Combat and military operations expose Marines, as they do all U.S. military service members, to extremes of psychological stress. In response to the 1999 U.S. Department of Defense (DoD) Directive 6490.5 on combat stress–control programs, Marine Corps leadership designed an innovative in-unit stress-mitigation program, Operational Stress Control and Readiness (OSCAR). The OSCAR program is designed to enhance the prevention, identification, and treatment of combat and operational stress problems by integrating psychiatric expertise, concepts, and tools—traditionally the domain of medical and psychiatric professionals—into military culture. OSCAR is innovative in that it complements the Marine Corps tradition of small-unit leadership by training select Marine Corps leaders to identify and assist Marines affected by combat-related stress.
This article describes findings from an evaluation of the OSCAR program's success in achieving its key objectives of improving the prevention, identification, and management of combat and operational stress problems among Marines and, in turn, decreasing their mental health problems. We focus on the performance of OSCAR as it pertains to Marines' experiences with its implementation in Iraq and Afghanistan, conflicts recognized for high exposure to combat, as well as multiple, extended deployments.
The OSCAR evaluation had two primary aims: (1) to determine the impact of OSCAR on such outcomes as stress-related attitudes, help-seeking for stress problems, and mental health and alcohol use problems, and (2) to determine Marine Corps leaders' perceptions of OSCAR's impact on attitudes toward stress response and recovery; unit cohesion and morale; stigma around mental health and help-seeking; and unit leaders' abilities to prevent, identify, and manage stress problems in the unit. To this end, the OSCAR evaluation consisted of four components: (1) longitudinal pre- and postdeployment surveys of Marines from OSCAR-trained and non–OSCAR-trained battalions, i.e., the individual Marine survey, (2) longitudinal pre- and postdeployment surveys of OSCAR team members, i.e., the team member survey, (3) focus groups with Marines, and (4) semistructured interviews with commanding officers of battalions that had received OSCAR training. The remainder of this summary describes the key findings, conclusions, and recommendations from this evaluation.
Overview of OSCAR
The OSCAR program was originally conceived of as a new partnership between psychiatry and the military. In the early years of the program, mental health professionals were embedded at the regiment level, but, over time, OSCAR has evolved to extend mental health resources down to the battalion and company levels through the deployment of OSCAR teams. The OSCAR teams are made up of embedded mental health care professionals (OSCAR providers), selected medical and religious ministry personnel (OSCAR extenders), and selected officers and noncommissioned officers (NCOs) (OSCAR team members). All OSCAR program personnel receive training in combat and operational stress–control principles and management practices prior to a combat deployment. The cornerstones of OSCAR's approach to combat and operational stress control are the Combat and Operational Stress Continuum, a tool for identifying combat stress problems of varying severity, and Combat and Operational Stress First Aid (COSFA), a psychological first aid intervention for combat and operational stress.
The OSCAR program was designed to work through the actions of people trained to identify combat stress problems and react quickly and appropriately. The program was also designed to have a broad cultural impact by reducing the stigma attached to combat stress reactions and mental health care. In so doing, OSCAR is expected to have a positive effect on long-term outcomes of interest, including better mental health, lower levels of alcohol use, and lower levels of functional impairment. Figure 1 depicts a logic model summarizing the program's desired outcomes from OSCAR personnel training (predeployment) to long-term goals (distal goals).
Individual Marine Survey
A quasi-experimental study was conducted to examine OSCAR's impact on a wide array of short- and long-term outcomes. A sample of 1,307 Marines in units deploying to Afghanistan or Iraq sometime between March 2010 and December 2011 were surveyed before and after deployment to assess stress-related attitudes, behaviors, and psychological and behavioral health. The study compared Marines in battalions that had received OSCAR training prior to deployment (i.e., OSCAR-trained battalions) with Marines in battalions that had not received OSCAR training (i.e., non–OSCAR-trained battalions) to determine whether Marines in the OSCAR-trained battalions had fared better from pre- to postdeployment on the outcomes assessed in the survey than the Marines in the non–OSCAR-trained battalions. The quasi-experimental design meant that the assignment of Marines to OSCAR-trained and non–OSCAR-trained battalions was not random. Thus, all comparisons were made with statistical adjustment, i.e., propensity score adjustment and covariate adjustment, for differences between Marines in OSCAR-trained and non–OSCAR-trained battalions in baseline characteristics and deployment experiences that could potentially confound OSCAR's effects on outcomes. Data collection began in March 2010 and concluded in October 2012.
OSCAR Increases the Use of Support for Stress Problems, but There Was No Evidence of an Impact on Marines' Mental Health Status or Any Other Outcomes
The survey results suggest that OSCAR had its intended effect on some of the proximal outcomes but did not have an impact on the distal outcomes. In particular, Marines in the OSCAR-trained battalions were more likely than Marines in the control battalions to report that they sought help for their own stress problems from fellow Marines, leaders, and corpsmen. At the same time, OSCAR did not appear to affect help-seeking from formal medical sources of care. This pattern of results persisted after statistical adjustment for traumatic experiences during deployment and participants' reactions to their most stressful deployment-related experiences.
We did not find evidence that OSCAR had its intended effect on the more-distal outcomes assessed in the survey, including probable major depression, probable PTSD, current stress levels, alcohol use, and such attitudes as expectations for stress response and recovery and stigmatization of help-seeking behavior. In fact, for some mental health measures, outcomes were worse in the OSCAR-trained battalions than in the control battalions, although these differences did not reach statistical significance when the level of exposure to traumatic events and other deployment-related stressors were taken into account.
The survey findings should be interpreted in light of the fact that all of the control battalions were combat service support, while the OSCAR-trained battalions were mostly infantry. This means that members of the OSCAR-trained battalions were likely to have had more-stressful experiences during combat than members of the control battalions. We assessed exposure and response to deployment-related stressors, but it is possible that these assessments did not capture the full extent of variation between these groups in their deployment experiences. Greater exposure to stressors might have accounted for the observed increase in help-seeking among the OSCAR-trained battalions. However, it is notable that the same pattern was not observed for help-seeking from formal clinical sources, which presumably would have been affected by the same factors.
The survey findings should also be interpreted in light of the fact that Marines in both the OSCAR-trained and control battalions reported high levels of stress-related trainings in the T1 (predeployment) survey. Specifically, 84 percent of Marines in the OSCAR-trained group and 97 percent of Marines in the control group reported one or more prior stress-related trainings, and more than 60 percent of the control group had received four or more stress-related trainings. Thus, the comparison between Marines in the OSCAR-trained and control battalions, which is the primary focus of this evaluation component, reflects the incremental contribution of OSCAR over and above the stress-related training that all Marines receive.
We also examined variation in outcomes by battalion among only the OSCAR-trained battalions. We found significant differences across the OSCAR-trained battalions in changes over time on all of the outcomes examined, providing support for the hypothesis that the implementation of OSCAR might have varied among battalions. We note, however, that there might be other reasons that outcomes varied across battalions.
Team Member Survey
The OSCAR team member survey was designed to assess OSCAR team members' perceptions of the impact of OSCAR before and after deployment. Participants in the team member survey were officers and NCOs from the same six OSCAR-trained battalions that completed the individual Marine survey; 206 OSCAR team members completed the predeployment survey, and 91 OSCAR team members completed the postdeployment survey.
Predeployment Expectations and Postdeployment Perceptions of OSCAR's Impact Were Generally Positive or Neutral
In general, prior to deployment, survey participants reported positive expectations of OSCAR's ability to positively influence unit cohesion, mission readiness, and morale and of leadership's ability to manage combat and operational stress problems in their units. However, the postdeployment surveys revealed that most team members believed that, in practice, OSCAR had less effect on these domains than they had initially expected. The survey results also suggested that team members only infrequently received requests for assistance with stress-related problems, either before or after deployment. This could explain in part why team members' perceptions of the OSCAR program's impact after deployment were lower than their expectations of OSCAR before deployment—because OSCAR team members might have been disappointed at having little opportunity during deployment to apply the principles and practices learned in OSCAR training. OSCAR team members were also asked whether, if it were up to them, the OSCAR budget would be eliminated, decreased, increased, or kept the same. Despite team members' muted expectations about the effectiveness of the program, the majority of respondents indicated that they would increase the budget for OSCAR or have it stay the same.
Focus Groups with Marines
We conducted focus groups to understand the ways in which OSCAR affects Marine Corps culture. A RAND researcher led the discussions with a set of questions developed to stimulate broad discussion of combat-related stressors, as well as more-detailed discussion about OSCAR. Participants were also asked to provide recommendations for improving the management of combat stress–related problems in the Marine Corps. Seven focus groups were sampled from five battalions; participants in the focus groups included OSCAR-trained team members, as well as NCOs and enlisted Marines, who were the intended beneficiaries of the OSCAR program but whose experience with and knowledge of the OSCAR program varied greatly.
Participants Voiced Varied Views of Combat Stress–Management Programs
Marines participating in the focus groups uniformly agreed that combat stress is a problem but emphasized that combat stress management has always been an important part of Marine Corps culture. Participants perceived OSCAR to be a set of formal methods for accomplishing goals that have always been accomplished informally. Participants frequently did not distinguish OSCAR from other combat stress–related programs, including more-general non–combat-related training on such topics as sexual harassment, and perceived that the volume of combat stress–control training Marines received is excessive. Overall, focus group members expressed a preference for nonclinical peer-to-peer approaches to combat stress and emphasized the importance of peer relations and effective leadership in combat stress management. Participants suggested that the stigma associated with mental health problems might prevent some Marines from seeking formal help, but they expressed too that an overemphasis on stress response could lead to overdiagnosis and dependence on formal care, compromising force readiness.
Participants Who Had Received OSCAR Training Appreciate It as a Platform
Participants with direct experience of the OSCAR program appreciated the value of OSCAR as a way to respond to serious combat-related stress problems without disrupting military routine. Some emphasized the ways in which the program complemented existing informal support networks. Participants also described how OSCAR is beneficial in that it provides a “common language” or “platform” for managing combat stress. Some participants stated a strong preference for OSCAR trainers with combat experience.
Interviews with Commanding Officers
Battalion commanders observe a broad range of reactions to combat among their Marines and thus can offer a valuable perspective on the management of combat-related stress and the effectiveness of the OSCAR program. We conducted 18 semistructured interviews by telephone with commanding officers of battalions that had received OSCAR training. We asked them about their views of combat stress in general, their understanding of how OSCAR addresses their needs, and their recommendations for the future.
Commanders Emphasized the Importance of Effective Leadership in Combat and Operational Stress Management
The commander interviews were remarkable for their unanimity with respect to one dominant theme: that combat and operational stress management should be viewed primarily as a problem of effective leadership rather than medical intervention. According to this view, effective leaders create cohesion and high morale in the units they lead, and cohesive units are naturally conducive to responding to stress. These responses include the early identification of behavioral change, the absence of stigma related to care-seeking, and the presence of strong peer support that can reduce the need for removing affected people for medical care. This view echoes Marines' preference for informal peer-to-peer stress support rather than formal mental health intervention.
Commanders View OSCAR as Consistent with Effective Leadership
Overwhelmingly, commanders voiced positive opinions of OSCAR because they view it as consistent with their existing principles of effective leadership. They noted how OSCAR normalizes open communication about stressful experiences and psychological reactions, provides a common language for communicating about stress, and mobilizes and reinforces peer support without involvement of external resources or authorities.
Commanders' Views of OSCAR Personnel and Training
Commanders suggested that training should not be limited to select NCOs and officers but, instead, opened to lower-ranking Marines. They also expressed the value of an OSCAR trainer with extensive combat experience or who had been seriously wounded but had gone on to have a successful Marine Corps career. There was some concern that OSCAR training would be difficult to maintain during peacetime because there would be less emphasis on combat stress in general.
Conclusions and Recommendations
Although findings from the team member survey, focus groups, and interviews collectively suggest that Marines, both enlisted and officers, widely perceive OSCAR as a useful tool for combat and operational stress control, findings from the individual Marine survey indicate that OSCAR has not fulfilled its mission of improving many of the key outcomes that it was designed to affect. Specifically, the individual Marine survey found no evidence that OSCAR significantly influenced stress-related attitudes or health-related outcomes. The lack of significant effects of OSCAR on these outcomes might be attributable to methodological limitations of the individual Marine survey—namely, limited precision to detect significant effects because of multiple statistical adjustments for confounds; variability in the implementation of OSCAR across battalions, which was suggested by findings of variability in outcomes across battalions in the OSCAR group; and the possibility that OSCAR, even if implemented consistently and with fidelity to the program's design, does not improve stress-related attitudes, help-seeking behavior, and mental health outcomes relative to the other types of stress-control training received by all Marines, including those in the non–OSCAR-trained (control) battalions.
The individual Marine survey also demonstrated that OSCAR significantly increased the use of unit resources, such as fellow Marines, leaders, and corpsmen, for stress-related problems. However, given the possibility of residual confounding of battalion type with receipt of OSCAR training, these effects might alternatively reflect a greater need for help in the OSCAR-trained battalions, which were nearly all infantry and had greater combat exposure, than the control battalions, which were all combat service support.
Thus, this evaluation did not find evidence of OSCAR's effectiveness that would support the continuation of OSCAR in its current form. In recommending a way forward for the Marine Corps in its efforts to manage combat and operational stress, we rely on findings from this evaluation's qualitative components, other research, and best practices for program improvement and implementation. Because none of the recommendations has been formally tested, we do not know the extent to which their adoption will positively affect combat and operational stress management in the Marine Corps. Moreover, some of the recommendations might be very difficult to implement in light of organizational, policy, regulatory, and budgetary constraints. Thus, the recommendations offered here should be viewed as suggestive rather than prescriptive.
Review and Streamline Marine Corps Combat and Operational Stress–Control Training Programs
The evaluation results highlighted the excess of combat and operational stress–control training received by Marines, suggesting the need for a more streamlined approach to this type of training. In integrating and streamlining combat and operational stress–control training programs, the Marine Corps might wish to consider retaining or strengthening the positive features of OSCAR and redesigning or eliminating features that were less positively perceived.
- Identify and reduce duplication of effort in combat and operational stress–control trainings. Marines reported receiving multiple trainings related to management of combat and operational stress, in addition to OSCAR. We recommend a thorough review of the concepts and methods of combat and operational stress–control training programs that would align the content and rationalize the scheduling of training in this area across the Marine Corps.
- Enhance the use of a common language for concepts related to combat and operational stress control across combat and operational stress–control programs. Findings from the qualitative components of the evaluation indicated that OSCAR was valued because of its being a shared language for talking about and managing combat and operational stress. Thus, we also recommend that, in the process of reviewing and streamlining combat and operational stress–control training, decisionmakers pay attention to consistency in the concepts and specific language across training programs and the procedures that are taught.
- Ensure that combat and operational stress–control program trainers have combat experience. Marines emphasized that they prefer OSCAR trainers who have combat experience. Consistent with the current OSCAR training guidelines, we recommend maintaining a pool of certified trainers who have personal experience with combat and skill in communicating the importance of combat and operational stress control to Marines.
Identify Potential Changes to the Design and Implementation of Combat and Operational Stress–Control Training
Ideas about potential changes to the design and implementation of combat and operational stress–control training that might increase the effectiveness of such training can come from many sources, including program participants, implementation literature, and other programs. Here we suggest potential changes to this training based on the findings from this evaluation:
- Consider providing combat and operational stress–control training to all Marines in the chain of command, down to the level of squad leader. Although some commanders value the OSCAR team members as resources for Marines experiencing combat-related stress, a consistent concern was that Marines are not likely to seek out help from someone simply because that person has been designated as a mentor. Further, the survey results show that the number of Marines seeking advice about combat stress issues from team members did not change as a result of OSCAR training. In light of these findings, we recommend that combat and operational stress–control training be provided to a broader range of people in leadership positions so that individual consultations are not stigmatized and the effectiveness of response to combat-related stress will not be compromised.
- Integrate combat and operational stress–control training into the deployment cycle and maintain it regularly among nondeploying troops. Participants made two important suggestions regarding the timing of training. First, some suggested improvement to the linkage of the training to the deployment cycle, including, for instance, booster sessions and postdeployment sessions. Second, some suggested that the training be reinforced routinely, regardless of the deployment schedule—e.g., on an annual basis—in order to maintain readiness during peacetime.
Pilot Test Changes to Combat and Operational Stress–Control Training
Consistent with best practices for program development and implementation (Ryan et al., 2014), changes to the combat and operational stress–control training program should be pilot-tested on a small scale to determine its feasibility and effectiveness with respect to its impact on key outcomes. If results of the pilot test are promising, the program's implementation can be gradually expanded and assessed to identify and correct challenges of implementation that inevitably accompany program expansion.
If the pilot test is not successful, then the Marine Corps might wish to revise the program based on process improvement data collected during the pilot test and test the revised version. Alternatively, the Marine Corps might prefer to abandon this approach to stress-control training and consider shifting its investments in psychological health to other policies and programs that have a stronger evidence base.
Expand the Evidence Base Regarding Operational Stress Management
Much work remains to be done in order to learn the lessons from the initial implementation of OSCAR and use those lessons to improve combat and operational stress management in the Marine Corps. To continue improving Marine Corps methods for managing combat and operational stress, further research will be necessary. We therefore make the following recommendation:
- Examine patterns of support-seeking and help-seeking in more detail. Although the survey results demonstrate an increase in certain types of help-seeking in OSCAR-trained battalions, we did not study the nature of this help-seeking and the providers' response to it. Information on the process for seeking support from informal sources and help from formal sources is critical to the continuing improvement of combat and operational stress–control systems.
Ryan, Gery W., Carrie M. Farmer, David M. Adamson, and Robin M. Weinick, A Program Manager's Guide for Program Improvement in Ongoing Psychological Health and Traumatic Brain Injury Programs: The RAND Toolkit, Volume 4, Santa Monica, Calif.: RAND Corporation, RR-487/4-OSD, 2014. As of January 23, 2014:
This research was sponsored by the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) and conducted within the Forces and Resources Policy Center of the RAND National Defense Research Institute, a federally funded research and development center sponsored by the Office of the Secretary of Defense, the Joint Staff, the Unified Combatant Commands, the Navy, the Marine Corps, the defense agencies, and the defense Intelligence Community.