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Overview | Definitions | Risk Factors | Resiliency Factors
Why Marines May Not Seek Help |
Prevention | Suggested Resources
Guidance | Key Terms
Service in the Marine Corps is challenging and stressful. It is intended to be. Stress that does not exceed Marines’ capacities to adapt makes them stronger and tougher, which is why Marine Corps training ranks among the most stressful on the planet. As the Nation’s “shock troops,” Marines are repeatedly called on to perform tough and challenging missions in remote locations. Frequent deployments away from home and family have always been the norm for the Marine Corps, and Marine Corps leadership has always excelled at managing stress to get the job done while preserving fighting strength. However, since combat and operational stress cannot always be controlled or kept within the capacities of Marines to adapt, combat/operational stress injuries (COSIs) will always be a risk and consequence of Marine Corps operations. Therefore, it is imperative for all Marine Corps leaders to recognize circumstances that place their Marines at risk for stress injuries, prevent stress injuries in their Marines whenever possible, and quickly identify stress injuries when they occur so that appropriate care can be given. Like many physical injuries, most stress injuries heal over time no matter what you do. But also like physical injuries, stress injuries heal more quickly and completely if they are acknowledged and taken care of. Combat/Operational Stress Control (COSC) — defined as all planning, training, and implementing of policies, programs, and actions to prevent, identify, and treat COSIs — is the responsibility of every Marine leader at every level. The readiness of the Marine Corps as a fighting force and the health of its Marines, Sailors, and family members depend upon it.
- Combat Stress:
- changes in mental functioning or behavior due to the challenges of combat and its aftermath. These changes can be positive and adaptive (e.g., increased confidence in self and peers), or they can be indications of distress or loss of normal functioning that may be symptoms of a combat/operational stress injury (see below).
- Operational Stress:
- changes in mental functioning or behavior due to the challenges of military operations other than combat.
- Stressor:
- any particular mental or physical challenge or set of challenges.
- Stress Adaptation:
- the normal, reversible process of coping with a stressor, usually by either changing oneself physically and mentally to be better suited for that particular stressor, or by becoming numb to the mental and physical effects of that stressor. Stress adaptation is always temporary, and it always fades after the stressor is no longer experienced.
- Combat/Operational Stress Injury (COSI):
- potentially irreversible changes in the brain and mind due to combat or operational stress that exceed in intensity or duration the ability of the individual to adapt. Symptoms of stress injury normally resolve over time as the injury heals, but intervention may be needed to promote healing in some cases. COSIs can be of three types, differing mostly in the cause of the injury: (1) traumatic stress injury, (2) fatigue stress injury, and (3) grief. Many COSIs include components of more than one type of stress injury, since trauma, fatigue, and grief are not mutually exclusive.
- Traumatic Stress Injury:
- a stress injury caused by the impact of specific events involving serious or sustained threat to one’s own life, or a loss of life or serious injury witnessed in another.
- Fatigue Stress Injury:
- a stress injury caused by the wear-and-tear of unrelenting exposure to operational stress during long or repeated deployments, often compounded by concurrent stress from other sources such as family problems.
- Grief:
- Stress caused by the loss of someone who is cared about, such as a buddy, leader, or family member. Although everyone who lives long enough suffers the loss of others who are cared about, and grief is a normal healing process, it is important to recognize that losses of close friends, valued leaders, or family members inflict mental and emotional wounds that take time to heal, and may interfere with normal functioning until they do heal.
- Posttraumatic Stress Disorder (PTSD):
- a traumatic stress injury that fails to heal such that the symptoms and behaviors it causes remain significantly troubling or disabling beyond 30 days after their onset. PTSD is not the only stress disorder that can result from unhealed stress injuries; others include clinical depression and anxiety, and substance abuse or dependence.
- Combat/Operational Stress Control (COSC):
- policies, programs and actions designed to prevent, identify, and manage COSIs.
All Marines are at risk for stress injuries, no matter how strong, seasoned or experienced. Everyone has a breaking point, and for everyone, that breaking point changes over time due to many internal and external factors. However, certain risk factors increase the probability that stress reactions or injuries will occur. The presence of risk factors does not automatically mean someone will be injured by excessive stress, but it raises that risk. Many of these risk factors can be modified, reduced, or eliminated. Risk factors include:
- Duration of current deployment greater than six months
- Repeat deployments without sufficient time to recover and reset
- Sleeping less than 6-8 hours per day on average
- Witnessing death close up, especially of other Marines or civilian non-combatants
- Being responsible for the death or serious injury of a non-combatant or allied combatant
- Losing a close friend or valued leader in combat or other operations
- Witnessing or participating in violations of the Law of War and the Marine Corps code of conduct
- Being physically injured, especially if seriously
- Sustaining a traumatic brain injury
- Close brushes with death, especially if the individual believed they were going to die
- Handling remains, especially of other Marines
- History of previous stress injuries, whether sustained during or prior to service
- Previous mental health problems
- Being new to the unit or lacking mutual trust with other unit members
- Being impacted by family, relationship, or other homefront stressors
- Being young and inexperienced
All Marines also possess traits and abilities that make them resilient to the potentially damaging effects of combat and operational stress. Some of these resiliency factors are inborn, while others are acquired through training and experience, or interactions with others. All Marine leaders are responsible for promoting resiliency in their Marines. Resiliency factors include:
- Tough and realistic training
- Knowing what to expect, at every turn
- Being more mature
- Having served in a previous operational deployment without physical or stress injury
- Having faith in God, the Marine Corps, leaders, and peers
- Being physically fit
- Having a stable and supportive home and family life
- Being good at pushing self-defeating thoughts or perceptions out of conscious awareness
- Tending to cope with problems by taking action
- Having an optimistic attitude
Some Marines are reluctant to admit to themselves or anyone else that they have been affected by the stress of combat or other operational experiences, and some are reluctant to ask for help for stress injuries that don’t heal quickly on their own. Such reluctances are often due to the stigma that surrounds behavioral health and stress problems, particularly among Marines, who pride themselves in their ability to endure extreme stress. Stigma is the number one enemy of combat/operational stress control. Therefore, it is the duty of every Marine leader, at every level and at all times, to fight stigma — to reduce its interference with stress-injured Marines getting needed help. Fighting stigma begins with understanding its causes, which include:
- Not understanding that stress injuries are like other physical injuries — treatable and not the individual’s fault
- Believing that adverse reactions to stress are a sign of weakness or personal failure
- Not knowing that even the strongest Marine can suffer a stress injury
- Fearing that having an emotional problem or getting help for it will negatively impact their careers
- Fearing that other Marines will think less of them because they got help for a stress injury
- Fearing their peers or leaders won’t trust them as much in future tough situations if they admit to having suffered a stress injury
- Not understanding that the longer they wait to get help for stress injuries that don’t heal quickly on their own, the less likely they are to heal fully
- Not realizing that avoiding getting help may place their unit members at risk because of decreased readiness and performance caused by untreated stress injury symptoms
- Not realizing that avoiding getting help for persistent stress injuries can hurt their careers, relationships, and future health more than accepting help will
- A command climate that discourages getting help or tells Marines to just “suck it up” or “get over it”
Just as physical injuries are sometimes inevitable consequences of combat or other high-intensity military operations, stress injuries may also sometimes be unpreventable in Marine Corps operations. However, just as it is the responsibility of all Marine leaders to protect the physical health and welfare of their Marines, it is the responsibility of all Marine leaders to prevent stress injuries to the extent they can be prevented. The following are leader actions to prevent COSIs.
- Tough, realistic training
- The history of elite combat units such as the Marine Corps has proven again and again that the harder troops train, and the more closely their training reflects their operational mission, the more confident they will be in themselves and each other, and the more resilient they will be to combat stress. Making training shorter or easier leaves Marines less prepared, and less able to cope with severe stress without sustaining a stress injury. But just as athletic coaches must guard against physical injuries during training, Marine leaders must guard against stress injuries as they push their Marines in training.
- Maintain unit cohesion
- Marine leaders already know that highly cohesive, well-disciplined units are more effective in combat and other military operations. Units with a high degree of mutual trust, loyalty, and pride also tend to experience fewer stress injuries in combat. Pay special attention to new additions to the unit, such as individual augments, FAPs, or members of other military units and services assigned to augment a Marine unit. Strangers to the unit are at higher risk for stress injuries, themselves, but they also make other unit members feel less safe and confident.
- Ensure adequate sleep
- Rare individuals can function adequately on less than 6-8 hours of sleep per night; most people cannot. Sleep deprivation — defined as receiving less than the quantity of sleep required by the brain and body to rest and recharge — is cumulative and potentially deadly. Sleep-deprived Marines make poorer decisions, have slower reflexes, regulate their actions and emotions more poorly, and are more susceptible to being damaged by intense or prolonged stress than Marines who have had enough sleep. Friendly fire incidents and accidents of all kinds can be traced to sleep deprivation. Make sure you and your Marines get at least 6 hours of sleep each day. When 6 hours of sleep per day is not operationally feasible, schedule and enforce make-up sleep as soon as possible.
- Limit unnecessary exposure to terror and horror
- Although the use or witnessing of deadly force can be necessary in military operations, exposure to deadly force of any kind is potentially toxic to Marines’ minds and brains. Being responsible for others’ deaths, witnessing death and its aftermath up close, and nearly being killed oneself are all potentially toxic stressors for anyone. The greater and more prolonged Marines’ exposures to such stressors, the greater their risk for COSI. Therefore, limit Marines’ exposure to deadly force and its aftermath whenever possible. If possible, do not allow Marines to watch others die, and do not allow them to gawk at gory scenes, however mesmerizing they may be. If your Marines must see, hear, or smell death up close for some reason (for example, to participate in personnel retrieval), warn them in advance about what they will experience in vivid detail. As much as possible, protect your Marines from identifying personally with the dead and dying. Choose your most mature and experienced Marines for tasks that involve high exposure to blood and gore. Provide as much rest and recuperation as possible between exposures to deadly force and its aftermath.
- Keep your Marines informed
- Marines who are forewarned are also forearmed. When Marines know what to expect — and what actually happens meets their expectations — their heart rates remain lower, and they are less likely to be damaged by the stress of their experiences. Share information freely up and down the chain of command. Anticipate. Rehearse. It is always the unexpected that is most damaging to the mind and brain.
- Hold regular “hot wash” After-Action Reviews (AARs)
- Marine leaders are already familiar with the hot wash or After-Action Review (AAR) as a tool for gathering and sharing information with their Marines after significant actions or events, in order to promulgate lessons learned and to improve future performance. These same AARs can also be effective tools for Marine leaders to help their Marines achieve a common understanding of what happened and why it happened, and what purpose was served by their actions and sacrifices. Open and honest two-way discussions during a small-unit AAR can help reduce excessive feelings of guilt or shame, and help restore lost confidence in peers or leaders. AARs can also help identify which Marines in the unit are experiencing persistent stress injury symptoms. Helping Marines make sense of their combat experiences, restoring their confidence in themselves and each other, and ensuring that seriously stress-injured Marines get immediate help all promote readiness and healing and prevent long-term disability.
- Maintain physical fitness
- Marines who are physically fit, and who engage in regular strenuous exercise, are more resilient to extreme stress. In any given situation, physically fit Marines’ heart rates will be lower, and their capacities to endure stress will be greater.
- Reduce unnecessary stress during operations
- Marine leaders sometimes heap additional stress on their Marines during training to toughen them up and make them stronger. But avoid stressing Marines unnecessarily during deployment because all stress is cumulative, and you never know what unavoidable, severe stress may be just around the corner. Reduce or eliminate unnecessary stress during operational deployments.
- Ensure rest and recuperation after intense and prolonged actions
- Continuous exposure to mortal danger, day after day, takes a toll on every Marine, even though signs of strain may not become apparent until after more than 6 months of continuous deployment. In order to prevent fatigue stress injuries, ensure adequate down time in a relatively safe location after long or tough actions. Sleep, rest, and recreation restore depleted internal resources and make Marines ready for the next challenge they will face.
- Encourage time for spiritual renewal
- Marines also need time to strengthen and renew their spiritual lives, whatever their faith group may be. By encouraging and giving opportunities to Marines to participate in individual and collective worship, Marines can be strengthened and renewed in their spiritual lives which will enhance their physical and mental acuity, and their resiliency to extreme stress.
- Honor the fallen
- Losses through death or serious injury, besides reducing the fighting strength of a unit, also reduce the resiliency of its members because of the grief most of them experience after a loss. Grief is a wound — an injury to the mind, brain, and spirit — that takes time to heal and cap sap internal resources until it does heal. Promote the healing of your Marines’ grief by honoring the fallen through ceremonies and memorials of their courage and sacrifice.
ALMAR on Deployment Cycle Support
Old ALMAR on warrior transition and preparation
ALMAR 032/03 Policy for Return and Reunion
DoD Directive 6490.1 Mental Health Evaluation
DoD Directive 6490.5 Combat Stress Control (CSC) Programs
DOD/ VA guidelines for COSR
MCO P1700.24B Marine Corps Personal Services Manual
MCO P1700.27A Marine Corps Community Services Policy Manual
MCO P1700.29 Marine Corps Semper Fit Manual
MCO P3040.4E Marine Corps Casualty Procedures Manual
ALMAR 067/02 Suicide Awareness
ALMAR 030/99 Suicides in the Marine Corps
ALMAR 367/98 Suicide Awareness
MCRP 6-11c Commander's Handbook on Combat Stress
Active Listening:- Active, effective listening is the foundation of effective communication. Active listening intentionally focuses on who you are listening to in order to understand what he or she is saying. As the listener, you should then be able to repeat back in your own words what they have said to their satisfaction. You do not have to agree with, like, or fix the problems that you are hearing. Your job is simply to convince the other person that you understand what they're trying to say. A good web site on this technique can be found at: http://www.taft.cc.ca.us/lrc/class/assignments/actlisten.html
Administrative Actions:- Any alcohol related misconduct or unsatisfactory performance will be subject to prompt and appropriate administrative action. Charges of intoxicated driving in violation of local legal blood alcohol content (BAC) will be treated as an alcohol related incident.
Career Consequences:- Many Marines worry that seeking help will make them appear "weak" or "defective" to their peers or leaders. In the past there has probably been some basis for this worry, and the stigma associated with seeking help may still be a problem in some units. Current Marine Corps policy is for commands to create a climate where seeking help is encouraged to promote maximum personal and unit readiness. If a Marine were drowning, they would not hesitate to ask for help, and peers and leadership would do everything in their power to help, regardless of the reason for the distress. It needs to be the same way for Marines "drowning" in personal problems or distress. Our readiness and their lives may depend on it. It is important for Marines to be confident they can ask for help without prejudice to their careers. It is especially important for them to understand that what is more likely to affect their careers is not seeking help, and waiting until problems affect their job performance or mental health. But at any point, seeking help should be welcomed and encouraged as the right and courageous thing to do, for the benefit of not only the Marine involved, but also team-mates who depend on him/her to be there when needed.
Chaplain:- Provides spiritual guidance, personal counseling, and life issues counseling in a confidential setting. Chaplains are protected by the Uniform Code of Military Justice, which ensures confidentiality. Under military law, chaplains must keep conversations confidential when service members seek their spiritual guidance, either as a formal act of religion or a matter of conscience. Chaplains do not have to keep conversations confidential when a service member speaks with them for reasons other than spiritual guidance. When it is in the best interest of the person involved, the chaplain is expected to assist the individual in identifying the appropriate means of self-disclosure without violating the individuals trust. For additional information of the Chaplains confidentiality guidelines, contact the base legal office or the installation chaplain's office.
Command Directed Evaluation (CDE):- When a Marine will not go for a Mental Health Evaluation for suicide risk, and there is good cause to suspect the Marine is at risk, the unit commander will have to initiate a Command-Directed Mental Health Evaluation and order the Marine to submit for evaluation. This requires specific sequence of actions due to the legal issues involved.
Helping Agencies:The following agencies offer the services listed.
Hospitalization:- Psychiatric hospitalization (also known as inpatient treatment) is necessary when a Marine is evaluated for suicide risk and found to be at high enough risk for self-harm that it would be unsafe to treat them as an outpatient. Inpatient treatment is usually done in a locked ward, where the patient can be contained for their own safety, and monitored 24/7 by specially-trained staff an appropriate level (one-on-one, line of sight, or safety checks at prescribed intervals) depending on the level of risk determined by their mental health provider. Further, their behavior can be assessed in more detail and in a more continuous and controlled manner to see if they are truly depressed, mentally ill, suicidal, or manipulative. More intensive, daily therapy is also available in the inpatient environment than in outpatient services. However, such services are also exceptionally expensive, and so are generally reserved for c
ases where outpatient services are unlikely to be enough to keep them from harming themselves, or in cases where a suicide attempt or gesture has just occurred and further evaluation, treatment, and monitoring are advised, at least overnight, to ensure their ability to be treated safely on an outpatient basis.
Limited Duty:- Limited Duty status allows a Marine to remain on active duty when they are not currently fit for full duty, but there is high likelihood that, with appropriate treatment, they can be restored to ongoing full and productive duty in a reasonable amount of time (defined as 6-14 months). This status will usually prevent them from being deployable and has some other administrative ramifications
Live as a Team:- Encourage Marines to handle issues (lack of privacy, personality conflicts, alienation, etc.) early, openly and as a team. A simple self-check and buddy-check system can identify and reduce the incidence of operational stress and increase overall unit effectiveness.
Maintain Unit Cohesion:- Cohesive, well-disciplined units have fewer severe stress reactions. Marines should routinely debrief each other after an operation, and discuss what they saw and how they felt. Marines who have strong emotional reactions to traumatic events should be kept with the unit and treated as Marines, not as casualties.
Malingering:- Deliberately faking symptoms of a disorder, including suicidal thoughts, personality disorder, etc, for secondary gain, such as getting out of military service obligations.
Marine Corps Community Services (MCCS):- Enhances unit and family readiness by delivering programs such as Marine Corps Family Team Building (MCFTB), Military One Source Information and Referral Service, Counseling Services and New Parent Support. The programs are designed specifically for Marines and families to increase their awareness of relevant readiness issues, while offering creative ideas to build a healthy family. Through proactive education, training, coordination of support services, materials and tools, MCCS promotes personal and family readiness that can be applied in everyday situations. Military One Source is also able to coordinate counseling services for Marines and families in need of counseling support to help cope with deployment related issues, reunion concerns, parenting, childcare and other everyday issues. Marines and family members are allowed six face-to-face counseling sessions per incident with a civilian mental health practitioner for free. A Marine or family member will call a One Source consultant who will determine if there are on base resources readily available to assist the caller. If on base resources are not available, the One Source consultant will provide the caller an immediate referral to counseling assistance, and using their nationwide network of providers, will find a licensed mental health practitioner near the caller. Utilizing Military One Source is ideal for Marines and Marine Reservists (and families) needing counseling services but who are not located near an installation. Marine and Family Services (MFS) counseling is available to those units and families in need of counseling support in the areas of combat stress, stress reduction, anger management, new parent support, and couples counseling.
Marine and Family Services (MFS) Center:The EFMP Coordinators are located at the MFSCs. MFSCs also offers a wide variety of counseling services for families who may need some help in coping with the emotional side or caring for a family member with special needs. The MFSCs also have financial counselors who can assist families who need help achieving their financial goals or when they need guidance when problems arise. Click here for more details.
Medical Retirement:- Medical Retirement is an option for Marines who are not in Entry Level status (>180 days active duty), are suffering from a problem that did not exist prior to enlistment, and are not suffering from a problem that requires administrative separation instead.
Military OneSource:- The services of Military OneSource supplement the existing support system for Marines and their families by providing assistance 24 hours a day, 7 days a week via toll free telephone and Internet access. In addition, Military OneSource supports geographically dispersed Marines and their families (recruiters, Inspector and Instructor staffs, and mobilized reservists) who do not have traditional services available. Resources are available on topics to include parenting and childcare issues, education services, financial information and counseling, legal, elder care, health and wellness, crisis support and relocation. Marines or family members seeking assistance can call 800-342-9647. Military OneSource Online can be visited at www.militaryonesource.com.
Operational Stress:- is the term used to describe physiological, behavioral, and psychosocial reactions experienced due to increased operational tempo during any phase of operations or deployment. It can be the stress or preparation for deployment, the boredom of waiting for action, the frustration of close quarters, the burnout of 24/7 operations, the anxiety of not knowing who is the enemy and never being out of their reach, the shock of seeing and handling human remains, or the stress of reintegrating at home after the deployment is over.
Post Traumatic Stress Disorder (PTSD):- is a psychiatric illness characterized by chronic intrusive recollections, emotional numbing, and hyper-alertness associated with a prior traumatic experience. A related condition, Acute Stress Disorder, is psychiatric illness characterized by immediate, severe response to a traumatic incident -- usually involving significant dissociation or mental "disconnection" from the person's surroundings. These conditions are relatively uncommon, and only a subset of those exposed to a traumatic situation will go on to develop PTSD or other psychiatric conditions such as clinical depression. The rest of those individuals who undergo a difficult experience such as combat are likely to experience some short-term emotional response. This is normal and is, in fact, valuable: increased alertness and decreased sleepiness, for example, are useful short-term responses to danger. When these reactions persist a
fter the danger is passed, they are referred to as "combat/operational stress reactions" -- a normal response to an abnormal situation. It encompasses reactions not only to combat, but also other challenging experiences encountered working in an operational environment.
Protective Measures:- Commanders can expect to be informed promptly when dangerousness issues arise in the course of a mental health evaluation or treatment. If the Marine was referred for a formal Command-Directed Evaluation, both oral and written feedback will be given to the commander addressing the specific issues raised by the commander. The provider may recommend duty restrictions such as removal from weapon-bearing duties or temporary change in flying status. Commanders can also help ensure the individuals duties do not involve significant time alone which there would be opportunity for dwelling on problems and potentially attempting suicide. Commanders may also be directly advised to take steps to reduce access to weapons at the individuals home. While it is impossible to limit a persons access to all potential suicidal means, it is important to take reasonable steps to ensure safety when possible. Firearms pose the greatest risk as a readily available means of self-harm and should always be removed from a suicidal individuals home when legally possible. When this is not possible, counseling the Marine, family, or friends, about the dangers of keeping a firearm available to the suicidal Marine so that it is voluntarily removed, should accomplish weapons removal. Security Forces will generally secure personal firearms in the armory.
Traumatic Events:- are events outside the normal experience of people that pose actual or perceived threats of injury or exposure to death that can overwhelm both an individual's and organization's coping resources. Examples of such critical incidents include combat, natural disasters, acts of terrorism, mass casualty accidents, acts of violence (with and without fatalities), observations of traumatic deaths, and aircraft, boat and ship accidents/mishaps.
Trying to Manipulate:- Occasionally a Marine may feign suicidal thoughts or behavior for secondary gain, such as to get out of the Marine Corps. Even if you think this is the case, the liability is too high not to take appropriate action, so you must get the Marine evaluated by Medical for suicide risk whether you think they are faking or not. Medical is qualified and licensed to determination the level of suicide risk and will let you know what to do with the Marine, including possible administrative actions to hold a manipulative Marine accountable, if appropriate.
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