Psychologist Role Flexibility in War Zones

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Psychologist Role Flexibility in War Zones

• Joseph Francis, Psy.D.
• Christina Carmody, Psy.D.
• Brian Smullen, M.D.
• July 21, 2006

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Objectives

• Discuss the differences of deployment platforms
  that affect the nature of the mission and range
  of psychologist activities.
• Compare anecdotal data of recently deployed
  psychologists to incident rates of problems
  widely reported in the recent literature.
• Discuss the risk factors for development of
  pathology in deployed personnel.
• Discuss methods of improving the readiness of
  deploying psychologists.

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Common Deployment Platforms

• Field hospitals
• USMC Support
• Hospital Ships
• Organic Units
• Aircraft carriers
• USMC Division
• OSCAR
• Expeditionary Warfare
• Special warfare units

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Background for 2005/6 Deployment

• Chain of Command- 2nd Marine Division, 2nd Marine
  Logistics Group (FSSG), Regiments and Battalions
• Location
• Setting
• Medical Units- e.g., SSTP

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TQ Combat Stress Clinic

• By Diagnostic Group Percent
• Adjustment Disorders 29
• No Psyc Dx 16.5
• Axis I Depressive DOs 14
• Axis I Anxiety DOs 11
• Occupational Problems 8
• Personality DOs 5
• Substance Abuse/Dep 5
• Sleep DOs 4
• ADHD 3
• Others 4

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Etiology, Treatment and Disposition

• Prevailing Complaints Home front distress,
  infidelity, occupational
• Percent cases related to combat 19
• Percent medicated 39
• Sleep Aids 34
• Antidepressants 55
• Benzodiazepines 13
• Stimulant 5
• Combined 20

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Treatment and Disposition

• Average visits/patient 3.5
• Return to duty 96
• Return home early/medevac n13
• Benzodiazepine withdrawal
• Severe PTSD
• Dissociative episodes and violence
• Thought Disorder
• Assault

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Post-traumatic Conditions- every label has its
own continuum

• Symptomatic responses
• Combat/ Operational Stress Reactions
• Acute Stress Disorder
• Post-traumatic Stress Disorder
• Anxiety and Affective Disorders
• Substance Abuse Disorders
• Secondary Personality Changes- midlife change in
  personality?

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Symptomatic and Combat Stress Reactions (1-72
hours)

• Sleep disturbance and nightmares
• Fatigue and exhaustion
• Concentration disturbance
• Somatic complaints
• Subjective anxiety and dysphoria
• Emotional numbing or dissociation
• Appetite changes
• Typically respond to rest and reassurance
• PIES- Proximity, Immediacy, Expectations,
  Simplicity

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Acute Stress Disorder

• Exposure to trauma associated with intense fear,
  hopelessness, horror
• Dissociative Symptoms
• Re-experiencing traumatic event- thoughts,
  dreams, flashbacks
• Avoidance of related stimuli
• Anxiety or hyperarousal
• Significant impairment
• Sx onset- within 4 weeks of trauma, lasting 2-30
  days

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Post-traumatic Stress Disorder

• Exposure to trauma associated with intense fear,
  hopelessness, horror
• Re-experiencing traumatic event- thoughts,
  dreams, flashbacks
• Avoidance of related stimuli
• Anxiety or hyperarousal
• Significant impairment
• Sx duration gt 4 weeks Acute/Chronic Onset
• High co-morbidity with MDD and substance abuse

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Scope of the PTSD Problem

• 1700 patients were dxd in 2004
• 5.2 million patients aged 18-54 are being treated
  in the US.
• Pentagon estimates that 100k soldiers may
  require mental health treatment
• It is estimated that 15 of the soldiers in
  combat situations will have sxs of PTSD
• Hodge (2004)- 19-21 of soldiers returning from
  Iraq present with anxiety, depression, or PTSD

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Common Sources of Stress Disorders

• MVAs
• Sexual Assault and violent crime
• Sustained Abuse
• Sustained Combat
• Single experience trauma
• Body Handling
• Loss of life and property in disasters

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Psychological Relevance and context of Trauma-
the more personal the more devastating

• Natural Disasters
• Accidents
• Combat
• Indirect Fire
• Sustained combat conditions
• Killing someone else
• Seeing others killed- friends and enemies
• Terrorism
• Assault- betrayal of safety

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Higher risk for combat trauma

• Friendly fire incidents
• Collateral damage, especially to children and
  women
• Handling dead bodies and body parts
• Watching someone die, especially for the person
  responsible
• Avoidable casualties and losses
• Barbaric behavior by our own troops
• Witnessed death/injury of a close friend or
  valued leader
• Killing unarmed or defenseless enemy

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Mechanisms of Pathology

• Physiological
• Cognitive
• Emotional
• Behavioral

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Risk Factors for Combat-related Post-traumatic
Symptoms

• Severity and duration of combat
• Female gender
• Lack of unit cohesion
• Lack of preparation and training
• Reservist v. Active Duty
• Prior Trauma- early, chronic, or single events
• Prior psychiatric sxs
• Ethnic minority

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Protective Factors

• Realistic training and expectations
• Belief in mission and leadership
• Resources
• IQ
• SES
• Unit and family support
• Resilience

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Preventive Measures Prior to War Zone

• Unit Cohesion, belief in mission and leaders
• Examine procedures, rules, consistency
• Cut out the unnecessary musters and duties
• Review the strategic and tactical missions
• Know your people
• Basic education
• Healthy behaviors- rest, nutrition, exercise
• Effects of stress and trauma
• Coping strategies

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Preventive Measures in War Zone

• Operational debriefings
• Command response to signs of stress
• Demobilizations, Defusings Debriefings
• Available resources in Chain of Command,
  Chaplains, Medical Services
• Combat Stress Centers- range from rest to
  medevac

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Individual Intervention

• Immediate intervention to reduce sxs and prevent
  them from developing a life of their own.
• Command- ensure that patient is not punished
  for their sxs
• Medicate acute sxs in theater or out.
• Involve others- Refer to necessary resources for
  support, counseling or therapy

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Dominant Therapeutic Approaches

• Support and Group Psychotherapies
• Cognitive Behavioral approaches to improve
  physiological control, anger control,
  re-experiencing sxs, interpersonal intimacy,
  self-efficacy
• Exposure therapies
• Couples and family therapy
• Psychodynamic therapies
• EMDR- Eye Movement Desensitization Reprocessing

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Psychologist Readiness

• Patience- avoid muster anxiety
• Gear- know your setting, what gear you need and
  do not need
• Physical fitness- you will carry your gear
• Pre-deployment family readiness- who is covering
  your responsibilities
• Communication
• Down time activities

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Psychologist Readiness

• Professional
• Be ready to discern when debriefs are appropriate
  and when they are not
• Prepare to raise your threshold for safety-
  everyone carries a weapon
• Set clinic boundaries- who comes and when
• Learn the command medevac system
• Plan to use your psychiatric technicians
• Obtain protocols for running support groups
• Consult with others
• Market yourself to the chain of command

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Debriefing Recommendations

• Ensure event being debriefed is over.
• Discuss need for debrief with chain of command
  and chaplain support.
• Wait until memorial services have concluded.
• Discuss who actually needs/wants a debriefing.
• Ensure that all participants are voluntary.