Application of the U.S. Military Combat Stress Control to Civilian Emergency Teams in Catastrophic Events

1. Application of the U.S. Military Combat Stress Control to Civilian Emergency Teams in Catastrophic Events Philip Gruzalski, LCSW Commander, IL-2

2. Objectives To describe: • The likely stressors and their affects in a catastrophic event. 2. The key components of the U.S. Military’s CSC. 3. The application of CSC to civilian responders.

3. WMD

4. Anticipate High Stress from WMD • Technical and unfamiliar: “Uncontrollable” • Tendency to overestimate and overreact • Tendency to deny and ignore • Agents and deliveries are AMBIGUOUS • Many FALSE ALARMS • High ambiguity and bad consequences lead to high stress reactions. James Stokes, MD

5. WMD & Terrorism • Sense of Wrongfulness: Immoral, unfair • Indiscriminate • Attacks the innocent and defenseless • Hooks in the sense of victimhood. • James Stokes, MD

6. WMD & Terrorism • Will be catastrophic. • Will produce extreme stress and trauma. • Will require a critical need for stress control.

7. Stressors “ Events or conditions that may cause physiological and behavioral reactions and present coping difficulties for the individual experiencing them” Mental health and Mass Violence, 2002

8. Stress Reaction “ The physiological and behavioral response to stressors, such as fatigue, high blood pressure, anger, and psychological distress.” Mental health and Mass Violence, 2002

9. A Traumatic Event An event or events that involve: • Actual or threatened death or • Serious injury or • A threat to the physical integrity of self or other DSM IV

10. Immediate Common Signs of Extreme Stress • 1. Anxiety • 2. Irritability • 3. Attention • 4. Thinking • 5. Sleep • 6. Sadness • 7. Anger • 8. Lost Confidence

11. Some Early Warning Signs of Severe Stress • 1. Hyperactivity • 2. Trembling or cowering • 3. Spaced-out appearance • 4. Rapid speech • 5. Irritable or angry outbursts • 6. Memory loss • 7. Exaggerated startle response

12. Stress Stress can be a silent enemy having adverse effects on an emergency program’s mission and performance.

13. Types of Post-Mobilization Stress Reaction • Sub-clinical Stress Disorders • Boredom, sensation seeking and recklessness, • Burnout, job change, • Alcohol/drug misuse (self-medication) • Family disturbance, abuse, break-up, • Chronic medical complaints, problems. James Stokes, MD

14. Long Term Effect of Severe Disaster Stress on First Responders • PTSD • Depression

15. Dual Effect of Extreme Stress • Effects response performance. • Has long-term consequences.

16. Some Objective Factors Affecting the Victim • 1. Proximity to the event. • 2. Duration of the Stressor. • 3. Degree of physical harm. • 4. Intentionality of the injury. • 5. Exposure to grotesque, mutilating death of others. • 6. Suddenness of the event. • 7. Death and injury to children (Meichenbaum, 94)

17. MODERATORS Antecedent variables such as prior trauma, demographics, intelligence, temperament, situational stress at home, religious beliefs: these can be negative in terms of increasing vulnerability or positive in that they enhance resilience. Gal and Jones, ‘95

18. MEDIATORS These are present items that seem to be more changeable and can be both good or bad: unit cohesion, leadership, peer support all which affect the individual’s appraisal of the situation and the individual’s coping with the realities of the situation. Jones and Gal, 95

19. Resilience An adaptive, good mix of moderators and mediators that helps a person to adapt and recover.

20. Combat and Operational Stress Control (COSC) • Became U.S. Army doctrine in 1986. • DoD Directive 6490.5 (1999) directed all services to design and implement a CSC program to preserve mission effectiveness and …

21. Directive 6490.5 “…to minimize the short and long-run adverse effects of combat on the physical , psychological, intellectual and social health of the service members.”

22. TRISERVICE CSOC UNITS & MH TEAMS • USAF: “COSC” includes: • Mental Health Rapid Response Team (MHRRT), • Mental Health Augmentation Team (MHAT) - - Aeromed Evacuation Squadron • NAVY / USMC: “COSC” includes: • --Special Psych Rapid Intervention Team –Marine Div, Med Battalion Tm

23. Other Uniformed Services Programs • Royal Marines: Fleet Risk Management Program (TRIM). • Royal Netherlands Marines Corp: Stress Program.

24. Positive Aspects of COSC for Civilian Teams Preparing for Catastrophic Events • Designed to mitigate stress throughout a deployment: from the beginning to the end. • Designed to be implemented in highly stressful situations, i.e. Combat. • Designed to have high rates of RTD. • May mitigate long-term effects of extreme stress.

25. Il-2 COSC Training • Ft. Gordon, with the 785th COSC, 2000 • Camp Bullis, 2003 • Ft. Snelling, 88th RRC, 2003 • Ft. McCoy, 88th RRC, 2004

26. COSC Measures and Activities Primary Prevention Surveillance and Mitigation activities: to reduce or avoid stressors, and increase workers/victims tolerance and resilience to stress

27. COSC Measures and Activities:Secondary Prevention Surveillance and Mitigation activities: 1:1’s with individuals identified as having possible warning signs of stress reactions with the goal of returning them to work ASAP.

28. COSC Measures and Activities:Tertiary Prevention Mitigation/stabilization activities to reduce long term effects in workers/victims with pre-existing mental health conditions with the goal of returning them to work ASAP.

29. COSC Measures and Activities: Forward Tx • Proximity • Immediacy • Expectancy • Simplicity

30. COSC Measures and Activities: The 5 R’s Reassure (of normality). Rest (respite). Replenish physiologic needs. Restore confidence (work, talk). Return (reunite) to duty & team.

31. Application of COSC: WTC Preventive Measures included: • Education on stress • Secondary and Tertiary prevention.

32. Deployments since 9/11 • Hurricane Isabel • Hurricane Charley • Hurricane Ivan

33. Consultation Introductions Briefings on Stress TBWA Consultation Briefings on Stress Secondary and Tertiary Prevention Stress Control General Plan

36. Command Staff

40. Points of Distribution • Staff may not show up. • Greater risks. • Stigmatization issues. • Problems at the home front. • Reinforcements from the Outside?

41. Controlling Worker Stress • Limit exposure to traumatic stimuli • Ensure reasonable hours • Provide reasonable rest, sleep, diet, exercise • Allow private time • Make counseling available • Provide an identifiable end for involvement

42. Stress Programs ought to be Organic • To enhance positive identification & cohesions, • To understand the teams they are helping.

43. Stress Control is the Second Business of … • Every nurse. • Every police officer. • Every firefighter. • Every leader. • Every environmental health worker. • Every public affairs officer. • Every support staff.

44. Second Business (cont.) • Everyone’s Second Business is no-one’s business when First Business must be done. • Stress control throughout the event, both response and recovery, is mental health’s First Business.

45. Ground Zero Cross

46. Questions?