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War Debriefers Counter Combat Stress

- Matt Pueschel

WASHINGTON-As the Army has recently deployed some post-traumatic stress disorder (PTSD) specialists to help soldiers fighting in Iraq overcome traumatic experiences there, other "debriefing" specialists have returned from the Afghanistan conflict after performing such duties there. Cdr. Bryce LeFever, PhD, MSC, USN, department head of the substance abuse rehabilitation program at the Naval Medical Center in Portsmouth, Va., worked as a psychologist attached to a Special Forces unit during the Afghanistan conflict for three months in the summer of 2002. "I was happy to do it," he said.

Cdr. LeFever said setting up some form of debriefing program for soldiers fighting in conflicts is an important maintenance tool for personnel. He conducted "debriefings," or group discussions following traumatic events, at the time of soldiers' redeployments or after particularly traumatic and shocking combat incidents. For many soldiers who are very young and inexperienced, "in a sense there were a lot of times where they don't know what to think about the incident. We give them a healthy way to remember it-to put it in its place," he said.

Cdr. LeFever said the debriefing helps them put a traumatic combat incident into context. He said that everybody feels strange after such incidents, and the debriefers are there to try to impart that to the soldiers, as well as acknowledge their hard work in the field. Cdr. LeFever said he debriefed soldiers at different locations where he could get to them, at times being sent to remote areas. The debriefings were conducted within a whole unit, with the aim of keeping the group united. They were conducted as a 7-step "guided conversation" that took the soldiers through a series of questions.

A pair of debriefers start the process by making introductory remarks to a unit of about 20-25 soldiers, assuring them that the conversation is confidential and not an investigation. Their goal is to help them process the event and deal with the stress of it. The debriefer asks the unit to go over the facts of the event, what happened, what they did, and what thoughts may have gone through their minds at the time. The conversation then tries to get the soldiers to discuss their emotional reactions to the experience.

The debriefers then discuss symptoms that can emerge from the experience in as little as a day afterward, such as sleep problems. They go over how to manage the event, such as staying away from alcohol and things that can exacerbate the problem or cause additional stress. The final step is aimed at summarizing and communicating the experience and ways in which soldiers can handle it so they can re-enter the field. "What they [often] find out is that they are having pretty similar reactions, so they feel more connected to each other," said Cdr. LeFever. "It's great for unit integrity."

The debriefer's role is to provide support and help the soldiers work on processing the event.

For example, if a soldier walked into a fire fight, witnessed carnage and trauma, and shot someone who was pointing a gun at him or her, the debriefer might say that it was a stressful event and indicate that the soldier may have had no option but to fire because they didn't know if the other person, whether a 16-year old kid or an adult enemy soldier, was going to fire at them. If the soldier describes facts of an event that sound as if perhaps firing on someone may be perceived, in hindsight, as not warranted, the debriefer might instead say that it was a tough situation and encourage the soldier to work on processing the event. But Cdr. LeFever said the key component that debriefers stress is that they are not conducting operational critiques and they are not investigators. They are just talking about the events confidentially. In any particular debriefing, Cdr. LeFever said he usually spots one or two soldiers who he thinks may need extra one-on-one counseling sessions. He said he has provided individual follow-up sessions to some soldiers who he has debriefed originally in the group setting.

Timing Of Counseling

Some research has indicated that rapid delivery of counseling immediately after trauma has taken place is not always effective. "I would agree with that," Cdr. LeFever said. "You should not provide in-depth counseling prior to the termination of the incident, or series of events or combat missions. While these missions are part of daily routines, we want to support the troops, by and large. We just say, 'you're doing a good job, we're proud.' After the mission is completed, we work with the soldier to process the event so that he can make a successful transition to his more normal life at home."

Unless there is a particularly bad, isolated event where the unit seems to be in need of an immediate debriefing, Cdr. LeFever said debriefers will often not try to get soldiers to think about the event right away. This way, they can continue to operate on autopilot and focus on their work at hand. Debriefers will then carry out a full debriefing when combat operations have ended or soldiers are being redeployed or returned to the U.S. "We're providing a transition from the insane world of combat," he said. "This was a big problem in Vietnam, where this wasn't being done."

According to a paper written by Cdr. LeFever, during the Vietnam conflict there was a phenomenon known as "foxhole to front door syndrome." One day a soldier was in Vietnam and the next standing at his front door back in the states, and he or she was expected to be normal without having processed any of his or her combat experiences. "There was no psychological transition between the two worlds," Cdr. LeFever said. In the case of the Afghanistan conflict, Cdr. LeFever said he and other debriefers were able to get to most of the Special Forces soldiers as they were leaving the theater of operations.

Although immediate debriefings may not always have an impact, Cdr. LeFever said there is some research that indicates debriefing sessions within 72 hours of a traumatic event are likely to prevent PTSD. "You can have an immediate reaction to a critical incident," he said. However if a soldier delays getting counseling, more severe symptoms can develop after six months. Cdr. LeFever said it's much more cost-effective to do debriefings up front.

He said PTSD occurs because an avoidance system develops within the individual who has experienced a traumatic event. "You want to avoid what caused you to hurt," he said. "So you avoid situations that are similar, you avoid people who are associated with an event, places, anniversaries and the problem is, although it's natural to feel this way, all of the avoidances can lead to failures." Cdr. LeFever said someone also may be reminded of his or her traumatic experience by being somewhere that looks or smells similar to the place where the event took place. In the event that full-blown PTSD develops, this could trigger flashbacks. "We try to help them deal head-on with the trauma within a short period of time," he advised.

The object is for the individual to face their trauma and process it, so that they don't need to avoid it. Cdr. LeFever said this can be a "profound" learning experience for them, and can lead them to see a whole different way of being. By avoiding it, they may be avoiding things like traveling and even dealing with other people. Facing the traumatic event head on right away can make a big difference, he advised.


Cdr. LeFever said he also provides debriefing training for medics, nurses, psychologists, physicians and others, when requested by the various military Services. He said he has been carrying out debriefings himself for about 10 years. He originally received training from Jeff Mitchell, a psychologist who formalized a debriefing procedure in 1980 and established a non-profit organization called the International Critical Incident Stress Foundation, which is dedicated to the prevention and mitigation of disabling stress through education, training and support services for all emergency services professions; continuing education and training in emergency mental health services for psychologists, psychiatrists, social workers and licensed professional counselors; and consultation in the establishment of crisis and disaster response programs for varied organizations and communities worldwide.

Cdr. LeFever said he conducts the debriefing training as requested for the various military medical commands and facilitates the training for military psychologists and others. His belief is that the military can drastically reduce the incidence of PTSD through following through with debriefing sessions. "I think it's getting a lot of attention," he said. "It's more like getting the word out to people." He said they try to get the core mental health providers in the various Services trained to carry out debriefings. "In doing this successfully, it is necessary to do a lot of leadership training," he said.

He said the debriefing training usually takes 2-4 days. He said this includes simulations of real scenarios in which the students are given roles to play. Although such teams might be trained together, they are generally not sent off or deployed as a team, Cdr. LeFever added.

Fort Bragg Killings

The importance of debriefings following redeployment was elevated during a six-week period in June and July of 2002 at Fort Bragg, N.C., when the wives of four active duty soldiers were killed, and one active duty soldier was killed. In each case, the spouse was believed to have been the killer. In addition, two of the soldiers committed suicide immediately after their wives were killed. Three of the four soldiers accused of killing their wives had been deployed to Afghanistan, and two of them returned early from war theater operations to resolve marital difficulties.

A 19-member Epidemiological Consultation (EPICON) team, composed of behavioral health experts from the Army and the Centers for Disease Control and Prevention and assigned to the investigation by the Army surgeon general's office, later reported that focus groups at Fort Bragg indicated that high operations tempo, leading to lengthy separations for military couples, exacerbated marital problems. Among the team's recommendations was that DoD should commission a systematic study of the link between high operations tempo and the health of soldiers and their families, and that DoD should reenergize deployment transitional programs in a more routine care delivery model.

"Those were going on while I was in Afghanistan," said Cdr. LeFever. "Those are very complicated, and would have to be compared with the base murder rate in the military. There is nothing about combat that would cause you to kill your spouse."

Furthermore, only three of the returning soldiers had actually been involved in combat in Afghanistan, he added. "The investigation showed that in the four cases there was something seriously wrong in the marriage," he said. "Add alcohol to [such problems], and [people] become more impulsive. There are multiple causalities."

Many soldiers who have fought in combat return to have loving marriages, Cdr. LeFever said. However the debriefing teams in Afghanistan at the time of the killings were made aware of them, and Cdr. LeFever said that they made sure to carry out as many debriefings as they could, so that soldiers wouldn't slip through the cracks.

Despite the apparent benefits of debriefings, they aren't required of soldiers. "It's heavily recommended, but not required," Cdr. LeFever advised.

Some unit commanders may require it at their discretion, however.

Shedding Stigma

When asked if some soldiers shun debriefings because they may associate them with mental illness and the stigma that carries, Cdr. LeFever said there is stigma, but usually only until soldiers find out what it is debriefers are really doing. He said he emphasizes that the debriefing is confidential and that he is there only to guide soldiers through it. He said soldiers are usually incredibly grateful afterwards. When asked if some soldiers feel more comfortable talking to chaplains than psychologists, Cdr. LeFever said some might initially, but it depends more on the individual.

Furthermore some soldiers may not be ready to talk about their traumatic event. "Some are too numb," he said. "We just offer the best we have."

Response Teams

Teams sent by the Navy, Army or Air Force to help survivors deal with traumatic incidents go by various names: Critical Incident Stress Debriefing Teams, Stress Management Teams, Special Psychiatric Rapid Intervention Teams or Special Intervention Response Teams.

Major civilian medical centers have sanctioned such teams, as well, Cdr. LeFever advised.

Cdr. LeFever has served on both civilian and military event response debriefing teams. One such team was sent to the Mediterranean in February of 1997 after a jet crashed and killed four crewmembers of a 200-plus member squadron based aboard the USS THEODORE ROOSEVELT. "There were 215 people in the squadron who knew these people, and needed to be debriefed," he said.

Another event he responded to was a midair collision of helicopters that killed 14 servicemembers at Camp LeJeune, N.C., in 1996. A Special Psychiatric Rapid Intervention Team (SPRINT) from the Naval Medical Center in Portsmouth, Va., was activated to assist surviving servicemembers and families through the ordeal. According to Cdr. LeFever, they used Dr. Mitchell's seven-step critical incident stress debriefing (CISD) model, providing 1-2 hour psychological debriefs for victims. The team consisted of psychiatrists, psychiatric nurses, psychiatric technicians, social workers, chaplains and psychologists. It was a tough job, since some of the servicemembers who were debriefed had actually been assigned to recover the victims' bodies and were particularly shaken up by the experience.

"The debriefing teams had to get to all those units and talk with members who had just lost their fellow unit soldiers. Some even had to pick up the bodies," Cdr. LeFever said.

Over the course of a week, the SPRINT team performed about 20 debriefings and reached about 400 of the most affected personnel. They coordinated follow-up care with civilian and military health providers in the area.

According to Cdr. LeFever, combat psychiatric casualties historically comprise at least 10 per cent of all casualties. During World War II, some units suffered psychiatric casualty rates higher than 50 per cent, he advised in his paper. "Clearly, soldiers in combat situations face stressful conditions, and face the threat of harm or death," he wrote. "Exposure to threat in the theater of operations not only results from combat, but also from search and seizure operations, and from riot/crowd control. Most also face long stretches of out and out boredom, which is particularly stressful for adolescents and young adults."

Cdr. LeFever wrote that the use of CISD techniques fall under five basic management guidelines for treating combat stress: immediacy-treating the casualty as soon as possible; proximity-treat the psychiatric casualty as close to the front line and his or her unit as possible; normalcy-do not treat the casualty as a psychiatric patient, but deal with his or her immediate concern or trauma; familiarity-return the soldier to his or her original unit as soon as possible; and expectancy-create the expectancy that the soldier will recover quickly and will return to their normal level of functioning.

According to Cdr. LeFever, there are four officially sanctioned Navy SPRINT teams in the U.S. and one in Europe. Cdr. LeFever said there is a cadre of people who can comprise a team.

Cdr. LeFever said PTSD has a ripple effect that affects the people who were closest to the trauma the most, but spreads out to those who were associated with it in other ways, as well as the families of victims and first responders. Ideally, if the Army had enough resources it would reach out to the families of those afflicted with PTSD, as well. "I think the answer is taking care of the immediate community," Cdr. LeFever said. But he said they do let people know where to go for follow-up care. "We're only getting the inner ring of that trauma," he said. "Our fear is maybe [the debriefings] are not enough, but we offer to come back [if they need it], [or] we say call this person..."

Debriefing The Debriefer

Cdr. LeFever said there is also a process called "Debriefing the Debriefer," in which psychologists who respond to disasters have a chance to talk with other psychologists about their own processing of running the debriefing sessions and hearing the horror stories of those they help. "We go over the incident and make sure they're taking care of themselves," said Cdr. LeFever. "The rule of thumb is we try to stay detached from it." This means that when a debriefer responds to a scene, and is asked, for example, 'do you want to see the actual crash or carnage?' the rule of thumb is to stay away from it, Cdr. LeFever advised. This rule also applies if the debriefer has a personal attachment, such as being a friend or relative of the victims or people involved in an incident.

Substance Abuse

The importance of reaching soldiers before they experience a breakdown years down the line can be witnessed in the numbers of veterans and others who have been through traumatic experiences and may have subsequent problems with alcohol and drugs. As Department Head of the Substance Abuse Rehabilitation Program at the Naval Medical Center in Portsmouth, Va., Cdr. LeFever said about 80 per cent of the cases there are alcohol-related. "We treat every branch of Service here, mostly active duty," he said. "90 per cent are active duty and it's a four-week intensive and residential program."

Cdr. LeFever said such chronic substance abuse problems can have roots in trauma and PTSD. "We look at trauma using a mental health model," he said. "[Looking at how they] develop the disorder. You have to really get in there and go back through hell with them."

Cdr. LeFever said this is a lot harder to do with soldiers who went through something years ago and were never debriefed afterwards or never talked about it before. A large part of it is getting them to get in touch with the emotional impact of what they witnessed or went through, so they can begin to process it.

He said they treat all levels of cases. Since the Iraq conflict is still relatively young, it remains to be seen whether it will produce a large number of PTSD cases. But Cdr. LeFever said the potential is there just because these young soldiers are being traumatized there. He said the program at Portsmouth has an 89 per cent success rate for graduation. The program treats 20 people a week in residence and about 1,000 a year, making it a major substance abuse recovery facility on the East Coast. Furthermore Cdr. LeFever said many people with alcohol or substance abuse problems can experience an average of five relapses after recoveries, which makes such programs ever more important.

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