Evaluation of a Third-Location Decompression Program for Canadian Forces Members Returning From Afghanistan

MILITARY MEDICINE, 177, 4:397, 2012 Evaluation of a Third-Location Decompression Program for Canadian Forces Members Returning From Afghanistan Bryan G. Garber, MD, MSc; Mark A. Zamorski, MD, MHSA ABSTRACT Background: Service members returning from combat can experience difficulty adapting to home life. To help ease this transition, the Canadian Forces provides a Third-location Decompression (TLD) program in Cyprus to members returning from deployment to Afghanistan. Methods: The 5-day program consists of individual free time, structured recreational activities, and educational programming. Its perceived value and impact were measured immediately afterward and 4 to 6 months later. Results: Respondents overwhelmingly supported the TLD concept, with 95% agreeing that some form of TLD is a good idea. Eighty-one percent of participants found the program valuable, and 83% recommended it for future deployments to Afghanistan. Perceived value persisted 4 to 6 months after return, and 74% felt that it helped to make reintegration easier for them. Conclusion: Canadian Forces members saw value in the TLD program, and most members believed that the program had its intended effect of making the reintegration process easier for them. INTRODUCTION Service members returning from a difficult deployment experience drastic changes in their physical and social environment. To successfully negotiate this transition, they must adapt psychologically, physically, and socially. 1 Although there is an extensive literature on the outcomes of this transition (i.e., psychological and social well-being 2 7 ), research on the process of adaptation itself is surprisingly limited. What is known is that although service members are generally happy to be home, some find at least parts of this transition process to be difficult. 1 We also know that although most will transition successfully, an important minority will have longstanding psychosocial difficulties. 2 7 Decompression refers to a particular phase of this transition, specifically the early period during which service members move quickly from the high-pressure deployed environment to the low-pressure home environment. 8 This phase has attracted particular attention for several reasons: First, it is obviously the most acute phase of the transition process, during which the differences between the home environment and the deployed environment are most stark. Second, modern air travel makes this transition occur more abruptly relative to historical times when service members came home slowly by ship. 8,9 Finally, research on Vietnam veterans, in particular, has demonstrated that difficult homecoming experiences are strongly correlated with long-term psychopathology. 10 14 Deployment Health Section, Canadian Forces Health Services Group Headquarters, 1745 Alta Vista Dr., Ottawa, ON K1A 0K6, Canada. This research was previously presented at the Third Location Decompression Workshop sponsored by the Military Operational Medicine Research Program of the UA Army Medical Research and Materiel Command in Portsmouth, United Kingdom, May 11 13, 2009. Parts of this research were also presented at the International Society for Traumatic Stress Studies Annual Meeting, Montreal, QC, Canada, November 2010. Parts of this research were also presented at the Canadian Psychological Association Annual Convention, Ottawa, ON, Canada, June 2007. Much has been made of this last observation: Some authors have suggested that making the homecoming process easier will prevent later psychopathology. 15 These authors must believe that difficult homecoming experiences cause (or contribute heavily to) mental disorders such as posttraumatic stress disorder (PTSD). Others point out that the research demonstrating this correlation is nearly entirely cross-sectional, done many years after the events of interest. 1 Even without considering the possibility of recall and other biases inherent in this kind of research, it is also plausible that the difficult homecoming experiences (or the perception thereof) were the consequence of psychopathology rather than the cause of it. Irrespective of whether parts of the early phases of transition are permanently toxic or merely temporarily unpleasant, military organizations have taken an avid interest in developing tools to make the transition process easier for service members and their families. Decompression programs are one such tool designed to allow service members to adapt to the home environment in a more gradual way. 8 Third-Location Decompression (TLD) programs take place in a location that is neither the operational theater nor the home, thereby allowing the early phases of transition to occur in a neutral environment before reunification with family and friends. TLD has been used intermittently by a number of Armed Forces over the years including those of The Netherlands, United Kingdom, and Australia. 8 More recently, the United States has offered decompression to at least some personnel in the Air Force (USAF Deployment Transition Center 16 ), the Naval Special Warfare Command, 17 and the Marine Corps. 9 Since August 2006, the Canadian Forces (CF) has implemented a TLD for members returning from deployment on its combat and peace support mission in Kandahar Province, Afghanistan. The intent of the program is to ease transition by giving service members some time to achieve a sense of closure and prepare for their return home. MILITARY MEDICINE, Vol. 177, April 2012 397

Despite its common sense appeal and widespread use, published data on the perceived value and impact of TLD are scarce. The purpose of this article is (1) to describe the TLD program currently in use by the CF in Cyprus and (2) to report the results of the surveys conducted on participants immediately after TLD and 4 to 6 months after their return home. METHODS Program Description The participants were CF members completing a tour of duty of 6 months or more in Kandahar Province, Afghanistan, from August 2006 through March 2007. The mission has been a demanding one, and more than 150 CF members have been killed on it since late 2005. The island nation of Cyprus was selected as the site for the program after consideration of various programmatic and logistical factors. The facility employed is a four- to five-star civilian resort hotel, with two participants lodged in each room. The 5-day program consisted of mandatory educational briefings and both structured and unstructured recreational activities. Up to 300 personnel who had largely worked together while deployed were on the ground at any given point in time. To mitigate the risk of alcohol-related misconduct and physical injuries, a variety of command and control measures were put into place (e.g., making certain problem-prone drinking establishments offlimits). TLD participants were subject to the Service Code of Discipline while on TLD. At least during the study period reflected in this report, consumption of alcohol in quantities that increase the risk of injuries and adverse social consequences was nevertheless common. However, alcohol-related incidents occurred only in a distinct minority of participants, and most such incidents had no lasting consequences. To decrease the risk of serious accidents, operating a motor vehicle or a motorbike was prohibited. Educational Program The purpose of the educational programming is (1) to minimize the distress associated with transition by normalizing it and by providing guidance on how to manage common transition problems and (2) to facilitate care seeking for mental health and transition problems by reviewing their signs and symptoms, identifying potential sources of care, and refuting common misconceptions about mental health care. Thus, all TLD participants received a video version 18 of the US Army s Post-deployment BATTLEMIND training (US Army Medical Department 19 ). The video consists of 4 vignettes of soldiers experiencing transition problems or mental health problems. Facilitators played each vignette and the accompanying commentary and then led some brief group discussion. This program was selected because of evidence that it improves mental health and well-being in soldiers returning from combat. 20 The video was intended to be used 3 to 6 months after return from deployment, but it was used on TLD because of its engaging nature. A central message of the BATTLEMIND program is that there is nothing wrong with seeking help for mental health problems. 20 This core program was complimented by a variety of 1-hour elective sessions. Between four and eight different electives were offered per TLD. Participants were required to attend two sessions but could select whichever suits their needs and preferences. The most popular topics included Coping with Stress and Anger, Healthy Relationships, and Post-deployment Reintegration from the Veteran s Perspective. The latter offering was presented by Peer Support Coordinators from the CF/Veterans Affairs Canada Operational Stress Injury Social Support Program. This program uses trained veterans with a history of service-related mental health problems as a source of peer support for those with similar problems. All training was delivered by one or two facilitators to groups of approximately 15 to 25 participants in English or French; a professionally dubbed French language version of the BATTLEMIND video was used. The delivery team consisted of approximately six military or civilian clinicians (social workers, mental health nurses, or psychologists), two Peer Support Coordinators, and a chaplain with pastoral counseling qualifications. Team members also provided both informal and formal mental health consultation/peer support for members requesting it. Questionnaire Methodology A 68-item, voluntary, anonymous survey was administered as participants were leaving Cyprus. The survey covered sociodemographic and military characteristics (including combat exposure), support for the general concept of TLD, the perceived value of the TLD program as delivered, and the satisfaction with various aspects of the program such as the location and the educational program. This was framed as a routine user satisfaction evaluation of a new educational and personnel welfare program, and as such, review by a Research Ethics Board was not required under Canadian guidelines. 21 A subset of participants was also anonymously surveyed approximately 4 to 6 months after returning home as part of the CF s Human Dimensions of Operations (HDO) survey that is routinely administered at that time. This survey was administered en masse to personnel identified from the CF Tasking Data Base as having been deployed at the main mounting base by Personnel Selection Officers. Nine items touching on the support for the TLD concept and the perceived value of the program were included, along with nine items on the precise ways in which the participants felt the TLD helped. These were adapted from a validated scale of postdeployment transition (Defence Research and Development Canada 22 ). Although the HDO survey content is largely standardized, several sociodemographic and military variables (e.g., age) were dropped from the survey in 2007. The HDO survey protocol was approved by a CF Research Ethics Board. 398 MILITARY MEDICINE, Vol. 177, April 2012

Primary and Secondary Outcome Variables The primary outcome was the perceived value of the TLD as a whole ( Overall, I think this TLD was a valuable experience for me ), both at the end of TLD (hereafter termed immediate ) and 4 to 6 months afterward (hereafter termed postdeployment ). Secondary outcomes include both immediate and postdeployment satisfaction with different aspects of the program and the ways in which the program was perceived to have helped ease the transition process. Statistical Analysis Descriptive data analysis was carried out using SPSS, version 15.0. 23 Significance testing on contingency table data was conducted using the c 2 statistic. A four-point, forcedchoice Likert scale was used for responses to all questions, but for ease of presentation and interpretation, most data were analyzed by collapsing the agree and strongly agree categories into a single category and the disagree and strongly disagree into a single category. RESULTS Between August 2006 and September 2008, 10,598 CF members serving in Kandahar participated in TLD. However, TABLE I. 4- to 6-month follow-up was only completed for the first two rotations. Therefore, data provided will only be for surveys administered to the 3,473 CF members from those rotations. A total of 3332 CF members completed the immediate satisfaction surveys (96% completion) and 1846 completed the postdeployment survey (53% completion). Sociodemographic and Military Characteristics of Respondents As shown in Table I, sociodemographic and military characteristics of respondents were mostly similar between the two surveys. They were largely male (92% in both immediate and postdeployment samples), young adults (30% and 31% in immediate and postdeployment samples, respectively, were 26 years old or younger), anglophone (88% and 87%, respectively), and over half (58% and 59%, respectively) were married or living with a partner. They were largely junior, noncommissioned members (70% and 71%, respectively), and most had spent more than 6 years in military service. Key differences between the two survey respondents were a higher proportion of combat arms personnel in the postdeployment survey compared with the immediate survey (66% vs. 56% respectively, p < 0.0001) and a smaller proportion Sociodemographics and Military Characteristics of Survey Respondents Immediately After TLD and 4 to 6 Months Later Timing of Questionnaire Immediately After TLD (Overall N = 3332) 4 6 Months Postdeployment (Overall N = 1846) N % N % Age (Years) 26 994 30 307 31 27 36 1,349 40 405 41 ³37 989 30 267 27 Sex Male 2,990 91 1,662 92 Female 279 9 154 8 First Language English 2,865 88 1,586 87 French 389 12 232 13 Marital Status Married or Living With Partner 1,911 58 1,066 59 Not Married (Single, Widowed, 1,381 42 752 41 Divorced, or Separated) Rank Junior Noncommissioned Member 2,292 70 1,280 71 Senior Noncommissioned Member 579 18 317 17 Officer 413 13 216 12 Component a Regular 2,884 87 1,703 94 Reserves 413 13 117 6 Military Occupation b Combat Arms 1,827 56 612 66 Support Staff 1,337 41 291 31 Administrative Staff 95 3 31 3 Years of Military Service <5 878 27 512 28 6 15 1,421 44 782 43 ³16 953 29 521 29 a c 2 = 46.965, 1 df; p < 0.0001. b c 2 = 29.783, 2 df; p < 0.0001. MILITARY MEDICINE, Vol. 177, April 2012 399

of Reservists in the postdeployment respondents compared to the immediate survey respondents (6.4% vs. 12.6%, respectively, p < 0.0001). The most frequent combat exposures reported by participants were as follows: being subject to shelling at least once (88%), seeing serious injuries (69%), seeing widespread destruction (69%), dangerous traffic conditions/incidents (67%), and being fired at (67%). Immediate Questionnaire Results Participants overwhelmingly supported the concept of TLD: 95% agreed that some form of TLD is a good idea, 90% agreed that letting off steam before going home is a good idea, 81% of respondents felt the TLD was a valuable experience for them, 91% felt that it was a valuable experience for others, and 83% would recommend the TLD for future rotations to Afghanistan (see Fig. 1). Delayed Questionnaire Results The perceived value of TLD still remained strong postdeployment with 81% indicating that it was a valuable experience for me, 89% responding that it was valuable for others, 84% recommending the TLD for future rotations coming out of Afghanistan, and 94% responded that some form of TLD was a good idea (see Fig. 1). There were small but statistically significant decreases in those who thought that the TLD was valuable for others (89% vs. 91%: immediate vs. postdeployment, p = 0.009) and a small but statistically significant increase in those who felt it was a good idea to let off steam before going home (93% vs. 90%: immediate vs. postdeployment, p < 0.0001). There was a greater and statistically significant decrease in the satisfaction with educational component postdeployment compared to the immediate survey (74% vs. 85%, p < 0.0001). Analysis of the native response categories showed divergent results: There was a 6% increase in those strongly dissatisfied with the educational program (4% vs. 10%), but there was also a 13% increase in those who were strongly satisfied with the educational program (14% vs. 27%). The most frequently identified benefits of TLD were as follows: 75% felt that it made them realize there is nothing wrong with seeking help, 74% believed that it made reintegration easier for them, 65% felt that it helped them to focus on things other than the tour, 60% felt that it made reintegration easier for their family, and 58% felt that it helped them to readjust to the Canadian way of life (see Table II). DISCUSSION Key Findings The results of these surveys demonstrate strong support for both the concept of TLD and the way the CF implemented it in Cyprus. Satisfaction with the concept and the program remained strong at least over the first 4 to 6 months after return, and most participants believed that the program made the reintegration process easier for them and for their families. They also believed that the program favorably changed their attitudes toward seeking help this was a central message of the educational component of the program. Comparison With Other Literature Other nations have also reported strong support for their TLD programs 24,25 and high immediate 24 and long-term satisfaction FIGURE 1. Satisfaction with TLD program: immediate vs. 4 to 6 months postdeployment. 400 MILITARY MEDICINE, Vol. 177, April 2012

TABLE II. Perception on How TLD Helped Their Transition on the Subset of Participants Surveyed 4 to 6 Months Later (Overall N = 1,846) Agree + Strongly Agree N % The TLD has helped me realize there is nothing wrong with seeking help 1,700 75 The TLD made the reintegration process easier for me 1,707 74 The TLD has helped me focus on things other than the tour 1,705 65 The TLD made the reintegration process easier for my family 1,694 60 The TLD has helped me readjust to the Canadian way of life 1,702 58 The TLD has helped me realize how important my family and friends are to me 1,695 53 The TLD has helped me put the events of the tour behind me 1,703 52 The TLD has helped me deal with real life situations 1,702 50 The TLD has helped me get back into sync with family life 1,695 48 The TLD has helped me become more involved in my family relationships 1,696 46 The TLD has helped me become more responsive to my family s needs 1,697 45 (Geerligs E: Adapatie te Cyprus. Report No.: GW-05-062, The Hague, Netherlands Ministry of Defence, 2005; Field C: Ration packs to the Sunday roast: an analysis of the Australian Defence Forces experience with postdeployment reintegration. Unpublished thesis for Postgraduate Diploma of Psychology, Monash University, 2005). Some have also found that spouses were supportive of the program (Geerligs E: Adapatie te Cyprus. Report No.: GW-05-062, The Hague: Netherlands Ministry of Defence, 2005). Consistent support and satisfaction are seen even though the specifics of the TLD program vary with respect to duration, setting (military base vs. hotel), access to alcohol, educational content, logistics, location, etc. For example, the U.K. program lasts only 36 hours, the participants are confined to a military base for the entirety of the program, and access to alcohol is tightly controlled. What these programs do have in common is as follows: (1) use after more difficult deployments; (2) having those who worked together go through decompression together; (3) brevity (less than 5 days); (4) use of a safe location in-between the theater of operations and home; (5) delivery of limited educational content on the transition process; (6) a mixture of individual free time and group recreational activities; (7) at least some access to alcohol; and (8) a focus on rest and recreation. This consistent support for TLD and satisfaction with varied TLD programs used in different nations suggest that the TLD concept is robust and does not depend heavily on the particulars of the program. Alternatively, each nation may have been highly effective at tailoring their TLD programs to the unique needs of their personnel. Limitations This study does have a number of limitations. The use of cross-sectional survey data capturing participants perceptions of the value of TLD does not prove that it had a true impact on their reintegration experience. However, we can say that participants supported the idea of TLD, that they found it valuable, that the perceived value persisted over time, and that they perceived it to have made reintegration easier for them and for their families. Whether it actually did so is another question. In addition, although participants believed that the program helped to make reintegration easier for their families, we did not directly assess this from the families perspective. The TLD experience was a pleasant one, and participants appeared to genuinely appreciate the attention and effort made on their behalf. As such, the favorable satisfaction and perceived impact ratings are more likely to be overestimates than underestimates of the true underlying effects. 26 We used questionnaires with face validity rather than going through a rigorous process of questionnaire development and validation. Nevertheless, we did draw on research on decompression and transition/reintegration in the design of our questionnaire. 22 Only a subset of participants had the opportunity to complete the delayed evaluation 4 to 6 months after return, and the response rate for this survey was low enough that selection bias may have distorted the results. The survey strategy likely targeted those in more forward roles while deployed, and those in the combat arms were overrepresented among respondents while reservists were underrepresented. The satisfaction of these individuals and the perceived impact of the program may have been lower in those in less forward roles. Even if participants perceptions of the favorable effect of the TLD on their transition experience are accurate, we don t know the magnitude of this effect. That is, did it help a little or a lot? We also can t say whether the same or better results might have been achieved with a less expensive, less logistically complex, and perhaps even less risky approach. In particular, our methods don t allow us to tease out the unique effects of the educational content from the R & R aspects of the program. This is important because the same educational content might be more (or less) effective if presented in some other context. 9 Indeed, engaging and retaining the attention of service members fresh out of a combat zone was a constant challenge. Finally, because of the way we structured the offering of elective educational sessions, it is not possible to attribute the perceived impact MILITARY MEDICINE, Vol. 177, April 2012 401

on attitudes about mental health care to any particular educational module. Notwithstanding these limitations, this study provides evidence that a good majority of CF members support the TLD concept and perceive our TLD program to be of value following their rotation to Afghanistan. It is unclear how the program would have been received by personnel returning from a very different type of deployment (e.g., a humanitarian mission after a natural disaster). Jones et al 24 recently noted that decompression was counterintuitively less favorably evaluated by those with heavier combat exposure. Implications for Policy and Research Any program should be evaluated against its intended objectives. In the case of TLD in the CF, the objective is to make the transition process easier for members and their families. These surveys of attitudes and perceptions provide supportive evidence that the program achieved that objective. Others 8,9 have looked for evidence that TLD or similar programs influence long-term distress or psychopathology such as PTSD. We chose not to do so because we did not believe that the decompression aspect of the program was likely to achieve this end. As we discussed in the introduction, we are skeptical that assuring a nicer homecoming or easing transition will prevent PTSD in those who will go on to develop it. In other words, we think our program is helpful, not life transforming. We think it likely that its benefits are largely limited to making the first weeks to months a bit easier on our members, and we unapologetically judge this to be a humane and sensible thing to do for those who have already sacrificed so much. Although we downplay the potential for TLD to prevent long-term mental disorders, we believe that the complex relationship between the transition/reintegration experience and psychopathology does merit further research. Longitudinal research at multiple points of the deployment cycle will provide insight as to which problem comes first and the extent to which transition problems are mediated by mental disorders. If the goal of TLD is indeed to ease transition, then studying it presents further challenges. Transition is a remarkably complex and poorly understood phenomenon. For example, it is clear that there are a number of dimensions to it, including physical, social, and emotional dimensions. 1 Each of these has subdimensions (e.g., the social dimension includes family, workplace, and community reintegration). Each seems to have both negative and positive aspects, 1,22 and each may follow a different time course. Furthermore, there is much interindividual variation in how this all plays out. It is believed that deployment experiences influence transition, but in what precise ways is unclear. Finally, tools to study this complex process are only just being developed and validated. 1,22 A richer understanding of transition and reintegration will facilitate the evaluation of how TLD and other interventions might influence these. Such research would facilitate exploration of questions such as: What sorts of deployment circumstances make TLD more or less valuable? Are there certain kinds of education that are more (or less) effective on TLD as opposed to elsewhere in the deployment cycle? What are the fundamentals of an ideal TLD program, and how does this vary from deployment to deployment and from nation to nation? Specifically, is the third location essential, or could the same results be seen with a similar program in theater or in garrison? Is there a role for some sort of decompression program for those who return home on mid-tour leave? Program evaluation should also be driven by consideration of the cost of the program and its potential risks. Although the cost of TLD is substantial in absolute terms, it is small relative to the overall cost of the mission. The risk for alcoholrelated problems is harder to dismiss out of hand: Wherever high-risk drinking occurs (whether on TLD or elsewhere), the potential for serious injury exists, and control measures will never eliminate this entirely. Legal or disciplinary problems can also have life-altering implications. However, these risks need to be weighed against the risks personnel face while decompressing on their own at home, where access to alcohol is virtually uncontrolled, where peer and military supervision is more limited, and where operating a motor vehicle cannot be restricted. In any case, as our TLD program has matured, we have added additional controls (e.g., curfews, military police patrols) to decrease the risk of alcohol-related harm and to minimize the impact of alcohol on the educational program. CONCLUSION Everyone ultimately transitions from the deployed environment to the home environment: The fundamental question is whether this goes more smoothly with TLD than without it. Rigorously answering this would require a randomized controlled trial (RCT). Other study designs are unlikely to be strong enough to convincingly control for the many confounding factors that are likely to contribute to variation in the relevant outcomes. If one views TLD as a medical intervention like a medication, an RCT makes sense. Viewed as a human resources wellness tool, an RCT seems less urgent. Each military organization will have to decide whether evidence of the sort we present is strong enough to sustain its TLD program. ACKNOWLEDGMENTS The authors would like to thank MAJ Marie Norris, LTC Lisa Noonan, and Dr. Don McCreary for their assistance in the planning and execution of the 4- to 8-month postdeployment survey. This research was funded by the Department of National Defence (Canada). 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