209

Behavioral Healthcare at Landstuhl Regional Medical Center

Chapter 14

behavioral healthcare at landstuhl regional medical center

JEFFREY V. HILL, MD*; DAVID REYNOLDS, PhD†; and RONALD CAMPBELL, MD‡

INTRODUCTION

ROLE OF LANDSTUHL REGIONAL MEDICAL CENTER IN WARTIME

Initial Assessments

Medical and Surgical Evacuees

Psychiatric Evacuees

CHALLENGES TO PROVIDING PSYCHIATRIC CARE TO EVACUEES

Patient Actions and Behaviors

Staff Characteristics and Actions

Development of an Emergency Mental Health Model

Local Area Support

INPATIENT PSYCHIATRY AT LANDSTUHL REGIONAL MEDICAL CENTER, 

2003–2007

Increasing Patient Load

Psychological Stressors and Staff Resilience

DEVELOPMENT OF LANDSTUHL’S staff RESILIENCY PROGRAM

Precipitating Event and Command Response

Structure and Focus of Program

DAily OPERATIONS

Member Dispersal

Committee Meetings

Surveys

CHALLENGES AND FUTURE DIRECTIONS

Program Director

Personnel

Central Point of Contact

Stigma

Data Collection

Types of Stressors

SUMMARY

*Lieutenant Colonel, Medical Corps, US Army; Chief, Child and Adolescent Psychiatry, Landstuhl Regional Medical Center, CMR 402 Box 1356, APO 

AE 09180; formerly, Chief, Outpatient Psychiatry, Landstuhl Regional Medical Center 

†

Major, Biomedical Sciences Corps, US Air Force; Mental Health Element Leader, Department of Psychology, Malcolm Grow Medical Center, 1050 

West Perimeter Road, 779 MDOS/SGOH, Andrews Air Force Base, Maryland 20762; formerly, Chief, Department of Health Psychology, Landstuhl 

Regional Medical Center, Landstuhl, Germany

‡

Chief, Inpatient Psychiatry Service, Department of Behavioral Health, Landstuhl Regional Medical Center, CMR 462, APO AE 09180
210

Combat and Operational Behavioral Health

The mission of Landstuhl Regional Medical Center 

(LRMC) is to provide world-class comprehensive and 

compassionate care to the nation’s warriors, their families, retirees, and all other patients as directed, while 

maintaining unit and personal readiness to meet the 

demands of the United States. This is accomplished by 

maintaining a trained and ready healthcare force that 

seeks, thrives on, and embraces change while accomplishing the healthcare mission, utilizing outcomes to 

drive medical decisions. 

LRMC sits on a hill overlooking the German city of 

Landstuhl. The garrison belongs to the Kaiserslautern 

military community, which consists of several military 

bases scattered in the Kaiserslautern area. Landstuhl is 

a city of 20,000 located in the Rheinland-Pfalz province 

of Germany, about 30 miles east of the French border, 

near the town of Kaiserslautern and Ramstein Air 

Force Base. US Army outpatient psychiatric care in 

Germany catchment areas consists of the Wurzburg 

area in the southeast, the Heidelberg area in the southcentral region, and LRMC, covering outpatient psychiatric care in southwest Germany (Figure 14-1).1

This US Army facility is the largest American hospital outside the United States and the only American 

tertiary (specialty) care hospital in Europe, serving 

245,000 beneficiaries within the European command, of 

which 100,000 are primary care beneficiaries. Landstuhl 

also supports active duty service members, their family 

members, and other beneficiaries in Africa and Asia. 

About half of the LRMC permanent staff is civilian, with 

Army personnel making up the next largest group, and 

the remainder being US Air Force and small percentages of Navy personnel. Some personnel are borrowed 

from local units. There are also global war on terror 

augmentees (including civilians). In total, about 2,800 

personnel are assigned to work at LRMC, with about 

ROLE OF LANDSTUHL REGIONAL MEDICAL CENTER IN WARTIME

LRMC serves as the primary evacuation center for 

Central Command, thus the majority of Operation 

Iraqi Freedom (OIF) and Operation Enduring Freedom 

(OEF) evacuees pass through LRMC. (Table 14-1 details 

the impact of OIF/OEF on the patient load at LRMC.1

) 

Nearly every day a transport aircraft lands at Ramstein 

Air Force Base near the city of Frankfurt and unloads 

medical evacuees who are then transported to LRMC. 

As they arrive, medics, nurses, physicians, and other 

clinicians gather in front of the emergency room. The 

patients are unloaded from the back of the bus, some 

walking, others on stretchers. As of November 24, 

2008, over 51,750 OIF and OEF service members have 

Figure 14-1. Landstuhl Regional Medical Center and outlying clinics as of 2007.

NATO: North Atlantic Treaty Organization

SHAPE: Supreme Headquarters Allied Powers Europe

Wiesbaden

Dexheim

Kleber

Vicenza

NATO

SHAPE

Baumholder

Landstuhl

Livorno

100,000 Primary

Care Beneficiaries

245,000 Total

Beneficiaries in

the European Command

2,200 permanent party. A typical day at LRMC in Fiscal 

Year 2008–2009 will see 20 admissions, 14 operating 

room cases, an intensive care unit (ICU) census of 6.4, 

2.5 births, and an average length of stay of 3.2 days.1

been treated at LRMC (10,575 battle injuries, 41,178 

nonbattle injuries). Of these, 35,939 were outpatients; 

the remaining 15,814 were inpatients.1

 Over 9,000 were 

returned to duty in Central Command.1

Initial Assessments

Staff members triage the patients, taking the most 

seriously injured to the ICU or surgery. The less seriously wounded and injured are taken to the medical 

and surgical wards, where they share rooms with 

other, similarly injured patients. The psychiatric 

patients are quickly evaluated and either sent to the 

INTRODUCTION
211

Behavioral Healthcare at Landstuhl Regional Medical Center

on the local economy. Patients treated at LRMC are 

usually discharged or complete their course of treatment within a week, thereafter returning to theater, 

the United States, or their home station. Many leave 

within 72 hours of arrival. 

Medical and Surgical Evacuees 

All patients evacuated to LRMC for medical and 

surgical reasons are screened for mental health issues 

by their primary physicians both downrange and 

upon arrival at LRMC. Most inpatients are briefly 

screened by members of the outreach team, which is 

separate from the consultation team and consists of 

multidisciplinary healthcare professionals, chaplains, 

and technicians trained to provide proactive mental 

health outreach to wounded warriors. Chaplains 

brief all arriving soldiers on combat operational stress 

awareness. Many primary care providers also include 

brief education and screening for combat-related emotional problems. Medical staff members are constantly 

trained to recognize and provide basic levels of care 

for combat stress and other combat-related symptoms. 

Few of these patients evacuated for medical or surgical 

reasons demonstrate significant psychiatric symptoms. 

Those demonstrating significant psychiatric symptoms 

are referred to behavioral health providers after ruling 

out medical etiologies. Inpatients in emotional distress 

or with symptoms secondary to emotional distress are 

referred to the behavioral health inpatient consultation 

team. Outpatients are referred to the outpatient behavioral health team. The inpatient consultation team 

consists of multidisciplinary behavioral healthcare 

workers (social workers, psychiatric nurses, psychologists, psychiatrists, counselors, and mental health technicians) who provide consultation and management 

suggestions to primary medical staff. 

Psychiatric Evacuees

Most arriving psychiatric casualties are triaged 

through either the outpatient behavioral health clinic, 

consisting of a multidisciplinary team of technicians, 

psychiatrists, psychologists, and social workers, or the 

after-hours on-call emergency clinicians. After-hours 

services are provided through the combined efforts of 

the LRMC and Ramstein Air Force Base psychiatrists, 

social workers, psychologists, nurses, and mental 

health technicians. 

Characteristics of Psychiatric Evacuees

Landstuhl supports various coalition countries. 

Foreign service members are rare in the outpatient 

TABLE 14-1

IMPACT OF OPERATIONS IRAQI FREEDOM

and ENDURING FREEDOM ON PATIENT

LOAD: A TYPICAL DAY AT LANDSTUHL. 

COMPARISON BETWEEN 2001 AND 2006

2001 2006 Change

Admissions 16 23 + 43%

Operating Room Cases 9 16 + 73%

Intensive Care Unit

Census 3 9 + 300%

Overall Acuity 2.7 5.01 + 85%

Meals 800 1,178 + 47%

Births 3 2.3 - 23%

Average Length of Stay 

(days)

4.6 3.4 - 27%

Pharmacy Products 1,026 1,589 + 54%

outpatient clinic or seen in the emergency room by the 

mental health team after hours. All psychiatric evacuations are seen, evaluated, and have their dispositions 

determined the day of their arrival. Many are on medications; most have been traveling for hours, some for 

days, and may be tired and hungry. 

While psychiatric patients are at LRMC, the Deployed Warrior Medical Management Center (DWMMC) tracks their progress and provides logistical 

support, including briefings, housing, food, finance, 

and other needed support. Each soldier is assigned 

a DWMMC case manager, a liaison from the service 

member’s unit or service, and given access to primary 

care physicians. DWMMC has other staff members, 

nurses, and medics or corpsmen, to assist as needed. 

The case managers and liaisons manage service members with the full spectrum of illness, from the severely 

injured to stable routine patients. 

Until 2007, outpatient evacuees from OIF/OEF 

usually stayed at another military base within the 

Kaiserslautern military community. Due to concerns 

about supervision and access to the hospital, a new 

facility known as the Medical Transient Detachment 

was opened in 2007, allowing many outpatients (especially psychiatric) to stay next to the hospital on the 

Landstuhl base. These patients fall under a military 

command organization with regular formations and 

accountability. During their free time they may engage in on- and off-post activities such as visiting the 

gym and the post exchange, or engaging in activities 
212

Combat and Operational Behavioral Health

Numbers of service

members with the diagnosis

160

140

120

100

80

60

40

20

0

Adjustment Disorder

Depression

Posttraumatic Stress Disorder

Anxiety Disorder

Bipolar Disorder

Figure 14-3. Top five Landstuhl Regional Medical Center outpatient psychiatry diagnoses for Operation Iraqi Freedom/

Operation Enduring Freedom evacuations during 2005 (563 

patients, diagnosis known on 507). Anxiety includes acute 

stress disorder/acute stress reaction. 

mental health setting but are often seen in medical 

and surgical wards. The number of OIF/OEF patients 

evacuated to LRMC has steadily increased since the 

war began (Figure 14-2). This influx of battle-zone patients significantly affects the daily mission at LRMC. 

Figure 14-3 demonstrates the top five diagnoses given 

to OIF/OEF evacuees by outpatient psychiatry during 

a 1-year period: (1) adjustment disorder, (2) depression, 

(3) posttraumatic stress disorder (PTSD), (4) anxiety 

disorder, and (5) bipolar disorder. 

Dangerous Patients

One notable characteristic of a majority of patients 

evacuated for psychiatric reasons is concern for 

dangerousness to self or others. Patient Movement 

Requests are the documents the evacuating physician 

completes in the combat theater when evacuating a 

service member from the combat environment. Each 

request contains a brief paragraph about the concerns 

leading to the evacuation. In a 3.5-month review of all 

available Patient Movement Requests of psychiatric 

patients evacuated to LRMC, the evacuating physician 

had concerns about suicidality or homicidality in nearly 60%. By the time of arrival at LRMC, however, active 

suicidal or homicidal thoughts diminish considerably. 

Less than 3% of OEF/OIF service members reported 

active suicidal or homicidal thoughts on presentation 

at LRMC in the psychiatric intake paperwork. Nevertheless, patient safety cannot be assumed; each evacuee 

receives a clinical assessment for dangerousness to 

self or others. When the evaluating provider deems a 

patient at-risk for harm to self or others, the patient is 

admitted to the inpatient psychiatry service. 

Patient Actions and Behaviors 

Patients who are evacuated for psychiatric reasons 

often have behavioral components to their illness. 

As described above, a high proportion are evacuated 

because of potential for harming themselves or others. They may be in the midst of an emotional crisis 

when they arrive at LRMC. Sometimes their efforts 

are manipulative attempts to avoid combat or simply 

to go home.2

 They often do the unexpected. By policy, 

if the assessing clinician has doubt about the patient’s 

ability to function in the outpatient setting, the pateint 

is admitted to LRMC Inpatient Psychiatry. 

Minimally Supervised

Until the establishment of the Medical Transient Detachment , evacuees were minimally supervised. Now 

there is a chain of command that increases supervision 

substantially. However, determined service members 

have accessed alcohol and weapons. Case Study 14-1 

describes the potential problem of an unsupervised 

patient stay at LRMC. 

Case Study 14-1: Two service members in their early 

twenties were evacuated from theater with adjustment 

disorder symptoms and triaged to outpatient evacuation to 

700

600

500

400

300

200

100

0

2003 2004 2005 2006

Year

Number of Patients

Figure 14-2. Operation Iraqi Freedom/Operation Enduring 

Freedom evacuations by year. Those seen in the Landstuhl 

Regional Medical Center outpatient clinics represent the 

majority, but do not include those admitted to the psychiatric 

ward in the evening or on the weekend.

CHALLENGES TO PROVIDING PSYCHIATRIC CARE TO EVACUEES
213

Behavioral Healthcare at Landstuhl Regional Medical Center

the United States. The evening after their evacuation they 

returned to the barracks and immediately booked a hotel in 

downtown Kaiserslautern, where they spent the next 2 days 

drinking local beer and missing medical and accountability 

formations. This resulted in delays in the soldier’s treatment. 

The soldiers’ down-range rear detachment commands were 

notified. 

Potential Harm to Self or Others 

Frequently by the time service members arrive 

at LRMC they expect to be sent home to the United 

States. They no longer consider returning to duty an 

option. When clinicians attempt to send such service 

members back to combat duty, it almost always leads 

to a worsening of symptoms with frequent acting out. 

Case Study 14-2 describes such a case. 

Case Study 14-2: A 25-year-old active-duty male soldier became involved in a love triangle with his girlfriend 

and her other boyfriend in the deployment environment. 

An altercation ensued in which the patient was attacked. 

Shortly afterwards he described symptoms of acute stress 

disorder relating to the attack. He was evacuated to LRMC 

after mentioning suicidal thoughts. On arrival at LRMC he 

related that the treating clinicians in theater had told him 

he would be going home. By the time he arrived at LRMC 

he demonstrated no symptoms. When told he would be 

returning to duty he became extremely anxious and all his 

symptoms of flashbacks, reported dissociation, dreams, and 

jumpiness returned. The following morning he presented 

to the emergency room after superficially cutting both his 

wrists. The treating clinician continued the air evacuation to 

the continental United States (CONUS) for treatment and 

disposition there. 

Case Study 14-3 describes the interaction of two 

soldiers who arrived at LRMC for different reasons 

requiring psychiatric evaluation and shared quarters 

while awaiting their evaluations. 

Case Study 14-3: Soldier #1 is a 30-year-old seasoned 

veteran, family man with several young children, on his third 

deployment. In prior deployments he had been personally 

involved in some of the most notable battles with intense 

urban warfare, including hand-to-hand fighting. He witnessed 

multiple deaths and maimings of both friendly and enemy 

forces. He presented to Landstuhl cardiology for onset of 

chest pains. There were no medical findings and he was 

referred to psychiatry for evaluation. 

His roommate, Soldier #2, a 24-year-old junior noncommissioned officer (NCO) on his first combat tour, had flown to 

the forward operating base on a helicopter, had never been 

outside the perimeter, never seen any combat action, nor 

witnessed trauma of any sort. He was anxious and reported 

vague suicidal ideation contingent on his return to theater. 

The two soldiers arrived together at the psychiatry clinic. 

Soldier #2 was evaluated first. The clinician felt that he presented too much risk for acting out if returned to duty and 

decided to return him as an outpatient to the United States. 

On his way out he met Soldier #1, the veteran war fighter, and 

gloated over the psychiatrist’s decision to send him home. 

He was happy and felt he got what he desired. 

After Soldier #1’s evaluation the clinician informed him he 

would be returned to duty. The chest pain was likely related 

to stress. Though he had some combat-related symptoms, 

the clinician felt he could be returned to duty with continued 

mental healthcare in theater. The veteran NCO pleaded with 

the evaluator not to send him back to combat. He cited past 

experiences, heroic actions, and circumstances contrasting with those of his “suicidal” roommate. He related how 

he knew his roommate was just lying to get out of duty. He 

stated he could never harm himself or lie about suicidality 

to get out of duty, but cited the unfairness of the situation 

where someone who had truly sacrificed and experienced 

much was returned to harm’s way, while someone who had 

never faced any danger would be spared threat. He further 

stated that after doing more than his share of combat he had 

been having premonitions that he would be killed in action, 

leaving his family alone and his wife widowed. The provider 

empathized with the soldier, but could not justify removing 

him from combat. In the end, the heroic NCO, Soldier #1, 

was returned to duty while Soldier #2 (most likely malingering) was taken out of theater. 

Similar situations repeat themselves nearly every 

day at LRMC and most likely throughout the military. 

Soldiers and other service members who have already 

sacrificed much are required to give more. Many other 

soldiers are returned to CONUS for suicidal ideation 

based solely on anxiety about returning to combat. Often the providers suspect malingering as a cause but are 

unable to act on mere suspicions and are unwilling to 

risk repercussions of a bad outcome due to the provider 

taking a risk returning such a patient to combat. 

Because of such incidents and the lack of supervision and control of return-to-duty patients while they 

await return to their units, most clinicians are not willing to send such patients back to the combat environment. In many cases such service members are using 

statements of self-harm to manipulate the system or go 

home early.3 An unfortunate aspect of their evacuation 

is that other soldiers, who will not go to the extremes of 

manipulation and may have some symptoms, will return to duty while those manipulating the system will 

achieve their exit from the situation. In this embroiled 

climate, clinicians are likely to continue exercising 

conservative judgment such that many patients will 

be sent to CONUS instead of returning to duty in Iraq 

or Afghanistan. The return-to-duty rate for OIF/OEF 

mental health evacuees at LRMC varies between 3% 

and 6%. Even when it is clear that a service member 

is malingering, the risks of that soldier acting out if 

forced to return to duty may necessitate continued air 

evacuation to the home station (Figure 14-4). 
214

Combat and Operational Behavioral Health

Circumvention of Evacuation Channels 

Many service members are evacuated to LRMC 

for routine medical evaluation. Often they present to 

LRMC’s behavioral health division as a self- or clinician referral. For the most part they have not yet been 

treated by behavioral health personnel in theater.3

Clinicians noted that this population’s return-to-duty 

rates were especially low. Often the mental symptoms 

increased after arrival at LRMC and even further after 

presenting to behavioral health. They are especially 

challenging to treat, given their isolation from sources 

of support and unit supervision.4

 Some were expecting 

to be sent to CONUS for treatment of their medical 

symptoms, but instead were found medically able 

to return to the combat zone. In essence, they skip 

in-theater mental health resources and become a rearechelon psychiatric evacuation upon presentation at 

LRMC. 

Clinicians observe that with this rear-echelon 

presentation, service members’ chances of return to 

duty are considerably less than if they first presented 

in theater (95%–99% vs 3%).5

 It seems that with each 

passing moment at LRMC, it becomes more difficult 

to return such a soldier to the combat zone. Living 

in a safe environment, along with a lowered expectancy of returning to combat duty, decreases levels 

of vigilance and combat mind frame, and alters one’s 

view of oneself. Often such service members develop 

ever-increasing psychiatric symptoms as their returnto-duty day draws near (see Case Study 14-2 and Case 

Study 14-3). One potential factor contributing to these 

mental symptoms is the loss of expectancy that they 

will return to duty. Such loss of expectancy has been 

found to be related to worse outcomes.6

One controversial approach, based on the assumption that these service members’ units and 

social supports are better in theater, is to return such 

soldiers to their combat duty stations to receive 

their care. They are triaged for dangerousness, and 

evaluation and treatment at LRMC are minimized. 

They are expected to return to duty and get further 

care in theater. Appropriate mental health resources 

are usually available through combat stress control 

or other behavioral health personnel in theater. This 

approach not only maintains the fighting force but 

potentially improves the long-term prognosis for 

those treated in theater. In a sense, without the presence of fellow soldiers to provide social support and 

a leadership role in a service member’s care, they will 

actually receive a lower level of care at LRMC than 

they would in theater with such peer support.3,4,6–8 It 

is assumed that many service members with similar 

emotional symptoms are functioning in the combat 

zone. Their presentation at Landstuhl behavioral 

health, rather than at their in-theater mental health 

service, is determined solely by their need for a medical evaluation, which should not determine the level 

of mental healthcare required. 

This approach, however, is not entirely without risk. 

Some of the potential hazards are that the service members may act out at LRMC, there may not be adequate 

care available for them in their combat duty stations, 

and they may perceive that they are being denied care 

at LRMC. The alternate approach of thoroughly evaluating and treating each such soldier is risky and may 

cause unnecessary delays in return to duty and thus 

lessen overall return-to-duty rates (Figure 14-5). 

Staff Characteristics and Actions

Rotating Staff

To meet the additional duty of immediately evaluating all OIF/OEF mental health evacuees, LRMC is 

augmented with clinicians who have been rotating 

to LRMC for the majority of the wars. Though the 

augmentees are vital to performing the LRMC OEF/

OIF mission, the rotations are not always predictable. 

Year

2003 2004 2005 2006 2007

Evacuations Return to Duty

700

600

500

400

300

200

100

0

Figure 14-4. Operation Iraqi Freedom/Operation Enduring 

Freedom total evacuations compared to return to duty by 

year until February 2007. Those seen in Landstuhl Regional 

Medical Center outpatient clinic represent the majority, but 

do not include those admitted to the psychiatric ward in the 

evening or on weekends.
215

Behavioral Healthcare at Landstuhl Regional Medical Center

Sometimes the clinicians scheduled to arrive never 

show up. Usually this is due to an administrative or 

mobilization problem. Sometimes the rotation schedule is manipulated, bringing a clinician to LRMC either 

later or earlier than expected, thereby creating overlap 

or underlap and resulting in too many clinicians at 

some times and too few at others. 

Augmentees are generally Army, Navy, or Air Force 

reservists. Usually they are clinically adept. They 

share the latest skills and knowledge from the civilian world, keeping the staff current. Some understand 

principles of combat operational stress control while 

others do not. They often need extensive training and 

supervision as they take on the relatively unique role 

of OIF/OEF evaluation and disposition. Figure 14-6 

demonstrates a 5-month period in which the numbers 

of OIF/OEF patients are graphed compared with the 

number of available providers in the clinic. The number of clinicians available does not always correlate 

with the number of OIF/OEF evacuations. In some 

instances it is almost an inverse relationship. The 

unpredictable OIF/OEF load and the unpredictable 

augmentee support challenge the ability of the clinic 

to provide cohesive, continuous mental healthcare to 

those living in the local area. 

The primary difficulty lies in maintaining adequate 

clinician availability to meet the surges of OEF/OIF 

patients without wasting clinician time or tying them 

down with excessive case loads. The need to maintain 

this reserve challenges measures of provider performance and productivity with the ever-looming threat 

that future personnel allocations will be based on that 

productivity. 

Outreach to Wounded Warriors 

As already mentioned, the majority of OIF/OEF 

evacuees sent to LRMC will stay only a couple of days. 

Concerned clinicians have consistently pondered the 

question, “What can we do to help the mental health 

of these patients?”9 Concerns expressed by clinicians 

interacting with the wounded warriors include concern about harming the soldiers’ mental recovery 

(perhaps by making them talk about their experience 

before they are ready, or by creating or worsening 

symptoms through conscious or unconscious suggestion during interactions) and concern about loss of 

follow-up care. 

More than one soldier has stated that discussing 

the problem once was hard enough. There was no 

desire or intent to discuss it with another professional 

later. The relationship that is formed when a soldier 

discusses trauma is often intense and trusting, and 

may be ill-timed given that the soldier will leave 

within the next couple of days. Thus the mental health 

professional may have concerns about consciously or 

unconsciously pathologizing or labeling the patient’s 

symptoms, or concerns about stigmatizing service 

members as either “crazy” or weak.10

Development of an Emergency Mental Health 

Model

The majority of clinicians serving in this capacity 

Mental Health

Channels in Theater

Buddy

Medic

Chaplain

Unit Leadership

CSC or BDE

Mental Health Team

Division Mental

Health Team

Restoration/Fitness

CSH

LRMC

Battle Lines

Combat

Support Hospital

Landstuhl Regional Medical Center

Brigade

Support

Area

Brigade

Support

Area

Division

Support 

Area

Brigade

Reserve

Area

Figure 14-5. Circumventing mental healthcare in theater. 

Soldiers evacuated for medical reasons who then present at 

Landstuhl for mental health reasons may have skipped all 

mental health resources in theater and, in essence, become 

rear-echelon psychiatric casualties (with rear-echelon returnto-duty rates). 

BDE: brigade; CSC: combat stress control; CSH: combat support hospital; LRMC: Landstuhl Regional Medical Center.

120

110

100

90

80

70

60

50

40

30

Number of OIF/OEF Patients

Number of Available Providers

10

9

8

7

6

5

4

OIF/OEF patients Providers available

Aug 06 Sep 06 Oct 06 Nov 06 Dec 06 Jan 07 Feb 07

[Note: Delete text at the bottom that begins with “LRMC Outpatient...” and 

bump up the font size of the text to the left and right sides of the graphic, 

as well as that on the bottom that indicates dates (“Aug06,” etc.).]

Figure 14-6. Comparison between Operation Iraqi Freedom/

Operation Enduring Freedom evacuations and available clinicians at Landstuhl Outpatient Behavioral Health Clinic.
216

Combat and Operational Behavioral Health

at LRMC have supported an emergency mental health 

model with the following key components: 

	 •	 Avoid stigmatizing service members. Avoid 

diagnostic labeling,11 and do not single out 

any one soldier. For example, clinicians could 

say: “Hello, I’m a psychiatrist working with 

your medical team. Every patient gets ‘topto-bottom’ care.”

	 •	 Look after basic needs. Many patients are less 

than 2 days out from a major traumatic event, 

though many of them have been having traumatic events for months in the deployment 

setting. Ensure that their physical needs (rest, 

food, medical care) are being met.

	 •	 Help them learn to ask for help and to communicate their needs. Let them know that the 

more comfortable they are, the sooner they 

will heal. Observe comfort measures—pain 

control, room temperature, hydration, nutrition, sunlight, and privacy.

	 •	 Ask about their pain and comfort. Using a 

0-to-10 pain scale (with 10 being the most pain 

possible and 0 being no pain), ask soldiers 

how they would rate the pain and at what 

level they would call the nurses. Catching 

the pain early may reduce the total amount 

of pain medication required.

	 •	 Help them answer questions about what 

happened. The most common questions 

asked by wounded service members at Landstuhl concern the status of their buddies, what 

happened, what weapons were involved, and 

whether they were personally responsible for 

what happened.

	 •	 Connect them with their unit if indicated. 

The unit may provide information to clarify 

the event and prevent solidification of false 

impressions or memories.

	 •	 Normalize reactions. Educate patients on 

symptoms they may experience.

	 •	 Refrain from making statements indicating 

that they are ill, or even that they scored higher than others on various screening tools.

	 •	 Talk about normal things—sports, football, 

or their hometown.

	 •	 Assess them for posttraumatic stress symptoms.

	 •	 Help service members take charge of their 

medical care. Ensure that they know what 

they need to about their condition and options, give them a sense of control, explore 

their knowledge of their injury, and help them 

understand the injury.

	 •	 Help them know when they can expect to fly 

and where they will be transferred. Many are 

anxious about the next step in their evacuation.

	 •	 Follow up on their care. Communicate to 

receiving physicians about service members 

demonstrating psychological symptoms.

	 •	 Instill hope by discussing others who have 

recovered from similar events.

	 •	 Sincerely express appreciation for what they 

have gone through. Add value and meaning 

to their experience.

Case Study 14-4: A 22-year-old soldier lost his vision 

in an explosion and was evacuated to LRMC. One of the 

outreach team members entered his room and noticed 

that the soldier’s lips were parched and dry. The team 

member asked him if he was thirsty. The soldier replied 

“Yeah, I guess I could use a drink.” There was a glass 

of ice water sitting a few inches away from where the 

soldier was resting his hand. The team member gave 

him the water then took his hand and showed him where 

the water was placed. During the ensuing conversation 

the team member mentioned that all the soldier needed 

to do is ring for a nurse to help him with his needs. The 

soldier replied, “I know that, but they are busy and there 

are a lot of us here.”

Case Study 14-5: A 23-year-old soldier lost his leg in 

an explosion in Iraq. When he arrived at LRMC he was 

agitated and anxious to know if his gunner had survived 

the explosion. His primary physicians were unsure whether 

25

20

15

10

5

0 Sept 06 Oct 06 Nov 06 Dec 06 Jan 07

Consults

ETOh

PTSD/ASD

Nighmares

TBI

Physical Trauma Other

Figure 14-7. Landstuhl Regional Medical Center psychiatric 

consultation to medical and surgical wards, September 1, 

2006, to February 1, 2007. By November 2006, the multidisciplinary Combat and Operational Stress/Staff Resiliency 

team and patient outreach teams were effectively established 

throughout the hospital. There was a significant drop in official consultations as informal, nonstigmatizing outreach efforts proceeded. Data are from 236 inpatient consultations.

ETOh: ethanol (alcohol abuse); PTSD/ASD: posttraumatic 

stress disorder/acute stress disorder; TBI: traumatic brain 

injury. 
217

Behavioral Healthcare at Landstuhl Regional Medical Center

they should tell him that the gunner, a close friend of his, 

had died. They contacted the behavioral health consultation team. In discussing his desire to know about his friend 

with the treating physicians, chaplains, and members of 

the soldier’s unit (by telephone), the team decided on an 

appropriate time and place to let him know the bad news. 

The team arranged for the service member to speak to 

his unit members by telephone during the meeting. The 

soldier was notably saddened by the news but stated that 

the additional support of his unit by telephone helped him 

“drive on.”

Case Study 14-6: A 25-year-old squad leader lost several 

squad members during a firefight and blamed himself for not 

reacting appropriately during the action. Regardless of what 

the physician and nursing staff told him, he continued to hold 

himself responsible for actions over which he had no real 

control. The outreach team arranged a telephone consultation with the soldier’s command and fellow unit members. 

During the conversation, the events of the firefight were 

related and the squad leader realized that he did not cause 

the deaths of his subordinates, but rather that he acted as 

any other NCO would have done. 

Local Area Support

One of the greatest challenges of the LRMC behavioral health division is to maintain consistent, continuous, mental health support to its catchment area 

despite unpredictable surges in staffing and patient 

load (Figure 14-7). Eight outlying clinics—(1) North 

Atlantic Treaty Organization, Holland; (2) Supreme 

Headquarters Allied Powers Europe, Belgium; (3) 

Vicenza, Italy; (4) Livorno, Italy; (5) Kleber, Germany; 

(6) Dexheim, Germany; (7) Wiesbaden, Germany; 

and (8) Baumholder, Germany—fall under the LRMC 

support area, which covers approximately 100,000 

primary care beneficiaries (see Figure 14-1). In addition 

to the primary care mission, the tertiary care mission 

includes approximately 245,000 total beneficiaries in 

the European command. Many service members in 

the LRMC support area have served in OIF/OEF and 

experience ongoing sequelae of their time there,1,12

resulting in additional combat-related patients for the 

psychiatry service.

INPATIENT PSYCHIATRY AT LANDSTUHL REGIONAL MEDICAL CENTER, 2003–2007

Increasing Patient Load

The inpatient psychiatry service maintains an 18-

bed service for all active duty service members and 

beneficiaries throughout Europe, Asia, Africa, and 

the Middle East. Criteria for admission are similar to 

those in the civilian world. However, given the limited 

supervision of patients treated and evacuated in the 

outpatient setting, if an evaluating provider has concerns about safety, including the patient’s potential to 

abuse substances, then the patient is admitted, usually 

for continued evacuation in the inpatient setting. In 

2003 there were 382 OIF/OEF service members admitted; in 2004 there were 269; in 2005 there were 346; in 

2006 there were 408; in 2007 there were 563; and as of 

October 2008 there were 481 OIF/OEF admissions. As 

for total admission numbers, which include OIF/OEF 

as well as other patient populations (family members, 

local military), there were 902 total in 2006, 990 total 

in 2007, and 822 (as of Oct 2008) in 2008. 

The majority of OIF/OEF patients admitted remain in the inpatient setting for evacuation to the 

United States. Most OIF/OEF admissions continue 

their evacuation within a couple of days, leading to 

extremely rapid turnover on the ward. Contacting 

an accepting physician in the United States can be 

challenging, especially given the 6- to 9-hour time 

difference and sheer volume of turnaround. This is 

partially resolved by the ability to send patients on to 

Army hospitals with an “open OIF/OEF” status that 

does not require physician-to-physician discussion to 

establish an accepting physician. However, such is not 

the case with accepting hospitals from sister services, 

which often require physician-to-physician establishment of acceptance. 

Prior to 2003, the 18-bed inpatient psychiatry service 

had averaged about 675 admissions per year. By June 

2003, it was admitting 100 patients per month (1,200 

annualized rate). As many of the admissions seemed 

inappropriate, a 100% screening was implemented for 

patients arriving from OIF. This helped, but in 2005, for 

example, 902 patients were still admitted (Figure 14-8 

and Figure 14-9). The 100% screening, in turn, caused 

its own problems. It became necessary to change the 

psychiatry call schedule to accommodate the numbers 

of OIF patients who were arriving and needed screening. The inpatient psychiatrists were augmented by 

outpatient psychiatrists and further augmented by the 

local Air Force providers. 

The ward itself was augmented by a succession of 

reservists. The nursing personnel came for a year at 

a time. Their “train up” required an intensive schedule of activities before they could begin to “orient.” 

Even after the formal train-up activities, the nursing 

personnel required considerable time to make them 

comfortable in handling all the nuances of the inpatient ward. 

The psychiatrists who came to augment LRMC were 

there for only 90 days. They varied greatly in experience levels, ranging from current active duty to reserv-
218

Combat and Operational Behavioral Health

ists who had never been activated. Some were quickly 

able to absorb the complexities of the rapid turnover of 

patients, while others could master only a portion of 

the tasks at hand. The Composite Health Care System 

electronic medical record used throughout the military 

proved to be a record-keeping system that many inexperienced physicians could not master. 

The effect of the patient volume can be understood 

by dividing 902 admissions in 2006 by the number 

of inpatient beds available: 18. The result, 50.1, is the 

number of times that a bed was turned over during 

the year. Dividing that 50 into 365 yields a theoretical 

length of stay of slightly over 7 days. 

Receiving patients, screening them, stabilizing them 

on the ward, and placing them on an aeromedical evacuation became the routine. With increased OIF/OEF 

workload, the ward was frequently too full to accept 

nonactive duty patients. The “available to nonactive 

duty” measure (over 90% on an annual basis during 

the pre-OIF period) decreased to approximately 60% 

once casualties from OIF began arriving (meaning that 

there were spaces available to nonactive duty personnel only 60% of the time.) 

With the slowly increasing census of inpatients 

since 2003, air evacuation flights from Landstuhl to 

CONUS became more and more crowded. Beginning 

in November 2006 and continuing regularly over the 

next several months, the inpatient team encountered 

difficulties getting patients out on air evacuation 

flights fast enough to have beds available for incoming service members. Service members coming 

from garrisons in Europe were diverted to German 

hospitals. Such diversions of active-duty soldiers to 

German hospitals usually lasted only a few hours 

to a couple of days, but demonstrate that the 18-bed 

inpatient psychiatry ward is insufficient to handle 

both local support and air evacuation missions during wartime. 

Psychological Stressors and Staff Resilience 

The daily psychological stressors for LRMC team 

members are significant. A recent article in a German 

newspaper described LRMC’s role as being at the outer 

perimeter of the Iraq battlefield.13 Indeed, in previous 

wars many of the casualties arriving at LRMC would 

not have made it out of theater. Now, however, modern 

transportation and stabilization capabilities bring the 

battle to LRMC’s front door,13 exposing many LRMC 

staff to trauma of combat casualties on a daily basis. 

In previous wars the patients seen at LRMC would 

probably have been seen in a hospital much closer to 

Number of Patients

Year

Operation Enduring Freedom

Operation Iraqi Freedom

2002 2003 2004 2005 2006 2007

1000

900

800

700

600

500

400

300

200

100

0

Figure 14-8. Landstuhl Regional Medical Center inpatient 

admissions, 2002 through July 2007.

Suicidal

Year

Suicide Attempt

Homicidal

PTSD

2003 2004 2005 2006 2007

400

350

300

250

200

150

100

50

0

Figure 14-9. Landstuhl Regional Medical Center (LRMC) 

inpatient admissions, 2003 through July 2007. LRMC began 

tracking homicidal ideations and posttraumatic stress disorder (PTSD) in 2004.
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Behavioral Healthcare at Landstuhl Regional Medical Center

the battlefield. The Combat and Operational Stress 

Response/Staff Resilience Program at LRMC was 

developed to address the short- and long-term consequences of this experience with casualties. 

Compassion Fatigue

In its present-day connotation, compassion fatigue 

refers to the deleterious effect on caregivers of repeated 

exposure to physically or psychologically traumatized 

patients. Compassion fatigue was initially construed 

as a secondary trauma experienced by those treating 

PTSD patients, who have experienced primary trauma.14 The symptoms are similar. And although it has 

been called various things (secondary traumatic stress 

disorder or compassion stress), the main point is that 

anyone in a care-giving or helping profession—from 

psychotherapists to nurses to police—can experience 

acute and chronic stress reactions in the course of their 

duties. So, too, may they experience symptoms as a 

result of their own primary trauma or occupational 

burnout. 

Specific to LRMC, compassion fatigue results from 

caregivers’ repeated exposure to soldiers with severe 

burns, amputated limbs, or traumatic brain injury. 

With the exception of those staff who have worked 

in major metropolitan trauma centers, most have 

not been exposed to this frequency and severity of 

wounds. Because LRMC is the deployed location for 

many of its personnel (ie, the Navy and Army reservists who deploy to Landstuhl to help with the wartime 

mission), many staff who are actually deployed personnel will face deployment-related stressors such as 

being away from home and loved ones. 

Combat and Operational Stress Reaction

Army Field Manual 4-02.51, Combat and Operational 

Stress Control,15 redefines soldiers’ negative reactions 

to combat and support operations (previously known 

as “battle fatigue”) as combat and operational stress 

reactions (COSR). This new term considers soldiers 

who are not directly involved in battle but nonetheless develop stress-related symptoms (loss of appetite, 

increased irritability, or a desire to smoke), as having 

a normal reaction to a potentially hostile environment 

and the related demands that this entails (high operations tempo, living in austere conditions, and extensive 

separations from family). 

Resiliency

Just as two soldiers can be involved in the same 

firefight and one develop COSR while the other 

does not, so, too, can two providers treat a similar 

number and type of patients and one develop compassion fatigue while the other remains intact. The 

mechanism that allows this has come to be called 

“resilience.” Combat and Operational Stress Control15

mentions resilience as something that is desirable 

and can be increased, but does not describe how this 

can be accomplished. 

Resilience as a phenomenon has been studied in 

the civilian population, including in children who 

suffer physical and emotional abuse or neglect,16 adult 

victims of crime,17 and people exposed to natural 

disasters.18 Proposed factors leading to individual 

resilience are physical (exercise, nutrition), emotional 

(social support, optimism), psychological (attributional 

style), and spiritual (a life meaning or purpose). Unit 

morale and cohesion are additional factors within 

the military social context that may lead to resiliency 

among troops. 

DEVELOPMENT OF LANDSTUHL’S STAFF RESILIENCY PROGRAM

Precipitating Event and Command Response

Following a series of patient fatalities in LRMC’s 

ICU in July 2005, the hospital commander contacted 

the on-call chaplain to discuss what could be done to 

alleviate some of the providers’ stress. After that discussion (and the resulting actions taken to help reduce 

the effect of these ICU deaths on the staff), a team was 

formed to address this overlooked need among physicians, nurses, and their technical staff. 

A consultative team approach was deemed the best 

way to deal with these operational stressors. Although 

various agencies (chaplaincy, employee assistance 

program, behavioral health) already existed to help 

LRMC staff cope with stress or PTSD symptoms, these 

services were not accessed by those in need for various reasons (eg, stigma, availability). The plan was to 

provide outreach by chaplains and behavioral health 

staff who typically worked in close proximity with 

LRMC staff to address their concerns and direct them 

toward the best resources. 

Structure and Focus of Program

In November 2006, the compassion fatigue team 

changed its name to “Combat and Operational Stress/

Staff Resiliency” (COSR/SR). This is not merely semantics. Rather, the scope of concern has been widened beyond compassion fatigue (trauma secondary 

to care giving) to include COSR, acute or chronic 
220

Combat and Operational Behavioral Health

reactions to primary trauma (ie, PTSD), burnout, and 

efforts to restore or improve resiliency. In addition to 

physicians and nurses in the ICU, COSR/SR consultation now includes all LRMC staff, from those who 

carry litters and help move patients, to the finance 

staff who hear soldier’s stories as they help with pay 

and benefits. 

Program Director

Prior to August 2006, LRMC’s COSR/SR team 

utilized an informal committee led by a behavioral 

health provider. Funding was secured to hire a clinical 

psychologist to fill the position of program director. 

This individual leads the team and, more importantly, serves as the main point of contact for COSR/

SR-related questions. This program director is tasked 

to conduct a majority of the brief consultations and 

office visits. 

Team Membership

The COSR/SR team is composed of chaplains, 

nurses, and behavioral health providers in officer 

ranks or their civilian equivalent. Team members 

voluntarily take on—as an additional duty—reaching 

out to LRMC personnel who might not otherwise access services for symptoms that develop as a result of 

treating severely wounded soldiers and operations in 

support of this mission. They also make short presentations at various venues—newcomers’ orientation, 

professional and clinic staff meetings, and for new 

leadership. Additional ways of “getting the word out” 

about the program include a trifold brochure that outlines the program. A business card listing online and 

local resources is also used. Finally, e-mail messages 

distributed to LRMC staff describe sponsored events 

(sleep hygiene or stress-management classes) and 

highlight the COSR/SR program. 

Confidential Visits

In an attempt to circumvent the often-noted stigma 

associated with seeking help, LRMC’s COSR/SR team 

allows for two consultation meetings that are highly 

confidential. If there is no diagnosis, there is no documentation. As always, domestic violence, child abuse, 

and intent to harm oneself or others must be reported. 

Although previously one “free” visit had been advertised, the hope was that a second such visit would 

allow for additional assessment of any advice or suggestions given. If the problems were continuing, this 

second visit would give the COSR/SR team member 

a better opportunity (because of increased rapport) to 

encourage entry into some form of treatment or referral 

to an appropriate resource.

The goal is for LRMC staff to feel comfortable in 

reaching out to COSR/SR team members, knowing 

they can get some advice on psychological or emotional symptoms they may experience as a result of 

their work at LRMC or from other situations. Some 

of the symptoms LRMC staff may experience include 

poor sleep, increased irritability, and hypervigilance. 

The key is that LRMC staff must have confidence that 

their personal affairs will remain private and their 

careers will not be put in jeopardy. In those cases 

where minor support and guidance is not enough, 

COSR/SR team members will point the LRMC staff 

member in the right direction and, perhaps, answer 

some questions of concern such that, in most cases, 

their anonymity is protected. 

Hallway Consultation Versus Office Visit

In an attempt to track the utility of LRMC’s COSR/

SR program, short, informal consultations were differentiated from longer, sit-down sessions. This differentiation is useful to characterize support and minimal 

advice-giving from processing and intervention. For 

example, during October through December 2006, 65 

LRMC staff were provided hallway consultation and 

four were seen in an office visit. Of these, 20% were 

later seen in formal treatment. Due to a multitude 

of changes from one month to the next, these visits 

fluctuate. In March and April 2007, for example, the 

COSR/SR team had 38 hallway consultations and 46 

office visits. In part due to the increase in office visits, 

the follow-on to treatment rate dropped to 10%. 

In addition to tracking hallway consultation versus 

office visits, COSR/SR team members collect information on the staff member’s ward or clinic. By learning 

about the events and environment of wards and clinics 

throughout the hospital, the COSR/SR team is able to 

understand the experiences and conditions of most 

of the hospital workers. The COSR/SR team can then 

reallocate resources to those areas most needing them. 

When the mental health needs, working environment, 

or experience of the staff dictates, consultation with the 

clinic or service chief may prove beneficial. 

Debriefs

Critical incident stress management defusings and 

debriefings appear to have fallen out of favor. However, hospital staff can still benefit from a chance to 

process their experiences in a safe, nonjudgmental 

setting. LRMC’s COSR/SR team attempts to provide 

this environment. A prime example of where this ap-
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Behavioral Healthcare at Landstuhl Regional Medical Center

pears to be helpful is with the personnel team, which 

provides litter bearers and evacuation personnel for 

the incoming and outgoing flights. Many of these 

team members are exposed to physically traumatized, 

wounded, maimed, and dying service members. 

These LRMC staff are at substantial risk for mental 

and emotional problems. At the end of each team’s 

1-month rotation, a debrief is held during which 

a chaplain, supported by another COSR/SR team 

member (typically a behavioral health staff member), 

leads the members through mental processing. Most 

of the manpower team members feel the experience 

is meaningful and generally positive. Often they develop a greater appreciation for the positive factors 

in their lives, such as health, well-being, and a supportive family. Occasionally problems with the system 

are discussed in the debriefings. Problems (with the 

personnel system or other units debriefed) that can 

be remedied by command action are anonymously 

conveyed to command staff who may act to correct 

the situation. 

In the months of March and April 2007, 134 LRMC 

staff were debriefed in some capacity, either because 

of a critical event (death of a patient who was on the 

ward for an unusually long time) or a chronic stressor (higher than average number of amputees). One 

example of the latter is a young troop member who, 

while replacing equipment in a wounded soldier’s 

room, was affected by the smell of the patient’s burn 

wound. He said that on and off for several nights afterward he dreamt of the event. By addressing how the 

human brain processes trauma to self or others, and 

normalizing his reaction, he was able to quickly return 

to his previously high-functioning status. 

DAILY OPERATIONS

Member Dispersal

Team members are dispersed throughout the 

hospital to consult on COSR/SR as needed. Additionally, members take part in hospital committees 

and functions to ensure that system-wide efforts are 

made to reduce stress or provide input to command 

staff on actionable items. The main point is that the 

COSR/SR team attempts to address issues not only 

on a one-on-one basis, but also at higher levels within 

the organization, by consulting with supervisors and 

commanders. In large part this is due to research suggesting that unit morale and cohesion are factors of 

resiliency, which should be addressed at all levels by 

everyone involved. 

Committee Meetings

The multidisciplinary COSR/SR team convenes 

weekly to discuss consultation trends and upcoming 

issues, either in terms of wards or units affected, or 

the types of stressors reported. The meeting is vital 

to disperse information and provide emotional and 

leadership support to team members. Based on the 

feedback from the team members, an accurate picture 

can be developed of the emotional status throughout the hospital and resources can then be allocated 

to those areas needing them. A forum is provided 

where advice dealing with particular situations can 

be asked for and shared. Additional planning is also 

coordinated at these meetings to ensure continued 

advertising and coverage for clinic debriefs or presentations. 

Surveys

In an attempt to keep pace with LRMC as a dynamic 

organization, the COSR/SR team periodically surveys 

various wards or sections on stress levels, morale, and 

general knowledge of the program.

CHALLENGES AND FUTURE DIRECTIONS

Program Director 

Presently [in 2007], the COSR/SR program has 

funds for a 1-year program manager position, someone solely dedicated to advancing the program and 

working with staff. Although additional funds will 

be requested, it is difficult to find potential candidates 

willing to relocate to Germany, knowing their position 

is time-limited. Other options, such as using interns 

or community volunteers, are being considered. Additionally, there is some debate whether the ideal candidate for the position of COSR/SR program director 

should be a psychiatrist, psychologist, or social worker, 

with or without experience in community or systemwide interventions. Ideally the candidate would be 

familiar with the military and its deployment process 

as well as the healthcare system in general and work 

at a major medical hospital, specifically. 

Personnel

The Mental Health Advisory Team II noted that 
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Combat and Operational Behavioral Health

20% to 30% of behavioral health personnel reported 

burnout, low motivation, or some form of impairment 

related to deployment.19 Thus, it will be important to 

assess COSR/SR team members and provide respite 

or resiliency support to avoid their becoming overwhelmed.19 Consideration is being given to the use 

of enlisted medical technicians to work with enlisted 

LRMC staff seeking access to the COSR/SR program. 

Additionally, peer support personnel may be culled 

from LRMC’s wards and clinics to help augment the 

COSR/SR team. Within the framework of focusing on 

building and supporting staff resiliency, clinic chiefs 

and NCOs may be encouraged to identify those subordinates they see as “resilient” and match them up 

with those deemed “at risk.” 

Central Point of Contact 

One difficulty noted is that hospital staff may not 

know who to contact, especially given the need for 

team members to rotate on-call availability. Asking 

around to find the appropriate person may feel uncomfortable. It also decreases the anonymity of the 

person seeking help. Efforts are being made to simplify 

the process by establishing a designated cell phone 

number to be carried by the COSR/SR team member 

on duty. That cell phone number could be published 

throughout the hospital, thus ensuring that hospital 

workers know how to access the team. 

Stigma

Recent surveys of LRMC staff show continued 

evidence of a stigma against seeking help from any 

official program. The COSR/SR team continues to 

advertise the difference between COSR help and being ”crazy” (ie, psychotic), as well as the likelihood 

of career impact from voluntarily seeking behavioral 

health counseling versus being command directed to 

seek such help. These data collection points will be 

included on future surveys. 

Data Collection

The aforementioned surveys used a modified form 

of the Secondary Trauma Cost-of-Caring scale20 with 

unknown validity and reliability. Future efforts will go 

toward securing or developing a sound psychometric 

tool with which to assess COSR/SR. Ideally such 

measures would include objective indicators of the 

organization’s health as a whole. For example, days 

missed from work or number of letters of counseling 

or reprimand might be useful signs of organizational 

distress, which could then be tracked. 

Types of Stressors

In an effort to obtain more data to form more 

precise interventions, LRMC’s COSR/SR team has 

begun to collect information about the types of 

stressors addressed—operational, organizational, 

occupational, home front, interpersonal, or other. 

The pace of one’s duty is an example of an operational stressor. An organizational stressor could be 

the impact of staff turnover during the permanentchange-of-station season. Occupational stressors 

include burnout and the effect of a specific duty 

(working with amputees or burn victims). Home 

front and interpersonal issues are self-explanatory 

and take the form of relationship problems or parenting issues, and communication or teamwork in the 

workplace, respectively. Considered in the “other” 

category are attempts by COSR/SR team members 

to reassure staff that psychotherapy works, addressing how confidential sessions really are, or defining 

various diagnostic categories (ie, “Am I dealing 

with acute stress disorder or PTSD and what does 

that mean?”). 

SUMMARY

The COSR/SR team at LRMC has grown from a 

“psych–spiritual” dyad, consisting of a behavioral 

health provider and chaplain supporting ICU staff, 

to a full compliment of providers from several 

disciplines and branches dispersed throughout the 

hospital, to include the much-appreciated ancillary 

and support services such as finance and personnel 

teams. The scope of concern has been widened from 

provider secondary trauma (ie, compassion fatigue) 

to all stress reactions produced by operating in a 

major medical facility that receives nearly every 

OEF/OIF casualty. This adaptive contingent of professionals will be bolstered by additional direction 

and support from higher command levels (in terms 

of funding and personnel), and will lean towards 

becoming a proactive (rather than a reactive) force, 

perhaps through a newcomer’s combat and operational stress assessment and resiliency development 

plan, yet to be created. Work remains to be done, 

but the underlying concept of the COSR/SR team 

approach is sound and of value to the LRMC staff 

and the patients they serve. 
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Acknowledgment

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and developed many of the interventions discussed in this chapter.
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