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US Marine Corps and Navy Combat and Operational Stress Continuum Model: A Tool for Leaders

Chapter 7

US Marine coRps and Navy 

combat and operational stress

continuum model: a tool for 

leaders

WILLIAM P. NASH, MD*

INTRODUCTION

COMBAT AND OPERATIONAL STRESS CONTINUUM

Background and Development

Ready: The Green Zone

Reacting: The Yellow Zone

Injured: The Orange Zone

Ill: The Red Zone

FIVE CORE LEADER FUNCTIONS FOR PSYCHOLOGICAL HEALTH

Strengthen Service Members

Mitigate Stressors

Identify Stress Reactions, Injuries, and Illnesses

Treat Stress Injuries and Illnesses

Reintegrate Stress Casualties

SUMMARY

*Captain, US Navy (Retired); Assistant Clinical Professor, Department of Psychiatry, University of California at San Diego; formerly, Senior Consultant, 

Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, Rosslyn, Virginia
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Combat and Operational Behavioral Health

INTRODUCTION

In the US military, the overall responsibility for preserving the health of operationally deployed service 

members is assigned to commanders of combatant 

commands.1

 Only operational commanders are in a 

position to balance the evolving tactical requirements 

that inevitably place service members in harm’s way 

against the enduring strategic imperative to preserve 

the health of the force. Only line commanders can 

lead the full spectrum of force health protection 

activities necessary to “promote, protect, improve, 

conserve, and restore the mental and physical well 

being of Service members across the range of military 

activities and operations.”1(p10) And only trusted 

leaders and mentors can reduce the stigma associated 

with acknowledging mental health problems, and 

make it acceptable for service members to receive help 

for them. Even in garrison, line commanders cannot 

delegate their force health protection responsibilities 

to medical or religious ministry support personnel, 

although such support is crucial to accomplishing 

the health protection mission. The dual goals of force 

health protection are force conservation and long-term 

physical and psychological health and well-being for 

service members and their families.

Military commanders and their health and religious 

ministry advisors have historically approached 

psychological health (PH) protection, including 

combat and operational stress control (COSC), 

somewhat differently from physical health protection 

because of the “demedicalized” model of combat stress 

reactions that has persisted since World War I.2–4 In 

this model, combat and operational stress reactions 

have been viewed not as injuries or illnesses but as 

temporary and reversible responses to stress over 

which the individual is believed to retain a significant 

degree of control. Principles of forward management 

of stress reactions based on this model, summarized in 

the acronyms PIES (proximity, immediacy, expectancy, 

simplicity) and BICEPS (which adds brevity and contact 

or centrality), recommend that service members 

suffering from combat and operational stress reactions 

not be permitted to perceive themselves as sick, ill, or 

injured (see also Chapter 4, Combat and Operational 

Stress Control).5 Early screening and treatment for 

significant symptoms of mental illness is eschewed 

in favor of “normalizing” stress reactions and using 

the power of suggestion (“expectancy”) to encourage 

return to previous occupational functioning. The 

approach to be taken to service members suffering 

from combat stress in a war zone, according to this 

demedicalized model, is summarized in the words of 

Colonel (Retired) Franklin D Jones, former psychiatry 

and neurology consultant to the US Army surgeon 

general, writing in War Psychiatry in 1995: “You are 

neither sick nor a coward. You are just tired and will 

recover when rested.”5(p9)

However, evolving scientific thought provides a 

strong argument, in this author’s opinion, for developing a model that bases PH protection and COSC 

on the same preventive medicine principles that 

underlie physical health protection. Posttraumatic 

stress disorder (PTSD), for example, is now known 

to be a relatively common, potentially disabling, and 

possibly preventable illness with significant biological, psychological, and social-spiritual components.6

The risk for PTSD rises in direct proportion to the 

level of exposure to combat,7 and the symptoms of 

PTSD and other stress-related mental disorders are 

clearly present in personnel in deployed operational 

settings.8 Also, the overlap between PTSD and mild 

traumatic brain injury, both in symptoms and underlying brain pathology, argues for adopting similar 

approaches to recognizing and managing these two 

separate but related health problems.9 Furthermore, 

PH protection efforts based on previous, demedicalized models have failed to prevent significant 

postdeployment PTSD in veterans of the wars in 

Vietnam10–14 and Iraq.7,15,16

In recent years, operational commanders in the 

US Marine Corps and Navy have collaborated with 

mental health and religious ministry professionals to 

develop new PH protection tools for the operating 

forces. Based on the science of preventive medicine and 

the art of leadership, these tools have been crafted to 

fit the needs of commanders and subordinate leaders 

at all levels. The most basic of these tools is the combat 

and operational stress continuum doctrinal model 

(also known as the stress injury continuum model, 

as described in Chapter 8, Expeditionary Operational 

Stress Control in the US Navy).

COMBAT AND OPERATIONAL STRESS CONTINUUM

Background and Development

The February 1996 Department of Defense (DoD) 

inspector general report on combat stress control in the 

military defined comprehensive COSC as consisting of 

three key activities—(1) prevention, (2) identification, 

and (3) treatment—to be applied before, during, and 

after deployment.17 Three years later, DoD directed all 

services to implement COSC programs that included 

these key activities.18 However, the imperative to 
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US Marine Corps and Navy Combat and Operational Stress Continuum Model: A Tool for Leaders

implement PH prevention, identification, and treatment based on the normalizing, demedicalized model 

has posed two challenges:

1. If all reactions to stress in operational environments are truly “normal,” then what is there 

to prevent and treat? After all, normality is 

neither prevented nor treated. 

2. If all reactions to stress are normal, whereas 

PTSD and other stress-induced mental disorders are clearly not normal, where is the 

line to be drawn between them? Where does 

normality end and pathology begin?

To meet these challenges, the bridging concept of 

“stress injuries” was developed in the Marine Corps in 

2004.19 Independently, and for similar reasons, the term 

“operational stress injury” had been established in 

the Canadian Forces by Lieutenant Colonel Stephane 

Grenier, a veteran of the 1994 United Nations mission 

to Rwanda.20 The validity of the idea that overwhelming or persistent stress can inflict literal injuries to the 

brain, mind, and spirit is supported by two lines of 

reasoning. First is the argument that the only alternative to acknowledging that humans can be literally 

injured by stress is to posit that human brains, minds, 

and spirits are invincible and unbreakable regardless 

of the forces acting on them, which cannot be true because the mind and brain are material living systems 

that are susceptible to damage, senescence, and death.

The second argument is based on the assertion that 

some (though not all) stress responses or outcomes in 

operational environments fully meet the definitions 

of the terms “injury” or “wound” as commonly used 

in medical and nonmedical discourse.21 In common 

usage, an injury can be defined as something that

	 •	 happens to a person rather than being chosen,

	 •	 involves a loss of normal integrity,

	 •	 causes at least a temporary loss of function,

	 •	 provokes predictable self-protective and healing responses, and

	 •	 cannot be undone, although it usually heals

over time.

The element of volition in this definition, when 

applied to stress outcomes, is hard to prove; there is a 

long tradition of viewing all stress “responses” as chosen by the individual on at least an unconscious level. 

However, the universal experience of individuals who 

experience traumatic stress involving terror, horror, 

or helplessness is one of being acted upon rather than 

acting. In fact, it may be that the loss of volition during 

a traumatic event partly defines it as traumatic. Furthermore, the most disabling symptoms of unhealed 

traumatic stress, such as panic attacks, flashbacks, and 

rage outbursts, are disabling to the extent they cannot 

be predicted or prevented by conscious choice. 

The second element in the list, loss of integrity, is 

certainly not externally evident in the same way that 

loss of the integrity of skin or bone is obvious in the 

case of physical injury. However, the preponderance 

of evidence from preclinical studies suggests that 

acute or chronic stress can cause a loss of the normal 

integrity of the neurobiological systems necessary 

for effectively coping with stress, particularly those 

responsible for regulating arousal and emotional 

intensity.6

 And the integrity of necessary and deeply 

held beliefs and attachments are clearly compromised 

by trauma or loss.6

The loss of function caused by a stress injury, 

the third listed item, is likely the most evident and 

observable feature, although sometimes only to stressinjured individuals themselves, or those closest to 

them. Little is known about normal self-protective 

and healing responses to stress injuries (the fourth 

item listed), but included in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, diagnostic 

criteria for PTSD and acute stress disorder are the 

characteristic avoidance of reminders of traumas 

and efforts to reduce excessive arousal through 

isolation.22

Finally, the assertion that stress injuries cannot be 

undone, although also not yet convincingly shown 

empirically, is strongly supported by the characteristic 

and lasting vulnerabilities (or increased growth, in 

many cases) demonstrated by individuals following 

acute traumatic stress or stress-induced depressive or 

anxiety disorders.19 Certainly, traumatic memories and 

losses of close comrades cannot be undone.

The concept of stress injuries, as a bridging construct between reversible stress reactions at one end 

of the stress response spectrum and stress illnesses at 

the other, has gained partial acceptance in the US sea 

services. Analogous to physical injuries, stress injuries 

may be seen as less the fault of the individual than how 

they are considered in the demedicalized model, which 

implied that disabling and persistent stress reactions 

were due to preexisting weakness.3

 However, in 2007, 

the commanding generals of the three Marine Expeditionary Forces expressed concern that a doctrine based 

on the stress injury conception could be problematic 

if it did not give sufficient attention to promoting and 

restoring resiliency before stress reactions progressed 

to become injuries, or injuries became illnesses. Therefore, in September 2007, the three forces convened a 

working group including line commanders, senior 

enlisted leaders, chaplains, medical and mental health 

professionals, and Marine Corps Headquarters policy 
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Combat and Operational Behavioral Health

makers. The resulting discussion yielded the combat 

operational stress continuum model, Figure 7-1, which 

has since become the foundation for all PH and COSC 

doctrine, training, and early interventions in both the 

Marine Corps and Navy.23

The continuum model is a paradigm that recognizes 

the entire spectrum of stress responses and outcomes, 

from adaptive coping and full readiness (color-coded 

green as the “ready” zone), to mild and reversible distress or loss of function (the yellow “reacting” zone), to 

more severe and persistent distress or loss of function 

(the orange “injured” zone), to clinical mental disorders arising from stress and unhealed stress injuries 

(the red “ill” zone). 

Ready: The Green Zone

The green “ready” zone can be defined as encompassing adaptive coping, effective functioning in all 

spheres, and personal well-being. The green zone is 

not conceived to represent the absence of stress, but 

rather its effective mastery without significant distress 

or impairment. One important goal of all selection, 

training, and leadership in the military is to promote 

green zone readiness, or to restore individuals and 

units to the green zone once they have experienced 

distress or loss of function because of stress. The ability 

to remain in the green zone under stress, and to return 

quickly to it once impaired or injured by stress, are two 

crucial aspects of resiliency. Both individual service or 

family members and entire military or family units can 

be said to operate in the green zone.

The following are some of the attributes and behaviors characteristic of the green “ready” zone:

	 •	 remaining calm and steady;

	 •	 being confident in self and others;

	 •	 getting the job done;

	 •	 remaining in control physically, mentally, and

emotionally;

	 •	 behaving ethically and morally;

	 •	 retaining a sense of humor;

	 •	 sleeping enough;

	 •	 eating the right amount;

	 •	 working out and staying fit;

	 •	 playing well and often; and

	 •	 remaining active socially and spiritually.

Reacting: The Yellow Zone

The yellow “reacting” zone can be defined as 

encompassing mild and temporary distress or loss 

of function due to stress. By definition, yellow zone 

reacting is always temporary and reversible, although 

while stress reactions are occurring it is hard to know 

whether they will be temporary and leave no lasting scars. Yellow zone reactions can be inferred by 

their time course, relative mildness, and commonness. Although no research has yet been done on the 

prevalence of subclinical distress or loss of function 

in operational settings, it is likely that such yellow 

zone stress reactions may be extremely common, if not 

READY

DEFINITION

• Adaptive coping

• Effective functioning

• Well-being

FEATURES

• In control

• Calm and steady

• Getting the job done

• Playing

• Sense of humor

• Sleeping enough

• Ethical and moral behavior

REACTING

DEFINITION

• Mild and transient distress or 

 loss of function

FEATURES

• Anxious

• Irritable, angry

• Worrying

• Cutting corners

• Poor sleep

• Poor mental focus

• Social isolation

• Too loud and hyperactive

INJURED ILL

DEFINITION

• More severe and persistent 

 distress or loss of function

TYPES

• Trauma

• Fatigue

• Grief

• Moral injury

FEATURES

• Loss of control

• Can’t sleep

• Panic or rage

• Apathy

• Shame or guilt

DEFINITION

• Clinical mental disorders

• Unhealed stress injuries

TYPES

• PTSD

• Depression

• Anxiety

• Substance abuse

FEATURES

• Symptoms persist > 60 days 

 after return from deployment

Figure 7-1. The combat and operational stress continuum model with its four color-coded stress zones.

PTSD: posttraumatic stress disorder
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US Marine Corps and Navy Combat and Operational Stress Continuum Model: A Tool for Leaders

universal. Figure 7-2 depicts the time course of green 

zone adaptation and yellow zone reactions in the face 

of a new challenge such as an operational deployment 

or combat mission.19 As depicted in this diagram, the 

times of greatest risk for yellow zone stress reactions 

are just before or at the onset of a new challenge, and 

at the very end or immediately following that challenge.

The following experiences, behaviors, and symptoms may be characteristic of the yellow “reacting” 

zone:

	 •	 feeling anxious,

	 •	 worrying,

	 •	 cutting corners on the job,

	 •	 being short-tempered or mean,

	 •	 being irritable or grouchy,

	 •	 having trouble falling asleep,

	 •	 eating too much or too little,

	 •	 feeling apathetic or losing energy or enthusiasm,

	 •	 not enjoying usual activities,

	 •	 keeping to oneself,

	 •	 being overly loud or hyperactive,

	 •	 being negative or pessimistic, and

	 •	 having diminished capacity for mental focus.

Injured: The Orange Zone

The orange “injured” zone can be defined as encompassing more severe and persistent forms of distress or 

loss of function that may not completely reverse over 

time. Whereas yellow zone reactions, by definition, 

are like a tree branch bending with the wind—always 

capable of springing back into place once the wind 

calms—orange zone injuries, by definition, are like a 

branch breaking, to some extent, because it was bent 

beyond its limits. Although stress injuries cannot be 

undone, like physical injuries, their usual course is to 

heal over time. But as with physical injuries, healed 

stress injuries may leave behind a “scar”—a mental or 

physical remnant, vulnerability, or weakness that will 

likely fade but may never disappear. As with yellow 

zone stress reactions, the more lasting nature of stress 

injuries in the orange zone cannot be easily discerned 

in their early stages. However, stress injuries may be 

identified in their early stages both by the severity 

and persistence of the symptoms they provoke and 

the intensity of the stressors that cause them. Because 

stress injuries are not clinical mental disorders, they 

do not require clinical mental health expertise to recognize them, although operational commanders and 

small unit leaders rely heavily on their chaplains and 

organic medical personnel to identify and help take 

care of orange zone stress injuries.

Combat and operational stress injuries have four 

different possible mechanisms or causes19:

1. Life threat: exposure to life-threatening situations provoking terror, horror, or helplessness.

2. Wear and tear: the accumulation of stress 

from all causes, including from nonoperational sources, without sufficient sleep, rest, 

and restoration.

3. Loss: separation from cherished people, objects, or portions of oneself.

4. Inner conflict: carrying out or bearing witness to acts of omission or commission that 

violate or disrupt deeply held moral values 

and beliefs.

Although stress injuries may be caused by one or 

more of these four different mechanisms, the experiences, behaviors, and symptoms that characterize them 

are similar regardless of mechanism. They include

	 •	 losing control of one’s body, emotions, or

thinking;

	 •	 being frequently unable to fall or stay

asleep;

	 •	 waking up from recurrent, vivid nightmares;

	 •	 feeling persistent, intense guilt or shame;

	 •	 feeling unusually remorseless;

	 •	 experiencing attacks of panic or blind rage;

	 •	 losing memory orthe ability to think rationally;

Anticipation or

Alarm at Onset

of Challenge

HIGH

LOW

Rebound After

Challenge Ends

“In the Groove”

Time

Ready

End ofChallenge

Beginningof Challenge

Level of Distress

Reacting

Reacting

Figure 7-2. Time course of coping and adaptation to a new 

challenge.
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Combat and Operational Behavioral Health

	 •	 being unable to enjoy usually pleasurable

activities;

	 •	 losing grounding in previously held moral

values;

	 •	 displaying a significant and persistent change

in behavior or appearance; and

	 •	 harboring serious suicidal or homicidal

thoughts.

Ill: The Red Zone

The red “ill” zone can be defined as including all 

mental disorders arising in individuals exposed to 

combat or other operational stressors. Because red zone 

illnesses are clinical mental disorders, they can only 

be diagnosed by health professionals. However, commanders, other leaders, peers, and family members can 

and should be aware of the characteristic symptoms 

of stress illnesses. The most widely recognized stress 

illness is PTSD. However, stress illnesses may take 

many different forms, often co-occurring in the same 

individual at the same time or at different times. Common red zone illnesses include

	 •	 PTSD;

	 •	 depressive disorders, especially major depression;

	 •	 anxiety disorders, including generalized anxiety and panic disorder; and

	 •	 substance abuse or dependence.

Although the relationship between orange zone 

stress injuries and red zone stress illness has not yet 

been well studied, the presence of a stress illness 

should be strongly suspected whenever symptoms of 

a stress injury either do not improve or worsen even 

after removal of the sources of stress. Specific indicators for possible stress illnesses—and the need for 

mental health evaluation—include 

	 •	 stress injury symptoms or behaviors that do

not significantly improve within 60 days of 

returning from operational deployment;

	 •	 stress injury symptoms that worsen overtime

rather than improving;

	 •	 stress injury symptoms that return after improving or resolving; and

	 •	 significant and persistent distress or loss of

function that arises after removal from the 

sources of stress.

The 60-day duration threshold suggested above 

for diagnosing stress illnesses is somewhat arbitrary. 

However, it is believed to represent the best compromise between the competing priorities of quickly 

identifying problems that may not get better without 

clinical help, and hesitating to clinically label stress 

problems that may yet resolve on their own. Again, 

military leaders need not be concerned about whether 

particular service members do or do not suffer from 

diagnosable mental disorders, as much as whether the 

individuals warrant immediate referral to a mental 

health professional for evaluation of fitness for duty 

or treatment requirements.

FIVE CORE LEADER FUNCTIONS FOR PSYCHOLOGICAL HEALTH

The combat and operational stress continuum 

model is broad in its scope, encompassing all conceivable responses and outcomes to stress, both for service 

members and their families. Clearly, no one group of 

individuals can manage the entire stress continuum 

as defined. At the far left of the continuum—the green 

and yellow zones—the activities of line leadership 

predominate to promote resiliency. Here, prevention 

is paramount. At the far right of the continuum—the 

orange and red zones—medical and mental health 

professionals are most critical to providing necessary 

treatment. Chaplains act in operational units both to 

promote green zone resiliency and to recognize and 

respond to yellow, orange, and red zone reactions, 

injuries, and illnesses, including making appropriate 

referral decisions, although they usually cannot provide definitive treatment for stress injuries or illnesses. 

Individual service members and family members bear 

responsibility for maintaining their own psychological 

health across the stress continuum, including building their own resiliency, managing their own stress 

reactions, and recognizing and getting help for stress 

injuries and illnesses when needed. Even though managing the stress continuum requires the involvement 

and expertise of several groups of stakeholders, the 

overall PH promotion effort remains the primary responsibility of operational commanders, as previously 

stated. Line commanders and their subordinate small 

unit leaders are responsible for coordinating PH and 

COSC efforts across the stress continuum to preserve 

both fighting strength and the long-term health and 

well-being of service members and families.

The Marine Corps and Navy have identified five 

core leader functions for the promotion of PH across 

the stress continuum: (1) strengthen, (2) mitigate, (3) 

identify, (4) treat, and (5) reintegrate. These five core 

leader functions are defined below as the context 

within which the stress continuum model is utilized.
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US Marine Corps and Navy Combat and Operational Stress Continuum Model: A Tool for Leaders

Strengthen Service Members

Building resiliency in individuals, units, and families is the first core PH function of military leaders. 

Individuals enter military service with a set of preexisting strengths and vulnerabilities based on genetic 

makeup, prior life experiences, personality style, family supports, and a host of other factors that may be 

largely immutable. However, centuries of experience 

in military organizations, as well as a number of research studies, have demonstrated that commanders 

of military units can do much to enhance the resilience 

of unit members and their families. Activities available 

to commanders to strengthen their troops fall into 

three main categories: (1) training, (2) unit cohesion, 

and (3) leadership.

Training

Tough, realistic training develops physical and 

mental strength and endurance, enhances service 

members’ confidence in their ability as individuals 

and as members of units to cope with the challenges 

they will face, and inoculates them to future stressors. 

Exactly how preexposure to stress enhances hardiness 

is not well understood, but emerging evidence suggests that resilience secondary to stress inoculation 

has both psychological and biological components. 

Hardy service members have lower heart rates and 

higher levels of peptides in the brain that are essential 

for staying calm in the face of severe stress.24 They also 

face familiar challenges with greater confidence and 

less anxiety-induced loss of mental focus or dissociation.25 One particular challenge for unit leaders is to 

deliver training that is tough and realistic enough to 

build resilience, without making it so tough that it 

inflicts orange zone injuries on the training field.

Unit Cohesion

Unit cohesion, defined broadly as mutual trust 

and support in a social group, is developed through 

sharing adversity over time in a group with a stable 

membership. Two-way communication, both horizontally among peers and vertically between leaders and subordinates, is essential to unit cohesion. 

Seamless teamwork is a well-known outcome of 

unit cohesion. Less well known is how membership 

in a cohesive unit strengthens unit members against 

the damaging effects of stress, but it is likely that 

unit cohesion has both biological and psychological 

impacts. As psychiatrist and author Jonathan Shay 

has repeatedly pointed out, “the human brain codes 

social recognition, support, and attachment as physical safety.”26(p210) Most leaders know how to build 

cohesive units given enough time and unit stability, but an all too common challenge is to maintain 

unit cohesion in the face of rotations into and out of 

the unit, including casualties and combat replacements. Certainly, the unit rotation policies currently 

practiced in the US military are more conducive to 

unit cohesion than the individual rotations common 

during the Vietnam era, but individual augmentees 

and members of reserve or National Guard units may 

still be disadvantaged in this important component of 

resilience. Another challenge for unit leaders is how to 

forge mutual trust and peer support among families 

left behind; they are no less part of the unit than the 

active duty service members who deploy in cohesive 

units, but they often have much less opportunity to 

develop social cohesion with other families.

Leadership

Although complex and multifaceted, leadership 

is an essential factor for the strengthening of unit 

members and families. Unit members are strengthened by leaders who teach and inspire them, keep 

them focused on mission essentials, instill confidence, 

and provide a model of ethical and moral behavior.27

Another crucial way in which leaders enhance the 

resilience of their unit members is by providing a 

resource of courage and fortitude on which unit 

members can draw during times of challenge.28,29 The 

influence leaders have over their subordinates is a 

sword that can cut both ways—leaders who are in the 

yellow, orange, or red zones themselves may become 

detriments to their units unless their own stress is 

effectively managed.

Mitigate Stressors

Because no service member, however strong and 

well prepared, is immune to stress, the prevention of 

stress injuries and illnesses requires continuous mitigation of the stressors to which individuals and units 

are exposed. Optimal mitigation of stress requires 

balancing competing priorities. On one side is the 

intentional subjection of service members to stress in 

order to train and toughen them, and to accomplish 

assigned missions while deployed. On the other side 

are the imperatives to reduce or eliminate stressors 

that are not essential to training or mission accomplishment, and to restore the biological, psychological, social, and spiritual resources for resilience that 

are depleted under stress. As depicted in Figure 7-3, 

each individual’s stores of resources for resilience can 

be likened to a leaky bucket constantly being drained 
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Combat and Operational Behavioral Health

Physical 

resources

Mental

resources

Social

resources

Spiritual

resources

Unit and

 family members

 as containers

 of resources

Resources continually drained away by stress

Figure 7-3. “Leaky bucket” metaphor for stress. Each individual’s stores of resources for resilience are continually 

depleted by stress, as if contained in a leaky bucket.

by stress. To keep it from running dry, it must be constantly refilled through sleep, rest, and other forms of 

replenishment. 

Mitigation is a prevention activity, aimed at keeping 

unit members in the green “ready” zone in the face of 

operational challenges, and to return them to the green 

zone after yellow zone reactions. A few of the tactics 

that can be used by unit leaders to mitigate stress are 

the following:

	 •	 ensure and enforce adequate sleep—7 hours

per day for most people;

	 •	 ensure physical fitness and recreation;

	 •	 encourage spiritual fitness and religious participation;

	 •	 enforce ethical standards and the “rules of

war”;

	 •	 rotate units to the rear periodically forrest and

replenishment, if possible;

	 •	 rotate individual assignments to reduce boredom and complacency;

	 •	 protect unit members from scenes of gore

whenever possible;

	 •	 anticipate and discourage excessive self-blame

(guilt or shame); and

	 •	 use after-action reviews to give meaning to

sacrifices and losses.

Identify Stress Reactions, Injuries, and Illnesses

Even the best PH prevention efforts cannot eliminate all stress problems that might have an effect on 

occupational functioning or health. Therefore, effective 

PH protection requires continuous monitoring of stressors and stress outcomes. Operational leaders must 

know the individuals in their units, including their 

specific strengths and weaknesses, and the nature of 

the challenges they face both in the unit and in their 

home lives. Leaders must recognize when individuals’ 

confidence in themselves, their peers, or their leaders 

is shaken, or when units have lost cohesion because 

of casualties, changes in leadership, or challenges to 

the unit. Most importantly, every unit leader must 

know which stress zone each unit member is in at 

every moment, every day. Service members cannot be 

depended upon to recognize their own stress reactions, 

injuries, and illnesses, particularly while deployed to 

operational settings. The external focus of attention 

and denial of discomfort necessary to thrive in an arduous environment also make it harder to recognize 

a stress problem in oneself. And stigma can be an 

insurmountable barrier to admitting stress problems 

to someone else. Therefore, the best and most reliable 

method of ensuring that everyone who needs help 

gets it is for small unit leaders to continually watch 

out for their subordinates, and for peers to watch out 

for each other.

To help with this crucial stress zone assessment 

function, the Marine Corps and Navy have developed 

the combat and operational stress decision flowchart, 

Figure 7-4. The flowchart is made up of just four questions. The first is whether there are signs of distress 

or loss of function, both of which are briefly defined 

with examples. In the continuum model and decision 

flowchart, the threshold for recognizing yellow zone 

reactions is set intentionally low. In other words, to 

qualify as “distress” or “loss of function,” subjective 

feelings of uneasiness or observable behaviors that 

interfere with optimal function need not be profound, 

but merely noticeable. The point is to recognize yellow zone stress reactions early and consistently so 

they can be monitored and mitigated by leaders, 

chaplains, and medical support personnel before they 

progress to orange zone injuries. This is not to say that 

service members in the yellow zone cannot be pushed 

harder—just that they may require reassessment 

and at least stress mitigation as soon as operational 

requirements permit.

If neither distress nor loss of function is present, 

then the individual is judged to be in the green zone, 

and no further action is required other than continuing to monitor for stress. If either distress or loss of 
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US Marine Corps and Navy Combat and Operational Stress Continuum Model: A Tool for Leaders

Green Zone (Ready):

• Continue to monitor for signs of 

 distress or loss of function in 

 the future

Service Member Under Stress

Distress or Loss of Function:

•Difficulty relaxing and sleeping

•Loss of interest in usual activities

•Unusual and excessive fear, worry, or anger

•Recurrent nightmares or troubling memories

•Hyperactive startle responses to noises

•Difficulty performing normal duties

•Any change from normal personality Yellow Zone (Reacting):

•Ensure adequate sleep and rest

•Manage home-front stressors

•Discussions in small units

•Refer to chaplain or medical if 

 problems worsen

Is the distress 

or loss of function

SEVERE?

Orange Zone (Injured):

•Keep safe and calm

•Rest and recuperation 24–72 h

•Refer to medical or chaplain

•Mentor back to full duty and 

 function

Has the distress

or loss of function

PERSISTED?

Red Zone (Ill):

•Refer to medical

•Ensure treatment compliance

•Mentor back to duty if possible

•Transition to VA if necessary

SEVERE Distress or Loss of Function:

•Inability to fall asleep or stay asleep

•Withdrawal from social activities

•Uncharacteristic outbursts of rage or panic

•Nightmares or memories that increase heart rate

•Inability to control emotions

•Serious suicidal or homicidal thoughts

•Loss of usual concern for moral values

PERSISTENT Distress or Loss of Function:

•Stress problems that last for more than 60 days

 postdeployment

•Stress problems that don’t get better over time

•Stress problems that get worse over time

Are there signs

of DISTRESS or

LOSS OF

FUNCTION?

{

{

{

NO

NO

NO

YES

YES

YES

Figure 7-4. The combat and operational stress decision matrix flowchart.

VA: Department of Veterans Affairs

function is present, the individual is at least in the 

yellow “reacting” zone, and the next question to be 

answered is whether distress or loss of function is 

severe. The decision about whether distress or loss of 

function is severe is admittedly one of the most challenging judgments to be made in the decision matrix, 

but it is also one of the most important. By definition, 

stress responses that involve severe distress or loss of 

function are at least in the orange zone—at least stress 

injuries, if not diagnosable stress illnesses. These are 

stress outcomes that may significantly interfere with 

effective occupational functioning, may persist or 

leave a mental or emotional “scar,” and may confer 

increased risk for long-term mental health problems. 

Because of these risks associated with orange and red 

zone stress, it is imperative that unit leaders quickly 

and consistently identify service members with severe distress or loss of function that places them in 

these two zones. Orange and red zone stress injuries 

and illnesses all potentially benefit from care and 

treatment, and all deserve to be closely monitored to 

ensure recovery. 

If severe distress or loss of function is present, the 

next question—whether these severe stress symptoms have persisted long enough to meet criteria for 

diagnosis of a clinical mental disorder—is not as crucial for operational commanders to answer. Clinical 

medical and mental health professionals are normally 
116

Combat and Operational Behavioral Health

consulted to help form that judgment. However, the 

importance to commanders of having a service member in the red zone is significant because a number of 

important leader decisions follow, including whether 

the red zone service member is fit to deploy or remain 

deployed, and whether and how soon the individual 

can be mentored back to full duty after receiving 

treatment.

Treat Stress Injuries and Illnesses

As in the case of physical injuries and illnesses, 

available tools for the treatment of stress injuries and 

illnesses exist along a broad spectrum, including: 

(a) self- or buddy-applied aid; (b) supportive care 

and advanced aid from a buddy, leader, chaplain, or 

family member; and (c) definitive psychological or 

medical treatment. Although some of these forms of 

treatment can clearly be delivered only by a trained 

medical or mental health provider, others require 

little special training and can be provided by a small 

unit leader, peer, or spouse. However, as with the rest 

of the core functions required to manage the combat 

and operational stress continuum, the primary responsibility for ensuring that every service member 

receives the appropriate level of care for orange zone 

injuries or red zone illnesses rests with operational 

commanders.

Combat and Operational Stress First Aid

The core principles for immediate, preclinical care 

of stress injuries, like those for first aid of physical 

injuries, are built on a simple hierarchy of three priorities: (1) sustain life, (2) minimize further damage, and 

(3) decide whether further care is needed. For physical first aid, life is sustained through the “ABCs” of 

basic life support or cardiopulmonary resuscitation—

airway, breathing, and circulation—and further damage is minimized through the cleaning and covering 

of wounds, rest, immobilization, and other basic 

protective actions. To provide military personnel and 

their families a set of procedures for the care of stress 

wounds analogous to those of physical first aid, the 

Navy, Marine Corps, Defense Centers of Excellence 

for Psychological Health and Traumatic Brain Injury, 

and the Veterans Affairs (VA) National Center for 

PTSD collaborated to develop combat and operational 

stress first aid (COSFA),30 based on the evidence-based 

principles and procedures of psychological first aid 

previously created by the National Child Traumatic 

Stress Network and the National Center for PTSD.31

The seven core components (the “seven Cs”) of COSFA 

are as follows: 

1. Check: assess continuously for distress or 

changes in functioning suggestive of a possible stress injury and need for further intervention; reassess after every intervention; 

continue to assess for delayed or persistent 

problems.

2. Coordinate: continuously inform those who 

need to know, such as leaders or family 

members, about identified stress problems; 

enlist further help from others, as indicated; 

and ensure that help is obtained.

3. Cover: ensure the safety (get to cover) of those 

experiencing acute distress or alterations in 

functioning, and ensure the safety of others 

until normal functioning returns.

4. Calm: reduce the intensity of physiological 

arousal (heart rate and blood pressure) and 

potentially destructive emotions such as 

fear or anger; practice deep, diaphragmatic 

breathing, mental grounding, and other relaxation techniques.

5. Connect: ensure peer support in the aftermath of a stress reaction, injury, or illness; 

restore normal unit or family cohesion as a 

protective and healing factor; listen empathically and reassure.

6. Competence: restore capabilities and effectiveness in all areas of function, including 

occupational, family, and other social function; mentor back to full duty, if possible.

7. Confidence: restore self-esteem and the trust 

of others in the unit and family in the aftermath of a stress reaction, injury, or illness; 

restore hope. 

Definitive Psychological or Medical Treatment 

Definitive clinical care can be delivered in forward 

operational settings by mental health professionals, 

such as those attached to Marine Corps Operational 

Stress Control and Readiness (OSCAR) teams,32 or it 

can be delivered in higher echelon treatment facilities 

in theater or in garrison. The principles of evidencebased care for traumatic stress injuries and illnesses, 

including PTSD, are contained in the current VA/DoD 

clinical practice guideline for the treatment of posttraumatic stress.33 Some of these treatment principles 

can be applied only by a mental health specialist, 

but others can be delivered by primary care providers organic to, or in support of, operational units. 

Regardless of who delivers definitive clinical care, 

the crucial role of operational commanders and their 

subordinate small unit leaders in this segment of the 

treatment continuum is to ensure that treatment is 
117

US Marine Corps and Navy Combat and Operational Stress Continuum Model: A Tool for Leaders

afforded to all service members who need it, and that 

barriers to care such as stigma and ongoing training 

or operational time commitments do not preclude 

care. The earlier stress-injured or ill service members 

receive definitive clinical care, the more likely they are 

to recover quickly and fully. Operational commanders bear great responsibility for reducing the stigma 

associated with receiving mental healthcare because 

of their influence on the attitudes and behaviors that 

underlie stigma.

Reintegrate Stress Casualties

As stated above, the normal course for a stress 

injury, as for a physical injury, is to heal over time. 

The vast majority of these injuries do heal, with or 

without treatment. Similarly, the normal course for a 

stress illness, especially if properly treated, is to improve significantly over time, perhaps even to remit. 

For example, of all active duty marines diagnosed 

and treated for PTSD between the start of the war in 

southwest Asia in 2003 and the end of 2006, fewer 

than 10% received a medical disability discharge for 

PTSD.34 Therefore, operational commanders face one 

final challenge in their management of service members treated for stress injuries or illnesses—that of 

continually monitoring their fitness for duty, including 

worldwide deployment, and mentoring them back 

to full duty as they recover. This is the challenge of 

reintegration. For stress casualties to be effectively 

reintegrated in their units, stigma must be continually addressed. Confidence in stress casualties, both 

in themselves and their peers and small unit leaders, 

must be restored. This process may take months to 

bring to successful conclusion, for recovery from a 

stress injury or illness can take several months. In 

cases in which substantial recovery and return to full 

duty is not anticipated, the challenge for operational 

commanders is to assist service members as they 

transition to civilian life and VA care.

SUMMARY

The US Marine Corps and the US Navy, in collaboration with the Defense Centers of Excellence 

for Psychological Health and Traumatic Brain Injury, 

have developed and adopted a new model for the 

promotion of psychological health in service members 

and operational units based on the health sciences 

and leadership arts. The core of this new paradigm—

the combat and operational stress continuum—

recognizes that stress responses and outcomes occur 

across a broad spectrum, whose zones can be color 

coded green (for “ready,” adaptive coping); yellow 

(for “reacting,” mild and reversible distress or loss 

of function); orange (for “injured,” more severe and 

persistent distress or loss of function); and red (for 

“ill,” a diagnosable mental disorder). Although chaplains and medical and mental health professionals 

are important for the management of yellow, orange, 

and red zone stress, operational commanders and 

small unit leaders bear primary responsibility for the 

effective management of the entire stress spectrum. 

The five core psychological health leader functions 

developed by the Marine Corps and Navy are: (1) 

strengthen, (2) mitigate, (3) identify, (4) treat, and (5) 

reintegrate.

The new PH and COSC model described in this 

chapter has gained traction in the Marine Corps and 

Navy partly because it reduces stigma and demystifies 

aspects of PH promotion. It has also gained acceptance because it forms an effective bridge between the 

worlds of the troops, the chaplain, the family member, 

and the medical or mental health professional. Only 

through a shared language and set of tools can all these 

stakeholders combine forces to address the challenges 

posed by warfare to the psychological health of service 

members and their families.

The stress continuum model and associated core 

leader functions described in this chapter have not 

yet been empirically tested, although they are solidly 

informed by scientific evidence. It is anticipated that 

empirical evaluation will validate some aspects of 

the model while suggesting improvements to other 

aspects. Regardless of these outcomes, the approach 

to combat and operational stress described here lends 

itself more fully to empirical assessment than previous models based on a less medical view of adverse 

stress outcomes.

Acknowledgment

The author wishes to thank Brett Litz, Patricia Watson, Mark Smith, Jeffrey Rhodes, and Eduardo Leardo 

for helpful comments on the manuscript.
118

Combat and Operational Behavioral Health

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