MILITARY MEDICINE, 174, 1:21, 2009 Time-Driven Battlemind Psychological Debriefing: A Group-Level Early Intervention in Combat Amy B. Adler, PhD*; COL Carl Andrew Castro, MS USAf; MAJ Dennis McGurk, MS USA' ABSTRACT Military personnel who experience combat-related events are more likely to report mental health problems yet few early interventions have been designed to do more than assess those with problems or treat those with diagnoses. Psychological debriefing is one early intervention technique that has been used with military populations to reduce symptoms across entire groups. Although there are several different kinds of debrieñngs, this article describes timedriven Battlemind Psychological Debriefing procedures for use during a combat deployment. The five phases include: Introduction, Event, Reactions, Self and Buddy Aid, and Battlemind Focus. The paper reviews implementation guidelines, scientific support for Battlemind Psychological Debriefing, and feedback from military behavioral health providers in Iraq. Comparisons with other military debriefing models identify unique features and how Battlemind Psychological Debriefing is integrated into the larger Battlemind Training system. BATTLEMIND PSYCHOLOGICAL DEBRIEFING: A GROUP-LEVEL EARLY INTERVENTION IN COMBAT It is estimated that between 20 and 30% of US military personnel returning from combat report significant psychological symptoms.' Furthermore, evidence suggests that symptoms may not be evident immediately following a combat-related experience but may increase over time.'-^ Thus, mental health interventions for service members on combat deployments are needed for those with symptoms and for those who may develop symptoms over time. Nevertheless, there have been few early interventions developed specifically for supporting mental health during a combat deployment. Two types of interventions that do exist are Combat Operational Stress Control (COSC)^ and Trauma Risk Management (TRiM).'' These programs support far-forward psychiatric care, early identification of mental health problems, brief and immediate interventions, and appropriate follow-up. Despite the prevalence of mental health problems on deployment, most of the interventions provided by these programs target individuals. The interventions, whether delivered by a professional (in COSC) or trained peer (in TRiM), are geared to providing assessment and clinical services to individuals with significant symptomatology or functional impairment. The exceptions to this individual approach include psychoeducation, which is typically taught in groups, command consultation, which can lead to changes that affect the entire unit. *US Army Medical Research Unit-Europe, APO AE 09042. tMedical Research and Materiel Command, RAD III, Medical Research and Materiel Command, 504 Scott Street, Fort Detdck, MD 21702. Material has been reviewed by the Walter Reed Army Institute of Research. There is no objection to its presentation and/or publication. The opinions or assertions contained herein are the private views of the authors, and are not to be construed as official, or as reflecting true views of the Department of the Army or the Department of Defense. This manuscript was received for review in January 2008. The revised manuscript was accepted for publication in September 2008. MILITARY MEDICINE, Vol. 174, January 2009 and group-level assessments (e.g., the Unit Behavioral Health Needs Assessment).^ Another type of group-level intervention is group psychological debriefing. The focus of the present paper is time-driven Battlemind Psychological Debriefing, a new type of group psychological debriefing designed for use at periodic intervals with deployed units. PSYCHOLOGICAL DEBRIEFING Group psychological debriefing is one of the most common early interventions with military units.* Although there are several different types of psychological debriefings, they contain similar elements: a structured group discussion designed to review a stressful experience. Specific debriefing models vary in terms of number of phases, focus of discussion, and degree of structure provided to the group.^ Several reviews have described the development of debriefing in the military context.^' The military's debriefing tradition is rooted in Marshall's World War II Historical Group Debriefing (HGD).« These after-action reviews appeared to have the added benefit of clarifying misperceptions and promoting unit cohesion.'" Thus, the military developed a tradition of unit-based debriefing, although debriefing techniques differed in terms of focus on emotional content. There is some controversy, however, as to whether psychological debriefing is effective, neutral, or even potentially harmful. Those studies reporting harmful effects have generally misapplied psychological debriefing by debriefing victims of traumatic events such as victims of severe burns," motor vehicle accidents,'^ and violent crime,'^ rather than those exposed to traumatic events as part of their occupational responsibility, and by conducting psychological debriefings with individuals (rather than with intact occupational groups). Despite these limitations (see Litz et al.' for a review), metaanalyses of these studies'''-'^ have led some to call for a stop to debriefing in any form.'"* Given that these studies involved individual victims of trauma, it is difficult to discern whether the conclusions are 21 Time-Driven Battlemind Psychological Debriefing: A Group-Level Early Intervention in Combat relevant for military units. Clearly, however, there is a need for military-relevant research. Unfortunately, most previous studies with military samples have been conducted without control groups'* or random assignment to condition,'^"* although results from such studies suggest it is worth examining the positive impact of debriefing on military populations. In an exception, peacekeepers randomly assigned to debriefing who reported high levels of mission-related Stressors reported slightly better mental health outcomes compared to those assigned to stress education. Although effect sizes were small, subjects reported liking debriefing more than stress education. Although this was the first randomized trial of debriefing with the military, there were few deployment-related critical incidents, reducing the degree to which conclusions could be drawn regarding debriefing efficacy on deployment." In a subsequent randomized trial, debriefing, developed specifically for soldiers returning from combat, was assessed. Compared to postdeployment stress education, this form of psychological debriefing was associated with better mental health 4 months later for individuals reporting high levels of combat experiences in Iraq.^° As a result of these findings, Walter Reed Army Institute of Research (WRAIR) researchers further developed these postdeployment debriefing procedures for use in theater. These procedures comprise Battlemind Psychological Debriefing. In this article, we describe the rationale for developing Battlemind Psychological Debriefing, introduce three Battlemind Psychological Debriefing techniques, detail implementation guidelines for one of these techniques (in-theater time-driven Battlemind Psychological Debriefing), contrast it with other debriefing models, and report on feedback from behavioral health providers using this technique in Iraq. Developing Battlemind Psychological Debriefing Besides the empirical support for developing Battlemind Psychological Debriefing, the need to create new debriefing procedures was also driven by anecdotal evidence that existing models did not meet the demands of a combat deployment. Although other psychological debriefing models such as HGD,'« After-Action Debriefing (AAD),^' Critical Event Debriefing (CED),^^ and Critical Incident Stress Debriefing (CISD),^' have been used with the Army, accounts suggested that implementation of these procedures was random with facilitators dropping or modifying phases partly because the models did not address the deployment-related concerns of military personnel. Most recently, for example, the Mental Health Advisory Team (MHAT) V found haphazard implementation of debriefing procedures in Afghanistan.^'' Besides the lack of consistency, published critiques of psychological debriefing have typically focused on the problems with single-session debriefing. These critiques centered on the fact that debriefing could potentially lead to harm through re-exposing individuals to trauma, exposing other team members to trauma, interfering with natural healing processes, and suggesting negative messages regarding recovery.^^ Up to now, some debriefing procedures have been delivered within 22 a framework of trauma management but otherwise do not address the other criticisms of debriefing. Battlemind Psychological Debriefing was developed to address shortcomings of previous models, capitalize on the unique nature of military deployments, and provide a common method across behavioral health providers. Specifically, Battlemind Psychological Debriefing does not elaborate on traumatic events. This lack of historical review (or reconstruction) avoids the risk of exposing individuals to details of the original trauma. In addition, the new procedure emphasizes personal resilience and avoids sending the implicit message that participants will develop mental health symptoms. Also, Battlemind Psychological Debriefing does not subvert natural recovery but instead encourages the use and provision of social support. Eurthermore, the procedure is not conducted as a standalone intervention but is part of behavioral health support provided to operational units as well as integrated with Battlemind Training, the Army's mental health training program. The Battlemind Training System Battlemind Training, developed by the WRAIR for military personnel across the deployment cycle, was mandated in 2007 as part of the Deployment Cycle Support program. The training is a strength-based approach designed to enhance soldier skill development, adaptation to the Stressors of combat, and management of the transition from combat to home.^'' It also targets stigma and help-seeking attitudes related to mental health problems. Research on Battlemind Training has found high user acceptability. Eurthermore, although effect sizes were small, three group randomized trials have demonstrated that Battlemind Training positively affected the adjustment of soldiers returning from combat.^""-^** Thus, the evidence supports the value of an integrated mental health training system which reinforces similar terminology and principles; Battlemind Psychological Debriefing exemplifies this approach. BATTLEMIND PSYCHOLOGICAL DEBRIEFINGS In all, WRAIR researchers have developed three different types of Battlemind Psychological Debriefing. There are two in-theater models. Time-driven Battlemind Psychological Debriefing is designed to occur at intervals during the deployment and addresses the cumulative effects of the deployment. Event-driven Battlemind Psychological Debriefing can be used when a commander requests support following a specific traumatic incident. The third type of Battlemind Psychological Debriefing occurs at postdeployment. Combatrelated events are acknowledged with an emphasis on the process of transitioning home, adapting specific Battlemindrelated skills for postdeployment, and resetting one's Battlemind. The present article focuses on time-driven Battlemind Psychological Debriefing, provides considerations for implementation, outlines each debriefing phase, and identifies how Battlemind Psychological Debriefing is integrated into Battlemind Training. MILITARY MEDICINE, Vol. 174, January 2009 Time-Driven Battlemind Psychological Debriefing: A Group-Level Early Inten'ention in Combat Time-driven Battlemind Psychological Dehriefing uses a set of specific questions to guide participants through phases in which combat events or deployment experiences are acknowledged among unit members. In addition, Battlemind Psychological Debriefing involves a review of common reactions to combat-related Stressors and actions that can be taken to facilitate functioning during the deployment. This kind of approach is not expected to prevent the development of psychiatric disorders but rather to reduce the level of mental health symptoms for the unit overall. Although the full procedures (e.g., specific phrasing for each phase and transitions between phases) are available,^' the next sections highlight key elements of this approach. Implementation Guidelines Participants Individuals participating in a Battlemind Psychological Debriefing should be members of a platoon or other group that functions as an equivalent team (e.g., route clearance teams and personnel security detachments), typically involving -20-30 individuals. Units with high levels of combat exposure should be prioritized. Individual service members should include all ranks in that team, including the team leadership. Facilitators Battlemind Psychological Debriefings need to have at least two facilitators: a leader and one cofacilitator. Qualifications Ideally, Battlemind Psychological Debriefing leaders should be behavioral health officers or chaplains with training in counseling and should be responsible for providing services to that unit to minimize territorial issues with other behavioral health providers. Cofacilitators should be service members with related specialties (e.g., enlisted mental health specialist, military personnel who have received Battlemind Psychological Debriefing training). The facilitators may be part of the same unit (e.g., battalion or brigade), or they may be external to that unit (e.g., combat operational stress control team). Regardless, facilitators should have pre-established relationships with the unit, have worked with the unit prior to deployment, or at least have visited the unit during the deployment. The lead facilitator should be able to provide appropriate follow-up consultation. Facilitator Role The facilitator's job is to establish rapport with the group, set a tone of respect and confidentiality, and transition the group through each of the phases. In serving this vital function, the facilitator should not dominate the discussion, should not allow one or two unit members to dominate the discussion, and should avoid allowing the session to turn into a questionand-answer dyad. Lead facilitators and cofacilitators need to work together to keep the discussion on track with appropriate summary comments and transitions. If participants are MILITARY MEDICINE, Vol. 174, January 2009 reluctant to respond during one of the phases, the facilitators can prompt discussion by introducing what other units like theirs have typically described. Timing Time-driven Battlemind Psychological Debriefings should be scheduled at intervals during the deployment (e.g., 4 and 8 months into a 12-month deployment). These debriefings are particularly well-suited to long deployments in which there may be so many serious incidents that units are reluctant or unable to hold a debriefing after each one and repeated debriefings may lead unit members to perceive the session to be a rote exercise. In addition, the cumulative effect of deploymentrelated Stressors can be addressed with time-driven debriefing. Given real-world constraints regarding accessing remote sites, it is recommended that Battlemind Psychological Debriefings be prioritized for units experiencing high levels of combat and for those units distant from other mental health resources. At minimum, such units should receive one time-driven Battlemind Psychological Debriefing midway through their deployment because the 6-month point has been associated with increased reports of mental health problems.^** Previous research has also documented the increase in Stressors experienced by military personnel over the course of shorter deployments.^" Thus, for shorter deployments more typical of NATO and other allied nations, the time-driven method could be scheduled across shorter intervals (e.g., 2 and 4 months of a 6-month deployment). Ideally, Battlemind Psychological Debriefings should be conducted at the end of the duty day. After the session, individuals may continue to talk with one another or support one another. If individuals immediately return to duty, they may be distracted from providing or receiving on-going support. Battlemind Psychological Debriefing can be expected to take -60-120 minutes depending on platoon size, participation, and the range of issues potentially affecting the unit. Preparation The facilitator should touch base with the key unit leaders before the start of the session to find out about significant unit event(s) (e.g., casualties, combat experiences, changes in morale). In addition, the leaders should be told what to expect from the Battlemind Psychological Debriefing. They should be told that the session provides an opportunity for the leaders to promote unit member resilience by: (1) normalizing the experience of the significant event or the postdeployment transition, (2) talking about events and feelings, (3) reinforcing the meaning of the unit's sacrifice, and (4) preparing the unit psychologically to return to duty and to have a story with which they can live when they eventually return home. Identify Local Resources Facilitators need to know what mental health resources are available to service members and to have a plan for what to do in the unlikely event a unit member needs an immediate 23 Time-Driven Battlemind Psychological Debriefing: A Group-Level Early Intervention in Combat mental health evaluation. Part of this planning means communicating with mental health resources responsible for the unit to inform them that the Battlemind Psychological Debriefing will be occurring and clarifying the way such referrals should be facilitated. Know Battlemind Training Facilitators also need to become familiar with Battlemind Training (training materials are available through www.battlemind.army.mil). By incorporating language and themes from Battlemind Training, the facilitators reinforce the key points of this mental health training program. Follow Up After Battlemind Psychological Debriefing is completed, key unit leaders should be provided a status report, including a brief description of any pertinent facts and recommendations as appropriate. In addition, follow-up contact with the leader should be scheduled to obtain feedback and a status update. Throughout, standard confidentiality regarding specific unit members needs to be maintained. Time-Driven Battiemind Psychoiogicai Debriefing Procedures The objectives of each phase, sample prompts for each phase, and the transition between phases of time-driven Battlemind Psychological Debriefing are provided in Table I. Phase I: The Introduction The introduction should be brief, establish the climate and ground rules, and provide basic information about the facilitators' experience with the subject of combat reactions and TABLE I. Phase 24 Phase 2: The Events The goal of the second phase is to establish the kinds of events that have placed a significant demand on unit members. The facilitator asks participants to consider one or two deploymentrelated events that have been the most difficult, the ones that "still stick with them," The facilitator does not need to repeat back what each person says. Facilitators must be sure they know what event service members are describing but not get In-Theater Time-Driven Battlemind Psychological Debriefing Phases: Goals, Prompts, and Transitions Goal Introduction Introduce facilitators, objectives, and ground rules. Event Establish the kinds of events that have placed a significant demand on unit members. Normalize thoughts and reactions. Reaction the transition between critical events and returning to duty. The Battlemind Psychological Debriefing itself should be introduced as a training opportunity for the unit to talk about significant events. The facilitators should set positive expectations by commenting that other units have found Battlemind Psychological Debriefing helpful as a way to maintain focus and support each other as a team. The facilitators should also acknowledge that although time needs to be set aside to talk, the reality is that the unit will have to return to duty. The facilitators should also acknowledge that 1 hour of training will not take away problems but that the training can help soldiers identify unit members who may be struggling during the deployment and equip soldiers with skills to help themselves and their buddies. Throughout, facilitators should set the expectation that despite these struggles service members will successfully manage the demands of deployment and be able to complete their mission. The ground rules for Battlemind Psychological Debriefing should be reviewed including session length, confidentiality, participation (attendance is expected and participation is encouraged), as well as reminders not to engage in leadership bashing and to be mindful of rank. Misperceptions should be clarified by stating that the Battlemind Psychological Debriefing is not therapy, an investigation, or a critique. Self and Buddy Aid Discuss anger, withdrawal, and sleep problems and emphasize what individuals can do for themselves and their buddies. Battlemind Focus Reinforce Battlemind principles (steel your battlemind, trust your training. listen to your leaders, be a buddy) and help the group get psychologically ready to continue the mission. Sample Prompt Transition "This training is designed to help units take some time to think about the deployment so far, to take a moment to talk about how things are going." "Think about one or two events that have been the most difficult, the ones that "still stick with you." What are they?" "What were your first thoughts when you went off auto-pilot?" "Even though this is hard, most of you will be okay. Still after an event... there are common symptoms that you may notice in yourself or your buddy. I'd like to highlight three of these for you." "You know first hand that combat is hard. The things that happen take time to understand and put in perspective. And at the same time, you know you still have a mission to do." Complete review of ground rules, ask if there are questions, then begin next phase. Summarize the specific events Summarize common reactions and mention typical positive and negative reactions not discussed by the group Highlight the importance of buddy aid. Recognize that seeking help is a sign of courage and a part of leadership. MILITARY MEDICINE, Vol. 174, January 2009 Time-Driven Battlemind Psychological Debriefing: A Group-Level Early Intervention in Combat the group mired in details. In transitioning to the next phase, the facilitator should very briefly summarize the events without allowing the remarks to become generic. Common events may be described such as a date when an ambush occurred or the name of a service member who was killed. If the unit is not an established cohesive team, the debriefing approach in this phase will need to be adapted. The unit will probably not spontaneously relate to a set of events identified by participants. Instead, the facilitators will need to select a theme such as threat or isolation that is common across the unit despite the disparate experiences of individuals. Phase 3: Reactions The goal of this third phase is to have the service members share their reactions to normalize the unit's thoughts and reactions overall. This phase begins by asking about initial cognitive responses and moves on to include emotional responses as well. Typically, soldiers will bring up emotional issues spontaneously, and these reactions will not need to be prompted. The facilitator may transition to the next phase by summarizing common reactions and mentioning typical negative reactions not discussed by the group. For example, participants often second-guess their behavior, believing that if they had only sat in a different vehicle or not gone on midtour leave, somehow a terrible event could have been avoided. The facilitator can address this directly by reminding participants of the randomness of such events to encourage acceptance while discouraging guilt and self-blame. Phase 4: Self and Buddy-Aid The goal of this phase is to identify three common symptoms (anger, withdrawal, and sleep problems), normalize these symptoms, and emphasize what service members can do for themselves and their buddies. In discussing anger, this phase teaches that it may be normal to develop a quick fuse and the desire for revenge. Participants are explicitly reminded that although they may want "pay back," the key is to ensure professionalism and be able to return home with a story with which they can live. By introducing the concept of being able to tell their story, this phase reinforces a key point brought up again in postdeployment Battlemind Training about being able to communicate effectively with family and friends about the deployment. This focus on telling their story also introduces the concept of developing a narrative, which may facilitate adjustment following deployment. Previous research has demonstrated the benefit associated with creating a personal narrative and expressing it following difficult experiences.^'••'•^ Participants are also encouraged to look out for and monitor one another when grappling with the desire for revenge. In discussing withdrawal, participants should discuss common signs as well as the importance of being a good buddy in providing support and ensuring friends in trouble access professional help. In discussing sleep problems, the focus is on normalizing sleep problems and discussing possible ways to MILITARY MEDICINE, Vol. 174, January 2009 alleviate sleep difficulties. In transitioning to the next phase, the facilitator should reiterate the importance of buddy aid. Phase 5: Battlemind Focus In this final phase, the goals are to reinforce Battlemind principles and to help the group become psychologically ready to continue the mission. Questions are asked to elicit ways in which participants have maintained perspective, identify practical coping strategies, focus on positive adaptation, and recognize both individual differences and commonalities in how service members adjust. Key Battlemind themes from the predeployment Battlemind Training program are highlighted. These principles include (1) steeling one's Battlemind by remaining resilient, (2) trusting one's military training and personal decisions, (3) listening to leaders and letting leaders know if there is a problem, and (4) being a buddy and watching out for one another. In closing, facilitators should provide information about ways to access mental health services, including chaplains as well as medics trained in Battlemind Warrior Resiliency, a type of psychological first aid. Battlemind Warrior Resiliency is a recent addition to core-competency training for Army Medical Department enlisted and officer personnel and has been integrated into the appropriate training courses. Besides emphasizing ways to access services, facilitators should emphasize the importance of unit leaders and buddies being familiar with this information. At this point, the facilitators should also reinforce that recognizing and seeking help when an individual or a buddy needs it is a sign of leadership and strength. After acknowledging the personal sacrifice of unit members, the facilitators should end the training by suggesting that over time, individuals may find that the deployment was hard but had a positive effect on their lives. This perspective may include the fact that the deployment helped individuals grow personally and professionally although that may not be apparent now. Facilitators should be available to talk with unit members afterward and to approach those who may be in need of a referral. Although not part of the Battlemind Psychological Debriefing process per se, delivering this intervention should occur in an on-going context of mental health support. Facilitators should continue to work with the unit over time as they would any unit in theater, obtaining feedback at follow-up visits, providing command consultation, continuing to assess unit morale either formally or informally, and providing far-forward care. Contrasts to Other Debriefing Modeis In Table II, the phases of time-driven Battlemind Psychological Debriefing are compared to HGD, AAD, CED, and CISD. In terms of similarities, each model has phases, and each model begins with an introduction and some mention of a critical event. Acknowledging that a critical event has occurred serves as a mechanism for identifying that the occupational group has gone through challenging times. At one point, all but HGD directly address reactions. Beyond that, the models begin to diverge. 25 Time-Driven Battlemind Psychological Debriefing: A Group-Level Early Intervention in Combat TABLE II. Phase 1 2 3 4 5 6 7 Compatison by Phases of Different Psychological Debriefing Models with Battlemind Psychological Debriefing Historical Group Debriefing (HGB)^' Leader-Led After-Action Debriefing (AAD)^^ Critical Event Debriefing (CED)" Critical Incident Stress Debriefing (CISD)^" Introduction Chronological reconstruction Purpose and ground rules Chronological reconstruction Thought and reaction Introduction Chronological reconstruction Cognitive and affective reaction Introduction Fact Introduction Event Thought Reactions Symptom Symptom Teaching Wrap-up Mission-related Lessons Learned One differetice is the degree to which a critical event is recoutited. HGD, AAD, and CED focus on getting a detailed reconstruction of some specific event. Although the goal for this recotistmction differs, the historical approach shows participants other perspectives of what occurred. In CISD, recounting an event is more general hut also includes the individual's role in that event. In Battlemind Psychological Debriefings, however, a chronological reconstruction of the critical event is not needed. There may be too many events that occurred over the course of months to make a detailed review helpful. Simply identifying the event should suffice for the goal of the debriefing. Furthermore, discussing details like team member names and roles is not necessary and does not benefit the platoon members since they have been deployed together for some time, and the debriefing is conducted with an intact platoon. The relative lack of focus on critical events is also reflected in the timing of debriefing. The other models are designed to occur in response to a specific critical event and typically soon after that event (there are exceptions, as in the case of delayed onset CISD, but it is not the modal design). In comparison, time-driven Battlemind Psychological Debriefings are not in response to a discrete event. Battlemind Psychological Debriefing does have some parallels to the way in which reactions are handled in other models. Like AAD and CED, both cognitive and emotional reactions are addressed within one phase. This combined phase was developed because in our early research with Battlemind Psychological Debriefing, service members naturally merged cognitive and emotional reactions in their discussions. To separate the cognitive and emotional reactions appeared artificial. Battlemind Psychological Debriefing also has unique phases not found in other models. The Self and Buddy Aid phase addresses specific deployment-related problems. This focus has parallels in the symptom and teaching phases of AAD, CED, and CISD; however, this phase is limited to a discussion of three concerns (anger, withdrawal, and sleep), the emphasis is on watching out for one another, and actions to address these concerns are provided as each one is discussed and not as part of a separate phase. We chose these three concerns because of their prevalence and because fellow unit members and leaders are likely to be able to notice when 26 Reaction Symptom Teaching Re-Entry Battlemind Psychological Debriefing (Time-Driven) Self and buddy-aid Battlemind Focus someone is exhibiting these kinds of reactions. Furthermore, the reactions are linked to potentially high-risk behaviors. Anger has been linked to self-reported ethical violations;^* withdrawal is a symptom of depression and can be a warning sign for self-destructive behavior.'' Other studies have found that sleep problems are comorbid with other symptoms and yet low in stigma, providing a gateway to mental health care.'"* Although Battlemind Psychological Debriefing, AAD, CED, and CISD all have a final phase, the intent of this phase differs. In AAD, CISD, and CED there is a general wrapping up and referral information is provided. In contrast, the Battlemind Focus phase reinforces essential Battlemind principles, including buddy care, leader responsibility, and the need to reduce stigma. It also prepares the group to resume the mission. Furthermore, this phase explicitly addresses possible positive reactions, broadening AAD's focus on mission-related lessons learned. PERSPECTIVES Current Status and Provider Feedback Current Army doctrine recommends that mental health providers "avoid psychological debriefings as a means to reduce acute post-traumatic distress or to slow progression to PTSD."" In addition, the Army Field Manual (FM 4-02.51) does not recommend for or against the use of structured group debriefings. Nevertheless, the Field Manual stipulates that debriefings with pre-existing groups may improve cohesion, morale, and other unit climate variables. This stance was reinforced following the development of in-theater Battlemind Psychological Debriefing in 2007. At that time, Battlemind Psychological Debriefing was formally integrated into the COSC course conducted at the Army Medical Department Center and School. The COSC course is recommended for mental health providers serving Army personnel in Iraq and Afghanistan. Thus far, feedback from military mental health professionals deployed to Iraq has been encouraging. One mental health team, for example, used time-driven Battlemind Psychological Debriefings to provide proactive mental health support to units in outlying areas that had MILITARY MEDICINE, Vol. 174, January 2009 Time-Driven Battlemind Psychological Debriefing: A Group-Level Early Intervention in Combat previously received little support. Providers commented that the changes to traditional debriefing methods made Battlemind Psychological Debriefing particularly appropriate for the combat environment. In particular, the providers commented that they liked the fact that the Battlemind Psychological Debriefings did not focus on historical reconstruction, avoided redundancy, avoided individuals reciting a story with which others in the unit were familiar, and maintained the interest of other unit members. Others commented that the procedures were an improvement because they allowed for the natural flow between cognitive and emotional reactions. Providers also commented that the inclusion of Battlemind concepts resonated with unit members and many participants recalled the concepts from predeployment training. Providers reported following up Battlemind Psychological Debriefings by visiting units weeks later and receiving feedback from unit leaders that morale and cohesion had increased. At follow-up, individual participants commented to providers that they thought about combat-related experiences more positively than before. Other providers found Battlemind Psychological Debriefing to be particularly wellsuited for cohesive units encountering danger outside the relative safety of a base. Moreover, results from the 2007 Mental Health Advisory Team survey of behavioral health providers in Iraq found that providers using the procedures in Iraq were uniformly positive, endorsing it as "very" or "extremely" relevant.^" Future Directions Currently, there is no systematic research on the efficacy of in-theater Battlemind Psychological Debriefing. Anecdotal evidence suggests that Battlemind Psychological Debriefings in theater are well received and helpful, but these reports are potentially subject to bias. Although the MHAT survey systematically assessed provider feedback, research is needed to assess Battlemind Psychological Debriefing efficacy using a group randomized trial that assesses a variety of outcomes such as mental health, attitudes toward management of mental health problems, and unit climate. At the very least, there is a need for continued examination of user acceptability and feedback from providers. While waiting for empirical evidence, as a field, we are left to decide how to guide our interventions in the absence of scientific rigor. On the one hand, evidence from civilian-based trials using inappropriate intervention methods suggests that psychological debriefing is, at best, not effective. On the other hand, evidence from military studies conducted post-deployment suggests psychological debriefing can be effective in positively influencing mental health. Meanwhile, service members deployed to combat are at risk for developing significant mental health problems, and Battlemind Psychological Debriefing may be able to provide some early intervention support. Although if Battlemind Psychological Debriefing is effective in theater, it is still not a panacea. It does, however, represent one example of how the military can move toward developing MILITARY MEDICINE, Vol. 174, January 2009 an integrated framework of support, mental health training, consultation and follow-up that targets both at-risk individuals and units by tapping into the strength of small unit support. ACKNOWLEDGMENTS We gratefully acknowledge support from the staff at the US Army Medical Research Unit-Europe and the Department of Military Psychiatry at the Walter Reed Army Institute of Research (WRAIR), as well as the Director of Psychiatry and Neurosciences at WRAIR. We also gratefully acknowledge feedback about Battlemind Psychological Debriefing from a team of behavioral health providers deployed to Iraq. REFERENCES 1. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL: Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N EngI J Med 2004; 351: 13-22. 2. Bliese PD, Wright KM, Adler AB, Thomas JL, Hoge CW: Timing of post-combat mental health assessments. Psychol Serv 2007; 4; 141-8. 3. Lewis SJ: Combat stress control: putting principles into practice. In: Military Life: The Psychology of Serving in Peace and Combat (Vol. 2: Operational Stress), pp 121-140. Edited by Adler AB, Castro CA, Britt TW. Westport, CT, Praeger Security International, 2006. 4. March C, Greenberg N: The Royal Marines approach to psychological trauma. In: Combat Stress Injury: Theory, Research, and Management, pp 247-260. Edited by Figley CR, Nash WP. New York, Routledge, 2007. 5. Cox A, Castro CA: (2006). The Mental Health Needs Assessment. In: Human Dimensions in Military Operations: Military Leaders' Strategies for Addressing Stress and Psychological Support, pp. 7-1-7-8. Meeting Proceedings RTO-MP-HFM-134, Paper 7. Available at ftp://ftp.rta.nato. int/PubFullText/RTO/MP/RTO-MP-HFM-134/MP-HFM-134-07.pdf; accessed August 25, 2008. 6. Adler AB, Bartone PT: International survey of military mental health professionals. Milit Med 1999; 164: 788-92. 7. Raphael B, Wilson JP: Introduction and overview: key issues in the conceptualization of debriefing. In: Psychological Debriefing, pp 1-14. Edited by Raphael B, Wilson JP. New York, Cambridge University Press, 2000. 8. Castro CA, Engel CC, Adler AB: The challenge of providing mental health prevention and early intervention in the U.S. military. In: Early intervention for trauma and traumatic loss in children and adults, pp 301-318. Edited by Litz BT. New York, Guilford Press, 2004. 9. Litz BT, Gray M, Bryant RA, Adler AB: Early intervention for trauma: current status and future directions. Clin Psychol Sei Pract 2002; 9: 112-34. 10. Shalev AY: Stress management and debriefing: Historical concepts and present patterns. In: Psychological debriefing: Theory, practice, and evidence, pp 17-31. Edited by Raphael B, Wilson JP. New York, Cambridge University Press, 2000. 11. Bisson Jl, Jenkins PL, Alexander J, Bannister C: Randomized controlled trial of psychological debriefing for victims of acute burn trauma. Br J Psychiatry 1997; 171:78-81. 12. Hobbs M, Mayou R, Harrison B, Worlock P: A randomized controlled trial of psychological debriefing for victims of road traffic accidents. BMJ 1996; 313: 1438-9. 13. Rose S, Brewin CR, Andrews B, Kirk M: A randomized controlled trial of individual psychological debriefing for victims of violent crime. Psychol Med 1999; 29: 793-9. 14. Rose S, Bisson J, Wessely S: Psychological debriefing for preventing post traumatic stress disorder (PTSD) (Cochrane Review). In The Cochrane Library, 3, Oxford, Update Software, 2001. 15. van Emmerik AAP, Kamphuis JH, Hulsbosch AM, Emmelkamp PMG: Single session debriefing after psychological trauma: A meta-analysis. Lancet 2002; 360: 766-71. 27 Time-Driven Battlemind Psychological Debriefing: A Group-Level Early Intervention in Combat 16. Shalev AY, Peri T, Rogel-Fuchs Y, Ursano RJ, Marlowe D: Historical group debriefing after combat exposure. Milit Med 1998; 163: 494-8. 17. Deahl M, Srinivasan M, Jones N, Thomas J, Neblett C, Jolly A: Preventing psychological trauma in soldiers: The role of operational stress training and psychological debriefing. Br J Med Psychol 2000; 73; 77-85. 18. Eid J, Johnsen BH, Weisaeth L: Group psychological debriefing: does it make a difference? Presented at the International Conference on Human Dimensions on Military Deployments, Heidelberg, Germany, September 2000. 19. Adler AB, t.itz BT, Castro CA, et al: Group randomized trial of critical incident stress debriefing provided to U.S. peacekeepers. J Trauma Stress 2008; 21: 253-63. 20. Adler AB, Castro CA, Bliese PD, et al: Post-deployment interventions to reduce the mental health impact of combat deployment to Iraq. Presented at the International Society for Traumatic Stress Studies, Hollywood, CA, November 2006. 21. US Army; FM 22-51 Leaders' manual for combat stress control. Washington, DC, Appendix A, 1994. 22. Koshes R, Young S, Stokes J: Debriefing following combat. In: War Psychiatry, pp 271-90. Edited by the Office of Surgeon General. Washington, DC, Department of the Army, 1995. 23. Mitchell JT, Everly GS Jr: Critical incident stress debriefing: an operations manual for the prevention of traumatic stress among emergency services and disaster workers, Ed 2, Ellicott City, MD, Chevron Publishing Corporation, 1996. 24. Mental Health Advisory Team (MHAT) V Report: Office of the Surgeon General, US Army Medical Command, 2008. Available at http://www. armymedicine.army.mil/reports/mhat/mhat_v/mhat-v.cfm; accessed August 25, 2008. 25. McNally RJ, Bryant RA, Ehlers A; Does early psychological intervention promote recovery from traumatic stress? Psychol Sei Public Interest 2003; 4: 45-79. 26. Castro CA: How to build Battlemind, NCO Journal 2004; April: 23-24. 28 27. Adler AB, Castro CA, Bliese PD, McGurk D, Milliken C; The efficacy of Battlemind training at 3-6 months post-deployment. In The Battlemind Training System: Supporting Soldiers Throughout the Deployment Cycle, Castro CA (Chair). Symposium conducted at the meeting of the American Psychological Association, San Francisco, CA, August, 2007. 28. Thomas JL, Castro CA, Adler AB, et al: The efficacy of Battlemind at immediate post deployment réintégration. In The Battlemind Training System: Supporting Soldiers Throughout the Deployment Cycle. Castro CA and Thomas JL (Chairs). Symposium conducted at the meeting of the American Psychological Association, San Francisco, CA, August 2007. 29. Adler AB, Castro CA, McGurk D: Battlemind Psychological Debriefings. US Army Medical Research Unit-Europe Research Report 2007-001. Heidelberg, Germany: USAMRU-E. Available at http://www.usamru-. hqusareur.army.mil/Battlemind%20Psych%20Debriefing%20 Procedures%202%20APR%2007.pdf; accessed November 20, 2007. 30. Britt TW, Adler AB; Stress and health during medical humanitarian assistance missions. Milit Med 1999; 4; 275-9. 31. Smyth JM, True N, Souto J; Effects of writing about traumatic experiences; The necessity for narrative structuring. J Soc Clin Psychol 2001; 20; 161-72. 32. Lyubomirsky S, Sousa L, Dickerhoof R: The costs and benefits of writing, talking, and thinking about life's triumphs and defeats. J Pers Soc Psychol 2006; 90; 692-708. 33. Jones DE, Kennedy KR, Hourani LL; Suicide prevention in the military. In: Military Psychology; Clinical and Operational Applications, PP 130-162. Edited by Kennedy CH, Zillmer EA. New York, Guilford Press, 2006. 34. Bliese PB, Wright KM; Psychological screening; Validation studies, key findings, and future directions. Presented at the Hungarian-US Military Medicine Conference, Garmisch, Germany, September, 2005. 35. US Army; FM 4-02.51 Combat and Operational Stress Control, Chapter 6, p 6-3. Washington, DC, 2006. MILITARY MEDICINE, Vol. 174, January 2009 Video Transcript Michael Wilkinsin FC-1 – Unite States Navy My name is Michael Wilkinson FC-1. I’m in the U.S. Navy and have been in the U.S. Navy for thirteen years. I enjoy being part of the military because it’s serving my country. When I first came in, I didn’t really understand the whole concept of serving your country and as I’ve stayed in I have become more proud of what I do, knowing that I am here defending my country, my friends, my family. Some of the reasons my job is a high-risk job is because is one you never know what is going to happen. Good example, the U.S.S. Cole. They were pulling into a port for a nice vacation time there in Yemen and all of the sudden they got hit by a suicide bomb. You don’t know what’s going to happen, so at any time something can happen. Engines can blow up, things on the boat can go wrong, fires, and your contained right there on one vessel and you have to be able to react to that, and if you are not able to then you can lose life, the crew, the ship, and you could be just out there on your own. On my first deployment, I think it was 1999, we were in the Persian Gulf doing our normal stuff and one of the air crafts was coming in for a landing, an as it landed it went off the side of the deck and crashed. Two pilots ejected out of the aircraft. We sent out a rescue helicopter to get them, and unfortunately those two pilots passed away. The next cruise I went on which was in 2002, we had another aircraft sitting on deck about to get launched and as they were getting launched the catapult system which launches the aircraft with the help of its engines ripped the nose cone off the plan and that plane crashed into the water too, and we lost that pilot. So when they lose somebody, it hurts like a family, and those guys, you saw people just distraught, upset, and just taking it really hard sometimes, you could see their attitudes they kept to themselves a lot, they wouldn’t talk about things. It was more like they were hurting inside. They were able to continue on with their jobs, I believe, with the support of everybody around them. That’s the thing about being in the military, you have support. You have, between just your buddies that you work with, from everybody on the ship, from the chaplain, you have a support system there to help you through the hard times. Off the coast of San Diego we lost five sailors in a helicopter crash from the U.S.S. Nimitz. We were out there just doing routine operations like normal. They took off to do their helicopter runs into Coronado and they never came back. Nobody knew whatever happened to them. It was just, they were there one minute and they were gone. That hit the crew pretty hard. Me personally, I didn’t know too many of them, but I did feel, since we been on three deployments with these guys that they’re pat of our family and it upset me a lot. It was probably one of the one times while I was on the ship that I really had a hard time, during the funeral ceremony that it really hit me hard. What I was feeling it was a shame that we lost five young people who were just doing their job, and nobody knows why and a lot of them had families and that kind of got to me too, because I’m thinking at the same time now that I’m married and have a daughter and if this happened to me what would happen to my family. After I got married, it was more difficult to away for the six months at that point compared to when I wasn’t married and just going on deployment. I had nothing to worry about at home and didn’t really care about what was going on back home. It was more, I’m out here enjoying myself, just living life the way anybody else would, and then once I did get married, the all I wanted to do was be at home with family, so it made it a little more difficult, but I still enjoyed going overseas and experiencing the different countries and the cultures and the food and stuff like that, but always in the back of my mind was my family back at home.
Purchase answer to see full attachment