LT Michael R. Melia, MC, USNLT Michael R. Melia, MC, USN

Combat Stress Control Brief, OIF-II-2, Combat Stress Control Brief, OIF-II-2,

Redeployment Stresses Redeployment Stresses

And Preventive Maintenance For the Mind

And Preventive Maintenance For the Mind

ObjectivesObjectives For This Brief For This Brief

1.1. BasicsBasics of “stress” and “adaptation” of “stress” and “adaptation”

2.2. Stresses Stresses andand problems problems of of redeploymentredeployment

3.3. Traumatic stress injuriesTraumatic stress injuries (including (including PTSDPTSD))– What are they?What are they?– How do you identify them?How do you identify them?

4.4. Operational fatigue Operational fatigue (“Battle Fatigue”)(“Battle Fatigue”)– What is it?What is it?– How do you identify it?How do you identify it?

5.5. Ten stepsTen steps for for mental preventive mental preventive maintenancemaintenance during redeployment during redeployment

Part One:Part One:

A Few Basics About “Stress” and “Adaptation”

A Few Basics About “Stress” and “Adaptation”

““Stress”Stress” Isn’t Always a Bad Thing Isn’t Always a Bad Thing

• Stress is Stress is anyany challenge challenge or demand placed or demand placed on the body or mindon the body or mind

• Stress is always Stress is always bothboth::– A A dangerdanger or threat or threat– And an And an opportunityopportunity

• Stress provokes (requires) an adaptive Stress provokes (requires) an adaptive response (we are never indifferent to it)response (we are never indifferent to it)

• Stress is continuous and Stress is continuous and necessarynecessary

• Problems arise if stress is Problems arise if stress is too intensetoo intense or or lasts lasts too longtoo long

Chinese pictogram Chinese pictogram for “STRESS”for “STRESS”

““DANGER”DANGER”

““OPPORTUNITY”OPPORTUNITY”

TypesTypes of Operational Stresses of Operational Stresses

PHYSICAL

• Heat • Dehydration • Illness

• Cold • Sleep deprivation • Injury

MENTAL

• Conflicting values or morals

• Damaged beliefs • Unmet expectations

EMOTIONAL

• Fear • Hatred of the enemy

• Death of friends • Shame over failure

SOCIAL

• Loss of trust in peers or superiors

• Being in a strange/different culture

SPIRITUAL

• Loss of meaning to life • Guilt

• Loss of faith • Loss of purpose

There Are Only ThreeThere Are Only Three Ways Ways to to AdaptAdapt to Any to Any StressStress

SURRENDER CONQUER DISENGAGE

• Change yourselfChange yourself to better suit the to better suit the environmentenvironment

• The goal of all The goal of all trainingtraining and and education education

• This makes you This makes you more tolerant to more tolerant to that particular that particular stressstress

• Change the Change the environment to environment to better suit youbetter suit you

• The goal of all The goal of all leadershipleadership

• This lessens the This lessens the force and impact force and impact of that particular of that particular stressstress

• Detach mentallyDetach mentally from thefrom the environment, environment, yourself, or bothyourself, or both

• Least effectiveLeast effective but but most most commoncommon strategy strategy

• E.g.: denial, E.g.: denial, dissociation, dissociation, numbnessnumbness

Now That We’ve Adapted to Deployment…Now That We’ve Adapted to Deployment…

• To some extent, we have all been To some extent, we have all been changedchanged– Learned how to live and work here in IraqLearned how to live and work here in Iraq– Forgotten how to live back home and work in garrisonForgotten how to live back home and work in garrison

• To some extent, we have all become To some extent, we have all become numbnumb– To fear and dangerTo fear and danger– To loneliness and griefTo loneliness and grief

• So, when we go back home:So, when we go back home:– We will have to change back again to re-adapt We will have to change back again to re-adapt – Our numbness will have to wear off (over days or weeks)Our numbness will have to wear off (over days or weeks)

-80%

-40%

0%

40%

80%

Three Phases of Adaptation to Any StressThree Phases of Adaptation to Any Stress

““In The Groove”In The Groove”

Fatigue, Fatigue, Burn-outBurn-out

• This same time-course applies to deployment This same time-course applies to deployment andand redeployment! redeployment!

Dread, Dread, AlarmAlarm

Str

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Time Time

-80%

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40%

80%

Phase-Specific Stress ProblemsPhase-Specific Stress Problems

• This same time-course applies to deployment This same time-course applies to deployment andand redeployment! redeployment!

Str

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Traumatic Traumatic Stress InjuriesStress Injuries

BoredomBoredom ComplacencyComplacency

Operational Operational FatigueFatigue

Part Two:Part Two:

The Stresses and Problems of Redeployment

The Stresses and Problems of Redeployment

RedeploymentRedeploymentRedeploymentRedeployment

External StressesExternal StressesExternal StressesExternal Stresses Internal StressesInternal StressesInternal StressesInternal Stresses

• People People • ThingsThings• ProblemsProblems• JobJob• HomeHome• Alcohol & Alcohol &

drugsdrugs

• ThoughtsThoughts• FeelingsFeelings• ImpulsesImpulses• ExpectationsExpectations• ConflictsConflicts• InjuriesInjuries• SymptomsSymptoms

ExternalExternal Stresses of Redeployment Stresses of Redeployment

1.1. Infidelity of spouse/partnerInfidelity of spouse/partner

2.2. Money problems: “Where did it all go?”Money problems: “Where did it all go?”

3.3. Boredom, lack of excitementBoredom, lack of excitement

4.4. Garrison routine/hassles: back to just trainingGarrison routine/hassles: back to just training

5.5. Family conflicts: everyone’s changedFamily conflicts: everyone’s changed

6.6. Vehicles and trafficVehicles and traffic

7.7. Crowds, rude peopleCrowds, rude people

8.8. Not carrying a weaponNot carrying a weapon

9.9. Not being able to fight back any moreNot being able to fight back any more

10.10. Being separated from buddies and leadersBeing separated from buddies and leaders

11.11. The lure of alcohol and drugsThe lure of alcohol and drugs

12.12. The press, media and public opinionThe press, media and public opinion

InternalInternal Stresses of Redeployment Stresses of Redeployment

1.1. Disillusionment after the homecomingDisillusionment after the homecoming

2.2. Bitterness over not being appreciated/understoodBitterness over not being appreciated/understood

3.3. Grief and anger over the loss of friendsGrief and anger over the loss of friends

4.4. Still hating the “enemy”Still hating the “enemy”

5.5. Guilt, shame over surviving or failing in some wayGuilt, shame over surviving or failing in some way

6.6. Emotional numbness: to both pleasure & dangerEmotional numbness: to both pleasure & danger

7.7. Low frustration toleranceLow frustration tolerance

8.8. Anger, irritability, fear, paranoiaAnger, irritability, fear, paranoia

9.9. Startle responses to loud noises or being touchedStartle responses to loud noises or being touched

10.10. Not being able to Not being able to talktalk

11.11. Not being able to Not being able to rememberremember

12.12. Not being able to Not being able to make sensemake sense of it all of it all

5%

17%

23%

33%

40%

52%

55%

70%

82%

0% 20% 40% 60% 80% 100%

Illegal drug use

Domestic violence

Drove intoxicated

Got into a fistfight

Drank too much

Smashed / broke objects

Threatened someone

Exaggerated startles

Lost temper and shouted

Anger Anger andand Substance Abuse Substance Abuse Problems After OIF-I/II-1 (Infantry)Problems After OIF-I/II-1 (Infantry)

Other ProblemsOther Problems After Redeployment After Redeployment

• Hazing of junior troops Hazing of junior troops • SuicideSuicide• HomicideHomicide• Reckless drivingReckless driving• AccidentsAccidents• MisconductMisconduct

– DisrespectDisrespect– InsubordinationInsubordination– U.A.U.A.

• Loss of motivation and loyalty to unit and Loss of motivation and loyalty to unit and CorpsCorps

0%

5%

10%

15%

20%

25%

0 1-2 3-5 >5

More Exposure to More Exposure to CombatCombat Increases Risk Increases Risk for Post-Traumatic Stress Disorder for Post-Traumatic Stress Disorder (PTSD)(PTSD)

Percent of Marines and soldiers Percent of Marines and soldiers reporting significant PTSD symptoms reporting significant PTSD symptoms

3-6 mos. after OIF-I3-6 mos. after OIF-I

Percent of Marines and soldiers Percent of Marines and soldiers reporting significant PTSD symptoms reporting significant PTSD symptoms

3-6 mos. after OIF-I3-6 mos. after OIF-I

— — Hoge CW, et al. N Engl J Med 2004; 351Hoge CW, et al. N Engl J Med 2004; 351

Number of firefights in Iraq in OIF-INumber of firefights in Iraq in OIF-I

Part Three:Part Three:

Traumatic Stress Injuries(Including PTSD)

Traumatic Stress Injuries(Including PTSD)

Traumatic Stress Injuries: Traumatic Stress Injuries: DefinitionDefinition

• InjuriesInjuries to the brain, mind, and spirit to the brain, mind, and spirit

• Due to specific Due to specific “critical event(s)”“critical event(s)” involving: involving:– TerrorTerror, , horrorhorror, or , or helplessnesshelplessness– DamageDamage to deeply-held to deeply-held beliefsbeliefs– HyperarousalHyperarousal (heart pounding, laser-beam focus, (heart pounding, laser-beam focus,

“adrenaline” pumping)“adrenaline” pumping)– ShameShame

• May be cumulativeMay be cumulative

-50%

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25%

50%

75%

100%

Time CourseTime Course of Traumatic Stress of Traumatic Stress Symptoms After a “Critical Event”Symptoms After a “Critical Event”

CRITICAL CRITICAL EVENTEVENT

CRITICAL CRITICAL EVENTEVENT

HYP

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USA

LH

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AR

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SAL

HYP

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RO

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LH

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SALSYMPTOM DURATIONSYMPTOM DURATION:: “ “Normal”: 0-3 daysNormal”: 0-3 days Acute Stress Disorder : 3-30 daysAcute Stress Disorder : 3-30 days PTSD: >30 daysPTSD: >30 days

Time Time

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ExamplesExamples of Traumatic Stresses in OIF of Traumatic Stresses in OIF

1.1. Multi-casualty incidents (SVBIEDs, ambushes)Multi-casualty incidents (SVBIEDs, ambushes)2.2. Friendly fireFriendly fire3.3. Death or maiming of children and womenDeath or maiming of children and women4.4. Seeing gruesome scenes of carnageSeeing gruesome scenes of carnage5.5. Handling dead bodies and body partsHandling dead bodies and body parts6.6. “ “Avoidable” casualties and lossesAvoidable” casualties and losses7.7. Witnessed atrocitiesWitnessed atrocities8.8. Witnessed death/injury of a close friend or leaderWitnessed death/injury of a close friend or leader9.9. Killing unarmed or defenseless enemyKilling unarmed or defenseless enemy10.10. Being helpless to defend or counterattackBeing helpless to defend or counterattack11.11. Injuries or near missesInjuries or near misses12.12. Killing someone in close combatKilling someone in close combat13.13. Media, public opinionMedia, public opinion

Traumatic Stress Injuries: Traumatic Stress Injuries: EarlyEarly FeaturesFeatures

• DissociationDissociation is always is always immediateimmediate; of ; of two typestwo types::– NumbnessNumbness, detachment, or unresponsiveness – like a trance state, detachment, or unresponsiveness – like a trance state– Or may just be a Or may just be a persistent change in personalitypersistent change in personality

• In either type of dissociation, the individual:In either type of dissociation, the individual:– Is Is cut offcut off from his usual values, feelings, and attachments from his usual values, feelings, and attachments– Cannot calmCannot calm his own fear or anger as well his own fear or anger as well– Cannot thinkCannot think as rationally or as rationally or rememberremember as clearly as clearly

• Possible Possible behaviorsbehaviors::– ““Panic Run”Panic Run” or going berserk (reckless aggression)or going berserk (reckless aggression)– RegressionRegression: becoming helpless and passive like a child: becoming helpless and passive like a child– Freezing or “locking up”Freezing or “locking up”

• OrOr, there may be , there may be nono visible change in behavior visible change in behavior

Traumatic Stress Injuries: Traumatic Stress Injuries: LaterLater Features (PTSD Symptoms)Features (PTSD Symptoms)

• Re-experiencingRe-experiencing– Severe (repetitive) nightmaresSevere (repetitive) nightmares– Flashbacks or intrusive memories or imagesFlashbacks or intrusive memories or images

• Avoidance:Avoidance:– Of reminders of the traumatic experienceOf reminders of the traumatic experience– Of situations that look or sound similar (e.g., the CA desert)Of situations that look or sound similar (e.g., the CA desert)

• Emotional numbingEmotional numbing– Feeling “cold”, hardFeeling “cold”, hard– Feeling detached, not inside your own skinFeeling detached, not inside your own skin

• Increased arousal or agitationIncreased arousal or agitation– Can’t calm down or relaxCan’t calm down or relax– Can’t sleepCan’t sleep– Exaggerated startle responsesExaggerated startle responses

• Anxiety or anger attacksAnxiety or anger attacks

OtherOther Common Common PTSDPTSD Symptoms Symptoms

• Poor stress tolerance (easily upset, frustrated)Poor stress tolerance (easily upset, frustrated)• Substance abuse and dependence of all kindsSubstance abuse and dependence of all kinds• Emotional instability, moodinessEmotional instability, moodiness• Short-term memory problemsShort-term memory problems• Persisting personality changes (loss of morals)Persisting personality changes (loss of morals)• Paranoia (sleeping with a weapon, etc.)Paranoia (sleeping with a weapon, etc.)• Unintentional aggressive acts (e.g., domestic Unintentional aggressive acts (e.g., domestic

violence, startle responses)violence, startle responses)• Aggressive fantasies and intentional aggression Aggressive fantasies and intentional aggression

(e.g., cruising tough neighborhoods, bar fights)(e.g., cruising tough neighborhoods, bar fights)• Guilt over and fear of aggressive impulsesGuilt over and fear of aggressive impulses• Self-destructive behaviorsSelf-destructive behaviors• Sexual problems (e.g., erectile dysfunction)Sexual problems (e.g., erectile dysfunction)

What is Injured By a Traumatic Stress?What is Injured By a Traumatic Stress?

3–3–SerotoninSerotonin:: Inhibition, Inhibition,

ControlControl

3–3–SerotoninSerotonin:: Inhibition, Inhibition,

ControlControl

1–1–NorepinephrineNorepinephrine:: ”Get up and go”, ”Get up and go”, Energy, IntensityEnergy, Intensity

1–1–NorepinephrineNorepinephrine:: ”Get up and go”, ”Get up and go”, Energy, IntensityEnergy, Intensity2–2–DopamineDopamine::

“Rush”, “Rush”, Motivation, Motivation, AddictionAddiction

2–2–DopamineDopamine:: “Rush”, “Rush”,

Motivation, Motivation, AddictionAddiction

5–5–Hippocampus-Hippocampus-Prefrontal CortexPrefrontal Cortex::

Conscious decisions, Conscious decisions, Values and beliefs, Values and beliefs,

Courage Courage

5–5–Hippocampus-Hippocampus-Prefrontal CortexPrefrontal Cortex::

Conscious decisions, Conscious decisions, Values and beliefs, Values and beliefs,

Courage Courage

4–4–AmygdalaAmygdala:: Threat reactor, Threat reactor, Fear and angerFear and anger

4–4–AmygdalaAmygdala:: Threat reactor, Threat reactor, Fear and angerFear and anger

Five Brain Systems of the Stress ResponseFive Brain Systems of the Stress Response

The Hippocampus- Prefrontal Cortex (PFC) The Hippocampus- Prefrontal Cortex (PFC) & the Amygdala& the Amygdala

HIPPOCAMPUS -PFC

• Keeps track of where you are

• Makes sense out of all experiences

• Manager of belief and value systems

• Decision-making, self-control

• Hippocampus = “Hard-drive”

• PFC = “CPU” of brain computer

AMYGDALA

• Monitors all incoming stimuli

• Searches for threats or dangers

• Reacts to danger:– Fear or anger– Arousal

• Triggers reflexive behaviors

• Remembers forever!

PFCPFC

What Happens at the Moment of a What Happens at the Moment of a Traumatic Experience?Traumatic Experience?

• The The hippocampushippocampus frantically attempts to make frantically attempts to make sense out of a situation that doesn’t make sensesense out of a situation that doesn’t make sense– Because it violates your belief systemsBecause it violates your belief systems– Because it violates your need to be in controlBecause it violates your need to be in control– Because it violates your self-conceptBecause it violates your self-concept

• If arousal level is high enough…If arousal level is high enough…

CRASH!CRASH!

– NeuronsNeurons in the hippocampus in the hippocampus burst and burst and diedie

– The The hard-drivehard-drive in your brain in your brain computer computer crashescrashes!!

The Hippocampus is Damaged in PTSD…The Hippocampus is Damaged in PTSD…

The Charioteer Is Temporarily Knocked OutThe Charioteer Is Temporarily Knocked Out

• And even after the hippocampus recovers, it still And even after the hippocampus recovers, it still can’t make sense of the traumatic memorycan’t make sense of the traumatic memory

But the Good News Is…But the Good News Is…

• The The Hippocampus can healHippocampus can heal—but —but slowlyslowly, and, and• Only if obstaclesOnly if obstacles to healing to healing areare removedremoved

– Nightmares, flashbacks, panic attacks, blind ragesNightmares, flashbacks, panic attacks, blind rages– Shame, guiltShame, guilt– Refusing to “deal with” the memories and losses—you can’t just Refusing to “deal with” the memories and losses—you can’t just

pretend they didn’t happenpretend they didn’t happen

• May require treatment to promote healingMay require treatment to promote healing– Talking therapy, counseling, group therapyTalking therapy, counseling, group therapy– Medications: 6-9 monthsMedications: 6-9 months– Social support and validationSocial support and validation– Spiritual supportSpiritual support

Part Four:Part Four:

Operational FatigueOperational Fatigue

Operational Fatigue: Operational Fatigue: DefinitionDefinition

• PersistingPersisting emotional changesemotional changes after after prolonged prolonged exposureexposure to combat/operational stress to combat/operational stress– Can occur after only 14-21 days of high-intensity combatCan occur after only 14-21 days of high-intensity combat– Commonly begins after 90 days of moderate-intensity deploymentCommonly begins after 90 days of moderate-intensity deployment– Eventually, Eventually, everyoneeveryone succumbs if exposure is continuous, even to succumbs if exposure is continuous, even to

low-intensity operational stresseslow-intensity operational stresses

• Caused by an Caused by an accumulationaccumulation of small stresses of small stresses– DangerDanger– MonotonyMonotony– Insufficient rest or recuperationInsufficient rest or recuperation

• More common in officers and SNCOs than in More common in officers and SNCOs than in younger troopsyounger troops– ““Old Sergeant's Syndrome”Old Sergeant's Syndrome”

Operational Fatigue: Operational Fatigue: FeaturesFeatures

• DepletionDepletion of internal resources of internal resources– Tiredness, lethargyTiredness, lethargy– ApathyApathy

• AnxietyAnxiety and panic attacks and panic attacks– Generalized worry, insomnia, tension, physical symptomsGeneralized worry, insomnia, tension, physical symptoms– Panic attacksPanic attacks:: “Soldier’s Heart”“Soldier’s Heart”

• AngerAnger and irritability and irritability• InsomniaInsomnia

– Can’t get to sleepCan’t get to sleep– Can’t stay asleepCan’t stay asleep

• Loss of confidenceLoss of confidence

But the AMYGDALA But the AMYGDALA continues to generate continues to generate

FEAR and ANGER!FEAR and ANGER!

In Operational Fatigue, the In Operational Fatigue, the HorsesHorses andand the the ReinsReins Get Get Worn OutWorn Out

Part Five:Part Five:

Mental Preventive Maintenance

Mental Preventive Maintenance

Steps for Mental Preventive MaintenanceSteps for Mental Preventive Maintenance

1.1. KnowKnow your Marines and sailors your Marines and sailors– Everyone’s experience of redeployment is differentEveryone’s experience of redeployment is different– You You cannot order them to feel or think the way you want them tocannot order them to feel or think the way you want them to– The only way to know The only way to know whowho will be vulnerable to will be vulnerable to whichwhich problems on problems on

redeployment is to redeployment is to know them personallyknow them personally– Pay special attention to:Pay special attention to:

Personal losses (deaths of close friends or a relationship loss)Personal losses (deaths of close friends or a relationship loss) Traumatic experiences during deploymentTraumatic experiences during deployment Whether an individual has family supports in the rearWhether an individual has family supports in the rear Personal moral beliefs and valuesPersonal moral beliefs and values History of alcohol or drug abuse in the pastHistory of alcohol or drug abuse in the past History of violence, fighting, or domestic violence in pastHistory of violence, fighting, or domestic violence in past History of depression or suicide attempts in the pastHistory of depression or suicide attempts in the past

Steps for Mental Preventive Steps for Mental Preventive Maintenance…Maintenance…

2.2. Create an environment in which it’s Create an environment in which it’s OK to have OK to have problemsproblems– Your attitudeYour attitude toward mental, emotional, and behavioral problems toward mental, emotional, and behavioral problems

may determine whether these problems may determine whether these problems ever get betterever get better!!– Don’t promote Don’t promote shameshame—shame prevents healing—shame prevents healing– Don’t permit Don’t permit stigmastigma

86% of Marines and soldiers with problems after OIF-I 86% of Marines and soldiers with problems after OIF-I recognized themrecognized them

But only 45% said they would ever get helpBut only 45% said they would ever get help 66% said they would be perceived as weak if they admitted 66% said they would be perceived as weak if they admitted

to a problemto a problem 47% said they thought it would harm their careers47% said they thought it would harm their careers

– Mental health treatment will not end someone’s careerMental health treatment will not end someone’s career

3.3. Prepare Prepare your Marines and sailors for the stresses your Marines and sailors for the stresses of redeploymentof redeployment– Teach them about what they may expectTeach them about what they may expect

Startle responses, nightmaresStartle responses, nightmares Anxiousness in crowds or trafficAnxiousness in crowds or traffic Boredom, numbness, craving excitementBoredom, numbness, craving excitement Easy frustration, anger outburstsEasy frustration, anger outbursts

– Warn them about what they should avoidWarn them about what they should avoid Alcohol, drugs, reckless drivingAlcohol, drugs, reckless driving Situations in which they may lose their temperSituations in which they may lose their temper

– Tell them what they can do to copeTell them what they can do to cope Stay connectedStay connected with members of unit with members of unit TalkTalk about problems with peers, superiors, chaps, doc about problems with peers, superiors, chaps, doc Be patientBe patient with themselves and their family and friends with themselves and their family and friends Maintain Maintain physical fitnessphysical fitness—a great stress reliever—a great stress reliever

Steps for Mental Preventive Maintenance…Steps for Mental Preventive Maintenance…

4.4. Informal Informal briefsbriefs at small unit level at small unit level by otherby other experiencedexperienced MarinesMarines—another way to prepare—another way to prepare– Find Marines in your unit who have been through it beforeFind Marines in your unit who have been through it before– Schedule informal briefs at platoon or squad levelSchedule informal briefs at platoon or squad level– Have them describe their own experiences of:Have them describe their own experiences of:

Re-uniting with family and friendsRe-uniting with family and friends Their own emotional and mental reactions to redeploymentTheir own emotional and mental reactions to redeployment How they reacted to traffic, crowds, alcohol, sex, bar scenesHow they reacted to traffic, crowds, alcohol, sex, bar scenes What worked for them, what didn’t workWhat worked for them, what didn’t work Q & AQ & A Open discussionOpen discussion

Steps for Mental Preventive Maintenance…Steps for Mental Preventive Maintenance…

5.5. Help your Marines and sailors Help your Marines and sailors make sense make sense ofof their sacrifices, sufferingtheir sacrifices, suffering andand losseslosses– Symbolic validationSymbolic validation

Awards, when due (don’t let these fall through the cracks)Awards, when due (don’t let these fall through the cracks) Ceremonies, celebrationsCeremonies, celebrations Memorial services, physical memorialsMemorial services, physical memorials

– Validation by Validation by listeninglistening and and giving meaninggiving meaning to experiences to experiences Honest sharing of experiences in atmosphere of trustHonest sharing of experiences in atmosphere of trust Reduce sense of being “the only one”Reduce sense of being “the only one”

– Address any especially traumatic experiences during deploymentAddress any especially traumatic experiences during deployment Be honest if you canBe honest if you can Answer question: Why did it have to happen?Answer question: Why did it have to happen?

– Tell them what purpose they servedTell them what purpose they served!!

Steps for Mental Preventive Steps for Mental Preventive Maintenance…Maintenance…

6.6. Time offTime off—as much as possible, consistent with —as much as possible, consistent with other unitsother units– For most unit members:For most unit members:

96 hour liberty, then96 hour liberty, then A few short workdays: for briefs and medical stuff, thenA few short workdays: for briefs and medical stuff, then Regular leave, if possibleRegular leave, if possible

– For IAs and reservists:For IAs and reservists: A few days at Camp Lejeune for briefs and medical, thenA few days at Camp Lejeune for briefs and medical, then Return to parent unit or home, if possibleReturn to parent unit or home, if possible

– EncourageEncourage taking taking time offtime off To re-adapt to the stresses of being back homeTo re-adapt to the stresses of being back home To re-acquaint with family and friendsTo re-acquaint with family and friends To address unresolved home or family problemsTo address unresolved home or family problems

Steps for Mental Preventive Steps for Mental Preventive Maintenance…Maintenance…

7.7. Don’t forgetDon’t forget about your about your MarinesMarines who are who are stuck stuck in thein the barracks barracks– Ensure Ensure leadershipleadership and and companionshipcompanionship for Marines who can’t for Marines who can’t

go home or don’t have families to go home togo home or don’t have families to go home to– Don’t just let them sit and do nothing or join working parties Don’t just let them sit and do nothing or join working parties

while the rest of the unit is on leavewhile the rest of the unit is on leave– Assign SNCOs to be responsible for themAssign SNCOs to be responsible for them– They also must feel valued and appreciatedThey also must feel valued and appreciated

Steps for Mental Preventive Steps for Mental Preventive Maintenance…Maintenance…

8.8. Don’t letDon’t let your Marines your Marines take their stresses take their stresses out out on on each othereach other– Discipline can never be relaxedDiscipline can never be relaxed– But all leaders must But all leaders must monitor themselvesmonitor themselves and and subordinatessubordinates for: for:

Excessive yelling at subordinatesExcessive yelling at subordinates Abusive language toward subordinatesAbusive language toward subordinates Threatening of subordinatesThreatening of subordinates Publicly criticizing or shaming subordinatesPublicly criticizing or shaming subordinates Assaulting subordinatesAssaulting subordinates

– It’s easy to go too far when you are feeling stressed or frustrated It’s easy to go too far when you are feeling stressed or frustrated yourselfyourself

– Harassing a subordinate “proves” to him that “Semper Fi” is not Harassing a subordinate “proves” to him that “Semper Fi” is not a two-way streeta two-way street

Steps for Mental Preventive Steps for Mental Preventive Maintenance…Maintenance…

9.9. Identify Identify Marines and sailors who have persistent Marines and sailors who have persistent problems (>30 days, or beginning problems (>30 days, or beginning afterafter 30 days) 30 days)– Task all subordinates to watch for and report any changes in other Task all subordinates to watch for and report any changes in other

Marine’s behaviorMarine’s behavior Increase in angerIncrease in anger Social withdrawal—becoming quiet and avoiding othersSocial withdrawal—becoming quiet and avoiding others Homicide or suicide threatsHomicide or suicide threats Changes in military bearing or groomingChanges in military bearing or grooming Any loss of disciplineAny loss of discipline

– Encourage everyoneEncourage everyone in unit to in unit to ask for helpask for help if any problems persist if any problems persist for more than 30 days after return to CONUSfor more than 30 days after return to CONUS

– Mental Health Mental Health BriefBrief and and ScreenScreen: 60-120 days after return: 60-120 days after return– Early treatment predicts better outcomesEarly treatment predicts better outcomes!!

Steps for Mental Preventive Steps for Mental Preventive Maintenance…Maintenance…

10.10. Refer Refer Marines and sailors who need helpMarines and sailors who need help– Reasons to referReasons to refer someone for help: someone for help:

Marine asks for help (even if you don’t believe him)Marine asks for help (even if you don’t believe him) Severe problems at any point that affect work or home lifeSevere problems at any point that affect work or home life PTSD symptoms that persist after 30 daysPTSD symptoms that persist after 30 days

– ResourcesResources:: Chaplain, ministersChaplain, ministers BAS, hospital ER, other medical personnelBAS, hospital ER, other medical personnel Marine Corps Community Services, Family Services CenterMarine Corps Community Services, Family Services Center Division PsychiatryDivision Psychiatry Vet Centers (after release from active duty)Vet Centers (after release from active duty) VA Medical Centers (after release from active duty)VA Medical Centers (after release from active duty)

Steps for Mental Preventive Steps for Mental Preventive Maintenance…Maintenance…