Expeditionary operational stress Control in the us navy
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Expeditionary Operational Stress Control in the US Navy
Chapter 8
expeditionary operational
stress control in the us navy
ROBERT L. KOFFMAN, MD, MPH*; RICHARD D. BERGTHOLD, PsyD†; JUSTIN S. CAMPBELL, PhD‡;
RICHARD J. WESTPHAL, PhD, RN§; PAUL HAMMER, MD¥; THOMAS A. GASKIN, PhD¶; JOHN RALPH,
PhD**; EDWARD SIMMER, MD, MPH††; and WILLIAM P. NASH, MD‡‡
INTRODUCTION
STRESS INJURY CONTINUUM MODEL
EXPEDITIONARY MEDICAL PLATFORMS
Hospital Ships
Expeditionary Medical Facilities
COMBAT AND OPERATIONAL STRESS CONTROL ELEMENTS
Special Psychiatric Rapid Interventions Teams
Carrier Psychology Program
Operational Stress Control and Readiness (OSCAR)
EMERGING CHALLENGES FOR OPERATIONAL NAVY MEDICINE
Individual Augmentation
Care for the Caregiver
SUMMARY
*Captain, Medical Corps, US Navy; Director of Deployment Health, Department of the Navy, Bureau of Medicine and Surgery, Deployment Health,
2300 E Street NW, Washington, DC 20372
†
Commander, Medical Service Corps, US Navy; Chief of Staff, Wounded, Ill and Injured, Bureau of Medicine and Surgery, 2300 E Street NW, Wash-
ington, DC 20372
‡
Lieutenant, Medical Service Corps, US Navy; Deployment Health Senior Analyst, Department of the Navy, Bureau of Medicine and Surgery, Deploy-
ment Health (M3C3), 2300 E Street NW, Washington, DC 20372
§
Captain, Nurse Corps, US Navy; Psychological Health Promotion Programs, Department of the Navy, Bureau of Medicine and Surgery, Deployment
Health, 2300 E Street NW, Washington, DC 20372
¥
Captain, Medical Corps, US Navy; Director, Naval Center for Combat and Operational Stress Control, 34960 Bob Wilson Drive, Suite 400, San Diego,
California 92134-6400
¶
Director of Combat Operational Stress Control, US Marine Corps, Manpower and Reserve Affairs, Personal and Family Readiness Division, 3280
Russell Road, Quantico, Virginia 22134
**Commander, Medical Service Corps, US Navy; Director for Mental Health, National Naval Medical Center Bethesda, 8901 Wisconsin Avenue, Bethesda,
Maryland 20889; formerly, Officer-in-Command, Presidential Support Program, Marine Barracks, Washington, DC
††
Captain, Medical Corps, US Navy; Executive Officer, Naval Hospital, 1 Pinckney, Beaufort, South Carolina 29902; formerly, Senior Executive Director
for Psychological Health, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, Silver Spring, Maryland
‡‡
Captain, US Navy (Retired); Assistant Clinical Professor, Department of Psychiatry, University of California at San Diego; formerly, Senior Consultant,
Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, Rosslyn, Virginia 22209
121Combat and Operational Behavioral Health
INTRODUCTION
The diversity of US Naval operations, which span the lifetime prevalence to be 40%, based on struc-
air, land, and sea/subsea dimensions, places extraordi- tured computerized telephone interviews designed
nary demands on sailors and their families. Although to make DSM-III-R (Diagnostic and Statistical Manual
the US Navy has traditionally been a deployed force, of Mental Disorders, 3rd edition, revised) psychiatric
the global war on terror (GWOT) has added to the diagnoses.3 For those deploying to Operation Endur-
Navy’s list of deployment-related stressors. Stress, as ing Freedom and Operation Iraqi Freedom (OEF/
it is referred to in this chapter, is considered as a trans- OIF), the risk for having symptoms of either of two
actional model1,2 described as a general strain imposed illnesses, posttraumatic stress disorder (PTSD) or
by the operational milieu that disrupts the physical major depressive disorder, is nearly the same: 20%
and psychological equilibrium of sailors, the outcome of these service members reported symptoms of at
of which is mediated by a complex interplay between least one of the two disorders, according to a report
variables specific to the individual, the situation, and from the RAND Corporation’s Center for Military
the dynamic interaction between the two. Health Policy Research.4 The dual imperatives of mis-
The impact of operational stress upon sailors sion effectiveness and moral responsibility for sailor
is manifested in the prevalence of mental health health provide the impetus for the Navy Medicine
problems among sailors who routinely deploy upon Support Command to develop and implement pro-
operational platforms. For instance, a study of 782 grams based on a comprehensive operational stress
active duty sailors and marines found the 1-year control doctrine.5 Discussion of these efforts is the
prevalence of any psychiatric illness to be 21% and focus of this chapter.
Stress Injury Continuum Model
Because stress injuries occur across a continuum charges unit leadership with ensuring that sailors are
of severity and settings, Navy stress control doctrine ready for deployment by fostering an atmosphere
must encompass all sailors regardless of their duty, within commands that promotes mental health and
platform, or assignment (afloat and ashore), not just resilience through realistic training, unit cohesion,
sailors in specific combat environs. Consequently, and mission focus. Sailors who deploy should be
Navy leadership (in collaboration with the US Marine competent, socially supported, and mentally prepared
Corps) has developed an overarching operational to encounter and adaptively cope with operational
stress control program applicable to the full panoply stressors.6 The SIC model contains five functions
of Navy missions (see also Chapter 7, US Marine Corps for leaders that encourage them to (1) strengthen
and Navy Combat and Operational Stress Continuum the mental resiliency of sailors through realistic and
Model: a Tool for Leaders). However, much of the purposeful training; (2) mitigate physiological stres-
seminal theory and applications for stress control in the sors by maximizing sailors’ access to proper sleep,
military are, as one would expect, derived from stress exercise, and nutrition; (3) develop processes for the
control practices in the combat environment. In that early identification of stress reactions and injuries;
vein, the doctrine being developed to forge broader (4) encourage sailors to care for one another (eg, with
Navy stress control initiatives into a more theoreti- “battle buddies”); and (5) remove barriers to care by
cally consistent and unified whole is adapted from supporting the transition of stress-injured sailors to
the combat stress injury model explicated by Figley higher levels of care and fostering stigma-free reinte-
and Nash.1 The starting point for this new paradigm gration of stress-wounded sailors.
in Navy stress control is the stress injury continuum At the first stage of the SIC, sailors are prepared
(SIC) model (see Chapter 7, Figure 7-1 for a description to confront stress. At the second stage, sailors are
of the model). This chapter will apply the SIC model reacting to the unique operational stressors that chal-
as the rubric for interpreting extant and future Navy lenge their physical and psychological equilibrium.
stress control programs. The outcome of this reaction becomes a function of
Adopted because of its ability to educate, accultur- person, situation, and person–situation interactions
ate, and engage all sailors in stress control, the SIC that influence whether the reaction is mild, transient
paradigm highlights how the onus for stress control distress or impairment with associated anxiety, irri-
is shared among line-duty leadership (eg, squadron tability, and unwanted behavioral change. However,
commanders, division officers, department heads), each operational milieu has some degree of stress re-
the individual sailor, and caregivers (eg, Navy Medi- action that is normative, which makes distinguishing
cine personnel, the Chaplain Corps). The SIC model between normative and abnormal stress reactions a
122Expeditionary Operational Stress Control in the US Navy
critical consideration for leadership, caregivers, and identify these injuries in themselves and others, Navy
individual sailors alike. Yet, at the reacting point in the Medicine and caregivers begin to play a more promi-
continuum, individual sailors must assume primary nent role in the stress injury phase of the continuum.
responsibility for identifying whether they and their At this phase, sailors are not expected to cope with
fellow shipmates are effectively coping with the strain their injury alone, but are empowered to seek help
of their deployment. Although stress reactions are from caregivers, who are the primary support for
considered normal reactions to high-stress environ- prevention of permanent, debilitating stress injuries.
ments, the severity, persistence, and impairment ex- Once a stress illness (behaviors that fall primarily
perienced by some sailors may transcend the reactions within diagnostic categories such as PTSD, depres-
experienced by the majority of sailors when perceived sion, anxiety, and addiction) is identified in a sailor,
through the eyes of leaders, shipmates, caregivers, or treatment becomes the primary responsibility of Navy
reacting sailors themselves. Medicine. Implementation of the SIC model includes
Rather than establishing clear dividing points, the the expectation that all leaders, sailors, and caregivers
conceptualization of stress injury as a continuum ac- will be able recognize and respond appropriately to
knowledges the complex interplay between sailors and sailors in distress.
situations that must be considered when attempting to The stress injury decision matrix (see Chapter
ascertain whether an individual’s stress reaction has 10, Figure 10-3) is an example of an SIC-based tool
surpassed the normative response and moved from designed to help leaders, sailors, and caregivers
stress reaction to the third stage in the SIC—stress in- determine if a sailor is ready, reacting, injured, or
jury. Use of the term “injury” here is important because ill because of an operational or life stressor. The na-
it conveys to leaders the presence of a more serious scent state of SIC makes it difficult to ascertain the
threat to both the sailors’ individual well-being and outcomes of the model as a doctrine for combat stress
operational effectiveness. Sources of stress injury can control. However, the model’s multidisciplinary
include trauma from experiencing horror, terror, and and theoretical nature, as well as the incorporation
helplessness during deployment; fatigue derived from of multiple stakeholders, is a promising feature for
accumulated deployment stressors; grief associated establishing doctrine. The multifaceted nature of the
with the loss of a valued person or thing; and moral SIC model also makes it an ideal context for integrat-
conflict in belief and value systems.1 ing the various operational stress control programs
Although stress-injured sailors are still expected to currently in place.
EXPEDITIONARY MEDICAL PLATFORMS
As alluded to in the SIC model, the Navy as an to humanitarian assistance and disaster response.
organization assumes two primary roles in combat- Serving as major instruments of diplomacy, these
ing stress: (1) preventive consultation and (2) care expeditionary platforms have taken Navy Medicine
provision. To keep sailors ready, preventive consul- into Afghanistan, Iraq, and Kuwait while simultane-
tation with line leadership supports development of ously providing preventive medicine, combat medical
command policies and procedures that both prepare support, health maintenance, medical intelligence,
sailors to face the mental rigors of deployment, and operational planning, and mental health services to
identify, help, and reintegrate sailors who have experi- military personnel.
enced stress injuries and illness. The more traditional
role involves direct healthcare service provision to Hospital Ships
those with stress injuries and the treatment of those di-
agnosed with stress illness. Because of the quantity of The fleet of hospital ships consists of the USNS
medical personnel, expeditionary medical platforms Mercy and USNS Comfort, which are home ported on
offer perhaps the widest range of Navy preventive the west and east coast of the United States, respec-
and direct care services in deployed environments. tively. The hospital ships have inpatient capabilities
Expeditionary platforms in the Navy consist of fleet comparable to major medical facilities ashore. They
hospital ships and expeditionary medical facilities each have 12 fully equipped operating rooms, a 1,000-
(EMFs). These platforms are a mixture of specific bed hospital facility, radiological services, a medical
capabilities that ensure mission flexibility within the laboratory, a pharmacy, an optometry laboratory, a
logistical constraints of the deployed environment. computed tomography scanner, and two oxygen-
Expeditionary combat and operational stress control producing plants. Both have a flight deck capable of
platforms must be capable of performing missions landing large military helicopters, as well as side ports
that range from combat service support in GWOT to take on patients at sea.
123Combat and Operational Behavioral Health
Expeditionary Medical Facilities independently or in combination with the theater’s
joint health system for evacuation, medical logistics,
EMF facilities are designed to approximate the medical reporting, and other functions.
same capabilities as fleet hospital ships, yet maintain a Taken together, hospital ships and EMFs are unique
smaller logistic footprint with high mobility. EMFs are among forward-deployed operational stress con-
fully modular, task-organized structures that can be set trol platforms with respect to the medical nature of
up in as little as 48 hours. As EMFs continue to evolve, their mission. Perhaps the greatest strength of these
they will provide more robust medical care for major platforms is that they include high concentrations of
conflicts, low-intensity combat, operations other than caregivers, providing a versatile mixture of expertise
war, and disaster/humanitarian relief operations. As and resources that can anchor both ends of the SIC
modular expeditionary units, EMFs may be employed model.
COMBAT AND OPERATIONAL STRESS CONTROL ELEMENTS
The three combat and operational stress control Composition and Mission
elements discussed in this section—(1) the Special
Psychiatric Rapid Intervention Teams (SPRINT), In 1983 SPRINT teams were formally chartered
(2) the carrier psychology program, and (3) the as one of the Navy’s Mobile Medical Augmentation
Operational Stress Control and Readiness (OSCAR) Readiness teams. Navy SPRINT teams are formally or-
program—have arisen within the last 30 years as ganized at Bethesda, Maryland; Portsmouth, Virginia;
outgrowths of a larger trend within the US armed and San Diego, California. Some informal teams are
services to institutionalize the integration of medical located at various overseas locations. Since their incep-
health expertise within operational units. In relation tion, SPRINT teams have not only provided interven-
to the SIC model, all three programs are oriented to tion in maritime mishaps, but also supported military
intervene between the stress injury and illness phases operations other than war, military contingency opera-
of the continuum. However, the carrier psychology tions, terrorist attacks, and natural disasters. Each team
program, and the OSCAR program in particular, also consist of two psychiatrists, two clinical psychologists,
play roles at the readiness end of the stress reaction one or two chaplains, two or more psychiatric nurses,
continuum, through the use of operationally embed- one or two clinical social workers, and four or more
ded caregivers to provide training and preventive hospital corpsmen psychiatric technicians. An officer
consultation to leaders in supporting individual is designated as the team leader, and a senior psychi-
sailor readiness. atric technician serves as the leading petty officer. The
SPRINT team’s mission is to be trained and immedi-
Special Psychiatric Rapid Intervention Teams ately available in the event of a contingency to (a) assess
the psychological effects of traumatic stress, (b) offer
History direct support to individuals and units affected by the
event, (c) identify and refer those needing psychiatric
In 1975 a collision occurred between the USS Belknap treatment, and (d) consult with commanders and lead-
and the USS John F Kennedy, resulting in a significant ers to mitigate the negative impact of the event. From
loss of life and extensive damage to both ships. Sub- the SIC perspective, SPRINT teams become involved
sequently, in 1977, a Navy liberty launch collided with at the reacting stage, the goal being to prevent sailors
another ship in the Barcelona harbor. In both incidents, from moving further along toward the injured and ill
the vessels involved were home ported on the east end of the spectrum. Teams also provide support to
coast, and the psychiatry department at Portsmouth families of active duty members.
Naval Hospital (now Naval Medical Center, Ports- Unit leaders are responsible for bringing SPRINT
mouth) in Virginia received a significant number of teams into the picture. The teams have limited equip-
patients presenting with stress symptoms related to ment consistent with their goal of being a rapid-
the incidents. It became apparent to Navy Medicine reaction force. Rapid fielding requires that the request-
that a plan for early intervention to avoid stress ill- ing command or agency provide logistical support
ness was needed. The same concepts developed to (berthing, messing, communications, transportation,
treat stress in combat were modified for use in early etc) to the team. Thus, SPRINT teams are deployable
intervention with disasters at sea; the result was the worldwide within 24 hours’ notice. Examples of prior
birth of the Special Psychiatric Rapid Intervention SPRINT deployments include Hurricanes Andrew,
Teams—“SPRINT.” Ivan, and Katrina; the terrorist attack on the USS Cole;
124Expeditionary Operational Stress Control in the US Navy
the TWA [formerly Trans World Airlines] Flight 800 including surface ships, submarines, and aviation
disaster; a civilian airline crash in Guam; and severe platforms; ground-centric Seabee and marine operat-
flooding and landslides in Central America. SPRINT ing areas; and joint service operations. Team members
teams also supported the guard force in the early days must also be knowledgeable and comfortable in deal-
of the detainee mission at Guantanamo Bay, Cuba. In ing with various Navy systems, organizations, and
addition to high-profile events, SPRINT teams also structural issues that affect how well a command
regularly respond to smaller-scale events such as withstands the impact of a stressful event. Most
work-related accidents that result in the death of a SPRINT responses are short-term (often only 1 day),
crewmember, suicides, and aircraft mishaps. but have lasted up to 6 months. In virtually all cases,
SPRINT teams work closely with local resources, and
Intervention Strategies turn over functions to the local resources as the situ-
ation permits.
SPRINT does not adhere to any specific professional Training for SPRINT teams involves a variety of
doctrine on intervention methodology. However, team approaches. New members always participate in
members are expected to be competent in their respec- SPRINT missions under instruction before leading
tive disciplines and well versed on the latest informa- missions. Psychiatric residents and psychology interns
tion in crisis intervention techniques and treatment are encouraged to participate, under supervision of
strategies for acute stress and PTSD. This allows the experienced team members. Psychiatric technician
teams the flexibility to adapt their responses to the students also receive training in disaster and trauma
demands of a particular situation while ensuring that response. Teams conduct regular refresher training in
their methodology is based on best practices and, when combat and operational stress first aid (COSFA),10 and
possible, evidence-based science. During the 1980s and many team members also receive familiarity training in
1990s, the critical incident stress management (CISM) CISM (although CISM’s use is discouraged, command-
technique was developed to help emergency service ers and others often ask about it, and knowledge of the
workers, such as firefighters, paramedics, and police technique can help to educate them). SPRINT teams
officers, address particularly stressful events. Attempts remain active during wartime, because natural disas-
were made to adopt CISM for use in military interven- ters, maritime accidents, and other noncombat stressful
tions, but its use has since been officially discouraged events continue during war, although staffing can be a
because it has not been proven effective in controlled challenge. The concepts, skills, and techniques devel-
trials, and some evidence shows that it could poten- oped through the Navy SPRINT teams’ experiences in
tially be harmful.7–9 peacetime are invaluable for informing and educating
Instead, the current focus is on providing command the wider Navy mental health community as a whole
consultation, psychoeducational intervention, and and contributing to the overall improvement of stress
psychological first aid. The team assists the command intervention and treatment of the operating forces.
in developing a strategy to mitigate the impact of the
event on the entire organization; provides timely, tar- Carrier Psychology Program
geted, and useful information for command members;
briefly contacts as many potentially affected individu- History
als as possible; and supports individuals in acute dis-
tress. Every attempt is made to avoid early labeling Since the mid-1990s, psychologists and psychiatric
or diagnoses, even for individuals demonstrating technicians have served as permanent members of
significant stress reactions. Rather, affected individuals ship’s company on all US Navy aircraft carriers. Be-
are encouraged to mobilize their own and community fore the initiation of the carrier psychology program,
resources to enhance recovery and restore functioning. 25 to 30 sailors were medically evacuated (medeva-
SPRINT teams generally provide support rather than ced) from a carrier for mental health reasons during
treatment. A benefit to adopting the support role is that a 6-month deployment.11 Since the inception of the
the teams generally do not contribute documentation program, the number of medevacs has averaged fewer
to medical records, thereby offering a higher level of than five per deployment. In 2001 the average fuel/
confidentiality. It is thought that such confidentiality transportation cost of a medevac from a deployed
can reduce the potential stigma associated with seek- carrier was estimated to be $4,400, suggesting that
ing mental healthcare. a typical deployed psychologist saves the Navy at
In addition to maintaining expertise in intervention least $110,000 per deployment in prevented medevacs
theory and techniques, SPRINT team members must alone.11 “Prevented medevacs” are defined as situa-
be proficient serving in diverse operational settings, tions in which sailors are retained onboard, but due
125Combat and Operational Behavioral Health
to serious psychological difficulties, would likely not patients’ chains of command. These consultations are
have been retained in the absence of a psychologist. intended to educate the command, but also to discuss
Moreover, this figure ignores the immeasurable costs strategies for preventing a worsening of symptoms.
of losing personnel with valuable experience, and Sailors who are reacting, injured, or ill constitute a
the lowered morale among remaining crew members considerable responsibility for carrier psychologists
who are forced to perform extra work to make up for and their staff. Carrier psychologists report an aver-
unexpected personnel shortages. Nor does the figure age of 105 patient contacts per month, so they are well
include the cost of providing escorts for medevaced utilized in the caregiving role. No doubt contributing
personnel. Additionally, nondeployed carriers report to the high utilization of carrier psychologist is the
an average of 2.8 prevented medical evacuations per fact that they live and work among their patients, fre-
month, thus this cost savings extends throughout the quently encountering them throughout the workday,
carrier training cycle. observing them performing their jobs and interacting
There are numerous examples of this cost savings. with peers. As shipmates, they are able to obtain an
Aboard the USS John F Kennedy in 1999, 28 sailors in-depth understanding of their patients’ daily lives.
were medevaced for psychological problems during Given this regular presence, unit members are more
a 6-month Mediterranean deployment. In 2001, on likely to utilize mental health services than they would
the ship’s first deployment with a psychologist, there if obtaining such care required a trip to a mental health
were no psychological medevacs.12 Similar results were clinic at a medical facility.
seen aboard the USS Carl Vinson in 199911 and the USS
Enterprise in 2001.13 More recent data continue to sup- Stigma Reduction
port this trend. Through 2006 and 2007, the estimated
number of prevented medevacs from deployed carri- Of all factors obstructing the provision of effective
ers averaged slightly more than four per month. (All mental healthcare to military personnel, the most
statistics are derived from monthly reports made by powerful may be the lingering perception within many
each carrier psychologist; the data are maintained by military units that seeking psychological treatment
the Navy clinical psychology community.) is a sign of personal weakness, or that such care will
harm one’s military career. One of the major findings
Prevention of Chronic Psychological Problems of the 2007 Department of Defense (DoD) task force
on mental health14 was that significant stigma remains
Embedded mental health providers are in the associated with seeking mental healthcare in the mili-
unique position of being able to identify problems at tary. A key recommendation, deemed “crucial to the
early stages in the SIC. By staying abreast of morale psychological health of service members,” was that
and remaining vigilant about the level of stress among “the military services should embed mental health
unit personnel, carrier psychologists can intervene professionals as organic assets in line units.”15(p4)
before problems become severe, either by reaching out Three obvious benefits of the SIC model in the
to individuals or groups at particularly high risk for carrier psychology program are apparent. First, the
mental health problems, or by advising the command familiarity between sailors and the ship’s psycholo-
on policies to enhance a unit’s overall psychological gist reduces the stigma associated with seeking help,
readiness. For many psychological disorders, most making it more likely for a sailor to ask for help be-
notably PTSD, early identification and treatment is fore a stress injury becomes a stress illness. Second,
essential to avoiding long-term difficulties. the proximity of mental health services reduces the
One of the best ways to prevent pathology before it temporal distance between recognition of stress injury
occurs is through education. In this role, carrier psy- symptoms and access to care, lessening the need for
chologists also buttress the work of unit leaders, who medical evacuations of sailors who have developed
ultimately bear the responsibility of readiness within debilitating stress illnesses. Third, psychologists de-
the SIC model. Carrier psychologists and shipboard tailed to a carrier are able to support the line leadership
psychiatric technicians conduct an average of 4.5 in developing a mentally ready force.
prevention-oriented classes per month. Such classes
are designed to help service members identify growing Operational Stress Control and Readiness (OSCAR)
psychological problems at an early stage (yellow and
orange zone) before they become debilitating. Embed- History
ded psychologists can also prevent serious problems
from developing through frequent interaction with OSCAR teams and carrier psychologists share
unit leadership. Carrier psychologists conduct over 40 many of the same preventive medicine and direct
consultations per month with representatives of their caregiving roles in addressing mental health issues
126Expeditionary Operational Stress Control in the US Navy
across the spectrum of the SIC. The OSCAR concept Corps. In response, the commanding generals of the
was begun in 1999 and piloted as the 2nd Marine three Marine expeditionary forces (MEFs) wrote to the
Division’s operational stress control and restoration commandant of the Marine Corps, stating, “We need .
program in 2000. Early OSCAR teams included mental . . OSCAR teams across the three MEFs. We must fully
health professionals, corpsmen, chaplains, and Ma- staff, fund, and equip the OSCAR program as soon
rine Corps staff noncommissioned officers in a fully as possible to support current combat operations.”17
integrated multidisciplinary team. In 2004 the Marine A formal request for OSCAR staffing was sent by the
Corps collaborated with the Navy Bureau of Medicine Marine Corps to the Navy in early 2008. Within a few
to authorize a 2-year pilot of OSCAR across all three months, the Navy approved funding to permanently
active Marine divisions. Staffing of the OSCAR teams staff OSCAR in the Marine divisions and regiments,
was tenuous due to competing wartime demands both active and reserve, starting in 2010.
for scarce mental health resources, but the pilot team
performed well, proving to be a valuable asset to Ma- Capabilities
rine Corps leadership. In 2006 the Center for Naval
Analyses16 evaluated the efficacy of the OSCAR pilot OSCAR teams provide the following capabilities
and summarized the model as follows: for operational commanders:
Applying a community mental health model to the • psychological health surveillance of unit
expeditionary and forward placed nature of Marine members and units as a whole;
life, and taking account of Marine culture, OSCAR is • preventive psychological health training and
an organic program embedded in the units it serves, education when and where needed;
expeditionary (accompanying the unit throughout the
• early interventions to promote recovery in
deployment cycle), multidisciplinary (incorporating a
team approach), preventative (stressing the full range
individuals and units from traumatic stressors
of primary, secondary, and tertiary prevention mea- or losses;
sures), and therapeutic (providing appropriate mental • clinical mental healthcare services in forward
health services).16(p1) operational environments where such services
would otherwise be unavailable;
The center deemed the OSCAR pilot and model • professional coordination of comprehensive
successful in reaching target audiences and capable mental healthcare services in garrison before
of producing expected outputs. OSCAR was recom- and after deployments to ensure readiness;
mended for continuation and expansion beyond the • support of spiritual fitness of operational forc-
active Marine divisions to the air wings, logistics es throughout the deployment cycle through
groups, and possibly the drilling reserves. partnerships between religious ministry and
In 2006 and 2007, the Marine Corps sponsored mental health personnel; and
several working groups to further develop OSCAR • psychological health support for unit medical
capabilities and requirements, with representation and religious ministry personnel who are at
from stakeholders including Marine Corps health high risk for stress-related problems.
services, religious programs, training and education,
and the operating forces. Optimal OSCAR capabili- OSCAR capabilities are critically dependent on
ties were developed. In acknowledgment of the core teams being organic, that is, embedded within opera-
Marine Corps concept that combat and operational tional units, much like the traditional model of Navy
stress control is primarily a leadership responsibil- hospital corpsmen. By placing OSCAR teams within
ity, and should be focused on force preservation and units, team members can fully learn and appreciate the
readiness through prevention and early identification specific missions and cultures of the units they support
more than treatment, the OSCAR program was moved throughout the deployment cycle: before, during, and
from health services to the Combat Operational Stress after deployment.
Control Program under the deputy commandant for The ultimate objectives of OSCAR capabilities in op-
manpower and reserve affairs. erational units are (a) enhanced readiness, (b) reduced
Despite the 2007 DoD report15 recommending that stress-related decrements to mission effectiveness,
operational psychological health professionals be em- and (c) enhanced long-term health and well-being
bedded in line units, staffing of OSCAR teams by the of marines, sailors, and their families. OSCAR teams
Navy remained on an ad-hoc basis because of other provide psychological health training to marines and
pressing needs for mental health resources across the Marine leaders, and reduce the stigma associated with
system. Sustaining OSCAR became increasingly dif- receiving mental healthcare. They can assist leaders
ficult without a formal requirement from the Marine and marines with informal “hallway consultations”
127Combat and Operational Behavioral Health
on symptoms and complaints to encourage early miti- • one prescribing, licensed, independent mental
gation of stress and to promote the earliest interven- health practitioner (psychiatrist, prescribing
tions when necessary. Team members also serve unit psychologist, or psychiatric nurse practitio-
leaders as advisors on how to prevent stress, monitor ner);
the psychological health of their units, and take neces- • one nonprescribing, licensed, independent
sary actions to promote healing. Compared to mental mental health practitioner (psychologist or
health services provided at medical treatment facili- licensed clinical social worker); and
ties, OSCAR is much more focused on prevention and • two psychiatric corpsmen.
population-based mental health than on individual
clinical care, relying on familiarity between marines Although still not an ideal ratio of providers to
and mental health professionals established prior to marines to meet the intent of close proximity, familiar-
deployment and maintained through and after de- ity, and trust, this configuration affords OSCAR team
ployment. The goal is to increase psychological health members a much larger presence than previously pos-
awareness and break down barriers to seeking mental sible. The use of other unit medical professionals, such
healthcare. as physicians and more numerically abundant corps-
men, as OSCAR extenders through training and con-
Team Design sultation with team members may be another avenue
to improve OSCAR efficacy. The goal is to eventually
Marine Corps OSCAR teams provide two licensed place teams in all operating units, not only infantry
mental health professionals and two psychiatric tech- regiments but also air wings and logistics groups.
nicians per regiment, or approximately one licensed Although OSCAR may be the newest combat and
professional and one psychiatric technician per 2,500 operational stress control program, it has clearly es-
marines. According to the 2007 DoD task force on tablished itself as an integral component in the Navy’s
mental health report to Congress: mental health support to the Marine Corps. The SIC
model itself is an outgrowth of experiences derived
Determining the proper ratio of embedded providers from OSCAR operations. The conceptual link between
to service members would require additional research;
OSCAR and the SIC model is clear: a shared responsi-
however, evidence from site visits suggested that the
Army’s ratio of one psychologist or social worker and bility between unit leadership and medical/chaplain’s
one psychiatric technician per 5,000 service members corps. This interaction fosters hardiness and resilience
is probably not sufficient.14(p17) within the individual marine, who ultimately must
bear the burden of combat and operational stress ex-
A team is also attached to each division to provide posure. Consistent with the core values of the Marine
services to independent battalions and oversight to Corps, personal responsibility is a critical component
the regimental OSCAR teams. OSCAR teams are part for maintaining mental health readiness, whereas
of each commander’s special staff, reporting to the leadership assumes responsibility for cultivating
command surgeon. Several different clinical special- mental health resilience, and medical personnel and
ties are utilized on OSCAR teams, with a typical team chaplains help restore mental health if stress injury or
configuration as follows: illness overcomes the individual.
EMERGING CHALLENGES FOR OPERATIONAL NAVY MEDICINE
The US military forces have been strained by the for a force of medical professionals who, as the OSCAR
GWOT.4 Despite being a service dedicated to control of the section explicates, are in high demand, and as a result have
seas, the Navy has stepped forward to share the burden of sustained a high operational tempo and been exposed to
this prolonged conflict and continues to play a substantial elevated levels of combat.
role in ground operations for OIF and OEF. However, the
allocation of Navy personnel to ground combat operations Individual Augmentation
remains a nontraditional deployment, resulting in special
challenges to combat and operational stress control pro- Although the percentage of sailors assigned to
grams based on the SIC model. Two of the more vexing IA duty constitutes approximately 3% of active and
challenges are detailed below. The first challenge is to reserve duty assignments in the US Navy, the cumu-
provide care for Navy personnel individually assigned to lative effect of these deployments has created over
augment positions within combat-deployed Army units, 46,000 combat veteran sailors through 2006, with over
a duty referred to as “individual augmentation” (IA). The 7,000 sailors being added to this total annually.18 The
second deals with the development of a program to care relative obscurity of this duty warrants a description
128Expeditionary Operational Stress Control in the US Navy
of the IA deployment cycle and the Navy combat and to guard force operations takes 17 days (with a ca-
operational stress control programs currently in place pability for 4 additional days). A lack of confidence
to address the unique and diverse mental health needs in performing a job can increase overall anxiety, and
of “sandbox sailors.” experience and training improve the ability to modu-
late combat stress (hence the dictum, “fight like you
Training and Deployment Cycle train, train like you fight”). An Army study19 found
that at the start of OIF, 70% of soldiers deploying to
As implied by their name, IA sailors prepare, deploy, Iraq were not psychologically prepared to experience
and redeploy alone, and for the most part, outside combat trauma.
Navy chains of command. Thus, standard Navy medi- To address this shortcoming, Navy Medicine has
cal programs designed to monitor and treat mental introduced a combat stress component to IA train-
health problems are not routinely accessible to IAs ing, the goal of which is to cultivate cognitive coping
during many of the most critical points in their deploy- strategies consistent with Kobasa’s stress hardiness
ments. Before IAs deploy, Navy Medicine personnel cognitive style,20 characterized by (a) recasting chal-
conduct a mandatory predeployment health assess- lenges as opportunities for growth, (b) a commitment
ment (PDHA). The form used to conduct the PDHA to self-improvement, and (c) the development of in-
is DD2795. The mental health aspect of the screen- ternal locus of control (ie, the ability to control events
ing consists of the question, “During the past year, that affect one’s life). Evaluating the influence of this
have you sought counseling or care for your mental component is essential to refining and maintaining IA
health?” If this question is answered in the affirmative, combat stress coping training, especially because the
the physician or healthcare specialist conducting the empirical data evaluating the efficacy of predeploy-
PDHA may refer the sailor to a mental health provider. ment stress control programs are inconclusive.21
Depending on the outcome of the mental health refer- The IA deployment phase starts with transportation
ral, the individual conducting the PDHA can classify to the theater of operations for additional field-based
the member as either deployable or nondeployable. combat skills training for 3 to 4 days. Then the IA
Once deemed deployable, the IA detaches (either in platoon is disbanded and individuals are transferred
a temporary duty status or as a permanent change of to their ultimate combat duty stations, where, except
station, depending on the specific assignment) from the for rest and recreational leave (up to 14 days), the IAs
parent command and travels alone to a Navy mobili- remain for the duration of their 6-, 9-, or 12-month
zation processing site for final health, administrative, obligation. At their combat duty station, IAs are under
and legal processing. After spending a week at the the authority of the requesting service (primarily the
processing site, sailors essentially leave Navy culture Army, although the Marine Corps also utilizes IAs). If
as they travel to their next destination, which for most necessary, the IA seeks healthcare services, including
is Navy IA combat skills training. mental health, from the parent command. However,
There, a cadre of Army drill instructors teach IAs Navy combat and operational stress control programs
elementary combat skills such as basic marksmanship, reenter the picture as soon as the IA returns to the
field medical procedures, rules of engagement, convoy continental United States. As the IAs transit from their
operations, and codes of conduct to prepare the IA for OEF/OIF deployment, they pass through the Navy’s
integration into an Army-centric combat environment. Warrior Transition Program (WTP).
In addition, most combat gear is provided at this train- The WTP addresses the “four Rs” of operational
ing. Most Navy IAs receive the same training regard- stress control: (1) reassurance that the IAs’ response
less of the duties they will perform when attached to to their deployment is nonpathological; (2) rest to
their respective Army unit in theater. Although this compensate for the high operational tempo associ-
broad-based training is beneficial because of the pos- ated with 14-hour (or more) days, 6 to 7 days a week;
sibility of being remissioned (sometimes more than (3) replenishment in terms of time to leisurely eat and
once) during an IA assignment, some of the missions shower; and (4) restoration of confidence.6 Relieving
now taken on by the Navy require competencies that the sailors of their bulky combat gear and completing
can only be achieved by years of experience. customs inspections in advance also contribute to rest
One such example is detainee operations; although and replenishment, while reassurance and restora-
sailors with specific master-of-arms (equivalent to the tion are initiated with combat stress briefs delivered
Army’s military police) training are prepared for this by mental health and faith-based caregivers. More
duty, the majority of sailors conducting these missions than a prudent use of logistics, the act of gear turn-in
are trained for unrelated positions, such as culinary (off-loading of “battle rattle”) and the surrendering
specialists, machine mates, or yeomen. Within the of issued weapons (after one last ritualistic cleaning)
typical 60-day IA training period, instruction relevant are as symbolic as they are practical. The sudden
129Combat and Operational Behavioral Health
absence of weapons may produce anxiety, which can appreciation for the protective nature of unit cohesion
be addressed by caregivers as part of the preparatory had arisen:
framework for returning home.
The impetus for this program can be found in the One of the most significant contributions of World
postdeployment experiences of combat veterans like War II and modern warfare was the recognition of the
those described in Jonathan Shay’s seminal volume, sustaining influence of the small combat unit on the
individual member. . . . Interpersonal relationships
Achilles in Vietnam.22 In his book, Shay explored the
develop among soldiers and between them and their
need for leadership to provide a sanctioned time for leaders. . . . It is these relationships which, during
“mutual support and communal reworking of combat times of stress, provide a spirit or force which sus-
trauma,”22(p61) which was part of “the long trip home” tains the members as individuals and the individuals
in World War II but tragically absent in Vietnam. Rather as a working, effective unit.19(pI-1)
than screen for, or immediately address, combat stress
reactions (eg, PTSD), a goal of WTP is to give IA sailors Recent data indicate that unit cohesion can help
“permission” to grieve and acknowledge the toll of reduce factors that place service members at risk for
their deployment, while also celebrating successes and combat-stress–induced mental disorders such as PTSD.
gains made during the deployment. These efforts are Brailey et al25 evaluated the contribution of unit cohe-
to help IAs begin integrating potentially fragmented sion to the prediction of PTSD symptoms in a sample
and disassociated deployment experiences into a of 1,579 nondeployed US Army soldiers. Next to
more coherent and integrated self-script or schema. By predeployment life trauma, the degree of unit cohe-
institutionalizing time for the IA to acknowledge the sion was the best predictor of predeployment PTSD
psychological effect (positive and negative) of deploy- symptoms.25 A diagnosis of PTSD or other psychologi-
ment, it is hoped that WTP will reduce the perception cal illness prior to deployment has been shown to put
of organizational stigma that service members consis- service members at increased risk for future develop-
tently cite as a barrier to accessing mental healthcare.23 ment of PTSD.26 In another study,27 a comprehensive
Mental health services are readily accessible during metaanalysis of 39 military samples prior to OEF/OIF
the WTP process. indicated that unit cohesion was a significant predictor
Analogous to the “third location decompression” of well-being among a host of other outcomes such
process practiced by North Atlantic Treaty Organi- as individual performance, job/military satisfaction,
zation countries, WTP takes place at temporal and retention, and readiness.
geographical distance from the deployment site (the Despite the general consensus that mental health in
potential source of trauma), making it much different combat-deployed units is bolstered by the social sup-
from critical incident stress debriefing approaches, port structures that emerge within cohesive units that
which have been found to be ineffective or even det- train, deploy, and return together, the IA deployment
rimental to mental health.7–9 WTP is more consistent has exposed a new generation of service members to
with end-of-tour unit debriefings shown to improve the isolation of Vietnam-style individual deployments.
perceptions of organizational support.24 Nevertheless, Adding to this problem is the IA’s loss of service and
because IAs do not participate in WTP with their professional identity. Data clearly support a link be-
combat comrades-in-arms, but with other IAs from tween job satisfaction and work-related stress.28 A com-
different deployment locations and experiences, it mon frustration voiced by IAs is dissatisfaction with
remains to be seen whether group debriefing works the substance of their mission—work that may not uti-
for the IA population. Following WTP, which lasts 3 lize their hard-earned Navy designation or operational
days, IAs are flown directly home. Upon arrival at specialty. Also sometimes lost when sailors go on IA
their destination airport, parent commands of some duty is respect for their rank. Each service emphasizes
IAs may provide formal homecoming ceremonies ranks differently. For instance, once enlisted sailors pin
that help foster reintegration. However, for many on the coveted anchors of a chief petty officer at E7,
IAs, their mission often ends how it started—in they become “khaki” (the same uniform officers wear)
isolation. and are afforded great respect and autonomy within
the Navy. However, many IAs indicate that the social
Isolation Issues status given to E7s in the Navy is equivalent only to
that given to an E9 sergeant major in the Army. Data
In Vietnam, soldiers trained with one group of indicate that loss of social rank status is detrimental to
people, deployed alone to serve a 1-year combat tour mental health and a source of both psychological and
in units of ever-changing composition, and returned physiological stress.29
home alone to either finish their service commitment Unfortunately, due to the nascent nature of IA
or integrate into a new unit.22 By the 1980s a renewed deployment, little or no data are publicly available
130Expeditionary Operational Stress Control in the US Navy
to evaluate the relative contributions of absent unit zone remains a challenge to Navy Medicine and its
cohesion, low job satisfaction, and loss of social rank health surveillance programs.
status in the prediction of combat-related stress reac-
tions. One of the few studies to compare the mental Care for the Caregiver
health status of Navy IAs to nondeploying sailors18
found that in both the enlisted and officer ranks, Mission and Personnel
sailors deployed to an IA billet exhibited signifi-
cantly more mental health problems, but only if that Navy caregivers include a broad range of profes-
deployment was to a hostile combat zone. This find- sional and paraprofessional personnel charged with
ing suggests that deployments to the Army have the providing care and support to wounded, ill, and in-
greatest impact within the combat zone, highlighting jured sailors and marines. Navy caregivers assume a
the interaction between combat exposure and type of number of roles, both traditional and nontraditional,
deployment. including corpsmen, chaplains, substance abuse coun-
Administrative issues can also cause stress for Navy selors, recovery coordinators, case managers, nurses,
IAs. The handoff from Army to Navy at the end of a de- clinical support staff, and physicians. Some are civil-
ployment is not always well coordinated, and because ians and some are contractors.
many Army units are unfamiliar with writing evalu- Operational and occupational stress faced by care-
ations, fitness reports, or awards for Navy personnel, givers is cumulative and extends across the deploy-
recognition for IA duty can be lacking (if evaluations ment cycle. The acute injuries and chronic illnesses
and fitness reports are not in a Navy format, they are of war are treated across a continuum of care, from
not accepted by the Navy Bureau of Personnel for in- the front to hospitals and outpatient centers in the
clusion in the service record). The Navy also reviews United States. For instance, a corpsman who tended
awards given by the Army, and has occasionally re- to wounds in Iraq in July may be dressing wounds in
fused to accept or downgraded these awards, with a San Diego, California in January. Dwell time (ie, the
significant impact on the IA’s morale. amount of time between deployments) does not neces-
An additional issue is family support. Although sarily include a respite from exposure to the wounds
deployed Army units have robust family support of war for caregivers. As a result, caregivers have an
programs, these programs are generally not designed especially abbreviated opportunity for rest, replenish-
to cross service lines and include the families of as- ment, and restoration. The consequences of untreated
signed Navy personnel. For IAs who are transient cumulative stress can result in medical errors; somatic
between permanent commands, the family may be left complaints such as changes in eating habits, gastroin-
with little support. Thus, an area for further attention testinal distress, headache, fatigue, and sleep disorders;
is ensuring that the families of deployed IAs receive change in work habits such as tardiness and absentee-
appropriate support and information from the Army ism; mental and emotional difficulties such as memory
unit’s family support system. disturbances, anger, self-doubt, isolation, and impaired
Adding to problems caused by the unique risks of judgment; and accidents.30–32
combat and operational stressors for IA soldiers is the Navy Medicine caregivers are usually deployed
logistical distance between these sailors and the tra- as IAs to the combat zone, the exceptions being care-
ditional Navy medical infrastructure. Navy Medicine givers who are assigned to embedded duty within
personnel have limited opportunities to share the SIC operational units (eg, hospital ships, EMFs, SPRINT
model with the IA’s Army leadership, and thus the teams, OSCAR teams). Uniformed caregivers selected
model’s emphasis on the interaction between unit for IA duty typically possess specific skill sets that
leadership and caregivers to develop mental health are synergized to form an operational field medical
resiliency is difficult to carry out. New initiatives based asset. Personnel with combat-essential skills (Fleet
on IA duty continue to emerge, such as GWOT Sup- Marine Force corpsmen, surgery, anesthesia, critical
port Assignment orders, wherein GWOT requirements care, mental health) are particularly likely to deploy,
are folded into normal permanent change-of-station often making multiple deployments within a given
orders. In response, Navy Medicine has initiated the tour of duty. IA medical personnel are selected from
development of combat and operational stress control hospitals and clinics around the world, given “just in
programs tailored to meet the evolving needs of the time” training, and then configured with other care-
IA mission, with programs at both the predeployment givers to form a functional unit. At the end of their
and postdeployment phases that introduce sailors to deployment, caregivers return as individuals to their
resilience-inducing cognitive coping skills and provide hospitals and clinics. The protective connectedness
institutionally sanctioned time to grieve and begin the of unit cohesion is lost when they leave their parent
healing process. However, access to IAs in the combat command and again when they leave their operational
131Combat and Operational Behavioral Health
unit. Even more stress may be encountered by those early stress symptoms such as fatigue, impaired sleep,
who joined preexisting deployed units, a situation that and confusion decrease the self-awareness necessary to
makes “fitting in” even more difficult. initiate self-care. Third, caregivers are “other focused”
and may consider self-care unnecessary or antithetical
Trauma Exposure and Intervention Strategies to their goals.
When intervention is necessary, the “five Cs” of
Providing care in a combat zone increases the likeli- COSFA1—cover, calming, connectedness, capacity, and
hood of experiencing direct and secondary exposure confidence—can prove especially helpful. Using the
to traumatic injuries. Direct exposure constitutes the COSFA model, caregivers are encouraged to focus on
threat to physical safety from direct and indirect fire, other caregivers and their shipmates: facilitating con-
as well as the plethora of fatigue-inducing operational nectedness and accessing the healing capability of unit
stressors. Secondary trauma can be encountered by cohesion requires breaking the “code of silence” by
working in close contact for extended periods of time asking coworkers questions about their stress coping.
with wounded, ill, and injured sailors, the result to Most caregivers do not feel comfortable approaching
caregivers being a phenomenon known as occupa- their peers with questions and concerns about the
tional or compassion fatigue. In relation to the SIC peer’s behaviors. The typical, “How are you doing?”
model, direct and secondary trauma can, individually is usually met with a response of, “Fine.”
or in tandem, contribute to full-blown stress illnesses A strategy for facilitating connectedness is based on
for Navy caregivers. Stress injury and illnesses can af- role expectations of shipmates and uses an “OSCAR”
fect mission effectiveness in the form of medical errors, acronym (Exhibit 8-1). The OSCAR communication
job dissatisfaction, and poor retention.33 strategy encourages shipmates to address coworker
Part of the responsibility for enhancing the resil- behavior in five steps. First, observe the behavior,
ience of Navy caregivers rests with the leadership of particularly signs of possible impairment, such as
Navy Medicine itself. Actions are underway within poor concentration, looking tired, falling asleep dur-
Navy Medicine to implement training based on the ing change of shift, or irritability. Second, state the
SIC model to run through all phases of training for observation. The observation must be overtly stated
Navy medical personnel. The core leader functions because decreased self-awareness is one of the early
have been applied to day-to-day clinical leadership casualties of a stress reaction. Third, clarify one’s role.
activities as well as facilitating the transition of Navy The roles of shipmate, subordinate, supervisor, friend,
Medicine personnel in and out of different operational and spouse help show why the behavior is being ad-
settings. One key point the SIC model should impart dressed, and help determine which options should
to the leaders of caregivers is that their roles and work
environments are inherently stressful, and that stress
reactions are common. Many leaders recognize that
initial stress reactions increase caregivers’ energy and
EXHIBIT 8-1
focus their attention on critical changes in a patient’s
condition, while sustained stress causes a degrada- OPERATIONAL STRESS CONTROL
tion of performance. Leaders should be aware that in ASSESSMENT AND RESPONSE
caregivers’ work environments, occupational stress COMMUNICATION
is endemic and may go unrecognized because such
reactions become normalized. A difficult challenge to
Observation: actively observe behaviors; look for
the leaders of caregivers is reintegrating individually patterns.
deployed staff into a cohesive unit that did not de-
ploy; the IA caregiver faces the dual task of reintegra- State observations: focus all attention on the
tion while simultaneously letting go of relationships behaviors; just the facts without interpretations or
judgments.
formed during deployment.
The traditional work-stress–response paradigm in Clarify role: state why you are concerned about the
both civilian and Navy literature has several common behavior, which validates why you are addressing
elements: know the sources of job stress, know the the issue.
signs and symptoms of stress, take care of oneself, and
Ask why: seek clarification; try to understand the
seek help when there is the beginning of impairment other person’s perception of the behaviors.
in daily life.5 There are several significant barriers to
self-help for caregivers. First, endemic job stress pro- Respond: clarify concern if indicated; discuss de-
duces some level of stress symptoms in all workers, so sired behaviors; state options in behavioral terms.
that moderate and high stress appear normal. Second,
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