The following document was written primarily for the US Marines, but I believe that the information is valid for all members of the military (no matter for which country they served for) who were put into positions where they are still being bothered by. So read this as a help for everyone but remember some things at the end are valid only for US military veterans.
Dealing with Combat and Operational Stress
It’s not unusual for anyone participating in combat or seeing its aftermath to be filled with complicated and conflicting emotions — including fear, sadness, and horror — all legitimate reactions to the combat experience. Even Marines who haven’t been in direct combat, but have been through a life-threatening situation, seen enemy or civilian casualties, had a friend die, or been in charge of prisoners of war, can experience the many feelings that come together as a Combat and Operational Stress Reaction (COSR).
It’s important to understand that strong feelings are a natural reaction to being confronted with danger. The feelings are part of the “fight or flight” response that makes you alert and vigilant, and puts you in high gear.
But a reaction to combat stress can be disturbing, especially when you are in a situation that requires you to appear strong and courageous. And sometimes reactions to combat stress can interfere with a Marine’s ability to do his or her job — whether that job is on the front or back at home. It’s important to learn to recognize signs of a reaction to combat stress — in yourself, in another Marine, or in a family member who has returned home from a war zone. Knowing when and where to seek professional help — and knowing that it’s the right thing to do — is a critical step toward getting better.
A combat stress reaction needs to be recognized, understood, and treated promptly
• What is combat stress?
• The signs of combat stress
• What causes a severe reaction?
• How you can help yourself and the people around you
• Habits that can help you manage stress
• Seeking professional help
• Delayed stress reactions
• Back at home
What is combat stress?
Feeling stress in a war zone is, as one Navy psychiatrist said, “a normal reaction by a normal person to an abnormal, horrific situation.” The stress you feel helps you brace for danger. But you can sometimes witness an event so severe or experience a threat so prolonged that your body may continue to maintain that state of high alert long afterwards, when your body and mind need to rest.
Stress — from a single event, from a series of events, or from a continuous stressful situation — can cause a wide range of reactions, including
– brief combat stress reactions, which can range from exhaustion to hallucinations
– behavior changes, which can range from recklessness to brutality
– post-traumatic stress disorder (PTSD), which includes persistent re-experiencing of the events, avoidance of reminders, and hyper-arousal.
Historically, combat stress reactions have represented anywhere from under 10 percent to half of all battlefield casualties, depending upon the difficulty of the conditions.
Signs of combat stress
The signs that someone is suffering from combat stress can be physical, mental, emotional, or behavioral. Keep in mind that just having certain symptoms doesn’t necessarily mean that you need help. You are likely to experience at least some of these signs as a normal reaction. This normal reaction can last from a few days to a few weeks. When you see any of these symptoms in yourself or someone else, be alert to how severe the symptom is and how long it lasts. If it interferes with your ability to do your job or interact with other people, it is important to get professional help.
Here are some of the possible signs of a combat stress reaction. (The first two items in each list are generally earlier warning signs.)
• Physical signs
– inability to fall asleep or stay asleep
– sweating, heart pounding
– nausea, frequent urination, or diarrhea
– jitters, trembling, or jumpiness
– numbness, tingling, or total loss of function of limbs or other body parts
• Mental signs
– difficulty concentrating, confusion
– inability to make decisions, to process information
– memory loss
– flashbacks, reliving the trauma
– loss of a sense of what is real
– hallucinations or delusions (not taken care of by adequate sleep)
• Emotional signs
– fear, worry, extreme nervousness
– irritability, anger
– mood swings
– despair and sadness
– feelings of isolation
• Behavioral signs
– carelessness or recklessness
– outbursts of anger or aggressiveness
– staring into space, sometimes called the “thousand-yard stare”
– inability to do your job
– increased use of alcohol or drugs
– misconduct or crime
– complete unresponsiveness to others
You need to use sound judgment when you see these signs. For example, if you are working on equipment that is headed for operations, it is important to take the responsibility of reporting these symptoms.
Depression can be another result of intense or prolonged stress. Signs of depression include
– change in appetite (eating too much or too little), weight loss or gain
– sleep problems
– lack of energy
– withdrawing from other people
– trouble concentrating
– feelings of hopelessness
– uncontrollable crying
If symptoms like these persist for longer than two weeks, it’s important to seek professional help. If you — or a service member you know — are having thoughts about suicide, it’s important to get help immediately.
What causes a severe reaction?
No one knows for certain why some people have stronger stress reactions than others do. People seeing combat for the first time may be at higher risk, but service members with past combat experience may also have stress reactions. People with pre-existing psychological problems may be more at risk. Anyone who sees something particularly gruesome or is part of a terrifying situation may also be at high risk. Even the most seasoned Marine can have a severe reaction under certain conditions.
Here are just some of the things that could contribute to a stress reaction, alone or in combination:
– inexperience with the stressful experiences (combat, casualties)
– isolation (being new to a unit, feeling out of touch with the veterans)
– sleep deprivation
– ongoing exposure to danger
– sense of helplessness from being pinned down by enemy fire with no room to maneuver or inability to return fire
– killing the enemy or civilians at close range, especially under unusual circumstances (accidentally or when they were trying to surrender)
– the sight and smell of dead bodies, especially close friends
– being shot at by people you think you are helping
– accidental deaths (such as friendly fire by you or someone else)
– being in charge of prisoners of war, especially if atrocities are observed, condoned, or performed
– noise, a blast, or vibration (especially intensive enemy attacks)
– being cold, wet, or without a shower for an extended period
– trouble or bad news from home (even good news if uncertainty is involved, such as a new baby coming soon)
– lack of information, leading to exaggerated fears and loss of perspective
Modern warfare may add some other factors, such as
– continuous operations made possible by all-weather, day and night equipment
– not knowing where or who the enemy is, as with suicide bombings
– knowing that the war is a subject of debate back home
– having rules of engagement that do not allow you to return fire in some circumstances (leading to greater feelings of helplessness)
– enemy use of new, unexpected tactics for which you are unprepared
How you can help yourself and the people around you
While there is no certain, guaranteed way to protect yourself from the cumulative stress that can cause a stress reaction, there are things you can do to help yourself or others in stressful circumstances:
• Provide a sense of physical well-being.
– When possible, try to remove physical stress, with food, a shower, and a nap.
– Drink plenty of nonalcoholic fluids and avoid exclusive use of caffeinated or carbonated drinks, which can be dehydrating.
– Restore a routine as soon as possible, with regular meals, sleep, and exercise.
• Take care of your mental health.
– Say positive things to yourself, such as “I can do it” or “Easy does it.”
– Remember that combat stress reactions are common to all ranks, all races, both genders, and to military personnel from all walks of life.
– When you can, talk about what you are going through with others who have had similar experiences. They are probably feeling a lot of the same feelings that you are.
– Share your worries, including concern that someone’s behavior is worrying you.
– Work to build trust, communication, and a reliable flow of information within your unit. Participate in unit after-action debriefings if possible.
– Remember that risk of injury and death is “built-in” to all military operations.
– Ask for reasonable help in managing problems at home from a distance.
• Learn about combat stress.
– Know the signs of a combat stress reaction.
– Understand that the reaction is normal and that you can recover from it.
– Don’t demean anyone who has a severe reaction.
• Get professional help if a stress reaction is interfering with your work or your interactions with other people.
Habits that can help you manage stress
There are certain habits or routines that can help make it easier to handle stress. For example,
• Eat nutritious food in moderation; avoid foods with lots of salt and sugar; reduce your intake of caffeine and alcohol, and drink plenty of water.
• Exercise. It can reduce stress and be an effective treatment for depression and anxiety.
• Seek out social support. Research shows that spending time talking with friends can make you feel better and have a significant effect on your health.
• Talk or write about your emotions. Talking and writing about your feelings can help reduce tension and relieve stress.
• Address your spiritual needs. Some people find strength in some form of prayer or through discussing their concerns with a chaplain.
• Have a sense of humor. Sometimes humor can help you look at stressful situations from a different perspective.
• Try deep breathing. Breathe in to a slow count of five, then breathe out to a slow count of five, and repeat for several minutes. This can relax both your body and mind. Techniques such as meditation and visualization can also help.
Seeking professional help
Combat and Operational Stress Reaction is common and can be helped. If you are suffering from a combat stress reaction that is interfering with your work or your interactions with other people, it is important to get professional help. In fact, it is critical to the strength of your unit to treat a stress reaction promptly and to learn ways to deal with the stress. If you are at home, it is critical to our overall health and to your relationships with friends and family. Finding help is the right thing to do, just as supporting other Marines who seek help is the right thing to do. The earlier you identify the signs of a severe stress reaction in yourself or in another service member, the faster and fuller recovery can be.
Treatment strategies include
• Operational Stress Control and Readiness (OSCAR) teams, which the Marine Corps has begun to set up with infantry units close to the front, consisting of a psychiatrist or psychologist, a Staff NCO, and a chaplain. There are also combat stress platoons with some units. The job of these teams is to evaluate, treat, and educate Marines suffering from combat stress, and, in most cases, return them to their unit without referring them to higher-level care. Treatment by these teams is based on a method called PIES. (Proximity, which calls for treatment as close to the front as possible so that the Marine still feels a part of his or her unit; Immediacy, which puts a high priority on prompt, quick treatment, usually for no more than three days; Expectancy, which fosters the attitude that this is a temporary need for recuperation; and Simplicity, which encourages the use of the simplest, most direct approach to treatment.)
• Critical Incident Stress Management (CISM), where you can talk about an event that might have triggered the reaction in a supportive environment.
• Religious or spiritual support, from a chaplain or counselor.
• Distraction, such as sports events, movies, or exercise.
If you are already away from the front and feel that you need to talk to someone, seek out the medical facility that is supporting your unit, which may have an Operational Stress Control and Readiness team. If not, your primary care manager can refer you to the right person for help.
Delayed stress reactions
A combat stress reaction can be delayed, which means that may begin to feel the effects only after you return home. It’s also possible that for a time you may continue to react as you did while deployed — for example, dropping to the ground when you hear a loud noise — behavior that was a normal reaction in combat, but that may seem abnormal to others back at home.
Your family will need to learn about combat stress reactions so that they can help you if you need it. Families can help by letting you establish your own schedule for talking about what you’ve been through — that is, by listening when you are ready to talk — and by recognizing that you may need time to adjust to the changes that have happened in your absence.
There are many resources for help at home for Marines and their families. On the installation, you can go to
• a medical treatment facility, clinic, or hospital, where you can ask to speak to a counselor or mental health professional
• a chaplain or other spiritual advisor
If you don’t live on the installation, or you would rather speak with someone off the installation, you can
• call the MCCS One Source program at 800-869-0278 or go to the Web site at www.mccsonesource.com (user name: marines; password semperfi)
• call or go to a community mental health center (your state’s office is listed at www.ncd.gov/mental.htm)
• call the Veterans Administration (if active duty or reserves) at 800-827-1000, or visit the Web site at www.va.gov.
• call the local chapter of the American Red Cross for a referral or for information about a deployed family member or visit the Web site at www.redcross.org.
• for family members, find a private psychologist or social worker through a personal referral or by searching the Web sites of organizations such as the American Psychological Association (apa.org) or the National Association of Social Workers (naswdc.org).
Don’t let concern about cost stand in your way. Tricare may cover such services for family members in some cases (for information call your regional Tricare office and ask about mental health benefits or visit their Web site at www.tricare.osd.mil.) Other outside family health insurance may also cover mental health services; community mental health centers must charge people within their service area on a sliding scale.
This article was written with the help of Lieutenant Commander Anthony P. Doran, Ph.D., clinical psychologist and program manager for the Navy’s suicide prevention program; Commander Thomas A. Gaskin, Ph.D., a Navy clinical psychologist and advisor to the Marine Corps on suicide prevention and combat/operational stress control; Walter R. Schumm, Ph.D., retired Army Reserve Colonel and professor of family studies and human services at Kansas State University; and James E. Smith, Ph.D., retired Army Lieutenant Colonel and assistant professor of social work at the University of Wyoming.
© 2004 Ceridian Corporation. All rights reserved.
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