Letters to the Editor

Military Medicine, May 2006 by Hill, Jeffrey V, Johnson, Robert C, Barton, Richard

To the Editor

As the professional mental health team for 1st Infantry Division (Mech), we thoroughly enjoyed Keller et al's May 2005 Soldier "Peer mentoring care and Support" article. We would like to add our experience implementing portions of the Royal Marine TRiM program during our unit's preparation for and deployment to Iraq. In the fall of 2003 we consulted with LCDR Greenburg (the second author of Major Keller's article), to develop a more comprehensive division-wide preventive and critical incident response program.

At that time, the primary preventive mental health programs in the division were:

(1) The Combat Stress Lifesaver Course: a peer-driven program directed at Non-Commissioned Officers (NCO's), which included a one-day educational and role playing curriculum in topics such as recognizing and responding to combat stress and suicidality.

(2) The ASIST(Applied Suicide Intervention Skills Training) program sponsored primarily by Unit Ministry Teams (UMT), taught support skills in the context of recognizing and responding to suicidal soldiers.

As the pre-deployment OPTEMPO increased, it became impossible to implement the full TRiM-spectrum training. Thus, a modified stepwise program was developed in which we lessened the emphasis on individual Soldier TRiM indoctrination and increased mental health team involvement in critical incidents.

Commands not ftilly trained in TRiM felt ill equipped to fully deal with psychological trauma. Given our time constraints, CSLS and ASIST were the primary programs teaching peer support and early identification of mental health problems.

We focused on eliminating the stigma of mental health care and received strong support from many line leaders including the Division as well as Brigade, Battalion, and Company Commanders and NCO chains. Some commanders implemented pro-mental health talking points into unit training, while others wrote articles for community and deployment newsletters that de-stigmatized mental health care. With this positive command climate, we strove to maintain mental health care provider credibility by ensuring that all mental health efforts were coordinated, consistent, and reliable. We placed particular emphasis on:

(1) Keeping the same primary mental health point of contact for each unit.

(2) Establishing critical event Standard Operating Procedures (SOP), including rehearsals and line involvement.

(3) Maintaining trustworthiness by not embarrassing or openly criticizing commands.

(4) Approaching problems at the lowest command level as much as possible

(5) Ensuring that all the mental health providers were on the same sheet of music.

Unity of mental health effort among Division Soldiers was essential. We recognized that our support network for identifying issues early included individual Soldiers, buddies, chains of command at all levels, chaplains, Social Work, and primary medical providers including medics, mental health techs (MOS 91X), and professional medical staff within the area. There was constant cross talk at all levels especially between mental health providers from different units (ie Combat Stress Control units, Division Mental Health, Combat Support Hospitals, and chaplains) operating in the same areas. Such comprehensive coordination greatly increased mental health credibility amongst line soldiers decreasing the stigma associated with seeking care. Due to mission requirements, the majority of mental health care in the division was provided by chaplains and general medical personnel. Efforts to increase their understanding and comfort levels in addressing mental health issues were well received and successful.

The home-front played a major role in Soldiers' mental health during deployment and upon return. Homefront agencies included Army Community Services (ACS), Family Readiness Groups (FRG), Rear Detachment commands, chaplains, medical, and Social Work Services. Bringing all of these agencies and personnel into a coordinated system required tremendous effort and constant diplomacy, but provided a seamless continuum of care, further reducing the stigma of mental health care.

The Critical Incident Response portion of the UD system varied by brigade and by who provided care. Many Combat Stress Control personnel and Chaplains in the 1 ID area were trained in critical incident stress debriefing and were reluctant to adapt new programs during deployment. Brigades cared for mainly by them used traditional Army debriefing methods. Soldiers and commands continued to report these procedures as beneficial.

The Critical Incident Response for two brigades and a Cavalry Squadron were provided almost exclusively by Division Mental Health personnel trained in the UD TRiM through an SOP that emphasized the following key points:

(1) Line Soldiers, Chaplains, and medical personnel provided on site psychological management including ensuring safety, rest, ; and recuperation for Soldiers involved.

(2) Written handouts were available for Soldiers.

(3) Efforts were made to maximize mental health assets already in place, though most commanders expected onsite mental health management. We worked to have a mental health team on site within one day of the event.