcivilianaccrediteduniversitiestoproduceArmysocialworkers,wouldtheArmyseektodevelopagraduatesocialworkdegreeproducingprogram?Eventhoughcivilianuniversitiesarethesoleproprietorofaccreditationsthatenablethemtooffergraduateandundergraduatesocialworkdegrees,thereremainsadearthofinformationinsocialworkcurriculaaboutpracticingsocialworkinamilitaryenvironment.6Asaresult,eventhoughgraduate-leveltrainedsocialworkerspossessgeneralknowledgeaboutthevalues,practices,andskillsofsocialwork,mostofthemknowlittletonothingaboutpracticingsocialworkinamilitaryenvironment.SimmonsandVaughn6revealedthatthemajorityofmilitarysocialworkersfoundthatalargepercentageoftheirgraduateeducationwasirrelevant,andthattheirbesttrainingwasreceivedonthejob.Therefore,eventhoughnewTheArmyMasterofSocialWorkProgramDexterFreeman,DSWMAJGraemeBicknell,MS,USA

PAGE 75

JulySeptember200873Armysocialworkershadtoendurethearduouseducationalprocessthatgraduatesocialworkprogramsoffered,noviceArmysocialworkersenteredtheArmywithasignificantdegreeofignoranceabouthowtoapplytheirsocialworkknowledgeandskillsinamilitaryenvironment.Infact,itwastherecognitionofanabsenceofknowledgeabouthowtopracticesocialworkasauniformedofficerinamilitaryenvironmentthatcompelledtheAMEDDtoestablishtheArmyPsychiatricSocialWorkTrainingProgramatFortSamHouston,Texas,in1945.2AnothercontributingfactortothedevelopmentoftheArmy-FSUMSWProgramwastheArmysinabilitytoaccessnewsocialworkgraduatesduetoindependentpractitionerlicensingrequirements.SinceOctober1998,incompliancewithfederallaw,7theArmyMedicalCommandhasrequiredthatallactiveduty,reservist,individualmobilizationaugmentee,andcivilservicesocialworkersmustpossessacurrent,valid,unrestricted(independent)professionallicensetopracticeaspartoftheArmyMedicalDepartment.Overtheyears,thispolicyhasimpactedtheavailabilityofsocialworkersthatwereeligibletoenteranddeployasindependentlypracticinghealthcareproviders.Inmoststates,agraduateleveleducatedsocialworkermustcompleteaminimumof2yearspostgraduatesupervisionunderalicensedclinicalsocialworkerbeforeheorshewillbecomeeligibletotaketheindependentpractitionerexam.8Asaresult,civiliansattendingtraditionalsocialworkprogramsarenoteligibletoentertheArmyupongraduationbecauseofthestatutoryrequirementforArmysocialworkerstohaveindependentpractitionerstatus.Therefore,theArmyhasbeenlimitedinitsabilitytorecruitthosenewsocialworkerswhomaybeinclinedtopursueacareerinthemilitary.Instead,theArmyhassoughttoattractsocialworkerswithindependentpractitionerstatus,manyofwhomarealreadyestablishedinastableprofessionalcareer,andthereforelesslikelytoconsideracareerinthemilitary.AfinalcontributingfactorfortheestablishmentofanArmyMSWProgramisrelatedtothestressanduniquenessofservingasanArmysocialworker.Therigorofservingasasocialworkerwiththemilitaryforceisdefinitelytakingatollonthesocialworkforce,reflectedbyanestimated10%attritioneachyearinthenumberofsocialworkersonactiveduty.Althoughnewsocialworkersarerecruitedeachyear,itisalmostimpossibletokeeppacewiththeattritionrate.Thisfactorhashighlightedtheimportanceofrecruitingsocialworkerswhoarenotonlyknowledgeable,butwhoarealsocommittedtoservingasmilitarysocialworkers.ThisprovedtobeamajorfactorthatinspiredthefocusoftheArmy-FayettevilleStateUniversityMSWProgram.COLJosephPecko,DirectoroftheArmy-FSUMSWProgram,pointedoutthattheprogramisdesignedtoaddresstheretentionproblembyrecruitingcurrentmilitarypersonnelwhounderstandtheArmylifestyleandhaveanappreciationforwhattheircommitmententails.9PROGRAMORGANIZATIONANDADMISSIONSTANDARDSTheArmyMSWProgramisaffiliatedwithFSUasanoffsiteprogram.FayettevilleStateUniversityisaccreditedbytheCouncilonSocialWorkEducationtoprovidegraduatesocialworkeducation.Further,thecurriculumofferedbytheAMEDDC&StostudentsthatattendtheArmy-FSUMSWProgramisidenticaltothecurriculumthatthestudentsreceiveontheFSUmaincampus.Thecurriculumisdesignedtoprovidegraduatesocialworkeducationtoindividualswithanundergraduateeducationinsocialworkandotherliberalartsrelatedareas.TheArmyMSWProgramwasdesignedtoserveasaforcemultiplierforthedepletedsocialworkinventorybyeducatingandtraining15to20Armysocialworkersperyear.TheprogrammeetstheCouncilofSocialWorkEducationcurriculumstandardsforanoffsiteprogramofFayettevilleStateUniversity.Thestudentsselectedtoattendtheprogrammusthavealiberalartsundergraduateeducation,havedemonstra-tedanabilitytoperformacademicallyatthegraduatelevel,andexpressastrongdesiretoserveasanArmysocialworker.CurrentactivedutySoldiershavebeentargetedastheprimarysourceforstudentsintheArmy-FSUMSWProgram.ThefirstcohortattendingtheArmy-FSUMSWProgramisbeingexposedtoanintense,clinically-focusedsocialworkcurriculumthatwillhelpstudentsunderstandthehistory,principles,practices,andskillstheywillrequiretosuccessfullyperformassocialworkersinamilitaryenvironment.Inaddition,thestudentsreceiveaheavydoseofsocialworkethics,humanbehaviorinthesocialenvironment,policypractice,avarietyofdirectclinicalpracticecourses,aswellasanumberofmilitaryspecificelectives.Theobjectiveofthisgraduateprogramistothoroughlyprepare,inamilitaryenvironment,futuresocialworkersinaccordancewiththestandardsofthe

PAGE 76

74www.cs.amedd.army.mil/references_publications.aspxTheArmyMasterofSocialWorkProgramCouncilofSocialWorkEducationsothateachgraduatewillbewellversedinhowtoapply,withinthemilitary,theknowledge,skills,andvaluestheyhaveacquiredduringtheirgraduateprogram.Itwouldtypicallyrequireacivilianprogram2yearstoprovidethetypeofeducationalprogramthatastudentintheAMEDDC&Sprogramwillbecompletingin12to13months.Oncethesestudentsgraduate,theywillgoontoaselectmilitaryinstallationtocompletea2-yearinternshipunderthedirectsupervisionofalicensedclinicalsocialworker.ThiswillenablegraduatesoftheArmyMSWProgramtoserveassocialworkofficersinhalfthetimeitwouldhavetakenthemhadtheyattendedatraditionalcivilianeducationprogram.Inaddition,graduatesoftheArmyMSWProgramwillhaveadirectimpactonthesocialworkinventoryupongraduation,andwillimmediatelybeginworkingwithSoldiersandFamilymemberswhomaybeaffectedbytherequirementsoftheGlobalWaronTerror.However,graduatesoftheprogramwillnotbeeligibletodeployuntilaftertheyhavereceivedtheirlicenseasindependentpractitioners.Thiswilloccuraftereachgraduateoftheprogramcompletesthepostgraduateinternshipandpassestheindependentpractitionerlicensingexamination.PROMOTINGCONTINUITYTHROUGHPARTNERSHIPInFebruary2008,FSUandAMEDDC&SdevelopedaneducationalpartnershipthatmarkedachangeinthewaysocialworkeducationwouldoccurforArmysocialworkers.However,anenormousamountofcollaborationoccursbehindthescenetoensurethattheintegrityofthecurriculumremainsintact.KeymembersfromtheFSUDepartmentofSocialWorkandtheAMEDDC&Steachingfacultyremaininconstantcontactviatelephoneconferencecalls,sitevisits,andvideoconferencecalls.TheAMEDDC&SteachingfacultyhavejointappointmentsasfacultyatFSUandattheAMEDDC&S.AllcurriculumandadmissiondecisionsareapprovedbytheprogramdirectoratFSUandthedirectoratAMEDDC&S.TheteachingfacultyattheAMEDDC&SattendmonthlyfacultymeetingswiththeotherFSUfacultyviavideoteleconferences,andtheyarealsomembersofotherfacultycommitteesatFSU.DrTerriMoore-Brown,DirectoroftheFSUDepartmentofSocialWork,describedthepartnershipasawin-winsituation.9Thestrengthofanypartnershipiscontingentuponthedegreetowhichbothpartiesbenefitfromtherelationship.Inthispartnership,FSUbenefitsthroughtheopportunitytoeducatefutureArmysocialworkerswho,inturn,willservethroughouttheworld.Inaddition,FSUwillalsohavetheopportunitytoserveascoprincipalinvestigatorsinanarrayofresearchopportunitiesthatwilltakeplaceattheAMEDDC&S.TheAMEDDC&Sbenefitsfromtheopportunitytoworkwithaqualityuniversitythathasacurriculumthatisconsistentwiththeneedsofthemilitary,whichenablestheArmytoexpeditiouslyofferanaccreditedgraduateeducationtoqualifiedSoldierswhodesiretobecomesocialworkofficers.CONCLUSIONSince1918,theArmyhasrelieduponcivilianuniversitiestoeducateandpreparesocialworkerstoserveinthemilitary.Throughouttheyears,thisarrangementhasbeenfraughtwithcomplicationsforwhichthemilitaryhascompensatedbyestablishingitsownmilitaryspecificon-the-jobtraining.TheWaronTerror,withalargepercentageofSoldiersandFamilymemberssuffering,hascausedtheArmytorethinkthisarrangement.TheSurgeonGeneraloftheArmycalledformorementalhealthproviders,andthesocialworkconsultantrecognizedthatitwasatimeforachange.TheArmyneededmorecompetentandcommittedsocialworkersnow,andtheArmysrelianceuponcivilianuniversitieshadprovedtobeinsufficientinprovidingthenumberofsocialworkersthatwasneeded.TheArmy-FSUMSWProgramrepresentsthechangethatwasrequiredtoequiptheArmywith15to20newsocialworkerseachyear.REFERENCES 1.GarberDL.Armysocialwork:fiftyyearsofprofessionalinnovation,vision,competence,andinitiative.Paperpresentedat:USArmySocialWorkPracticesCourse;June1992;SanAntonio,TX.2.CampE.TheArmyspsychiatricsocialworkprogram.SocWorkJ.1948;April:76-78.3.PeckoJ.Openingremarks.Paperpresentedat:TheArmy-FayettevilleStateUniversityMasterofSocialWorkProgramopeningceremony,FortSamHouston,TX;June23,2008.4.KendallKA,ed.WorldGuidetoSocialWorkEducation.2nded.NewYork:CouncilonSocialWorkEducationPress;1984.

PAGE 77

JulySeptember200875THEARMYMEDICALDEPARTMENTJOURNAL5.SmithCollegewebsite.SchoolofSocialWork:HistoryoftheSchoolpage.Availableat:http://www.smith.edu/ssw/admin/about_history.php.AccessedAugust,20,2008.6.SimmonsCA,VaughnD.Militarysocialworkersatwar:theirexperiencesandtheeducationalcontentthathelpedthem.JSocWorkEduc.2007;43(3):497-513.7.10USC1094(1998).8.AssociationofSocialWorkBoardsresourcesite.Licensingrequirements:table3:experienceandsupervisionrequirements.Availableat:http://www.datapathdesign.com/ASWB/Laws/Prod/cgi-bin/LawWebRpts2DLL.dll/EXEC/1/0bt906a10zjxfu1-czclwb1p6kn03.AccessedSeptember14,2008.9.WilsonE.Soldierscanearnmastersdegreeinsocialwork.FortSamHoustonNewsLeader.2008;50(13):1.Availableat:http://www.samhouston.army.mil/pao/pdf/04_03_08.pdf.AccessedSeptember18,2008.AUTHORS DrFreemanisanAssociateProfessorandtheAssistantDirectoroftheUSArmy-FayettevilleStateUniversityMasterofSocialWorkProgram,AMEDDCenterandSchool,FortSamHouston,Texas.MAJBicknellisanAssistantProfessorattheUSArmy-FayettevilleStateUniversityMasterofSocialWorkProgram,AMEDDCenterandSchool,FortSamHouston,Texas. TheUSArmyMedicalDepartmentCenterandSchool,FortSamHouston,Texas

PAGE 78

SUBMISSIONOFMANUSCRIPTSTOTHEARMYMEDICALDEPARTMENTJOURNALTheUnitedStatesArmyMedicalDepartmentJournalispublishedquarterlytoexpandknowledgeofdomesticandinternationalmilitarymedicalissuesandtechnologicaladvances;promotecollaborativepartnershipsamongtheServices,components,Corps,andspecialties;conveyclinicalandhealthservicesupportinformation;andprovideaprofessional,highquality,peerreviewedprintmediumtoencouragedialogueconcerninghealthcareissuesandinitiatives.REVIEWPOLICYAllmanuscriptswillbereviewedbytheAMEDDJournalsEditorialReviewBoardand,ifrequired,forwardedtotheappropriatesubjectmatterexpertforfurtherreviewandassessment.IDENTIFICATIONOFPOTENTIALCONFLICTSOFINTEREST1.Relatedtoindividualauthorscommitments:Eachauthorisresponsibleforthefulldisclosureofallfinancialandpersonalrelationshipsthatmightbiastheworkorinformationpresentedinthemanuscript.Topreventambiguity,authorsmuststateexplicitlywhetherpotentialconflictsdoordonotexist.Authorsshoulddosointhemanuscriptonaconflict-of-interestnotificationsectiononthetitlepage,providingadditionaldetail,ifnecessary,inacoverletterthataccompaniesthemanuscript.2.Assistance:AuthorsshouldidentifyIndividualswhoprovidewritingorotherassistanceanddisclosethefundingsourceforthisassistance,ifany.3.Investigators:Potentialconflictsmustbedisclosedtostudyparticipants.Authorsmustclearlystatewhethertheyhavedonesointhemanuscript.4.Relatedtoprojectsupport:Authorsshoulddescribetheroleofthestudysponsor,ifany,instudydesign;collection,analysis,andinterpretationofdata;writingthereport;andthedecisiontosubmitthereportforpublication.Ifthesupportingsourcehadnosuchinvolvement,theauthorsshouldsostate.PROTECTIONOFHUMANSUBJECTSANDANIMALSINRESEARCHWhenreportingexperimentsonhumansubjects,authorsmustindicatewhethertheproceduresfollowedwereinaccordancewiththeethicalstandardsoftheresponsiblecommitteeonhumanexperimentation(institutionalandnational)andwiththeHelsinkiDeclarationof1975,asrevisedin2000.IfdoubtexistswhethertheresearchwasconductedinaccordancewiththeHelsinkiDeclaration,theauthorsmustexplaintherationalefortheirapproachanddemonstratethattheinstitutionalreviewbodyexplicitlyapprovedthedoubtfulaspectsofthestudy.Whenreportingexperimentsonanimals,authorsshouldindicatewhethertheinstitutionalandnationalguideforthecareanduseoflaboratoryanimalswasfollowed.GUIDELINESFORMANUSCRIPTSUBMISSIONS1.Articlesshouldbesubmittedindigitalformat,preferablyanMSWorddocument,eitherasanemailattachment(withillustrations,etc),orbymailonCDorfloppydiskaccompaniedbyoneprintedcopyofthemanuscript.Ideally,amanuscriptshouldbenolongerthan24double-spacedpages.However,exceptionswillalwaysbeconsideredonacase-by-casebasis.Ingeneral,4double-spacedMSWordpagesproduceasinglepageof2columntextintheAMEDDJournalproductionformat.2.TheAmericanMedicalAssociationManualofStylegovernsformattinginthepreparationoftextandreferences.Allarticlesshouldconformtothoseguidelinesascloselyaspossible.Abbreviations/acronymsshouldbelimitedasmuchaspossible.Inclusionofalistofarticleacronymsandabbreviationscanbeveryhelpfulinthereviewprocessandisstronglyencouraged.3.Acompletelistofreferencescitedinthearticlemust beprovidedwiththemanuscript.ThefollowingisasynopsisoftheAmericanMedicalAssociationreferenceformat:Referencecitationsofpublishedarticlesmustincludetheauthorssurnamesandinitials,articletitle,publicationtitle,yearofpublication,volume,andpagenumbers.Referencecitationsofbooksmustincludetheauthorssurnamesandinitials,booktitle,volumeand/oreditionifappropriate,placeofpublication,publisher,yearofcopyright,andspecificpagenumbersifcited.Referencecitationsforpresentations,unpublishedpapers,conferences,symposia,etc,mustincludeasmuchidentifyinginformationaspossible(location,dates,presenters,sponsors,titles).4.Eithercolororblackandwhitephotographsmaybesubmittedwiththemanuscript.Colorproducesthebestprintreproductionquality,butpleaseavoidexcessiveuseofmultiplecolorsandshading.Digitalgraphicformats(JPG,GIF,BMP)andMSWordphotofilesarepreferred.Printsofphotographsareacceptable.PleasedonotsendphotosembeddedinPowerPoint.Imagessubmittedonslides,negatives,orcopiesofX-rayfilmwillnotbepublished.Forclarity,pleasemarkthetopofeachphotographicprintontheback.Tapecaptionstothebackofphotosorsubmitthemonaseparatesheet.Ensurecaptionsandphotosareindexedtoeachother.Clearlyindicatethedesiredpositionofeachphotowithinthemanuscript.5.Theauthorsnames,ranksoracademic/certificationcredentials,titlesorpositions,currentunitofassignment,andcontactinformationmust beincludedonthetitlepageofthemanuscript.6.Submitmanuscriptsto:EDITOR,AMEDDJOURNALATTN:MCCSDT2423FSH-HOODSTFORTSAMHOUSTON,TX78234-5078 DSN471-6301Comm210-221-6301Email:amedd.journal@amedd.army.mil