Leaders Guide - Combat and Operational Stress

Traumatic stress injuries are literal damage to the brain and mind due to an experience involving real or threatened death or serious injury, or its aftermath. Not everyone who is exposed to real or threatened death or its aftermath is damaged by that experience; most people are not. But everyone is susceptible to experiencing intense terror, horror, or helplessness when confronted with their own or their peers’ mortality, and each Marine’s susceptibility varies over time due to the accumulation of stress from other causes. No one knows how common traumatic stress injuries are among Marines engaged in combat operations because most are minor — more like bruises than fractures — and most heal quickly on their own without help from others. Even more serious traumatic stress injuries tend to be disabling for only a matter of seconds or minutes, although completely normal functioning may not be regained for days, weeks, or months. The major challenges of managing traumatic stress injuries in Marines include:

To meet these challenges, Marine leaders must closely monitor their Marines for traumatic stress injuries during and long after deployment, make it OK for their Marines to ask for help when it is needed, and ensure that traumatic stress injuries that are still troubling or disabling after 30 days get professional care.

Successful identification and management of traumatic stress injuries requires Marine leaders to be aware of three possible indicators: (1) events that have a high potential for inflicting traumatic stress injuries in Marines — known as potentially traumatic events (PTEs), (2) the immediate symptoms and behaviors that most commonly accompany these injuries in their acute stages, and (3) the symptoms and behaviors that most commonly arise later in un-healed traumatic stress injuries.

Potentially traumatic events:
are situations that place Marines at risk for traumatic stress injuries. These situations vary in their toxic effect on Marines, and each Marine’s vulnerability to various PTEs is unique. PTEs in current operations include:

Immediate traumatic stress injury symptoms and behaviors:
are those that appear instantaneously or soon after the impact on the mind and brain by a PTE if it is sufficiently intense for that person at that moment. Immediate symptoms and behaviors all involve a temporary and partial loss of control, lasting from a few seconds to several hours, but rarely continuing after a period of sleep. Immediate traumatic stress injury symptoms and behaviors include:

Subsequent traumatic stress injury symptoms and behaviors:
are those that either persist after the immediate loss of control symptoms have resolved, or arise later. Whereas immediate symptoms and behaviors almost never last for more than a day or two, subsequent traumatic stress injury symptoms can be much slower to resolve as wounds to the mind and brain heal. Nevertheless, even these later symptoms often resolve without professional care. Later traumatic stress injury symptoms and behaviors include:

Appropriate leader actions for managing traumatic stress injuries are analogous to those for managing physical injuries in Marines, including (1) applying psychological first aid for affected individuals, (2) applying psychological first aid for affected units, (3) assessing the need for professional care, and (4) monitoring healing and mentoring back to full health and readiness.

Psychological first aid for units with traumatic stress injuries

Unit-level interventions after traumatic events are the responsibility of unit leadership, at all levels — including unit chaplains and medical personnel — with assistance and support of mental health personnel and others outside the unit as needed. Routine psychological debriefing in units, such as Critical Incident Stress Debriefing (CISD), is not encouraged because it is not believed to be helpful, and it may be harmful for certain individuals. The following are steps for psychological first aid for units affected by traumatic stress:

A Marine you know is having problems denies it: Remember that most people are ashamed of having emotional problems of any kind, but most especially of losing control under stress. In order to admit to themselves or anyone else that they need help, stress-injured Marines have to believe that asking for help is not an admission of failure or weakness, and that they and their unit will be better off in the long run if they ask for help. You can make it more OK for a Marine with stress problems to admit to them if you disclose stress problems that you, yourself, or that other respected Marines have experienced. If the Marine is concerned that getting help for a traumatic stress injury will hurt their career or future employability, remind them that there is a much greater chance that not getting help when needed will hurt their careers, health, and safety, as well as the safety of their fellow Marines. If a Marine with traumatic stress injury symptoms refuses to talk about them or to consider getting help, honor that decision unless the Marine’s potential risk to themselves or others requires you to order the Marine to submit to a command-directed mental health evaluation in accordance with DoDD 6490.1.
A Marine asks for help, but you think they’re faking: Because stress injury symptoms are invisible, it’s certainly possible to fake them in an attempt to get out of trouble or to avoid doing something someone doesn’t want to do. Faking illness or injury for such purposes is malingering, of course — a violation of the UCMJ. However, studies have shown that malingering of combat-related stress disorders such as PTSD is rare. Most service members or veterans who go through the hassle and potential humiliation of reporting stress injury problems truly have them. In cases in which possible malingering of stress injury (or PTSD) symptoms is suspected, remember that although a Marine getting away with deception is an injustice, so also is a Marine being denied help for a real stress injury. Resist the urge to jump to conclusions, but always refer such Marines for an in-depth mental health evaluation. Detailed interviews almost always uncover blatant lying because few malingerers are able to correctly guess all the symptoms they should have experienced, in the right order, and in as great detail as they should easily recall if they were telling the truth. And when asked enough questions, the consistency of malingerers’ stories eventually breaks down. Collateral input from others who knew the Marine well before the stress injury, or witnessed the traumatic event, itself, is also helpful. Then, with all information available, make a judgment based on reason and fact, not suspicion and "gut feeling."
You send a Marine for help, but you’re not sure they’re getting the right kind of help: Although chaplains, counselors, physicians, psychologists, and psychiatrists all have skills to help Marines recover from traumatic stress injuries, not all helping professionals are equally trained and experienced in providing such help. Since the last time our country was in a sustained conflict, PTSD didn’t yet exist as a diagnostic entity, there is a great deal about combat-related stress injuries that has only recently been learned or developed. If one of your Marines seeks care from a professional who seems not to be helping as much as expected or desired, you have a few options. First, talk to the helping professional and express your concerns or questions about their plan of care. Tell them what is desired. Second, if direct liaison with the helping professional doesn’t help, seek help for your Marine through another of the many available portals of care (listed elsewhere in this guide). Third, contact one of the leaders of a helping professional community or service for further assistance and guidance.