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Expeditionary Operational Stress Control in the US Navy

Chapter 8

expeditionary operational 

stress control in the us navy

ROBERT L. KOFFMAN, MD, MPH*; RICHARD D. BERGTHOLD, PsyD†; JUSTIN S. CAMPBELL, PhD‡; 

RICHARD J. WESTPHAL, PhD, RN§; PAUL HAMMER, MD¥; THOMAS A. GASKIN, PhD¶; JOHN RALPH, 

PhD**; EDWARD SIMMER, MD, MPH††; and WILLIAM P. NASH, MD‡‡

INTRODUCTION

STRESS INJURY CONTINUUM MODEL

EXPEDITIONARY MEDICAL PLATFORMS

Hospital Ships

Expeditionary Medical Facilities

COMBAT AND OPERATIONAL STRESS CONTROL ELEMENTS

Special Psychiatric Rapid Interventions Teams 

Carrier Psychology Program

Operational Stress Control and Readiness (OSCAR) 

EMERGING CHALLENGES FOR OPERATIONAL NAVY MEDICINE

Individual Augmentation

Care for the Caregiver

SUMMARY

*Captain, Medical Corps, US Navy; Director of Deployment Health, Department of the Navy, Bureau of Medicine and Surgery, Deployment Health, 

2300 E Street NW, Washington, DC 20372

†

Commander, Medical Service Corps, US Navy; Chief of Staff, Wounded, Ill and Injured, Bureau of Medicine and Surgery, 2300 E Street NW, Washington, DC 20372

‡

Lieutenant, Medical Service Corps, US Navy; Deployment Health Senior Analyst, Department of the Navy, Bureau of Medicine and Surgery, Deployment Health (M3C3), 2300 E Street NW, Washington, DC 20372

§

Captain, Nurse Corps, US Navy; Psychological Health Promotion Programs, Department of the Navy, Bureau of Medicine and Surgery, Deployment 

Health, 2300 E Street NW, Washington, DC 20372

¥

Captain, Medical Corps, US Navy; Director, Naval Center for Combat and Operational Stress Control, 34960 Bob Wilson Drive, Suite 400, San Diego, 

California 92134-6400 

¶

Director of Combat Operational Stress Control, US Marine Corps, Manpower and Reserve Affairs, Personal and Family Readiness Division, 3280 

Russell Road, Quantico, Virginia 22134 

**Commander, Medical Service Corps, US Navy; Director for Mental Health, National Naval Medical Center Bethesda, 8901 Wisconsin Avenue, Bethesda, 

Maryland 20889; formerly, Officer-in-Command, Presidential Support Program, Marine Barracks, Washington, DC

††Captain, Medical Corps, US Navy; Executive Officer, Naval Hospital, 1 Pinckney, Beaufort, South Carolina 29902; formerly, Senior Executive Director 

for Psychological Health, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, Silver Spring, Maryland

‡‡Captain, US Navy (Retired); Assistant Clinical Professor, Department of Psychiatry, University of California at San Diego; formerly, Senior Consultant, 

Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, Rosslyn, Virginia 22209
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Combat and Operational Behavioral Health

INTRODUCTION

The diversity of US Naval operations, which span 

air, land, and sea/subsea dimensions, places extraordinary demands on sailors and their families. Although 

the US Navy has traditionally been a deployed force, 

the global war on terror (GWOT) has added to the 

Navy’s list of deployment-related stressors. Stress, as 

it is referred to in this chapter, is considered as a transactional model1,2 described as a general strain imposed 

by the operational milieu that disrupts the physical 

and psychological equilibrium of sailors, the outcome 

of which is mediated by a complex interplay between 

variables specific to the individual, the situation, and 

the dynamic interaction between the two. 

The impact of operational stress upon sailors 

is manifested in the prevalence of mental health 

problems among sailors who routinely deploy upon 

operational platforms. For instance, a study of 782 

active duty sailors and marines found the 1-year 

prevalence of any psychiatric illness to be 21% and 

the lifetime prevalence to be 40%, based on structured computerized telephone interviews designed 

to make DSM-III-R (Diagnostic and Statistical Manual 

of Mental Disorders, 3rd edition, revised) psychiatric 

diagnoses.3

 For those deploying to Operation Enduring Freedom and Operation Iraqi Freedom (OEF/

OIF), the risk for having symptoms of either of two 

illnesses, posttraumatic stress disorder (PTSD) or 

major depressive disorder, is nearly the same: 20% 

of these service members reported symptoms of at 

least one of the two disorders, according to a report 

from the RAND Corporation’s Center for Military 

Health Policy Research.4 The dual imperatives of mission effectiveness and moral responsibility for sailor 

health provide the impetus for the Navy Medicine 

Support Command to develop and implement programs based on a comprehensive operational stress 

control doctrine.5

 Discussion of these efforts is the 

focus of this chapter.

Stress Injury Continuum Model

Because stress injuries occur across a continuum 

of severity and settings, Navy stress control doctrine 

must encompass all sailors regardless of their duty, 

platform, or assignment (afloat and ashore), not just 

sailors in specific combat environs. Consequently, 

Navy leadership (in collaboration with the US Marine 

Corps) has developed an overarching operational 

stress control program applicable to the full panoply 

of Navy missions (see also Chapter 7, US Marine Corps

and Navy Combat and Operational Stress Continuum 

Model: a Tool for Leaders). However, much of the 

seminal theory and applications for stress control in the 

military are, as one would expect, derived from stress 

control practices in the combat environment. In that 

vein, the doctrine being developed to forge broader 

Navy stress control initiatives into a more theoretically consistent and unified whole is adapted from 

the combat stress injury model explicated by Figley 

and Nash.1

 The starting point for this new paradigm 

in Navy stress control is the stress injury continuum 

(SIC) model (see Chapter 7, Figure 7-1 for a description 

of the model). This chapter will apply the SIC model 

as the rubric for interpreting extant and future Navy 

stress control programs. 

Adopted because of its ability to educate, acculturate, and engage all sailors in stress control, the SIC 

paradigm highlights how the onus for stress control 

is shared among line-duty leadership (eg, squadron 

commanders, division officers, department heads), 

the individual sailor, and caregivers (eg, Navy Medicine personnel, the Chaplain Corps). The SIC model 

charges unit leadership with ensuring that sailors are 

ready for deployment by fostering an atmosphere 

within commands that promotes mental health and 

resilience through realistic training, unit cohesion, 

and mission focus. Sailors who deploy should be 

competent, socially supported, and mentally prepared 

to encounter and adaptively cope with operational 

stressors.6

 The SIC model contains five functions 

for leaders that encourage them to (1) strengthen 

the mental resiliency of sailors through realistic and 

purposeful training; (2) mitigate physiological stressors by maximizing sailors’ access to proper sleep, 

exercise, and nutrition; (3) develop processes for the 

early identification of stress reactions and injuries; 

(4) encourage sailors to care for one another (eg, with 

“battle buddies”); and (5) remove barriers to care by 

supporting the transition of stress-injured sailors to 

higher levels of care and fostering stigma-free reintegration of stress-wounded sailors. 

At the first stage of the SIC, sailors are prepared 

to confront stress. At the second stage, sailors are 

reacting to the unique operational stressors that challenge their physical and psychological equilibrium. 

The outcome of this reaction becomes a function of 

person, situation, and person–situation interactions 

that influence whether the reaction is mild, transient 

distress or impairment with associated anxiety, irritability, and unwanted behavioral change. However, 

each operational milieu has some degree of stress reaction that is normative, which makes distinguishing 

between normative and abnormal stress reactions a 
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Expeditionary Operational Stress Control in the US Navy

critical consideration for leadership, caregivers, and 

individual sailors alike. Yet, at the reacting point in the 

continuum, individual sailors must assume primary 

responsibility for identifying whether they and their 

fellow shipmates are effectively coping with the strain 

of their deployment. Although stress reactions are 

considered normal reactions to high-stress environments, the severity, persistence, and impairment experienced by some sailors may transcend the reactions 

experienced by the majority of sailors when perceived 

through the eyes of leaders, shipmates, caregivers, or 

reacting sailors themselves. 

Rather than establishing clear dividing points, the 

conceptualization of stress injury as a continuum acknowledges the complex interplay between sailors and 

situations that must be considered when attempting to 

ascertain whether an individual’s stress reaction has 

surpassed the normative response and moved from 

stress reaction to the third stage in the SIC—stress injury. Use of the term “injury” here is important because 

it conveys to leaders the presence of a more serious 

threat to both the sailors’ individual well-being and 

operational effectiveness. Sources of stress injury can 

include trauma from experiencing horror, terror, and 

helplessness during deployment; fatigue derived from 

accumulated deployment stressors; grief associated 

with the loss of a valued person or thing; and moral 

conflict in belief and value systems.1

Although stress-injured sailors are still expected to 

identify these injuries in themselves and others, Navy 

Medicine and caregivers begin to play a more prominent role in the stress injury phase of the continuum. 

At this phase, sailors are not expected to cope with 

their injury alone, but are empowered to seek help 

from caregivers, who are the primary support for 

prevention of permanent, debilitating stress injuries. 

Once a stress illness (behaviors that fall primarily 

within diagnostic categories such as PTSD, depression, anxiety, and addiction) is identified in a sailor, 

treatment becomes the primary responsibility of Navy 

Medicine. Implementation of the SIC model includes 

the expectation that all leaders, sailors, and caregivers 

will be able recognize and respond appropriately to 

sailors in distress. 

The stress injury decision matrix (see Chapter 

10, Figure 10-3) is an example of an SIC-based tool 

designed to help leaders, sailors, and caregivers 

determine if a sailor is ready, reacting, injured, or 

ill because of an operational or life stressor. The nascent state of SIC makes it difficult to ascertain the 

outcomes of the model as a doctrine for combat stress 

control. However, the model’s multidisciplinary 

and theoretical nature, as well as the incorporation 

of multiple stakeholders, is a promising feature for 

establishing doctrine. The multifaceted nature of the 

SIC model also makes it an ideal context for integrating the various operational stress control programs 

currently in place. 

EXPEDITIONARY MEDICAL PLATFORMS

As alluded to in the SIC model, the Navy as an 

organization assumes two primary roles in combating stress: (1) preventive consultation and (2) care 

provision. To keep sailors ready, preventive consultation with line leadership supports development of 

command policies and procedures that both prepare 

sailors to face the mental rigors of deployment, and 

identify, help, and reintegrate sailors who have experienced stress injuries and illness. The more traditional 

role involves direct healthcare service provision to 

those with stress injuries and the treatment of those diagnosed with stress illness. Because of the quantity of 

medical personnel, expeditionary medical platforms 

offer perhaps the widest range of Navy preventive 

and direct care services in deployed environments. 

Expeditionary platforms in the Navy consist of fleet 

hospital ships and expeditionary medical facilities 

(EMFs). These platforms are a mixture of specific 

capabilities that ensure mission flexibility within the 

logistical constraints of the deployed environment. 

Expeditionary combat and operational stress control 

platforms must be capable of performing missions 

that range from combat service support in GWOT 

to humanitarian assistance and disaster response. 

Serving as major instruments of diplomacy, these 

expeditionary platforms have taken Navy Medicine 

into Afghanistan, Iraq, and Kuwait while simultaneously providing preventive medicine, combat medical 

support, health maintenance, medical intelligence, 

operational planning, and mental health services to 

military personnel. 

Hospital Ships

The fleet of hospital ships consists of the USNS 

Mercy and USNS Comfort, which are home ported on 

the west and east coast of the United States, respectively. The hospital ships have inpatient capabilities 

comparable to major medical facilities ashore. They 

each have 12 fully equipped operating rooms, a 1,000-

bed hospital facility, radiological services, a medical 

laboratory, a pharmacy, an optometry laboratory, a 

computed tomography scanner, and two oxygenproducing plants. Both have a flight deck capable of 

landing large military helicopters, as well as side ports 

to take on patients at sea.
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Combat and Operational Behavioral Health

Expeditionary Medical Facilities 

EMF facilities are designed to approximate the 

same capabilities as fleet hospital ships, yet maintain a 

smaller logistic footprint with high mobility. EMFs are 

fully modular, task-organized structures that can be set 

up in as little as 48 hours. As EMFs continue to evolve, 

they will provide more robust medical care for major 

conflicts, low-intensity combat, operations other than 

war, and disaster/humanitarian relief operations. As 

modular expeditionary units, EMFs may be employed 

independently or in combination with the theater’s 

joint health system for evacuation, medical logistics, 

medical reporting, and other functions.

Taken together, hospital ships and EMFs are unique 

among forward-deployed operational stress control platforms with respect to the medical nature of 

their mission. Perhaps the greatest strength of these 

platforms is that they include high concentrations of 

caregivers, providing a versatile mixture of expertise 

and resources that can anchor both ends of the SIC 

model. 

COMBAT AND OPERATIONAL STRESS CONTROL ELEMENTS

The three combat and operational stress control 

elements discussed in this section—(1) the Special 

Psychiatric Rapid Intervention Teams (SPRINT), 

(2) the carrier psychology program, and (3) the 

Operational Stress Control and Readiness (OSCAR) 

program—have arisen within the last 30 years as 

outgrowths of a larger trend within the US armed 

services to institutionalize the integration of medical 

health expertise within operational units. In relation 

to the SIC model, all three programs are oriented to 

intervene between the stress injury and illness phases 

of the continuum. However, the carrier psychology 

program, and the OSCAR program in particular, also 

play roles at the readiness end of the stress reaction 

continuum, through the use of operationally embedded caregivers to provide training and preventive 

consultation to leaders in supporting individual 

sailor readiness. 

Special Psychiatric Rapid Intervention Teams

History

In 1975 a collision occurred between the USS Belknap

and the USS John F Kennedy, resulting in a significant 

loss of life and extensive damage to both ships. Subsequently, in 1977, a Navy liberty launch collided with 

another ship in the Barcelona harbor. In both incidents, 

the vessels involved were home ported on the east 

coast, and the psychiatry department at Portsmouth 

Naval Hospital (now Naval Medical Center, Portsmouth) in Virginia received a significant number of 

patients presenting with stress symptoms related to 

the incidents. It became apparent to Navy Medicine 

that a plan for early intervention to avoid stress illness was needed. The same concepts developed to 

treat stress in combat were modified for use in early 

intervention with disasters at sea; the result was the 

birth of the Special Psychiatric Rapid Intervention 

Teams—“SPRINT.” 

Composition and Mission

In 1983 SPRINT teams were formally chartered 

as one of the Navy’s Mobile Medical Augmentation 

Readiness teams. Navy SPRINT teams are formally organized at Bethesda, Maryland; Portsmouth, Virginia; 

and San Diego, California. Some informal teams are 

located at various overseas locations. Since their inception, SPRINT teams have not only provided intervention in maritime mishaps, but also supported military 

operations other than war, military contingency operations, terrorist attacks, and natural disasters. Each team 

consist of two psychiatrists, two clinical psychologists, 

one or two chaplains, two or more psychiatric nurses, 

one or two clinical social workers, and four or more 

hospital corpsmen psychiatric technicians. An officer 

is designated as the team leader, and a senior psychiatric technician serves as the leading petty officer. The 

SPRINT team’s mission is to be trained and immediately available in the event of a contingency to (a) assess 

the psychological effects of traumatic stress, (b) offer 

direct support to individuals and units affected by the 

event, (c) identify and refer those needing psychiatric 

treatment, and (d) consult with commanders and leaders to mitigate the negative impact of the event. From 

the SIC perspective, SPRINT teams become involved 

at the reacting stage, the goal being to prevent sailors 

from moving further along toward the injured and ill 

end of the spectrum. Teams also provide support to 

families of active duty members. 

Unit leaders are responsible for bringing SPRINT 

teams into the picture. The teams have limited equipment consistent with their goal of being a rapidreaction force. Rapid fielding requires that the requesting command or agency provide logistical support 

(berthing, messing, communications, transportation, 

etc) to the team. Thus, SPRINT teams are deployable 

worldwide within 24 hours’ notice. Examples of prior 

SPRINT deployments include Hurricanes Andrew, 

Ivan, and Katrina; the terrorist attack on the USS Cole; 
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Expeditionary Operational Stress Control in the US Navy

the TWA [formerly Trans World Airlines] Flight 800 

disaster; a civilian airline crash in Guam; and severe 

flooding and landslides in Central America. SPRINT 

teams also supported the guard force in the early days 

of the detainee mission at Guantanamo Bay, Cuba. In 

addition to high-profile events, SPRINT teams also 

regularly respond to smaller-scale events such as 

work-related accidents that result in the death of a 

crewmember, suicides, and aircraft mishaps. 

Intervention Strategies

SPRINT does not adhere to any specific professional 

doctrine on intervention methodology. However, team 

members are expected to be competent in their respective disciplines and well versed on the latest information in crisis intervention techniques and treatment 

strategies for acute stress and PTSD. This allows the 

teams the flexibility to adapt their responses to the 

demands of a particular situation while ensuring that 

their methodology is based on best practices and, when 

possible, evidence-based science. During the 1980s and 

1990s, the critical incident stress management (CISM) 

technique was developed to help emergency service 

workers, such as firefighters, paramedics, and police 

officers, address particularly stressful events. Attempts 

were made to adopt CISM for use in military interventions, but its use has since been officially discouraged 

because it has not been proven effective in controlled 

trials, and some evidence shows that it could potentially be harmful.7–9

Instead, the current focus is on providing command 

consultation, psychoeducational intervention, and 

psychological first aid. The team assists the command 

in developing a strategy to mitigate the impact of the 

event on the entire organization; provides timely, targeted, and useful information for command members; 

briefly contacts as many potentially affected individuals as possible; and supports individuals in acute distress. Every attempt is made to avoid early labeling 

or diagnoses, even for individuals demonstrating 

significant stress reactions. Rather, affected individuals 

are encouraged to mobilize their own and community 

resources to enhance recovery and restore functioning. 

SPRINT teams generally provide support rather than 

treatment. A benefit to adopting the support role is that 

the teams generally do not contribute documentation 

to medical records, thereby offering a higher level of 

confidentiality. It is thought that such confidentiality 

can reduce the potential stigma associated with seeking mental healthcare. 

In addition to maintaining expertise in intervention 

theory and techniques, SPRINT team members must 

be proficient serving in diverse operational settings, 

including surface ships, submarines, and aviation 

platforms; ground-centric Seabee and marine operating areas; and joint service operations. Team members 

must also be knowledgeable and comfortable in dealing with various Navy systems, organizations, and 

structural issues that affect how well a command 

withstands the impact of a stressful event. Most 

SPRINT responses are short-term (often only 1 day), 

but have lasted up to 6 months. In virtually all cases, 

SPRINT teams work closely with local resources, and 

turn over functions to the local resources as the situation permits. 

Training for SPRINT teams involves a variety of 

approaches. New members always participate in 

SPRINT missions under instruction before leading 

missions. Psychiatric residents and psychology interns 

are encouraged to participate, under supervision of 

experienced team members. Psychiatric technician 

students also receive training in disaster and trauma 

response. Teams conduct regular refresher training in 

combat and operational stress first aid (COSFA),10 and 

many team members also receive familiarity training in 

CISM (although CISM’s use is discouraged, commanders and others often ask about it, and knowledge of the 

technique can help to educate them). SPRINT teams 

remain active during wartime, because natural disasters, maritime accidents, and other noncombat stressful 

events continue during war, although staffing can be a 

challenge. The concepts, skills, and techniques developed through the Navy SPRINT teams’ experiences in 

peacetime are invaluable for informing and educating 

the wider Navy mental health community as a whole 

and contributing to the overall improvement of stress 

intervention and treatment of the operating forces. 

Carrier Psychology Program

History

Since the mid-1990s, psychologists and psychiatric 

technicians have served as permanent members of 

ship’s company on all US Navy aircraft carriers. Before the initiation of the carrier psychology program, 

25 to 30 sailors were medically evacuated (medevaced) from a carrier for mental health reasons during 

a 6-month deployment.11 Since the inception of the 

program, the number of medevacs has averaged fewer 

than five per deployment. In 2001 the average fuel/

transportation cost of a medevac from a deployed 

carrier was estimated to be $4,400, suggesting that 

a typical deployed psychologist saves the Navy at 

least $110,000 per deployment in prevented medevacs 

alone.11 “Prevented medevacs” are defined as situations in which sailors are retained onboard, but due 
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Combat and Operational Behavioral Health

to serious psychological difficulties, would likely not 

have been retained in the absence of a psychologist. 

Moreover, this figure ignores the immeasurable costs 

of losing personnel with valuable experience, and 

the lowered morale among remaining crew members 

who are forced to perform extra work to make up for 

unexpected personnel shortages. Nor does the figure 

include the cost of providing escorts for medevaced 

personnel. Additionally, nondeployed carriers report 

an average of 2.8 prevented medical evacuations per 

month, thus this cost savings extends throughout the 

carrier training cycle.

There are numerous examples of this cost savings. 

Aboard the USS John F Kennedy in 1999, 28 sailors 

were medevaced for psychological problems during 

a 6-month Mediterranean deployment. In 2001, on 

the ship’s first deployment with a psychologist, there 

were no psychological medevacs.12 Similar results were 

seen aboard the USS Carl Vinson in 199911 and the USS 

Enterprise in 2001.13 More recent data continue to support this trend. Through 2006 and 2007, the estimated 

number of prevented medevacs from deployed carriers averaged slightly more than four per month. (All 

statistics are derived from monthly reports made by 

each carrier psychologist; the data are maintained by 

the Navy clinical psychology community.) 

Prevention of Chronic Psychological Problems

Embedded mental health providers are in the 

unique position of being able to identify problems at 

early stages in the SIC. By staying abreast of morale 

and remaining vigilant about the level of stress among 

unit personnel, carrier psychologists can intervene 

before problems become severe, either by reaching out 

to individuals or groups at particularly high risk for 

mental health problems, or by advising the command 

on policies to enhance a unit’s overall psychological 

readiness. For many psychological disorders, most 

notably PTSD, early identification and treatment is 

essential to avoiding long-term difficulties. 

One of the best ways to prevent pathology before it 

occurs is through education. In this role, carrier psychologists also buttress the work of unit leaders, who 

ultimately bear the responsibility of readiness within 

the SIC model. Carrier psychologists and shipboard 

psychiatric technicians conduct an average of 4.5 

prevention-oriented classes per month. Such classes 

are designed to help service members identify growing 

psychological problems at an early stage (yellow and 

orange zone) before they become debilitating. Embedded psychologists can also prevent serious problems 

from developing through frequent interaction with 

unit leadership. Carrier psychologists conduct over 40 

consultations per month with representatives of their 

patients’ chains of command. These consultations are 

intended to educate the command, but also to discuss 

strategies for preventing a worsening of symptoms. 

Sailors who are reacting, injured, or ill constitute a 

considerable responsibility for carrier psychologists 

and their staff. Carrier psychologists report an average of 105 patient contacts per month, so they are well 

utilized in the caregiving role. No doubt contributing 

to the high utilization of carrier psychologist is the 

fact that they live and work among their patients, frequently encountering them throughout the workday, 

observing them performing their jobs and interacting 

with peers. As shipmates, they are able to obtain an 

in-depth understanding of their patients’ daily lives. 

Given this regular presence, unit members are more 

likely to utilize mental health services than they would 

if obtaining such care required a trip to a mental health 

clinic at a medical facility.

Stigma Reduction

Of all factors obstructing the provision of effective 

mental healthcare to military personnel, the most 

powerful may be the lingering perception within many 

military units that seeking psychological treatment 

is a sign of personal weakness, or that such care will 

harm one’s military career. One of the major findings 

of the 2007 Department of Defense (DoD) task force 

on mental health14 was that significant stigma remains 

associated with seeking mental healthcare in the military. A key recommendation, deemed “crucial to the 

psychological health of service members,” was that 

“the military services should embed mental health 

professionals as organic assets in line units.”15(p4)

Three obvious benefits of the SIC model in the 

carrier psychology program are apparent. First, the 

familiarity between sailors and the ship’s psychologist reduces the stigma associated with seeking help, 

making it more likely for a sailor to ask for help before a stress injury becomes a stress illness. Second, 

the proximity of mental health services reduces the 

temporal distance between recognition of stress injury 

symptoms and access to care, lessening the need for 

medical evacuations of sailors who have developed 

debilitating stress illnesses. Third, psychologists detailed to a carrier are able to support the line leadership 

in developing a mentally ready force. 

Operational Stress Control and Readiness (OSCAR)

History

OSCAR teams and carrier psychologists share 

many of the same preventive medicine and direct 

caregiving roles in addressing mental health issues 
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Expeditionary Operational Stress Control in the US Navy

across the spectrum of the SIC. The OSCAR concept 

was begun in 1999 and piloted as the 2nd Marine 

Division’s operational stress control and restoration 

program in 2000. Early OSCAR teams included mental 

health professionals, corpsmen, chaplains, and Marine Corps staff noncommissioned officers in a fully 

integrated multidisciplinary team. In 2004 the Marine 

Corps collaborated with the Navy Bureau of Medicine 

to authorize a 2-year pilot of OSCAR across all three 

active Marine divisions. Staffing of the OSCAR teams 

was tenuous due to competing wartime demands 

for scarce mental health resources, but the pilot team 

performed well, proving to be a valuable asset to Marine Corps leadership. In 2006 the Center for Naval 

Analyses16 evaluated the efficacy of the OSCAR pilot 

and summarized the model as follows:

Applying a community mental health model to the 

expeditionary and forward placed nature of Marine 

life, and taking account of Marine culture, OSCAR is 

an organic program embedded in the units it serves, 

expeditionary (accompanying the unit throughout the 

deployment cycle), multidisciplinary (incorporating a 

team approach), preventative (stressing the full range 

of primary, secondary, and tertiary prevention measures), and therapeutic (providing appropriate mental 

health services).16(p1)

The center deemed the OSCAR pilot and model 

successful in reaching target audiences and capable 

of producing expected outputs. OSCAR was recommended for continuation and expansion beyond the 

active Marine divisions to the air wings, logistics 

groups, and possibly the drilling reserves. 

In 2006 and 2007, the Marine Corps sponsored 

several working groups to further develop OSCAR 

capabilities and requirements, with representation 

from stakeholders including Marine Corps health 

services, religious programs, training and education, 

and the operating forces. Optimal OSCAR capabilities were developed. In acknowledgment of the core 

Marine Corps concept that combat and operational 

stress control is primarily a leadership responsibility, and should be focused on force preservation and 

readiness through prevention and early identification 

more than treatment, the OSCAR program was moved 

from health services to the Combat Operational Stress 

Control Program under the deputy commandant for 

manpower and reserve affairs. 

Despite the 2007 DoD report15 recommending that 

operational psychological health professionals be embedded in line units, staffing of OSCAR teams by the 

Navy remained on an ad-hoc basis because of other 

pressing needs for mental health resources across the 

system. Sustaining OSCAR became increasingly difficult without a formal requirement from the Marine 

Corps. In response, the commanding generals of the 

three Marine expeditionary forces (MEFs) wrote to the 

commandant of the Marine Corps, stating, “We need . 

. . OSCAR teams across the three MEFs. We must fully 

staff, fund, and equip the OSCAR program as soon 

as possible to support current combat operations.”17

A formal request for OSCAR staffing was sent by the 

Marine Corps to the Navy in early 2008. Within a few 

months, the Navy approved funding to permanently 

staff OSCAR in the Marine divisions and regiments, 

both active and reserve, starting in 2010.

Capabilities

OSCAR teams provide the following capabilities 

for operational commanders: 

	 •	 psychological health surveillance of unit

members and units as a whole; 

	 •	 preventive psychological health training and

education when and where needed; 

	 •	 early interventions to promote recovery in

individuals and units from traumatic stressors 

or losses; 

	 •	 clinical mental healthcare services in forward

operational environments where such services 

would otherwise be unavailable; 

	 •	 professional coordination of comprehensive

mental healthcare services in garrison before 

and after deployments to ensure readiness; 

	 •	 support of spiritual fitness of operational forces throughout the deployment cycle through 

partnerships between religious ministry and 

mental health personnel; and 

	 •	 psychological health support for unit medical

and religious ministry personnel who are at 

high risk for stress-related problems. 

OSCAR capabilities are critically dependent on 

teams being organic, that is, embedded within operational units, much like the traditional model of Navy 

hospital corpsmen. By placing OSCAR teams within 

units, team members can fully learn and appreciate the 

specific missions and cultures of the units they support 

throughout the deployment cycle: before, during, and 

after deployment. 

The ultimate objectives of OSCAR capabilities in operational units are (a) enhanced readiness, (b) reduced 

stress-related decrements to mission effectiveness, 

and (c) enhanced long-term health and well-being 

of marines, sailors, and their families. OSCAR teams 

provide psychological health training to marines and 

Marine leaders, and reduce the stigma associated with 

receiving mental healthcare. They can assist leaders 

and marines with informal “hallway consultations” 
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on symptoms and complaints to encourage early mitigation of stress and to promote the earliest interventions when necessary. Team members also serve unit 

leaders as advisors on how to prevent stress, monitor 

the psychological health of their units, and take necessary actions to promote healing. Compared to mental 

health services provided at medical treatment facilities, OSCAR is much more focused on prevention and 

population-based mental health than on individual 

clinical care, relying on familiarity between marines 

and mental health professionals established prior to 

deployment and maintained through and after deployment. The goal is to increase psychological health 

awareness and break down barriers to seeking mental 

healthcare.

Team Design

Marine Corps OSCAR teams provide two licensed 

mental health professionals and two psychiatric technicians per regiment, or approximately one licensed 

professional and one psychiatric technician per 2,500 

marines. According to the 2007 DoD task force on 

mental health report to Congress:

Determining the proper ratio of embedded providers 

to service members would require additional research; 

however, evidence from site visits suggested that the 

Army’s ratio of one psychologist or social worker and 

one psychiatric technician per 5,000 service members 

is probably not sufficient.14(p17)

A team is also attached to each division to provide 

services to independent battalions and oversight to 

the regimental OSCAR teams. OSCAR teams are part 

of each commander’s special staff, reporting to the 

command surgeon. Several different clinical specialties are utilized on OSCAR teams, with a typical team 

configuration as follows: 

	 • one prescribing, licensed, independent mental 

health practitioner (psychiatrist, prescribing 

psychologist, or psychiatric nurse practitioner);

	 • one nonprescribing, licensed, independent 

mental health practitioner (psychologist or 

licensed clinical social worker); and 

	 • two psychiatric corpsmen.

Although still not an ideal ratio of providers to 

marines to meet the intent of close proximity, familiarity, and trust, this configuration affords OSCAR team 

members a much larger presence than previously possible. The use of other unit medical professionals, such 

as physicians and more numerically abundant corpsmen, as OSCAR extenders through training and consultation with team members may be another avenue 

to improve OSCAR efficacy. The goal is to eventually 

place teams in all operating units, not only infantry 

regiments but also air wings and logistics groups.

Although OSCAR may be the newest combat and 

operational stress control program, it has clearly established itself as an integral component in the Navy’s 

mental health support to the Marine Corps. The SIC 

model itself is an outgrowth of experiences derived 

from OSCAR operations. The conceptual link between 

OSCAR and the SIC model is clear: a shared responsibility between unit leadership and medical/chaplain’s 

corps. This interaction fosters hardiness and resilience 

within the individual marine, who ultimately must 

bear the burden of combat and operational stress exposure. Consistent with the core values of the Marine 

Corps, personal responsibility is a critical component 

for maintaining mental health readiness, whereas 

leadership assumes responsibility for cultivating 

mental health resilience, and medical personnel and 

chaplains help restore mental health if stress injury or 

illness overcomes the individual. 

EMERGING CHALLENGES FOR OPERATIONAL NAVY MEDICINE

The US military forces have been strained by the 

GWOT.4

 Despite being a service dedicated to control of the 

seas, the Navy has stepped forward to share the burden of 

this prolonged conflict and continues to play a substantial 

role in ground operations for OIF and OEF. However, the 

allocation of Navy personnel to ground combat operations 

remains a nontraditional deployment, resulting in special 

challenges to combat and operational stress control programs based on the SIC model. Two of the more vexing 

challenges are detailed below. The first challenge is to 

provide care for Navy personnel individually assigned to 

augment positions within combat-deployed Army units, 

a duty referred to as “individual augmentation” (IA). The 

second deals with the development of a program to care 

for a force of medical professionals who, as the OSCAR 

section explicates, are in high demand, and as a result have 

sustained a high operational tempo and been exposed to 

elevated levels of combat. 

Individual Augmentation 

Although the percentage of sailors assigned to 

IA duty constitutes approximately 3% of active and 

reserve duty assignments in the US Navy, the cumulative effect of these deployments has created over 

46,000 combat veteran sailors through 2006, with over 

7,000 sailors being added to this total annually.18 The 

relative obscurity of this duty warrants a description 
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Expeditionary Operational Stress Control in the US Navy

of the IA deployment cycle and the Navy combat and 

operational stress control programs currently in place 

to address the unique and diverse mental health needs 

of “sandbox sailors.” 

Training and Deployment Cycle

As implied by their name, IA sailors prepare, deploy, 

and redeploy alone, and for the most part, outside 

Navy chains of command. Thus, standard Navy medical programs designed to monitor and treat mental 

health problems are not routinely accessible to IAs 

during many of the most critical points in their deployments. Before IAs deploy, Navy Medicine personnel 

conduct a mandatory predeployment health assessment (PDHA). The form used to conduct the PDHA 

is DD2795. The mental health aspect of the screening consists of the question, “During the past year, 

have you sought counseling or care for your mental 

health?” If this question is answered in the affirmative, 

the physician or healthcare specialist conducting the 

PDHA may refer the sailor to a mental health provider. 

Depending on the outcome of the mental health referral, the individual conducting the PDHA can classify 

the member as either deployable or nondeployable. 

Once deemed deployable, the IA detaches (either in 

a temporary duty status or as a permanent change of 

station, depending on the specific assignment) from the 

parent command and travels alone to a Navy mobilization processing site for final health, administrative, 

and legal processing. After spending a week at the 

processing site, sailors essentially leave Navy culture 

as they travel to their next destination, which for most 

is Navy IA combat skills training.

There, a cadre of Army drill instructors teach IAs 

elementary combat skills such as basic marksmanship, 

field medical procedures, rules of engagement, convoy 

operations, and codes of conduct to prepare the IA for 

integration into an Army-centric combat environment. 

In addition, most combat gear is provided at this training. Most Navy IAs receive the same training regardless of the duties they will perform when attached to 

their respective Army unit in theater. Although this 

broad-based training is beneficial because of the possibility of being remissioned (sometimes more than 

once) during an IA assignment, some of the missions 

now taken on by the Navy require competencies that 

can only be achieved by years of experience. 

One such example is detainee operations; although 

sailors with specific master-of-arms (equivalent to the 

Army’s military police) training are prepared for this 

duty, the majority of sailors conducting these missions 

are trained for unrelated positions, such as culinary 

specialists, machine mates, or yeomen. Within the 

typical 60-day IA training period, instruction relevant 

to guard force operations takes 17 days (with a capability for 4 additional days). A lack of confidence 

in performing a job can increase overall anxiety, and 

experience and training improve the ability to modulate combat stress (hence the dictum, “fight like you 

train, train like you fight”). An Army study19 found 

that at the start of OIF, 70% of soldiers deploying to 

Iraq were not psychologically prepared to experience 

combat trauma. 

To address this shortcoming, Navy Medicine has 

introduced a combat stress component to IA training, the goal of which is to cultivate cognitive coping 

strategies consistent with Kobasa’s stress hardiness 

cognitive style,20 characterized by (a) recasting challenges as opportunities for growth, (b) a commitment 

to self-improvement, and (c) the development of internal locus of control (ie, the ability to control events 

that affect one’s life). Evaluating the influence of this 

component is essential to refining and maintaining IA 

combat stress coping training, especially because the 

empirical data evaluating the efficacy of predeployment stress control programs are inconclusive.21

The IA deployment phase starts with transportation 

to the theater of operations for additional field-based 

combat skills training for 3 to 4 days. Then the IA 

platoon is disbanded and individuals are transferred 

to their ultimate combat duty stations, where, except 

for rest and recreational leave (up to 14 days), the IAs 

remain for the duration of their 6-, 9-, or 12-month 

obligation. At their combat duty station, IAs are under 

the authority of the requesting service (primarily the 

Army, although the Marine Corps also utilizes IAs). If 

necessary, the IA seeks healthcare services, including 

mental health, from the parent command. However, 

Navy combat and operational stress control programs 

reenter the picture as soon as the IA returns to the 

continental United States. As the IAs transit from their 

OEF/OIF deployment, they pass through the Navy’s 

Warrior Transition Program (WTP). 

The WTP addresses the “four Rs” of operational 

stress control: (1) reassurance that the IAs’ response 

to their deployment is nonpathological; (2) rest to 

compensate for the high operational tempo associated with 14-hour (or more) days, 6 to 7 days a week; 

(3) replenishment in terms of time to leisurely eat and 

shower; and (4) restoration of confidence.6

 Relieving 

the sailors of their bulky combat gear and completing 

customs inspections in advance also contribute to rest 

and replenishment, while reassurance and restoration are initiated with combat stress briefs delivered 

by mental health and faith-based caregivers. More 

than a prudent use of logistics, the act of gear turn-in 

(off-loading of “battle rattle”) and the surrendering 

of issued weapons (after one last ritualistic cleaning) 

are as symbolic as they are practical. The sudden 
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Combat and Operational Behavioral Health

absence of weapons may produce anxiety, which can 

be addressed by caregivers as part of the preparatory 

framework for returning home. 

The impetus for this program can be found in the 

postdeployment experiences of combat veterans like 

those described in Jonathan Shay’s seminal volume, 

Achilles in Vietnam.

22 In his book, Shay explored the 

need for leadership to provide a sanctioned time for 

“mutual support and communal reworking of combat 

trauma,”22(p61) which was part of “the long trip home” 

in World War II but tragically absent in Vietnam. Rather 

than screen for, or immediately address, combat stress 

reactions (eg, PTSD), a goal of WTP is to give IA sailors 

“permission” to grieve and acknowledge the toll of 

their deployment, while also celebrating successes and 

gains made during the deployment. These efforts are 

to help IAs begin integrating potentially fragmented 

and disassociated deployment experiences into a 

more coherent and integrated self-script or schema. By 

institutionalizing time for the IA to acknowledge the 

psychological effect (positive and negative) of deployment, it is hoped that WTP will reduce the perception 

of organizational stigma that service members consistently cite as a barrier to accessing mental healthcare.23

Mental health services are readily accessible during 

the WTP process. 

Analogous to the “third location decompression” 

process practiced by North Atlantic Treaty Organization countries, WTP takes place at temporal and 

geographical distance from the deployment site (the 

potential source of trauma), making it much different 

from critical incident stress debriefing approaches, 

which have been found to be ineffective or even detrimental to mental health.7–9 WTP is more consistent 

with end-of-tour unit debriefings shown to improve 

perceptions of organizational support.24 Nevertheless, 

because IAs do not participate in WTP with their 

combat comrades-in-arms, but with other IAs from 

different deployment locations and experiences, it 

remains to be seen whether group debriefing works 

for the IA population. Following WTP, which lasts 3 

days, IAs are flown directly home. Upon arrival at 

their destination airport, parent commands of some 

IAs may provide formal homecoming ceremonies 

that help foster reintegration. However, for many 

IAs, their mission often ends how it started—in 

isolation. 

Isolation Issues

In Vietnam, soldiers trained with one group of 

people, deployed alone to serve a 1-year combat tour 

in units of ever-changing composition, and returned 

home alone to either finish their service commitment 

or integrate into a new unit.22 By the 1980s a renewed 

appreciation for the protective nature of unit cohesion 

had arisen: 

One of the most significant contributions of World

War II and modern warfare was the recognition of the 

sustaining influence of the small combat unit on the

individual member. . . . Interpersonal relationships 

develop among soldiers and between them and their 

leaders. . . . It is these relationships which, during 

times of stress, provide a spirit or force which sustains the members as individuals and the individuals 

as a working, effective unit.19(pI-1)

Recent data indicate that unit cohesion can help 

reduce factors that place service members at risk for 

combat-stress–induced mental disorders such as PTSD. 

Brailey et al25 evaluated the contribution of unit cohesion to the prediction of PTSD symptoms in a sample 

of 1,579 nondeployed US Army soldiers. Next to 

predeployment life trauma, the degree of unit cohesion was the best predictor of predeployment PTSD 

symptoms.25 A diagnosis of PTSD or other psychological illness prior to deployment has been shown to put 

service members at increased risk for future development of PTSD.26 In another study,27 a comprehensive 

metaanalysis of 39 military samples prior to OEF/OIF 

indicated that unit cohesion was a significant predictor 

of well-being among a host of other outcomes such 

as individual performance, job/military satisfaction, 

retention, and readiness. 

Despite the general consensus that mental health in 

combat-deployed units is bolstered by the social support structures that emerge within cohesive units that 

train, deploy, and return together, the IA deployment 

has exposed a new generation of service members to 

the isolation of Vietnam-style individual deployments. 

Adding to this problem is the IA’s loss of service and 

professional identity. Data clearly support a link between job satisfaction and work-related stress.28 A common frustration voiced by IAs is dissatisfaction with 

the substance of their mission—work that may not utilize their hard-earned Navy designation or operational 

specialty. Also sometimes lost when sailors go on IA 

duty is respect for their rank. Each service emphasizes 

ranks differently. For instance, once enlisted sailors pin 

on the coveted anchors of a chief petty officer at E7, 

they become “khaki” (the same uniform officers wear) 

and are afforded great respect and autonomy within 

the Navy. However, many IAs indicate that the social 

status given to E7s in the Navy is equivalent only to 

that given to an E9 sergeant major in the Army. Data 

indicate that loss of social rank status is detrimental to 

mental health and a source of both psychological and 

physiological stress.29

Unfortunately, due to the nascent nature of IA 

deployment, little or no data are publicly available 
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Expeditionary Operational Stress Control in the US Navy

to evaluate the relative contributions of absent unit 

cohesion, low job satisfaction, and loss of social rank 

status in the prediction of combat-related stress reactions. One of the few studies to compare the mental 

health status of Navy IAs to nondeploying sailors18

found that in both the enlisted and officer ranks, 

sailors deployed to an IA billet exhibited significantly more mental health problems, but only if that 

deployment was to a hostile combat zone. This finding suggests that deployments to the Army have the 

greatest impact within the combat zone, highlighting 

the interaction between combat exposure and type of 

deployment. 

Administrative issues can also cause stress for Navy 

IAs. The handoff from Army to Navy at the end of a deployment is not always well coordinated, and because 

many Army units are unfamiliar with writing evaluations, fitness reports, or awards for Navy personnel, 

recognition for IA duty can be lacking (if evaluations 

and fitness reports are not in a Navy format, they are 

not accepted by the Navy Bureau of Personnel for inclusion in the service record). The Navy also reviews 

awards given by the Army, and has occasionally refused to accept or downgraded these awards, with a 

significant impact on the IA’s morale.

 An additional issue is family support. Although 

deployed Army units have robust family support 

programs, these programs are generally not designed 

to cross service lines and include the families of assigned Navy personnel. For IAs who are transient 

between permanent commands, the family may be left 

with little support. Thus, an area for further attention 

is ensuring that the families of deployed IAs receive 

appropriate support and information from the Army 

unit’s family support system. 

Adding to problems caused by the unique risks of 

combat and operational stressors for IA soldiers is the 

logistical distance between these sailors and the traditional Navy medical infrastructure. Navy Medicine 

personnel have limited opportunities to share the SIC 

model with the IA’s Army leadership, and thus the 

model’s emphasis on the interaction between unit 

leadership and caregivers to develop mental health 

resiliency is difficult to carry out. New initiatives based 

on IA duty continue to emerge, such as GWOT Support Assignment orders, wherein GWOT requirements 

are folded into normal permanent change-of-station 

orders. In response, Navy Medicine has initiated the 

development of combat and operational stress control 

programs tailored to meet the evolving needs of the 

IA mission, with programs at both the predeployment 

and postdeployment phases that introduce sailors to 

resilience-inducing cognitive coping skills and provide 

institutionally sanctioned time to grieve and begin the 

healing process. However, access to IAs in the combat 

zone remains a challenge to Navy Medicine and its 

health surveillance programs. 

Care for the Caregiver

Mission and Personnel

Navy caregivers include a broad range of professional and paraprofessional personnel charged with 

providing care and support to wounded, ill, and injured sailors and marines. Navy caregivers assume a 

number of roles, both traditional and nontraditional, 

including corpsmen, chaplains, substance abuse counselors, recovery coordinators, case managers, nurses, 

clinical support staff, and physicians. Some are civilians and some are contractors. 

Operational and occupational stress faced by caregivers is cumulative and extends across the deployment cycle. The acute injuries and chronic illnesses 

of war are treated across a continuum of care, from 

the front to hospitals and outpatient centers in the 

United States. For instance, a corpsman who tended 

to wounds in Iraq in July may be dressing wounds in 

San Diego, California in January. Dwell time (ie, the 

amount of time between deployments) does not necessarily include a respite from exposure to the wounds 

of war for caregivers. As a result, caregivers have an 

especially abbreviated opportunity for rest, replenishment, and restoration. The consequences of untreated 

cumulative stress can result in medical errors; somatic 

complaints such as changes in eating habits, gastrointestinal distress, headache, fatigue, and sleep disorders; 

change in work habits such as tardiness and absenteeism; mental and emotional difficulties such as memory 

disturbances, anger, self-doubt, isolation, and impaired 

judgment; and accidents.30–32

Navy Medicine caregivers are usually deployed 

as IAs to the combat zone, the exceptions being caregivers who are assigned to embedded duty within 

operational units (eg, hospital ships, EMFs, SPRINT 

teams, OSCAR teams). Uniformed caregivers selected 

for IA duty typically possess specific skill sets that 

are synergized to form an operational field medical 

asset. Personnel with combat-essential skills (Fleet 

Marine Force corpsmen, surgery, anesthesia, critical 

care, mental health) are particularly likely to deploy, 

often making multiple deployments within a given 

tour of duty. IA medical personnel are selected from 

hospitals and clinics around the world, given “just in 

time” training, and then configured with other caregivers to form a functional unit. At the end of their 

deployment, caregivers return as individuals to their 

hospitals and clinics. The protective connectedness 

of unit cohesion is lost when they leave their parent 

command and again when they leave their operational 
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Combat and Operational Behavioral Health

unit. Even more stress may be encountered by those 

who joined preexisting deployed units, a situation that 

makes “fitting in” even more difficult.

Trauma Exposure and Intervention Strategies

Providing care in a combat zone increases the likelihood of experiencing direct and secondary exposure 

to traumatic injuries. Direct exposure constitutes the 

threat to physical safety from direct and indirect fire, 

as well as the plethora of fatigue-inducing operational 

stressors. Secondary trauma can be encountered by 

working in close contact for extended periods of time 

with wounded, ill, and injured sailors, the result to 

caregivers being a phenomenon known as occupational or compassion fatigue. In relation to the SIC 

model, direct and secondary trauma can, individually 

or in tandem, contribute to full-blown stress illnesses 

for Navy caregivers. Stress injury and illnesses can affect mission effectiveness in the form of medical errors, 

job dissatisfaction, and poor retention.33

Part of the responsibility for enhancing the resilience of Navy caregivers rests with the leadership of 

Navy Medicine itself. Actions are underway within 

Navy Medicine to implement training based on the 

SIC model to run through all phases of training for 

Navy medical personnel. The core leader functions 

have been applied to day-to-day clinical leadership 

activities as well as facilitating the transition of Navy 

Medicine personnel in and out of different operational 

settings. One key point the SIC model should impart 

to the leaders of caregivers is that their roles and work 

environments are inherently stressful, and that stress 

reactions are common. Many leaders recognize that 

initial stress reactions increase caregivers’ energy and 

focus their attention on critical changes in a patient’s 

condition, while sustained stress causes a degradation of performance. Leaders should be aware that in 

caregivers’ work environments, occupational stress 

is endemic and may go unrecognized because such 

reactions become normalized. A difficult challenge to 

the leaders of caregivers is reintegrating individually 

deployed staff into a cohesive unit that did not deploy; the IA caregiver faces the dual task of reintegration while simultaneously letting go of relationships 

formed during deployment. 

The traditional work-stress–response paradigm in 

both civilian and Navy literature has several common 

elements: know the sources of job stress, know the 

signs and symptoms of stress, take care of oneself, and 

seek help when there is the beginning of impairment 

in daily life.5

 There are several significant barriers to 

self-help for caregivers. First, endemic job stress produces some level of stress symptoms in all workers, so 

that moderate and high stress appear normal. Second, 

early stress symptoms such as fatigue, impaired sleep, 

and confusion decrease the self-awareness necessary to 

initiate self-care. Third, caregivers are “other focused” 

and may consider self-care unnecessary or antithetical 

to their goals. 

When intervention is necessary, the “five Cs” of 

COSFA1—cover, calming, connectedness, capacity, and 

confidence—can prove especially helpful. Using the 

COSFA model, caregivers are encouraged to focus on 

other caregivers and their shipmates: facilitating connectedness and accessing the healing capability of unit 

cohesion requires breaking the “code of silence” by 

asking coworkers questions about their stress coping. 

Most caregivers do not feel comfortable approaching 

their peers with questions and concerns about the 

peer’s behaviors. The typical, “How are you doing?” 

is usually met with a response of, “Fine.” 

A strategy for facilitating connectedness is based on 

role expectations of shipmates and uses an “OSCAR” 

acronym (Exhibit 8-1). The OSCAR communication 

strategy encourages shipmates to address coworker 

behavior in five steps. First, observe the behavior, 

particularly signs of possible impairment, such as 

poor concentration, looking tired, falling asleep during change of shift, or irritability. Second, state the 

observation. The observation must be overtly stated 

because decreased self-awareness is one of the early 

casualties of a stress reaction. Third, clarify one’s role. 

The roles of shipmate, subordinate, supervisor, friend, 

and spouse help show why the behavior is being addressed, and help determine which options should 

EXHIBIT 8-1

OPERATIONAL STRESS CONTROL

ASSESSMENT AND RESPONSE

COMMUNICATION

Observation: actively observe behaviors; look for 

patterns.

State observations: focus all attention on the 

behaviors; just the facts without interpretations or 

judgments.

Clarify role: state why you are concerned about the 

behavior, which validates why you are addressing 

the issue.

Ask why: seek clarification; try to understand the 

other person’s perception of the behaviors.

Respond: clarify concern if indicated; discuss desired behaviors; state options in behavioral terms.
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Expeditionary Operational Stress Control in the US Navy

be used for the shipmate. Fourth, ask the shipmate 

for personal perception of what the behaviors are. 

Often, the act of talking about the behavior will allow 

the individual to clarify how a problem is affecting 

work behavior. Fifth, respond with guided options 

that are intended to facilitate change or offer to help 

the shipmate connect with other resources, such as a 

leader, chaplain, financial counselor, the Navy-Marine 

Corps Relief Society, or mental healthcare. 

Despite the increased risks of sustaining stress injuries when deployed or in the course of day-to-day 

work, Navy caregiver duty can be extremely rewarding and satisfying. The Navy “care for the caregiver” 

concept, based on the SIC model, encourages caregivers to use the same skills they developed to help their 

patients for helping each other. 

SUMMARY

The SIC model represents an ambitious attempt 

to assimilate the disparate conceptual frameworks of 

various stress control programs within the Navy, each 

of which has its own unique history, into a single yet 

comprehensive operational stress control paradigm. 

Within this model, three major stakeholders are responsible for supporting sailors and marines faced 

with the inevitable challenge of sustained operations: (1) leadership, (2) the service member, and (3) 

the caregiver. Leadership establishes the foundation 

for effective combat stress control by cultivating a 

command climate that recognizes the importance 

of mental health, institutionalizes stress resilience 

training, and removes barriers to care for those who 

experience stress reactions and develop illness or 

injury. Individual service members trained in stress 

resilience should be capable of developing their own 

individual stress coping strategies, identifying when 

their stress reactions are beyond their coping capacity, 

and knowledgeable and comfortable enough with the 

care options available to easily seek help when needed. 

Caregivers must actively pursue a consultative role, 

working to support the leadership in stress control 

efforts, yet remaining vigilant to identify sailors who 

react adversely to stress, and providing quality care 

to those whose stress reactions lead to illness and 

injury.

Expeditionary medical platforms, such as hospital 

ships and EMFs, provide a large, forward-deployed 

medical capacity for applying the SIC model. However, combat stress control program elements such 

as SPRINT, carrier psychologists, and OSCAR teams 

are the best embodiment of the SIC model. In fact, 

the SIC model itself is an outgrowth of OSCAR philosophy. Unfortunately, both the forward-deployed 

medical platforms and combat stress control elements 

are straining to adapt to the burgeoning demands of 

GWOT that have focused pressure on caregivers themselves, and taken sailors outside of the Navy sphere of 

influence during the course of IA duty assignments. 

Building upon the successes of the combat stress 

control program elements described in this chapter, 

which arose to meet specific operational demands, 

Navy medicine can again rise to meet the challenge 

of caring for combat deployed sailors.

A consistent theme in this chapter has been the utility of mobile and expeditionary Navy Medicine assets. 

Despite the necessity and quality of the centralized 

Navy medical capacity, it has been recognized that 

delivering care within deployed units has reduced the 

stigma associated with seeking help for stress-related 

illness. Moreover, the benefit is reciprocal: proponents 

seem to agree that caregivers themselves benefit from 

the social cohesion of serving within a unit, a situation that appears to improve caregivers’ credibility 

as well as their overall ability to intervene and treat 

stress-related injuries. 

Each section of this chapter represents cumulative knowledge gleaned from professional training, 

reviews of the literature, and most importantly, firsthand experiences with Navy combat and operational 

stress control programs. This chapter should also 

alert readers to areas where data are needed to evaluate whether the programs discussed are effective in 

managing combat and operational stress. Despite 

the myriad models and approaches described, Navy 

combat and operational stress control programs in 

their present state are a mission-centered collection 

of efforts that reflect the multifaceted and dynamic 

issues associated with stress control in combat and 

operational environments. The SIC model is a bold, 

yet necessary, attempt to weave these programs’ elements into an overarching Navy combat stress control 

philosophy. 

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