Walter Reed Army Institute of Research,

1
Impact of Combat on the Mental Health and
Well-Being of Soldiers and Marines7 Things I
Think I Know
Colonel Carl A. Castro Director, Military
Operational Medicine Research Program Smith
College School for Social Work Combat Stress
Understanding the Challenges, Preparing for the
Return Northampton, New Hampshire 26-28 June 2008
2
Biography of Colonel Castro

• Born in Kansas City, Missouri
• Enlisted as an infantryman in the U.S. Army at
  the age of 17
• Obtain BA from Wichita State University and MA
  and PhD from the University of Colorado (major
  psychology)
• Entered active duty as a psychologist in 1989
• Served on deployments to Bosnia (1998), Kosovo
  (2000, 2002), and Iraq (2003, 2006)
• Authored, co-authored around 100 publications
• Promoted to colonel in FEB 2007
• Serves on several NATO, TTCP panels
• Just started a new job as Director of Military
  Operational Medicine, Fort Detrick, Maryland
• Areas of research interest include
• Impact of combat and operations on mental
  health and well-being of Soldiers and Families
• Development of validated mental health training
  instrument and procedures to facilitate effective
  adaptation and growth
• Junior Leader development and their role in
  facilitating mental health and well-being in
  subordinates

3
1. Combat impacts the mental health and
well-being of Soldiers and Marines.
4
Prevalence of PTSD
There is a 3-fold increase for U.S. Soldiers
screening positive for PTSD when assessed 3
months after returning from a year in Iraq.

n 2,414
n 3,781
5

Combat-related Risk Factors PTSD

• Firefights, high combat, high perceived
  danger,
• dissociative experiences increased PTSD risk.

6
Anger and Aggressive Behaviors
Got angry with someone and yelled or shouted at
them
Got angry with someone and kicked or smashed
something, slammed the door, punched the wall,
etc.
Threatened someone with physical violence
Got into a fight with someone and hit the person
Percent one or more times
7
2. Not all Soldiers are at equal risk for mental
health problems.
8
Combat Experiences Combat vs. Support

• Soldiers in combat units experienced more
  combat-related events than Soldiers in combat
  support (CS) and combat service support (CSS).

9
Mental Health Status By Unit Types

• Soldiers were more likely to screen positive
  for a mental health problem if they were in a
  combat arms unit, engineer, transportation, or
  support unit than Soldiers in other types of
  units.

10
The Frontline in Iraq

• Soldiers were divided into low, medium and high
  combat based on frequency of combat events during
  the deployment.
• Soldiers with higher levels of combat were more
  likely to screen positive for anxiety,
  depression, or PTSD, indicating that all Soldiers
  are NOT at the same level of risk for a mental
  health problem.

11
3. Leadership is important for maintaining
Soldier mental health.
12
Leadership and Mental Health

• Soldiers with high perceptions of Leadership
  were less likely to screen positive for a mental
  problem (PTSD, Depression or Anxiety) compared to
  those Soldiers with low perceptions of leadership.

Percent Screened Positive for any mental health
problem
Percent Screened Positive for any mental health
problem
Adjusted R Square .15 and the Chi Square is
significant at the .01 level
13
Battlemind Training as an Example

• Battlemind Training is mental health training
  focused on the development of skills, involving
  self-aid, buddy aid, and leadership.
• Battlemind Training involves
• Evidence-based Built on findings from the Land
  Combat Study. Validated through research.
• Experience-Based Uses examples that Soldiers
  can relate to.
• Strengths-based Builds on existing Soldier
  strengths and skills rejects a deficit or
  illness model.
• Training Focuses on skill development not
  education.
• Explanatory Highlights conflicted/misunderstood
  reactions.
• Team-based Self awareness through helping
  buddy.
• Action-Focused Discusses specific actions to
  guide Soldier behavior.

14
4. Mental health training works.
15
Soldier Attitudes Training Utility

• Battlemind Training had high ratings.

16
Battlemind Training PTSD Depression

• Soldiers who received Battlemind Training
  (BMT) (p lt .01) reported fewer PTSD symptoms at 3
  months post-deployment compared to Soldiers who
  received the standard stress education training.
• Depression symptoms for Soldiers who received
  BMT were only marginally significantly lower than
  for Soldiers who received stress education (p lt
  .10).

17
Battlemind Training Stigma Sleep

• Soldiers who received Battlemind training
  reported less psychological stigma at 3 months
  post-deployment compared to Soldiers who received
  the standard stress education training (p lt .01).
• Soldiers who received Battlemind training also
  reported fewer sleep problems than Soldiers who
  received the standard stress education training
  (p lt .01).

18
Battlemind Training System Deployment Cycle
Tough Facts about Combat
and what leaders can do to mitigate risk and
build confidence
Transition to Post-Conflict
Alert
Pre-Deployment Battlemind For Leaders Junior
Enlisted Helping Professionals
Spouse/Couples Pre-Deployment Battlemind
Battlemind AAR Psychological Debriefing
Preparing for a Military Deployment
Post-Deployment Battlemind
Battlemind Training I
Spouse/Couples Post-Deployment Battlemind
Battlemind Training II
Continuing the Transition Home
Transitioning from Combat to Home
19
5. Mental health re-setting following a
year-long combat tour takes more than 12 months.
20
High Performing Soldiers with Mental Health
Symptoms Returning to Iraq

• Soldiers mental health status does not
  re-set after 12 months following return from a
  combat tour.

(Castro Hoge, 2005)
21
6. Longer and multiple deployments are likely to
lead to more mental health issues.
22
Soldier Multiple Deployments

• Soldiers deployed to Iraq more than once were
  more likely to screen positive for a mental
  health problem than first-time deployers.

23
Soldier Deployment Length

• Soldiers deployed longer than 6 months were more
  likely to screen positive for a mental health
  problem than those deployed for 6 months or less.

24
7. Every combat Soldier (and Marine) will face
moral and ethical challenges.
25
Battlefield Ethics Attitudes

• Treatment of non-combatants and views on torture

All non-combatants should be treated with dignity
and respect
All non-combatants should be treated as insurgents
Torture should be allowed if it will save the
life of a Soldier/Marine
Torture should be allowed in order to gather
important info about insurgents
I would risk my own safety to help a
non-combatant in danger
26
Battlefield Ethics Behaviors

• Treatment of Noncombatants and ROEs

Insulted/cursed at non-combatants in their
presence
Damaged / destroyed Iraqi property when it was
not necessary
Physically hit / kicked non-combatant when it was
not necessary
Members of unit modify ROEs in order to
accomplish the mission
Members of unit ignore ROEs in order to
accomplish the mission
Soldiers and Marines who report better officer
leadership are more likely to follow the ROE.
27
Battlefield Ethics Reporting
I would report a unit member for
injuring or killing an innocent non-combatant
stealing from a non-combatant
mistreatment of a non-combatant
not following general orders
violating ROEs
unnecessarily destroying private property
We prefer to handle things within the unit
would only turn someone in if it put the safety
of unit members in jeopardy. ---Junior NCO
28
Battlefield Ethics Training

• Although Soldiers and Marines reported
  receiving adequate battlefield ethics training,
  over one quarter reported encountering situations
  in which they didnt know how to respond.

Received training that made it clear how I should
behave toward non-combatants.
Received training in the proper treatment of
non-combatants.
Training in proper treatment of non-combatants
was adequate.
NCOs and Officers in my unit made it clear not to
mistreat non-combatants
Encountered ethical situations in Iraq in which I
did not know how to respond.
29
Soldier Mental Health, Combat and Ethics

• Soldiers who screened positive for a mental
  health problem or who had high levels of anger
  were twice as likely to engage in unethical
  behavior on the battlefield compared to those
  Soldiers who screened negative or who had low
  levels of anger.
• Soldiers with high levels of combat were more
  likely to engage in unethical behaviors than
  Soldiers with low levels of combat.

• The relationship between mental health and
  unethical behavior holds even when controlling
  for anger.
• These findings indicate the need to include
  Battlefield Ethics awareness in all mental health
  counseling and anger management courses.

Insulted/cursed at non-combatants in their
presence
Damaged and/or destroyed Iraqi private property
when it was not necessary
Physically hit / kicked non-combatant when it was
not necessary
30
Point of Contact

• COL Carl Castro
• Director, Military Operational Medicine Research
  Program, Fort Detrick, MD
• carl.castro_at_us.army.mil