Leaders Guide - Combat and Operational Stress

Fatigue stress injuries are potentially irreversible changes in the brain and mind due to the accumulation of stress from many sources over the duration of very long or repeated deployments. Whereas traumatic stress injuries occur abruptly, as a result of one or more specific incidents involving terror or horror, fatigue stress injuries occur gradually due to the wear-and-tear of smaller stressors over time. Everyone is familiar with the stressors that can contribute to fatigue stress injuries, for they are commonplace in operational and training environments, and everyone is familiar with the early symptoms of fatigue stress, for they are likewise common during tough training and even tougher operational deployments. However, what characterizes a fatigue stress injury is not only the severity of stress symptoms that accompany it, but the fact that these symptoms may not completely disappear on their own once sources of stress are no longer present. That’s what makes fatigue stress a literal injury in some cases — the potential irreversibility of fatigue stress symptoms post-deployment, primarily in the form of persistent clinical depression or anxiety symptoms. And that is why the prevention and early recognition of fatigue stress injuries is so crucial for the health and well-being of your Marines — and yourself. In contrast to traumatic stress injuries, to which younger Marines are often most vulnerable, older Marines tend to be more vulnerable to the wear-and-tear damage of fatigue stress injuries.

Successful identification and management of fatigue stress injuries requires Marine leaders to be aware of two possible indicators: (1) stressors that have a high potential for contributing to fatigue stress, and (2) the symptoms and behaviors that most commonly accompany fatigue stress injuries.

Any and every stress experienced by a Marine can contribute to fatigue because stress from any cause depletes internal coping resources, both in the brain and mind. However, certain specific stressors seem to be uniquely toxic in their ability to contribute to or worsen fatigue stress injuries. They include:

are those that appear gradually, usually over many months, from the depletion of internal biological and psychological resources without sufficient opportunities to replenish these resources. Physical changes in the brain, in its attempt to compensate for depleted resources, produce further symptoms that may persist long after sources of stress are removed. Common fatigue stress injury symptoms and behaviors include:

The most important leader action for fatigue stress injuries is prevention through keeping operational tours short and ensuring that Marines receive adequate sleep and rest and recreation while deployed. Once Marines develop symptoms and behaviors suggesting fatigue stress, appropriate leader actions include: (1) applying psychological first aid, (2) assessing the need for professional care, and (3) mentoring back to full duty and function.

A Marine you know is having problems denies it: Remember that most people are ashamed of having emotional problems of any kind, especially in combat or operational situations in which everyone is stressed. 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 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. Remind the Marine that although there is a small chance that getting help for a stress injury will hurt their career or future employability, there is a much greater chance that not getting help when needed will hurt their health or safety, as well as the safety of their fellow Marines. If a Marine with fatigue 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 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 a person doesn’t want to do. Faking illness or injury for such purposes is malingering, of course - a violation of the UCMJ. However, malingering of operational stress problems such as depression, anxiety, or other fatigue stress symptoms is exceedingly 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 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 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.