Prepared by: BPSO Calgary Capt Kuschnereit 5760-7 (BPSO)
5 Aug 92
AIM
1. The aim of this brief is to provide background information on Combat Stress
Reaction and Critical Incident Stress and describe their ramifications on LFWA personnel.
Methods for preventing and reducing the effects of Stress will be described. In addition, a
programme to provide a structure for educating, debriefing and counselling personnel on
Stress will be proposed followed with specific recommendations.
DEFINITIONS
2. Combat Stress Reaction. Combat Stress Reaction (CSR) is a term which
encompasses an array of reversible effects caused by the stressors of combat and refers to the
temporary psychological upset causing an inability to function normally (normal function
includes the ability to engage the enemy and survive). CSR encompasses the terms battle
fatigue, battle shock, and critical incident stress, as well as older terms such as shell shock and
combat exhaustion. It should be emphasised that CSR is a normal reaction to an abnormal
situation. Soldiers experiencing CSR are not cowards or medically sick but when left
untreated, the effects of combat stress reaction can last long after the physical wounds have
healed. In 1942 64% of the population of veteran hospitals were World War I Combat Stress
Reaction casualties. The proportion of Combat Stress Reaction cases to medical casualties
has been increasing over the years as wars increase in their intensity. For example in Italy,
during the period 1 December 1943 - 12 Feb 1944, 23.2% of the PPCLI casualties were due
to Combat Stress Reaction. In 1982, when Israel invaded Lebanon, Combat Stress Reaction
casualties were twice the number of those killed and accounted for 27% of those wounded.
Although the incident of combat stress reaction is related to many factors including the length,
type, and intensity of battle, it is estimated that 25 - 50% of future casualties will be due to
Combat Stress Reaction. The Canadian Army has standardized their doctrine concerning the
prevention and management of Combat Stress Reaction casualties with that of the American,
British and Australian armies as outlined in Quadripartite Standardization Agreement 909,
(Flag A).
3. Critical Incident. A critical incident is a single peacetime event which causes
the personnel involved to experience unusually strong emotional reactions. The following are
examples of critical incidents:
a. The serious injury or death of a service member or DND civilian while
on duty;
b. The serious injury or death of a civilian involving military members;
c. Almost any case which is charged with profound emotion such as the
sudden death of an infant under particularly tragic circumstances;
d. Almost any case which attracts extremely unusual attention from the
news media; and
e. Almost any incident in which the circumstances are so unusual and the
sights and sounds so distressing as to produce a high level of
immediate or delayed emotional reaction that surpass the normal
coping mechanisms of service members or DND civilians.
4. Critical Incident Stress. Critical Incident Stress (CIS) is the reactions
experienced by personnel facing an exceptional event which causes unusually strong physical
and emotional reactions and has the potential to interfere with their ability to function now or
later. Personnel affected by CIS can either be primary victims (those at the scene at the time
of the incident) or secondary victims (those arriving soon after an incident, i.e., rescuers, or
those who are close to primary victims such as buddies, medical assistants, families, etc.).
Left unmanaged, CIS can become a psychological disorder to some personnel as evidenced
by the fact that several CF personnel tasked with the clean-up and body removal after the
Aero Air crash at CFB Gander are still under psychological/psychiatric care suffering from
post traumatic stress disorder seven years after that accident.
5. Post Traumatic Stress Disorder. Post Traumatic Stress Disorder (PTSD) is
the chronic psychological reaction to overwhelming traumatic events or stress that is far
beyond normal human experiences. The disorder has two common features that can occur
separately or concurrently. The first is a general emotional numbing and loss of normal
effective responsiveness to life situations and to interpersonal relations. The second is that
victims re-experience the event in a number of ways, in the form of painful and fearful
recollections, intrusive thoughts, recurrent dreams and nightmares, chronic anxiety states, and
disassociative episodes. The prognosis for individuals suffering from PTSD is very poor.
The most serious symptom is depression and a drastic increase in the risk of suicide. During
the Vietnam conflict the United States suffered 58,000 fatalities. Since 1975 it is estimated
that 60,000 Vietnam veterans have committed suicide. Even now, 27 years after the end of
the conflict, the US Veteran's Administration estimates that as many as 25% of the men and
women who served in South East Asia still suffer some symptoms of PTSD.
6. CIS Debriefing. Combat Stress Reaction and Critical Incident Stress, if left
untreated, can lead to Post Traumatic Stress Disorder. This cycle can be broken by debriefing
all personnel involved in an incident. Critical incident stress debriefing (CISD) is a structured
group debriefing procedure that has been found to be effective in that it reaches all personnel
concerned and allows facts, feelings and thoughts to be worked through rather than being
internalized. Key features of CISD are the need to conduct debriefings as soon as possible
after an incident and in as close proximity to their units as possible. For combat stress, the
issues of immediacy and proximity are especially important to insure that combat stress
casualties will be able to return to duty. The Israeli Defence Force has found that personnel
taken away from their units for psychological treatment were less likely to return than those
treated at or near their unit. The further away from the action the soldier was taken the more
guilt, stigma and trauma were experienced. By conducting debriefings near the scene, all
personnel can be involved and the approach of "normal people talking about an abnormal
situation" can be maintained. This approach allows the majority of personnel to ventilate and
thereby deal with the emotional reactions caused by the event. Not all personnel will find
complete relief using this method and trained debriefers will be needed to identify those who
may require further counselling. The CISD procedure is explained in detail at Flag B.
BACKGROUND
7. A proposal for NDHQ - sponsored CISD teams was made in Jan 90 by the
Director of Social Development Services (DSDS). An ad hoc CISD/Combat Stress team was
formed and deployed to the Persian Gulf during the Gulf War conflict. Although the team did
not conduct any formal debriefings due to the limited Canadian combat involvement, the
Canadian Commander, Comdr Summers, regarded the team's efforts in the area of stress
education and management as a valuable contribution and stated that they should have been
deployed sooner. DSDS does not yet have approval for their plan and a permanent national
CISD team has not been formed. Several ad hoc CISD teams were formed virtually overnight
after the crash of the Hercules aircraft at Alert but the majority of these teams were headed
by civilians.
8. A Critical Incident Stress Debriefing Team was formed at CFB Calgary in Nov 91. To date they have conducted two series of interventions. The first was following the suicide of a member of the LdSH(RC) and the second was after a training accident at CFB Suffield where a member of 2 PPCLI was crushed by an APC. During RV92 a Social Worker conducted a series of interventions after a member of the LdSH(RC) was killed in the training area while on a road move. BPSO Calgary has been active in Combat Stress Reaction education at several 1 CBG units and has also prepared a series of three aide-memoirs on the subject (Flags C, D, E). He, along with the Area
PSO, has developed a proposal for CSR/CIS management which offers support to soldiers,
service families and DND civilians.
PROPOSED CSR/CISM PROGRAMME
9. The overall programme comprises of four areas: education/prevention,
resource referral, family education and support, and debriefings. Education would include
briefing LFWA personnel on what a combat stress/critical incident is, what reactions are
normal and to be expected, how to prevent or minimize stress reactions (leadership, exercise,
diet and lifestyle factors) and what support can be provided in the event of a critical incident
(i.e., requesting CISD). A resource referral system would be created to provide literature in
the area of CSR/CISD and a list of community contacts of professionals trained in CISD and
follow-up counselling would be created. Family education and support would comprise part
of the overall programme and would likely be administered through the various Base Family
Support Centres. Support for the families would be offered in the form of support groups and
debriefings allowing for ventilation of feelings as secondary victims.
10. Debriefings would be provided for all victims (primary and secondary) of an
incident and would be conducted by trained teams made up of a combination of professional
and peer support team members. Professional team members would be volunteers drawn
from the helping professions (Personnel Selection Officers, Social Workers, Padres, etc.) and
trained in debriefing techniques. Peer support personnel would be volunteers from any MOC
or civilian occupation (preferably at the senior NCO rank level) and trained in debriefing
techniques.
11. The makeup and size of the team assigned to any critical incident would be
determined by a Base team leader in conjunction with a Base administrator and LFWA
coordinator. These positions are deemed necessary to the chain of command for selecting,
training, supervising and the calling out of CISD teams. In an operational situation,
CSR/CISD teams could be employed at the division/brigade level at Stress
Recovery/Personnel Conservation Centres. It should be noted that the chain of evacuation for
CSR casualties is separate but parallel to the medical chain (Flag F). For a UN peacekeeping
operation such as OP HARMONY, the CSR/CISD team could be attached to the HQ and
visit units as required.
12. If a LFWA CSR/CISD team were deployed as part of OP HARMONY they
could respond to incidents as required and without excessive delay. By living with the troops
they would become accepted as part of the team rather than being outsiders. They could
educate peer counsellors and be available to help people deal with the day to day stresses of
being in a war zone.
CURRENT STATUS
13. An ad hoc national CISD team has been just created and placed on standby
to conduct debriefings in Yugoslavia for the troops currently stationed there. The team
consists of a Navy psychiatrist from CF Hospital Halifax, an Air Force Social Worker from
Air Command and a 6B MED A. Their plan is to debrief the 800 troops over a period of two
weeks. Unfortunately, they have yet to receive approval from the United Nations to deploy
in spite of the 18 Canadian casualties that have already been incurred.
14. Both Maritime Command and Air Command have CISD coordinators and
have formed teams. When the Navy lost two divers in the Mediterranean, their team was
flown in within 72 hours. When the Air Force C-130 crashed at Alert, a number of teams
responded. Unfortunatly, the Army has unique requirements. The requirement to deploy a
team to an operational zone precludes the employment of civilian experts as was the case with
the Hercules crash. In a war zone, our soldiers are exposed to stressful situations every day
over an extended period of time. The fact that the Army does not have a coordinator and the
ad hoc national CISD team has yet to deploy to Yugoslavia, due to delays in receiving United
Nation approval, underscores the requirement to have a trained Army CSR/CISD team in
theatre that could respond within 24 hours. Col Green at NDHQ Medical Operations has
indicated that LFWA will be responsible for CISD support to our own troops for the next
rotation. LCol Cameron, 1 CBG Brigade Surgeon supports this plan and believes that
qualified personnel can be attached to 3 PPCLI from LFWA for the six month tour.
RECOMMENDATIONS
15. Land Forces Western Area personnel and their families face numerous
dangerous and potentially emotionally damaging incidents in the course of their careers. OP
HARMONY personnel in particular may be exposed to extremely stressful conditions and
potentially combat. We owe it to them to ensure that they have every advantage in dealing
with such intense stress. In addition, by alleviating the effects of such stress, we ensure the
continuing effectiveness of our personnel and a reduced requirement for replacement. It is
recommended that:
a. An Area Coordinator responsible for CSR/CIS Management be assigned
from within Land Forces Western Area;
b. A CSR/CISD education/prevention program be immediately initiated with
a priority going to OP HARMONY personnel;
c. Professional and peer support team members be selected and a training
plan developed;
d. An Area CSR/CISD team be formed;
e. Requirements for funding for training be identified;
f. CSR/CISD SOPs and call-out procedures be developed within LFWA;
g. Team members be trained; and
h. Consideration should be given to deploying a CSR/CISD team with 3
PPCLI for OP HARMONY.
List of Flags:
Flag A. Quadripartite Standardization Agreement 909
Principles of Prevention and Management of Combat Stress Reaction
Flag B. The Use of the Critical Incident Stress Debriefing Program for Combat Stress
Flag C. Combat Stress Reaction: Notes for Commanding Officer
Flag D. Combat Stress Reaction: Leader's Action
Flag E. Combat Stress Reaction: Self and Buddies
Flag F. Annex A to QSTAG 909