Discusses the challenges of grief and traumatic stress injury using the case of the combat medic as an example of resilience despite the sadness and confusion in the shadows of war.

1. Charles R. Figley, Ph.D.
Tulane University Kurzweg Chair in
Disaster Mental Health

2. 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

3. 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

4. Acknowledgement
My Research Team
Joseph Boscarino
Joia Speciale
Kathy Figley
Jeff Nagy

5. 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.

6. 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.

7. 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

8. 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.

9. 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.

10. 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 (Posttraumatic Growth)

11. 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
X
X

12. 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)

13. 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

14. 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.

15. 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)

16. 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,

17. 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.

18. 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.

19. 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.

20. Recruitment Numbers
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21. 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

22. Combat Experiences
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23. Preliminary Findings
! Consistent with compassion fatigue
theory, they experienced higher
levels of depression than other
soldiers.

24. 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.

25. Recruits 17 combat medic
interviews
Initial Survey
(n=848)
Nominates
Medics with
Mettle (n=40)
Successfully
Interviews 17

26. 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.

27. Interview Process
Pre-Interview
Paperwork
Semi-structured
Video Interview
Post-Interview
Team
Discussion

28. Post-Interview Team
Discussion

29. VGA Procedure for each
Video Interview using Quick
Time (video) Markers
Primary
Reviewer
Secondary
Reviewer
Tertiary
Reviewer

30. Example of Reviewer
Assignments for VGA Analysis
Subject # A Reviewer
B Reviewer C Reviewer
1
2
3
4
5
Secondary
Tertiary
Primary
Secondary
Tertiary
Primary
Secondary
Tertiary
Primary
Secondary
Tertiary
Primary
Secondary
Tertiary
Primary

31. 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

32. Variable Generating
Activity s Five Variable
Domains
P te tiv
ro c e
F c rs
a to
(P )
F
9
B h v ra
e a io l
Ha
e lth
In ic to s
d a r
(B )
H
8
1
0
2
S so
tre s rs
(S
)
6
3
5
7
1
4
In rv n n
te e tio s
(I)
C lla ra
o te l
Ss m
y te ic
Im a t
pc
(C )
S

33. Video Data Analysis: Video
Generating Activity (VGA)
Assign Data
Analysis Roles
VGA
138-item Scale

34. Medic Mettle Scale Face
Validity Analysis
138-item
Scale
104-items
4 Factors

35. 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.

36. 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

37. Examples of LEADERSHIP
Items
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38. Example of PERSONAL
BELIEF/EXPERIENCE Items
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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.

39. Examples of Technical/
Medical Training Items
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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.

40. Examples of Soldiering Skills/
Training Items
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SOLDIERING SKILL/TRAINING
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.

41. Medic Mettle Scale (MMS)
Psychometrics
MMS
Completed by
838 Medics
MMS-2

42. Medic Mettle v2
! Strong psychometric properties
! Correlated with measures of
readiness, self confidence, resilience,
thriving
! Help build the statistics model of
medic resilience (mettle)

43. 9. Combat Stress Injuries and
Resilience
The following figure was
originally developed to identify
the process by which combatstress injuries could be predicted
and prevented.

44. 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.

45. "&!
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
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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WORKER STRESS REACTIONS
" Biological Markers
" Psychological Markers
" Social Relationship Markers
" Behavioral Markers
" Spiritual Markers
Stress Injuries and
Resilience of Disaster

46. 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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48. 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

49. WORKER STRESS REACTION
MARKERS
" Biological Markers – i.e., indicators
of immune suppression
" Psychological Markers -- e.g.
emotional indicators of stress, sleep
dysfunction
AND

50. WORKER STRESS REACTION
MARKERS
" Social Relationship Markers –social
support and colleague care
" Behavioral Markers –job competence
" Spiritual Markers –sense of direction,
hope, and fulfillment

51. 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

52. 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.

53. 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.

54. 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?

55. 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.

56. Combat Medic Functioning:
1. Physically
capable (measured by level of energy due to sleep,
health)
capable (measured by level of
enthusiasm, intellectual capability, morale, spiritual
support)
2. Psychologically
. Interpersonally capable (measured by level of social
3
support and cohesion with group)
4. Technical
and administratively capable (measured by
standard productivity, client satisfaction, and competence
scales)
(Care) Regulation capable (measured by the
existence of an EB self care plan and following it). EB
self care plan (see Greencross.org)
5. Self

57. 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

58. 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

59. 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

60. 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

61. Level 3: Challenged
Resilience
! Many are in this category and
require attention
! Acceptable Functioning
! Challenged in 1-3 Functions
! Provide Coaching and Peer
Support

62. Level 2: Supported
Resilience
# Unacceptable Functioning
# Challenged in 4-5
# Functions
# Explicit Plan Implemented for
Resilience

63. 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

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

65. 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.

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

67. Conclusion (cont.)
# Caregivers should utilize good self care,
practice colleague (buddy) care, and;
# Encourage supervisory support for
caregivers

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

70. Charles Figley s
Contact Information:
! Figley@Tulane.edu
! 504-862-3473
! Charlesfigley.com

71. 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

72. 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.