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05-24-08, 10:27 AM
Last modified Friday, May 23, 2008 6:09 PM PDT
MILITARY: Trauma treatment

By GARY WARTH - Staff Writer

For warriors returning from battle, it sometimes is the final and most difficult foe they face.

The lingering emotional effects of battle can have dire effects years after the last bullet is fired. Depression, substance abuse and even suicides have been linked to combat stress.

But while the condition probably is as old as war itself, there never has been a single treatment for combat stress. That changed for the Marines just two years ago, when the Corps devised a therapy called Combat Operational Stress Control and adopted it as its soul official treatment program.

Other therapy methods still are practiced outside of the Corps, however, and medical researchers have gathered each year to discuss the various treatments at the International Military & Civilian Combat Stress Conference, founded by La Costa psychologist Bart Billings and held at Camp Pendleton for 15 years.

This year, however, the conference ended its long run at the base and was held instead at the Los Angeles Marriott from May 2 to 6. Billings' conference was bumped because of a scheduling conflict, as the Corps had coincidentally planned to hold its own stress conference that same week on base, said Camp Pendleton spokesman 2nd Lt. Tom Garnett.

Billings said the Corps simply does not want people learning about treatment programs other than its own, as was evident last year when a base chaplain trained to treat combat stress circulated an e-mail asking his colleagues not to attend the 2007 conference.

At the very least, the two conferences and the chaplain's e-mail demonstrate that the debate about how to treat combat stress is far from settled.

The issue also has raised questions of whether a single, targeted message about its treatment is better than an open debate about various approaches.

A U.S. congressman who has attended Billings' conference supports the latter.

"Nobody has a monopoly on the best techniques," Rep. Bob Filner said earlier this month.

Filner said the Corps should welcome a conference that presents various methods for dealing with combat stress, especially in a time of war. Last year, 18 combat-experienced Marines took their own lives, twice as many as the year before.

"We're letting tens of thousands of Marines and soldiers out into the civilian world with PTSD (post-traumatic stress disorder) and brain injuries," he said. "We've got suicides at the highest rate since Vietnam. They should be open to any kind of techniques and suggestions."

Not everybody agrees that more is better, however.

Capt. William Purdue, a Camp Pendleton chaplain trained in Combat Operational Stress Control, said some practices can cause more harm than good. One of those practices, he said, is taught at Billings' annual conference.

Critical Incident Stress Management

Billings said his last two conferences have included the Corps-approved Combat Operational Stress Control, but also featured sessions on Critical Incident Stress Management, an alternative, older program.

Critical Incident Stress Management, Billings said, is a crisis-intervention program that emphasizes immediate and multifaceted treatments for people who have experienced traumatic events.

Among the actions recommended within 24 hours of an incident are journal-writing, talking with family and friends, and moderate exercise and relaxation. The program, created by civilian Drs. Jeffrey Mitchell and George Everly Jr., also trains teams of people to be ready to treat trauma during emergencies.

Critical Incident Stress Management includes a component called Critical Incident Stress Debriefing, which involves structured group discussions shortly after the crisis.

"The concept is, it's good to talk about it right away," Billings said about debriefings. "If you can talk about it on the battlefield, so much the better. Every hour they don't sit down and talk, it gets harder and harder on them."

But not everybody agrees that debriefing is helpful. Purdue said a fellow chaplain last year advised others on the base to stay away from Billings' conference specifically because of the topic.

"It has a tendency to retraumatize those who have been injured," he said about the debriefing component. "If a person has PTSD or significant issues, there's some research that shows Critical Incident Stress Debriefing has the potential of making it worse for people. So consequently, the Marine Corps and the Navy have kind of moved away from the older Critical Incident Stress model, and they have gone with Combat Operational Stress training."

Billings and Mitchell have defended the debriefing component of Critical Incident Stress Management, saying critics are misrepresenting it.

But Purdue said the Corps has other reasons to promote its own program over others.

Combat Operational Stress Control

"The commanders were not happy that everyone was being treated as an injury when they came back from Iraq, when in reality, 8 percent to 14 percent may be diagnosed with PTSD," Purdue said about why the Corps created Combat Operational Stress Control. "They wanted more of a wellness model, a prevention model."

Among the significant elements of the Corps' treatment strategy is a color-coded spectrum that identifies conditions ranging from well to ill, with each condition itself identified by symptoms ranging from "fit and tough" to depression and post-traumatic stress disorder.

The chart also identifies who is responsible for care. On the preventive side, Corps leaders are responsible for preparing Marines and watching them for signs of stress. On the other side of the spectrum, chaplains and medical professionals are responsible for caring for somebody suffering from trauma or stress after an incident.

While Billings said Combat Operational Stress Control is rooted in Critical Incident Stress Management, Purdue said there are significant differences.

"They're different animals," he said. "CISM is a very narrow, crisis-response modality. But COSC is an overarching institutional way of dealing with operational stress, which is much broader."

Call for investigation

Last year, Marine Capt. Dick Pusateri sent an e-mail to his fellow chaplains urging them to stay away from Billings' conference at Camp Pendleton because of its advocacy of Critical Incident Stress Management, which includes practices not approved by the Corps.

After learning of the e-mail, Filner wrote to Marine Commandant Gen. James Conway to ask for an investigation.

"As chairman of the Veterans Affairs Committee in the U.S. House of Representatives, I am concerned that the very people who should encourage service members to seek help were actually discouraging them from attending a conference that was created for their benefit," he wrote. "The bottom line is that Marines and their families were deprived of valuable information, from some of the top people in the field, on how to best cope with many combat-related injuries."

While people from Camp Pendleton were advised to avoid it, Filner noted that last year's conference was attended by many high-ranking military officials, including Deputy Secretary of the Navy Lynda Davis, Marine Col. Stewart Navarre and Dr. Thomas Hicklin of the office of Surgeon General of the Army. Two of Filner's fellow congressional representatives, Brian Bilbray and Susan Davis, also attended.

In response to Filner, Marine Brig. Gen. Michael Regner replied that people were asked to avoid last year's conference because it would send a mixed message about what type of therapy the Corps supports.

"They (Camp Pendleton leadership) concluded that conference principles and treatment approach were not in concert with current Department of the Navy guidance on combat stress treatment," Regner wrote in a letter dated July 30, 2007. "They were concerned that the conflict in treatment approaches would confuse the very people they were trying to assist."

Regner also wrote that while Critical Incident Stress Management itself is consistent with Marine Corps practices, its Critical Incident Stress Debriefing component is not.

"After more than 15 years of scientific study, (Critical Incident Stress Debriefing) has not been found effective in preventing long-term problems after exposure to trauma, such as Post Traumatic Stress Disorder," he wrote. "Furthermore, certain individuals may be adversely affected by (Critical Incident Stress Debriefing.)"

Upon seeing Regner's response, Mitchell fired off a letter to Filner in defense of his treatment program and wrote that he was dumbfounded by the general's "surprising misstatements of facts and astonishing misinterpretations."

"There simply have not been 15 years of negative-outcome scientific study on the CISD process," he wrote. "To indicate that such science exists is to promote the equivalent of an 'urban legend.' "

Filner dropped the matter after receiving the response from Regner.

"I didn't want to keep the argument going," he said. "You're talking to a brick wall there. It's just a waste of time."

Billings said he has no plans to bring the conference back to Camp Pendleton and added that he sees a silver lining in moving it to Los Angeles. Without the Marines calling the shots, he said getting publicity was easier, and overall there were fewer hoops to jump through.

Contact staff writer Gary Warth at (760) 740-5410 or gwarth@nctimes.com.