Charles R. Figley, Ph.D. Tulane University Kurzweg Chair in

Disaster Mental Health

Presentation Dedication

This presentation is dedicated to the thousands of combat medics who

served their country and must anticipate and adopt to the deaths of all their “clients” the rest of their lives

Acknowledgements

!  Ted Rynearson and his team for choosing Tulane and New Orleans for this training conference

!  Dean Ron Marks and the Tulane University School of Social for their support of this conference and my work represented here

Acknowledgement My Research Team

Joseph Boscarino

Joia Speciale

Kathy Figley

Jeff Nagy

Purpose of the Presentation

Suggest that since combat medics are among the most resilient in adopting to violent death in combat what may be the reasons and what can we learn from them.

Objectives

After this presentation, participants will:

1.  Be more familiar with the special circumstances of modern combat medics as caregivers vulnerable including the same challenges all caregivers face.

2.  Be familiar with the combat stress injury model and the four types of injuries including a grief/loss injury.

Objectives (cont.)

After this presentation, participants will:

3. appreciate the connection emotionally and socially between what combat medics do and the importance of building secondary stress resilience capacity

4. understand and apply knowledge about the "Spectrum of Compassion Response” as an indicator of the level of thriving as human beings

Thesis

!  Combat medics adapt to violent death by focusing on their job, apart from the emotional reactivity experienced by non-medic soldiers

!  Thus, combat medics adapt to violent death through effective self regulation that includes focusing on the mechanics of their job as caregivers.

!  Medics avoid stress injuries by a set of strategies that include displays of leadership, soldiering, and medical care.

Studies of combat vets responses to death

!  1. Death was a “central and profound” experience for vets the studied

!  2. Pre-military service predicts, like personality, religious atmosphere at home, and contact with death, reactions

!  3. Investment in life – family, life generally, and education – increase death anxiety.

Other factors that influence death anxiety

!  Stress management generally manages any anxiety

!  Strategic use of denial, desensitization, and compartmentalization to manage death anxiety

!  The value of life increases with each exposure to death

!  Being near death is most often traumatizing but offers important lessons that can make it worth it (Post-traumatic Growth)

Similarities of Disaster and War Deployment

Characteristics War Deployment

Disaster Deployment

Lots of Training Preparation X X

Away from home and family X X

Exposed to a range of traumatic stressors

X X

Work long hours in difficult conditions for an extended period

X X

Expectations are to withhold self care and endure the conditions

X X

Varying levels of danger and uncertainty, and periods of boredom

X X

Who are Medics and Navy Corpsmen?

1.   Revered military role in all service branches

2.   Critical to combat operations

3.   Responsible for treating wounded Soldiers and allies civilians and enemy combatants

4.   Potentially conflicting Dual Role (Soldier/Medic)

Combat Medics (cont.)

5.   No studies specifically on combat medics

6.   Focus on resilience or combat mettle to enable them to survive and thrive mentally and physically

Combat Medics

! Required to fight battles

! provide front line trauma care, often in the heat of a battle, with limited resources and under enormous stress.

!  In modern warfare, however, they must be able to transition from a soldier role to a medic role quickly and decisively in accordance with the tactical situation and rules of engagement.

Combat Medics

! They must not only understand the nature of war, but also the nature of war-related injuries and

!  the implications for medical procedures that will be effective given the tactical environment, current location, resources available, and capabilities.

!  must not only cope with the emotional burden medic duties but also must be prepared to die and to participate in a killing (Mazurek and Burgess, 2006)

Combat Medics

! All this plus endure war in the middle east

!  changing rules of engagement,

!  the stop loss and other war service-related rules and regulations,

! The media limited slants on the wars’ efforts,

Combat Medics

!  the changing and increasing deployment schedule that prevents sufficient down time to reach a healthy “re-boot” and

! more prepared psychologically for the next deployment, and many other realities of these post-9-11 wars.

From the Combat Medic’s Prayer

!  If I am called to the battlefield, give me the courage to conserve and protect our fighting forces by providing medical care to all that are in need.

!  If I am called to a mission of peace and mercy, give me the strength to lead by caring for those who need my assistance.

!  Finally, Lord give me the strength and insight to take care of my own spiritual, physical, and emotional needs.

Combat Medic Mettle: Our teams focus

!  Dictionary definition of mettle: vigor and strength of spirit or temperament

!  Having “medic mettle” means possessing the right stuff to adapt and thrive as a leader, healer, soldier, and person.

!  Ours is part of a larger group conducting a longitudinal survey of 848 combat medics in two continents since late 2009.

!  This is our final year of the 3-year study.

Recruitment Numbers

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Preliminary Findings

!  First study to confirm medics experience secondary trauma, like other medical health care providers.

!  Though witnessing significantly more combat stress, medics scored better in behavioral health measures

Combat Experiences

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Preliminary Findings

!  Consistent with compassion fatigue theory, they experienced higher levels of depression than other soldiers.

Getting Behind the Statistics

!  The Tulane Research Team was responsible for the qualitative elements of the three-year study

!  Our team conducted intensive video interviews with 17 named by the group as the best representation of combat mettle.

!  The first measure of CMM that will help build a model of combat medic mettle that will assist us in measuring the essence of what is required to thrive.

Recruits 17 combat medic interviews

Initial Survey (n=848)

Nominates

Medics with Mettle (n=40)

Successfully Interviews 17

Purpose of the Interviews

! First identify key truisms about combat medics that may contribute to medic mettle.

!  Second, convert these observations into items in the first draft of a Medic Mettle Scale

! Third, administer the scale to all 848 combat medics and investigate the predictive power of the Scale in predicting behavioral health markers.

Interview Process

Pre-Interview Paperwork

Semi-structured Video Interview

Post-Interview Team

Discussion

Post-Interview Team Discussion

VGA Procedure for each Video Interview using Quick

Time (video) Markers

Primary Reviewer

Secondary Reviewer

Tertiary Reviewer

Example of Reviewer Assignments for VGA Analysis

Subject # A Reviewer B Reviewer C Reviewer

1 Primary Secondary Tertiary

2 Secondary Tertiary Primary

3 Tertiary Primary Secondary

4 Primary Secondary Tertiary

5 Secondary Tertiary Primary

VGA Methodology to Generate Scale Items

Identify items for the scale that may be truisms about being a combat medic:

!  Personal experiences and observations

!  Methods of coping with adversity and change

!  Words to live by in coping and resilience

Variable Generating Activity’s Five Variable

Domains

Interventions(I)

Stressors(S)

CollateralSystemicImpact(CS)

BehavioralHealth

Indicators(BH)

Protective Factors

(PF)

1

2 3

4

56

7

8

9

10

Video Data Analysis: Video Generating Activity (VGA)

Assign Data Analysis Roles VGA 138-item Scale

Medic Mettle Scale Face Validity Analysis

138-item Scale 104-items 4 Factors

COMBAT MEDIC METTLE SCALE (v1)

Instructions:

!  Thanks for helping medics. This Scale is composed of statements by active duty medics interviewed in 2010 near their base.

!  The purpose of the Scale is to help understand military resilience and how to help combat medics be as resilient as possible in their important work. The Scale is divided into four, color-coded sections (Leadership, Personal Beliefs/Experiences, Technical Skill/Medical Training, and Soldiering Skill/Training) that represent medic skills sets.

COMBAT MEDIC METTLE SCALE (v1)

Instructions (cont.):

!  Please consider each statement as it applies to you and your opinions and rate how the statement describes you during the last week by selecting one of 4 options:

!  0= Not like me or NA; 1= Sort of like me; 2= Like me; 3=Very much like me; 4= That’s totally me

Examples of LEADERSHIP Items

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Example of PERSONAL BELIEF/EXPERIENCE Items

*%+,- .$/0' PERSONAL BELIEF/EXPERIENCE

27. I like to keep my mind occupied. 28. have taken prescription drugs to help with sleep but

they had no effect. 29. I have taken prescription drugs to help with sleep

and they worked well.

Examples of Technical/Medical Training Items

*%+,- .$/0' PERSONAL BELIEF/EXPERIENCE

69. I value being called doc. . 70. I maintain a strong relationship with my chaplain. 71. My training helps me overcome any fears.

Examples of Soldiering Skills/Training Items

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92. I work hard, train hard, and am prepared.

93. I believe that my soldiers are like family to me.

94. I allow negative events to affect me.

Medic Mettle Scale (MMS) Psychometrics

MMS Completed by 838 Medics MMS-2

Medic Mettle v2

! Strong psychometric properties

! Correlated with measures of readiness, self confidence, resilience, thriving

! Help build the statistics model of medic resilience (mettle)

9. Combat Stress Injuries and Resilience

The following figure was originally developed to identify the process by which combat-stress injuries could be predicted and prevented.

9. Combat Stress Resilience

Most deployed do well in both the short and long-term.

However, some develop some form of psychosocial stress injuries that require attention.

The following describes a “roadmap” for appreciating the psychosocial variables in predicting the stressors and stress reactions during deployments.

"&!

"&!TRAIT RESILIENCE FACTORS

" Intelligence " Trait Resilience (ER-89) " Stress Adaptation Competence " Self Confidence and Self Confidence

Occupational Hazards

" Individual Demands " Unit Demands " Environmental Demands " Family Demands WORKER STRESS REACTIONS

" Biological Markers " Psychological Markers " Social Relationship Markers " Behavioral Markers " Spiritual Markers

Trauma-RELATED STRESS INJURIES AND RESILIENCES

" Physical Fatigue Injury and Resilience " Grief Injury and Resilience " Belief Injury and Resilience " Trauma Injury and Resilience

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Stress Injuries and Resilience of Disaster Workers

TRAIT RESILIENCE FACTORS

" Intelligence - i.e., logic, critical thinking

" Trait Resilience (ER-89) – adaptive, adventurous

" Stress Adaptation Competence " Self Confidence " Sense of Humor

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Occupational Hazards/Stressors

" Individual Demands – e.g., physical " Unit Demands – e.g., frequent

deployments " Environmental Demands – e.g.,

internal politics, weather " Family Demands – e.g., pressures to

be home, financial stressors

WORKER STRESS REACTION MARKERS

" Biological Markers – i.e., indicators of immune suppression

" Psychological Markers -- e.g. emotional indicators of stress, sleep dysfunction

AND

WORKER STRESS REACTION MARKERS

" Social Relationship Markers –social support and colleague care

" Behavioral Markers –job competence " Spiritual Markers –sense of direction,

hope, and fulfillment

Trauma-RELATED STRESS INJURIES AND RESILIENCE

" Trauma Injury and Resilience – i.e.,

memory management and re-establishing safety

" Physical Fatigue Injury and Resilience –i.e., wear and tear

" Belief Injury and Resilience –moral and ethical challenges

" Grief Injury and Resilience -- adaptation to loss of person, place, thing

Inner Conflict

!  Most recent and controversial (guilt, shame that can lead to suicide)

!  Most often due to conflict between moral/ethical beliefs and

!  current experiences such as

!  taking action outside of the rules of engagement and

!  where there is harm to an innocent life;

!  not preventing harm to a buddy.

Grief Injury and Resilience --

nner Conflict — or beliefs injury is most often due to conflict between moral/ethical beliefs and current experiences such as taking action outside of the rules of engagement and where there is harm to an innocent life; not preventing harm to a buddy.

Enabling Medics to Recover from Stress Injuries

! Estimating Functioning

! Using the Spectrum of Combat Resilience to determine the level of functioning.

How do we know to refer for

professional help?

According to the Spectrum Model (vs psychopathology)

!  It takes a system to coordinate care for those who require help

! versus those who deserve praise and respect

! without negatively affecting those who are dysfunctional

! Functioning is defined by the presence of five capabilities.

Combat Medic Functioning: 1. Physically capable (measured by level of energy due to sleep,

health)

2. Psychologically capable (measured by level of enthusiasm, intellectual capability, morale, spiritual support)

3. Interpersonally capable (measured by level of social support and cohesion with group)

4. Technical and administratively capable (measured by standard productivity, client satisfaction, and competence scales)

5. Self (Care) Regulation capable (measured by the existence of an EB self care plan and following it). EB self care plan (see Greencross.org)

Spectrum of Caregiver Stress Resilience

! FIVE LEVELS OF FUNCTIONING

! Useful for caregivers to determine the effectiveness of their self care plan and for

! Leaders and role models in stress resilience

Spectrum of Caregiver Resilience

Level 5 Level 4 Level 3 Level 2 Level 1

Highly Resilient

Resilient Challenged Resilience

Supported Resilience

Failed Resilience

Exceptional Role Model

Good Functioning

Acceptable Functioning

Unacceptable Functioning

Dysfunctional

No challenges in functioning

Challenged in 1 provider function

Challenged in 2 functions

Challenged in 4-5 Functions

Failing in 1 or more functions

Train and Coach others on the team

Maintain Provide Coaching and Peer Support

Explicit Plan Implemented for Resilience

Immediate behavioral health services

Level 5: Highly Resilient

! Many people are in this category and are thriving in their career.

! They score high on thriving and human development

! Tend to score high on trait resilience and the other protective factors

Level 4: Resilient

! Most people are in this category and are challenged but meet the challenge in their career.

! They score moderately high on thriving and human development and on trait resilience and the other protective factors

! May have one of the five

Level 3: Challenged Resilience

! Many are in this category and require attention

! Acceptable Functioning

! Challenged in 1-3 Functions ! Provide Coaching and Peer

Support

Level 2: Supported Resilience

# Unacceptable Functioning

# Challenged in 4-5

# Functions

# Explicit Plan Implemented for Resilience

Level 1: Ineffective Resilience

# Failing Resilience

# Dysfunctional

# Failing in 1 or more functions # Need aggressive behavioral health services

# Benefit from the MASTERS Transformative approach to establishing and sustaining an appropriate self care plan

Conclusions

Combat medics are caregivers like social workers, nurses, child welfare workers, and others trying to help others

Conclusions

Stress and stress regulation are among the biggest challenges in war and are vulnerable to stress injuries that may lead to mental disorders but can also lead to growth.

Conclusion

! Medics and other caregivers’ secondary stress reactions must be closely monitored and given proper positive attention

Conclusion (cont.)

#  Caregivers should utilize good self care, practice colleague (buddy) care, and;

#  Encourage supervisory support for caregivers

Dedication: To the memory, life, and contributions of LtCol Dave Cabrera, PhD, killed in action October 29, 2011

Charles Figley’s Contact Information:

!  Figley@Tulane.edu

!  504-862-3473

!  Charlesfigley.com

The role of leadership in promoting post-trauma resilience

Leadership characteristics:

! 1. Inspiring: Sense of mission and history

! 2. Caring: Perceived to have the best interests of the deployed and the deployment teams in mind

! AND

The role of leadership in promoting post-trauma resilience (cont.)

! 3. Skilled: Knows operations, experienced in a variety of disasters and disaster mitigation

! 4. Personable: Knows team members by name and duties

! 5. Role Model: Others see their efforts at self care, sense of humor, and being ethical and humane.