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Symposium Focuses on Combat, Operational Stress Control


Speakers Discuss PTSD, Embedded Mental Health, Combat Attachment

By Bernard S. Little
WRNMMC Command Communications

Focused on care of the mind and spirit of service members, Walter Reed National Military Medical Center hosted the 2017 Combat and Operational Stress Control Symposium Aug. 2.
The Naval Center for Combat and Operational Stress Control organized the day-long symposium for the greater Navy and Marine Corps psychological health community.
“Our mission is to optimize Navy and Marine Corps psychological readiness through development, aggregation and dissemination of best practices and innovations in the prevention of and restoration from psychological injury and disease,” explained Navy Cmdr. (Dr.) Jeffrey Millegan, NCCOSC director. He added that a goal was for attendees to leave the symposium “with increased clinical knowledge and a renewed inspiration to nurture their ideas into the innovative solutions for tomorrow.”
This was the eighth annual symposium, and its speakers addressed multiple aspects of psychological health including the Veterans Affairs/Department of Defense Clinical Practice Guideline for Post-Traumatic Stress Disorder, personal firearm safety, the benefits of embedded mental health services in deployed units, enlisted behavioral health information, global mental health engagement and the hidden variable of combat attachment behaviors.
Dr. Charles W. Hoge, a retired Army colonel who directed the research program addressing psychological and neurological consequences of the Iraq and Afghanistan wars at the Walter Reed Army Institute of Research, discussed the new VA/DOD clinical practice guideline (CPG) for PTSD. He served as an attending psychiatrist at the former Walter Reed Army Medical Center, providing treatment to warriors and family members, deploying to Iraq in 2004 and traveling throughout the region to improve combat stress care in the field. In 2011, he deployed to Afghanistan as a civilian provider for service members, veterans and family members.
According to Hoge, more than 2.5 million U.S. men and women have deployed to Iraq and Afghanistan and faced considerable challenges including possible attack and ambush, knowing someone seriously injured or killed, seeing those injured and not being able to help, and being wounded or injured themselves. He explained war is often as challenging on the mind as it is the body.
“PTSD exists on a continuum of normal reactions to trauma,” Hoge explained. “Most of the reactions that occur after trauma are normal reactions, [but] it’s only when those reactions interfere with one’s life, [such as] one’s ability to have happiness or ability to have meaningful relationships, that we start to talk about it as a disorder.”
He added that many of the symptoms of PTSD are also “adaptive beneficial functions in the combat environment. You want to be hyper alert in that environment (situational awareness). You want to be able to channel your anger in a way that is useful [within the combat environment]. Anger is the adrenaline [and the] energy that gets the mission done. [This can] obviously can cause problems for people when they get home, but [anger] is an emotion our service members learn to channel. It helps to control fear, physical pain, and gives the focus and concentration one needs in combat. Also, being detached or numb, which can really affect relationships when our service members come home, stems from that emotional control in very difficult circumstances [such as combat]. Even when one’s loses a team member, you have to be able to go on with the mission, which is very difficult.”
Reliving the combat experience (often associated with PTSD), guilt or second-guessing is part of the normal human response to try and figure things out and to learn from it, Hoge continued. He added this is deeply rooted in military training.
“There is no on-and-off switch for the physiological responses to trauma,” Hoge explained. He said these responses affect the entire body through the autonomic nervous system, which controls breathing, digestion, blood pressure and other functions.
It’s not helpful for people to use alcohol or substances to self-medicate in order to deal with PTSD, Hoge stated. “They may seem to help at first, like for instance getting to sleep, but it only makes things worse [in the long run],” he added.
“Figuring out ways to dial back the physiological reactivity is very important,” Hoge continued. He said research has shown positive relationships with loving people with whom service members can share their experiences can be healing. Acceptance, self-forgiveness and humor are also important for those facing PTSD challenges.
Hoge said reducing the stigma of mental illness is very important. “Very likely all of us are touched by mental illness in one way or another either personally or by a close family member or friend. Oftentimes we bear those struggles as if we’re alone, when in fact we are connected to everyone in this experience in one way or another.”
He added that after nearly two decades of war and extensive efforts to improve care, approximately 50 percent of services members and veterans with mental health concerns still do not receive the care they need. He said a big hurdle is service members and veterans who start mental health treatment often drop out, most often due to stigma perceptions (“I would be seen as weak.” “It will harm my career.”); organizational or other barriers (“It’s too difficult to get an appointment or to take time off work.”); belief in self-sufficiency (“I should be able to take care of problems on my own.”); and negative perception of mental health care (“I don’t trust mental health professionals.” “I didn’t like the treatment offered.” “I felt judged or misunderstood.”).
“The most promising strategies to improve treatment efficacy are those that address engagement, therapeutic, rapport, and treatment retention,” Hoge said. He added the VA/DOD Clinical Practice Guideline for PTSD (2017) offers evidence-based treatment recommendations. The CPG recommends individual trauma-focused psychotherapies, particularly Prolonged Exposure (PE), Cognitive Processing Therapy (CPT) and Eye Movement Desensitization and Reprocessing (EMDR), specific cognitive behavioral therapies, Brief Eclectic Psychotherapy, Narrative Exposure Therapy and written narrative exposure as the most effective treatments for PTSD.
“Coordination of care is critical to address chronicity and comorbidities,” Hoge continued, adding, “We need to continue to explore novel treatment approaches, particularly reconsolidation paradigm.”
Embedded Mental Health
Navy Lt. Cmdr. (Dr.) Russell Balmer agreed in discussing the benefits of embedded mental health services in deployed units. The Navy psychiatrist emphasized the importance of pushing behavioral health providers out with the force to help mitigate suicide risk and other mental health challenges faced by service members. He stressed care needs to be “proactive, preemptive and collaborative” with providers going to where the service members are located.”
Balmer, who served with the 2nd Marine Regiment, 2nd Marine Division OSCAR (Operational  Stress Control and Readiness) Team, stressed the importance of embedding mental health providers with deployed service members which allows for more informed command decisions and risk management plans, and moves care from a more reactive to proactive posture. “It’s that one team, one fight concept,” he said.
Air Force Maj. Geoffrey Oravec, chief knowledge officer at Uniformed Services University’s Center for Global Health Engagement, explained global health engagement is an important priority for the Military Health System in terms of ensuring the health and safety of warfighters, operation security, expanding military readiness, and building trust and professional medical relationships worldwide. “It’s something that we’re being asked to do [within the MHS] more and more.”
Oravec  stated that mental, neurological and substance use disorders constitutes 10 percent of the global burden of disease, as well as are the leading causes of disability worldwide and results in lost economic output in the trillions of dollars. He added depression remains a global challenge affecting approximately 350 million people globally.
In discussing personal firearm safety, Navy Capt. (Dr.) James C. West, of USU, stated there are approximately 30,000 firearm fatalities in the United States every year. West, assistant chair of USU’s Department of Psychiatry, a scientist at its Center for the Study of Traumatic Stress and a fellow of the American Psychiatric Association, explained the majority of firearm fatalities in the U.S. are due to suicide or accidently firearm death. “The availability of a gun roughly doubles the likelihood of death by homicide and more than tripled the likelihood of death by suicide,” he added. However, he explained evidence suggests that adopting safe storage practices can reduce the likelihood of deaths due to firearms. West, a psychiatrist, served embedded with Marine Corps units in Iraq and Afghanistan.
Marjorie Campbell, Ph.D., of DoD’s Deployment Health Clinical Center, Defense Centers of Excellence, concluded the symposium addressing combat attachment behaviors. She has conducted research into the phenomenon of combat attachment, which she explains “represents a hidden, under- recognized variable in treatment outcomes.” She defines combat attachment as “a pattern of habitually engaging in combat-related experiences for considerable amounts of time, accompanied by feelings of excitement or euphoria and physiological hyperarousal, with impairment in social or occupational functioning.” Campbell explained the initial research into combat attachment behaviors my lead to “developing and disseminating more effective treatment strategies.”
There are a number of contacts on Naval Support Activity Bethesda who are available to talk to about mental health services and suicide prevention, including the Fleet and Family Support Center at 301-319-4087; Walter Reed National Military Medical Center Behavioral Health at 301-295-0500; WRNMMC Department of Pastoral Care offices at 301-295-1510; NSAB Religious Ministries office at 301-319-5058; USU Family Health Clinic at 301-295-3630; or going to the WRNMMC Emergency Room.
Service members or veterans seeking help can call the Military Crisis Line at 1-800-273-8255 (press 1), text 838255, or visit www.militarycrisisline.net for a confidential online chat.