July – September 2008

Perspective 1

MG Russell J. Czerw

Combat Duty in Iraq and Afghanistan, Mental Health Problems 7

and Barriers to Care

COL Charles W. Hoge, MC, USA; COL Carl A. Castro, MS, USA; Stephen C. Messer, MA, PhD; et al

Effectiveness of Critical Event Debriefings During Operation Iraqi Freedom II 18

CPT Patrick J. Pischke, MS, USAR; CPT Christian J. Hallman, MS, USAR AGR

Dialectical Behavior Therapy Deployed: An Aggressive Alternative to 24

Traditional Mental Health on the Noncontiguous Battlefield

CPT Brian D. Parrish , MS, USA

Warrior Resilience Training in Operation Iraqi Freedom: Combining Rational 32

Emotive Behavior Therapy, Resiliency, and Positive Psychology

MAJ Thomas Jarrett, MS, USA

Behavioral Health Activity and Workload in the Iraq Theater of Operations 39

MAJ Barron Hung, MS, USA

Remind: Addressing the Risk of Illegal Violence in Military Operations 43

LTC Karen L. Marrs, AN, USA

The Army Medical Department Behavioral Health Proponency 50

COL Elspeth Ritchie, MC, USA

Why Teach Mental Health Topics to Physician Assistants and 52

Other Allied Healthcare Professionals?

Karen C. Shea, LCSW, DCSW; Maryann Pechacek, PsyD

Department of Defense Response to Posttraumatic Stress Disorder 54

Gerard A. Grace, PhD

Army Provider Resiliency Training: Healing the Wounds “on the Inside” 57

Richard R. Boone, PhD; et al

Down Range and Beyond: Preparing Providers to Support Warriors in 60

Resolving Problematic Substance Use

Joseph E. Hallam, MS

The Family Advocacy Staff Training Program 63

Cindi Geeslin, LCSW; John Hartz, LCSW; Michael Vaughn, LMSW

Battlemind Training System: “Armor for Your Mind” 66

MAJ (Ret) John M. Orsingher, MS, USA; et al

The Army Master of Social Work Program 72

Dexter Freeman, DSW; MAJ Graeme Bicknell, MS, USA

Behavioral and Mental healthcare:

total warrior care commitment
LTG Eric B. Schoomaker

The Surgeon General

Commander, US Army Medical Command

MG Russell J. Czerw

Commanding General

US Army Medical Department Center and School

July – September 2008 The Army Medical Department Center & School PB 8-08-7/8/9

0819815

GEORGE W. CASEY, JR

General, United States Army

Chief of Staff

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July – September 2008 1

From the beginning of the recorded history of

campaigns and combat between organized armies,

wars and battles were usually characterized in terms of

glory and pride, focused on the noble leaders and the

outcomes. Soldiers were the heroes returning from

some distant and unknown place, with only the stories

they told to family and friends portraying the grim

reality of the actual events. Lip service was given to

the sacrifice of the Soldiers, but the public’s interest in

the details of conflicts were short-lived or nonexistent.

Usually only the outcomes framed in terms of the

glory and righteousness of the effort remained in

anyone’s memory, except those of the combatants. The

Soldiers were expected to return from the campaigns

and simply resume their normal lives, without regard

to their experiences—or their memories. After all, to

those who were not there, combat was a glamorous

enterprise, surrounded by flags, banners, drummers,

and flashy uniforms.

There is no better example of the naiveté of the public

about the stark realities of the battlefield than that

demonstrated in July 1861 by the wealthy elite of

Washington, DC, including some members of

Congress. After the Army of Northeastern Virginia left

the capital with great fanfare to engage nearby

Confederate forces, news of the impending battle at

Bull Run near Manassas, Virginia, quickly spread

around the capital. The prospect of witnessing such a

glamorous undertaking became a fashionable event.

As the battle began, the hillsides and meadows behind

Union lines were populated with fancy carriages as

families socialized and spread their picnic meals to

relax and enjoy the spectacle. Unfortunately, the grim

facts of warfare quickly interrupted their holiday, as

the Union Army was routed and they were engulfed in

the tide of fleeing Soldiers, severely complicating the

retreat in their panic.1

The Civil War has been described as the first conflict

of modern warfare. Advances in technology in

weapons, communications, and transportation

combined with a higher level of sophistication in

strategy and tactics to make the Civil War the most

lethal conflict to that point in history. Technology also

allowed Mathew Brady to document the war as

photographic images, something that had never

occurred before. Of course, stiffly posed pictures of

military leaders and Soldiers had been published, but

Brady took his cameras into the battlefield. He

photographed the carnage and devastation he found

there. In September 1862, Brady was present at the

Battle of Antietam, which included the bloodiest single

day in American military history. His exhibits of the

pictures of the dead of that battle were a shocking

revelation to the public. For the first time, they could

see the experiences of the men who left them to go to

war. However, perhaps more importantly, for the first

time the public at large had a sense of how warfare

affected those who fought, and returned. In presenting

the reality of warfare, Brady’s photographs challenged

the popular notions that combat and death on the

battlefield were noble, glorious undertakings. During

this extended, horrific war, the medical sciences began

to recognize a psychological disorder, called battle

fatigue (BF), as a direct result of the experiences of the

battlefield. Indeed, one of the most respected

physicians of his time, Dr Oliver Wendell Holmes,

Perspective

Major General Russell J. Czerw
2 www.cs.amedd.army.mil/references_publications.aspx

who himself had gone to the Antietam battlefield to

locate his wounded son, commented on Brady’s

photographs:

Let him who wishes to know what the war is look at

this series of illustrations. These wrecks of manhood

thrown together in careless heaps or ranged in ghastly

rows for burial were but alive yesterday.... Many people

would not look through this series. Many, having seen it

and dreamed of its horrors, would lock it up in some

secret drawer.2

As profound as Holmes’ comments are, they were

directed at the reactions of those who viewed the

photographs. The “secret drawer” of the combat

veteran contains memories of not only the sights of

battlefield carnage, but also the sounds, smells, tastes,

and pain of the experience.

Fifty years later, greater leaps in technology and

tactics produced carnage at an even greater scale in the

First World War. Fortunately, increased knowledge

and sophistication in mental health care allowed

military medicine to recognize and address the

psychological toll of such horrific environments:

When the German Army initially introduced ‘gas’

warfare, psychiatric to WIA ratios in Allied ground

forces often exceeded 2:1; ie, two ‘hysterical’ reactions

occurred for every one casualty due to actual gas

exposures. The large number of BF casualties produced

and the inability to evacuate and replace these Soldiers

prompted the Allies to develop basic principles of

effective treatment: treat as far forward as possible,

treat as quickly as possible, and treat with the

expectation that the Soldier will recover and return to

combat.3

The learning process continued through World War II,

Korea, Vietnam, and Operation Desert Storm, and

continues today in the Global War on Terror. The

RAND Center for Military Health Policy Research has

recently released a detailed report4from a

comprehensive study of the mental and psychological

health of Warriors returning from combat deployments

to Iraq and Afghanistan. The RAND report reinforces

the increasing emphasis that military medicine is

placing on the behavioral and mental health of our

Warriors, reflected in the Army Medical Department’s

increased application of resources, changes in

structure, and aggressive, proactive actions addressing

prevention, intervention, therapy, and recovery. Those

aspects of our efforts to address the behavioral and

mental health needs of our Warriors are featured in

this dedicated issue of the AMEDD Journal.

We are pleased to open this issue with a reprint of an

article from the New England Journal of Medicine

which presents what has become the de facto baseline

study of the mental health situation among Warriors

engaged in combat operations in Afghanistan and Iraq.

In 2003, COL Charles Hoge and his team of

experienced researchers evaluated the mental health

conditions of ground combat troops both before and

after deployment into the combat theaters. Their rigid

scientific method, large sample sizes, and detailed,

careful data reduction and analysis have provided

invaluable information for those charged with the

mental health care of our Warriors, both during and

after their experiences in the fluid and unpredictable

combat environments of today. Indeed, this article has

often been referenced in other writings on these topics.

COL Hoge et al set the stage for the articles that

follow in this very important issue of the AMEDD

Journal.

We are fortunate to have 4 articles in this issue which

were written by authors providing behavioral and

mental healthcare to our Warriors on the ground in

Iraq. The first article in this collection is by CPT

Patrick Pischke and CPT Christian Hallman. Their

excellent article describes their experiences with

critical event debriefing, a technique developed to deal

with psychological trauma, not only by the military in

a combat environment, but also used for police,

firefighters, rescue personnel, emergency room staff,

and others who experience traumatic events. Research

and experience in past extended conflicts solidly

support the proposition that mental health service

provided as quickly as possible after a traumatic event

is critical to prevention of the onset of posttraumatic

stress and other anxiety disorders. Research also shows

that such disorders can become chronic and more

resistant to treatment with the passage of time. The

article details the research, and describes the results of

38 group critical event debriefings administered in Iraq

between March 2004 and January 2005. The data

gathered by CPT Pischke and CPT Hallman strongly

validate the presence of mental healthcare resources

among front line forces, and the application of

assistance to those experiencing traumatic events as

quickly as possible.

Perspective
July – September 2008 3

THE ARMY MEDICAL DEPARTMENT JOURNAL

CPT Brian Parrish has contributed an intriguing, very

informative article about the innovative adaptation of a

treatment regimen designed for those with borderline

personality disorder to assist Soldiers in the combat

environment. The intense emotions which are driven

by the never-ending pressures of life and death

decisions in a constant crisis environment can cause

some Soldiers to exhibit some of the same

psychological liabilities as those with classic

personality disorders. CPT Parrish’s article describes

the use of dialectical behavior therapy as an

intervention tool, designed to keep the Soldier

functioning within the duty environment while dealing

with the issues that threaten their psychological wellbeing. Therapy is available 24 hours a day at a specific

location, a wellness center located within the troop

medical facility which mitigates the stigma Soldiers

often feel about seeking mental health assistance. This

creative approach to ensuring our Warriors have

assistance where and when needed is another

demonstration of the high level of initiative and

professionalism that is fundamental to military

medicine.

As important as intervention and therapy are to those

Soldiers who experience psychological problems in the

combat environment, those actions represent one

aspect of mental healthcare—treatment. Mental

healthcare also has a preventive care responsibility.

MAJ Thomas Jarrett’s article is a detailed, carefully

organized discussion of the development and

implementation of Warrior-oriented combat stress

prevention training to be presented in-theater. This

Warrior Resilience Training is designed to strengthen

our Soldiers’ psychological resistance to the

deleterious effects of traumatic events. The approach

to this type of training contains much reinforcement in

the ethics, values, and standards that are reflected in

Army Ethos and Army Values, as well as the various

codes of conduct and rules that are part of professional

military discipline and character. MAJ Jarrett details

the foundations of the Warrior Resilience Training,

how it is integrated into the deployment training cycle,

and the overwhelmingly positive feedback received

from those who receive it in-theater.

Obviously, the remoteness and stark reality of the

combat deployment environment introduces types of

stress and pressures unseen in a normal garrison

situation, therefore mandating the provision of far

greater range of behavioral and mental healthcare

services than those required for the typical garrison

clinical setting. The previous 3 articles reflect the

diversity and extent of some of those services.

However, the activity workload metrics used in a

“normal” environment are not designed to track much

of the workload of behavioral and mental health

personnel on these deployments. Without such data,

the requirements experienced in that real world cannot

be quantified. Planners and developers for

organizations, structure, doctrine, and training, just to

name a few, are unable to address the needs for

ongoing support, much less look to future

requirements. Also, and perhaps more important,

commanders cannot be provided with real-time data

about the services used by their Soldiers. To the

properly educated leader, such data is invaluable

information about the psychological readiness of his or

her Soldiers to perform the required missions. The

leader can then take necessary measures to address

problem areas revealed in the statistics. In his very

informative article, MAJ Barron Hung describes the

Combat and Operational Stress Control Workload and

Activity Reporting System (COSC-WARS), which

was implemented at the beginning of Operation Iraqi

Freedom in response to the need for such data. MAJ

Hung presents and discusses COSC-WARS data for

the 6-month period January to June 2008, as an

example of the type of information that is obtained,

and the implications that the results have for the

individual Soldiers and their units. This article is a

succinct and valuable validation of the methods and

support services discussed in the 3 preceding articles,

as well as a revealing look at the extent and diversity

of the factors causing tension and stress among our

Warriors.

Of the several destructive behaviors that may result

from psychological anxieties induced by the combat

environment or other high stress situations, none is

more pernicious than acts of violence, including

murder, against enemy prisoners, noncombatants, or

even other US service members. Although extremely

rare, these incidents do happen in our military. The

occurrence of such acts is not only tragic for the victim

and the perpetrator, but it may also have serious

ramifications for the success of the mission, and for

the military in general. LTC Karen Marrs has written

an important article which presents the research,

theories, and facts surrounding illegal violence by
4 www.cs.amedd.army.mil/references_publications.aspx

Perspective

military members. Her article details a concept for an

addition to the current combat and operational stress

control actions to deal directly with a Soldier’s state of

mind, usually involving revenge and frustration,

which, if unchecked, can lead to illegal violence. The

potential for such incidents may be greater than we

think, as LTC Marrs points out that the DoD Mental

Health Advisory Team V’s report5(2007) found a

troubling attitude of disdain and disrespect for local

national noncombatants among a majority of deployed

Soldiers and Marines. As expertly explained in the

article, without a baseline of respect for such

individuals, the overwhelming combination of rage,

frustration, and revenge has no check, often with tragic

results. LTC Marrs presents the Remind concept as a

proactive effort to give Warriors a psychological tool

to deal with the environment, the circumstances, and

especially the emotions encountered in the current

deployed environments. This is a thoughtful,

informative article about a very serious subject which

warrants the close attention of military leaders and

mental health professionals.

Those professionals providing behavioral and mental

healthcare services to Warriors and their Families are

the front lines of assistance for those in need. They are

also the leading edge of an extensive structure of

planners, researchers, training specialists, and other

support staff who make it possible for them to apply

their skills, training, and dedication to their work. The

remaining articles in this issue of the AMEDD Journal

present information on the leadership and training

provided within the behavioral health disciplines of the

Army Medical Department. Leading off this section,

COL Elspeth Ritchie, the first Director of the

Behavioral Health Proponency of the Office of The

Surgeon General, has contributed an article describing

the establishment of the Proponency in March 2007.

She discusses the background of her position, and

outlines the initiatives that have addressed areas of

concern within behavioral healthcare, both existing

and future. The Proponency provides a badly needed

focal point at the highest levels of Army medicine for

an increasingly important aspect of Soldier healthcare.

The largest obstacle in the provision of behavioral or

mental healthcare services is the unwillingness of

those needing assistance to avail themselves of the

service. That unwillingness may stem from failure to

recognize the need (or rejection of the idea), but quite

often it is present due to the stigma associated with

mental healthcare. For this reason, it is important for

military healthcare providers (ie, primary care, allied

healthcare provider) to be equipped with the tools to

recognize and manage mental health disorders. In their

article, Karen Shea and Dr Maryann Pechacek describe

the importance of the properly trained healthcare

provider in the actual delivery of psychological health

therapy to many patients who would otherwise avoid

or reject it. Their interesting article details the

circumstances that make such an arrangement ideal for

many patients. Military healthcare providers are

currently taught the information and skills necessary

for the effective management of mental health

disorders within the military healthcare setting at the

AMEDD Center & School (AMEDDC&S).

The Mental Health Advisory Team V 5reported that

15.5% of Soldiers and Marines surveyed in

Afghanistan and Iraq (2007) screened positive for

acute stress/posttraumatic stress disorder (PTSD). The

previously mentioned RAND study’s findings4support

that statistic, indicating that 14% of service members

returning from Iraq met the criteria for PTSD.

Obviously, this disorder represents a significant

challenge for military behavioral healthcare

professionals, both in-theater and at home garrison

medical treatment facilities. Dr Gerard Grace’s article

presents the clinical background, evolution, and

implementation of a PTSD treatment training program

at the AMEDDC&S. This important article clearly

details the challenges and complexities faced by those

charged with developing the most effective approach

to training our behavioral health professionals to

recognize and treat PTSD, now and into the future.

Just as the Warrior Resilience Training discussed by

MAJ Jarrett in his article is designed to enable Soldiers

on the line to resist the deleterious psychological

effects of traumatic combat events, so must we be

concerned with the psychological fitness of the

caregivers who must deal with the aftermath of

combat, the wounded Soldiers and noncombatants.

During periods of heavy combat operations, the stream

of severely wounded people can be nonstop, and the

wounds are often horrific and extensive. This

circumstance places extreme pressure and stress on the

medical professionals who labor to save those lives,

sometimes continuously for many hours without relief.

In their well-written article, Dr Richard Boone and his
July – September 2008 5

THE ARMY MEDICAL DEPARTMENT JOURNAL

coauthors describe the Army Provider Resiliency

Training (PRT) Program, developed and implemented

to address the psychological health of those dedicated

to saving and improving the lives of others. Although

the PRT Program has been a formal part of Army

medical training only since July 2008, the need was

recognized in 2001. Since then, various approaches to

providing healthcare professionals the necessary

knowledge and tools have been used, all part of the

evolution to the current PRT Program, which will be

mandatory training for all AMEDD caregivers. This

program is one of the Army’s answers to the perpetual

question, “who takes care of the caregivers?”

Throughout history, humans have used mood altering

substances for various purposes, some beneficial, some

detrimental. The concern for society in general is, of

course, the detrimental abuse of such substances. The

damage to the abuser is profound, but the danger to

others who are not involved in that person’s selfdestructive activity is even more tragic. In the situation

of a military, especially combat, environment,

interdependence among all members of a unit is a

daily, life and death reality. An individual whose

psychological, and physical, capabilities are impaired

by the effects of alcohol and/or drugs represents a truly

serious liability to the safety of the other members of

the unit. Further, a substance abuser may also be a

direct physical threat to other Soldiers, and/or to him

or herself. Joseph Hallam has contributed an important

article describing the current situation among our

Soldiers in Iraq, and the AMEDDC&S training

resources which are addressing those problems. There

are currently 6 formal courses providing training to

military Mental Health Specialists, Healthcare

Specialists, civilian counselors, clinical directors and

supervisors, and physicians. The increased availability

of counseling services, both in-theater and at home

installations, provides healthcare providers,

commanders, and other leaders with additional

resources to assist our Warriors and their Families with

this extremely difficult personal and societal problem.

Another of the undesirable consequences of the

psychological pressures, stresses, and disorders that

affect Soldiers in a combat environment is the negative

impact they can have on the Warrior’s Family

relationships. Dissolutions of marriages and family

breakups following return from deployment are far too

common. At the extreme, we see the reports of

physical abuse, including the death of one or both

spouses, and sometimes children. The family advocacy

approach to address the stresses of military life on the

family was developed in the 1980s. Cindi Geeslin and

her coauthors describe the evolution of the AMEDD

Family Advocacy Staff Training Course which

debuted in 1985 to prepare Family Advocacy Program

staff members to implement the program throughout

the Army. Their article lays out how the course is

designed, and how it has changed over the years in

adaptation to DoD requirements and in response to the

latest research in the areas of family dynamics and

violence. As the family advocacy approach has

matured, new requirements and methods of training

have been identified. In addition to the 2-week basic

course, AMEDDC&S now presents 6 advanced

courses to address the specific training needs of the

professional staff. Also, a distance learning component

of the basic course is nearing completion. Not only

will the distance learning element reduce the resident

training requirement to one week with attendant

savings in time and money, but it also allows

expansion of content in the course, a clear benefit to

the Soldiers and their Families who need help. The

energy, professionalism, and commitment of resources

described in this article clearly show the commitment

of the Army to the “whole” Soldier, which includes the

Family as full partners in service to our country.

The previous 5 articles have dealt with the

AMEDDC&S training directed at those charged with

providing mental and behavioral health evaluation,

treatment, and counseling. A recently created (March

2007) organization within AMEDDC&S, the

Battlemind Training Office (BTO) has the mission to

develop and deliver evolving, sophisticated, and

multifaceted psychological resiliency training

packages aimed at the Warriors themselves. In their

article, MAJ (Ret) John Orsinger and his coauthors

chronicle the establishment of the BTO to address the

need for an organizational approach to the mental

preparation of Soldiers to successfully deploy and then

transition back to their home lives. The Battlemind

concept is an extremely important “big picture”

approach, not focused exclusively on that period a

Soldier spends in the combat theater. Rather, when

fully instituted, Battlemind training will encompass the

entire cycle that prepares a Soldier for deployment, the

deployment itself, and the “decompression” that is

necessary as a Warrior leaves the combat environment
6 www.cs.amedd.army.mil/references_publications.aspx

and undergoes the psychological transition to the

safety and security of normal life. Both pre- and

postdeployment training include blocks with the

Warriors and their Families together to ensure all

parties are prepared for those changes that are

unavoidable, for both the Warrior and Family.

Understandably, the development of such an

expansive, yet integrated concept into the numerous

training packages necessary is a major undertaking.

The Battlemind Training Office has become the largest

entity in the Soldier and Family Support Branch of the

AMEDDC&S. Its mission is recognized throughout

the AMEDD and Army senior command levels as

critical to combat readiness and effectiveness, Soldier

and Family satisfaction, and, of course, retention of

that invaluable resource, our professional Warriors.

Dr Dexter Freeman and MAJ Graeme Bicknell close

this issue of the AMEDD Journal with an article

presenting a exciting new professional education

opportunity within the AMEDD. The AMEDD has

teamed with Fayetteville State University to establish a

Master of Social Work degree granting program for

military members which is presented at the

AMEDDC&S. The program, which started its initial

class in June 2008, addresses a complicated problem

which has plagued Army Social Work since its

establishment in 1943. Until now, it was necessary for

the Army to source graduates of civilian institutions

for all of its military social workers. Of course, those

new Soldiers, although well educated in the knowledge

and skills of the civilian social work environment, had

no exposure to the markedly different environment of

the military. Since 1945, AMEDD has presented a

subprofessional training program to orient new social

workers, but the adjustment period on the job is long,

and effectiveness of services is sometimes adversely

affected as the new Army social worker becomes

accustomed to the unfamiliar world in which he or she

must practice their skills. A further complication arose

in 1998 when federal law mandated that military social

workers must possess a professional license to

practice. This requirement extended the period

between graduation and eligibility to enter the Army

and practice by over 2 years, further shrinking the pool

of potential candidates as their interest in the military

waned during their exposure to private practice. The

Army-Fayetteville State University Master of Social

Work program is designed to source students from

within the military—thus eliminating the need for

adjustment and reorientation—and provide a graduate

education from an accredited institution tailored to our

environment. The graduate then completes the

supervised practice-examination-licensure phase at a

military facility, providing the Army with a much

needed resource who is more effective from day one

than those entering the military directly from civilian

education and practice. The professionals within the

AMEDDC&S have worked long and hard on this

innovative, desperately needed initiative that will help

ensure Soldiers and Families receive the best possible

support services and care. They are to be congratulated

on their success.

REFERENCES

1. McPherson JM. Battle Cry of Freedom: The Civil

War Era. New York: Oxford University Press; 1988.

2. Hobart G. Masters of Photography: Mathew Brady.

London: Macdonald & Co; 1984:7.

3. Chermol BH. Wounds without scars: treatment of

battle fatigue in the US armed forces in the Second

World War. Mil Aff. 1985;49(1):9-12.

4. Tanielian T, Jaycox LH, eds. Invisible Wounds of

War: Psychological and Cognitive Injuries, Their

Consequences, and Services to Assist Recovery. Santa

Monica, CA: RAND Corporation; 1998. Publication

MG-720-CCF. Available at: http://veterans.rand.org.

5. Mental Health Advisory Team (MHAT) V: Operation

Iraqi Freedom 06-08, Iraq; Operation Enduring

Freedom 8, Afghanistan. Washington, DC: Office of

The Surgeon General, US Dept of the Army;

February 14, 2008:26. Available at: http://

www.armymedicine.army.mil/reports/mhat/mhat_v/

MHAT_V_OIFandOEF-Redacted.pdf.

Perspective
July – September 2008 7

BACKGROUND

The current combat operations in Iraq and Afghanistan

have involved US military personnel in major ground

combat and hazardous security duty. Studies are

needed to systematically assess the mental health of

members of the armed services who have participated

in these operations and to inform policy with regard to

the optimal delivery of mental health care to returning

veterans.

METHODS

We studied members of 4 US combat infantry units (3

Army units and a Marine Corps unit) using an anonymous survey that was administered to the subjects either before their deployment to Iraq (n=2530) or 3 to 4

months after their return from combat duty in Iraq or

Afghanistan (n=3671). The outcomes included major

depression, generalized anxiety, and posttraumatic

stress disorder (PTSD), which were evaluated on the

basis of standardized, self-administered screening instruments.

RESULTS

Exposure to combat was significantly greater among

those who were deployed to Iraq than among those

deployed to Afghanistan. The percentage of study subjects whose responses met the screening criteria for

major depression, generalized anxiety, or PTSD was

significantly higher after duty in Iraq (15.6% to

17.1%) than after duty in Afghanistan (11.2%) or before deployment to Iraq (9.3%); the largest difference

was in the rate of PTSD. Of those whose responses

were positive for a mental disorder, only 23% to 40%

sought mental health care. Those whose responses

were positive for a mental disorder were twice as

likely as those whose responses were negative to report concern about possible stigmatization and other

barriers to seeking mental health care.

CONCLUSIONS

This study provides an initial look at the mental health

of members of the Army and the Marine Corps who

were involved in combat operations in Iraq and Afghanistan. Our findings indicate that among the study

groups there was a significant risk of mental health

problems and that the subjects reported important barriers to receiving mental health services, particularly

the perception of stigma among those most in need of

such care.

The recent military operations in Iraq and Afghanistan,

which have involved the first sustained ground combat

undertaken by the United States since the war in Vietnam, raise important questions about the effect of the

experience on the mental health of members of the

military services who have been deployed there. Research conducted after other military conflicts has

shown that deployment stressors and exposure to combat result in considerable risks of mental health probCombat Duty in Iraq and Afghanistan,

Mental Health Problems and

Barriers to Care

COL Charles W. Hoge, MC, USA

COL Carl A. Castro, MS, USA

Stephen C. Messer, MA, PhD

MAJ Dennis McGurk, MS, USA

CPT Dave I. Cotting, MS, USAR

CAPT Robert L. Koffman, MC, USN

ABSTRACT

This article originally appeared in the New England Journal of Medicine: New Engl J Med. 2004;351:13-22.

Copyright © 2004 Massachusetts Medical Society. Reprinted with permission of the publisher.
8 www.cs.amedd.army.mil/references_publications.aspx

STUDY GROUPS

We summarized data from the first, cross-sectional

phase of a longitudinal study of the effect of combat

on the mental health of the Soldiers and Marines deployed in Operation Iraqi Freedom and in Operation

Enduring Freedom in Afghanistan. Three comparable

US Army units were studied with the use of an anonymous survey administered either before deployment to

Iraq or after their return from Iraq or Afghanistan. Although no data from before deployment were available

for the Marines in the study, data were collected from

a Marine Corps unit after its return from Iraq that provided a basis for comparison with data obtained from

Army Soldiers after their return from Iraq.

The study groups included 2530 Soldiers from an

Army infantry brigade of the 82nd Airborne Division,

whose responses to the survey were obtained in January 2003, one week before a year-long deployment to

Iraq; 1962 Soldiers from an Army infantry brigade of

the 82nd Airborne Division, whose responses were

obtained in March 2003, after the Soldiers’ return from

a 6-month deployment to Afghanistan; 894 Soldiers

from an Army infantry brigade of the 3rd Infantry Division, whose responses were obtained in December

2003, after their return from an 8-month deployment to

Iraq; and 815 Marines from 2 battalions under the

command of the 1st Marine Expeditionary Force,

whose responses were obtained in October or November 2003, after a 6-month deployment to Iraq. The 3rd

Infantry Division and the Marine battalions had spearheaded early ground-combat operations in Iraq, in

March through May 2003. All the units whose members responded to the survey were also involved in

hazardous security duties. The questionnaires administered to Soldiers and Marines after deployment to Iraq

or Afghanistan were administered 3 to 4 months after

their return to the United States. This interval allowed

time in which the Soldiers completed leave, made the

transition back to garrison work duties, and had the

opportunity to seek medical or mental health treatment, if needed.

RECRUITMENT AND REPRESENTATIVENESS OF THE SAMPLE

Unit leaders assembled the Soldiers and Marines near

their workplaces at convenient times, and the study

investigators then gave a short recruitment briefing

and obtained written informed consent on forms that

lems, including posttraumatic stress disorder, major

depression, substance abuse, impairment in social

functioning and in the ability to work, and the increased use of healthcare services.1-8 One study that

was conducted just before the military operations in

Iraq and Afghanistan began found that at least 6% of

all US military service members on active duty receive

treatment for a mental disorder each year.9 Given the

ongoing military operations in Iraq and Afghanistan,

mental disorders are likely to remain an important

healthcare concern among those serving there.

Many gaps exist in the understanding of the full psychosocial effect of combat. The all-volunteer force

deployed to Iraq and Afghanistan and the type of warfare conducted in these regions are very different from

those involved in past wars, differences that highlight

the need for studies of members of the armed services

who are involved in the current operations. Most studies that have examined the effects of combat on mental

health were conducted among veterans years after their

military service had ended.1-8 A problem in the methods of such studies is the long recall period after exposure to combat.10 Very few studies have examined a

broad range of mental health outcomes near to the time

of subjects’ deployment.

Little of the existing research is useful in guiding policy with regard to how best to promote access to and

the delivery of mental health care to members of the

armed services. Although screening for mental health

problems is now routine both before and after deployment11 and is encouraged in primary care settings,12 we

are not aware of any studies that have assessed the use

of mental health care, the perceived need for such care,

and the perceived barriers to treatment among members of the military services before or after combat

deployment.

We studied the prevalence of mental health problems

among members of the US armed services who were

recruited from comparable combat units before or after

their deployment to Iraq or Afghanistan. We identified

the proportion of service members with mental health

concerns who were not receiving care and the barriers

they perceived to accessing and receiving such care.

METHODS

Combat Duty in Iraq and Afghanistan, Mental Health Problems and Barriers to Care
July – September 2008 9

THE ARMY MEDICAL DEPARTMENT JOURNAL

included statements about the purpose of the survey,

the voluntary nature of participation, and the methods

used to ensure participants’ anonymity. Overall, 58%

of the Soldiers and Marines from the selected units

were available to attend the recruitment briefings (79%

of the Soldiers before deployment, 58% of the Soldiers

after deployment in Operation Enduring Freedom in

Afghanistan, 34% of the Soldiers after deployment in

Operation Iraqi Freedom, and 65% of the Marines after deployment in Operation Iraqi Freedom). Most of

those who did not attend the briefings were not available because of their rigorous work and training schedules (eg, night training and post security).

A response was defined as completion of any part of

the survey. The response rate among the Soldiers and

Marines who were briefed was 98% for the 4 samples

combined. The rates of missing values for individual

items in the survey were generally less than 15%; 2%

of participants did not complete the PTSD measures,

5% did not complete the depression and anxiety measures, and 7% to 8% did not complete the items related

to the use of alcohol. The high response rate was

probably owing to the anonymous nature of the survey

and to the fact that participants were given time by

their units to complete the 45-minute survey. The

study was conducted under a protocol approved by the

institutional review board of the Walter Reed Army

Institute of Research.

To assess whether or not our sample was representative, we compared the demographic characteristics of

respondents with those of all active-duty Army and

Marine personnel deployed to Operation Iraqi Freedom and Operation Enduring Freedom, using the Defense Medical Surveillance System.13

SURVEY AND MENTAL HEALTH OUTCOMES

The study outcomes were focused on current symptoms (ie, those occurring in the past month) of a major

depressive disorder, a generalized anxiety disorder,

and PTSD. We used 2 case definitions for each disorder, a broad screening definition that followed current

psychiatric diagnostic criteria14 but did not include

criteria for functional impairment or for severity, and a

strict (conservative) screening definition that required

a self-report of substantial functional impairment or a

large number of symptoms. Major depression and generalized anxiety were measured with the use of the

patient health questionnaire developed by Spitzer et

al.15-17 For the strict definition to be met, there also had

to be evidence of impairment in work, at home, or in

interpersonal functioning that was categorized as at the

“very difficult” level as measured by the patient health

questionnaire. The generalized anxiety measure was

modified slightly to avoid redundancy; items that pertained to concentration, fatigue, and sleep disturbance

were drawn from the depression measure.

The presence or absence of PTSD was evaluated with

the use of the 17-item National Center for PTSD

Checklist of the Department of Veterans Affairs.4,8,18,19

Symptoms were related to any stressful experience (in

the wording of the “specific stressor” version of the

checklist), so that the outcome would be independent

of predictors (ie, before or after deployment). Results

were scored as positive if subjects reported at least one

intrusion symptom, 3 avoidance symptoms, and 2 hyperarousal symptoms14 that were categorized as at the

moderate level, according to the PTSD checklist. For

the strict definition to be met, the total score also had

to be at least 50 on a scale of 17 to 85 (with a higher

number indicating a greater number of symptoms or

greater severity), which is a well-established cutoff.4,8,18,19 Misuse of alcohol was measured with the

use of a 2-question screening instrument.20

In addition to these measures, on the survey participants were asked whether they were currently experiencing stress, emotional problems, problems related to

the use of alcohol, or family problems and, if so,

whether the level of these problems was mild, moderate, or severe; the participants were then asked

whether they were interested in receiving help for

these problems. Subjects were also asked about their

use of professional mental health services in the past

month or the past year and about perceived barriers to

mental health treatment, particularly stigmatization as

a result of receiving such treatment.21 Combat experiences were modified from previous scales.22

QUALITY-CONTROL PROCEDURES AND ANALYSIS

Responses to the survey were scanned with the use of

ScanTools software (Pearson NCS). Quality control

procedures identified scanning errors in no more than

0.38% of the fields (range, 0.01% to 0.38%). SPSS

software (version 12.0) was used to conduct the analyses, including multiple logistic regression that was

used to control for differences in demographic characteristics of members of study groups before and after

deployment.23,24
10 www.cs.amedd.army.mil/references_publications.aspx

Combat Duty in Iraq and Afghanistan, Mental Health Problems and Barriers to Care

Table 1. Demographic Characteristics of Study Groups of Soldiers and Marines as Compared with Reference

Groups.*

Characteristic Army Study Groups Marine Study

Group

Army

Reference

Group

(N=61,742)

Marine

Reference

Group

(N=20,194)

Before

Deployment to

Iraq

(N=2530)

After

Deployment to

Afghanistan

(N=1962)

After

Deployment to

Iraq

(N=894)

After

Deployment to

Iraq

(N=815)

Age number (%)

18–24 yr 1647 (66) 1226 (63) 528 (59) 652 (80) 32,840 (53) 13,824 (69)

25–29 yr 496 (20) 387 (20) 206 (23) 114 (14) 13,737 (22) 3,174 (16)

30–39 yr 336 (13) 316 (16) 147 (16) 41 (5) 12,960 (21) 2,703 (13)

40 yr or older 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)

Female 26 (1) 23 (1) 14 (2) 541 (1) 104 (0.5)

Race or ethnic group

White 1749 (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)

Hispanic 331 (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

graduate or less 1955 (78) 1514 (78) 726 (82) 728 (89) 48561 (79) 16892 (84)

Some college or

other 202 (8) 153 (8) 73 (8) 29 (4) 3260 (5) 346 (2)

College graduate 339 (14) 277 (14) 85 (10) 54 (7) 8838 (14) 2945 (15)

Military grade

Enlisted personnel†

E1–E4 1585 (63) 1170 (60) 613 (69) 601 (84) 33823 (55) 13744 (68)

E5–E6 614 (24) 524 (27) 228 (26) 77 (11) 14813 (24) 2850 (14)

E7–E9 116 (5) 91 (5) 23 (3) 8 (1) 3819 (6) 607 (3)

Officer 200 (8) 168 (8) 30 (3) 26 (4) 9287 (15) 2993 (15)

Marital status

Single 1142 (50) 908 (52) 355 (46) 455 (63) 32636 (53) 12332 (61)

Married 936 (41) 685 (39) 338 (43) 204 (28) 27582 (45) 7499 (37)

Other 199 (9) 168 (9) 85 (11) 65 (9) 1485 (2) 363 (2)

*Data exclude missing values, because not all respondents answered every question. Percentages may not sum to 100 because

of rounding. Data for the reference groups were obtained from the Defense Medical Surveillance System’s deployment rosters of

Army and Marine personnel deployed in Operation Iraqi Freedom and in Afghanis tan in 2003. The total number of persons on

these rosters was 315,999, of whom 229,034 (72%) were active-duty personnel; the remaining 86,965 were members of the

Reserve and National Guard; 97,906 (31%) had a designation of a combat-arms occupation. Of the 229,034 active-duty service

members, 81,936 (36%) had combat-arms occupations, including 61,742 Soldiers and 20,194 Marines in the reference groups.

†Higher numbers indicate higher grades.
July – September 2008 11

THE ARMY MEDICAL DEPARTMENT JOURNAL

The demographic characteristics of participants from

the 3 Army units were similar. The Marines in the

study were somewhat younger than the Soldiers in the

study and less likely to be married. The demographic

characteristics of all the participants in the survey

samples were very similar to those of the general,

deployed, active-duty infantry population, except that

officers were undersampled, which resulted in slightly

lower age and rank distributions (Table 1). Data for the

reference populations were obtained from the Defense

Medical Surveillance System with the use of available

rosters of Army and Marine personnel deployed to Iraq

or Afghanistan in 2003 (Table 1).

Among the 1709 Soldiers and Marines who had

returned from Iraq, the reported rates of combat

experiences and frequency of contact with the enemy

were much higher than those reported by Soldiers who

had returned from Afghanistan (Table 2). Only 31% of

Soldiers deployed to Afghanistan reported having

engaged in a firefight, as compared with 71% to 86%

of Soldiers and Marines who had been deployed to

Iraq. Among those who had been in a firefight, the

median number of firefights during deployment was 2

(interquartile range, 1 to 3) among those in

Afghanistan, as compared with 5 (interquartile range,

2 to 13; P<0.001 by analysis of variance) among

Soldiers deployed to Iraq and 5 (interquartile range, 3

RESULTS

Table 2. Combat Experiences Reported by Members of the US Army and Marine Corps after

Deployment to Iraq or Afghanistan*

Experience Army Group Marine Group

Afghanistan (N=1962) Iraq (N=894) Iraq (N=815)

number/total number (%)

Being attacked or ambushed 1139/1961 (58) 789/883 (89) 764/805 (95)

Receiving incoming artillery, rocket, or mortar fire 1648/1960 (84) 753/872 (86) 740/802 (92)

Being shot at or receiving small-arms fire 1302/1962 (66) 826/886 (93) 779/805 (97)

Shooting or directing fire at the enemy 534/1961 (27) 672/879 (77) 692/800 (87)

Being responsible for the death of an enemy

combatant

229/1961 (12) 414/871 (48) 511/789 (65)

Being responsible for the death of a noncombatant 17/1961 (1) 116/861 (14) 219/794 (28)

Seeing dead bodies or human remains 771/1958 (39) 832/879 (95) 759/805 (94)

Handling or uncovering human remains 229/1961 (12) 443/881 (50) 455/800 (57)

Seeing dead or seriously injured Americans 591/1961 (30) 572/882 (65) 604/803 (75)

Knowing someone seriously injured or killed 850/1962 (43) 751/878 (86) 693/797 (87)

Participating in demining operations 314/1962 (16) 329/867 (38) 270/787 (34)

Seeing ill or injured women or children whom you

were unable to help

907/1961 (46) 604/878 (69) 665/805 (83)

Being wounded or injured 90/1961 (5) 119/870 (14) 75/803 (9)

Had a close call, was shot or hit, but protective gear

saved you

† 67/879 (8) 77/805 (10)

Had a buddy shot or hit who was near you † 192/880 (22) 208/797 (26)

Clearing or searching homes or buildings 1108/1961 (57) 705/884 (80) 695/805 (86)

Engaging in hand-to-hand combat 51/1961 (3) 189/876 (22) 75/800 (9)

Saved the life of a Soldier or civilian 125/1961 (6) 183/859 (21) 150/789 (19)

*Data exclude missing values, because not all respondents answered every question. Combat experiences are worded

as in the survey.

†The question was not included in this survey.
12 www.cs.amedd.army.mil/references_publications.aspx

to 10; P<0.001 by analysis of variance) among

Marines deployed to Iraq.

Soldiers and Marines who had returned from Iraq were

significantly more likely to report that they were

currently experiencing a mental health problem, to

express interest in receiving help, and to use mental

health services than were Soldiers returning from

Afghanistan or those surveyed before deployment

(Table 3). Rates of PTSD were significantly higher

after combat duty in Iraq than before deployment, with

similar odds ratios for the Army and Marine samples

(Table 3). Significant associations were observed for

major depression and the misuse of alcohol. Most of

these associations remained significant after control

for demographic factors with the use of multiple

logistic regression (Table 3). When the prevalence

rates for any mental disorder were adjusted to match

the distribution of officers and enlisted personnel in

the reference populations, the result was less than a

10% decrease (range, 3.5% to 9.4%) in the rates shown

in Table 3 according to both the broad and the strict

definitions (data not shown).

For all groups responding after deployment, there was

a strong reported relation between combat experiences,

such as being shot at, handling dead bodies, knowing

someone who was killed, or killing enemy combatants,

and the prevalence of PTSD. For example, among

Soldiers and Marines who had been deployed to Iraq,

the prevalence of PTSD (according to the strict

definition) increased in a linear manner with the

number of firefights during deployment: 4.5% for no

firefights, 9.3% for one to 2 firefights, 12.7% for 3 to 5

firefights, and 19.3% for more than 5 firefights (chisquare for linear trend, 49.44; P<0.001). Rates for

those who had been deployed to Afghanistan were

4.5%, 8.2%, 8.3%, and 18.9%, respectively (chi square

for linear trend, 31.35; P<0.001). The percentage of

participants who had been deployed to Iraq who

reported being wounded or injured was 11.6% as

compared with only 4.6% for those who had been

deployed to Afghanistan. The rates of PTSD were

significantly associated with having been wounded or

injured (odds ratio for those deployed to Iraq, 3.27;

95% confidence interval, 2.28 to 4.67; odds ratio for

those deployed to Afghanistan, 2.49; 95% confidence

interval, 1.35 to 4.40).

Of those whose responses met the screening criteria

for a mental disorder according to the strict case

definition, only 38% to 45% indicated an interest in

receiving help, and only 23% to 40% reported having

received professional help in the past year (Table 4).

Those whose responses met these screening criteria

were generally about 2 times as likely as those whose

responses did not to report concern about being

stigmatized and about other barriers to accessing and

receiving mental health services (Table 5).

DISCUSSION

We investigated mental health outcomes among

Soldiers and Marines who had taken part in the

ground-combat operations in Iraq and Afghanistan.

Respondents to our survey who had been deployed to

Iraq reported a very high level of combat experiences,

with more than 90% of them reporting being shot at

and a high percentage reporting handling dead bodies,

knowing someone who was injured or killed, or killing

an enemy combatant (Table 2). Close calls, such as

having been saved from being wounded by wearing

body armor, were not infrequent. Soldiers who served

in Afghanistan reported lower but still substantial rates

of such experiences in combat.

The percentage of study subjects whose responses met

the screening criteria for major depression, PTSD, or

alcohol misuse was significantly higher among

Soldiers after deployment than before deployment,

particularly with regard to PTSD. The linear

relationship between the prevalence of PTSD and the

number of firefights in which a Soldier had been

engaged was remarkably similar among Soldiers

returning from Iraq and Afghanistan, suggesting that

differences in the prevalence according to location

were largely a function of the greater frequency and

intensity of combat in Iraq. The association between

injury and the prevalence of PTSD supports the results

of previous studies.25

These findings can be generalized to ground combat

units, which are estimated to represent about a quarter

of all Army and Marine personnel participating in

Operation Iraqi Freedom and Operation Enduring

Freedom in Afghanistan (when members of the

Combat Duty in Iraq and Afghanistan, Mental Health Problems and Barriers to Care
July

– September 2008 13

THEARMYMEDICALDEPARTMENTJOURNAL

Table 3. Perceived Mental Health Problems and Percentage of Subjects Who Met the Screening Criteria for Major Depression, Generalized Anxiety, Post- Traumatic Stress Disorder, and Alcohol Misuse.*Mental Health Problem Army Study Groups Marine Study Group

Before

Deployment to

Iraq (N=2530)

After Deployment to Afghanistan (N=1962) After Deployment to Iraq (N=894) After Deployment to Iraq (N=815)

no./total no. (%) no./total no. (%) OR (95% CI) no./total no. (%) OR (95% CI) no./total no. (%) OR (95% CI)

Perceived moderate or severeproblem

323/2261 (14.3) 303/1769 (17.1)†‡ 153/784 (19.5)†‡ 123/720 (17.1)

Currently interested inreceiving professional help

211/2243 (9.4) 180/1769 (10.2) 131/786 (16.7)†‡ 106/706 (15.0)†‡

Received professional helpin the past month§

108/2280 (4.7) 118/1780 (6.6)†‡ 91/796 (11.4)†‡ 70/742 (9.4)†‡

Definition of mental disorder

Broad definition

Depression according to PHQ 275/2418 (11.4) 267/1885 (14.2) 1.29 (1.07–1.54)†‡ 128/840 (15.2) 1.40 (1.12–1.76)†‡ 114/775 (14.7) 1.34 (1.06–1.70)¶Anxiety according to PHQ 375/2419 (15.5) 324/1886 (17.2) 1.13 (0.96–1.33) 147/839 (17.5) 1.16 (0.94–1.43) 122/776 (15.7) 1.02 (0.81–1.27)PTSD according to PCL 226/2414 (9.4) 224/1956 (11.5) 1.25 (1.03–1.52)¶ 159/881 (18.0) 2.13 (1.71–2.66)†‡ 161/811 (19.9) 2.40 (1.92–2.99)†‡Any of above 522/2500 (20.9) 479/1958 (24.5) 1.23 (1.07–1.41)†‡ 246/882 (27.9) 1.47 (1.23–1.75)†‡ 237/813 (29.2) 1.56 (1.30–1.87)†

Strict definition

Depression according to PHQ 128/2418 (5.3) 130/1885 (6.9) 1.33 (1.03–1.71)‡¶ 66/840 (7.9) 1.53 (1.12–2.08)†‡ 55/775 (7.1) 1.37 (0.99–1.90)Anxiety according to PHQ 155/2419 (6.4) 140/1886 (7.4) 1.17 (0.92–1.48) 66/839 (7.9) 1.25 (0.92–1.68) 51/776 (6.6) 1.03 (0.74–1.43)PTSD according to PCL 120/2414 (5.0) 121/1956 (6.2) 1.26 (0.97–1.64) 114/881 (12.9) 2.84 (2.17–3.72)†‡ 99/811 (12.2) 2.66 (2.01–3.51)†‡Any of above 233/2500 (9.3) 220/1958 (11.2) 1.23 (1.01–1.50)¶ 151/882 (17.1) 2.01 (1.61–2.51)†‡ 127/813 (15.6) 1.80 (1.43–2.27)†‡

Alcohol misuse

Have you used alcohol morethan you meant to?

405/2358 (17.2) 452/1844 (24.5) 1.57 (1.35–1.82)†‡ 198/819 (24.2) 1.54 (1.27–1.86)†‡ 268/756 (35.4) 2.65 (2.20–3.18)†‡

Have you felt you wanted orneeded to cut down on yourdrinking?

289/2313 (12.5) 331/1821 (18.2) 1.56 (1.31–1.85)†‡ 168/815 (20.6) 1.82 (1.47–2.24)†‡ 219/744 (29.4) 2.92 (2.39–3.57)†‡

*Each study group who responded after deployment was compared with the group that responded before deployment, with the use of odds ratios (with 95% confidence intervals) and chi-square testing. Data excludemissing values, because not all respondents answered every question. OR denotes odds ratio, CI confidence interval, PHQ patient health questionnaire, PTSD post-traumatic stress disorder, and PCL the National Centerfor Post-Traumatic Stress Disorder Checklist.†P<0.01 for the comparison of groups responding after deployment with the group responding before deployment, calculated with the use of the chi-square test.‡The result remained significant after multiple logistic regression was used to control for age, rank, educational level, marital status, and race or ethnic group.§Professional help was defined as help from a mental health professional, a general medical doctor, or a chaplain or other member of the clergy, in either a military or civilian treatment setting.¶P<0.05 for the comparison of groups responding after deployment with the group responding before deployment, calculated with the use of the chi-square test.
14 www.cs.amedd.army.mil/references_publications.aspx

Reserve and the National Guard are

included) and nearly 40% of all activeduty personnel (when Reservists and

members of the National Guard are not

i n c l u d e d ) . T h e d e mo g r a p h i c

characteristics of the subjects in our

samples closely mirrored the

demographic characteristics of this

population. The somewhat lower

proportion of officers had a minimal

effect on the prevalence rates, and

potential differences in demographic

factors among the 4 study groups were

controlled for in our analysis with the use

of logistic regression.

One demonstration of the internal

validity of our findings was the

observation of similar prevalence rates

for combat experiences and mental health

outcomes among the subjects in the

Army and the Marine Corps who had

returned from deployment to Iraq, despite

the different demographic characteristics

of members of these units and their

different levels of availability for

recruitment into the study.

Table 5. Perceived Barriers to Seeking Mental Health Services among All

Study Participants (Soldiers and Marines)*

Perceived Barrier

Respondents Who

Met Screening

Criteria for a

Mental Disorder

(N=731)

Respondents Who

Did Not Meet

Screening Criteria

for a Mental

Disorder

(N=5422)

number/total number (%)

I don’t trust mental health professionals. 241/641 (38) 813/4820 (17)

I don’t know where to get help. 143/639 (22) 303/4780 (6)

I don’t have adequate transportation. 117/638 (18) 279/4770 (6)

It is difficult to schedule an appointment. 288/638 (45) 789/4748 (17)

There would be difficulty getting time off

work for treatment.

354/643 (55) 1061/4743 (22)

Mental health care costs too much money. 159/638 (25) 456/4736 (10)

It would be too embarrassing. 260/641 (41) 852/4752 (18)

It would harm my career. 319/640 (50) 1134/4738 (24)

Members of my unit might have less

confidence in me.

377/642 (59) 1472/4763 (31)

My unit leadership might treat me differently. 403/637 (63) 1562/4744 (33)

My leaders would blame me for the problem. 328/642 (51) 928/4769 (20)

I would be seen as weak. 413/640 (65) 1486/4732 (31)

Mental health care doesn’t work. 158/638 (25) 444/4748 (9)

*Data exclude missing values, because not all respondents answered every question. Respondents

were asked to rate“ each of the possible concerns that might affect your decision to receive

mental health counseling or services if you ever had a problem.” Perceived barriers are worded as

on the survey. The 5 possible responses ranged from “strongly disagree” to “strongly agree,” with

“agree” and “strongly agree” combined as a positive response.

Combat Duty in Iraq and Afghanistan, Mental Health Problems and Barriers to Care

Table 4. Perceived Need for and Use of Mental Health Services among Soldiers and Marines

Whose Survey Responses Met the Screening Criteria for Major Depression, Generalized Anxiety,

or Post-Traumatic Stress Disorder*

Outcome Army Study Groups Marine Study

Group

Before

Deployment to

Iraq (N=233)

After

Deployment to

Afghanistan

(N=220)

After

Deployment to

Iraq (N=151)

After

Deployment to

Iraq (N=127)

number/total number (%)

Need

Acknowledged a problem 184/215 (86) 156/192 (81) 104/133 (78) 91/106 (86)

Interested in receiving help 85/212 (40) 75/196 (38) 58/134 (43) 47/105 (45)

Received professional help†

In past year

Overall (from any professional) 61/222 (28) 46/198 (23) 56/140 (40) 33/113 (29)

From a mental health professional 33/222 (15) 26/198 (13) 37/138 (27) 24/112 (21)

In past month

Overall (from any professional) 39/218 (18) 34/196 (17) 44/136 (32) 23/112 (21)

From a mental health professional 24/218 (11) 25/196 (13) 29/136 (21) 16/111 (14)

*Data exclude missing values, because not all respondents answered every question.

†Professional help was defined as help from a mental health professional, a general medical doctor, or a chaplain

or other member of the clergy, in either a military or civilian treatment setting.
July – September 2008 15

THE ARMY MEDICAL DEPARTMENT JOURNAL

The cross-sectional design involving different units

that was used in our study is not as strong as a

longitudinal design. However, the comparability of the

Army samples and the similarity in outcomes among

subjects in the Army and Marine units surveyed after

deployment to Iraq should generate confidence in the

cross-sectional approach. Another limitation of our

study is the potential selection bias resulting from the

enrollment procedures, which were influenced by the

practical realities that resulted from working with

operational units. Although work schedules affected

the availability of Soldiers to take part in the survey,

the effect is not likely to have biased our results.

However, the selection procedures did not permit the

enrollment of persons who had been severely wounded

or those who may have been removed from the units

for other reasons, such as misconduct. Thus, our

estimates of the prevalence of mental disorders are

conservative, reflecting the prevalence among

working, nondisabled combat personnel. The period

immediately before a long combat deployment may

not be the best time at which to measure baseline

levels of distress. The magnitude of the differences

between the responses before and after deployment is

particularly striking, given the likelihood that the

group responding before deployment was already

experiencing levels of stress that were higher than

normal.

The survey instruments used to screen for mental

disorders in this study have been validated primarily in

the settings of primary care and in clinical populations.

The results therefore do not represent definitive

diagnoses of persons in nonclinical populations such

as our military samples. However, requiring evidence

of functional impairment or a high number of

symptoms, as we did, according to the strict case

definitions, increases the specificity and positive

predictive value of the survey measures.26,27 This

conservative approach suggested that as many as 9%

of Soldiers may be at risk for mental disorders before

combat deployment, and as many as 11% to 17% may

be at risk for such disorders 3 to 4 months after their

return from combat deployment.

Although there are few published studies of the rates

of PTSD among military personnel soon after their

return from combat duty, studies of veterans conducted

years after their service ended have shown a

prevalence of current PTSD of 15% among Vietnam

veterans28 and 2% to 10% among veterans of the first

Gulf War.4,8 Rates of PTSD among the general adult

population in the United States are 3% to 4%,26 which

are not dissimilar to the baseline rate of 5% observed

in the sample of Soldiers responding to the survey

before deployment. Research has shown that the

majority of persons in whom PTSD develops meet the

criteria for the diagnosis of this disorder within the

first 3 months after the traumatic event.29 In our study,

administering the surveys 3 to 4 months after the

subjects had returned from deployment and at least 6

months after the heaviest combat operations was

probably optimal for investigating the long-term risk

of mental health problems associated with combat. We

are continuing to examine this risk in repeated crosssectional and longitudinal assessments involving the

same units.

Our findings indicate that a small percentage of

Soldiers and Marines whose responses met the

screening criteria for a mental disorder reported that

they had received help from any mental health

professional, a finding that parallels the results of

civilian studies.30-32 In the military, there are unique

factors that contribute to resistance to seeking such

help, particularly concern about how a Soldier will be

perceived by peers and by the leadership. Concern

about stigma was disproportionately greatest among

those most in need of help from mental health services.

Soldiers and Marines whose responses were scored as

positive for a mental disorder were twice as likely as

those whose responses were scored as negative to

show concern about being stigmatized and about other

barriers to mental health care.

This finding has immediate public health implications.

Efforts to address the problem of stigma and other

barriers to seeking mental health care in the military

should take into consideration outreach, education, and

changes in the models of healthcare delivery, such as

increases in the allocation of mental health services in

primary care clinics and in the provision of

confidential counseling by means of employeeassistance programs. Screening for major depression is

becoming routine in military primary care settings,12

but our study suggests that it should be expanded to

include screening for PTSD. Many of these

considerations are being addressed in new military

programs.33 Reducing the perception of stigma and the

barriers to care among military personnel is a priority
16 www.cs.amedd.army.mil/references_publications.aspx

for research and a priority for the policymakers,

clinicians, and leaders who are involved in providing

care to those who have served in the armed forces.

ACKNOWLEDGEMENT

Supported by the Military Operational Medicine

Research Program, US Army Medical Research and

Materiel Command, Fort Detrick, Md.

We are indebted to the Walter Reed Army Institute of

Research Land Combat Study Team: Lolita Burrell,

PhD; Scott Killgore, PhD; Melba Stetz, PhD; Paul

Bliese, PhD; Oscar Cabrera, PhD; Anthony Cox,

MSW; Timothy Allison-Aipa, PhD; Karen Eaton, MS;

Graeme Bicknell, MSW; Alexander Vo, PhD; and

Charles Milliken, MD; for survey-instrument design

and data collection; to Spencer Campbell, PhD, for

coordination of data collection and scientific advice; to

David Couch for supervising the data-collection teams,

database management, scanning, and quality control;

to Wanda Cook for design and production of surveys;

to Allison Whitt for survey-production and datacollection support; to Lloyd Shanklin, Joshua Fejeran,

Vilna Williams, and Crystal Ross for data-collection,

quality-assurance, scanning, and field support; to

Jennifer Auchterlonie for assistance with Defense

Medical Surveillance System analyses; to Akeiya

Briscoe-Cureton for travel and administrative support;

to the leadership of the units that were studied, and to

our medical and mental health professional colleagues

at Fort Bragg, Fort Stewart, Camp Lejeune, and Camp

Pendleton; to the Walter Reed Army Institute of

Research Office of Research Management; to David

Orman, MD, psychiatry consultant to the Army

Surgeon General; Gregory Belenky, MD; and Charles

C. Engel, MD, for advice and review of the study; and,

most important, to the Soldiers and Marines who

participated in the study for their service.

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Study Group. Health status of Vietnam veterans. I.

Psychosocial characteristics. JAMA. 1988;259:2701-

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2. Helzer JE, Robins LN, McEvoy L. Posttraumatic

stress disorder in the general population: findings of

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Med. 1987;317:1630-1634.

3. Jordan BK, Schlenger WE, Hough R, et al. Lifetime

and current prevalence of specific psychiatric

disorders among Vietnam veterans and controls. Arch

Gen Psychiatry. 1991;48:207-215.

4. The Iowa Persian Gulf Study Group. Self-reported

illness and health status among Gulf War veterans: a

population-based study. JAMA. 1997;277:238-245.

5. Kessler RC, Sonnega A, Bromet E, Hughes M,

Nelson CB. Posttraumatic stress disorder in the

National Comorbidity Survey. Arch Gen Psychiatry.

1995;52:1048-1060.

6. Prigerson HG, Maciejewski PK, Rosenheck RA.

Population attributable fractions of psychiatric

disorders and behavioral outcomes associated with

combat exposures among US men. Am J Public

Health. 2002;92:59-63.

7. Prigerson HG, Maciejewski PK, Rosenheck RA..

Combat trauma: trauma with highest risk of delayed

onset and unresolved posttraumatic stress disorder

symptoms, unemployment, and abuse among men. J

Nerv Ment Dis. 2001;189:99-108.

8. Kang HK, Natelson BH, Mahan CM, Lee KY,

Murphy FM. Posttraumatic stress disorder and

chronic fatigue syndrome-like illness among Gulf

War veterans: a population- based survey of 30,000

veterans. Am J Epidemiol. 2003;157:141-148.

9. Hoge CW, Lesikar SE, Guevara R, et al. Mental

disorders among US military personnel in the 1990s:

association with high levels of healthcare utilization

and early military attrition. Am J Psychiatry.

2002;159:1576-1583.

10. Wessely S, Unwin C, Hotopf M, et al. Stability of

recall of military hazards over time: evidence from

the Persian Gulf War of 1991. Br J Psychiatry.

2003;183:314-322.

11. Wright KM, Huffman AH, Adler AB, Castro CA.

Psychological screening program overview. Mil Med.

2002;167:853-861.

12. VA/DoD clinical practice guideline for the

management of major depressive disorder in adults.

In: Major depressive disorder (MDD): clinical

practice guidelines. Washington, DC: Veterans

Health Administration; May 2000. Publication no.

10Q-CPG/MDD-00. Available at: http://

www.oqp.med.va.gov/cpg/MDD/MDD_Base.htm.

Accessed June 4, 2004.

13. Rubertone MV, Brundage JF. The Defense Medical

Surveillance System and the Department of Defense

serum repository: glimpses of the future of public

health surveillance. Am J Public Health.

2002;92:1900-1904.

Combat Duty in Iraq and Afghanistan, Mental Health Problems and Barriers to Care
July – September 2008 17

THE ARMY MEDICAL DEPARTMENT JOURNAL

14. Diagnostic and Statistical Manual of Mental

Disorders Fourth Edition (Text Revision).

Washington, DC: American Psychiatric Association;

1994.

15. Spitzer RL, Kroenke K, Williams JB. Validation and

utility of a self-report version of PRIME-MD: the

PHQ primary care study. JAMA. 1999;282:1737-

1744.

16. Lowe B, Spitzer RL, Grafe K, et al. Comparative

validity of 3 screening questionnaires for DSM-IV

depressive disorders and physicians’ diagnoses. J

Affect Disord. 2004;8:131-140.

17. Henkel V, Mergl R, Kohnen R, Maier W, Moller HJ,

Hegerl U. Identifying depression in primary care: a

comparison of different methods in a prospective

cohort study. Br Med J. 2003;326:200-201.

18. Blanchard EB, Jones-Alexander J, Buckley TC,

Forneris CA. Psychometric properties of the PTSD

Checklist (PCL). Behav Res Ther. 1996;34:669-673.

19. Weathers FW, Litz BT, Herman DS, Huska JA,

Keane TM. The PTSD checklist (PCL): reliability,

validity, and diagnostic utility. San Antonio, Tx:

International Society of Traumatic Stress Studies,

October 1993. abstract. Available at: http://

w w w . p d h e a l t h . m i l / l i b r a r y / d o w n l o a d s /

PCL_sychometrics.doc. Accessed June 4, 2004.

20. Brown RL, Leonard T, Saunders LA, Papasouliotis

O. A 2-item conjoint screen for alcohol and other

drug problems. J Am Board Fam Pract. 2001;14:95-

106.

21. Britt TW. The stigma of psychological problems in a

work environment: evidence from the screening of

service members returning from Bosnia. J Appl Soc

Psychol. 2000;30:1599-1618.

22. Castro CA, Bienvenu RV, Hufmann AH, Adler AB.

Soldier dimensions and operational readiness in US

Army forces deployed to Kosovo. Int Rev Armed

Forces Med Serv. 2000;73:191-200.

23. Kleinbaum DG, Kupper LL, Morgenstern H.

Epidemiologic Research: Principles and Quantitative

Methods. Belmont, CA: Lifetime Learning; 1982.

24. Menard S. Applied Logistic Regression Analysis. 2nd

ed. Thousand Oaks, CA: Sage Publications; 2002.

25. Friedman MJ, Schnurr PP, McDonagh-Coyle A.

Posttraumatic stress disorder in the military veteran.

Psychiatr Clin North Am. 1994;17:265-277.

26. Narrow WE, Rae DS, Robins LN, Regier DA.

Revised prevalence estimates of mental disorders in

the United States: using a clinical significance

criterion to reconcile 2 surveys’ estimates. Arch Gen

Psychiatry. 2002;59:115-123.

27. Hoge CW, Messer SC, Castro CA. Pentagon

employees after September 11, 2001. Psychiatr Serv.

2004;55:319-320.

28. Schlenger WE, Kulka RA, Fairbank JA, et al. The

prevalence of posttraumatic stress disorder in the

Vietnam generation: a multimethod, multisource

assessment of psychiatric disorder. J Trauma Stress.

1992;5:333-363.

29. Carlier IVE, Lamberts RD, Gersons BPR. Risk

factors for posttraumatic stress symptomatology in

police officers: a prospective analysis. J Nerv Ment

Dis. 1997;185:498-506.

30. Kessler RC, Berglund P, Demler O, et al. The

epidemiology of major depressive disorder: results

from the National Comorbidity Survey Replication

(NCS-R). JAMA. 2003;289:3095-3105.

31. Regier DA, Narrow WE, Rae DS, Manderscheid RW,

Locke BZ, Goodwin FK. The de facto US mental and

addictive disorders service system: Epidemiologic

Catchment Area prospective 1-year prevalence rates

of disorders and services. Arch Gen Psychiatry.

1993;50:85-94.

32. Kessler RC, McGonagle KA, Zhao S, et al. Lifetime

and 12-month prevalence of DSM-III-R psychiatric

disorders in the United States: results from the

National Comorbidity Survey. Arch Gen Psychiatry.

1994;51:8-19.

33. Deployment Health Clinical Center. Practice

guidelines–deployment cycle support and clinicians.

Available at: http://www.pdhealth.mil. Accessed June

4, 2004.

AUTHORS

COL Hoge is Director, Division of Psychiatry and

Neuroscience, Walter Reed Army Institute of Research,

Silver Spring, Maryland.

COL Castro is Director, Military Operational Medicine

Research Program, US Army Medical Research and

Materiel Command, Fort Detrick, Maryland.

Dr Messer is Chief of Research, Department of

Psychiatry, Walter Reed Army Medical Center,

Washington DC.

MAJ McGurk is Commander, US Army Medical

Research Unit-Europe, Heidelberg, Germany.

CPT Cotting is an Assistant Professor in the

Department of Psychology and Philosophy at the

Virginia Military Institute, Lexington, Virginia.
18 www.cs.amedd.army.mil/references_publications.aspx

INTRODUCTION

Perhaps nothing is more stressful than the experience

of war. The very sights, sounds, and smells that one

experiences in war can have an everlasting impact,

physically, emotionally, and mentally. Since the outbreak of the war in Iraq, the Army has sent numerous

medical units to the Middle East to help treat people

suffering from both physical and psychological

trauma. Specialized medical units called combat stress

control (CSC) are used primarily to provide mental

health related services throughout the theater of operation. Members of CSC units include a variety of mental healthcare professionals such as psychiatrists, psychologists, social workers, occupational therapists,

psychiatric nurses, and mental health specialists. CSC

units are mainly deployed to preserve the fighting

strength of the Army by treating wounds that do not

bleed. They often take a proactive approach by sending small teams around to different sites and offering a

variety of classes in the prevention of battle fatigue.

CSC members are also trained to provide individual

counseling and can even utilize a number of different

therapeutic techniques to help ease any psychological

suffering.

One technique that was designed to help people heal

from psychological trauma is called a critical event

debriefing (CED). Most CSCs use critical event debriefings in a group setting for any personnel who

were unfortunate enough to be directly involved in a

traumatic event. These CEDs were often conducted by

different team members of the CSC in numerous locations throughout the theater of operation. To attend a

CED, one had to either be a member of the CSC team,

or someone who was directly involved in some capacity with the traumatic event. No one else was permitted

to attend. Chaplains were sometimes in attendance as

part of the CSC team.

LITERATURE REVIEW

Recent research studies have indicated the severity and

distinction of mental health affects of combat Soldiers

engaged in wartime operations. It has been reported

that at least 17% of postcombat veterans have depression, anxiety, or posttraumatic stress disorder (PTSD).1

Hoge et al2reported in their study of combat infantry

Soldiers that the percentage of study subjects whose

responses met the screening criteria for major depression, generalized anxiety, or PTSD was significantly

higher after duty in Iraq (15.6% to 17.1%) than after

duty in Afghanistan (11.2%). A 12-member advisory

team surveyed 756 Soldiers in Iraq and found that 87%

of Soldiers reported high levels of stress over not

knowing how long they would be deployed, 71% reported high levels of stress regarding length of deployment, 57% reported high levels of stress over separation from family, and 55% reported high levels of

stress over the lack of privacy and personal space.3

According to the Diagnostic and Statistical Manual of

Mental Disorders,

4

PTSD and panic disorder (PD) are

classified as anxiety disorders, which are initially triggered by some kind of traumatic event that has not

been treated properly. Literature addresses the importance of early mental health treatment following a traumatic event. As cited by Vesper,5 Litz mentions that

Effectiveness of Critical Event Debriefings

During Operation Iraqi Freedom II

CPT Patrick J. Pischke, MS, USAR

CPT Christian J. Hallman, MS, USAR AGR

ABSTRACT

Team members of a US Army medical combat stress control unit provided critical event debriefings for military

personnel who were directly involved in a traumatic event during Operation Iraqi Freedom II. Each person attending

the debriefing was then given a short 5-question survey immediately following the session. Out of the 396 participants

who completed the survey questionnaire, 273 felt the debriefing given by the team was helpful, 97 had no opinion, and

26 did not feel it was helpful. This particular combat stress control team was located in Taji, Iraq. The data was

collected from debriefings conducted from the beginning of March 2004 to mid-January 2005.
July – September 2008 19

there is evidence that once veterans develop militaryrelated PTSD, the symptoms remain chronic across

their lifetime and they become resistant to treatment

that has been shown to work with other forms of

chronic PTSD. One of the most commonly reported

clinical problems in anxiety disorders, such as PTSD

and PD, are disturbances in sleep.6 Combat veterans

with PTSD frequently report sudden awakenings from

nightmares that closely resemble their most salient

traumatic experience.7PTSD patients with comorbid

PD may express additive symptoms of central fear system disturbance.8 Thus, it is vitally important to provide early intervention to reduce chronic impairments

in veterans.5Significant findings include the discovery

that providing Soldiers with immediate psychological

intervention close to the front lines increase the likelihood of their recovering sufficiently to return to duty.9

Psychologist Viktor Razdvev studied combatants in

Chechnya and indicated that he, and others, recognized

that if you can get to a person in hours, or no later than

2 to 3 days after suffering psychological trauma, you

could weaken or even prevent PTSD’s onset.10

Several studies have implicated the benefits derived

from providing mental health services, such as critical

incident stress debriefings (CISD), to individuals who

have experienced traumatic events. A debriefing can

be conducted near the site of the actual event.11,12 Another component of a CISD is a defusing. To be most

helpful, debriefing and diffusing techniques must be

done 24 to 72 hours after the initial impact of the

event.13,14 Eid et al15 studied military personal (n=9)

and civilian firefighters (n=9) involved with a severe

car accident in which rescue efforts placed the workers

in harms way. The group that received additional psychological debriefings reported fewer PTSD symptoms.15 Jenkins16 researched 34 male and 2 female

emergency medical technicians, paramedics, and firefighters who worked at the site of a mass shooting.

Jenkins reported that 52% of the sample (n=15) attended at least one CISD while the control group

choose not to participate with the CISD. It was found

that participation with debriefings as correlated with

lower depression and anxiety scores one month postshooting. Shalev et al17 studied 39 Israeli Soldiers exposed to direct combat and found the debriefing correlated with self-report reduction in anxiety symptoms

and improvement in self-efficacy. Burns and Harm18

studied emergency nurses (n=682) and found that 88%

of the survey population who had participated in debriefings found them helpful. Robinson and Mitchell19

studied 172 emergency service, welfare, and hospital

personnel in Australia and found that most personal

who reported symptoms of stress following a traumatic

incident stated that these symptoms had been reduced

as a consequence of attending the debriefing.

Some articles and studies address the barriers experienced by military personal to receive mental health

services. To treat combat stress effectively, the primary barrier that the US Army must overcome is the

fear of stigmatization that Soldiers associate with mental health treatment.20 Friedman21 mentions that those

returning from Operation Iraqi Freedom or Operation

Enduring Freedom who reported the greatest number

or most severe symptoms were the least likely to seek

treatment for fear that it could harm their careers,

cause difficulties with their peers and within unit leadership, and become an embarrassment in that they

would be seen as weak. Hoge et al2reported in their

study of US combat infantry Soldiers and Marines in

Iraq and Afghanistan that those whose responses were

positive for a mental health disorder, only 23% to 40%

sought mental health care. It has been determined that

at least 60% of veterans are unlikely to seek mental

health help secondary to the fear of stigma or loss of

career advancement opportunities.1

METHODOLOGY

This study involved a sample of convenience (n=396)

of US military personnel who attended a CED following a traumatic event. The CED technique used in this

study is based upon the 7-stage CISD Mitchell

Model.22 Data was collected from 38 separate CEDs

administered from the beginning of March 2004

through mid January 2005 during Operation Iraqi

Freedom II. The different groups that participated in

the CEDs ranged in size from 2 to 24 participants.

Each participant experienced a traumatic war event in

Iraq which involved death, serious injury, and/or life

threatening circumstances. The location of the study

was the Forward Operating Base, Camp Cooke, Taji,

Iraq.

The data collection instrument was a 5 item (Likert

scale) self-survey form as illustrated in Figure 1. Participants were given instructions for completion of the

survey after the CED. Survey forms were completed

confidentially and concise identification features were

excluded from each survey form to achieve the atomicity of each participant. Participation with the study was

voluntary, although strongly encouraged, and there

was a 100% participation rate.
20 www.cs.amedd.army.mil/references_publications.aspx

Effectiveness of Critical Event Debriefings During Operation Iraqi Freedom II

FINDINGS

Question 1 asked if the participant expected long-term

negative effects as a result of the critical event. Responses are shown in Figure 2: 29.55% (n=117) of the

sample population (n=396) disagreed; 26.52% (n=105)

indicated no opinion; 22.73% (n=90) strongly disagreed; 15.91% (n=63) agreed; 5.30% (n=21) strongly

agreed.

Question 2 responses as shown in Figure 3: 59.34%

(n=235) of participants agreed that the CED was helpful and 24.49% (n=97) had no opinion. 9.60% (n=38)

of participants strongly agreed, while 4.55% (n=18)

disagreed and 2.02% (n=8) of participants strongly

disagreed that the CED was helpful.

Question 3 asked participants if they felt the CED

would have been helpful within 2 hours of the critical

incident. As shown in Figure 4, 32.83% (n=130) of

participants indicated no opinion, while 26.77%

(n=106) indicated they disagreed. 18.69% (n=74) indicated that they agreed that the CED would have been

most helpful if conducted within 2 hours of the critical

event. 12.12% (n=48) indicated that they strongly disagreed, while 9.60% (n=38) indicated that they

strongly agreed.

Question 4 asked participants if they felt a follow-up

appointment was important after the CED. 36.87%

(n=146) of participants indicated no opinion, while

23.74% (n=94) disagreed. 22.98% (n=91) of participants indicated they agreed and 11.36% (n=45)

strongly disagreed. 5.05% (n=20) of participants indi90

117 105

63

21

0

20

40

60

80

100

120

140

Number of Responses

Strongly

Disagree

Strongly

Agree

Disagree No Agree

Opinion

Figure 2. Distribution of responses to Question 1: Do

you feel the critical event you experienced will have

a long-term negative impact on your activities of

daily living?

8

97

235

38

0

50

100

150

200

250

18

Number of Responses

Strongly Disagree

Disagree

No

Opinion

Agree Strongly

Agree

Figure 3. Distribution of responses to Question 2: Do

you feel this CED was helpful?

CRITICAL EVENT DEBRIEFING SURVEY

Today’s

Date:

Date of

Event:

Gender: Age: Rank:

1. Do you feel the critical event you experienced will have a long-term

negative impact on your activities of daily living? (Circle one that best

applies)

1 2 3 4 5

Strongly

Disagree

Disagree No

Opinion

Agree Agree

Strongly

2. Do you feel this CED was helpful?

1 2 3 4 5

Strongly

Disagree

Disagree No

Opinion

Agree Agree

Strongly

3. Do you think the CED would have been most helpful if conducted

within 2 hours of the critical incident?

1 2 3 4 5

Strongly

Disagree

Disagree No

Opinion

Agree Agree

Strongly

4. After the CED, do you think a follow up appointment is important?

1 2 3 4 5

Strongly

Disagree

Disagree No

Opinion

Agree Agree

Strongly

5. Have you had difficulty talking with others about the critical

incident?

1 2 3 4 5

Strongly

Disagree

Disagree No

Opinion

Agree

We appreciate your feedback. Feel free to write comments on back.

Agree

Strongly

Figure 1. The self-survey form used to collect data to

evaluate the effectiveness of critical event debriefings

following traumatic combat events in and around Taji, Iraq

(March 2004 - January 2005).
July – September 2008 21

THE ARMY MEDICAL DEPARTMENT JOURNAL

cated that they felt a follow-up appointment after the

CED was important. See Figure 5.

Question 5 asked participants if they had difficulty

talking with others about the critical incident. 35.61%

(n=141) of participants indicated they strongly disagreed and 31.31% (n=124) indicated that they disagreed. 16.67% (n=66) of participants indicated no

opinion, 11.87% (n=47) indicated they agreed and

4.55% (n=18) indicated that they strongly agreed. See

Figure 6.

DISCUSSION

Question 1. Do you feel the critical event you experienced will have a long-term negative impact on your

activities of daily living? Many participants either disagreed (29.55%, n=117), or strongly disagreed

(22.73%, n=90). These responses indicate a level of

self-assessed resilience among military personnel in a

combat zone involved with traumatic events. The participants who agreed, 15.91% (n=63), and strongly

agreed, 5.30% (n=21), indicate the cohort with a preconception of enduring future difficulties. This approximately 20% of the participants who either agreed

or strongly agreed with Question 1 provides an indication of individuals who have assessed themselves as

suffering long-term consequences from the traumatic,

critical event they experienced.

Question 2. Do you feel this CED was helpful? Approximately 69% (n=273) of participants either agreed

or strongly agreed that the CED was helpful. Only

2.02% (n=8) of participants strongly disagreed, and

4.55% (n=18) disagreed that the CED was helpful.

These findings are congruent with other studies of this

nature in which the majority of participants feel that

debriefings are helpful.

Question 3. Do you think the CED would have been

most helpful if conducted within 2 hours of the critical

incident? Findings from question 3 remained relatively

proportionate between participants who agreed, compared to those participants who disagreed. These findings would support the need for immediate mental

health intervention shortly after a critical event, as well

as after a calming-down period of 48 to 72 hours. The

highest response for this question was the No Opinion

option which was selected by 32.83% (n=130) of parFigure 4. Distribution of responses to Question 3: Do

you think the CED would have been most helpful if

conducted within 2 hours of the critical incident?

48

130

74

38

106

0

20

40

60

80

100

120

140

Strongly Disagree

Disagree

No

Opinion

Agree Strongly

Agree

Number of Responses

45

146

94 91

20

0

20

40

60

80

100

120

140

160

Number of Responses

Strongly Disagree

Disagree

No

Opinion

Agree Strongly

Agree

Figure 5. Distribution of responses to Question 4:

After the CED, do you think a follow-up appointment

is important?

141

66

47

124

18

0

20

40

60

80

100

120

140

160

Number of Responses

Strongly Disagree

Disagree

No

Opinion

Agree Strongly

Agree

Figure 6. Distribution of responses to Question 5:

Have you had difficulty talking with others about the

critical incident?
22 www.cs.amedd.army.mil/references_publications.aspx

ticipants. Approximately 28% (n=112) of the participants agreed or strongly agreed with the premise of the

question. These findings support the need for early

intervention, shortly after a traumatic event has occurred.

Question 4. After the CED, do you think a follow-up

appointment is important? The findings from question

4 remained relatively proportionate between those participants who either agreed or disagreed. The Agree

options were selected by 22.98% (n=91) (agree), and

11.36% (n=45) (strongly agree) of participants. These

findings implicate the importance of the provision of

ongoing mental health service availability after the

initial CED is completed. The findings also emphasize

the importance of the teaching phase of the CED in

which Soldiers can obtain information concerning services which are available.

Question 5. Have you had difficulty talking with others about the critical incident? The majority of participants either strongly disagreed (35.61%, n=141), or

disagreed (31.31%, n=124). Although a smaller cohort

of the sample population either agreed (11.87%,

n=47), or strongly agreed (4.55%, n=18), the findings

would support the benefits of a CED where a structured setting is available for those who have difficulty

talking about the critical event. Self-disclosure and

supportive interactions serve to ameliorate the negative

effects of exposure to combat.23-25

CONCLUSION

Without a doubt the most valuable asset of the US

military is the individual service member. Just as

maintenance is crucial to weapons and equipment,

mental health treatment availability is vital to individuals who have experienced wartime trauma. Although

mental health treatment in the military has improved

significantly over the past decades, the development

and provision of mental health services in a combat

zone remains a pioneering field. Hard lessons were

learned from Vietnam era veterans regarding consequences associated with not addressing the psychological aspects of wartime trauma. Consequently, personal

and social ills, such as PTSD, relationship problems,

domestic abuse, employment instability, homelessness,

and chemical dependency, are associated with a growing number of veterans who experienced trauma in the

context of war. Diminishing barriers for the reception

of mental health services and providing continuity of

care are some of the challenges faced with upfront

trauma treatment to our military personnel. A significant amount of stigma continues to exist for those

seeking mental health services.

This study provides valuable information that indicates

the need for psychological treatment and validates the

benefits of upfront mental health services, specifically

from CEDs, to our troops on the front lines. The treatment of combat stress and battle fatigue is a specialized field that relies on professionals who often put

themselves in harms way to administer these services

to our military service members in hostile regions.

There is a need to continue research in the area that

primarily concentrates on the provision of upfront,

mental health services in a combat zone and the implementation of improvements to the existing service system. Sadly, the battlefield often travels from foreign

lands back to their living rooms in the minds of traumatized war veterans. Although progress has been

made in mental health services in the US military over

the years, it is imperative to improve these services so

that no one is left behind.

ACKNOWLEDGEMENT

The authors thank SSG Jennifer Ann Davis, USAR,

who provided assistance with the data collection instrument and collation of the data.

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Effectiveness of Critical Event Debriefings During Operation Iraqi Freedom II
July – September 2008 23

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AUTHORS

CPT Pischke is a member of the 785th Medical Company Combat Stress Control, Fort Snelling, Minnesota.

CPT Hallman is with the 3rd Medical Recruiting Battalion, Fort Knox, Kentucky. Previously he was assigned

to 785th Medical Company Combat Stress Control, Fort

Snelling, Minnesota.
July – September 2008 24

INTRODUCTION

Soldiers protect the nation from threat by placing

themselves in harms way. They deserve the highest

quality of weapons, equipment, and training that will

increase their survival and ensure victory. Innovations

in technology must be matched by conceptual

innovations as we confront an elusive and ruthless

enemy. Soldiers must respond on a noncontiguous

battlefield†to seemingly unpredictable violence with

decisiveness, judgment, and professionalism. The

noncontiguous battlefield, where proximity often

compromises integrity, may be described as lacking

“frontlines,” or clear boundaries with enemies that are

difficult to distinguish from noncombatants.

We have successfully adapted our weapons and tactics

to the threats presented by terrorism. Now we are

challenged to adapt our cognitive response to

environmental threats in order to sustain the fighting

strength of those whom we send to war. Dialectical

behavior therapy,2slightly adapted to the combat zone,

has been demonstrated, through its implementation at

the Witmer Wellness Center, to be an effective

intervention that addresses the emotional

dysregulation3that is produced by the invalidating

environment4of the noncontiguous battlefield. The

“borderline” personality states that dialectical behavior

therapy was originally developed to treat has many

similarities to the noncontiguous battlefield. Both

produce a miasmic, anticathartic atmosphere that

creates dysregulation. The qualities of the Soldier

cohort that would serve on the noncontiguous

battlefield must also be considered in the context of

evaluating this modality. Soldiers utilizing dialectical

behavior therapy skills improved focus and attention,

increased composure in crisis, and developed a more

realistic appraisal of threat. The Wellness Center has

successfully intervened with life-saving symptom

reduction even as it was battle-tested during the

highest recorded suicide rates among Soldiers in our

history.5

Dialectical Behavior Therapy Deployed: An

Aggressive Alternative to Traditional Mental

Health on the Noncontiguous Battlefield

CPT Brian D. Parrish , MS, USA

ABSTRACT

This paper provides a description of the Witmer Wellness Center, the first successful military application of

dialectical behavior therapy in a theater of war. Dialectical behavior therapy is a dynamic and provocative

evidenced-based modification of cognitive behavioral treatment developed by Dr Marsha Linehan* for

patients with severe emotional dysregulation. One of the primary concepts of dialectical behavior therapy is

that self-harming behaviors are learned, and provide evidence of maladaptive coping that is reinforced in an

invalidating environment. Dialectical behavior therapy recommends a hierarchy of goals to effectively

address the behaviors associated with dysregulation. Chief among these goals is reducing risk of violence to

self or others. Dialectical behavior therapy is especially well-suited for the complex and dynamic

environment of the noncontiguous†battlefield with its chronic threat of ultraviolence, strain of nonresponse,

shifting rules of engagement, and extended duration and frequency of combat deployments. The Witmer

Wellness Center program uses an intensive outpatient organizational structure and minimal, but innovative,

modifications to standard dialectical behavior therapy designed to meet the special requirements of Warriors

in a combat zone. The Wellness Center program was designed and implemented during Operation Iraqi

Freedom 07-09, at a time during the troop surge when suicide rates among US forces had reached an

unprecedented level.

*Dr Linehan is a Professor of Psychology, Adjunct Professor of Psychiatry and Behavioral Sciences at the University of

Washington, and Director of the Behavioral Research and Therapy Clinics, a consortium of research projects developing

new treatments and evaluating their efficacy for severely disordered and multidiagnostic populations.

†Noncontiguous areas of combat operations do not share a common boundary.1
July – September 2008 25

Military subcultures, especially in a combat

environment, are very similar to that of police

subcultures.6 Both may produce an invalidating

environment over-controlling the expression of

emotions by its members. Traumatic experiences may

be invalidated. Inner emotional expressions may be

punished by attributing them, through ad hominem

attacks, to insanity, weakness, fear, lack of selfdiscipline, or competence. Through a powerful group

process with intense peer pressure and little privacy

available, the Soldier is taught to invalidate his own

experiences and beliefs in favor of the culture’s

beliefs. Due to wartime de-escalation and changing

rules of engagement, the Soldier may be unable to

experience any combat abreaction.7

Individual, organizational, and environmental factors

combine with chronic exposure to the strain of

nonresponse to threat, resulting in dysregulation.

Emotional dysregulation may be defined as an

individual’s poorly modulated emotional reactiveness

that exceeds the accepted or normative range for the

culture. Individuals may be more vulnerable to

emotional dysregulation because of biological

predisposition or because they have history of previous

exposure to an invalidating environment. Maintaining

military bearing requires, by necessity, an extremely

limited range of acceptable emotive responses.

Untreated dysregulation produces a myriad of

symptoms and shifting moods that effects

performance, well-being, and mission. All Soldiers,

lacking behavioral adaptation to the noncontiguous

battlefield, and without the benefit of any cognitive

restructuring to transcend traumatic events and adjust

to the chronic experience of threat, are vulnerable to

dysregulation. The effects of emotional dysregulation

may be cumulative and developmental.8

Dialectical behavior therapy, which was originally

designed for treatment of persons with borderline

personality disorder,9asserts that individuals who have

experienced invalidating environments during

childhood become extremely reactive to emotional

stimulation. They tend to be hypervigilant and their

arousal level escalates rapidly and takes much more

time to recover to a culturally acceptable baseline.

This provides an explanation of why persons with

borderline personality disorder often present with

extreme emotional liability, rapidly shifting their

emotions, and living lives that seem perpetually in

crisis. These individuals, with poorly developed

boundaries and a history of experiencing invalidation,

are not equipped to cope with intense emotions.

Dialectical behavior therapy recommends a hierarchy

of goals to effectively address the behaviors associated

with dysregulation. Chief among these goals is

reducing risk of violence to self or others. Next are

those behaviors that obstruct therapy interventions,

and finally, those behaviors that diminish the

participant’s quality of life. Soldiers, like law

enforcement officers, may experience an invalidating

work environment that leaves them ill equipped to

cope with the intense emotions provoked by the work

of distinguishing the “good guys” from the “bad

guys.” These Soldiers must then negotiate a largely

unpredictable and violent environment in which they

are, in essence, operating as police in a combat zone.

THE WELLNESS PROGRAM

The Witmer Wellness Center functions as an

integrated component within the facilities of the

Witmer Troop Medical Clinic. This Level II medical

facility was dedicated in the name of Michelle

Witmer,* the first female National Guard Soldier to be

killed in action in its 367 year history. The Wellness

Center provides full range, evidenced-based,

outpatient cognitive behavior treatment services for the

Witmer Troop Medical Clinic and the surrounding

area of responsibility. Its relatively discreet location

within a medical facility provides a less stigmatizing

opportunity for Soldiers who are concerned about

being identified as “mental health” patients. The

Wellness Center provides a voluntary, Soldiercentered, harm-reducing, integrative, nongenderspecific, wellness-focused approach to behavioral

health treatment, emphasizing personal responsibility

for behavioral health in the same manner that Soldiers

are held accountable for their physical fitness.

The Wellness Center provides a treatment platform

that delivers intensive outpatient treatment featuring

dialectical behavior therapy for the Soldier, while

maintaining close communication with the Soldier’s

command. When the Soldier's unit is actively engaged

in a therapeutic alliance on the Soldier’s behalf, an

exoskeletal structure is created, that can, temporarily,

but critically, filter negative projection. The engaged

unit may provide support, and the psychological

*SPC Michelle M. Witmer, a Soldier in the 32nd Military

Police Company, Wisconsin National Guard, was killed in

action in Baghdad, Iraq, on April 9, 2004.
26 www.cs.amedd.army.mil/references_publications.aspx

Dialectical Behavior Therapy Deployed: An Aggressive Alternative to

Traditional Mental Health on the Noncontiguous Battlefield

safety, that is required for the Soldier to reduce

“traumatic transference” and productively participate

in brief treatment with the therapist.

The primary treatment goal for all Soldiers

participating in the program at the Wellness Center is

to improve their performance and enhance their

functioning, emphasizing that it is highly preferred that

they remain on duty and focused on their mission

while actively engaged in therapy. Diligent effort is

applied to strengthen meaningful social support within

the Soldier’s unit, rather than removing the Soldier

from his base of primary support. Many Soldiers

function as members of teams or squads that are so

highly integrated that it may be detrimental to the

cohesion of the unit to remove one member for any

reason, but particularly for something as stigmatizing

as mental health therapy.

Assessment and outpatient therapy services are

provided 24 hours per day, 7 days per week by a

licensed clinician. The Wellness Center does not have

specified walk-in hours. Soldiers receive triage

services and are assessed immediately or scheduled for

further evaluation based upon the initial assessment,

the individual needs of the Soldier, and/or the

Soldier’s command.

There are no distinctions made between Soldiers who

work “outside the wire” and who travel into active

combat areas subject to roadside bombs and ambushes,

and those who work “inside the wire” and provide

support services in the combat zone which may

routinely place them at heightened risk of death or

dismemberment by the indirect fire of rockets,

mortars, or the occasional sniper. Threat is everpresent on the noncontiguous battlefield.

Since the treatment model is not focused on the

reduction of pathology, but on the development of

wellness, the only Soldiers that would probably be

inappropriate for inclusion into the open-ended

continuous groups are those who demonstrate

antisocial or schizoid personality traits and those

individuals who do not want treatment, or only request

psychopharmacological interventions. Equally,

malingerers and substance abusers are not attracted to

this modality due to the accountability, rigorous work

involved, and a core objective of having a clear mind,

free of all mood altering chemicals. Great emphasis is

placed on providing outstanding customer service that

is timely and tailored to the needs of the individual

Soldier. Soldiers that are new to the program and those

who are established in treatment in the Wellness

program may be seen on an emergent basis 24 hours

per day 7 days per week.

Established organizational doctrine and directives and

JCAHO* standards regarding confidentiality and care

are always maintained and every effort is made to

preserve the Soldier’s dignity with the assumption that

the Soldier entered therapy as a competent individual.

Soldiers engage in therapy with the expectation that

they will enhance their functioning and improve their

mission effectiveness while participating in evidencebased cognitive behavior therapy.

Individual and group dialectical behavior therapy is

featured as the primary clinical modality of the

Wellness Center. All Soldiers who participate are

provided with a comprehensive assessment and

treatment by a licensed clinician. Mission

requirements are always considered during the

development of the treatment plan, and the Soldier’s

individualized program is managed flexibly around

missions, unless safety would be compromised.

Soldiers may be seen for individual or group therapy,

as needed, in any configuration that is assessed as most

beneficial to the health, well-being, and mission of the

Soldier.

Dialectical behavior treatment is not intellectdependent. Soldiers who are temporarily cognitively

impaired by active symptoms are able to use the skills

on a concrete level until they improve. During this

deployment, I have successfully engaged Soldiers with

borderline intelligence, as well as officers who had

graduated from the Massachusetts Institute of

Technology and the US Military Academy.

All Soldiers are assessed for risk of harm to self or

others at every encounter. Contingent upon the level of

risk presented, and subsequent to a comprehensive

assessment that utilizes individualized psychometric

evaluation and the 2007 JCAHO Basic Suicide

Assessment Five Step Evaluation.10 Soldiers may be

determined to require transfer to a higher level of care.

Soldiers assessed as being at risk, but not requiring

medical evacuation, may be placed on a Command

Interest Profile that provides specific

*Joint Commission on Accreditation of Healthcare

Organizations
July – September 2008 27

THE ARMY MEDICAL DEPARTMENT JOURNAL

recommendations for safely managing direct

supervision of the Soldier by the Soldier’s command.

This allows the Soldier to remain as actively involved

in his mission as possible, while developing treatment

skills that will reduce risk. The Soldier’s

individualized Command Interest Profile will specify

all recommendations for enhanced safety measures,

limitations to duty, access, or activities. The Command

Interest Profile will be signed by a representative of

the command when they assume supervision of the

Soldier who was assessed to be at risk, commencing a

dialogue between the command and the licensed

clinician that is integral to the safe management of

Soldiers with high risk behaviors.

Communication regarding case management with the

Soldier’s command is essential in this process. The

commander or a member of the chain of command is

requested, when appropriate, to take an active role in

supporting the Soldier’s treatment. Commanders are

usually willing to invest in time, escorts, and resources

for the Soldier when they observe the behavioral

changes and improved functioning in the Soldier.

Soldiers who are assessed to be at risk receive

intensive levels of outpatient treatment, formally agree

not to harm themselves ("contract for safety"), and are

reassessed with documentation in the electronic

medical record at every encounter for the length of

treatment. When the Soldier is assessed as no longer

being at risk of harm to self or others, the Soldier is

formally recommended for removal from the

Command Interest Profile by the behavioral health

officer, in agreement with the Soldier and the Soldier’s

command.

The Wellness Center is structured on an intensive

outpatient treatment model in which the Soldier is

seen, as often as needed, based upon ongoing risk

assessment. Typically, Soldiers are seen a minimum of

twice per week, with one individual session of 60 to 90

minutes and one or more open-ended continuous group

sessions of 90 to 120 minutes. Soldiers may be seen on

a daily basis, as needed, in order to promote emotional

self-regulation and reduce the risk of harm to self or

others.

The Wellness model begins with the assumption of

competence in the Soldier being treated. The Soldier

being treated is always regarded with respect, and

every effort is made to preserve the dignity of a

Soldier in uniform. The Soldier under treatment is

typically carrying a weapon and ammunition. Even

when the Soldier is suicidal, the Soldier retains the

weapon, but that weapon is rendered inoperable.

Pathology is always deemphasized.

WELLNESS ADAPTATIONS TO STANDARD DIALECTICAL

BEHAVIOR THERAPY

Upon a review of the literature, the Wellness Center is

the first use of dialectical behavior therapy with

Soldiers in an active combat zone. Dialectical behavior

therapy was minimally adapted at the Wellness Center

for military use.11

The Wellness model promotes treatment interventions

that are very much like physical training, wherein the

person seeks to improve their performance, enhance

their functioning, and develop a pervasive sense of

well-being through a rigorous exercise regime that

involves self-discipline and personal accomplishment.

The licensed clinician, who acts as treatment provider,

often acts more like a personal trainer than the mediainfluenced stereotype of a therapist. Following the

analogy, the personal trainer seeks to coach the

“athlete” by assessing capabilities and form, teaching

skills, measuring progress, developing a clear

objective, and motivating the person to continue with

their individualized program. The personal trainer can

not do the exercises for the athlete. The personal

trainer emphasizes the qualities of accountability and

personal responsibility in the athlete engaged in the

program. Therefore, weekly individual and group

therapy sessions are structured very much like the

individual and group physical training sessions that are

so familiar to Soldiers. Individual sessions provide for

intensive skill building, while group sessions

emphasize coaching the application of those skills in

real world scenarios, including combat situations. As

the Soldier’s skills and general functioning increases,

the Soldier is encouraged to cofacilitate and to lead a

group session under the supervision of the licensed

clinician facilitator.

Soldiers, typically, participate in an individual session

and at least one group session per week unless the

Soldier is on a tapering schedule. The adaptation of

using a tapering schedule supported Soldiers who had

developed a foundation in dialectical behavior therapy

and acquired most of the skills, but who still requested

ongoing coaching with skills implementation. In some
28 www.cs.amedd.army.mil/references_publications.aspx

instances, Soldiers who, due to mission requirements,

would be unable to continue treatment in the standard

format would be provided with a truncated version of

the foundational skills. The standard dialectical

behavior therapy format has been expanded and

contracted based upon the individual needs of the

Soldiers.

Individual treatment, of any duration, is only

commenced subsequent to the completion of a

comprehensive assessment. The skills learned in

individual sessions follow the standard dialectical

behavior therapy12 format using 4 modules that include

mindfulness, interpersonal effectiveness skills,

regulation of emotions, and distress tolerance. The

skills are introduced based upon an individualized

treatment plan. Standard dialectical behavior skills are

modified only in the sense that military analogies that

are familiar and readily accessible are used to rapidly

explain and facilitate understanding of the concepts

presented in the 4 modules.

Individual treatment sessions, group skills training

sessions, and intensive case management are available

24 hours per day, and consultation sessions are held

with the Soldier’s command. The individual treatment

sessions, skills training group, and consultation group

sessions are scheduled and conducted, as needed,

based on the current risk assessment.

The group skills sessions are open only to Soldiers that

have been assessed and are participating in individual

treatment. The group skills training sessions reinforce

the skills already acquired in individual sessions and

emphasizes the application of those skills. Soldiers are

afforded multiple opportunities to share their

experiences as they practice their skills at work, in

interpersonal relations, and in combat situations. It is

often highly motivating for Soldiers to hear

testimonials of other Soldiers who are able to describe

their acquisition of dialectical behavioral therapy skills

and the functional changes that have occurred as a

direct result of implementing those skills. Group skill

sessions are open-ended and continuous. A specific

dialectical behavior therapy skill is highlighted in each

group session.

At the Wellness Center, a licensed clinician is

available to coach Soldiers through crises 24 hours per

day in person, and by telephone. The consultation

sessions are held with representatives of the Soldier’s

command as appropriate and on a voluntary basis with

a signed consent to release information to the

command. This creates a nonadversarial supportive

forum for mediation of grievances and practice of

interpersonal effectiveness skills in which validation is

role modeled for the command team. These adapted

consultation sessions provide a venue in which the

command may receive recommendations about their

Soldiers, and the licensed clinician is better able to

coordinate care and get feedback about the Soldier’s

functional improvements.

DEMOGRAPHICS

It has been estimated that more than 5,000 behavioral

health contacts with military personnel, contractors,

and others will be made through the Wellness Center

over the course of my current deployment. More than

95% of documented encounters were with Army

Soldiers, and the remaining 5% were Navy or Air

Force personnel, civilian contractors, third country

nationals, or Iraqi civilians. Approximately 30% of

those Soldiers whom I assessed and treated were

considered to be in a high risk category. Soldiers that

are assessed as being at high risk, as defined here,

would require a Command Interest Profile or clinical

recommendation for direct safety supervision, or

would have current or historical suicidal or homicidal

ideation or behavior, or significant history of criminal

violence or psychiatric treatment or hospitalization.

The Wellness Center has promoted the concept of

Remain on Duty rather than Return to Duty, working

around mission schedules and coaching Soldiers, as

much as possible, in place and without removing them

from an opportunity to use their dialectical behavior

therapy skills. The Wellness Center’s motto is remain

on duty, and it has maintained a return to duty rate

exceeding 99%, with only 5 medical evacuations for

Soldiers who required a higher level of care, and zero

incidents or negative outcomes that resulted from any

treatment or programmatic process. I attribute this

success in safely managing a high volume of Soldiers,

many in a high risk category, to the effectiveness of

dialectical behavioral therapy and its delivery system,

the Wellness Center.

The majority of Soldiers that participated in treatment

were identified as experiencing emotional

dysregulation, and nearly all patients were

Dialectical Behavior Therapy Deployed: An Aggressive Alternative to

Traditional Mental Health on the Noncontiguous Battlefield
July – September 2008 29

THE ARMY MEDICAL DEPARTMENT JOURNAL

experiencing significant symptoms. While the

available data supports the assumption that immediate

gains may be achieved in terms of symptom reduction

and increased survivability through realistic threat

assessment and enhanced attention, for sustainability

of gains, these cognitive lifestyle changes require the

same institutional support that physical fitness receives

within the existing military organizational structure.

Many of the Soldiers seen at the Wellness Center for

treatment appear to have impaired capacities for selfregulation,13 and some present with symptoms and

history that would be consistent with the diagnostic

criteria for complex trauma disorder,14 in that their

experience of trauma in childhood is being

exacerbated by the effects of environmental

invalidation while serving in a combat zone. We may

anticipate the behavioral health needs of Soldiers in

the next decade by looking at the children in the

United States today.

According to Perry’s research,15 each year more than 5

million children in the United States experience some

extreme traumatic event. More than 40% of these

children will develop some form of chronic

neuropsychiatric problem that can significantly impair

their emotional, academic, and social functioning. The

majority of these neuropsychiatric problems are

classified as anxiety disorders, with the most common

being posttraumatic stress disorder (PTSD). Typical

signs and symptoms of PTSD include impulsivity,

distractibility and attention problems (due to

hypervigilance), dysphoria, emotional numbing, social

avoidance, dissociation, sleep problems, aggressive

(often reenactment) play, school failure, and regressed

or delayed development. In most studies examining the

development of PTSD following a given traumatic

experience, twice as many children suffer from

significant posttraumatic signs or symptoms, but lack

all of the criteria necessary for the diagnosis of PTSD.

In these cases, the clinician may identify traumarelated symptoms as part of another neuropsychiatric

syndrome. For example, hypervigilance is often

considered an attention problem and traumatized

children will be diagnosed and treated as if they have

attention deficit hyperactivity disorder.15

The Soldiers who were these children, and who were

able to function to some degree prior to deployment,

now present, often in acute distress with dysregulation

of emotions and behavior when confronted by the rigor

of the noncontiguous battlefield.

In a comprehensive national survey completed in

2005,16 over the course of one year, researchers

conducted the Developmental Victimization Survey to

gather data on a range of victimizations from birth

until adulthood. Among the findings:

 Just more than half of the youths (530/1000)

experienced a physical assault.

 The highest rate of physical assault victimization

occurred between ages 6 and 12.

 One in 12 (82/1000) of the youths experienced

sexual victimization, including sexual assault

(32/1000) and attempted or completed rape

(22/1000).

 Child maltreatment was experience by a little less

than one seventh of the youths (138/1000).

The study divided maltreatment into 5 categories

(physical abuse, sexual abuse, emotional abuse,

neglect, and family abduction) of which emotional

abuse (name calling or denigration by an adult) was

most frequent in occurrence.

The high numbers of children who have experienced

invalidation in their predeployment origins support the

contention that we will be treating them when they

reexperience it under the added stressors and perceived

threat that they may encounter in a combat zone.

Twenty-two percent of children in a national sample

reported 4 or more different kinds of victimization in a

single year. Once children become polyvictims, their

risk for additional victimization tends to remain very

elevated. Polyvictims have extremely high levels of

traumatic stress symptoms. The undetected presence of

such multiple victimization exposure among research

samples of children identified because of a single

victimization type (victims of sexual abuse or

bullying) may be what accounts for a considerable

portion of the association between these individual

victimizations and traumatic symptom measures. If

researchers and practitioners can more effectively

identify polyvictims and those on the path to becoming

polyvictims, they might be able to direct prevention
30 www.cs.amedd.army.mil/references_publications.aspx

resources to forestall the most serious victimization

careers and most adversely affected children.17

Many of these adversely affected children may be our

very best Soldiers. Universal destigmatization training

in an evidenced-based therapy designed to reduce the

symptoms of complex or polytrauma, would, in all

probability, reduce the strain of nonresponse to threat

and the sense of invalidation that may result in

dysregulation.

The branch of developmental victimology that studies

the impact of victimization on children posits that

children at different stages of development experience

and cope with victimization in different ways. Prior

research into differing impacts has been narrowly

focused on sexual abuse and posttraumatic stress

disorder. Developmental victimology addresses a

much broader range of victimizations, focusing

particularly on victimizations experienced by a

majority of children, such as peer or sibling assault and

theft. Developmental victimology explores a broad

range of potential impacts beyond those falling in the

realm of psychopathology, including effects on

personality, social skills, political and social attitudes.

It further focuses on how these impacts are felt and

manifested at different stages of child development.18

Soldiers who have experienced the weighty

consequences of complex or polytrauma are often

highly motivated to engage in training with the

expectation that they will enhance their functioning

and improve their mission effectiveness by

participating in evidence-based cognitive behavior

therapy.

According to the most recent information available

from the National Alliance on Mental Illness,19 one in

four adults—approximately 57.7 million Americans—

experience a mental health disorder in a given year.

One in 17 lives with a serious mental illness, such as

schizophrenia, major depression, or bipolar disorder,

and about one in 10 children have a serious mental or

emotional disorder. Anxiety disorders, which include

panic disorder, obsessive-compulsive disorder, PTSD,

generalized anxiety disorder, and phobias, affect about

18.1% of adults, an estimated 40 million individuals.

Half of all lifetime cases of mental illness begin by age

14, three quarters by the age of 24.6 years. Despite

effective treatments, there are long delays, sometimes

decades, between first onset of symptoms and when

people seek and receive treatment. Fewer than one

third of adults and one half of children with a

diagnosable mental disorder receive any mental health

services in a given year. In the United States, the

annual economic, indirect cost of mental illness is

estimated to be $79 billion. Most of that amount,

approximately $63 billion, reflects the loss of

productivity as a result of illness.19 Suicide is the

eleventh leading cause of death in the United States,

and the third leading cause of death for decedents in

the 10 to 24 year age group.20 More than 90% of those

who die by suicide have a diagnosable mental

disorder. In July 2007, Kaplan et al published the

results of a nationwide report which indicated that

male veterans are twice as likely to die by suicide as

compared with their civilian peers in the general US

population.21

CONCLUSIONS

Research is needed to further develop understanding of

the behavioral health needs of Soldiers. Those needs

are dynamic and have changed, not only because of the

duration and frequency of deployments, but also

because of the qualities inherent in the environment of

the noncontiguous battlefield and the Soldier cohort

that will be serving there. Clearly, a more flexible and

Soldier-centered model of behavioral healthcare

delivery is needed in the military, especially in theater.

The success of the Wellness model supports an

argument for the development of a new paradigm for

the treatment of Soldiers in which, like the battletested way in which Soldiers are taught to use their

weapons in an effective manner, we will cease to

compartmentalize “mental” health, and, instead, align

body and mind in an integrative, nonstigmatizing,

relevant model of treatment and service delivery.

Research and statistical evaluation of the Wellness

Center model is needed. Factor analysis of each

program element would provide useful information, as

would development of the theoretical underpinnings of

the military adaptation of dialectical behavioral

therapy. Although gains may be immediately realized

in terms of symptom reduction and functional

improvement, they may not be permanent without

ongoing social support, preferably institutionalized

within the existing military structure. Analysis of longterm gains, maintenance of progress made, and relapse

prevention should be completed. Finally, it will also be

important to measure changes in postdeployment

Dialectical Behavior Therapy Deployed: An Aggressive Alternative to

Traditional Mental Health on the Noncontiguous Battlefield
July – September 2008 31

THE ARMY MEDICAL DEPARTMENT JOURNAL

relationships and quality of life subsequent to Soldiers

learning dialectical behavioral therapy skills.

REFERENCES

1. Field Manual 3-0: Operations. Washington, DC: US

Dept of the Army; February 2008:chap5,p5-14.

2. Linehan MM. Skills Training Manual For Therapy

Of Borderline Personality Disorder. New York:

Guilford Press; 1993.

3. Dimeff L, Koerner K, Linehan MM. Summary of

Research on Dialectical Behavior Therapy. Seattle,

WA: Behavioral Tech, LLC; 2002.

4. Cheavens, JS, Roenthal ZM, Daughters SB, Nowak J,

Kosson D, Lynch TR, Leiuez CW. An analogue

investigation of the relationships among perceived

parental criticism, negative affect, and borderline

personality disorder features: the role of thought

suppression. Behav Res Ther. 2005;43(2):257-268.

5. Mental Health Advisory Team (MHAT) V: Operation

Iraqi Freedom 06-08, Iraq; Operation Enduring

Freedom 8, Afghanistan. Washington, DC: Office of

The Surgeon General, US Dept of the Army;

February 14, 2008.

6. Figley CR. Police compassion fatigue (PCF): theory,

research, assessment, treatment, and prevention. In:

Violanti J, Paton D, eds. Police Trauma:

Psychological Aftermath of Civilian Combat.

Springfield, IL: Charles C. Thomas; 1999:37-53.

7. Wastell CA. Exposure to trauma: the long-term

effects of suppressing emotional reactions. J Nerv

Ment Dis. 2002;190(12):839-845.

8. Beaudhaine TP, Gatze-Kopp L, Mead HK. Polyvagal

theory and developmental psychopathology. Emotion

dysregulation and conduct problems from preschool

to adolescence. Biol Psychol. 2007;74:174-189.

9. Judd PH, McGlashan TH. Developmental Model of

Borderline Personality Disorder: Understanding

Variations in Course and Outcome. Arlington, VA:

American Psychiatric Publishing; 2003:31.

10. Jacobs D. A Resource Guide for Implementing the

Joint Commission on Accreditation of Healthcare

Organizations (JCAHO) 2007 Patient Safety Goals

on Suicide. Available at: http://www.naphs.org/

T eleco nference/d o cu me nts/ Reso urceG uid e

_JCAHOSafetyGoals2007_final.pdf. Accessed

September 5, 2008.

11. Linehan M. Commentary on innovations in

dialectical behavior therapy. Cogn Behav Pract.

2000;7:478-481.

12. Miller AL, Rathus JH, Linehan MM, Swenson CR.

Dialectical Behavior Therapy. New York: Guilford

Press;2007:1.

13. Pynoos R, Steinberg A, Placentini J. A

developmental psychopathology model of childhood

traumatic stress and interaction with anxiety

disorders. Biol Psychiatry. 1999;46:1542-1554.

14. van der Kolk BA. Developmental trauma disorder:

toward a rational diagnosis for children with complex

trauma histories. Psychiatric Annals. 2005;35(5):401-

402.

15. Perry BD. Maltreated Children: Experience, Brain

Development and the Next Generation. New York:

W. W. Norton & Company. In press.

16. Finkelhor D, Ormrod RK, Turner HA, Hamby SL.

The victimization of children and youth: a

comprehensive, national survey. Child Maltreatment.

2005;10(1):5-25.

17. Finkelhor D, Kendall-Tackett KA. Developmental

perspective on the childhood impact of crime, abuse

and violent victimization. In: Cicchetti D, Toth S,

eds. Developmental Perspectives on Trauma: Theory,

Research, and Intervention. New York: University of

Rochester Press; 1997:1-32.

18. Finkelhor D, Ormrod RK, Turner HA.

Polyvictimization: a neglected component in child

victimization trauma. Child Abuse Negl. 2007;31:7-

26.

19. NAMI Fact Sheet. Mental Illness: Facts and

Numbers, October 2007. National Alliance on Mental

Illness. Available at: http://www.nami.org/Tem

plate.cfm?Section=About_Mental_Illness&Template

=/ContentManagement/ContentDisplay.cfm&con

tentID=53155.

20. Federal Interagency Forum on Child and Family

Statistics. America’s Children: Key National

Indicators of Well-Being, 2005. Washington, DC:

Federal Interagency Forum on Child and Family

Statistics; July 2007. Available at: http://

www.childstats.gov/pdf/ac2007/ac_07.pdf.

21. Kaplan MS, Huguet N, McFarland B, Newsom JT.

Suicide among male veterans: a perspective

population-based study. J Epidemical Community

Health. 2007;61(7):619-624.

AUTHOR

CPT Parrish is the Behavioral Science Officer, 566th

Medical Company (Area Support), 62nd Medical

Brigade (Task Force 62), Camp Liberty, Iraq.
32 www.cs.amedd.army.mil/references_publications.aspx

Warrior Resilience Training in Operation

Iraqi Freedom: Combining Rational

Emotive Behavior Therapy, Resiliency,

and Positive Psychology

MAJ Thomas Jarrett, MS, USA

ABSTRACT

Warrior Resilience Training (WRT) is an educational class designed to enhance Warrior resilience, thriving, and

posttraumatic growth for Soldiers deployed in Operation Iraqi Freedom. Warrior Resilience Training uses rational

emotive behavior therapy (REBT), Army leadership principles, and positive psychology as a vehicle for students to

apply resilient philosophies derived from Army Warrior Ethos, Stoic philosophy, and the survivor and resiliency

literature. Students in WRT are trained to focus upon virtue, character, and emotional self-regulation by constructing

and maintaining a personal resiliency philosophy that emphasizes critical thinking, rationality, virtue, and Warrior

Ethos. The author, an Army licensed clinical social worker, executive coach, REBT doctoral fellow, and former

Special Forces noncommissioned officer, describes his initial experience teaching WRT during Operation Iraqi

Freedom to combat medics and Soldiers from 2005 to 2006, and his experience as a leader of a combat stress control

prevention team currently in Iraq offering mobile WRT classes in-theater. Warrior Resilience Training rationale,

curriculum, variants (like Warrior Family Resilience Training), and feedback are included, with suggestions as to

how behavioral health providers and combat stress control teams might better integrate their services with leaders,

chaplains, and commands to better market combat stress resiliency, reduce barriers to care, and promote force

preservation. Informal analysis of class feedback from 1168 respondents regarding WRT reception and

utilization is examined.

From the Army Leadership Manual1:

The Warrior Ethos is a component of character. It shapes and guides what a Soldier does. It is

linked tightly to Army values such as personal courage, loyalty to comrades, and dedication to

duty. (page 4-51)

Beliefs matter because they help people understand their experiences. Those experiences

provide a start point for what to do in everyday situations. Beliefs are convictions people hold

as true. Values are deep-seated personal beliefs that shape a person’s behavior. Values and

beliefs are central to character. (page 4-57)

Good leaders control their emotions...Maintaining self-control inspires calm confidence in the

team...Leaders who lose their self-control cannot expect those that follow them to maintain

theirs. (page 6-20)

Self-control, balance, and stability also assist making the right ethical choices. An ethical leader

successfully applies ethical principles to decision making and retains self-control. Leaders

cannot be at the mercy of emotion. It is critical for leaders to remain calm under pressure and

expend energy on things they can positively influence and not worry about things they cannot

affect. (page 6-22)
July – September 2008 33

WARRIOR RESILIENCE TRAINING

HISTORY AND RATIONALE

The Mental Health Advisory Team IV report,2released

in November of 2006, indicated that 17% of the

surveyed Soldiers who reported medium combat

exposure screened positive for combined mental health

problems, including depression, anxiety, and acute

stress reactions (posttraumatic stress disorder (PTSD)),

while positive screenings were indicated for 30% of

Soldiers with high combat experience. A full 37% of

those Soldiers and Marines who screened positive for

mental health problems reported not trusting mental

health professionals, fear of stigmatization or being

perceived as weak, and being treated differently if they

use available services. Other research confirmed

persistent and pervasive Soldier fear of stigmatization

as a barrier to care for utilization of behavioral health

services,3despite the presence of Army combat stress

control units in theater designed specifically to provide

prevention and reduce barriers through combat

operational stress control doctrine, and predeployment

combat training.4

From November 2005 to July 2006, I served as a

behavioral health officer for an area support medical

company supporting 30,000 to 50,000 Warriors at

Camp Liberty, Iraq. My experience in theater

confirmed the MHAT IV observations firsthand,

including institutional bias, Soldier resistance toward

behavioral health services, and difficulty providing

social work outreach due to an excessive caseload.

There was a need for a Warrior-oriented, combat stress

prevention class that could attract, instruct, and

psychologically inoculate Warriors against continued

combat operational and home front stressors.5Such a

class would need a psychological, standardized selfhelp system, like rational emotive behavior therapy

(REBT),6 which I used in time-limited interventions in

theater. A class appealing to Warriors would also gain

support from their leaders if designed and marketed

from a coaching and leadership resiliency approach,

focused on assisting Warriors to “return with honor,”

versus cataloguing their deficits. Using insights and

philosophies derived from the survivor, resiliency, and

prisoner of war literature,7Stoic philosophy (the

genesis of REBT),8 Army Warrior Ethos, and Army

Values,9a WRT evening class and a WRT medic

training course were initiated in December 2005, at

Camp Liberty, Iraq.

THEORETICAL FOUNDATIONS OF WARRIOR RESILIENCE

TRAINING: RATIONAL EMOTIVE BEHAVIOR THERAPY

Dr Albert Ellis,10 often referred to as the “Grandfather”

of cognitive therapy, started the cognitive and

philosophical counseling revolution in 1955,

introducing his trademark “ABC Theory of Emotions”

to assist clients to identify and dispute irrational beliefs

which create emotional suffering and block personal

fulfillment. He often referenced Epictetus, the wellknown Stoic philosopher, who said “man is not

disturbed by events, but the view he takes of them.”11

This view alone predated cognitive therapy by 2

millennium. REBT researchers have produced

hundreds of studies supporting the clinical utility of

REBT as an evidence-based practice. Dr Ellis virtually

pioneered the psychology self-help field, authoring

over 80 books on REBT applications, as well as audio

and videotapes, with international REBT centers

worldwide promoting “rational living.”12

Ellis credited his system heavily to his study of

philosophy, especially Stoicism.6 Ellis cited Roman

Emperor Marcus Aurelius (author of Meditations13)

and Epictetus as being highly influential in his creation

of REBT, which encourages self-discipline, rationality,

and the adoption of a resilient, adaptive mindset,

despite external adversity. REBT appeals especially

well to Warriors, who I have found to be often suspect

of dependent or overly expressive therapies, just as

Stoicism itself appealed to famous students like

Roman Emperor Marcus Aurelius13 and Admiral

James Stockdale, a senior Naval aviator who credited

the system with assisting him in his survival of

captivity and torture for over 7 years in North Vietnam

as the ranking prisoner of war among the officers.7

REBT naturally shares some principles with the

combat stress control doctrine of BICEPS4(p1-7) as well:

Brevity—REBT is a time limited approach. REBT

therapists train as if each session could be the last,

assisting clients rapidly identify and replace

maladaptive behaviors and emotions.

Immediacy—employed directly by combat stress

prevention teams, and the Soldiers themselves who

receive training.

Contact—teaching REBT fundamentals to Soldiers

and Leadership together.

Expectancy of recovery—REBT maintains that

humans can overcome their current issues and also
34 www.cs.amedd.army.mil/references_publications.aspx

deal effectively with a destructive past, including

traumas.

Proximity—REBT is taught at the unit level to

Soldiers, medics, peer-coaches, and leaders, and is

practiced in the Army Medical Department course

for mental health technicians (military occupational

specialty 68X).

Simplicity—the ABC theory is easily taught, with

clients rapidly mastering the A-B-C model. It is

used from school-aged children to executives in

business (rational emotive behavior coaching).

For example, after experiencing a noxious activating

event (A), Soldiers generate perceptions or beliefs (B)

about the event, producing emotional and behavioral

consequences (C). Soldiers are taught to identify and

vigorously dispute (D) those irrational beliefs which

are irrational or goal-thwarting. The most common

irrational processes (similar to cognitive therapy’s

cognitive distortions), which guarantee a “recipe for

suffering” include: Shoulds/Musts/Demands,

“Awfulizing” or "Catastrophizing," Low Frustration

Tolerance, and Self/Other Negative Rating or

Blaming. I concur with other REBT practitioners that

controlling or over-controlling could easily be the fifth

REBT Irrational Process, and is itself the antithesis of

Stoicism. Soldiers rehearse new Effective Beliefs

producing more manageable emotions (sorrow and

grief versus depression, or frustration versus rage) and

adaptive behavioral choices that lead to goal

attainment and Warrior performance. REBT works

equally well as a therapeutic intervention then selfcoaching model, when clients are trained by a

qualified REBT therapist or coach.

VIRTUE, CHARACTER, STOICISM, AND WARRIOR ETHOS

The focus of WRT on virtue and character, aside from

Army Leadership,1,14 is also supported by positive

psychological research which classified universal

“character strengths and virtues.”15 Seligman,16 (who

coined the term “learned optimism”) and Peterson15

catalogued 6 core virtues—wisdom, courage,

humanity, justice, temperance, and transcendence—

along with 18 supportive and underlying character

strengths which are described as mechanisms which

define and support these “virtues in action.” Whereas

the fourth edition of Diagnostic and Statistical Manual

of Mental Disorders17 and previous versions have

exclusively focused upon pathology, mental disorder

classification, and diagnoses (including personality

disorders, formerly known as character disorders), the

positive psychological virtue and strengths-based

approach (heralding back to ancient philosophy) uses a

research-grounded classification system of what is

exemplary in humans, morally superior, and accepted

universally as virtues.

Character and virtue-based counseling approaches

have relevance for Army Warriors who live by similar

virtues and values as in the 7 Army values of loyalty,

duty, respect, selfless service, honor, integrity, and

personal courage. Other codes that dictate standards

and demeanor for Warriors on and off the battlefield

include the Code of Conduct, rules of engagement, the

Geneva Convention, and the Noncommissioned

Officer and Ranger Creeds, which are all aimed

towards standardizing ethical behavior, agreed upon

martial virtues, and honor for professional Warriors.1,9

Positive psychology is a natural choice for Warriors as

it also firmly grounded in Aristotelian principles of

virtue and ethical behavior. Jorgensen and Nafstad18

note:

The Aristotelian model focuses on the virtuous individual and those inner traits, dispositions and motives that

qualify the individual to be virtuous, virtue of thought

and virtue of character: “Virtue of thought arises and

grows mostly from teaching; that is why it needs

experience and time. Virtue of character results from

habit (ethos).”19...the concept of good character constitutes, as shown, one of the conceptual cornerstones of

positive psychology.

STOICISM

Greco-Roman Stoicism, flourishing from 300 BC to

approximately 450 AD and still influential today, is a

practical system of philosophy which promotes selfcontrol, personal fortitude, detachment, and civic

responsibility through moral excellence, rationality,

and vigorous management of perceptions and

evaluations. Stoic cardinal virtues were wisdom,

courage, justice, and temperance, with humanity and

transcendence additionally recognized in modern

positive psychology. Well-known and often quoted

Stoics include Epictetus,11 Marcus Aurelius,13

Seneca,20 and Cicero.20 Sherman21 describes the

ancient and ever-present influence Stoicism still holds

on the Western Warrior military mindset:

The Stoics offer important lessons for the military, and,

I would urge, for civilians as well. They give guidance

Warrior Resilience Training in Operation Iraqi Freedom: Combining

Rational Emotive Behavior Therapy, Resiliency, and Positive Psychology
July – September 2008 35

THE ARMY MEDICAL DEPARTMENT JOURNAL

in shaping a character education that takes seriously the

values of discipline and self-mastery, while recognizing

our dependence upon others not only in small

communities, but also globally.21

MEDIC WARRIOR RESILIENCE TRAINING, 2005-2006

Medics were a natural choice to cross-train in WRT

coaching due to their direct daily contact with combat

Soldiers. WRT medics studied doctrinal combat stress

control material, emphasizing combat stress education

and prevention along with resiliency, thriving (similar

to Army adaptive stress reaction), and the

posttraumatic growth literature.22 The goal was to

assist medics to help reduce Soldier barriers to care,

while learning basic REBT coaching skills that could

assist them in serving Soldiers and reduce their own

compassion fatigue, which is promoted in the Army

provider resiliency training.23* Their role then was

similar to the current Battlemind† medic or unit

behavioral health advocates who receive mental health

cross training as a force multiplier. Over 8 two-hour

training sessions, voluntary WRT combat medic

students learned REBT principles, applied the

resiliency and survivor literature to Soldier scenarios,24

participated in peer-coach training (including

evocative role plays related to deployment stress), and

examined Army Values and Warrior Ethos as a source

of resiliency. They also studied Stoic principle sources

and commentaries and firsthand accounts of prisoner

of war survivors such as Admiral Stockdale and Victor

Frankl,7,25 while examining other Warrior codes such

as Japanese Bushido, which influenced the Army 7

Values selection in 1991. WRT medics routinely

practiced evocative, live, REBT coaching sessions

with a Soldier who role-played highly distressed,

theater-specific combat stress and relationship issues,

including strong reluctance to visit behavioral health.

All medics reported that this was the most valuable

training they received.

PUBLIC WARRIOR RESILIENCE TRAINING CLASS

In addition to the WRT medic course, a public WRT

class met 5 times weekly, reviewing basic REBT selfhelp principles, resiliency fundamentals, and Warrior

Ethos virtue ethics. Each 90-minute session reviewed

these same fundamentals as student composition

continually varied due to operational demands. WRT

classes were offered at 2 locations, 5 times weekly,

along with mobile class versions offered for units such

as infantry, military police, explosive ordnance

disposal, and combat engineer on Camp Liberty.

Typical attendance averaged 6 to 12 Soldiers nightly,

with most referrals having been made personally by

other class members. Providers, including physicians,

physician’s assistants, and chaplains, as well as other

officers, also attended, contributing to the ongoing

resiliency dialogue and growth. Those chaplains who

attended were especially supportive of any mental

health provider who spoke openly about moral

integrity, virtue, ethics, and character strength. I am

currently designing a resiliency summit with the

chaplains in theater.

INFORMAL OUTCOMES, 2005-2006

As WRT was an optional class rather than an

intervention or formal Army program, an outcome

study was not conducted, though it would have been

valuable. Personal exit qualitative interviews and

multiple command letters of support suggested the

course’s popularity. An article in the June 25, 2006

issue of the US Army 4th Infantry Division’s newspaper (published and distributed in Iraq), The Ivy Leaf,

entitled “Learning Stoic ABCs: Warrior resilience

trainers help Soldiers maintain mental, emotional

health in Iraq,” the WRT program was described as a

vehicle “To better train combat medics, senior

noncommissioned officers and ‘highly motivated E-4

and above’...in ‘Warrior’ or Stoic methods of

cognitive behavioral peer counseling...the progressive

sessions prepare Soldiers to be unit peer advocates for

emotional health and resiliency, as well as the key

referral source for Soldiers who need formal counseling, and a resource in potential emergencies.”26 An

article with a title that includes “Stoicism gives troops

‘armor for the soul’” appeared in the Atlanta JournalConstitution on March 29, 2006.27 Warrior resiliency

training predated the Field Manual 4-02.51 suggestion

that “Soldier peer mentors...[be] trained to provide

COSC [combat operational stress control] help-inplace assistance for COSC information to peers.”4(p5-1)

Upon redeployment, a 4-session, 8-hour Family

readiness group leader’s training version of WRT

called the Warrior Family Resilience Training

(WFRT) Program was developed for Fort Drum Social

Work Services and Operation Ready in February 2007,

and a WRT poster was presented by the author at the

2007 Force Health Protection Conference. While I was

a Behavioral Health Consultant in the 98th Combat

*See related article on page 57.

†See related article on page 66.
36 www.cs.amedd.army.mil/references_publications.aspx

Stress Control Detachment, I drew upon my Special

Forces background to help design an adaptation of the

WRT medic class, called Elite Warrior Resilience

Training (EWRT), in October 2007 for the 1st Special

Forces Group Surgeon. A 6-part WFRT was conducted

for the 62nd Medical Brigade and 1st Special Forces

Family Readiness Group leaders at Fort Lewis from

March to April 2008. I have also presented WRT for

the Warrior Resilience Program at the Army Medical

Department.

THE WARRIOR RESILIENCE TRAINING CLASS TODAY IN

OPERATION IRAQI FREEDOM

As of September 14, 2008, over 160 WRT classes,

with approximately 4,500 participants, have been

conducted by the 98th Combat Stress Control (CSC)

Multi-National Division Baghdad Prevention team in

Operation Iraqi Freedom. The current version,

“Warrior Resilience Training: Thriving, not Just

Surviving Through Your Combat Deployment,”

consists of a standardized, 90-minute presentation

which reviews combat operational stress reaction

stress-inoculation principles, resiliency, and

posttraumatic growth principles, Warrior Ethos, Army

Values, and REBT self-coaching, including a special

portion which relates the Army Values to Family

values. The presentation is delivered in an interactional

fashion using a PowerPoint slideshow or notes, and is

always copresented with both officer and enlisted

prevention team members when possible. Soldiers are

asked to examine their own resiliency and Warrior

philosophies regarding family separation, loss, unit

conflict, and combat operational stress. WRT uses

(with permission) resiliency and thriving material and

self-assessment tools produced by Al Siebert.24,28 We

recommend that Soldiers continue their resiliency selfeducation, providing online resiliency resources

produced by the Army Battlemind Training Office,

and other well known authors like Dave Grossman,5

who trained our combat stress control unit with his

signature “The Bulletproof Mind” lecture prior to our

deployment.

FEEDBACK FROM WARRIOR RESILIENCE TRAINING

Use of an anonymous, 5-question feedback form,

shown in the Figure, was initiated on July 14, 2008,

with the goal of improving the WRT class and gauging

content comprehension and relevancy. Unit members

are voluntarily surveyed upon completion of a WRT

class. An optional follow-up contact is offered, if

Soldiers choose to provide an email to be contacted

within 60 to 90 days. As of September 12, 2008, data

from 1,168 surveys have been collated. That data

suggests some very positive trends regarding WRT

Warrior Resilience Training in Operation Iraqi Freedom: Combining

Rational Emotive Behavior Therapy, Resiliency, and Positive Psychology

98th Combat Stress Control Detachment Warrior Resilience Training Feedback Form

Strongly

Disagree Disagree Neutral Agree StronglyAgree

1. I now understand and can recognize posttraumatic growth at least as

well as I understand and recognize posttraumatic stress disorder.

[mean=4.13/82.7 percentile]

1 2 3 4 5

2. I believe that I can and will be strengthened through my deployment

experiences, even when they are negative or painful.

[mean=4.27/85.4 percentile]

1 2 3 4 5

3. Compared to other Army combat stress, suicide awareness, or resiliency

briefings I have attended (including Battlemind), I believe this training will

be more useful in managing deployment, combat, and real-life stressors.

[mean=4.17/83.4 percentile]

1 2 3 4 5

4. The instructor(s) were professional and effective in conveying the

training.

[mean=4.60/92.1 percentile]

1 2 3 4 5

5. I believe this training will assist me to become more resilient and learn to

thrive during this deployment and when I return home.

[mean=4.19/83.9 percentile]

1 2 3 4 5

Representation of the feedback form offered to participants at the conclusion of Warrior Resilience Training

classes, from July 14 to September 12, 2008. The results from 900 completed forms were collated. The mean

score and percentile ranking for each question is shown in the brackets.

Note: Means rounded to nearest hundredth and percentile to nearest tenth, using unadjusted means.
July – September 2008 37

THE ARMY MEDICAL DEPARTMENT JOURNAL

acceptance as a class, and Soldier recognition of

resiliency and posttraumatic growth as a real potential

deployment outcome, rather than combat operational

stress reactions or posttraumatic stress disorder alone.

Written feedback comments collected from Soldiers in

ranks from Private to Colonel, including almost every

military occupational skill, routinely suggest that WRT

is a highly beneficial combat stress control class,

rivaling stress, anger management, combat stress, or

resiliency classes previously received in theater or

stateside. Respondents often recommend that WRT

classes be taught as doctrine. Four examples, used with

permission, illustrate typical feedback (all feedback

forms are available from the author for review):

One of the best combat stress courses I have ever

seen, this course should be at the top of the list of

deploying units.

Staff Sergeant, explosive ordnance disposal, 7/14/08

The single most beneficial mental health training I

have received in 15 years in the Army. This

training needs to be doctrine. Place in DVD with

links to web and push out to DoD.

Commander, explosive ordnance disposal unit, 7/14/06

Very informative, recommend this be a part of

predeployment and reintegration training.

Command Sergeant Major, commander’s conference,

8/6/08

All soldiers should go to this training. Very, very

helpful.

1st Sergeant, commander’s conference, 8/6/08

WARRIOR RESILIENCE TRAINING AND BATTLEMIND

Other typical comments suggest that WRT confirms

personal philosophies regarding human resiliency and

potential that Soldiers have long endorsed, yet had

never been conveyed or reinforced by Army mental

health practitioners—the exception being the Chaplain

Corps, which again is usually most supportive of

WRT. The 98th CSC Prevention Team endorses and

teaches Army Battlemind as an officially sanctioned

resiliency program, with empirical support and

Warrior, Spouse, and medic versions. However WRT

classes focus specifically on resilient virtues,

character, and leadership qualities more than

psychoeducation or stress inoculation strategies

normalizing combat operational stress reactions.

Experience in Iraq has revealed that completion of

Battlemind training is still rarely reported by Soldiers,

who are directly asked if they have received

Battlemind training and are often shown the

Battlemind acronym. It is possible that this valuable

training is one of many classes to which beleaguered

Soldiers are exposed prior to their combat or

deployment-specific training. The Battlemind Warrior

resiliency version shares some similarities with the

WRT products from a stress inoculation and Warrior

Ethos standpoint, with the term “Warrior resiliency”

possibly having been influenced by earlier Warrior

Resilience Training.

DISCUSSION

WRT provides a missing bridge and alloy between

Warrior Ethos, leadership, ethics, and current Army

combat stress management or resiliency training

programs. Soldiers must be made aware of their

tremendous capacity to not only endure, but thrive

through their combat deployment experiences and

home front stressors, and return with honor. They

should be trained to recognize and anticipate

posttraumatic growth, as well as combat operational

stress and PTSD symptoms. Most Soldiers will not

attend survival, evasion, resistance, and escape

training, or become Special Forces or Rangers

operators, yet they deserve elite mental training to

endure combat. Resiliency, rationality, virtue, ethics,

and Warrior Ethos, grounded in a positive

psychological framework that affirms the human spirit,

can be integrated together, taught to, and modeled by

our military leaders, Chaplains, behavioral health

practitioners, and the Soldiers themselves. Resiliency

can be strengthened in Army Families as well, who are

also part of the Warrior culture. Our nation, comprised

of virtually every race on earth, represents one of the

most resilient alloys in human history. The US Army

demands an excellence of character and advanced

resiliency that must be continually cultivated to sustain

an all-volunteer force. Army Values, Warrior Ethos,

and leadership are critical foundations of Army

resiliency training that can be skillfully integrated into

a model promoting internal combat stress control.

Warrior Resilience Training represents a pilot study of

what such an alloy might produce. If, as Epicurus said,

“Empty is the argument of any philosopher which does

not relieve any human suffering,”

20 then WRT is

making an effective opening argument that is both

relieving suffering and promoting Warrior resilience,

thriving, and recognition of posttraumatic growth

opportunities.
38 www.cs.amedd.army.mil/references_publications.aspx

Warrior Resilience Training in Operation Iraqi Freedom: Combining

Rational Emotive Behavior Therapy, Resiliency, and Positive Psychology

REFERENCES

1. Field Manual 6-22: Army Leadership: Confident,

Competent, and Agile. Washington, DC: US Dept of

the Army; 12 October 2006.

2. Mental Health Advisory Team (MHAT) IV Operation

Iraqi Freedom 05-07 Final Report. Washington, DC:

Office of The Surgeon General, US Dept of the

Army; November 17, 2006. Available at: http://

www.armymedicine.army.mil/reports/mhat/mhat_iv/

MHAT_IV_Report_17NOV06.pdf.

3. Hoge CW, Castro CA, Messer SC, McGurk D,

Cotting DL, Koffman MD. Combat duty in Iraq and

Afghanistan, mental health problems, and barriers to

care. New Engl J Med. 2004;351(1):13-22.

4. Field Manual 4-02-51. Combat and Operational

Stress Control. Washington, DC: US Dept of the

Army; 6 July 2006.

5. Grossman DA, Christensen LW. On Combat: The

Psychology and Physiology of Deadly Conflict in

War and Peace. Belleville, IL: PPCT Research

Publications; 2004.

6. Ellis A. Reason and Emotion in Psychotherapy : A

Comprehensive Method of Treating Human

Disturbances: Revised and Updated. New York: Lyle

Stewart/Birch Lane Press; 1994.

7. Stockdale JB. Courage Under Fire: Testing

Epictetus’ Doctrines in a Laboratory of Human

Behavior. Stanford, CA: Hoover Institution Press;

1993.

8. Sherman N. Stoic Warriors: The Ancient Philosophy

Behind the Military Mind. New York: Oxford

University Press; 2005.

9. Soldier Life web page, GoArmy website. Living the

Army Values. US Dept of the Army. Available at:

http://www.goarmy.com/life/living_the_army

_values.jsp. Accessed October 11, 2006.

10. Burns D, Velten E. The Lives of Albert Ellis: The

Authorized Biography. Tucson, AZ: See Sharp Press;

2006.

11. Long AA. Epictetus: A Stoic and Socratic Guide to

Life. New York: Oxford University Press; 2002.

12. David D, Szentagotai Z, Kallay E, Macavei B. A

synopsis of rational-emotive behavior therapy

(REBT); fundamental and applied research. J RatnlEmtv Cogn-Behav Ther. 2005;23(3):175-221.

13. Hadot P, Chase M. The Inner Citadel: the

Meditations of Marcus Aurelius. Cambridge, MA:

Harvard University Press; 1998.

14. Field Manual 22-51: Leaders’ Manual for Combat

Stress Control. Washington, DC: US Dept of the

Army; 29 September 1994.

15. Peterson C, Seligman MEP, eds. Character Strengths

and Virtues: A Handbook and Classification. New

York: Oxford University Press; 2004.

16. Seligman MEP. Learned Optimism: How to Change

Your Mind and Your Life. New York: Alfred A.

Knopf, Inc; 1991.

17. Diagnostic and Statistical Manual of Mental

Disorders Fourth Edition (Text Revision).

Washington, DC: American Psychiatric Association;

1994.

18. Jorgensen IS, Nafstad HE. Positive psychology:

historical, philosophical, and epistemological

perspectives. In: Peterson C, Seligman MEP, eds.

Positive Psychology in Practice. New York: John

Wiley & Sons; 2004:20.

19. Aristotle. Nicomachean Ethics. Crisp R, trans. New

York: Oxford University Press; 2000.

20. Long AA, Sedley DN. The Hellenistic Philosophers.

Vol 1. Cambridge, England: Cambridge University

Press; 1987.

21. Sherman N. Educating the stoic warrior. In: Damon

W, ed. Bringing in a New Era of Character

Education. Stanford, CA: Hoover Press 2005.

22. Calhoun LG, Tedeshi RG, eds. Handbook of

Posttraumatic Growth: Research and Practice.

Mahwah, NJ: Lawrence Erlbaum Associates; 2006.

23. Figley CR, ed. Compassion Fatigue: Secondary

Traumatic Stress Disorders from Treating the

Traumatized. New York: Brunner/Mazel; 1995.

24. Siebert A. The Survivor Personality. New York:

Berkeley Publishing Group; 1996.

25. Frankl VE. Man's Search for Meaning: An

Introduction to Logotherapy. New York, NY: Pocket

Books, Simon & Schuster; 1963.

26. Mott M. Learning Stoic ABCs: Warrior resilience

training helps Soldiers maintain mental, emotional

health in Iraq. The Ivy Leaf. 2006;1(12):11.

27. Basu M. Georgia's Guard: the 48th in Iraq: stoicism

gives troops "armor for the soul". Atlanta JournalConstitution. March 29, 2006:F1.

28. Siebert A. The Resiliency Advantage: Master

Change, Thrive Under Pressure, and Bounce Back

from Setbacks. San Francisco, CA: Berrett-Koehler

Publishers; 2005.

AUTHOR

MAJ Jarrett is the Prevention Team Officer-in-Charge, Victory Base Camp and Multi-National Division, Baghdad, Iraq.

He is deployed from the 98th Combat Stress Control Detachment, Fort Lewis, Washington.
July – September 2008 39

The services that US military behavioral health

personnel provide in a deployed environment are much

broader than in stateside clinical settings. Behavioral

health providers and mental health specialists in

support of Operation Iraqi Freedom (OIF) conduct

prevention, consultation, and restoration activities, in

addition to outpatient clinical services. Activity

workload metrics that are utilized in stateside military

behavioral health clinics do not accurately account for

much of the workload that behavioral health personnel

conduct on deployment. Consequently, the Combat

and Operational Stress Control Workload and Activity

Reporting System (COSC-WARS) was developed and

has been in use since the beginning of OIF.

The collection of the COSC-WARS data has been

inconsistent over the duration of OIF. The Mental

Health Advisory Team V Report1recommended that

COSC-WARS be reported throughout the Iraq theater

of operations (ITO). Since January 2008, the theater

Behavioral Health Consultant in Iraq has expanded the

collection of COSC-WARS from the combat stress

control (CSC) units, area support medical companies,

and combat support hospitals to include the Army

divisional behavioral health assets. The types of

services (excluding Navy/Marine behavioral health

information) provided by all CSC units and other

Army behavioral health assets from January to June

2008 are described below.

COMBAT STRESS PREVENTION

The prevention activities that behavioral health

personnel perform in the ITO are the emphasis of the

CSC Teams. The first of these include “walkabouts,”

which are described as outreach visits to unit locations

or around their area of operation for the purpose of

talking with service members to gather information on

the current stressors, problems, morale, or the status of

service members or their unit. Walkabouts, sometimes

referred to “stealth mental health,” are at the heart of

the prevention activities in that these out-of-office

casual contacts are less intimidating than a clinical

setting. The aim is to assess the well-being of the

troops, impart some helpful coping knowledge or

resources, and lend an objective, caring ear. These

contacts, which could be in a group or one-on-one,

appear as a normal conversation at places like the

dining hall, recreation areas, living areas, or even in

transport. For example, one mental health specialist

was stuck in a convoy that was halted for several hours

“outside the wire.” While other Soldiers in the vehicle

were becoming agitated with the extended wait, he

started a conversation with some of those Soldiers, and

even taught them some relaxation techniques. He

noted that these Soldiers calmed down and were able

to pass the time more easily. During the first half of

2008, some 80,400 walkabouts were conducted in the

ITO (average of 13,400 per month). The total may

include multiple contacts with the same individuals on

different days.

A second component of behavioral health prevention

activities is educational classes, including classes on

life skills, marital maintenance, personal growth,

sexual responsibility, tobacco cessation, stress

management, anger control, suicide/violence

Behavioral Health Activity and Workload in

the Iraq Theater of Operations

MAJ Barron Hung, MS, USA

ABSTRACT

Deployed service members encounter greater stressors such as combat, separation from normal support groups, and

high operational tempo in the Iraq theater of operations than in a stateside setting. Consequently, the services that

behavioral health personnel provide during deployment include a wider breadth of activities than are tracked and

provided in a US military medical treatment facility setting. The Combat and Operational Stress Control Workload and

Activity Reporting System was developed to track the diverse behavioral health activities performed in theater. These

activities during the period of January through June 2008 included psychoeducational classes (n=3,900), traumatic

event interventions (n=535), command directed mental health evaluations (n=750), and casual walkabout/prevention

contacts (n=80,400). These behavioral health treatment and prevention activities performed in the Iraq theater of

operations are a crucial part of the medical support provided to troops in a harsh environment. These activities serve as

force multipliers and help conserve the fighting strength of combat troops.
40 www.cs.amedd.army.mil/references_publications.aspx

Behavioral Health Activity and Workload in the Iraq Theater of Operations

prevention, substance abuse, combat stress, and coping

with deployment transitions. These classes are

designed to teach service members coping and

problem solving skills to help manage common

problems that they may encounter on deployment.

Classes are offered on a regular, recurring basis, or

given as needed. During the first half of 2008, a total

of 3,900 classes were given with 45,500 participants

(7,600 per month average).

Another major prevention effort is intervention

following potentially traumatizing events. These

events generally involve experiencing, witnessing, or

being threatened with significant human suffering,

injury, or death. Behavioral health personnel often

provide support through disseminating information

about typical reactions, coping skills, and resources.

Behavioral health personnel may also provide one-onone support, or group defusing/debriefing sessions as

needed. The specific intervention offered is based on

clinical judgment, depending on the severity of the

event and the input of the leaders and individuals. A

total of 535 traumatic event interventions were

conducted in the ITO with 7,600 participants (1,270

per month average) from January to June 2008.

Consultation with commanders and other leaders about

behavioral health issues is a prevention endeavor that

can have an exponential impact. Examples include

presentation of an overview of available behavioral

health services, discussions of unit morale and stress,

education about leadership strategies to reduce stress,

and consultations about individuals with behavioral

health challenges. From January to June 2008, there

were 5,200 consultations with leaders about individual

Soldiers, and 6,800 consultations about other issues.

Some commanders in the ITO are uninformed and

leery of the services and goal of behavioral health

interventions. Professional consultations have often

put these commanders’ concerns at ease, resulting in

commanders who more readily discuss their concerns

with behavioral health personnel, which in turn makes

it easier for their troops to receive services.

Furthermore, unit behavioral health surveys can be

used to inform commanders about the concerns and

needs of their troops. Over 300 units were surveyed

with 10,600 participants during the first 6 months of

2008.

BEHAVIORAL HEALTH TREATMENT IN THE ITO

With long-term deployments, many service members

require combat stress control or behavioral health

treatment in-theater. Troops who develop mild stress

reactions related to deployment are described as

having combat operation stress reactions (COSR). The

term COSR can apply to stress reactions in a deployed

military environment that are not adequately explained

by physical disease, injury, or a preexisting behavioral

health disorder. These symptoms are considered

transient reactions to the traumatic stress of combat

and/or cumulative stresses of military operations.

Those with COSR are not referred to as “patients,” but

are described as having “normal reactions to an

abnormal event.” This is designed to help reduce the

stigma associated with being a mental health patient.

COSR is distinguished from behavioral health

diagnoses (BHD), which are usually preexisting, more

enduring, or more severe disorders as described in the

Diagnostic and Statistical Manual of Mental

Disorders.

2 To help distinguish COSR symptom

constellations that resemble BHDs, the current

guidance is that adjustment disorders or relational,

occupational, and environmental problems (V codes*)

due to deployment related issues should be considered

COSR. These are symptoms that typically remit

shortly after return from deployment. In contrast, BHD

are more severe or enduring conditions such as

psychosis, major depression, posttraumatic stress

disorder, bipolar disorder, and substance intoxication

or dependence. Of course, the more severe cases were

evacuated from theater for a higher level of healthcare.

During January to June 2008 there were 10,700 new

COSR cases, 23,700 total COSR contacts, 8,160 new

BHD cases, and 25,800 total BHD contacts. Contacts

include multiple appointments with the same

individual on different days.

Of the individual appointments, 73% were for

counseling and 27% dealt with medication

management. In COSC-WARS, new COSR

appointments are further broken down by primary

stressor or complaint, the top two of which are “homefront” problems and combat exposure (see Table 1).

Home-front problems include issues at home such as

relational problems, problems with children, family

*Described in the chapter “Other Conditions that May be a Focus of Clinical Attention” in the Diagnostic and Statistical

Manual of Mental Disorders.

2

These codes are designed for occasions when circumstances other than a disease or injury

result in an encounter or are recorded by providers as problems or factors that influence care.
July – September 2008 41

THE ARMY MEDICAL DEPARTMENT JOURNAL

illness, and financial problems. The third most

common COSR stressor was conflict between peers

within the unit. Tied for fourth is conflict with or

between leaders, and mission requirements. The latter

is a broad category that includes continuous

operations, fragmented sleep, frequent harassment by

the enemy without serious casualties, little chance to

relax and replenish because of long hours, poor living

conditions, poor recreational facilities, poor

communication with home, long or uncertain tour

length, extension of tour or stop-loss,†etc. The sixth

highest COSR stressor is attributed to a potentially

traumatizing event other than direct combat (such as a

suicide in unit, severe accidents, and exposure to mass

suffering, dead bodies, or great danger). Other

stressors that are tracked include personality traits or

habits that cause significant conflict, and

environmental stressors such as heat, cold, dryness,

wetness, wind, dust, insects, poor hygiene, or minor

subclinical illnesses that can result (eg, mild

dehydration, mild diarrhea).

Table 2 displays the top behavioral health diagnoses

that were treated. The highest categories under “other”

were likely sleep disorders and adjustment disorders.

These 2 categories did not originally have separate

reporting lines on COSC-WARS, but they appear as

such on the report form as of July 2008.

The disposition of each appointment is tracked as well.

During the first 6 months of 2008 the vast majority of

individuals were returned to duty without limitations

(90.8%, n=45,100), followed by returned to duty with

limitations (4.4%, n=2,185). Only 0.67% of the

dispositions (n=335) were for evacuations out of

theater. The remaining 2 categories were for

“rest” (sent to a nonmedical support unit, typically

farther from the front lines; 3.4%, n=1700), and

“refer” to a higher level of medical care in theater

(0.91%, n=450). Over 99% of behavioral health

contacts resulted in service members continuing their

treatment in theater or being returned to full duty. A

logical extension of these results is that evacuation

rates out of theater for combat and operational stress

reactions and behavioral health diagnoses would have

been much higher if behavioral health teams were not

in theater providing high quality, broad spectrum care.

Empirical evidence indicates that, typically, when

service members complete their combat tour with their

unit while receiving behavioral health care as needed,

their overall functioning is better than that

demonstrated by those who are returned individually

to receive treatment out of theater.

Often, the higher level of medical care that a service

member is referred to in-theater is the restoration

program. There are several restoration centers in Iraq,

which host residential treatment programs ranging

from 3 days to 7 days in duration. The program gives

participants the opportunity to rest and recuperate,

while learning coping skills through classes and

individual appointments. The participants also engage

in physical training, arts and crafts, and other

recreational or social activities. Many of these

individuals just need a little time to recharge and

†Presidential authority under Title 10 US Code 12305 to

suspend laws relating to...separation of any member of the

Armed Forces determined essential to the national

security of the United States....3

Stressor Total Monthly

Average

Percent

Home-front problems 3091 515 29.0

Combat exposure 2150 358 20.4

Peer/unit conflict 1418 236 13.3

Leadership conflict 1211 202 11.3

Mission requirements 1211 202 11.3

Noncombat PTE* 469 78 4.0

Personality problems 408 68 3.8

Environmental factors 278 46 2.6

Other 440 74 4.2

*Potentially traumatizing event

Table 1. Stressors as reported in COSC-WARS for new

combat and operational stress response cases in the

Iraq theater of operations, Jan through Jun 2008.

Disorder Total Monthly

Average

Percent

Depression 1389 232 24.0

Nicotine problem 1002 167 17.1

Anxiety 928 155 15.8

PTSD/ASD‡ 720 120 12.3

Other substance

abuse problems 192 32 3.3

Other 1640 273 27.9

‡Posttraumatic stress disorder/acute stress disorder

Table 2. Leading behavioral health diagnoses

treated in the Iraq theater of operations as

reported in COSC-WARS, Jan through Jun 2008.
42 www.cs.amedd.army.mil/references_publications.aspx

Behavioral Health Activity and Workload in the Iraq Theater of Operations

develop some new coping techniques, and then can

return to their unit. The vast majority of those who

attended the restoration program during the first 6

months of 2008 were returned to duty or continued

treatment in-theater, only about 6% (36 of 594) of the

participants required evacuation out of theater.

Other behavioral health-related services that were

tracked in COSC-WARS from January to June 2008

included command-directed mental health evaluations

(n=750) and other Army required mental health

screenings (n=590). The latter includes screenings for

drill sergeants, recruiters, and Soldiers recommended

for administrative separation. Behavioral health

providers in the ITO also assist with cognitive

screening for troops with suspected concussions. Of

560 screened, 86 demonstrated probable transient

cognitive impairment.

SURVEY SAMPLE

The recipients of these behavioral health services in

the ITO have generally rated the services highly, as

indicated in satisfaction surveys. On the survey, the

recipients of our behavioral health interventions are

asked to rate the services as either poor (1 point), fair

(2 points), good (3 points), or excellent (4 points). In a

June 2008 sample of 126 recipients, 98% of those

surveyed rated the “Overall Quality of Care” as good

or excellent (Mean score=3.7). Other survey items

(and the respective mean scores) which, by percentage,

were rated as good or excellent:

 Services helped me cope better (86%, M=3.4)

 Personal manner of the staff (98%, M=3.7)

 Group educational classes (96%, M=3.6)

 Individual treatment (94%, M=3.6)

 Willingness of staff to answer my questions

(98%, M=3.8)

CONCLUSION

All of the behavioral health treatment and prevention

activities performed in the ITO are crucial elements of

the medical support provided to Soldiers in a harsh

environment. These activities serve as force

multipliers and help conserve the fighting strength of

combat troops. Although definitive data have not yet

been published, historical evidence and hard

experience shows the likelihood that, without the

breadth and depth of the behavioral health

interventions provided in theater, thousands of

additional troops would have been evacuated out of

theater. These losses would cause increased

operational, physical, and behavioral health strain on

others in the unit, compounding the existing strain

imposed by current deployment stressors. Further, the

early interventions build resiliency, likely helping to

prevent these symptoms from developing into more

severe disorders in the future. I am confident that,

eventually, definitive data will conclusively

demonstrate the true extent of the benefits our Soldiers

derive from the behavioral healthcare services

provided in-theater.

REFERENCE

1. Mental Health Advisory Team (MHAT) V: Operation

Iraqi Freedom 06-08, Iraq; Operation Enduring

Freedom 8, Afghanistan. Washington, DC: Office of

The Surgeon General, US Dept of the Army;

February 14, 2008. Available at: http://

www.armymedicine.army.mil/reports/mhat/mhat_v/

MHAT_V_OIFandOEF-Redacted.pdf.

2. Diagnostic and Statistical Manual of Mental

Disorders Fourth Edition (Text Revision). Arlington,

VA: American Psychiatric Association; 2000.

3. Joint Publication 1-02: DoD Dictionary of Military

and Associated Terms. Washington, DC: Joint Staff,

US Dept of Defense; March 4, 2008. Available at:

http://www.dtic.mil/doctrine/jel/new_pubs/

jp1_02.pdf.

AUTHOR

MAJ Hung is the Theater Psychology Consultant, 62nd

Medical Brigade (Task Force 62), Victory Base Complex,

Baghdad, Iraq.
July – September 2008 43

Remind: Addressing the Risk of Illegal

Violence in Military Operations

LTC Karen L. Marrs, AN, USA

PROACTIVE MEASURES ADDRESSING SERIOUS MISCONDUCT

A preface by COL (Ret) James Stokes, MC, USA

The Remind concept is on the cutting edge of methods to defend service members from succumbing to the

corrosive effects of war and committing crimes that endanger the mission and even the ultimate Army

objectives.

The concept of misconduct stress behaviors as a category alongside the positive combat stress behaviors and

battle fatigue (which is now called combat and operational stress reaction) entered US Army leadership and

medical doctrine in 1993 with publication of Field Manual 22-51, Leader's Manual for Combat Stress

Control,

1

and Field Manual 8-51, Combat Stress Control in a Theater of Operations [now obsolete]. Prior to

those manuals, discussion and training implied that only poor Soldiers and sociopaths committed the most

severe form of misconduct—the deliberate killing of surrendering enemy combatants or disarmed prisoners,

of noncombatants, and even of other US service members (ie, fragging). The new manuals emphasized that

serious misconduct (even murder) can be the second side of the double-edged sword of the positive combat

stress behaviors. Those crimes have been committed by heroic service members in exemplary units when

friction and distress became too intense or prolonged, and positive discipline and mission focus were not

actively and continuously sustained. In modern operations with worldwide media coverage, a single atrocity

can profoundly undermine the United States' objectives for the entire conflict, and put all our service

members at more risk.

The Remind concept and the routine and special actions it calls for are essential means for leaders and Battle

Buddies* to sustain positive discipline and mission focus under extreme stress and provocation.

COL (Ret) Stokes is recognized as one of the Army’s leading authorities on combat operational stress

control. He is currently a contract psychiatrist at the Brooke Army Medical Center, evaluating veterans

still on active duty or on the Temporary Duty Retirement List for Medical/Physical Evaluation Boards.

*Generally defined as the person to whom a Soldier can turn in time of need, stress, and emotional highs and lows who

will not turn the Soldier away, no matter what. This person knows exactly what the Soldier is experiencing because of

experience with similar situations or conditions, either current, previous, or both.

OVERVIEW

Currently, actions employed for combat and

operational stress control (commonly referred to as the

“5 Rs”) include:2(p1-8)

 Reassurance of normality

 Rest or a break from combat

 Replenishing bodily needs (thermal comfort,

water, food)

 Restoring Soldier confidence with purposeful

activity and contact with his unit

 Return to duty in an effort to decrease the

likelihood of long-term psychiatric disability and

maintain combat power

This article provides background information with

theory and context for “Remind,” a “6th R” that is

pending revision and inclusion in the next publication

of Army Field Manual 4-02.512and Field Manual 6-

22.5.

3 Remind is intended to provide guidance for

clinicians and military leaders involved in combat

operations to identify and intervene before thoughts

of harming or killing noncombatants result in

misconduct or, as a worst case scenario, in war crimes.

The Remind concept is based on mental health lessons

learned in combat and a review of recent combatspecific and relevant civilian literature. Of note, the

term “combat” is referenced throughout the article, but

Remind may be applied to peacekeeping or other

military operations that evolve into violence and death

(eg, torture and deaths of US Soldiers in Somalia4).
44 www.cs.amedd.army.mil/references_publications.aspx

Remind: Addressing the Risk of Illegal Violence in Military Operations

The “6th R” encompasses addressing unit and

individual risk factors and behaviors that precede

misconduct and reminding Soldiers that, although

good Soldiers commonly have vengeful thoughts in

the context of intense combat, acting on thoughts of

revenge and harming or killing noncombatants is

misconduct that will be punished. Soldiers are further

Reminded that resorting to illegal revenge dishonors

them and their friends (living and dead) and helps the

enemy discredit them and win. Remind stresses that

the ultimate objective is to return home with honor.

This article also addresses recommendations that

clinicians can offer commanders to maintain individual

and unit safety and conserve combat power. Finally,

this article discusses the proposed future application

and evaluation of the concept of Remind.

DESCRIPTION OF THE PROBLEM

Army policy and combat and operational stress control

doctrine address suicide awareness and prevention in

both garrison and combat environments. Soldiers who

are not mentally ill and threaten to harm or kill others

in garrison are processed in accordance with the

Uniform Code of Military Justice.* What is lacking is

a process to address common thoughts of vengeance

that are experienced by otherwise good Soldiers in the

context of the killing and death associated with intense

and/or prolonged combat before these thoughts result

in misconduct. Any Soldier suicide is a tragedy with

intense and lasting effects on the individuals, families,

and units involved; but misconduct by a single Soldier

can have a far wider ripple effect. In addition to

trauma for victims and perpetrators who later regret

acting on violent impulse, a war crime carried out by

an individual Soldier can undermine all tactical efforts

to solicit the cooperation of the local community. The

misconduct behaviors of a few can have imagedestroying international and strategic ramifications

that reverberate for generations (eg, My Lai6).

With the intense and prolonged conflicts in Iraq and

Afghanistan, the need for Department of Defense

approved guidance to behavioral health personnel is

increasingly clear. The fourth iteration of the Mental

Health Advisory Team (MHAT IV) survey of 1,320

Soldiers and 447 Marines deployed to Iraq that was

released in May 2007 verified that hostile thoughts

toward noncombatants are very common.7 The survey

found that only 47% of Soldiers and 38% of Marines

agreed that noncombatants should be treated with

respect. The MHAT IV survey also reported that 10%

of Soldiers and Marines indicated mistreating (kicking

or hitting) noncombatants or destroying or damaging

property unnecessarily. In addition to this evidence of

low grade misconduct behaviors, a significant number

of deployed Soldiers—nearly 16% of 425 Soldiers

seeking mental health services in a 2006 study 8—

endorsed thoughts of killing someone besides the

enemy within the last month.

OVERVIEW OF ORGANIZATION: ARMY COMBAT AND

OPERATIONAL STRESS CONTROL

The Army recognizes the detrimental physical and

psychological effects of combat on Soldiers and their

mission performance.9 Army combat stress control

(CSC) teams were developed to prevent, identify, and

manage combat as well as operational stress. The CSC

teams are deployed to maximize return to duty for

Soldiers who are temporarily impaired by stressrelated conditions or behavioral disorders. Field

Manual 4-02.51 2establishes the configuration,

assignment, and functions of CSC units that are

already in place. These teams are integral to the

current combat environment and can act now using

Remind to decrease the likelihood of misconduct

behaviors in combat.

CONTEXT FOR REMIND

Individual, combat/operational, constraint/relief, and

situational factors can all contribute to the occurrence

of misconduct during violent military operations.

Individual factors: Young men are at highest risk for

committing homicide in civilian settings.10 Mental

illness or personality disorders may also predispose an

individual to violence. Training/conditioning and the

recent experiences of the potential assailant (eg,

experiencing the death of a friend by enemy action)

have been linked with illegal killing behavior on the

battlefield.11 No studies were found linking substance

abuse with illegal violence in combat, but substance

abuse has been linked to increased civilian risk for

homicide.10

*The Uniform Code of Military Justice (UCMJ), a federal

law,5is the judicial code which pertains to members of

the United States military. Under the UCMJ, military

personnel can be charged, tried, and convicted of a range

of crimes, including both common-law crimes (eg, arson)

and military-specific crimes (eg, desertion).
July – September 2008 45

THE ARMY MEDICAL DEPARTMENT JOURNAL

Combat/operational factors that are known to increase

stress casualties include both a high rate of physical

wounding and death in battle and longer duration of

combat.9 Multiple deployments, unit extensions in

theater, and decreased dwell time all increase duration

of time in combat today.

Absence of constraints/relief: A lack of constraints

refers to the absence of any individual/entity that

might counter a Soldier’s proclivity to act on violent

impulse. Examples of constraints could include a

principled Battle Buddy, a platoon sergeant reinforcing

rules of engagement, or routine oversight of Soldier

activities by the command. High operations tempo

(OPTEMPO), or pace of activity without relief from

intense military operations may also contribute to

misconduct. Relief encompasses any activity that

allows a break from intense combat or operational

stress, eg, a full night of sleep or rotation of

individuals or small units away from high OPTEMPO.

Proactive CSC teams are in a position to provide relief

by allowing a Soldier time to verbalize thoughts and

feelings, and/or constraint in the form of Remind as

detailed below.

Situational factors refer to the presence of an easily

accessible (soft) target, weapon(s), and unsupervised

time to commit a violent act.

Although the presence (or absence in the case of

constraints/relief) of factors can independently trigger

illegal violence, recent combat experience suggests

that the influence of many variables simultaneously is

more likely to result in horrific war crime.

Metaphorically speaking, multiple storms combine and

result in a system that is far more destructive than any

individual weather pattern alone. Atrocities in combat

are the exception rather than every day occurrences

because multiple negative factors rarely converge to

create the “perfect storm.”

This model, illustrated at right, explains the context in

which a war crime might occur; but does not absolve

an individual of responsibility for his or her actions.

The construct also establishes multiple factors that

might be addressed to mitigate the risk of illegal

violence in combat. Examples include a standard for

enlistment that screens out applicants with a criminal

history, proper command oversight, breaks in

OPTEMPO, etc.

Remind is a tool intended to assist the individual

Soldier to make ethical decisions in circumstances that

are unimaginable in civilian or garrison settings. The

concept dovetails with Army Values to facilitate

ethical accomplishment of a combat mission. Soldiers

are instructed in the Army Value of Respect from the

earliest days of their training. Soldiers also receive

instruction in rules of engagement (ROE) and the Law

of Land Warfare12 before deployment to a combat

zone. Instructions concerning ROE are updated and

reiterated throughout deployment.

The purpose of Remind is to bridge the gap between

what Soldiers are taught about ethics and military

law, and what they do in the context of the horrors of

intense combat.

THE CONCEPT OF REMIND

The following are the key concepts of Remind for

behavioral health personnel:

US combat power is fundamentally comprised of

Soldiers who are trained and legally authorized to

engage with and destroy enemy combatants. The

destruction of enemy forces is constrained by ROE

that are based upon the Law of Land Warfare. These

rules governing the use of military force are much like

employing a controlled burn to clear a forest. Properly

applied combat power targets and damages or kills the

enemy without inflicting significant collateral damage.

Uncontrolled combat power, like a fire out of bounds,

can produce disastrous effects. Leaders engaged in

directing violent military operations are in the unusual

position of having to manage this “fire” of

dangerousness to others and killing.

Behavioral health personnel are in a position to

conduct unit and individual assessments and advise

combat commanders on the best course of action to

minimize the risk of misconduct and preserve combat

power.



Individual

Factors 

WAR

CRIME 

Absence of

Constraints /Relief



Situation

Combat/Operational Factors
46 www.cs.amedd.army.mil/references_publications.aspx

Thoughts of killing or harming others in garrison are

managed as misconduct. This tendency, applied to

combat actions decreases the likelihood that Soldiers

will verbalize their “forbidden” vengeful thoughts.

Thoughts of killing or injuring others outside of

established guidelines must be addressed before any

attempts at prevention are possible.

The Remind concept is based on the premise that

thoughts of killing and/or injury to others outside of

established ROE are best addressed as stress reactions

that can be expected in the life-and-death context of

combat.9Figley and Nash9equate the intensity of

friendships formed in combat to the strength of the

maternal-child bond. As such, the agony following the

death of a friend in combat parallels the pain a mother

feels at the death of her child. To add to this intensity,

combat deaths are frequently gruesome and horrific in

nature. Horrific combat deaths frequently lead Soldiers

to feel vengeful and verbalize a desire to kill or harm

civilians they believe to be aiding the enemy, or

toward those in command that they hold responsible

for the deaths of their friends.

Suicide and homicide rates are known to increase in

civilian settings bordering civil wars,13 so Soldiers

having violent thoughts towards themselves and

noncombatants in combat settings should not come as

a surprise. A wartime increase in thoughts of violence

to self and others can be understood on a continuum of

the well-known concept of fight or flight. The increase

in stress created by intense combat conditions

produces a corresponding increase in both the

frequency and intensity of:

 Thoughts of escaping a seemingly hopeless

situation by suicide (extreme flight) or

 Thoughts of revenge directed at noncombatants

(extreme fight)

Vengeful thoughts may occur in individuals or pervade

entire units impacted by intense and prolonged combat

trauma. Poorly trained and undisciplined Soldiers are

at highest risk, but proud cohesive units are also

susceptible during times of extreme combat stress.

Thoughts of killing or harming others outside of ROE

alone are not a reason to evacuate individuals/units,

consider them untrustworthy, or doubt their ability to

continue with the mission any more than suicidal

thoughts without intent or plan merit hospitalization or

permanent stigma.

Behavioral Health providers are routinely consulted to

assess for and intervene to decrease the risk of suicide.

In a combat context, behavioral health providers

should also expect to be consulted to assess for risk of

illegal violence, identify individual and unit risk

factors and behaviors that may precede illegal acts,

and employ interventions to decrease the risk of

violent misconduct. Clinical screening for unit and

individual risk factors and individual behaviors that

may precede acts of misconduct should include

assessment of the following risk factors and behaviors:

Unit risk factors that may precede illegal violence in

combat:

 Multiple Soldier and/or civilian deaths, in the

same unit, over a short period of time

 High OPTEMPO with little respite between

engagements

 Increased number of days in combat (a WWII

study cited increased vulnerability after 60 days

with at least one friendly casualty9)

 Rapid turnover of unit leaders (especially with

vacancy created by death of an admired, trusted

leader)

 Manpower shortages

 Restrictive or confusing ROE as evidenced by

themes of “powerless to fight back”

 Enemy that is indistinguishable from civilian

targets

 Collective perception of lack of support from

higher command

 Rumors of “overkill” of legitimate enemy targets,

eg, mutilation of an enemy combatant with

excessive firepower

Combat Context

Fight Flight

Murder HI*

Combat and

Operational

Stress Reaction

SI† Suicide

*Homicidal ideation

†Suicidal ideation

Remind: Addressing the Risk of Illegal Violence in Military Operations
July – September 2008 47

THE ARMY MEDICAL DEPARTMENT JOURNAL

Individual risk factors that can be applied to risk

assessment for illegal violence in any military or

civilian setting and remembered using the acronym IS

A MAD GUY:

 Impulsive

 Social support deficit

 Angry about incident

 Mental illness (eg, bipolar or psychotic disorder)

 Armed/access to weapons

 Did it before (violent crime with or without arrest/

jail or discipline under the Uniform Code of

Military Justice)

 Guiltless (antisocial traits or personality disorder,

other Cluster B* disorders)

 Under the influence (drug and/or alcohol history)

 Young male

Individual Military/Combat Specific Risk Factors that

may precede illegal violence in combat:

 Individual has suffered a combat loss (friend

wounded or killed in action)

 Soldier personally witnessed the injury or death or

was involved in the medical evacuation of friend/

unit member

 Gruesome, horrific combat loss

Individual Behaviors that may precede illegal violence

in combat:

 Soldier verbalizes thoughts of anger toward/lack

of support from higher command

 Soldier verbalizes anger toward and thoughts of

taking revenge on the indigenous civilian

population

 Change in appearance/behavior:

 lax military dress/bearing

 hyperarousal

 irritability/angry outbursts

 morose/isolative

 changes in sleep and appetite

 Deliberate cruelty to people or animals

 Risk taking (intentional near miss in traffic)

 Soldier pushing ROE to the maximum, eg,

excessive/indiscriminant/near miss warning shots

 Drug or alcohol use

By screening for unit and individual risk factors and

individual behaviors that might precede misconduct,

clinicians can intervene to decrease the likelihood that

thoughts of killing or harm to others will escalate to

uncontrolled violence. In addition to allowing time for

the Soldier to verbalize forbidden thoughts and

feelings, clinicians should inquire directly whether the

Soldier is thinking about taking illegal revenge.

Behavioral health personnel should advise Soldiers

that thinking about illegally harming or killing others

is a common reaction that good Soldiers have in

response to the sadness and anger that are part of

combat, but that taking action on illegal thoughts is

misconduct that must be punished.

The application of some combination or all of the 5Rs

of Combat Stress Control (Reassure, Rest, Replenish,

Restore, and Return) should include a 6th R: Remind.

Remind the Soldier(s) as appropriate before, during,

and after combat that:

1. You are (an) American Soldier(s) here to

complete a lawful mission.

2. American Soldiers behave honorably because it

is the right thing to do.

3. Harming or killing noncombatants dishonors

you and your fellow Soldiers, living and dead.

4. Stepping down to revenge helps the enemy to

discredit you and your unit, and win.

5. The ultimate objective is to “Return Home With

Honor.”

Most Soldiers who are provided with an opportunity to

verbalize their thoughts and feelings, treated with

reassurance, rest, etc, and reminded of their obligation

to themselves and their friends can regroup and safely

continue the mission. In the event of continued

thoughts of killing or harming others outside of

established ROE with intent and plan to act, or a

*Any of a group of disorders in which patterns of

perceiving, relating to, and thinking about one's self and

one's environment interfere with the long-term

functioning of an individual, often manifested in deviant

behavior and lifestyle.14
48 www.cs.amedd.army.mil/references_publications.aspx

combination of unit and/or individual risk factors/

behaviors that indicate unacceptable risk, further steps

must be taken to conserve safe and effective combat

power. The clinician may recommend that the

command:

 Increase supervision and control.

 Rotate the Soldier/unit away from high

OPTEMPO and heavy losses.

 Evacuate individual(s) to the next level of care if

required.

 Unless there is immediate danger, Soldiers who

are dangerous to others besides the established

enemy should not continue to carry a loaded

weapon (the firing pin of the weapon may be

removed to ensure safety and preserve dignity).

Behavioral health personnel should also:

 Consult command for collateral information.

 Maintain close contact with command and unit

medics to check on the status of Soldiers at risk.

 Conduct frequent face-to-face reassessments.

 Brief incoming behavioral health personnel on

existing cases and need for close follow-up to

maintain safety and continuity of Soldier care.

Of final note, clinicians who are stationed far forward

with Soldiers engaged in intense ongoing combat

operations with heavy losses are subject to many of the

same mental and physical stressors as the Soldiers they

treat. Sharing with Soldiers in the experience of danger

and death can create a strong sense of identification

with the supported unit. This cohesion is adaptive

when a high degree of CSC team involvement leads

Soldiers to feel comfortable seeking mental health

services. This same solidarity may make a neutral and

objective stance difficult to maintain in the ongoing

context of Soldier injuries and deaths. Clinicians

should take care to address how their own vengeful

thoughts and feelings may be transmitted to the

Soldiers they serve. CSC unit commanders should

keep in close contact with clinicians stationed at far

forward areas and consider periodic rotation of

individuals or teams from violent combat conditions to

less intense duties.

DESIRED OUTCOME

Application of Remind cannot eliminate all individual

acts of illegal violence any more than suicide

awareness training can eliminate all suicides. It can,

however, establish proactive risk assessment and

interventions designed to decrease the likelihood of

misconduct in combat.

THE ROAD AHEAD

Remind is currently being taught in the Combat and

Operational Stress Control (COSC) Course at the

AMEDD Center and School, and is pending revision

and inclusion into Army COSC doctrine. The training

should be incorporated into AMEDD Mental Health

and other officer basic courses as well as the basic and

advanced noncommissioned officer courses to

disseminate the concept to new behavioral health

providers and future Army leaders.

The success of prevention efforts in general, or the

absence of a negative outcome is notoriously difficult

to measure (eg, to what extent has Army Suicide

Awareness training actually decreased Soldier

suicides?). Even assuming extensive “buy in” and

promulgation by line-unit commanders, quantifying

the success of Remind will be difficult since actual

war crimes are, thankfully, relatively rare.

One less war crime attributable to a US Soldier could

be considered success, but better measures of the

future impact of Remind on misconduct in combat are

desirable. Mental Health Advisory Team surveys have

addressed the impact of Suicide Awareness training

and might also help to quantify the effects of Remind.

In particular, the MHAT IV report7addressed ethics

and battlefield behavior for the first time. Therefore,

MHAT IV could be a baseline against which Remind

efforts may be evaluated in future, with the

understanding that, even with audience saturation,

changes in Army attitudes and culture take time—

sometimes a very long time—to be realized.

Remind suggests a number of broader implications

that should also be considered across the Department

of Defense (DoD). Maintaining the initiative and

success in military operations requires control of the

combat environment. Failure to address the

connections between the ethical behavior of US forces

in combat and leader development, force protection,

information operations and media/public affairs across

the tactical, operational, and strategic spectrum could

cede military and political initiative to our adversaries.

Since such loss of initiative could make US strategic

objectives costly or even impossible to achieve, efforts

Remind: Addressing the Risk of Illegal Violence in Military Operations
July – September 2008 49

THE ARMY MEDICAL DEPARTMENT JOURNAL

should be made to advise all DoD personnel of the

importance of training and executing Remind at all

levels of military decision making.

REFERENCES

1. Field Manual 22-51: Leaders’ Manual for Combat

Stress Control. Washington, DC: US Dept of the

Army: 29 September 1994.

2. Field Manual 4-02.51: Combat and Operational

Stress Control. Washington, DC: US Dept of the

Army; 6 July 2006.

3. Field Manual 6-22.5: Combat Stress. Washington,

DC: US Dept of the Army; 23 June 2000.

4. US Army Center of Military History. The United

States Army in Somalia: 1992-1994. Washington,

DC: Office of the Administrative Assistant to the

Secretary of the Army; 2003. CMH Publication 70-

81-1.

5. 64 Stat. 109, 10 USC, ch 47.

6. Olson JS, Roberts R. My Lai, A Brief History with

Documents. New York: Macmillan; 1998.

7. Mental Health Advisory Team (MHAT) IV Operation

Iraqi Freedom 05-07 Final Report. Washington, DC:

Office of The Surgeon General, US Dept of the

Army; November 17, 2006. Available at: http://

www.armymedicine.army.mil/reports/mhat/mhat_iv/

MHAT_IV_Report_17NOV06.pdf.

8. Hill JV, Johnson RC. Suicidal and homicidal Soldiers

in deployment environments. Mil Med. 2006;171

(3):228-232.

9. Figley CR, Nash WP, eds. Combat Stress Injury:

Theory, Research, and Management. London:

Routledge Mental Health; Taylor and Francis Group;

2006.

10. Crandall CS, Jost PF, Broidy LM, Daday G, Sklar

DP. Previous emergency department use among

homicide victims and offenders: a case-control study.

Ann Emerg Med. 2004;44(6):646-655.

11. Grossman D. On Killing: The Psychological Cost of

Learning to Kill in War and Society. New York, NY:

Back Bay Books/Little Brown and Company; 1996.

12. Field Manual 27.10: The Law of Land Warfare.

Washington, DC: US Dept of the Army; 18 July

1956.

13. Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Rafael

Lozano R, eds. The World Report on Violence and

Health. Geneva, Switzerland: World Health

Organization; 2002. Available at: http://

www.who.int/violence_injury_prevention/violence/

world_report/en/index.html. Accessed April 6, 2007.

14. The American Heritage Medical Dictionary. Boston,

MA: Houghton Mifflin Company; 2007.

AUTHOR

LTC Marrs is a Psychiatric Mental Health Nurse

Practitioner at the US Army Institute of Surgical Research,

Fort Sam Houston, Texas.

US Army Institute of Surgical Research
50 www.cs.amedd.army.mil/references_publications.aspx

The Behavioral Health Proponency was created in

March 2007. It was modeled after the Proponency for

Preventive Medicine, to bring a host of different

disciplines and initiatives under one central

organization. There was also a recognition of the

importance of distinct behavioral health representation

at the Office of The Surgeon General, so that the staff

would be readily available within the Pentagon. The

author was appointed the first Director of the

Behavioral Health Proponency, having already been

the Psychiatry Consultant to The Surgeon General.

The Behavioral Health Proponency is nested within

Health Policy and Services. It subsumes the

Behavioral Health Division at the Army Medical

Command, including the new Suicide Prevention

Office. There is extensive coordination with the

Division of Neuropsychiatry at the Walter Reed Army

Institute of Research, the Soldier and Family Support

Branch of the Army Medical Department (AMEDD)

Center and School, the Center for Health Promotion

and Disease Prevention, and the Suicide Risk and

Surveillance Office at the Madigan Army Medical

Center.

As the organization and functions of the Proponency

have matured, responsibilities have been centered

around policy updates in behavioral health care and the

implementation of the recommendations of the

Department of Defense (DoD) Mental Health Task

Force.1 The office answers queries from senior

military leadership, DoD, Congress, and the media.

Staff members provide expertise to support the Army’s

Warrior Transition Office, Deputy Chief of Staff G-1,

and Installation Management Command, as well as the

Defense Center of Excellence and other related

agencies.

The Behavioral Health Proponency has improved

access to behavioral health care. Numerous initiatives

have focused on increasing the number of providers,

thus increasing the delivery of healthcare services to

Soldiers and Family members. The AMEDD has

steadily increased the number of providers. As a result

of a Memorandum of Agreement between DoD and

the Department of Health and Human Services,2the

US Public Health Service is recruiting providers to

work in DoD facilities. There are also major efforts to

enhance recruiting and retention of uniformed

providers, including a doubling of the size of the

psychology intern staff, a retention bonus for

psychologists, and an educational program for social

workers.

SUICIDE PREVENTION

Three critically important and highly publicized areas

have been the increase in suicides, administrative

separations, and the increase in the numbers of

diagnoses of posttraumatic stress disorder (PTSD) and

traumatic brain injury. The Proponency has been

working closely with the Army G-1, Chaplain Corps,

and Installation Command to improve surveillance,

decrease stigma, and improve educational materials,

with the goal of reducing suicidal behavior. The issues

have been elevated to the senior Army leadership, with

the formation of a General Officer Steering

Committee, cochaired by the G-1 and The Surgeon

General. A recent initiative is the establishment of an

epidemiological analysis cell at the Army Center for

Health Promotion and Disease Prevention.

ADMINISTRATIVE SEPARATIONS

Numerous media stories have alleged that the Army

has been wrongfully discharging Soldiers suffering

from PTSD, using a personality disorder diagnosis.

The Proponency conducted a major review of

discharge records from 2001 to 2006. Although the

reviewers did not find evidence of misdiagnosis, they

did find poor documentation in many cases. Two

relevant policies have been issued:

 The review of all personality disorder diagnoses

was mandated in August of 2007.

 Effective May 2008, medical clinics must ensure

that all Soldiers discharged under a wide variety of

administrative discharges are screened for

The Army Medical Department Behavioral

Health Proponency

COL Elspeth Ritchie, MC, USA
July – September 2008 51

traumatic stress disorder and traumatic brain

injury.

TRAINING RECOGNITION OF PTSD AND TBI

Numerous educational products have been developed

by the Walter Reed Army Institute of Research and the

AMEDD Center and School, under the Battlemind*

rubric. A chain-teaching†initiative on PTSD and

traumatic brain injury was launched in July 2007. It

focused on recognition of signs and symptoms, and

Soldier and leader actions. By the conclusion of the

program in the fall of 2007, over 800,000 Soldiers had

been trained. Other Battlemind products are being

implemented throughout the Soldier’s life and

deployment cycle.

THE FUTURE

In addition to rising reports of PTSD, there are

increasing reports of binge drinking among returning

veterans. The Proponency is working diligently with

the Army G-1, the responsible agency for the Army

Substance Abuse Program, to enhance and update

treatment for alcohol abuse and dependence.

Both intensive outpatient treatment and residential

treatment for substance abuse capacity must be

enhanced in our behavioral health system. The

TRICARE‡outpatient mental health/behavioral health

benefit has recently been enhanced.

The Chief of Staff of the Army requested a

Comprehensive Behavioral Health Strategy from the

Office of The Surgeon General. The Assistant Surgeon

General for Force Projection is leading the effort,

which has determined that comprehensive behavioral

health should be approached as a “whole-life fitness”

strategy, including the 6 categories of wellness (social,

spiritual, emotional, family/finance, career, and

physical). The strategy development group recognizes

the need to incorporate enhancement of current health

(Soldier and Family), prevention of future problems,

and treatment when problems arise. The group is

emphasizing use of standardized metrics to determine

success, standardized screening and treatment

modalities, and use of evidence-based clinical

guidelines. The Army’s Whole Life Fitness Strategy

will be formally released in the near future.

REFERENCES

1. Defense Health Board Task Force on Mental Health.

An Achievable Vision: Report of the Department of

Defense Task Force on Mental Health, June 2007.

Falls Church, VA: US Dept of Defense; 2007.

Available at: http://www.health.mil/dhb/mhtf/MHTFReport-Final.pdf. Accessed September 12, 2008.

2. Office of The Surgeon General. HHS, Department of

Defense agreement to increase mental health services

available to returning military service members. US

Dept of Health & Human Services; June 4, 2008.

News Release. Available at: http://www.surgeon

general.gov/news/pressreleases/20080604a.html.

Accessed September 12, 2008.

AUTHOR

COL Ritchie is Director of the Behavioral Health

Proponency in the Office of The Surgeon General,

Washington, DC.

*See related article on page 66.

†Chain-teach is a method of unit training in which designated unit members first receive the training, after which it is

their responsibility to train another level of personnel, who in turn will continue training others. The training continues

in a pyramid fashion until all personnel requiring such training have received it.

‡TRICARE is DoD’s healthcare program for members of the uniformed services, their families, and their survivors.

Information available at http://www.tricare.mil.
52 www.cs.amedd.army.mil/references_publications.aspx

Although there have been tremendous advances in

pharmacologic and psychotherapeutic treatments of

mental health and stress-related disorders, the military

primary care provider and allied healthcare

professional may represent the most potent treatment

for Soldiers and their Family members suffering from

these problems. Several factors enhance the power of

these providers to carry out psychotherapeutic

interventions. First, patients trust their primary care

and allied healthcare providers and believe them

capable of helping with emotional difficulties. Many

patients feel more comfortable talking with their

primary care provider, occupational therapist, or

physical therapist rather than an unfamiliar psychiatrist

or counselor. Some patients may perceive a referral to

a mental health specialist as a rejection by one of those

providers, and might fear the stigma associated with

seeing this specialist. As a consequence, many patients

may fail to follow-through with mental health

referrals. Overall, only about half of the outpatients

referred for a mental health consultation complete the

process.1

A second factor that puts the military healthcare

provider in an advantageous position to provide

psychotherapeutic interventions is that Soldiers and

their Family members typically come to them with

early signs of emotional distress. In fact, several

studies1conducted in the general population have

concluded that it is the emotional distress that activates

the visit to the primary care clinic in up to 60% of

cases, even when a medical illness is present. Military

healthcare providers are in the unique position to

intervene early in the course of mental health disorders

to prevent more significant morbidity. The provider

may actually carry out primary or secondary

prevention in some adjustments experienced by our

Warriors and their Families, such as a Soldier

returning to the home environment following

deployment. For example, educating patients in

advance about the emotional aspects of this

transition—“this often occurs when a spouse returns

home after a deployment”—may help the patient cope

with the stressor and prevent the onset of more serious

or pathological reactions. Moreover, because many

patients focus their distress on their health, such

providers are in a favorable position to address those

concerns.

The third and most significant factor is that the

primary care and allied healthcare provider has the

opportunity to maintain an ongoing relationship with

his or her patients. Continuity of care allows

familiarity, trust, and confidence to exist, which can

serve as a foundation for brief interventions as well as

support and encouragement for patients who require

referrals to mental health professionals. It allows our

Soldiers and their Family members to receive more

integrated care that incorporates the biopsychosocial

approach that is so essential to maintaining troop

readiness and peak Family functioning. Seeing patients

for brief visits may enable the healthcare professional

to deal with one aspect of the patient’s difficulty and

not overload the patient with too many psychological

issues. Similarly, the healthcare professional’s goal is

to achieve a modest change in the patient’s emotional

state. There always exists the possibility that the acuity

and complexity presented by a Soldier or Family

member will exceed the time limitations and expertise

of the primary care and allied healthcare provider. It is

these very instances in which a provider may deftly

use their relationship and communication skills to

achieve a successful transition to a mental health

professional, and hence, achieve a more auspicious

outcome for our Soldiers and their Families.

The objective of the behavioral health courses

currently offered at the Army Medical Department

Why Teach Mental Health Topics to

Physician Assistants and Other Allied

Healthcare Professionals?

Karen C. Shea, LCSW, DCSW

Maryann Pechacek, PsyD
July – September 2008 53

(AMEDD) Center and School is to equip our military

primary care and allied healthcare providers with the

knowledge and skills required to recognize and

manage mental health disorders. One of the chief

challenges for healthcare in our current operating

environment is the prevention of the underdiagnosis of

mental and stress-related disorders. Our exceptionally

well-trained and committed healthcare providers

require training in the selected skills that enable them

to collect information from patients for the purposes of

screening, diagnosis, further assessment, and outcomes

monitoring. These skills may also help to expedite the

provision of information to patients about their

disorders and management thereof. They often prove

invaluable in decreasing patients’ resistance to

accepting a mental health diagnosis and treatment by

enabling the patient to play a more active role in their

care. The knowledge and skills may also be used to

increase recognition of mental health and stress-related

disorders, improve documentation, and help organize

care so that nothing is missed or forgotten.

Special Subjects, a small but essential division within

the Psychological Health section of the Soldier and

Family Support Branch, AMEDD Center and School

at Fort Sam Houston, is currently charged with the

responsibility to teach the information and skills

necessary for the effective management of mental

health disorders within the military healthcare setting.

The mission of the Special Subjects division is to

impart knowledge in an academic setting about mental

health topics that will provide our providers with

readily available tools that are not a part of the usual

medical practice setting. These tools can be used to

overcome the barriers to mental healthcare with a

modicum of effort and expense, to help increase both

patient and provider satisfaction by improving the care

provided, and, most importantly, to improve patient

outcomes.

REFERENCE

1. Katzelnik DJ, Simon GE, Pearson SD, et al.

Randomized trial of a depression management

program in high utilizers of medical care. Arch Fam

Med. 2000;9:345-351.

AUTHORS

Ms Shea and Dr Pechacek are Instructor/Writers in the

Special Subjects section of the Soldier and Family

Support Branch, Department of Preventive Health

Services, AMEDD Center and School, Fort Sam

Houston, Texas.

“Two-Thousand Yard Stare”

A painting by Tom Lea, Life Magazine

combat artist and correspondent, from

the Marine Corps campaign for the

island of Peleliu, September 1944. This

famous painting is known for its

graphical depiction of the psychological

stress inflicted by the horrors of

extended, total combat.

Image courtesy of the US Army Center

for Military History, Washington, DC.
54 www.cs.amedd.army.mil/references_publications.aspx

Department of Defense Response to

Posttraumatic Stress Disorder

Gerard A. Grace, PhD

A review of current research literature clearly points to

the fact that the continued engagement for the US and

Allied Forces in Operation Iraqi Freedom (OIF) and

Operation Enduring Freedom (OEF) are presenting

significant challenges for the clinical and medical

services within the military system. These challenges

are making salient some systemic deficiencies in the

conceptualization and the delivery of appropriate

healthcare for the physically, psychologically, or

spiritually traumatized Warrior and their significant

loved ones. Conversely, this crisis has pushed the

military system towards a new and more evolved

homeostasis as it stretches to adequately meet the

holistic healthcare needs of the Warrior in theatre and

the returning Warrior. It is out of this stretching that a

posttraumatic stress disorder (PTSD) training program

for mental health providers has evolved. This training

program is now instituted as an integral part of the

Psychological Health Section of the Soldier and

Family Support Branch, Department of Preventive

Health Services of the Army Medical Department

Center and School. This article revisits the defining

parameters of PTSD, then summarizes the state of

affairs on the ground pertaining to PTSD and the

mental health of Soldiers as espoused by the Mental

Health Advisory Team IV report.1Finally, this article

speaks to the efficacy of empirically validated

treatment for PTSD, and how, based on this research,

the PTSD training program has been constituted. The

article concludes with a comment on some research in

progress that contains the seeds of much hope for

future providers, instructors, and military men and

women committed to assail the PTSD dragon.

According to the Diagnostic and Statistical Manual of

Mental Disorders,

2

PTSD is defined as:

A. Exposure to a traumatic event where,

 Person experienced, witnessed, or was

confronted with an event or events that

involved actual or threatened death or

serious injury.

 Person’s response involves intense fear,

helplessness, or horror.

B. Traumatic event is persistently reexperienced

through one or more of the following: recurrent

intrusive distressing recollections, recurring

distressing dreams, flashbacks, psychological

distress in response to reminders, cued

psychological reactivity.

C. Persistent avoidance of stimuli associated with

the trauma and numbing of general

responsiveness.

D. Persistent symptoms of increased arousal,

irritability, difficulty falling asleep or staying

asleep, difficulty concentrating, hyper

vigilance, exaggerated startle response.

E. Duration of disturbance is more than one month

after the trauma:

 Acute PTSD: 1 through 3 months

 Chronic PTSD: more than 3 months

 Delayed onset: more than 6 Months

MENTAL HEALTH ADVISORY TEAM IV FINDINGS

In 2003, the DoD instituted a working advisory team

called The Mental Health Advisory Team (MHAT).

The purpose of MHAT is to assess the mental health

and well-being of the deployed forces serving in Iraq,

and to assess the efficacy of the delivery of behavioral

healthcare during OIF. To date there has been a series

of 4 surveys conducted with the results published. The

last published results were in 2007 in the MHAT-IV

report.1* The population surveyed consisted of 1,320

Soldiers and 447 Marines. The findings of MHAT-IV

concur with the intuitive sense of concerned providers.

The 2007 report confirms a 50% increase over the last

year of service men and women from OIF and OEF

carrying a diagnosis of PTSD. This brings the total of

*Since this article was written, the MHAT V report for data

collected during 2007 was released by the Department of

the Army. The Editors
July – September 2008 55

Warriors afflicted with PTSD to 40,000 in the last 5

years. The Army and Marine Corps carry the majority

of the burden of this diagnosis. The following is a

synopsis of the MHAT IV findings:

 Not all Soldiers and Marines deployed to Iraq or

Afghanistan are at equal risk for screening

positive for mental health problems. The level of

combat is in direct proportion to mental health

status.

 For Soldiers, multiple deployments, deployment

length of time, and Family separation were

predictive of higher incidents of mental health

issues.

 Good noncommissioned officer leadership is key

to sustaining Soldier and Marine mental health

and well-being.

 Behavioral health providers require additional

combat and operational stress training prior to

deployment.

 Over three fourths of Soldiers reported being in

situations where they could be injured or killed

(first criteria for PTSD diagnosis).

 Seventeen percent of Soldiers screened positive

for Acute stress in-theatre.

The Walter Reed Army Institute of Research Land

Combat Study indicates that these rates are likely to

increase and evolve into Chronic PTSD 6 months and

12 months postdeployment.3

This report may not present any counterintuitive

information. It does, however, provide great clarity in

highlighting the immediate needs of the Soldier and

fellow service men and women. These particular and

salient needs in turn speak loudly to the military

healthcare delivery system. The needs of the Soldier in

relation to Acute stress in-theatre and PTSD

postdeployment have highlighted a paucity of mental

health resources to meet this burgeoning need. There

are 2 aspects to this impoverished resource: First,

having sufficient mental health professionals available

to allow the returning Warrior efficient access to care.

Second, having sufficient mental health providers who

are trained in the most effective treatment modalities

for PTSD continues to be an issue.

In response to the MHAT reports, the Department of

Defense (DoD) directed that all Army social workers,

nurse case managers, psychiatric case managers, and

nurse practitioners must be trained in evidence-based

treatment modalities for PTSD.

EMPIRICAL FINDINGS ON EFFICACY OF TREATMENT FOR

POSTTRAUMATIC STRESS DISORDER

It is the founding purpose of the PTSD training

program to ensure that the best training in all

empirically verified treatments for PTSD is made

available for all targeted providers. Research on

different treatment modalities is sufficient to conclude

that not all modalities of treatment in the body of

psychological literature are equally effective or even

appropriate when it comes to the complexity of

dynamics induced by combat trauma. The greatest

body of research has been conducted on Prolonged

Exposure Therapy. On comparative studies across the

different modalities of treatment for PTSD, Prolonged

Exposure seems to have an edge in terms of long-term

positive outcomes.4 Cognitive Processing Therapy

(CPT) has very similar outcomes to Prolonged

Exposure (PE), with the conduct of extensive

comparative studies by the University of Pennsylvania.

Eye Movement Desensitization Reprocessing (EMDR)

has much anecdotal appraisal as an effective treatment

for PTSD. While lacking extensive research, EMDR

has a number of scientific studies published, verifying

its efficacy in treating PTSD. EMDR is especially

appealing as a modality as it requires a minimal

amount of in-between session or preparation work

from the patient, whereas CPT and PE involve a strong

commitment to in-between session work. Therapeutic

literature is permeated with this problem of motivating

clients to take responsibility for in-between session

work and is associated with a high percentage of client

attrition. From this perspective, EMDR is efficient,

effective, and thus becoming a prominent modality of

treatment. All 3 modalities target the information

processing mechanism of traumatic memories.

The PTSD training program has instituted

comprehensive training in all 3 modalities of

treatment. The seminal authors of the theories

Prolonged Exposure Therapy and Eye Movement

Desensitizing and Reprocessing are integrally part of

the training, as instructors and supervisors. The

number of providers trained thus far in each modality:

Eye Movement Desensitizing and Reprocessing: 68

Prolonged Exposure Therapy: 127

Cognitive Processing Therapy: 81
56 www.cs.amedd.army.mil/references_publications.aspx

Department of Defense Response to Posttraumatic Stress Disorder

The far-reaching vision of this effort, once there is a

significant amount of providers trained, is the

designation of a core group that would train to become

trainers in each modality of treatment. This would

decrease DoD’s dependence on outsourcing for this

training and significantly reduce the expense

associated with this effort.

RESEARCH AND DEVELOPMENT

The research challenges associated with mental health

and the military system are daunting. The paucity of

quantitative data around Acute Stress Disorder intheatre, and its management, or treatment, and the

effective treatment of PTSD specific to combat trauma

is screaming at an already overstretched system to

conduct more research. The majority of research

conducted on PTSD has been normalized on civilian

populations in response to single traumatic events,

mostly involving rape and molestation. This research

may not always be transferable to the military

population where combat is ongoing and exposure to

repetitive trauma is inevitable. It is the intention of the

PTSD training program to develop a research tool that

will produce quantitative data to track the efficacy of

each modality of treatment for PTSD as it relates

specifically to combat trauma, and thus yield

significant information that will advance the

knowledge base in this growing area of need.

POSTTRAUMATIC STRESS DISORDER AND BEYOND

Within the body of psychological literature and

military training there is a perceptible paradigm shift

away from pathological categorizations and more

towards a resiliency and strengths-based narrative.

This reflects a universal dynamic always recognized

by ancient wisdom traditions. The universal dynamic

well documented in psychospiritual literature is that

very often psychological, spiritual, and human growth

is ushered in on the threshold of some major life

trauma or life-threatening event. Herein lies the seeds

of hope for the returning Warrior with PTSD. The

challenge is for healthcare providers to be excellently

equipped, so they can help the Warrior to mine the

gold from the sediment of his or her suffering. It is this

department’s goal to create a training context where

this can become a real possibility.

CONCLUSION

War in Iraq and Afghanistan continues to be personal,

leaving an existential vacuum in the life of the combat

trauma survivor. The returning Warrior with PTSD is

not an isolated cell, mind, or body. She/he is part of a

wider network of relationships and, as the Warrior

attempts to settle back into a normal familial context,

that whole network of relationships is affected by the

symptomatic cognitions and behaviors associated with

PTSD. As never before, the DoD has looked this

problem straight in the eye and responded with a huge

commitment of resources to provide whatever it takes

to lessen or eradicate unnecessary suffering in the lives

of the Warrior and their loved ones. As a department,

it is a privilege to be part of a solution to what has

been a very painful problem in the lives of generations

of military service men and women.

REFERENCES

1. Mental Health Advisory Team (MHAT) IV Operation

Iraqi Freedom 05-07 Final Report. Washington, DC:

Office of The Surgeon General, US Dept of the

Army; November 17, 2006.

2. Diagnostic and Statistical Manual of Mental

Disorders Fourth Edition (Text Revision). Arlington,

VA: American Psychiatric Association; 2000.

3. Hoge CW, Castro CA, Eaton KM. Impact of Combat

Duty in Iraq and Afghanistan on Family Functioning:

Findings from the Walter Reed Army Institute of

Research Land Combat Study, 2006. In: Human

Dimensions in Military Operations – Military

Leaders’ Strategies for Addressing Stress and

Psychological Support. Meeting Proceedings RTOMP-HFM-134, Paper 5. Neuilly-sur-Seine, France:5-

1–5-6.

4. Van Etten ML, Taylor S. Comparative efficacy of

treatments of posttraumatic stress disorder: an

empirical review. J Am Med Assn. 1998;268:633-638.

AUTHOR

Dr Grace is PTSD Trainer and Instructor for the

Psychological Health Division of the Soldier and

Family Support Branch, Dept of Preventive Health

Services, Army Medical Dept Center and School, Fort

Sam Houston, Texas. He is responsible for Army wide

training of licensed practitioners who provide direct

care to Soldiers carrying a diagnosis of PTSD.
July – September 2008 57

Army Provider Resiliency Training:

Healing the Wounds “On the Inside”

Richard R. Boone, PhD

Cheryl Camarillo, LCSW

Lisa Landry, PhD

SSG Jerome DeLucia, USA

From Iraq’s “IED Alley,” to Walter Reed’s Intensive

Care Center; from a Combat Operational Stress

Control clinic in Afghanistan to Brooke Army Medical

Center’s Burn Unit—Army medical and behavioral

health personnel are on the front lines of traumafighting and trauma exposure.

Famed psychoanalyst and Holocaust survivor Victor

Frankl once remarked, “That which is to give light

must endure burning.”1Perhaps the key word in that

wise remark is “endure.” If we, as Army healthcare

providers, must experience emotional and

psychological hardships to bring care to others, how

are we to “endure the burn” that is a necessary

component of “giving light?” To borrow from a recent

Army television advertisement: the Army has long

expected much of its medical and behavioral health

providers, and, at last, this class of Soldier can expect

more from the Army. What follows is a brief account

of how that “more” has become available and what

that more actually is.

The story of the Army Provider Resiliency Training

Program (PRT) is the story of how we came to

recognize the need to provide care for those whose

jobs and professions are to care for others. It is a story

with many contributors, and it is a story that has

evolved over many years. Finally, it is a story of a

community of caregivers coming to terms with the

unpleasant recognition that in giving light and life to

others, they may in the process, be burned by the

darkness of profound illness and catastrophic injury.

Herein lies a paradox: that the most vital meanings

offered by life are often found in the midst of

suffering, and yet, if suffering is to strengthen and

elevate, it must be “redeemed” by people who are

powerful agents in their own lives. The “redeemer”

must be an agent with an attitude: an attitude of

determination, an attitude of courage; an attitude of

humor; and an attitude that has as its bedrock the belief

that we will never, never give up—no matter the cost.

WOUNDS ON THE INSIDE

A few years ago the television network Home Box

Office presented the powerful documentary, “Baghdad

ER.” This critically acclaimed show gave viewers a

realistic, often harrowing, glimpse into what it can

mean to be an Army healthcare provider. As COL

Casper P. Jones III, the Commander of the show’s

primary focal point, the 86th Combat Support

Hospital, remarked at the time,

You can learn about war by walking through this

facility...the horrors of what man can do to man are

visualized right here. But we do our best, our level best,

to make sure our people survive and make it back to

their homes.2

“WE DO OUR BEST...”

That phrase captures well the informal creed of the

Army healthcare professional. It states clearly our

professional intent. Moreover, it suggests indirectly

that the circumstances wherein we carry out our intent

are often less than congenial. In fact, in our theaters of

war those circumstances can be nearly as dangerous as

the environments in which our patients receive their

wounds and injuries.

Being in close proximity to the trauma of our patients

(both geographically and emotionally), it should come

as no surprise that Army healthcare providers can

themselves experience some aspects of traumatization.

Consider the words of SPC Saidet Lanier, an 86th

Combat Support Hospital operating room assistant:

This is hardcore, raw, uncut trauma, day after day,

every day. Even if you’re lucky enough not to go home

with war wounds on the outside, if you’re not equipped

with coping skills, you’ll definitely have them on the

inside.”2
58 www.cs.amedd.army.mil/references_publications.aspx

Department of Defense Response to Posttraumatic Stress Disorder

ARMY PROVIDER RESILIENCY TRAINING:

THE BEGINNINGS

Not long after the tragic events of September 11, 2001,

and the initiation of the Global War on Terror

(GWOT), members of the Soldier and Family Support

Branch (SFSB) of the Army Medical Department

Center & School (AMEDDC&S) began to consider

issues related to the effects of the conflict on

healthcare providers. They realized then that the

GWOT might well be a difficult and protracted effort.

At that time, the concept of “care for the caregivers”

had already received attention in such areas as geriatric

psychiatry and behavioral medicine as mental health

professionals had begun to observe and respond to the

deleterious effects of prolonged care-giving on Family

members of the chronically ill, particularly those with

dementia.

Initially, the Branch’s interest in compassion fatigue,

secondary trauma, and caregiver burnout resulted in

briefings provided for a few courses at the

AMEDDC&S. Soon, however, decisions were made to

teach PRT principles in all AMEDDC&S courses, to

create a distance learning PRT video, and to create

Mobile Training Teams (MTT) to take PRT products

on the road.

As these products and services evolved, two subtle but

highly meaningful shifts began to take place in the

very nature of Army PRT. Firstly, as often happens

with Army initiatives, the SFSB began to “militarize”

the terminology. Compassion fatigue became provider

fatigue and caregiver satisfaction became provider

resiliency. Part of this change was driven by our desire

to make the terms more palatable to military

audiences. However, the other driving force, an

extremely welcome one, was the movement within

behavioral health away from a focus on

psychopathology to one of positive, strengths-building

psychology. Second, and perhaps even more

significant, it was agreed that the major psychological

assessment device for the measurement of these

variables, the Professional Quality of Life Test

(ProQOL*) would be modified to specifically and

explicitly address the unique stressors and operational

circumstances faced by military healthcare providers, a

process that is currently underway.

At the same time, primarily as a result of the feedback

to our MTT missions regarding the extent and severity

of provider fatigue and secondary trauma, the Branch

decided to develop a program that would make PRT

available to ALL members of the AMEDD community,

and to identify and teach special PRT trainers and

supervisors who would be embedded within most

military medical treatment facilities and regional

training commands, and whose job it would be to

provide ongoing PRT education, assessment, and

interventional action to medical treatment facility

providers.

ARMY PROVIDER RESILIENCY TRAINING:

THE “GIFT”

In December 2007, the SFSB invited Dr Charles

Figley†(founder of the field of traumatology), Dr Beth

Stamm‡(creator of the ProQOL), and Dr Al Siebert§

(foremost among resiliency experts) to the

AMEDDC&S to preview and comment on the recently

developed PRT products. This meeting coincided with

discussions between the SFSB and the Army Medical

Command’s (MEDCOM) Behavioral Health

Department regarding the development and execution

of a proposed AMEDD-wide PRT initiative. Out of

these discussions, and with the support of The Acting

Surgeon General, an Army Medical Action Plan task

was established which required assessment of provider

fatigue and burnout, and the implementation of a PRT

program that would “alleviate or decrease” provider

fatigue and burnout.

After numerous SFSB and MEDCOM meetings and

briefings, the program was presented to and approved

by The Surgeon General on June 3, 2008. Less than

one month later, on July 1, 2008, the Army PRT

initiative was launched.

At present, healthcare providers from across the Army

Medical Department are completing Phase I of the 3

phase PRT training syllabus. The first phase involves *A screening instrument which may be used to measure the

professional quality of life among medical and mental

health professionals in an organization. The ProQOL

measures one’s potential for compassion satisfaction (ie,

the pleasure one derives from doing a job well), burnout,

and compassion fatigue/secondary trauma (ie, symptoms

developing from secondary exposure to the traumatic

events of others).

†The Figley Institute, Tallahassee, FL.

http://www.figleyinstitute.com/indexMain.html

‡Institute of Rural Health, Idaho State University,

Pocatello, ID. http://www.isu.edu/irh/index.shtml

§The Resiliency Center, Portland, OR.

http://www.resiliencycenter.com/
July – September 2008 59

THE ARMY MEDICAL DEPARTMENT JOURNAL

administration of the ProQOL for which immediate

feedback is given to the provider regarding his current

levels of compassion satisfaction (the pleasure one has

from doing one’s work well), compassion fatigue

(work-related stress or trauma), and burnout (a feeling

of hopelessness in dealing with one’s occupational

circumstances). This phase also has a brief, but

extremely important, PRT video which sets the stage

for one’s ongoing self-care response to the inevitable

challenges to well-being brought on by difficult work.

Phase II involves additional, detailed education into

the markers of provider fatigue and the pathways to

resiliency. During Phase II the healthcare provider

discusses with his or her trainer the personal meaning

of the ProQOL results and maps out the all-important

self-care plan. This plan will be the foundation of the

provider’s commitment to developing a positive,

resilient attitude towards work, home, and indeed all of

life.

The final phase, a birth-month activity, involves

ProQOL reassessment and, if necessary, a fine-tuning

or even redirection of one’s self-care plan. Meanwhile,

at any time between the program’s phases, PRT

trainers will be readily available to assist individuals

with questions or concerns that relate to provider

fatigue, burnout, or the self-care plan.

Of course, as with any mandatory Army training, there

is going to be some push-back, some resistance to yet

another training mission to accomplish when there is

so much work to be done. Also, it has to be

acknowledged that making Army PRT mandatory runs

counter to the very nature of psychological help, an

enterprise that tends to believe that people have to

want help and ask for it before it is effective.

However, it was decided that the problem was

sufficiently significant and the program sufficiently

useful that it would, in the long run, be something that

we would be glad we were required to do. It is our

hope that this will be true, and in keeping with the

interactive nature of the program, its users will have

several opportunities to contribute their opinions as to

the quality and utility of the program.

In the meantime, we are convinced that Army PRT,

both the program and the trainers, are best understood

as a gift; a gift from your commander to you. It is a

gift of time and opportunity to reflect on yourself and

what you can do to improve not only aspects of your

job and your reactions to it, but also your life in

general.

CONCLUSION

The way ahead, a way toward which the PRT Section

of the SFSB is already engaged, is the way from

individual self-care to organizational resiliency. We

realize that the resiliency-building labors of each

healthcare provider, as necessary and significant as

they may be, will not bear full fruit if the organization

for which that person works is insensible and

insensitive to the issues of provider fatigue and

burnout. We continue to work closely with

commanders and other leaders in a mutual effort to

find ways of improving the lives of providers

throughout the Army Medical Department.

Meanwhile, trainers are being trained, and providers

are being assessed and educated. In these ways Army

PRT is beginning to make available the “coping skills”

about which SPC Lanier spoke. In so doing, we hope

to see a reduction in the extent that our brave and

capable healthcare-givers are negatively affected by

their wounds “...on the inside.”

REFERENCES

1. Frankl VE. Man's Search for Meaning: An

Introduction to Logotherapy. New York, NY: Pocket

Books, Simon & Schuster; 1963:129.

2. “Baghdad ER” [transcript]. Home Box Office. May

21, 2006.

AUTHORS

Dr Boone is a staff psychologist and instructor, Soldier

and Family Support Branch, Dept of Preventive Health

Services, AMEDDC&S, Fort Sam Houston, Texas.

Ms Camarillo is a PRT Instructor, Writer, and Subject

Matter Expert in the Soldier and Family Support

Branch, Dept of Preventive Health Services,

AMEDDC&S, Fort Sam Houston, Texas.

Dr Landry is a PRT Instructor and Writer in the Soldier

and Family Support Branch, Dept of Preventive Health

Services, AMEDDC&S, Fort Sam Houston, Texas.

SSG DeLucia is a PRT Instructor/Administrator in the

Soldier and Family Support Branch, Dept of Preventive

Health Services, AMEDDC&S, Fort Sam Houston,

Texas.
60 www.cs.amedd.army.mil/references_publications.aspx

INTRODUCTION

On September 28, 1971, Title V (known as the Hughes

amendment) of Public Law 92-129 1 was signed into

effect, mandating that the Armed Forces provide

substance abuse identification, treatment and

rehabilitation to service members. Since that time, the

initial concept for alcohol and drug treatment has

experienced many changes and challenges. The Army

Substance Abuse Program is governed by Army

Regulation 600-85,

2 which describes the roles and

responsibilities of the command, the prevention and

education aspects, and the treatment levels and

programs. Last revised in October 2001, Army

Regulation 600-85 does not address some of the

current challenges that Soldiers and commanders are

facing in Iraq and Afghanistan, nor those arising after

return to their home duty stations. The Mental Health

Advisory Team V (MHAT V) report3recognized that

substance abuse is a risk factor for both deployed and

postdeployment Soldiers who are experiencing high

stress levels, symptoms of posttraumatic stress

disorder (PTSD), depression, or other difficulties. A

clear need for substance abuse intervention and

treatment has been identified. This article examines

current substance use in theater, discusses how this has

developed and describes how the Army Medical

Department Center and School’s Alcohol and Drug

Training Section contributes to addressing the needs of

Soldiers.

CURRENT SUBSTANCE USE AND TREATMENT IN THEATER

From the first day of Operation Iraqi Freedom, March

19, 2003, the US Army’s 5th Corps prohibited alcohol

possession in the Iraq theater of war with General

Order Number 1. Unfortunately, articles in various

publications and media make it apparent that, despite

that mandate, alcohol and other substances are

available and being used by Soldiers in theater to

manage stress and psychological symptoms. An article

in The Army Times4in March 2008 described inhalant

use by Soldiers, sometimes resulting in death. A week

later, another article in the Stars & Stripes5described

alcohol as a “weapon of choice” in sexual assaults. An

internet search on substance use in Iraq produces

numerous articles describing the availability and use of

alcohol and other drugs by Soldiers during

deployment. For example, publications as diverse as

the International Herald Tribune6in 2007 and The

Arkansas Democrat-Gazette7in 2005 published

articles addressing problems with alcohol among US

military personnel in Iraq.

Such news and magazine articles make several things

clear. First, alcohol and other substances are now, and

have been, available. Second, Soldiers are using

substances for many different reasons. Third, the

major deterrent efforts used by commanders are

unannounced inspections and legal or administrative

actions—Soldiers found to possess and use alcohol or

drugs subject to court martial and confinement. There

is no mention in any of the articles we reviewed of any

type of therapeutic intervention, counseling, or

treatment being provided for Soldiers who are using

alcohol or drugs. It appears that the current approach is

to order Soldiers not to use, to punish them heavily

when they do, and not provide any type of mental

health intervention or support when drugs or alcohol

are involved.

There has long been conflict in the perception of

alcohol and drug use as a legal and moral issue versus

a behavioral or disease issue. There are multiple

reasons that a person might use substances. Some of

the reasons supported by the research are:

1. Self medication: the reduction of hyperarousal

resulting from consistently high levels of stress.

2. Shared vulnerability: genetic vulnerability to

substance abuse and other disorders which

increase the likelihood of substance use

following a traumatic event.

Down Range and Beyond: Preparing

Providers to Support Warriors in Resolving

Problematic Substance Use

Joseph E. Hallam, MS
July – September 2008 61

3. High risk: if high risk for developing a substance

abuse problem exists before a traumatic event,

the risk becomes even greater after such an

experience.

4. Susceptibility: when substances are used as a

coping tool in response to symptoms, the

symptoms are actually increased.

When any or a combination of these factors come into

play, they tend to override any considerations of

potential consequences such as inspections or legal

actions. Prohibition does appear to work on a shortterm basis. However due to the availability of

substances and the stress of the high tempo of

operations in the deployment environment, long-term

prohibition without therapeutic intervention represents

an unrealistic expectation. A deterrence strategy

limited to prohibition and punishment is therefore

bound to fail.

The MHAT V report3identifies several trends that

further indicate a need for drug and alcohol prevention

and counseling services during extended operations.

The assessment reveals an overall rate of alcohol use

during deployment of 8%.3(p30) During their second

deployment, Soldiers report twice the rate of alcohol

use, while noncommissioned officers report a 37%

increase.3(p47) The use of inhalants was reported at

3.8% during deployment.3(p30) These rates of substance

use support the conclusion that the number and length

of deployments are contributing factors to an increase

in substance use.

CURRENT PROBLEMS AND FORWARD SOLUTIONS

There are 2 obstacles to providing better support for

Soldiers who are at-risk for using substances. The first

is the lack of a policy for providing substance abuse

treatment in theatre. The second is too few trained care

providers to counsel at-risk Soldiers. Alcohol and drug

use is a known risk factor for Soldiers suffering from

any psychological and/or emotional difficulty. Policy

recommendations and development are beyond the

scope of this article. The MHAT V report addresses

the lack of care providers by recommending that, prior

to deployment, Soldiers with military occupational

specialties (MOS) 68X* and 68W†receive training in

substance abuse and other types of counseling.3(p100)

The concern about counselor training is also addressed

in the OTSG/MEDCOM Policy Memo 07-026 dated

17 July 2007.8 This memo focuses on the need for

Mental Health Specialists to have work assignments

that enable them to develop sufficient counseling skills

to be proficient when they are deployed. The

counseling training offered by the Alcohol and Drug

Training Section (ADTS) is another resource to help

Soldiers with either MOS 68X or MOS 68W gain

proficiency in both individual and group counseling

with little supervision.

Traditionally, the ADTS Individual and Group

Counseling courses have provided training to MOS

68X Soldiers, civilian counselors, and other Soldiers/

civilians with a background in providing healthcare.

This includes medics and other Soldiers assigned to

the Army Substance Abuse Program. This training,

along with supervised work experience, provides a

base of civilian and military counselors that have the

necessary skills to effectively provide counseling to

Soldiers. These basic counseling skills can be applied

to provide counseling to Soldiers who are experiencing

stress during deployment, or who may be drinking or

using drugs to relieve PTSD or other symptoms of

psychological distress. The AMEDD’s goal of greater

availability of counseling services in-theater is an

effort aimed at directly decreasing the rates of alcohol

and drug use during deployments.

ALCOHOL AND DRUG TRAINING COURSES

The ADTS at the Army Medical Department Center

and School is comprised of skilled staff members who

are committed to presenting relevant, quality training

to substance abuse treatment providers. Based on the

concept of life-long learning, the courses provided by

the ADTS are essential for the Mental Health

Specialist and the Healthcare Specialist. The courses

are also a significant enhancement for credentialed

providers at all levels of experience since students

completing the courses receive continuing education

units recognized by all major certification and

licensing boards. ADTS courses currently offered:

The Individual Counseling Course (5H-F4/302-F4): This

is a fast paced course that incorporates theory based

learning and hands-on learning while training to

improve the participant’s counseling skills. This

course provides a small group experience where

students improve their skills through practice utilizing

role play with a simulated patient.

The Group Counseling Course (5H-F5/302-F5): The

most talked about of all the training provided by

*Mental Health Specialist

†Healthcare Specialist
62 www.cs.amedd.army.mil/references_publications.aspx

Down Range and Beyond:

Preparing Providers to Support Warriors in Resolving Problematic Substance Use

ADTS, students can immediately use the skills they

learn upon returning to their jobs. Throughout the first

week, students get information and one-on-one time

with an instructor to create a group design that will

work in a deployed environment or at their home

stations. The second week of the course provides a

personal group experience for the participants. The

experience is not a therapy group, however,

participants do often report a therapeutic effect.

Participants are given the opportunity for a glimpse

into the power of group, both as a member and a

leader. At the most recent group course, the excitement

and reinvigoration of a civilian provider was evident as

she indicated that she had been “stuck” with how to

move forward with the PTSD group she was currently

leading. There is no doubt she will implement all that

she has learned to assist Warriors with their healing.

The Advanced Counseling Course (5H-F10/302/F10):

The Advanced Counseling Course is a one-week

residential course designed to provide military and

civilian mental health technicians and other

professionals with advanced training in substance

abuse treatment. Special emphasis is given to topics

frequently needed for license and certification renewal,

including ethics, cultural diversity, family violence and

HIV/AIDS. Experts from the field are invited as funds

permit.

The Family Counseling Course (5H-F7/302-F7): The

ADTS staff members are enthusiastic about the

reinstatement of the Family Counseling Course. Due to

lack of funding in the past, the April 2008 Family

Course was the first to be conducted in several years.

This year’s Family Course provided essential tools to

work with Warriors and their families who are under

pressure due to PTSD and substance use. The students’

response to the training was overwhelmingly

favorable. Because of the numerous requests from the

providers in the field, the ADTS staff is advocating for

this course to be presented annually, rather than the

current biennial schedule.

The Management Counseling Course (5H-F6): The

Army Substance Abuse Program (ASAP) Management

Course is limited to ASAP clinical directors or clinical

supervisors who have more than 50% of their duties

performing as a clinical director. The course is a oneweek residential course designed to provide clinical

directors with current treatment strategies, treatment

developments, research data in the substance abuse

arena, Joint Commission on Accreditation of

Healthcare Organizations information, and updates

from the Army Medical Command and other

appropriate sources.

The Clinical Consultant Course (5H-F9): This course is

designed primarily for physicians newly assigned as

clinical consultants to the ASAP. The practical

realities of the clinical consultant position, as well as

technical tips and traps, are discussed at length.

Experienced consultants also benefit because the

course content varies from year to year.

REFERENCES

1. Pub L No. 92-129, 85 Stat 361.

2. Army Regulation 600-85: Army Substance Abuse

Program. Washington, DC: US Dept of the Army;

March 24, 2006.

3. Mental Health Advisory Team (MHAT) V: Operation

Iraqi Freedom 06-08, Iraq; Operation Enduring

Freedom 8, Afghanistan. Washington, DC: Office of

The Surgeon General, US Dept of the Army;

February 14, 2008.

4. O'Connor S. Death by dust-off: huffing, the secret

war-zone epidemic. Army Times. March 10, 2008:14.

5. Burgess L. Report: alcohol affects assault rate in Army.

Stars & Stripes, Mideast Edition. March 18, 2008.

Available at: http://www.stripes.com/article.asp?

section=104&article=60775&archive=true.

6. Von Zielbauer P. In Iraq, American military finds it

has an alcohol problem. International Herald

Tribune. March 12, 2007. Available at: http://iht.com/

articles/2007/03/12/news/alcohol.php.

7. Schlesing A. Drugs, booze easy for GIs to get in Iraq.

The Arkansas Democrat-Gazette. January 3, 2005.

Available at: http://www.november.org/stayinfo/

breaking3/GIDrug.html.

8. OTSG/MEDCOM Policy Memo 07-26. Subject:

Military Occupational Specialty (MOS) 68X, Mental

Health Specialist Utilization. Fort Sam Houston,

Texas: Headquarters, US Army Medical Command;

July 17, 2008.

AUTHOR

Mr Hallam is Course Manager, Alcohol and Drug Training Section, Soldier and Family Support Branch, Department

of Preventive Health Services, AMEDD Center & School, Fort Sam Houston, Texas.
July – September 2008 63

The Family Advocacy Staff Training (FAST) Course

was first developed in the mid 1980s by social work

instructors and writers at the Behavioral Science

Division of the Academy of Health Sciences, Army

Medical Department Center and School

(AMEDDC&S), Fort Sam Houston, Texas. The course

was created in response to a request by the Department

of the Army for orientation training for new Family

Advocacy Program (FAP) staff in the family advocacy

mission. The course was designed for both Active

Army and civilian personnel, and included orientation

training for professional, paraprofessional, and support

personnel in 5 areas: direct services, administration,

evaluation, prevention, and education. The course

fielded by the Behavioral Science Division in 1985

was initially 3 weeks in length. Training was provided

in the following areas:

 Administration and management (to include

budget management) of the FAP

 Marketing of FAP

 Role of the Army Central Registry

 Development of primary and secondary prevention

programs

 Investigation and assessment of child and spouse

abuse reports

 Overview to the medical aspects of child and

spouse abuse

 Roles and responsibilities of the members of the

Family Advocacy Case Management Team

 Family Advocacy Case Management Team case

determination process

 Treatment plan development

To successfully complete the course, students were

required to prepare and present a 10-minute

information briefing about their role in the family

advocacy program to a senior field grade officer or

civilian equivalent during the last week of the course.

In the late 1980s, the FAST course was changed from

a 3-week Department of the Army Course to become

the 2-week Department of Defense Family Advocacy

Staff Training Course conducted by the AMEDDC&S.

Students for this 2-week interservice course were from

all branches of the military (Army, Air Force, Navy,

and Marine Corps) with each service responsible for

selecting their respective students to attend. The

number of participants from each branch of service

was determined by the size of their troop force, with

the Army having the largest number of student slots,

followed by the Air Force, Navy, and Marine Corps.

The newly designed 2-week course contained

instruction that amplified the military’s commitment to

preventing spouse and child abuse by providing a

range of essential services to strengthen Soldiers and

families. The importance of providing victim safety

and offender accountability continued to be a part of

the training. The curriculum also maintained a focus

on the primary purpose of the Family Advocacy

Program, the prevention of spouse and child abuse and

neglect. Breakout sessions for each student to meet

with their service representative about their respective

programs were included in the curriculum. Students

also received instruction on the organization of the

FAP, to include:

 Roles and responsibilities of the Case Review

Committee

 Dynamics of child and spouse abuse

 Medical assessment of child abuse and spouse

abuse

 Child sexual abuse

 Program implementation

 Legal issues

 Case investigation

 Records and resource management

The course continued to include a requirement that the

students successfully complete a 10-minute

information brief on their role in the FAP.

In the late 1990s, the Navy, Marine Corps, and Air

Force optioned out of the 2-week course. The course

again became the Department of the Army Family

The Family Advocacy Staff Training Program

Cindi Geeslin, LCSW

John Hartz, LCSW

Michael Vaughn, LMSW
64 www.cs.amedd.army.mil/references_publications.aspx

Advocacy Staff Training Course. A decision was also

made to drop the 10-minute briefing as a course

requirement.

The 2-week course has continued to evolve to meet the

needs of the field and to reflect the current research in

the field of family violence. For example, blocks of

instruction were added to address the issues of culture

and the impact of substance abuse in family violence.

Although the course is basic in orientation to the field

of family violence, the change in course content is

such that students who attended the course 10 years

ago or more may be given a waiver to attend the

course again to benefit from those changes.

DEVELOPMENT OF DISTANCE LEARNING

Another pending change is the development of a

distance learning component that will replace one

week of the 2-week course. After completion of the

distance learning element, students may apply to

complete the one-week resident course. This distance

learning component is being developed to conserve

both the cost of training and the length of time course

participants must be away from their jobs to attend

training. Also, the development of distance learning

training allows the inclusion of additional information

that cannot be included in the 2-week course due to

time constraints.

The first step in the development of the distance

learning component was the determination as to which

courses would be included in that training, and which

courses should remain in the resident portion of the

course. It was determined that blocks of instruction

that are administrative in nature, and that training

which is relevant to the problems of family advocacy

could be accomplished in the distance learning

component without compromising the quality of the

training. For example, the block of instruction that

addresses the topic of substance abuse and the family

was included in distance learning training, not because

it is not important in addressing the issues of child and

intimate partner violence, but because it is not as

pivotal in developing the accurate assessment and

treatment of family violence. Training in the resident

portion of the course will continue to be that

instruction which is pivotal to the prevention and

accurate assessment and investigation of the problems

of child and spouse abuse.

It is anticipated that the distant learning component

will be implemented no later than fiscal year 2010.

Once it is fully implemented, costs savings should be

substantial. The savings will allow more Army family

advocacy professionals to take advantage of the

training with no compromise in the quality of the

course.

ADVANCED TRAINING

The Family Advocacy Staff Training Course was

designed to provide an overview of the issues of

family violence by providing members of the

multidisciplinary Case Review Committee (CRC) with

an understanding of the role of each CRC member. To

that end, a requirement was identified to provide skillbuilding courses for the members of the family

advocacy program who have the primary responsibility

for the prevention, education, and treatment aspects of

the program. This recognition led to the development

of 6 advanced courses to address the specific training

needs of the family advocacy professional staff. With

the exception of the Supervisors Course (3 days), all

courses are 41⁄2 days in length. In order to provide

family advocacy clinicians and prevention and

education providers with the most up-to-date training,

the course content under the broader topic heading is

changed each year to reflect the state-of-the-art

training and most current research.

Child Abuse Family Advocacy Staff Training Course:

Designed to assist family advocacy clinicians and

educators in the development of skills to assess and

treat the problems of child abuse. Specific training is

provided on the prevention, identification,

investigation, and treatment of child abuse. Blocks of

instruction include training on child abuse risk

assessment, family strengths and needs assessment,

and intervention strategies for children and families.

Spouse Abuse Family Advocacy Staff Training Course:

Provides advanced instruction on spouse abuse

intervention and treatment issues. Blocks of instruction

in this 4 1⁄2 day course include an overview to the

problems of spouse abuse, as well as training on

spouse abuse risk assessment. Risk assessment is

especially critical, as this assessment provides a

foundation on which future treatment is based. For

example, risk assessment informs the clinician if

couples treatment is an option, or if the treatment

should be provided in gender specific groups. Training

The Family Advocacy Staff Training Program
July – September 2008 65

THE ARMY MEDICAL DEPARTMENT JOURNAL

is also provided on various treatment options to

address the problems caused by spouse abuse. Treatment approaches include treatment options for victims,

offenders, and the children who witness violence.

The Prevention Family Advocacy Staff Training Course:

Concentrates on prevention of abuse within the family

by planning and implementing various programs for

spouses, parents, and children. Law enforcement crime

prevention as it relates to the prevention of child and

spouse abuse is also included. Instruction addresses the

topics of program planning and evaluation, budget

management, and the development of prevention

programs for spouses, parents, and children.

The Forensic Family Advocacy Staff Training Course:

Provides advanced instruction on the acquisition of

forensic interviewing skills of children so that detailed

statements can be obtained of either their own abuse,

or abuse that they have witnessed. A thorough

statement with as much detailed information as

possible is required whenever an allegation of child

abuse or child sexual abuse is received. A researchbased protocol that has been demonstrated to illicit

free narrative from children about their experiences is

used in this training. Small group instruction with

multiple opportunities to practice the interview

protocol is utilized as a key method of instruction.

Training in court preparation is also included.

The Multivictim Family Advocacy Staff Training Course:

Designed in recognition of the complexities in

managing cases that include allegations of child sexual

abuse that involve the potential of large victim pools.

Frequently, allegations of this type of abuse occur in

DoD sanctioned activities, which further complicates

the assessment, investigation, and management of

these cases. Blocks of training include instruction in

the area of development of a victim matrix to assist in

the identification of potential victims to be

interviewed, legal issues associated with the

investigation of these cases, and interview strategies

for children, which includes information on memory

and recall of events.

The Supervisory Family Advocacy Staff Training

Course: Three days of training for civil service

employees and social work officers designed to

provide training in the development of supervisory

skills. The course was developed in recognition of the

need to provide training for individuals who are

supervisors, but who have no prior experience or

training in this mission. The course focuses on both

clinical supervision and administrative supervisory

responsibilities.

Training is also provided to military installations by

mobile training teams (MTTs). They provide a 11⁄2 day

training session which focuses on team building for the

CRCs and the installation clinical treatment team. The

focus of the training is current research in the area of

child abuse and intimate partner violence, as well as

team building activities to assist the CRC in their

group efforts.

Since the mission of the advanced training is to

provide information on the most current research in the

field of family violence, these courses are continuously

updated to reflect the needs of the clinicians and

prevention and education specialists serving our

Soldiers and their Families. An example of such

change is the inclusion of addiction information and its

impact on the problems of family advocacy in one

advanced course each year (either the spouse or child

abuse course). This course is also made available to

the alcohol and substance abuse clinical staff. The

joint training was implemented to provide clinicians in

both treatment areas with the best possible clinical

strategies in the treatment of Army Families.

Information on the impact of posttraumatic stress

disorder is also included in this training.

SUMMARY

The Family Advocacy Staff Training Course has

continued to evolve to provide the highest quality,

research-based training to meet the needs of Army

family advocacy professionals. The Behavioral

Science Division is committed to ensuring that those

charged with providing Family advocacy support

receive the best training available in prevention,

education, and treatment for our Soldiers and their

Families.

AUTHORS

Ms Geeslin and Mr Hartz are Family Advocacy

Program Instructors and Course Managers in the

Soldier and Family Support Branch, Department of

Preventive Health Services, AMEDD Center & School,

Fort Sam Houston, Texas.

Mr Vaughn is the Family Advocacy Program Manager,

Soldier and Family Support Branch, Department of

Preventive Health Services, AMEDD Center & School,

Fort Sam Houston, Texas.
66 www.cs.amedd.army.mil/references_publications.aspx

INTRODUCTION

From the time new recruits enter military service, they

are drilled with the understanding that to accomplish

the mission they must maintain and operate an

essential weapon system. That essential weapon

system is the trained and armed US Army Soldier.

Historically, the institutional development of the US

Army Soldier has included tough physical

conditioning coupled with realistic technical and

tactical training. This traditional approach to shaping

new recruits has consistently produced a corps of

tough, confident, flexible, and prepared Warriors

capable of winning in combat and waging successful

military operations. Battlemind training augments this

skill set by building upon the Warrior’s proven combat

skills and mental fortitude—for truly we cannot send

their bodies where we have not prepared their minds to

go.

The term Battlemind was originally coined during the

early 1990s by General Crosby Saint who, at the time,

was the Commander of US Army Europe.1 He

recognized that there was a need to mentally prepare

his troops to both deploy and then transition back to

their home life successfully. Battlemind, as it is known

today, came to fruition following the research findings

of the Land Combat Study (2003-2004) spearheaded

by COL Carl Castro and COL Charles Hoge.2 These

detailed deployment and subsequent redeployment

data were collected and analyzed by their team at the

Walter Reed Army Institute of Research (WRAIR).

The needs identified by the analysis paved the way for

the creation of the Army’s premiere psychological

resiliency program—Battlemind.

The Land Combat Study provided the statistical

foundation from which Battlemind transformed from

concept to application as a viable readiness enhancing

tool for deployment cycle support training. The

Battlemind Training System continues to develop as a

program under a 3-pillar approach which includes

deployment-related training, but has further evolved

into institutional training.

Battlemind is now defined as a Warrior’s inner

strength to face fear, adversity, and hardship during

tough times with confidence and resolution. It is the

will to persevere and win. Battlemind training seeks to

build upon a Warrior’s proven combat skills, selfconfidence, and mental toughness as critical aspects of

their training. The Battlemind Training Office, located

at the Army Medical Department (AMEDD) Center

and School, Fort Sam Houston, Texas, continues to

work in conjunction with WRAIR to develop researchbased, relevant, psychological resiliency training that

can be imparted in a language and manner to which

Warriors can relate.

BATTLEMIND TRAINING OFFICE

In March 2007, the Combat Stress Actions Office was

reorganized into the Battlemind Training Office, under

the umbrella of the Soldier and Family Support Branch

at the AMEDD Center & School. It is the platform

from which all Battlemind and Combat and Operational Stress Control Training is developed and

fielded.

The objectives of Battlemind training are to mentally

prepare our Warriors for the rigors of combat and

other military deployments; to assist our Warriors in

their successful transition back home; to provide our

Warriors with the skills to assist their Battle Buddy* to

transition home; and, finally, to prepare our Warriors

to deploy again in support of all types of military

Battlemind Training System:

“Armor for Your Mind”

MAJ (Ret) John M. Orsingher, MS, USA

2LT Andrew T. Lopez, MS, USAR

1SG (Ret) Michael E. Rinehart, USA

*Defined as the person to whom a Soldier can turn in time of need, stress, and emotional highs and lows, who will not

turn the Soldier away, no matter what. This person knows exactly what the Soldier is experiencing because he or she is

currently going through a similar experience or has been through a similar experience and/or situation before.
July – September 2008 67

operations, including additional combat tours. These

objectives are accomplished via 3 distinct cycles of

military life: Life-Cycle Training, Deployment-Cycle

Training, and Soldier-Support Training. Each of these

cycles builds from and complements the others. LifeCycle Training strives to eliminate the stigma that

surrounds the search for behavioral healthcare and to

promote resilience throughout a Warrior’s career.

Deployment-Cycle Training provides Warriors with

the skills necessary to thrive and adapt to the stressors

of deployment, and then successfully transition from

the extraordinary circumstances related to military

deployments back to garrison and Family life. Finally,

Soldier-Support Training addresses the unique needs

and specific requirements of Warriors, their Families,

and the military community at large.

LIFE-CYCLE TRAINING

Battlemind Life-Cycle Training institutionalizes

Battlemind principles and concepts into the US Army

training and education system. At the most basic level,

Warriors are trained how to mentally prepare

themselves for all types of contemporary military

deployments while caring for their Battle Buddies. At

the highest level, senior leaders will learn how to

design organizational models which promote growth,

reduce barriers to behavioral healthcare, and enhance

total unit readiness for large troop elements. In other

words, as our Warriors progress through their careers,

they will continue to build their Battlemind skills in a

way that is commensurate with their level of

responsibility. It ensures our Warriors understand what

is, and what is not, within their direct ability to control.

There are currently 7 Battlemind Life-Cycle Training

products in various stages of development. All

institutionalized Battlemind training products will be

fielded by the end of fiscal year 2009.

Basic Battlemind Training (BBT) is the building block

for all life-cycle training. BBT will be trained at Basic

Combat Training and One Station Unit Training

programs of instruction. The tenets of BBT include

trust in leaders, Battle Buddies, and promotes self-aid/

buddy-aid skills which include peer intervention

techniques to ensure physical and mental well-being.

Warriors are taught to focus their thoughts, actions,

and resiliency skills while never losing sight of their

duty, values, and the Warrior Ethos, regardless of the

situation they may find themselves.

Battlemind Warrior Resiliency (BWR) is the core

competency training for all AMEDD enlisted and

officer personnel. BWR is currently being trained in

the AMEDD Enlisted Advanced Individual Training

(AIT) and Officer Basic Officer Leadership Course

(BOLC). This skills-based training emphasizes those

skills learned in BBT; additionally, BWR teaches

AMEDD personnel how to identify and assist Warriors

who may be in need of behavioral health treatment.

The principle message will be that psychological

trauma derived from combat or operational

deployments consists of predictable emotions that,

when recognized and brought to light, are also

treatable. BWR strives to eliminate perceived stigmas

historically associated with Warriors seeking help for

behavioral health problems.

Battlemind Warrior Resiliency–Transition targets those

AMEDD enlisted and officer personnel who

completed AIT and BOLC before the BBT and BWR

were incorporated into training. This instruction

includes elements of both BBT and BWR.

Battlemind Warrior Resiliency–Recertification ensures

established BWR standards are maintained and

validated to the required skill sets in the execution of

unit-level resiliency programs. This module, akin to

cardiopulmonary resuscitation recertification, will

strive to remain a dynamic training program through

the continued use of relevant updates based on further

research findings.

Battlemind for Leaders (BFL) represents the continuation of Battlemind Life-Cycle Training resiliency

training through the professional military education

system. BFL builds upon the skills learned during

BBT and begins to shift its focus to effective

leadership techniques and its direct relationship to

individual morale and the incidence of behavioral

health issues in a unit. This training meets the

requirements specific to junior leaders in the grade of

E4(P) to E6 as well as that of company grade officers.

Target delivery will be to noncommissioned officers

(NCOs) attending the Warrior Leaders Course and the

Basic Noncommissioned Officer Course, as well as to

officers attending Basic Officer Leadership Course and

the Captains’ Career Course.

Battlemind for Leaders–Intermediate (BFL-I) builds

upon BFL training and extends its focus to the

implementation and management of organizational

health policies at battalion and similar sized elements

for staff positions and midgrade leaders. This training
68 www.cs.amedd.army.mil/references_publications.aspx

not only addresses aspects of Warrior leadership, it

also discusses effective techniques of mentoring junior

leaders. Targeted delivery will be for NCOs attending

Advanced Noncommissioned Officers Course, and to

officers attending Intermediate Leader Education.

Battlemind Precommand and Senior Leaders (BSL)

represents the culmination of Battlemind Life-Cycle

Training that started with BFL and BFL-I. BSL will

target the information and skills necessary to build,

manage, and enforce umbrella organizational policies

which promote unit readiness at brigade level and

higher. It will also maintain a focus on resiliency

issues unique for senior NCOs and senior officers in

command positions. BSL will be taught during

precommand and senior service courses, to include the

Sergeants Major Academy and the War College.

DEPLOYMENT-CYCLE TRAINING

Deployment-Cycle Training is part of the readiness

initiative sponsored by the Army G-1 called the

Deployment-Cycle Support Process. Battlemind

training provides targeted education to be delivered at

designated times throughout all 7 phases of

deployment (training/preparation, mobilization,

deployment, employment, redeployment,

postdeployment, and reconstitution). Responsibility for

the delivery of Deployment-Cycle Support training has

been shared with the Chaplains Corps as directed by

Army Directive 2007-02.

3 The combination of

chaplains and behavioral health professionals

significantly extends the capability for delivery of this

training for deploying units. Deployment-Cycle

training modules are designed to build upon existing

Warrior strengths such as mental toughness,

teamwork, and psychological resiliency as Warriors

prepare to deploy and return from all types of military

operations. These training modules were originally

created and developed by WRAIR using data analyses

from the Land Combat Study and subsequent Mental

Health Advisory Team findings. The findings showed

that Warriors wanted and needed training which

provided them with coping skills and techniques that

could be employed before, during, and after a difficult

deployment rotation. The resulting training helps

Warriors by providing them with concepts and tools

designed to reduce the impact of stress of potentially

traumatic events (PTE) prior to experiencing them in a

deployment setting.

Pre-Deployment Battlemind Training

Pre-Deployment Battlemind Training (PDBT) is

packaged into individual training for Warriors, leaders,

helping-professionals, and military Spouses. Ideally,

training is delivered in platoon-sized elements or

working groups of no more than 40 students. Training

for Spouses and Families is typically conducted by

Family Readiness Groups or representatives at Army

Community Service to similar sized groups of Family

members. All modules prepare each of these groups

for realities specific to their deployment experiences.

In predeployment training for Warriors and leaders,

they are prepared for a wide range of sensory,

psychological, and emotional stimuli associated with

military deployments. The leader training modules

expand on the education by highlighting 10 tough facts

for leaders, such as the expectation of and preparation

for injuries and deaths of one’s unit members, and to

understand that deployments place a tremendous strain

on Families. PDBT expounds on the 10 tough facts for

leaders, and gives them some ways to help mitigate the

predictable effects on both themselves and, especially,

unit members and their Families.

Predeployment training for helping-professionals

discusses 12 tough facts which include issues such as

dealing with burnout, the delivery of bad news, and

breaking down barriers to care. Finally, predeployment

training for Spouses and Family members fills an

extremely important, but sometimes overlooked, gap

in preparedness. The training is conducted with the

deploying Warriors and their respective Families. It

provides a group setting opportunity to discuss what

Warriors will experience on the battlefield, while also

providing perspective to the Warriors as to what the

Spouse and Family will experience while they are

deployed. It emphasizes the importance of

communication and understanding between Family

members. Furthermore, it provides the Spouse and

Family with home front expectations regarding the

temporary change of roles within the household,

having to wear “dual hats” as a parent, and when and

where to seek help if needed while the Warrior Spouse

is away.

Training During Deployment

During the deployment, Battlemind training focuses on

managing the level of health and unit efficacy in the

contemporary operating environment.4 During a

deployment, tragedy can take many forms, from a

close call under hostile circumstances, unit casualties,

Battlemind Training System: “Armor for Your Mind”
July – September 2008 69

THE ARMY MEDICAL DEPARTMENT JOURNAL

accidents, or even fratricide. Any of these incidents

can shatter individual or unit effectiveness.

Deployment-focused Battlemind training seeks to

mitigate the effects of such events by reinforcing

Warrior skills, self-aid/buddy-aid, battlefield ethics,

and preparing Warriors to continue their missions.

These skills are trained to Traumatic Event

Management practitioners and reinforced during

Battlemind Psychological Debriefings.

Traumatic Event Management (TEM) training plays an

enormous role in helping Warriors and units bounce

back. TEM offers information on combat and

operational stress reaction, PTE, posttraumatic stress

disorder, long-term stress reaction, and posttraumatic

growth. TEM also teaches how to facilitate structured

group discussions for Warriors who have experienced

a significant incident in theater, and how to move on

and grow from that experience. The TEM program

was designed to provide a conceptual framework to

provide the ability to flexibly apply supportive

interventions in response to a PTE. Such interventions

should be based on a thorough assessment of the

impact and level of dysfunction that a specific or series

of PTEs have caused organizations or individuals. The

analysis of degradation resulting from PTE exposure

results in a series of selective interventions intended to

maintain unit cohesion and help units regain combat

effectiveness as efficiently as possible. TEM was

developed to include event- and time-driven formats

which are flexible and focused on education, while

allowing participants to explore predictable reactions

to extraordinary stimuli.

Battlemind Psychological Debriefing (BPD) was

developed by WRAIR after extensive research with

military populations.6 While there are several different

kinds of debriefing models, BPD focuses on the

unique aspects of what Warriors must deal with on the

modern battlefield. BPD training is provided to

Behavioral Health and Unit Ministry assets. When

necessary, the BPD-trained TEM practitioner can lead

or facilitate a debriefing with a group who has just

experienced a PTE while serving in the contemporary

operating environment. The BPD format attempts to

help Warriors make sense of PTEs, and restore a sense

of duty and honor to the participants so that they can

continue with their mission. BPD is different from

existing civilian debriefing models in that the Soldier

in a combat zone may be required to endure similar

traumatic events on multiple occasions, simply

because of the nature of the work. That stands in stark

contrast to the normal civilian experience—the

affected individual will likely never be exposed to a

similar PTE again, and the odds of repeated exposures

are infinitesimally small. Therefore, the civilian

debriefing model has as its goal assistance and

preparation of the individual to recover and continue

with the rest of his or her normal life.

Postdeployment Battlemind Training

Postdeployment Battlemind training closes the loop on

training for Warriors and their Families in regards to

the deployment cycle. Part of the findings from the

Land Combat Study include a requirement for training

how to transition combat skills to home skills.

Warriors have difficulty reintegrating into their home

life and with their Families on predictable timelines

following a deployment.

Battlemind I Training (Postdeployment Health

Assessment) is presented to Warriors who are

redeploying, or who have recently returned from a

deployment. This module discusses normal

homecoming expectations and how to successfully

transition from the combat zone to the “home zone.”

This one-hour block of instruction provides selfawareness training to Warriors, adaptation skills, and

education on finding behavioral health resources.

Additionally, it discusses how to modify desirable

combat skills which helped the Warrior to survive the

deployment into skills that will be useful when back

with Family and friends.

Battlemind II Training (Postdeployment Health

Reassessment) is complementary training to the

Battlemind I module presented at the 3- to 6-month

mark following a deployment. It discusses the ongoing

transition home and how to work through problems

which commonly arise among combat veterans. The

training reinforces the self-aid/buddy-aid concept and

attempts to dispel common myths associated with

seeking behavioral health assistance.

Battlemind Training for Spouses and Families is

presented to Warriors and their Families in much the

same manner as the predeployment version. This block

reviews matters discussed prior to deployment, and

helps Families start a dialogue regarding how things

have changed since the Warrior was first deployed.
70 www.cs.amedd.army.mil/references_publications.aspx

Battlemind Training System: “Armor for Your Mind”

The major theme of this training centers on the

Warrior and Spouse becoming a team again. During a

Warrior’s deployment, the Family unit may begin to

rely on external support, and individuals may become

personally independent. The responsibility of the

Warrior to transition his or her combat skills is

discussed, but that responsibility is paired with the

spousal responsibility to transition the home front

deployment skills as well.

SOLDIER-SUPPORT TRAINING

Soldier-Support Training (SST) captures the unique

populations and subjects that Life-Cycle and

Deployment-Cycle modules do not. SST will provide

Battlemind training to extended support systems,

including specialized populations such as National

Guard and Reserve Component specific issues,

military Families, and network health providers.

Chaplain Train the Trainer: The goal of the course is to

teach chaplains and chaplain assistants how to return

to their installations and train remaining chaplains and

behavioral health assets in the effective presentation of

Deployment Cycle Support Battlemind Training.

Modules mandated by the Army G-1 include:

Predeployment Battlemind training for Leaders and

Warriors, Battlemind I (Postdeployment Health

Assessment training), Battlemind II (Postdeployment

Health Reassessment Training), Traumatic Event

Management training, Battlemind Psychological

Debriefing training, and Pre/Postdeployment modules

for Spouses and Families.

The Combat and Operational Stress Control (COSC)

Course is the premier platform of deployment centric

prevention training for behavioral health and unit

ministry personnel. The course offers 5 days of

didactic education and practical exercises on the latest

COSC doctrine and battlefield updates. In addition to

doctrinal training, students also receive briefings on

related areas including analysis of the most recent

Mental Health Assessment Team data, mild traumatic

brain injury/concussion awareness, the Army Center

for Enhanced Performance* Education Model,

Battlefield Ethics, Sexual Assault Prevention InTheater and briefings from the Navy, Air Force, and

Marine Corps COSC professionals. Priority of

attendance for this course goes to personnel preparing

to deploy overseas in support of Operations Iraqi

Freedom and Enduring Freedom. Priority attendees

also include Air Force behavioral health personnel

who have been tasked to deploy in lieu of Army

personnel to support Army missions. Advanced

modules of the COSC Course are in development and

will have more practical exercises and hands-on

training which focus on specific key COSC prevention

and intervention concepts.

Warriors in Transition (WT) are those Warriors who

are assigned to a Warrior Transition Unit (WTU).

These Warriors receive treatment and rehabilitation for

injuries sustained in the combat theater. The

Battlemind Training Office (BTO) has developed

training for WTU staff during the WTU Residence

Course to include training in Suicide Awareness and

Battlemind Resiliency Training. The Spouses,

Families, and friends who care for WTs who are

recovering from both physical and psychological

trauma are known as WT Caregivers. BTO is in the

process of developing training modules, videos, and a

counseling program that focuses on the unique needs

of WT Caregivers.

WEBSITE, INTERACTIVE VIDEOS, AND MARKETING

As with anything in this world, information is essential

in making sound decisions and keeping ourselves

aware of our surroundings. The marketing of

Battlemind is a crucial component in raising the

awareness of our Warriors, commanders, Families, and

other organizations about the products and programs

we have available. The BTO has and continues to

promote its programs in several different ways in order

to reach as many people as possible. Recently, the

BTO launched an internet portal which has become the

Army’s official Battlemind website (http://

www.battlemind.army.mil). It will become a major

conduit for the BTO to dispense information and

training, and will be a resource for Warriors, Families,

commanders, and behavioral health providers.

Marketing of the Battlemind logo and its tenets have

taken the BTO from booths at several conferences to

the training of Air Force behavioral health providers

and Canadian, El Salvadoran, and Slovenian military

personnel.

*The Center for Enhanced Performance is a department of the US Military Academy Preparatory School, West Point, New

York. Information is available at http://www.usma.edu/USMAPS/pages/academics/cep_home.htm.
July – September 2008 71

THE ARMY MEDICAL DEPARTMENT JOURNAL

Education is the primary leverage we have in the

development of awareness and an understanding of the

issues that challenge the wounded Warrior.

Technology as a fundamental modality of education

today is effective and readily available. The AMEDD

Battlemind Training Office believes that there is

significant value in creating Virtual Experience

Immersive Learning Simulations®that will allow both

wounded Warriors and those involved/invested in their

recovery to practice dealing with issues in computerbased and/or web-based experiences. Such simulations

allow people to explore and understand issues and

challenges in a way that helps them prepare for

successfully dealing with those issues and challenges

when they face them in real life.

The BTO in concert with AMEDD Television are

currently working on several video projects that will

be used to educate Warriors and Family members to

include Suicide Awareness, Posttraumatic Stress

Disorder, and Seeking Behavioral Health Care /

Reducing Stigma.

CONCLUSION

Although still in its infancy, the Battlemind Training

Office has become the largest training branch in the

Soldier and Family Support Branch at the

AMEDDC&S. The diverse and important missions of

BTO have become a focal point within the AMEDD

and at senior Army command levels. Campaigns

during Operations Iraqi Freedom and Enduring

Freedom have shown us that we must remain flexible

to be able to meet mission objectives. BTO strives to

be proactive, flexible, and as forward thinking as

possible. Remaining focused on the Warrior and their

Family needs remains our objective. Preparing

Warriors, leaders, and their Families for the

operational tempo of our current Army is of crucial

importance.

ACKNOWLEDGEMENT

The authors thank Laurence Hunter, Michael Hagan,

Curtis Collins, Val Wilson, Duane Meyer, and Toya

Trevino for their contributions and assistance in the

preparation and review of this article.

REFERENCES

1. Saint CE. Battlemind Guidelines for Battalion

Commanders. Heidelberg, Germany: Headquarters,

US Army, Europe and Seventh Army; 1992.

2. Hoge CW, Castro CA, Messer SC, et al. Combat duty

in Iraq and Afghanistan, mental health problems, and

barriers to care. N Engl J Med. 2004;351(1):13-22.

Note: The article is reprinted in this issue of the

AMEDD Journal, beginning on page 7.

3. Army Directive 2007-02. Deployment Cycle Support

(DCS) Policy Guidance. Washington, DC: US Dept

of the Army; March 26, 2007:12-13. Available at:

h t t p : / / w w w . a r m y . m i l / u s a p a / e p u b s / p d f /

ad2007_02.pdf. Accessed 18 August 2008.

4. The contemporary operating environment is the

operational environment that exists today and for the

clearly foreseeable future. An operational

environment is defined in DoD Joint Publication 1-

02 5as “a composite of the conditions, circumstances,

and influences that affect the employment of military

forces and bear on the decisions of the unit

commander.”

5. Joint Publication 1-02: DoD Dictionary of Military

and Associated Terms. Washington, DC: Joint Staff,

US Dept of Defense: July 12, 2007. Available at:

http://www.dtic.mil/doctrine/jel/new_pubs/

jp1_02.pdf.

6. Adler A, Castro C, McGurk D. Battlemind

Psychological Debriefings. Walter Reed Army

Institute of Research, US Army Medical Research

Unit – Europe, Report #2007-001; 2007. Available at:

h ttp :/ / www. u s a mr u - e. h q u sa re ur .ar m y. mi l/

B a t t l e m i n d % 2 0 P s y c h % 2 0 D e b r i e f i n g %

20Procedures%202%20APR%2007.pdf. Accessed

18 August 2008.

AUTHORS

MAJ (Ret) Orsingher, 2LT Lopez, and 1SG (Ret)

Rinehart are Instructor/Writers in the Battlemind

Training Office, Soldier and Family Support Branch,

Department of Preventive Health Services, AMEDD

Center & School, Fort Sam Houston, Texas.
72 www.cs.amedd.army.mil/references_publications.aspx

INTRODUCTION

For nearly a century, civilian universities have

assumed a major role in recruiting, preparing, and

equipping behavioral science professionals to serve in

the various uniformed services. This is especially true

as it relates to Army social workers, who have played

an integral role in the Army’s attempt to provide

comprehensive medical healthcare to Soldiers and

military Family members since the birth of Army

Social Work in November 1943.1Shortly after the

creation of the Army Social Work military

occupational specialty, Fort Sam Houston developed a

subprofessional training program that would help mold

and prepare civilian educated social workers for the

difficult mission that they had chosen to pursue.2From

1918, the year in which Smith College opened the

doors of the Smith Psychiatric Training Program with

the expressed purpose of educating civilians to work as

social workers in military communities, until 2008,

civilian universities have had a clear and definite role

in the development of military social workers. The

civilian universities educate them, and the Army

refines them via military specific training. However,

on February 2, 2008, the partnership between

Fayetteville State University (FSU) and the Army

Medical Department (AMEDD) changed this with the

development of the Army-Fayetteville State University

Master of Social Work (MSW) Program.

This article provides a historical glimpse at the

circumstances that led to the development of a master

of social work program at Fort Sam Houston. In

addition, the article provides an overview of the

admission standards, Council on Social Work Education considerations, and the steps that the Army

Medical Department Center & School (AMEDDC&S)

and Fayetteville State University take to ensure consistency through close collaboration and partnership in

the creation of the program.

HISTORICAL PERSPECTIVE

In November 2006, The Army Surgeon General, in

response to a recognized shortage of social work

officers, approved a proposal for the AMEDDC&S to

establish a master of social work program to educate

and train military social workers to meet the

behavioral health needs of Soldiers and their Families.

The plan for the Army to develop a graduate-level

education program was originally presented to The

Surgeon General by Colonel Yvonne Tucker-Harris,

the Social Work Consultant to The Surgeon General.3

The War on Terror, multiple deployments, increases in

the attrition of company grade social work officers,

and licensure requirements were adversely affecting

the social work inventory. Moreover, it has become

increasingly difficult to recruit and retain competent

and committed Army social workers. Thus, it was

clear to Army leadership that more social workers

were needed, and, based upon the reality that social

workers in the Army were operating at 75% strength, it

was apparent that the Army could no longer maintain

the status quo if it intends to meet the mental health

needs of the force in the present and years to come.

Civilian colleges and universities have been teaching

classes on social work related issues since 1898, and

offering graduate educations since 1945.4 The Army

has been relying upon civilian universities to develop

social workers who may be interested in pursuing a

career in the military since 1918.5 As such, one might

question why, after half a century of reliance upon

civilian accredited universities to produce Army social

workers, would the Army seek to develop a graduate

social work degree producing program?

Even though civilian universities are the sole

proprietor of accreditations that enable them to offer

graduate and undergraduate social work degrees, there

remains a dearth of information in social work

curricula about practicing social work in a military

environment.6 As a result, even though graduate-level

trained social workers possess general knowledge

about the values, practices, and skills of social work,

most of them know little to nothing about practicing

social work in a military environment. Simmons and

Vaughn6revealed that the majority of military social

workers found that a large percentage of their graduate

education was irrelevant, and that their best training

was received on the job. Therefore, even though new

The Army Master of Social Work Program

Dexter Freeman, DSW

MAJ Graeme Bicknell, MS, USA
July – September 2008 73

Army social workers had to endure the arduous

educational process that graduate social work

programs offered, novice Army social workers entered

the Army with a significant degree of ignorance about

how to apply their social work knowledge and skills in

a military environment. In fact, it was the recognition

of an absence of knowledge about how to practice

social work as a uniformed officer in a military

environment that compelled the AMEDD to establish

the Army Psychiatric Social Work Training Program

at Fort Sam Houston, Texas, in 1945.2

Another contributing factor to the development of the

Army-FSU MSW Program was the Army’s inability to

access new social work graduates due to independent

practitioner licensing requirements. Since October

1998, in compliance with federal law,7the Army

Medical Command has required that all active duty,

reservist, individual mobilization augmentee, and civil

service social workers must possess a current, valid,

unrestricted (independent) professional license to

practice as part of the Army Medical Department.

Over the years, this policy has impacted the

availability of social workers that were eligible to enter

and deploy as independently practicing healthcare

providers. In most states, a graduate level educated

social worker must complete a minimum of 2 years

postgraduate supervision under a licensed clinical

social worker before he or she will become eligible to

take the independent practitioner exam.8 As a result,

civilians attending traditional social work programs are

not eligible to enter the Army upon graduation because

of the statutory requirement for Army social workers

to have independent practitioner status. Therefore, the

Army has been limited in its ability to recruit those

new social workers who may be inclined to pursue a

career in the military. Instead, the Army has sought to

attract social workers with independent practitioner

status, many of whom are already established in a

stable professional career, and therefore less likely to

consider a career in the military.

A final contributing factor for the establishment of an

Army MSW Program is related to the stress and

uniqueness of serving as an Army social worker. The

rigor of serving as a social worker with the military

force is definitely taking a toll on the social work

force, reflected by an estimated 10% attrition each

year in the number of social workers on active duty.

Although new social workers are recruited each year,

it is almost impossible to keep pace with the attrition

rate. This factor has highlighted the importance of

recruiting social workers who are not only

knowledgeable, but who are also committed to serving

as military social workers. This proved to be a major

factor that inspired the focus of the Army-Fayetteville

State University MSW Program. COL Joseph Pecko,

Director of the Army-FSU MSW Program, pointed out

that the program is designed to address the retention

problem by recruiting current military personnel who

understand the Army lifestyle and have an

appreciation for what their commitment entails.9

PROGRAM ORGANIZATION AND ADMISSION STANDARDS

The Army MSW Program is affiliated with FSU as an

offsite program. Fayetteville State University is

accredited by the Council on Social Work Education to

provide graduate social work education. Further, the

curriculum offered by the AMEDDC&S to students

that attend the Army-FSU MSW Program is identical

to the curriculum that the students receive on the FSU

main campus. The curriculum is designed to provide

graduate social work education to individuals with an

undergraduate education in social work and other

liberal arts related areas.

The Army MSW Program was designed to serve as a

force multiplier for the depleted social work inventory

by educating and training 15 to 20 Army social

workers per year. The program meets the Council of

Social Work Education curriculum standards for an

offsite program of Fayetteville State University. The

students selected to attend the program must have a

liberal arts undergraduate education, have demonstrated an ability to perform academically at the graduate

level, and express a strong desire to serve as an Army

social worker. Current active duty Soldiers have been

targeted as the primary source for students in the

Army-FSU MSW Program.

The first cohort attending the Army-FSU MSW

Program is being exposed to an intense, clinicallyfocused social work curriculum that will help students

understand the history, principles, practices, and skills

they will require to successfully perform as social

workers in a military environment. In addition, the

students receive a heavy dose of social work ethics,

human behavior in the social environment, policy

practice, a variety of direct clinical practice courses, as

well as a number of military specific electives. The

objective of this graduate program is to thoroughly

prepare, in a military environment, future social

workers in accordance with the standards of the
74 www.cs.amedd.army.mil/references_publications.aspx

The Army Master of Social Work Program

Council of Social Work Education so that each

graduate will be well versed in how to apply, within

the military, the knowledge, skills, and values they

have acquired during their graduate program.

It would typically require a civilian program 2 years to

provide the type of educational program that a student

in the AMEDDC&S program will be completing in 12

to 13 months. Once these students graduate, they will

go on to a select military installation to complete a 2-

year internship under the direct supervision of a

licensed clinical social worker. This will enable

graduates of the Army MSW Program to serve as

social work officers in half the time it would have

taken them had they attended a traditional civilian

education program. In addition, graduates of the Army

MSW Program will have a direct impact on the social

work inventory upon graduation, and will immediately

begin working with Soldiers and Family members who

may be affected by the requirements of the Global War

on Terror. However, graduates of the program will not

be eligible to deploy until after they have received

their license as independent practitioners. This will

occur after each graduate of the program completes the

postgraduate internship and passes the independent

practitioner licensing examination.

PROMOTING CONTINUITY THROUGH PARTNERSHIP

In February 2008, FSU and AMEDDC&S developed

an educational partnership that marked a change in the

way social work education would occur for Army

social workers. However, an enormous amount of

collaboration occurs behind the scene to ensure that

the integrity of the curriculum remains intact. Key

members from the FSU Department of Social Work

and the AMEDDC&S teaching faculty remain in

constant contact via telephone conference calls, site

visits, and video conference calls. The AMEDDC&S

teaching faculty have joint appointments as faculty at

FSU and at the AMEDDC&S. All curriculum and

admission decisions are approved by the program

director at FSU and the director at AMEDDC&S. The

teaching faculty at the AMEDDC&S attend monthly

faculty meetings with the other FSU faculty via

videoteleconferences, and they are also members of

other faculty committees at FSU. Dr Terri MooreBrown, Director of the FSU Department of Social

Work, described the partnership as a win-win

situation.9

The strength of any partnership is contingent upon the

degree to which both parties benefit from the

relationship. In this partnership, FSU benefits through

the opportunity to educate future Army social workers

who, in turn, will serve throughout the world. In

addition, FSU will also have the opportunity to serve

as coprincipal investigators in an array of research

opportunities that will take place at the AMEDDC&S.

The AMEDDC&S benefits from the opportunity to

work with a quality university that has a curriculum

that is consistent with the needs of the military, which

enables the Army to expeditiously offer an accredited

graduate education to qualified Soldiers who desire to

become social work officers.

CONCLUSION

Since 1918, the Army has relied upon civilian

universities to educate and prepare social workers to

serve in the military. Throughout the years, this

arrangement has been fraught with complications for

which the military has compensated by establishing its

own military specific on-the-job training. The War on

Terror, with a large percentage of Soldiers and Family

members suffering, has caused the Army to rethink

this arrangement. The Surgeon General of the Army

called for more mental health providers, and the social

work consultant recognized that it was a time for a

change. The Army needed more competent and

committed social workers now, and the Army’s

reliance upon civilian universities had proved to be

insufficient in providing the number of social workers

that was needed. The Army-FSU MSW Program

represents the change that was required to equip the

Army with 15 to 20 new social workers each year.

REFERENCES

1. Garber DL. Army social work: fifty years of

professional innovation, vision, competence, and

initiative. Paper presented at: US Army Social Work

Practices Course; June 1992; San Antonio, TX.

2. Camp E. The Army’s psychiatric social work

program. Soc Work J. 1948;April:76-78.

3. Pecko J. Opening remarks. Paper presented at: The

Army-Fayetteville State University Master of Social

Work Program opening ceremony, Fort Sam

Houston, TX; June 23, 2008.

4. Kendall KA, ed. World Guide to Social Work

Education. 2nd ed. New York: Council on Social

Work Education Press; 1984.
July – September 2008 75

THE ARMY MEDICAL DEPARTMENT JOURNAL

5. Smith College web site. School of Social Work:

History of the School page. Available at: http://

www.smith.edu/ssw/admin/about_history.php.

Accessed August, 20, 2008.

6. Simmons CA, Vaughn D. Military social workers at

war: their experiences and the educational content

that helped them. J Soc Work Educ. 2007;43(3):497-

513.

7. 10 USC §1094 (1998).

8. Association of Social Work Boards resource site.

Licensing requirements: table 3: experience and

supervision requirements. Available at: http://

www.datapathdesign.com/ASWB/Laws/Prod/cgi-bin/

LawWebRpts2DLL.dll/EXEC/1/0bt906a10zjxfu1-

czclwb1p6kn03. Accessed September 14, 2008.

9. Wilson E. Soldiers can earn master’s degree in social

work. Fort Sam Houston News Leader. 2008;50

(13):1. Available at: http://www.samhouston.army.

mil/pao/pdf/04_03_08.pdf. Accessed September 18,

2008.

AUTHORS

Dr Freeman is an Associate Professor and the Assistant

Director of the US Army-Fayetteville State University

Master of Social Work Program, AMEDD Center and

School, Fort Sam Houston, Texas.

MAJ Bicknell is an Assistant Professor at the US

Army-Fayetteville State University Master of Social

Work Program, AMEDD Center and School, Fort Sam

Houston, Texas.

The US Army Medical Department Center and School, Fort Sam Houston, Texas
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 Reference citations of books must include the authors’ surnames and initials, book title, volume and/or edition if

appropriate, place of publication, publisher, year of copyright, and specific page numbers if cited.

 Reference citations for presentations, unpublished papers, conferences, symposia, etc, must include as much identifying

information as possible (location, dates, presenters, sponsors, titles).

4. Either color or black and white photographs may be submitted with the manuscript. Color produces the best print reproduction

quality, but please avoid excessive use of multiple colors and shading. Digital graphic formats (JPG, GIF, BMP) and MS Word

photo files are preferred. Prints of photographs are acceptable. Please do not send photos embedded in PowerPoint. Images

submitted on slides, negatives, or copies of X-ray film will not be published. For clarity, please mark the top of each

photographic print on the back. Tape captions to the back of photos or submit them on a separate sheet. Ensure captions and

photos are indexed to each other. Clearly indicate the desired position of each photo within the manuscript.

5. The authors’ names, ranks or academic/certification credentials, titles or positions, current unit of assignment, and contact

information must be included on the title page of the manuscript.

6. Submit manuscripts to:

EDITOR, AMEDD JOURNAL

ATTN: MCCS DT

2423 FSH-HOOD ST

FORT SAM HOUSTON, TX 78234-5078

DSN 471-6301

Comm 210-221-6301

Email: amedd.journal@amedd.army.mil