Headquarters Marine Corps

Combat and Operational 

Stress Control (COSC) 

Managing 

Combat & 

Operational 

Stress

A Handbook for Marines & Families
“Combat and operational stress can render any 

Marine incapable of focusing on the mission at hand. 

It impacts everyone, from the Marine’s family to the 

unit as a whole. This issue must be at the forefront 

of our commitment to take care of one another.

You, as leaders, are the key. It is important that each 

leader in our Corps learns how to better recognize and 

deal with combat and operational stress. Talk about it 

with your Marines.

Set the example on how to deal with it. Let your 

Marines know that it’s okay to get help so that they 

can get back in the fight. Then help them to do so.”

— General James F. Amos

Commandant of the Marine CorpsPhoto by GySgt Scott Dunn
Managing Combat & Operational Stress A Handbook for Marines & Families 1

Unique stresses of military life 2

What is Stress?

Stress and military life

Operational stress

Stress reactions in a war zone

How to better enjoy life 4

Happiness is a decision made daily

Recreation is important

Giving service

Personal growth from stress or deployment 6

Thinking styles

Create a personal resume

Consider possibilities of posttraumatic growth

Setting goals

Take care of your body 8

Eat a healthy, balanced diet

Regular exercise

Focus on form

Making safe choices, reconnecting with others 10

Consider moving if you live in an unsafe neighborhood

Get help to leave an abusive relationship

Limit exposure to traumatic stories in the media

Constructive worrying

Manage finances to reduce stress

Consider joining a self-help group

Make relationships a priority

Relaxation techniques decrease stress on your 

mind and body, and improve physical performance 12

Consciously pay attention

Deep breathing

Meditation

Other ways to relax

Spirituality and building resilience 14

Spirituality

Prayer

The Marine Corps will help

Letting go of anger 16

Anger can be helpful

Get help for managing anger

Pre-emptive strategies

Someone coping with severe stress may 

experience behavior or personality change 18

Someone with a stress injury

Don’t be your own enemy

Self-harm

Using alcohol and drugs can make any

combat or operational stress issue worse 20

Alcohol and other drugs are not a way to cope

Make a change plan

Facts about addiction

Your health care provider may 

recommend various treatments 22

Psychotherapy

Medication

Traumatic Brain Injury (TBI)

and Posttraumatic Stress (PTS) 24

TBI and PTS reactions

Healing stress illness

Coping with stress issues 26

Positive coping

Negative coping

Stigma

For friends and family 28

Effective communication is important

Ways you can help

Offer support and safety

Relationship maintenance

Maintain routines

Be kind to yourself

Sources of help and information 30

Operational Stress Control and Readiness (OSCAR) teams

DSTRESS 

Marine Corps Family Services

Military OneSource

Defense Centers of Excellence (DCoE) Outreach Center 

Psychological Health Outreach Program (PHOP)

National Guard Support Center

Veterans Affairs

American Red Cross

Real Warriors Campaign

Afterdeployment.org

HQMC Combat & Operational Stress Control (COSC)

Behavioral Health Information Network (BHIN)

Human Performance Resource Center (HPRC)

Managing Combat & Operational Stress

Contents

Ignoring a stress issue won’t make it go away and can make problems worse.

Stress issues are manageable and like physical injuries, treatable. Getting help is the key for Marines and veterans with combat or 

operational stress issues to move forward. The symptoms don’t define your capabilities or your future.

If you have, or think you have, a combat or operational stress injury, including posttraumatic stress (PTS), you shouldn’t go through it alone. 

This handbook provides strategies and resources to strengthen against future stress, mitigate current stress, and address the impacts of stress.
Any Marine can have an adverse reaction to stress.

What is stress?

Stress is a normal response to 

life changes — even positive 

ones. Stress is necessary to build 

strength. Most military training is 

based on using stress in controlled 

situations to strengthen resilience. 

This is a use of posttraumatic 

growth (described on page 6).

Everyone feels stress sometimes. 

But, too much stress can interfere 

with daily life. The negative impacts 

of stress can include:

� Physical problems, such as 

headaches, upset stomach or 

high blood pressure.

� Poor concentration, trouble 

making decisions, problems 

remembering things.

� Feeling anxious, frustrated, angry 

or depressed.

Stress and military life

Marines and their families face 

challenges everyday. Unique military 

life stressors include:

� Dislocation caused by frequent 

moves; having to repeatedly 

establish a household and 

routine. 

� Separation from friends, 

relatives and support network. 

� Concerns for Marine’s safety 

during training or deployment.

� Deployments cause additional 

stress due to increased 

workload, long workdays or 

unpredictable hours. 

� Requirements to organize 

personal affairs (including 

legal or financial) prior to 

deployment.

� Family separations and difficulty 

staying in contact with Marine—

even in noncombat areas.

� Multiple separations during 

training or deployment can make 

family and parenting routines 

difficult. 

� Marines may experience combat 

or operational stress. 

Operational stress

Marines have tough and challenging 

duties—even in noncombat areas. 

Experience or consequences of 

military operations other than 

combat can cause changes in 

physical or mental functioning or 

behavior. These changes can be 

positive. Operational stress can take 

place during peacetime or war and 

on land, at sea or in the air. Combat 

adds additional stressors.

Stress reactions in a 

war zone

are common and nearly all Marines 

will become stronger and quickly 

It’s important to recognize signs of 

combat or operational stress in yourself 

and in others. The stress continuum is 

a tool designed to help identify levels of 

stress.

Green Zone (Ready)

Marines in the Green Zone adapt to 

cope with stressors and continue to 

function well. This is not the absence 

of stress but a mastery of it to enable 

effective functioning. 

Signs of a Ready Marine:

• Remaining calm and steady

• Being confident in oneself and 

others

• Getting the job done

• Remaining in control physically, 

mentally and emotionally

• Behaving ethically and morally

• Sleeping enough

• Eating well and the right amount

• Working out and staying fit

• Retaining a sense of humor

• Playing well and often

• Remaining active socially and 

spiritually

• Being at peace with oneself.

Yellow Zone (Reacting)

Marines in the Yellow Zone feel mild 

and temporary distress or loss of 

function due to stress. Yellow Zone 

reactions are always temporary 

and reversible and are common, 

usually in response to something 

new. All training enhances skills and 

abilities through repeated exposure 

to intentionally stressful situations. 

Yellow Zone reactions can be 

recognized by their short duration 

and relative mildness.

Signs of Stress Reaction:

• Feeling anxious or fearful

• Feeling sad or angry

• 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

• Losing some interest, energy or 

enthusiasm

• Not enjoying usual activities

• Keeping to oneself

• Being overly loud or hyperactive

• Being negative or pessimistic

• Diminished mental focus.

Orange Zone (Injured)

The Orange or “Injured” Zone has 

more severe and persistent forms of 

distress or loss of function, signaling 

some kind of damage to the mind, 

brain or spirit. Yellow Zone reactions 

tend to resolve once the stress ends, 

but Orange Zone injuries are like 

a break when bent beyond limits. 

Like physical injuries, stress injuries 

occur from the barely noticeable to 

the more serious that may not heal 

without professional treatment. Stress 

injuries may be recognized in their 

early stages by the severity of the 

Stress causes a range of reactions

Unique Stresses 

 of Military Life

2 Unique Stresses of Military Life
return to the fight. Those exposed 

to combat will react in some way 

(Yellow Zone). Pay close attention 

to these four stressors that tend to 

cause stress injuries (Orange Zone):

� Life threat. An immediate threat 

to your own life.

� Loss. The death of close 

comrades, leaders or other 

cared-for individuals.

� Inner conflict. Carrying out 

or bearing witness to acts or 

failures to act that do not align 

with your beliefs.

� Wear and tear. Lack of sleep, 

rest and restoration, and the 

accumulated effects of smaller 

stressors over time, such as from 

non-operational sources.

Stress injuries may be due to a 

combination of stressors. Specific 

causes include the following: 

� Life-threatening situations, such 

as being fired upon, ambushes 

or improvised explosive device 

(IED) blasts.

� The threat of radiological, 

biological, chemical or nuclear 

weapons.

� Death or serious injuries to 

peers.

� Friendly-fire incidents.

� Harsh living conditions.

� Overwork, fatigue and sleep 

deprivation.

Military situations besides 

combat can also cause stress 

reactions, including:

� Handling bodies and body parts.

� Taking care of the dying or 

seriously injured.

� Involvement in peacekeeping 

missions.

� Exposure to terrorist attacks.

� Being taken prisoner of war.

� Assuming responsibility for 

enemy prisoners of war.

� Cleaning up a war zone.

� Being sexually assaulted or 

harassed while on active duty.

� Witnessing training injuries.

Any Marine can have an adverse 

reaction to stress.

Even the most motivated and 

well-trained Marines can find 

themselves challenged by combat 

and operational stress. Some 

Marines can overcome these 

reactions on their own and some 

are going to need help.

Like physical injuries, stress-related 

issues heal over time. They differ 

in that stress-related issues are 

invisible, harder to recognize, and 

can carry greater stigma. Stressrelated issues are less likely to 

be voluntarily reported by those 

affected. Physical injuries and 

stress-related issues can heal more 

quickly and completely if they are 

acknowledged and taken care of. 

All Marines and veterans need to 

be alert for signs of stress reactions 

in themselves and in their fellow 

Marines.

symptoms and the intensity of the 

stressors that cause them. Because 

Orange Zone injuries may not resolve 

on their own, signs of a stress injury 

should always be considered for 

further evaluation. Those who are 

injured may not perform as expected 

and are at risk for future illnesses.

Signs of Stress Injury:

• Having difficulty falling asleep 

or staying asleep

• Waking up from recurrent, vivid 

nightmares

• Feeling persistent, intense guilt 

or shame

• Feeling unusually remorseless 

or emotionally cold

• Experiencing attacks of panic 

or blind rage

• Losing the ability to remember 

or think rationally and clearly

• Being unable to enjoy usually 

pleasurable activities

• Losing confidence in previously 

held moral values

• Displaying a significant and 

persistent change in behavior or 

appearance.

Red Zone (Ill)

Red is the zone of diagnosable 

mental disorders in individuals 

exposed to combat or other 

operational stressors. Red Zone 

illnesses are clinical mental disorders 

that can only be diagnosed by 

mental health professionals. 

Still, commanders, unit leaders, 

peers and family members should 

be aware of the signs of stress 

illnesses so they can identify them 

and make appropriate referrals 

as soon as possible. The most 

widely recognized stress illness 

is posttraumatic stress (PTS), but 

stress illnesses may take many 

different forms, often occurring at 

the same time in individuals. 

Other common Red Zone illnesses 

include depressive disorders, 

especially major depression; anxiety 

disorders to include generalized 

anxiety and panic disorder; substance 

abuse or dependence.

Signs of Stress Illness:

• Long-lasting and disabling 

distress or impairment of normal 

functioning

• Impairment that does not 

significantly improve within 

several weeks of returning from 

deployment

• Symptoms that worsen over time 

rather than improve

• Problems and issues that return 

after improving or seeming to 

resolve.

All these symptoms are in relation 

to a Marine’s normal demeanor 

and activities; look for changes 

in behavior.

Managing Combat & Operational Stress A Handbook for Marines & Families 3
Happiness is a 

decision made daily, 

but sometimes you need help. 

Most people tend to be moderately 

happy most of the time. You cannot 

expect to be completely happy all 

the time. You can expect to bounce 

back from your lows. Happier 

people are healthier and more 

productive at work. You do not have 

to make major changes in your life 

to be happier; small adjustments in 

routine and habits are easier and 

usually more successful.

Everyone experiences stress; you 

can learn to manage it and enjoy 

life. Uncontrolled stress can be 

overwhelming; identify realistic 

goals (see page 7) and take action 

to reduce overall levels of stress.

There are positive responses to 

stress, humor is a great way to let 

go and feel good. Watch a funny 

movie, see a comedy show or share 

a joke with someone.

Pace yourself

Take things slowly. You don’t have 

to do everything at once. Taking 

small steps will soon result in big 

changes.

Stress is natural and it can be a 

motivator to protect ourselves or 

solve problems. It is when stress 

is larger than the reality of the 

problem, when fears hold you back 

from solving issues, or when stress 

is constant or overwhelming, that 

professional help is required.

The stress continuum (see pages 

2-3) helps identify levels of stress. 

If signs are severe, not getting 

better or lead to thoughts of hurting 

yourself or others, seek help 

from a health care professional 

immediately.

Recreation is 

important

It is tempting to stop doing onceenjoyable activities when feeling 

down and unmotivated. But, 

becoming less active can lead to 

feeling less and less like doing 

anything. Hobbies can help reduce 

stress, lift your mood and increase 

self-esteem (see

pages 8-9).

4 How to Better Enjoy Life

How to better 

 enjoy life

They may be “on alert.” Many people with stress injuries 

feel they need to be on guard looking out for danger, 

that makes it difficult to have restful sleep. Alertness may 

cause trouble falling asleep, as well as sensitivity to noise 

that may cause you to wake easily. 

They may worry or have negative thoughts. Thoughts 

can make it difficult to fall asleep. People with stress injuries 

often worry about general problems or feel they are in 

danger. If often troubled getting to sleep, they may start to 

worry that they won’t be able to fall asleep. These thoughts 

can keep you awake. 

They may use drugs or alcohol. Some people with 

stress injuries sometimes use drugs or alcohol to help in 

coping with their symptoms. Using too much alcohol can 

get in the way of restful sleep. Alcohol and other drugs 

change the quality of sleep and makes it less refreshing. 

They may have recurring thoughts or nightmares.

Nightmares are common for people after traumatic 

events. Interruptions from nightmares and thoughts 

make sleep less restful. Frequent nightmares may make 

it difficult to fall asleep due to fear of having another 

nightmare. 

They may have medical problems. Medical problems 

commonly found in people with stress injuries such as 

chronic pain or stomach problems, can make going to 

sleep difficult.

Here are things to do to make sleeping well more likely: 

Change your sleeping area. Create a quiet, comfortable 

sleeping area without noise, or the distractions of too 

much entertainment, like TV. 

Keep a bedtime routine and sleep schedule. Have 

a calming bedtime routine and a set wake-up time to 

help the body get used to a sleeping schedule. Other 

members of the household can help. 

Try to relax if you can’t sleep. Imagine a peaceful scene 

and focus on being in a relaxing place. Get up and do a 

quiet activity, such as reading, until you feel sleepy. 

Watch your activities during the day.

� Exercise early in the day.

� Limit caffeine, tobacco and alcohol, especially before 

bedtime.

� Don’t take naps.

� Don’t drink any liquids if you wake up often because 

you have to go to the bathroom.

� Avoid taking medicine that may keep you awake.

Talk to your doctor. A professional can help if you can’t 

sleep because you are in pain, have an injury, feel anxious 

at night; you often have bad dreams or nightmares.

Why do people with stress injuries 

have sleep problems?

What can you do if you have 

trouble sleeping?
Making yourself stay active and 

enlisting the company of others can 

help you gradually enjoy activities 

again.

Sharing recreational activities 

with others is an important part 

of developing supportive social 

networks which have been shown 

to help recovery (see pages 28-29).

Recreational and leisure time is 

one aspect of life where you are 

completely in control. It’s a time 

when you can really express 

yourself and what you enjoy in life.

It can also help develop strengths 

and interests while increasing 

energy and the ability to deal with 

challenges.

Giving service

can help you feel you have 

something to offer others, and it 

can help you reconnect with your 

community. Beyond informally 

helping family and friends, there 

are many opportunities to give your 

time and effort. 

By becoming a part of the 

Operational Stress Control and 

Readiness (OSCAR) team, you 

can help other Marines and sailors 

who have experienced combat or 

operational stress (see page 30).

Other ways to volunteer:

� At a school

� For a youth program

� At a homeless shelter

� By giving blood or helping 

arrange a blood drive

� At your church or place of 

worship.

Volunteer links:

� Redcross.org

� Specialolympics.org

� Habitat.org (Habitat for Humanity)

� Thousandsmiles.org

� Policevolunteers.org

Stay Active 

When experiencing stress-related 

issues, it is easy to forget about 

enjoyable activities. Or it may feel 

like nothing could be fun again. 

Make a plan to do at least one thing 

every day that makes you happy. 

Here is a list to start.

Social activities

� Visit family or friends

� Go out to eat with family or friends

� Join a club or attend a club meeting

� Participate in unit social activities

� Go to church socials or classes

� Join or coach a community sports 

team

� Join a walking or running group

� Go dancing

� Babysit

� Go on a date

� Hold or visit a garage sale

� Volunteer or do community service 

� Play pool or billiards

� Play board or card games

� Go golfing with friends

� Play in a band or sing in a choir

� Take art lessons

� Hire a personal trainer.

Active Recreation

� Camp, hike, rock climb or fish

� Garden or do yard work

� Go boating, kayaking, sailing

� Visit a national park

� Take a scenic road trip

� Plan a day trip or a vacation

� Water-ski, surf or swim

� Play a team sport

� Run, jog or bike

� Go horseback riding

� Go to a fair, zoo or amusement park

� Go to the movies

� Go to a comedy club

� Go to a museum, theater 

or concert

� Go to a college or professional 

sports event

� Try creative writing, blogging 

or journaling

� Fix a car, bike, motorcycle, etc.

� Play a musical instrument

� Start a collection

� Make art or a craft like 

woodworking

� Cook or take a cooking class.

Quiet Relaxation

� Take a bubble bath

� Sit in a sauna or jacuzzi

� Take a nap

� Read scriptures or other sacred 

works

� Read a novel

� Read a newspaper

� Try yoga

� Get a massage

� Watch a funny TV show or a movie

� Meditate

� Practice systematic relaxation

� Pet a dog or cat

� Put together a jigsaw puzzle

� Do word or number puzzles like 

crosswords, sudoku or word 

searches.

Managing Combat & Operational Stress A Handbook for Marines & Families 5

U.S. Marine Corps photo by Cpl Kenneth K. Trotter Jr.
U.S. Marine Corps photo by Cpl Michael Ptersheim 

Thinking styles

It is easy to criticize, not accounting 

for personal achievements and 

successes. Be aware of pessimistic 

thoughts and taking too much credit 

for minor faults or misfortune. Positive 

thinking can be learned improving 

well-being and the ability to face 

challenges.

Some sources of stress can be 

controlled and others can not. 

Improve your outlook by regularly 

reviewing personal strengths and 

accomplishments, they may not seem 

obvious at first. High expectations can 

be a strength, unless perfectionism, 

over competitiveness or a source of 

self-criticism develop when something 

doesn’t live up to personal standards. 

Life is complex. When making sense 

of it, avoid black and white thinking. 

In everything and everyone, there is 

good, bad, strength and weakness.

Approach difficulty in a positive and 

productive way by thinking of the best 

outcomes, not the worst. Thinking of 

the past is helpful when remembering 

good times or reviewing successes. 

Practice positive thinking; the future 

always has potential.

Create a personal 

resume

Documenting personal successes and 

strengths helps highlight your ability 

to overcome challenges. Just like a 

professional resumé, a private resumé 

helps identify your best talents and 

skills to help shape personal goals. 

Write achievements down or collect 

documents and objects, such as 

certificates, trophies, letters of 

appreciation, pictures of events or 

things you have created. Think in the 

following broad areas:

1. What awards or accomplishments 

did you receive both before and 

after entering the military?

2. Do you have thank-you notes or

letters of appreciation to include?

3. Are there choices you have made 

in your life that you believe have 

been particularly important, and 

have changed your life for the 

better?

4. What personal goals have you

accomplished about which you are 

glad?

5. Are there things you have done 

that you believe family members 

or friends have particularly 

appreciated?

6. What recognition have you 

received for service to others in 

your community?

7. In what ways are you kind or 

helpful to others?

8. What mental or physical abilities

do you have that you feel are 

above average?

9. Do you have a particular

personality trait or skill that others 

admire or enjoy?

10. Include brief descriptions or

pictures of times in your life that 

have been particularly positive and 

enjoyable.

Consider possibilities of 

posttraumatic growth

after successfully surviving negative 

experiences. Note any personal 

improvements, strengthening of 

relationships and positive lessons 

learned from these experiences.

Personal Development

�	I can better handle difficulties.

�	I feel more self-reliant.

�	I am better able to accept things.

�	I am stronger than I thought.

�	I have greater courage in the face 

of fear.

�	I have more confidence in my 

wisdom and judgment in difficult 

situations.

�	I have more independence.

�	I have more self-discipline.

�	I am more reliable, mature and 

dependable.

Relationships

�	I see that I can count on people in 

times of trouble.

�	I have a greater sense of closeness 

with others.

�	I am better able to express my 

emotions. 

�	I have more compassion for others.

�	I’m better at accepting that I need 

others.

�	I put more effort into my 

relationships.

�	I am better able to work with 

others.

�	I value my family and friends more.

New Meanings

�	I have a better understanding of 

spiritual matters.

�	I have a stronger religious faith.

�	I have a broader perspective, a 

better sense of the big picture.

6 Personal Growth from Stress or Deployment

Personal growth from 

 stress or deployment
�	I can better appreciate each day.

�	I have more pride in being an 

American.

�	I changed my priorities about what 

is important in life.

�	I have a greater appreciation for 

the value of my own life.

New possibilities

�	I established a new path for my 

life.

�	I am able to do better things with 

my life.

�	I developed new interests leading 

to new opportunities.

�	I am more able to make needed 

changes.

Setting goals

motivates you to achieve. 

Effective goals change behavior. 

Great hopes and good intentions are 

useless without taking action.

You are more likely to take action: 

�	If you have a clear plan for exactly 

what to do and exactly when to do 

it.

�	If focused on manageable goals 

rather than the big ones. Break 

long-range goals into specific, 

short-term tasks.

�	If your goals are doable, but 

still challenging. Goals too 

hard to achieve will cause 

discouragement. You will become 

bored with goals that are too easy.

You are more likely to complete 

goals that are meaningful to you 

rather than what other people think 

you should accomplish.

It is important to set goals 

that match your resources and 

personal strengths. Working with 

your best strengths will be the most 

productive.

Positive goals focused on 

accomplishing specific tasks, 

improving relationships, building 

character, or finding meaning and 

spirituality promoting well-being. 

Goals such as avoiding problems, 

being better than others or controlling 

other people are less satisfying and 

more difficult to accomplish.

It is tempting to change your basic 

personality. Some core aspects 

will be very difficult to change 

and are important to who you are. 

More surface characteristics such 

as personal habits, investment in 

important relationships, education, 

and personal attitudes or thoughts 

are much more controllable. 

Improving these will be more helpful 

to your general well-being.

Flexibility is important. Adjust goals 

and work toward something of true 

interest. Take time to enjoy your 

achievements.

Self-defeating thinking styles Positive Alternatives

Personalizing: Blaming yourself completely for problems. Seeing yourself as solely 

responsible rather than considering the impact of the situation, chance events, or other 

people’s actions.

Contextualizing: Acknowledge that many things have contributed to this 

problem. Think of everything that may have played a role, including others’ 

actions, chance events and past history.

Over-generalizing: Seeing problems in all aspects of your life that are your fault. 

Ignoring examples of your own success and focusing only on those instances that fit 

your “pattern of failure.”

Specifying: Think through when you have been able to successfully handle 

challenges. Recognize when you have been capable and successful.

Fortune-telling: Somehow knowing your problems will never get better, and they will 

always be your fault while assuming anything that can go wrong will.

Delimiting: Acknowledge the unique circumstances of this problem. There 

may be similarities in future challenges; what you have learned now can 

help you deal with those in the future.

All-or-nothing thinking: Seeing the world in black and white; always and never. 

Judging past events in terms of complete success or complete failure. 

Balancing: Realistically estimate what percentage of the situation is going 

poorly and what is still okay. Acknowledge what has gone well despite what 

could have been better.

Filtering: Focusing mostly on the negative aspects of the situation even though there 

may be many good things about it as well. 

Problem solving: Do not focus on the things that are going wrong. 

Instead, focus on the opportunities to make the situation better.

Mind reading: Worrying about the hidden reasons why people may say or do things. 

Assuming immediately, for example, that they are thinking poorly of you without 

investigating if that is truly the case.

Trusting: Accept that other people will think well of you and treat you well. 

Second guessing is unproductive. If you are really concerned about what 

they are thinking, ask about it.

Disqualifying: Discounting your successes and others’ encouragement or 

compliments and finding a way to interpret even these good things in a negative light.

Appreciating: Take time to think about your successes and value them. 

Remind yourself of your strengths and talents.

Magnifying: Noticing every little mistake or problem and overestimating their 

importance. Allowing small problems or criticisms to overly affect feelings.

Perspective taking: Review the positive facts about the situation in your 

mind. This includes dealing successfully with challenges.

Emotional reasoning: Judging things based on how you feel, not on the facts. Even 

though everything appears fine, if you are feeling worried, there must be a problem.

Grounding: Remind yourself of the facts of the situation. Consider 

whether there may be any outside factors that influence your feelings.

Obligating: Feeling obligated to live up to a lot of “shoulds.” These may be things you 

believe you need to do or that other people expect of you.

Gauging: Be flexible and recognize that perfection is not the goal. 

Remember that your best is what is expected.

Labeling: Judging and labeling yourself in a negative way, such as personal 

name-calling.

Acknowledging: Think of everything about yourself a single label could 

never capture. Remind yourself how inaccurate it is to pigeon-hole.

Comparing: Measuring self-worth by comparing with other people and thinking about 

how much better they are at everything in comparison.

Admiring: Think about someone you admire who is good at handling 

problems. Consider what you have learned from them and how that can 

help you in the future. 

Self-respecting: Compete only against yourself. Think of ways you 

have improved.

Managing Combat & Operational Stress A Handbook for Marines & Families 7
8 Take Care of Your Body

Eat a healthy, 

balanced diet

to support your lifestyle and health 

needs. If you are very physically 

active, your diet needs to support 

your fitness goals. If you are 

bothered by anxiety or you have 

trouble relaxing, what you eat can 

make a difference.

�	Eat a variety of foods that are rich 

in vitamins, minerals and fiber. 

Limit fats, cholesterol, salt (sodium) 

and added sugars (in food and 

beverages). The Nutrition Facts 

label will help.

�	Choose lean, low-fat or fat-free 

foods — for example, milk and 

meats. Bake, roast or poach 

instead of frying. Save higher 

fat options for occasional 

enjoyment or special occasions.

�	Avoid caffeine — it can alter moods 

and make stress reactions worse.

�	Eat regular meals at consistent 

times to help maintain energy.

�	Be aware of the impacts of 

supplements.

Regular exercise

can be one of the most important 

tools in maintaining good health and 

getting back a sense of routine in a 

time of transition. It is important to 

practice good form and safe exercise 

habits, especially if you are exercising 

frequently at a high intensity level.

�	Creating relevant goals aligned 

with a combined program of 

weight training, cardio and nutrition 

provides the best results.

�	Any amount of physical activity is 

better than none; participating in 

even a small amount of physical 

activity provides health benefits.

�	Before exercise, warm up for about 

10 minutes to reduce the chances 

of injury by overusing cold muscles.

�	For substantial health benefits, 

adults should do at least two 

hours and 30 minutes a week 

of moderate-intensity, or one 

hour and 15 minutes a week 

of vigorous-intensity aerobic 

physical activity, or an equivalent 

combination.

�	For more extensive health 

benefits, adults should increase 

their aerobic physical activity to 

five hours a week of moderateintensity, or two hours and 30 

minutes a week of vigorousintensity aerobic physical 

activity, or an equivalent 

combination. Additional health 

benefits are gained by engaging 

in physical activity beyond this 

amount.

�	Additional health benefits are 

gained from doing musclestrengthening activities that are 

moderate or high intensity and 

involve all major muscle groups 

on two or more days a week.

�	After exercise, stretch while 

muscles are warm. This will 

lengthen muscles to avoid injury 

Take care of your body

1. Reduce or eliminate alcohol and 

caffeine from your diet. Use the 

goal of staying within low risk 

alcohol limits and no more than 

one cup of coffee or equivalent 

per day. Cut caffeine back 

gradually to avoid headaches.

2. Cut back on sugar and simple 

carbohydrates such as refined 

flour in your diet. Eating a lot of 

sugar can temporarily raise your 

blood sugar, to be followed by 

very low blood sugar. Low blood 

sugar, or hypoglycemia, can lead 

to symptoms of anxiety such as 

nervousness, trembling, lightheadedness and irritability. 

3. Keep blood sugar at optimal

levels, by avoiding going for 

long periods of time without 

eating. Have a healthy snack 

between meals. 

4. Increase complex carbohydrates 

such as whole grains and 

starches in your diet. These are 

metabolized slower and may 

help raise serotonin levels in the 

brain which can improve not only 

mood, but also sleep patterns.

5. Eat foods high in tryptophan that 

metabolizes into serotonin such 

as milk products, bananas, oats, 

soy, poultry and nuts.

6. Drink enough liquids to stay well 

hydrated. Dehydration can affect 

physical performance, mental 

ability and mood.

7. Take supplemental vitamins such 

as B-6, C and zinc to help your 

body combat stress.

8. Avoid extreme diets. Eliminating 

any food group from your diet 

completely may affect your mood.

9. Eat for an active lifestyle to 

improve your energy and 

stamina. Work toward a diet of 

low-fat, moderate protein, high 

carbohydrates, and high fluids.

FAT

Eat monounsaturated and 

polyunsaturated fats, particularly 

Omega 3s such as vegetable oils, 

nuts, seeds, avocados and fish.

Avoid saturated and trans-fats as 

well as cholesterol such as fatty 

meat, butter, processed foods and 

fried foods.

PROTEIN

Eat poultry (especially skinless white 

meat), fish, lean meats, beans and 

low-fat or fat-free milk products.

Avoid red meats, including pork, 

especially fatty cuts.

CARBOHYDRATES

Eat whole grains, fresh fruits and 

vegetables that are high in fiber such 

as sweet potatoes, squash, apples, 

bananas, avocados and grapes.

Eating to improve your mood or to relax 
Exercise 

relieves 

symptoms 

such as 

anxiety 

and stress 

reactions.

Managing Combat & Operational Stress A Handbook for Marines & Families 9

and also reduce the amount of 

soreness felt later.

Exercise has many benefits 

including:

�	Relief of symptoms such as 

anxiety and stress reactions.

�	Lifted mood.

�	Improved self-esteem.

�	Improved sleep, which can have 

additional benefits.

�	Improved physical looks, which 

also can provide more benefits.

Focus on Form

during physical training to improve 

performance and reduce the risk of 

injury.

Building focus has benefits in other 

areas outside exercise, including: 

�	Improved mental skills gained 

by building a greater attention to 

detail.

�	Greater body awareness which 

improves the ability for relaxation.

�	See pages 12-13 for more about 

relaxation techniques.

U.S. Marine Corps photo by Cpl Gene A. Ainsworth III

Avoid foods with added sugar and 

refined grains such as white flour.

LIQUIDS

Moderately active people may 

need three to five liters of water per 

day while a very active person may 

need 10 liters. Monitoring urine 

color with a urine color chart can 

help you know your hydration level.

Avoid alcohol and carbonated 

beverages, which are high 

in calories and can lead to 

dehydration.

Guidelines are from the US Dept. of Agriculture 

and the US Dept. of Health & Human Services. 

For more info: www.health.gov/dietaryguidelines or 

www.health.gov/paguidelines

Eating when you exercise

About two to four hours BEFORE 

EXERCISE, eat a high carbohydrate, 

low-fat meal and drink 17 to 20 fluid 

ounces of water or a sport drink. 

Another carbohydrate snack and 

seven to 10 ounces of additional 

fluids can be helpful within 30 minutes 

of intense exercise. Avoid candy and 

foods high in sugar; these can spike 

your metabolism and actually lower 

your blood sugar.

DURING EXERCISE, drink 7 to 10 

fluid ounces about every 10 to 20 

minutes. Drink enough fluids to avoid 

dropping more than 2 percent of fully 

hydrated pre-exercise weight. At 

the same time, avoid drinking more 

fluids than your weight loss during 

exercise; over-hydration also can be a 

serious health risk. During prolonged 

exercise (over an hour), a 6 percent 

carbohydrate drink is recommended.

Within two hours AFTER EXERCISE, 

drink liquids equivalent to 125 to 

150 percent of the difference in your 

pre- versus post-exercise weight. 

Avoid alcohol and carbonated soda. A 

carbohydrate & protein snack of about 

300 calories is recommended within 

an hour of strenuous exercise.

Every athlete has a unique sweat 

rate. KNOW YOURSELF. Monitor 

changes in your body weight, thirst, 

and urine color. Watch for signs of 

dehydration such as feeling thirsty, 

hot, tired, or lethargic, poor physical 

performance, flushed skin, cramps, 

dizziness, headache, vomiting, 

nausea or chills.
10 Making Safe Choices, Reconnecting with Others

Consider moving if 

you live in an unsafe 

neighborhood.

A location with frequent robberies, 

assaults and drug-related crimes 

can amplify the feeling of danger. 

Consider moving to a safer area 

if possible. Moving is a major 

undertaking, but it could help lessen 

stress. Create distance from the 

unsafe area for an increased sense 

of safety.

If you are in a stress treatment 

program, your case manager may 

have resources to help find new 

housing.

Get help to leave an 

abusive relationship.

Family violence is never acceptable 

and is usually a serious crime. 

Family violence of any kind will

hinder your ability to manage

stress and may make feeling safe 

difficult.

If your spouse or partner is 

physically, sexually or verbally 

abusive, put your safely (and the 

safety of your family) first. Seek 

help from the Marine and Family 

Services Center, a chaplain or 

mental health professional.

If you think you may be in 

immediate danger, leave at once 

and call 9-1-1. From a safe location 

you can call the base Marine and 

Family Services Center or the 

National Domestic Abuse Hotline at 

1-800-799-SAFE (1-800-799-7233).

Limit exposure to 

traumatic stories in 

the media. 

For a Marine experiencing combat 

or operational stress, reading about, 

listening to or viewing stories about 

traumatic events can trigger stress 

symptoms. Think about limiting how 

much you take in the news, violent 

TV or movies as they can cause 

similar issues. Choose positive 

activities you enjoy instead - such 

as riding a bike or taking a walk; 

reading a book or watching an 

uplifting movie (see page 5). 

Constructive worrying

Recognize stress and set aside a 

time to deal with specific, nagging 

concerns.

Work through problems to 

potential solutions or steps to move 

forward. Make a record for future 

action.

What is the worst that can 

happen? This helps prepare for 

and give perspective on what may 

not be a significant problem in the 

bigger picture.

What is the best that can happen? 

This can provide something to look 

forward to and might lighten the 

mood immediately, while providing 

a longer-term sense of opportunity.

Manage finances 

to reduce stress:

� Live within your means.

� Make a budget.

� Invest within your risk tolerance.

� Avoid unnecessary debt.

� Set financial goals.

� Avoid gambling.

Consider joining a 

self-help group.

This includes your unit’s OSCAR 

team where Marines identify and 

manage combat and operational 

stress. Talking with other Marines 

who have experienced combat 

or operational stress can help. 

Increasing your contact with others 

is helpful and if you feel distrustful 

of others, contact can help you 

learn to trust again.

You can find self-help groups 

through:

•	 Your unit OSCAR team.

•	 Health care providers, mental 

health professionals or clinic.

•	 Marine and Family Services 

Center.

•	 Unit post-deployment program.

•	 Local VA facility.

•	 Online forums: 

` www.dailystrength.org

` www.mentalhealthamerica.

net/go/go/find_support_group

Make relationships 

a priority.

Quality is more important than 

quantity. Investing in existing 

strong relationships is usually more 

valuable and easier to maintain 

than trying to create additional 

relationships.

Make a special effort with 

loved ones.

If you have become distant from 

loved ones, take small steps to 

reconnect with them. Be flexible in 

your expectations of relationships with 

family and friends.

Make effort to explain how you are 

feeling to your family and close 

friends. If you are experiencing 

marriage or close relationship troubles, 

seek peer or professional counseling 

to help create solutions together.

Reach out to your children if not close 

to them. Show interest in 

their schoolwork, activities and 

hobbies. Be there for them when they 

need you.

Get in touch with close friends if you 

have lost touch. Call, send a letter 

or an e-mail. Get together for a cup 

Making safe choices, 

 reconnecting with others
of coffee or a short walk. Social 

networking sites can help you find 

and retain connections with friends.

Complement and encourage family 

and friends for positive things they 

have accomplished and thank them 

for their support.

Socializing

�	If face-to-face interaction is 

initially difficult, use e-mail, social 

networking sites or online forums 

to begin social connections.

�	Enroll in a class that interests 

you to meet people with similar 

interests.

�	Join a book group, hiking group 

or other interest group.

�	Start a blog. Blogging is similar 

to journaling, but with a social 

component.

�	Volunteer. Working together 

toward a positive common goal 

builds bonds and provides a 

sense of accomplishment (see 

page 5).

 v

While at 

work 

Having good relationships 

with people at work is 

one of the most important 

keys to job satisfaction. 

There are a number of 

ways you can improve 

work relationships. Taking 

the time to thank people, 

either in person or in 

writing, is a great way 

to improve relationships 

with coworkers, clients 

or others with whom you 

do business. Taking the 

time to talk with people 

throughout the day at 

work is also important. 

Social connections can 

help restore relationships 

if they have been strained 

by the effects of combat 

or operational stress.

Managing Combat & Operational Stress A Handbook for Marines & Families 11 U.S. Marine Corps photo by Cpl Tyler Main

Marines, attached Sailors, 

and families call: 

Anonymous DSTRESS Line at

1-877-476-7734 and online chat 

at www.dstressline.com. 

Veterans or Service members

and families call: 

Confidential Military Crisis Line 

at 1-800-273-8255 and press 1, 

use the online chat at 

www.veteranscrisisline.net or 

send a text message to 838255.

For emergencies call 

9-1-1 or go to your nearest 

Emergency Room. 
Consciously pay 

attention

to any emotional or bodily changes. 

Directly try to counteract some of 

these. 

•	 For example, if you typically find 

that shoulder muscles get tense 

when you are angry, try to relax 

those muscles.

•	 If you often find yourself clenching 

and unclenching your hands, try to 

do something else with them (fold 

your hands, doodle with a pencil). 

•	 If you breathe faster when you 

are angry, try taking deeper and 

slower breaths.

Deep breathing

This simple technique can be used 

anytime and anywhere.

1. Get in a comfortable position.

2. Exhale first, clearing your lungs

completely.

3. Inhale slowly through your nose. 

Draw the air deeply into your belly 

to a point below your navel.

4. Exhale slowly through your mouth. 

Push out as much air as possible. 

Try to make your exhalation twice 

as long as your inhalation.

5. While exhaling, imagine you

are letting go of tension, painful 

memories or distressing emotions.

6. This may take repeating a few 

times until you feel calmer.

Meditation

can help soothe stressful 

reactions. Over time, it can 

help you see your feelings and 

reactions from a more objective 

viewpoint. Try this simple 

technique:

1. Get in a comfortable position.

2. Close your eyes.

3. Think of a soothing word or 

phrase for a focus point, such as 

“quiet” or “peace.” Or visualize a 

calming scene.

4. Focus your mind on the word, 

phrase or image chosen. If other 

thoughts come to mind, just notice 

them briefly and let them go.

5. Let your breathing slow down. You 

may want to silently repeat the 

word or phrase in time with your 

inhalation or exhalation.

6. Start with just five minutes. As the

process becomes more 

Relaxation techniques

decrease stress on your mind and body, 

and improve physical performance.

Practicing relaxation 

techniques

•	 Be as consistent as possible in your 

practice.

•	 Practice once or twice a day if time allows.

•	 Practice in a quiet, relaxing place where 

you can be alone.

•	 Turn off the telephone and TV.

•	 Make sure clothing and room temperature 

are comfortable.

•	 After you have tried different techniques, 

choose the one that works best for you.

Stick with it — you may need some 

practice before starting to feel the benefits.

•	 Use your chosen technique any time you 

are feeling particularly stressed or are 

having stress symptoms.

Note: If any of these relaxation techniques 

make you feel uncomfortable, stop for a while 

and then try again when you feel ready. You 

may want to try them with the guidance of a 

professional.

12 Relaxation Techniques
comfortable, you can meditate for 

a longer time.

Mental concentration can be used 

as a form of meditation. Practice 

focusing your attention on a very 

simple thought, sound or image. 

Whenever you are distracted, simply 

return your attention to this simple 

focus. It can also be the practice of 

being aware or “mindful” of all levels 

of your current physical and mental 

experience, starting with awareness 

of breathing. Meditation is helpful to 

reduce anxiety, frustration and anger. 

There are a number of different ways 

to meditate, and you may already 

be doing a form of meditation. For 

example, chanting a short song as a 

group or by yourself while running is 

meditative. Prayer is also a form of 

meditation. Try spending about 20 

minutes daily practicing some form 

of meditation. Two easy techniques 

include: 

•	 Attention to and awareness of 

the present moment.

•	 Be accepting or willing to 

experience your thoughts and 

feelings without judging them.

Try this exercise:

1. Sit in a comfortable chair in a 

relaxing position. Do not cross 

your legs. Your feet should be 

flat on the floor, and your arms 

should be lying flat at your sides. 

Close your eyes.

2. Begin by taking several deep 

breaths. Think of the way your 

breathing feels as you are falling 

asleep and practice breathing 

like that. Pay attention to the air 

flowing gently in through your 

nose, into your lungs and out 

again. It should take several 

seconds for you to breathe in 

and out. Take about 10 or 15 

more breaths like this.

3. Flex your right foot up. Clench 

the muscles tightly, but not to the 

point of pain or discomfort, hold 

this position for about 5 to 10 

seconds. 

4. Now relax your right foot as 

much as you can. Focus on 

breathing deeply again. Each 

time you breathe out; try to relax 

the muscles in that foot just a 

little bit more. For about 20 to 30 

seconds, pay attention to how 

your right foot feels. 

5. Repeat this exercise for your 

left foot and then for each of 

the following parts of your body, 

tensing them and then relaxing 

them in order:

•	 Right leg (lift slightly; tighten 

quads).

•	 Abs (tighten)

•	 Left leg (lift slightly; tighten 

quads).

•	 Shoulders (shrug).

•	 Right hand (clench fist).

•	 Jaw (clench teeth in a big 

“smile”).

•	 Left hand (clench fist) 

•	 Forehead (screw eyes tightly 

shut).

•	 Right arm (tighten bicep).

•	 Left arm (tighten bicep).

6. After you have gone through 

the whole body exercise, take 

some time to continue breathing 

and relaxing your entire body. 

Pay attention to which parts of 

your body feel the most relaxed.

Take as long as you like to feel 

relaxed.

Be in the present

You can use routine tasks, such as 

taking a bath/shower or washing 

the dishes, as an opportunity to 

meditate. Make this task the most 

important thing in your life at that 

moment, and every movement 

about twice as slow as usual. Use 

this time to pay attention to your 

experience and each step in the 

process. The best way to gain the 

attention of the moment is to focus 

on your breathing and how it feels 

to breathe in and out. You may try 

slowly counting your breaths each 

time you exhale from one to 10, 

starting over when the count is 10 

or if you lose track of the count. 

After focusing on breathing for a 

few minutes, begin to pay attention 

to the task. 

For example, if washing dishes, 

notice how the water feels on 

your hands, the texture of the dish 

and the motion of your muscles 

as you clean. If a thought about 

anything other than this task 

interrupts you, notice what the 

thought is, acknowledge it and 

then refocus on your experience of 

the task. Generally, the best way 

to refocus is to pay attention to 

your breathing again. Some of the 

thoughts that interrupt your focus 

may be important to consider later, 

particularly if negative.

Other ways to relax

There are other activities that can 

also help you calm down and feel 

relaxed. For example, you could:

� Listen to quiet music.

� Draw or write in a journal or blog.

� Write stories or poetry.

� Play with your child or with a pet.

� Talk with a friend or counselor.

� Exercise, including yoga.

� Take time for prayer.

� Read inspirational or spiritual 

books.

� Have a massage.

Managing Combat & Operational Stress A Handbook for Marines & Families 13 U.S. Marine Corps photo by Cpl Tommy Huynh
14 Spirituality and Building Resilience

Spirituality

generally refers to that which 

gives meaning and purpose in life, 

including practice of a philosophy, 

religion, or way of living. Examples 

include commitment to family, 

love of life, esprit de corps and 

application of faith. Spirituality can 

help Marines:

�	Understand their stress issues 

— spiritually, psychologically and 

physiologically.

�	Rebuild their identity and accept 

themselves.

�	Gain meaning in daily life.

�	Adopt therapeutic spiritual 

disciplines to bring them closer 

to God or sacred Supreme Being. 

�	Process their loss and grief. 

�	Experience the freeing influence 

of giving and receiving 

forgiveness. 

�	Strengthen themselves spiritually 

against future stressors. 

�	Connect with the rest of the 

world and those who will support 

them. 

�	Reintegrate into society as a 

strengthened man or woman, 

to include becoming a positive 

influence on others with stress 

issues.

Spirituality may affect a number of 

stress symptoms. Mental health 

professionals often incorporate 

spiritual beliefs and practices into 

courses of treatment. 

For Marines with stress injuries, 

their spirituality could affect 

important clinical issues.

Drawing on supportive, healthy 

communities and spiritual 

connections can help address 

isolation and social withdrawal.

Spirituality can lead to selfforgiveness and an emphasis on 

compassion toward self. 

Beliefs and practices related to 

forgiveness can help anger and 

improve chronic hostility leading 

to social isolation and poor 

relationships with others.

Inwardly-directed practices such as 

mindfulness, meditation and prayer 

may help reduce hypervigilance.

Focusing on the present with 

enjoyable tasks to create a selfawareness of the value of life.

Prayer

Regardless of whether or not you 

are religious you can use prayer or 

meditation to find peace. If you are 

religious, you may already use some 

form of prayer. But, it can be very 

beneficial to lengthen the amount 

of time you spend praying daily and 

put some effort into choosing what 

to think of during prayer. If you are 

not religious, meditation can still be 

helpful to spend quiet time alone 

thinking through things in your 

mind that you appreciate from the 

universe or from a higher power of 

your choosing. The following are 

some categories of thoughts you 

may spend time rehearsing in your 

mind through meditative prayer.

1. If you have a religious prayer that is 

meaningful to you, recite this slowly 

and repeatedly in your mind.

2. Think of a list of things you 

are grateful for in your life and 

slowly rehearse in your mind a 

statement of gratitude for each 

of them.

3. Think of a list of good things you 

wish for, for those whom you love 

or care about. Rehearse in your 

mind a request for each of those 

benefits or blessings to come to 

each of those people.

4. If you have a goal you are 

working toward in your life, think 

of the steps you need to take to 

accomplish it. One by one make 

a simple request in your mind for 

help and success in your efforts 

to complete each step.

5. If you are using prayer 

specifically as a tool to help 

relax or feel more peaceful, 

think of a simple request or 

Talk with your 

chaplain or 

other spiritual 

leader

Many chaplains or other spiritual 

leaders have extensive working 

knowledge about stress injuries 

and understand how combat 

and operational stress reactions 

can affect a Marine’s or veteran’s 

spirituality and daily life. They can 

help manage stress and provide 

additional resources.

Spirituality and

 building resilience

Marines, attached Sailors, 

and families call: 

Anonymous DSTRESS Line at

1-877-476-7734 and online chat 

at www.dstressline.com. 

Veterans or Service members

and families call: 

Confidential Military Crisis Line 

at 1-800-273-8255 and press 1, 

use the online chat at 

www.veteranscrisisline.net or 

send a text message to 838255.

For emergencies call 

9-1-1 or go to your nearest 

Emergency Room. 
phrase asking for that feeling in 

your mind. Keep repeating that 

statement slowly in your mind.

The Marine Corps 

will help

Talking to other Marines or service 

members with similar experiences 

may be the most useful means for 

finding practical coping strategies.

Depending on whether you are 

currently on active duty or a 

veteran, you can get help from:

� Your unit’s OSCAR team.

� Your base medical clinic.

� A chaplain or other spiritual 

leader.

� Your Marine and Family Services 

Center.

� A Veterans Affairs (VA) hospital 

or clinic.

� Private sources, such as a 

healthcare provider, mental 

health professional or clinic.

OSCAR teams provide peer 

support and initial stress 

identification and referral.

OSCAR is Marine-led training

that builds teams of Marine 

leaders, medical and religious 

ministry personnel within each 

battalion-sized unit. This training 

is designed to give leaders the 

tools to prevent, identify and 

manage combat and operational 

stress issues as early as 

possible.

These teams are: 

� OSCAR Mentor/Team 

Members (trained unit 

Marines and leaders) 

� Extenders (unit medical and

religious ministry personnel).

� Mental Health Professionals 

(mental health providers and 

technicians associated with 

the unit).

� More info, see page 30.

Untreated stress 

issues tend to 

become worse

This can cause or worsen additional 

problems.

• Become isolated from friends and 

family.

• Use anger to control others.

• Have trouble getting along with 

co-workers.

• Feel more and more depressed or 

anxious.

• Try to manage feelings with alcohol 

or other drugs.

• Find your job performance negatively 

impacted. 

• Become unable to deploy as issues 

escalate.

• Experience negative effects to your 

career if stress injury symptoms lead to 

disciplinary issues.

If you have, or think you have, a combat 

or operational stress injury, including PTS, 

you don’t need to go it alone. Get the help 

you need and deserve.

Learning about combat and operational 

stress is a powerful step.

Learning about combat and operational stress can be the first step to 

getting better. A health care provider or mental health professional can 

provide information, you can also use these resources:

USMC COSC website

www.manpower.usmc.mil/cosc

USMC Behavioral Health Information Network websites

www.bhin.usmc-mccs.org/

National Center for PTSD, Dept of Veterans Affairs

www.ncptsd.va.gov

Center for the Study of Traumatic Stress

www.centerforthestudyoftraumaticstress.org

You can manage combat or operational stress issues, including PTS.

Some stress issues can be managed with only rest and support. But other 

stress issues and injuries such as PTS may require treatment. Treatment 

may involve:

•	 Psychotherapy.

•	 Medications.

•	 Self-help techniques, such as anger management and ways to 

control stress reactions.

Managing Combat & Operational Stress A Handbook for Marines & Families 15

U.S. Marine Corps photo by LCpl Kasey Peacock
Anger can be helpful

Properly channeled anger can 

motivate us to work towards goals 

and it alerts us that something is 

wrong and we need to respond. 

Marines may use anger to 

accomplish missions with energy 

and focus. At home, they may 

find themselves getting frustrated, 

keyed up and having a hard time 

sleeping or relaxing. Anger is 

normal and natural; it is important 

to know what triggers anger so it 

can be controlled. Uncontrolled 

anger can be a serious problem in 

relationships.

Pay attention

Think about how you feel when you 

get angry. Check for any of these signs 

you may have when you are angry:

� Tense muscles.

� Clenched jaw.

� Tight fists.

� Racing heartbeat.

� Feeling shaky.

� Upset stomach.

�	Loud talking or yelling.

Be aware

The idea is to become more aware 

of the types of situations that trigger 

your anger and the types of feelings 

and sensations you have as you 

begin to get angry. Awareness 

helps to better understand a cycle 

of anger.

Get help for 

managing anger

Taking control of anger can be 

challenging. Help is available, such 

as joining an anger management 

group. Resources can help with:

� Understanding why anger is part 

of stress.

� Learning what feelings and thoughts 

signal that you are getting angry.

� Controlling anger through 

managing stress.

� Communicating with others more 

effectively.

Marine and Family Service Centers 

offer anger management classes. 

A treatment program or VA facility 

can also help you find an anger 

management group. Ask your 

healthcare provider, mental health 

professional or counselor.

Pre-emptive strategies

You can decide ahead of time what 

you will do and say when angry. 

The best response may be to just 

walk away if a problem is not that 

critical. It may be worth learning 

Letting go of anger

16 Letting Go of Anger

U.S. Marine Corps photo by Sgt Michele Watson
some problem solving skills for 

more important relationships. 

Defuse the situation

Simple one-liners may be enough 

to exit a potential confrontation. 

Different situations may require 

different responses. The following 

are a few ideas to start:

1. I am sure we can work this out. 

Can we meet in the middle 

somewhere?

2. Okay, this day has just been too 

long for all of us.

3. It is not that big of a deal to me, I 

am happy to go along.

4. Okay, I’ll think about this; we can 

talk about it later.

5. This is all new to me. I will have to

think about it and get back to you.

6. I know, I really hate this situation; 

I am sorry about it.

7. I had no idea you felt this way. I 

can see how you feel now.

Immediate action

When you feel signs that you are 

getting angry and start thinking 

angry thoughts, follow these 

suggestions:

� Tell yourself: “Stop”.

� Take steps to relax — count to 

100, take a walk or take some 

deep breaths.

� Leave if necessary — if you feel 

angry with someone else, tell 

him or her you need to take a 

moment.

� Go to a safe place and calm down.

� Once you feel more in control, go 

back and talk with the person or 

face the situation that triggered 

your anger.

Thinking of some alternative 

conclusions can help the situation 

internally if conversation is not 

possible or applicable. Some 

possibilities are:

1. Under other circumstances, I 

would probably really like this 

person.

2. This is just a bad day, it will all 

look different tomorrow.

3. This situation would be hard 

for anyone.

4. How much do I really care 

about this? It may not be worth 

the conflict.

5. Just because this person is

acting like a jerk does not mean I 

should also.

6. It is not personal; we are all 

just tired and out of patience.

7. This person is not trying to hurt 

me; he/she just does not know 

how to handle the situation.

8. My relationship with this 

person is worth more than this 

stupid argument.

9. The most important thing is 

not justice, it is the kind of 

person I want to be.

10. I am not going to give this 

person the satisfaction of 

pushing my buttons.

Use assertive communication 

It is possible to preempt anticipated 

conflict with important people by 

addressing the underlying problem 

proactively. It is important to be 

able to communicate effectively 

when there is a problem rather than 

ignoring your feelings or avoiding the 

issue, which can make things worse.

1. Schedule a time for discussion 

with the other party.

2. Make sure you think through 

the problem beforehand so you 

can clearly communicate your 

position.

•	 Think of very specific, 

objective examples of things 

that have happened to 

illustrate the problem.

•	 How do you feel about the 

problem and what is your 

reaction to having this internal 

view?

•	 How specifically would 

you like to see the problem 

resolved and what is required 

from the other person?

•	 What is the most practical 

thing to do and what 

compromise might be 

required?

3. Take responsibility for your own 

thoughts and feelings by using 

“I” statements. “I” statements 

focus on the speaker’s 

observations, feelings, desires 

and intentions and clearly 

explain them. They are much 

more likely to be effective than a 

“You” statement which tends to 

become accusatory.

4. Stay calm during the 

conversation. If it will be difficult 

to remain calm or respectful, 

a public place may be a good 

location for the conversation. 

Planning some break times into 

the conversation may also be 

useful.

5. Focus on solving the problem 

in a way that makes both of you 

happy. Do not be distracted by 

other issues such as trying to be 

right or getting even.

6. Do not purposely push buttons. 

In every relationship, each 

partner usually knows what will 

really upset the other. In addition, 

it is always critical to stay away 

from yelling, swearing, insulting 

or threatening.

Managing Combat & Operational Stress A Handbook for Marines & Families 17

You can control 

your reactions 

to events 

including anger 

—anger does 

not have to 

control you.
Someone with a 

stress injury

experiences severity and 

persistence of symptoms (see 

pages 2-3, Orange Zone). For 

example, symptoms don’t get 

better after the stress is over; 

persisting for weeks or even years. 

Signs can include inability to fall or 

stay asleep, panic attacks or rage 

outbursts. If it looks like a Marine 

has a stress injury, you should get 

them help with a Senior OSCAR 

Team Member, chaplain, medical 

personnel or health care provider. 

Someone with thoughts of hurting 

them self or others should not be 

left alone and needs professional 

help right away.

Don’t dwell in the past. Mistakes 

are a part of being human; successful 

people learn from mistakes and find 

value in the resulting actions. Stress 

can be helpful if it motivates positive 

action in the future. Thinking of the 

past is unhelpful if it discourages you 

from acting confidently in the present. 

Identify experiences that may cause 

a stress injury; keep an eye out for 

red flag stressors (see page 3).

Take small, positive actions. 

Stress injuries usually heal, but will 

heal faster and leave less of a scar 

with help. Behavior or personality 

changes if untreated could move 

into a more serious issue.

1. Get some exercise (see pages 

8-9). Exercise has been shown to 

help with stress and depression.

2. Eat nourishing, healthy foods (see 

pages 8-9). It is hard to be at your 

best if you don’t have the right fuel.

3. Do something enjoyable every

day, such as a hobby, watching 

a movie or going for a walk (see

pages 4-5 for more ideas).

4. Stay busy with work, friends and

family. If you are depressed, a daily 

schedule can give you something 

to look forward to. Also, investing 

in personal relationships builds 

emotional support.

5. Volunteer in the community to 

increase feelings of connection 

and capability to contribute (see 

page 5).

6. If you can, get away for a while 

or go on leave. Sometimes a 

change of scene can give a new 

outlook on life.

Act rather than react. If you are 

still bothered by lingering thoughts 

or reminders from deployment, or 

the stress experienced in combat 

is still causing reactions, it can 

be helpful to have a plan to act 

and take some control. Returning 

veterans report the following are 

helpful in response to common 

experiences. Some actions are 

helpful for more than one issue.

Unwanted memories or thoughts 

about stressful deployment 

experiences are common.

� Talk to someone trustworthy 

about these unwanted memories; 

if you feel comfortable, share the 

experiences with them.

� Consider finding a buddy 

with whom you shared these 

experiences to talk to — often 

confiding in someone who 

was there and understands is 

extremely helpful.

Someone coping with severe stress 

may experience behavior or personality change 

U.S. Marine Corps photo by Brian Nygaard

18 Someone Coping With Severe Stress May be at Risk for Depression 
� Remind yourself that these 

are just memories; this is not 

happening now and you are safe.

� Remember that these unwanted 

memories or thoughts will 

come less often and be less 

bothersome in time.

If you feel like you are suddenly 

back in theater again:

� Remind yourself of where 

you actually are. Look around 

yourself and think of today’s 

date. Tell yourself that you are 

safe.

� Get up, move around, and touch 

familiar objects such as your 

clothes or the furniture.

� See if you can find a pattern 

to when this feeling may arise. 

What is the trigger?

Acknowledge feelings 

of inner conflict

� Do you worry about instances 

where you believe you failed to 

follow the rules of engagement?

� Do you feel you must keep a 

secret about something you did 

in combat because others may 

judge you for it if they knew?

� Do you worry about your 

responsibility for the death or 

injury of friendly troops?

� Do you worry about your 

responsibility for the death or 

injury of noncombatants?

� Do you ever think that it would 

have been better or more just if 

you had been injured or died in 

place of someone else?

� Do you believe you could have 

and should have prevented 

someone else’s injury or death?

A healthcare provider or mental 

health professional can help.

Don’t be your 

own enemy 

You may have no trouble arguing 

with discouraging or critical 

comments and suggestions when 

they come from the enemy. But 

unfortunately, when they come from 

within yourself, you may not even 

question them. That is when you 

become your own worst enemy.

Self-harm

Since returning from deployment, 

have any of the following statements 

been true for you?

� I frequently feel like life is very 

hopeless and not worth living.

� I frequently think about hurting 

myself or killing myself.

� I have previously attempted 

suicide and think about trying 

again.

� I have a plan in mind as to how I 

can kill myself.

� I have taken steps to get ready to 

kill myself (written a note, given 

away possessions, or chosen a 

method).

If any of these statements are 

true for you, you should get help 

from a health care professional 

right away.

Managing Combat & Operational Stress A Handbook for Marines & Families 19

Know the warning signs of suicide. 

The person may:

•	 Talk about harming him- or herself.

•	 Prepare for death — for example, make a will or give away 

possessions.

•	 Seem suddenly happier — a possible sign that the person has decided 

to end his or her life.

Know what to do

If you think someone you know is at risk for suicide, this is an emergency! 

Bring the person to your installation’s health-care facility or a local hospital 

or clinic. Or call:

•	 The National Suicide Prevention Lifeline at 1-800-273 8255 

(1-800-273-TALK).

•	 9-1-1 or your local medical emergency number.

•	 Your chaplain, the Marine and Family Services Center, or a mental 

health professional.

•	 Do not leave the person alone until he or she has been helped!

Warning: three thinking traps that 

can lead to a downward spiral

•	 It’s all my fault! (personalizing).

•	 It’s my fault all the time! (generalizing).

•	 It’s always going to be my fault! (fortune-telling) 

(see more on page 7).

U.S. Marine Corps photo by Cpl Chris Stone
20 Using Alcohol and Drugs

Alcohol and other drugs 

are not a way to cope.

They can:

� Harm your body and mind.

� Cause addiction.

� Cause problems with friends and 

family.

� Worsen feeling of anger and 

depression.

� Put you and others at risk for 

car accidents and other lifethreatening mishaps.

Get help if you need it.

� Ask for help from the unit 

Substance Abuse Control Officer 

(SACO), at your Marine and 

Family Services Center, from a 

chaplain, at a substance abuse 

treatment program or at a local VA 

facility.

� Call the Center for Substance 

Abuse Treatment’s Referral 

Service at 1-800-662-4357 

(1-800-662-HELP).

� Find local self-help groups, such 

as Alcoholics Anonymous (AA) or 

Narcotics Anonymous (NA) in the 

phone book or by internet search.

� For more information: www.

rethinkingdrinking.niaaa.nih.gov.

“Personal” Operational Risk

Management (ORM)

ORM is used in decision making to 

avoid unnecessary risk. It can also 

be used in personal planning to 

identify and eliminate disaster.

Identify the hazards. What might 

go wrong? The drinking scene could 

create social pressure to drink.

Assess the hazards. How 

dangerous is that action? It could 

lead to over-drinking. 

Make risk decisions. What can I 

do to eliminate that hazard or make 

it less dangerous? Alternate alcohol 

with soda, water or juice. Have 

conversation instead of playing 

drinking games.

Implement controls. Make changes 

to create a safer environment. Have 

a friend step in if needed. Leave the 

party after three drinks.

Supervise. Check the results; is it 

effective? If successful, continue 

to build good habits. If not, review 

whether different controls will be 

enough or if a different social scene 

might be needed.

Make a change plan:

If you are drinking too much, you 

can improve your life and health 

by cutting down. It is only your 

decision to cut back or quit. Once 

decided, it is easier for you to stay 

on track for yourself than doing 

it for some external or not welldefined reason.

�	Determine your reasons to quit or 

cut back. This will reinforce your 

goals.

�	Make strategies to help success.

�	Find people or resources to help.

�	Determine what makes your plan 

successful. What signs will tell 

you this?

�	Think of what problems may be 

encountered and how they can 

be solved.

Strategies to reduce or quit 

drinking:

Keep track of how much you drink. 

Find a way that works for you, such 

as a 3”x 5” card in your wallet, 

check marks on a kitchen calendar, 

or notes in a mobile phone notepad 

or personal digital assistant. Making 

note of each drink before drinking 

can slow you down.

Know the “standard” drink sizes

to count drinks accurately. Measure 

drinks at home. It can be harder 

to keep track away from home, 

especially with mixed drinks or if a 

glass of wine is “topped off” by 

a server.

Set limits: Decide beforehand how 

much to drink; number of days a week 

and how many drinks. Setting a goal 

helps keep alcohol use in lower risk 

amounts.

Pace and space: When drinking, 

pace yourself. Sip slowly and have 

no more than one standard drink of 

alcohol per hour. Have “drink spacers” 

— make every other drink nonalcoholic, such as water, soda or juice.

Include food so the alcohol will be 

absorbed more slowly.

Find alternatives for the time drinking 

occupies. Find alternatives for the 

time drinking occupies. If alcohol 

creates comfort in social situations, 

helps manage moods or coping with 

problems, seek healthy ways to deal 

with those areas. Fill free time by 

developing healthy activities, hobbies 

and relationships. 

Avoid “triggers” like certain 

people or places that make you 

drink even when not planned. 

Internal triggers are thoughts, 

emotions or physical sensations 

such as tension. Plan something 

else to do instead of drinking if 

certain activities, times of day or 

feelings trigger the urge. If drinking 

at home is a problem, keep little or 

no alcohol on hand.

Plan to handle urges when you 

cannot avoid a trigger:

�	Keep your reasons for change 

handy as a reminder.

�	Talk to a trusted person.

�	Get involved with a distracting 

activity that doesn’t involve 

drinking, such as physical exercise 

or a hobby. 

�	Accept the feeling and ride it out 

without giving in knowing it will 

pass instead of fighting the feeling 

and losing. 

Using alcohol and drugs 

can make any combat or operational stress issue worse
�	Analyze and challenge the thought 

leading to drinking.

�	Avoid or reduce high-risk situations. 

It helps to plan an escape in 

advance.

Build your “No.” Have a polite, 

convincing, “No, thanks” ready for 

the times when someone offers 

a drink and you don’t want one. 

The faster and more convincingly 

delivered, the less likely you are to 

give in. Hesitation allows time for 

excuses or well-meaning social 

pressures to erode your decision. 

Prepare increasingly assertive 

responses to deal with objections, 

and walk away if necessary. 

•	 Direct social pressure is when 

someone offers you a drink or an 

opportunity to drink. 

•	 Indirect social pressure is when 

you feel tempted to drink just 

by being around others who are 

drinking - even if no one offers 

you a drink.

Your doctor may advise you to 

drink less or not at all depending on 

your health.

Facts about addiction

�	Addiction can run in families 

and has many serious long-term 

consequences beyond impacts 

to health, including: damaged 

relationships, unemployment, 

physical dependence, legal and 

financial problems, depression and 

increased suicide risk.

�	Addiction can become stronger 

over time. Use may increase and 

associated problems often get 

worse.

�	Many people can recover from 

addiction.

�	It is easier to recover from an 

addiction fairly early on before the 

problem has progressed very far. 

Unfortunately, many people do not 

have the motivation to change until 

they “hit bottom.”

�	Things that can greatly help 

in recovering from addiction 

are getting involved in healthy 

activities (a hobby, meditating or 

work), finding a sense of meaning 

and hope (religion, spirituality 

or philosophy), and investing in 

healthy relationships (friends, family 

or support groups).

What counts as a drink?

A typical serving of an alcoholic 

beverage contains the same amount 

of alcohol, although different types 

will vary.

12 oz. beer = 8 oz. malt liquor = 6 oz. 

wine = 1.5 oz. 80 proof spirits

National Institute on Alcohol Abuse 

& Alcoholism recommended lowrisk drinking limits:

No 

Risk

0 drinks per day; appropriate if 

underage, when pregnant or with 

some health issues

Low 

Risk

No more 

than

Men Women

Per day 4 drinks 3 drinks

Per week 14 drinks 7 drinks

High 

Risk

Over 1 

drink per 

hour

More than either or 

both the single-day 

or weekly limit

Reduce your risk to avoid injuries 

or health problems including birth 

defects and alcohol-use disorders. 

Low-risk drinking can have health 

benefits. 

Do any apply to you?

•	 I sometimes feel I should cut down 

on my drinking or drug use.

•	 I have tried to cut down on my 

drinking or drug use, but I can’t.

•	 Other people have criticized my 

drinking or drug use.

•	 I sometimes feel guilty about my 

drinking or drug use.

•	 I sometimes have a drink or use 

other drugs first thing in the 

morning to steady my nerves or get 

rid of a hangover.

If any of these statements apply, you 

may have a problem with alcohol or 

other drugs. Talk to a substance abuse 

counselor (SACO), healthcare provider 

or mental health professional.

How do you know if 

you drink too much? 

Answer “yes” or “no”: 

•	 Do you drink alone when you feel 

angry or sad? 

•	 Does your drinking ever make you 

late for work? 

•	 Does your drinking worry your 

family? 

•	 Do you ever drink after telling 

yourself you won’t? 

•	 Do you ever forget what you did 

while you were drinking? 

•	 Do you get headaches or have a 

hang-over after you have been 

drinking? 

If you answered “yes” to any of these 

questions, you may have a drinking 

problem. Check with your doctor to be 

sure. Your doctor will be able to advise 

you whether you should cut down or 

abstain.

If you are alcoholic or have other 

medical problems, you should 

stop drinking completely, not just 

cut down. Your doctor will help 

you decide what is right for you.

Do you have a problem?

Managing Combat & Operational Stress A Handbook for Marines & Families 21 U.S. Marine Corps photo by Sgt Rachael Moore
22 Your Health Care Provider

Psychotherapy

aims to increase a person’s sense 

of own well-being. It can use a 

range of techniques to improve 

mental health. Any therapy will 

require commitment and regular 

practice to be effective, similar to 

physical training.

Cognitive processing therapy

helps by giving skills to handle 

distressing thoughts and gain an 

understanding of triggering events. 

This can give insight on why 

recovery has been hard and help 

show how going through a combat

or operational stress changed the 

way a Marine looks at the world, 

themselves and others.

Beliefs about safety, trust, control, 

self-esteem, other people and 

relationships can change after 

experiencing combat or operational 

stress. Cognitive processing 

therapy can help to find a better 

balance between the beliefs held 

before and after combat and 

operational stress. 

Prolonged exposure therapy

works by helping Marines approach 

triggering thoughts, feelings and 

situations they may have been 

avoiding due to the distress they 

cause. Repeated exposure to these 

thoughts, feelings and situations at 

a comfortable pace helps reduce 

the power they have to cause 

distress. With the help of a therapist, 

Marines can change how they react 

to stressful memories. This allows 

mastery of stressful situations and 

returns control of life back to the 

Marine.

Eye movement desensitization 

and reprocessing (EMDR)

EMDR is another type of therapy 

that can help change reactions to 

triggering memories for some people.

While thinking of or talking about 

memories, the therapist will provide 

other stimuli like eye movements, 

hand taps and sounds for focus. 

Experts are still learning how EMDR 

works. Studies have shown that 

it may help relieve stress injury 

symptoms, but research also 

suggests that the eye movements are 

not a necessary part of the treatment.

Spiritual counseling 

Can often help a Marine regain a 

sense of safety and purpose in 

Your health care provider may recommend various treatments

Questions to 

ask about 

therapy:

•	 Have you worked with people who 

have been through stress injury 

symptoms?

•	 Do you have special training in 

PTS treatment?

•	 What can I hope to achieve in 

therapy?

•	 Which kinds of treatment(s) will 

help me the most?

•	 Are there risks with this treatment?

•	 How long will I require this 

treatment?

•	 When should I start to feel better?

The Marines Corps encourages Marines to seek mental 

health treatment for issues related to combat or operational 

stress. Untreated stress can hurt a career.

U.S. Marine Corps photo by Staff Sgt Jennifer Brofer
life after stress issues. A chaplain, 

minister, priest, rabbi or other 

spiritual leader can help the person 

find meaning and reconnect with his 

or her spirituality.

Group therapy

In group therapy, Marines can talk 

about their stress injury with others 

who have had similar experiences. 

This can help them feel more 

comfortable talking about the 

stress injury and help cope with 

symptoms, memories, and other 

parts of life. Group therapy helps 

build relationships with others and 

teaches how to deal with emotions 

such as shame, guilt, anger, rage 

and fear. Sharing with the group 

builds self-confidence and trust. 

It also builds focus on the present, 

rather than feeling overwhelmed 

by the past. 

Family or marriage counseling

Stress injuries can affect the whole 

family when children or a partner 

may not understand the anger, 

or why their Marine is under so 

much stress. The family may feel 

scared, guilty, or even angry about 

the condition. Family therapy is a 

type of counseling that involves 

the whole family and can augment 

individual therapies. A therapist 

helps families to communicate, 

maintain good relationships, cope 

with tough emotions and learn more 

about stress injuries or illness and 

treatments.

Psychodynamic psychotherapy

teaches ways of dealing with 

emotional conflicts caused by 

combat or operational stress. This 

therapy helps Marines understand 

how their past affects the way they 

feel now.

Medication

Most of the time, medications 

provide a symptom reduction and 

are best used with a program of 

psychotherapy. There are also other 

medications to manage specific 

symptoms that have been used with 

some success. Talk to your doctor 

about which medications are right 

for you. 

Selective serotonin re-uptake 

inhibitors (SSRIs) are a type of 

antidepressant medicine that 

appear to be helpful and very 

effective in helping some people 

feel less sad and worried. SSRIs 

raise brain levels of serotonin, a 

chemical affecting feelings of wellbeing.

If you become more depressed, 

anxious or suicidal while taking 

antidepressants, get medical 

help right away. Never change 

the dose, start or stop taking 

them, without direction from your 

healthcare provider.

Note: The U.S. Food and Drug 

Administration (FDA), has added 

warnings to some antidepressants 

as there is a risk of worsening 

depression or increasing thoughts 

of suicide. Discuss all risks and 

benefits of any medication with your 

healthcare provider.

Please read: This handbook 

is not able to list all the risks, 

benefits, side effects and 

special precautions for each 

medication discussed. Patients 

should talk with their healthcare 

provider about these issues 

for each medication prior to 

use. Use medications only as 

prescribed or directed by your 

healthcare provider.

Managing Combat & Operational Stress A Handbook for Marines & Families 23

Questions to 

ask when taking 

medication:

•	 Is this medication potentially 

addictive and what signs should I 

look for when taking it?

•	 How will this medication 

interact with other medications 

prescribed or available over the 

counter? Will foods or herbs 

interact with this medication?

•	 How long should I expect to be 

taking the medication?

•	 Review regularly which 

medications to continue and 

whether they are all still required.

U.S. Marine Corps photo by Aquita Brown
TBI and PTS reactions

A TBI is basically a concussion that 

can occur even when there is no 

direct contact to the head and even 

when wearing a helmet. For example, 

when a person suffers whiplash, the 

brain may be shaken within the skull. 

Many of the symptoms that follow 

a TBI overlap with the common 

stress reactions, so it can be hard to 

determine the underlying problem and 

since the two often occur in the same 

person, the presence of one should 

alert leaders and caregivers to the 

possibility of the other.

It is important to be assessed because 

those who sustain TBI should not use 

some medications as the effects could 

be serious, no matter how mild or 

severe the injury.

TBI can be caused by:

� Explosion or blast.

� Fragment striking the head.

� Blunt object strike.

� Fall. 

� Motor vehicle crash.

� Gunshot wound. 

� Other.

Common symptoms

following a TBI

These symptoms are part of the 

normal process of getting better, but 

are not signs of lasting brain damage.

Physical

� Headache. 

� Feeling dizzy. 

� Being tired. 

� Trouble sleeping. 

� Vision problems. 

� Feeling bothered by noise 

and light.

Cognitive (Mental)

� Memory problems. 

� Trouble staying focused. 

� Poor judgment and acting without 

thinking. 

� Being slowed down. 

� Trouble putting thoughts 

into words.

Emotional (Feelings)

� Depression. 

� Anger outbursts or being quick 

to anger. 

� Anxiety (fear, worry or 

feeling nervous). 

� Personality changes.

Getting the right diagnosis

is important

Only a healthcare provider or mental 

health professional can diagnose PTS. 

Generally, a diagnosis of PTS is based 

on a person:

�	Going through a traumatic event 

(or events) that caused intense fear, 

helplessness or horror.

� Suffering from symptoms 

(described on page 3, Red Zone) 

— reliving the traumatic event(s), 

avoiding people or situations and 

acting as though danger is still 

present — after the traumatic 

event(s).

� Experiencing significant distress 

from symptoms.

� Having symptoms for a longer 

period of time.

PTS is a severe, prolonged 

reaction to traumatic stress.

24 Traumatic Brain Injury (TBI) and Posttraumatic Stress (PTS)

Traumatic Brain Injury (TBI) 

 and Posttraumatic Stress (PTS)

U.S. Marine Corps photo by Cpl Mondo Lescaud
A healthcare provider or mental health 

professional can also determine if a 

person has some other stress issue, 

even if that person does not meet the 

criteria for a PTS diagnosis.

Some Marines may be at a higher 

risk for stress issues.

Not all contributing factors for 

stress illness are known and why 

Marines react differently to similar 

circumstances is not well known. 

Studies have highlighted various risk 

factors.

This includes people who:

� Were physically or sexually abused 

as children.

� Are or were victims of domestic 

violence.

� Have other mental health problems, 

such as anxiety or depression.

� Have witnessed or been victims of 

other traumatic events such as car 

accidents, earthquakes, rape or 

terrorist events.

� Have other major problems in their 

lives, such as financial, legal or 

relationship problems.

Here are some ways to better 

understand stress illness:

� Stress illnesses are a medical 

condition that can be treated.

� Talk about your recovery to help 

others understand the challenges 

of recovery.

� Show strengths and use your 

talents. Don’t let stress illness stop 

activities.

� “You are the message.” Show how 

you wish to be treated by actions. 

Treating yourself with respect sets 

an example for everyone.

� Accept that you may need breaks 

during activities. Stress illness 

symptoms may make it harder to 

focus for very long.

� Work with your family and doctor 

to set manageable goals and make 

changes as you needed.

Coping with stress actively reduces 

feelings of helplessness.

� Accept the impact of stress on 

life and take direct action for 

improvement.

� Taking direct action to cope with 

stress dictates a position of power.

� Active coping is a way of 

responding to everyday life. 

Regularly building active coping 

into everyday solidifies a healthy 

habit.

Healing stress illness

is similar to physical injuries: it is a 

process. Just like someone with 

a physical injury, those with stress 

illnesses must account for changes 

in abilities. This does not mean 

disqualification from life. Maintain 

hope and do not quit.

Acknowledge the illness to realize 

the need for help. Some people are 

unaware that significant impacts to 

career or behaviors and relationships 

are signs of a stress illness. Often they 

will self-medicate as they try to figure 

out what is wrong which can make it 

worse. They may be aware of stress 

illnesses or PTS but deny they could 

have either due to stigma

(see page 27).

Name it and understand it: Learning 

how to manage stress illnesses can 

begin once it is acknowledged.

Move forward: In the event of a 

setback, plan to regroup and continue. 

Be realistic about expectations, know 

what will trigger problems and find 

ways to mitigate.

Always reassess: Based on 

personal history, reassess healing 

and interacting with the environment. 

In the event of a setback, figure out 

what happened and why. Then set 

reasonable goals and keep going.

Managing Combat & Operational Stress A Handbook for Marines & Families 25

U.S. Marine Corps photo by Sgt Mark Fayloga

Marines, attached Sailors, 

and families call: 

Anonymous DSTRESS Line at 

1-877-476-7734 and online chat 

at www.dstressline.com. 

Veterans or Service members

and families call: 

Confidential Military Crisis Line at 

1-800-273-8255 and press 1, 

use the online chat at 

www.veteranscrisisline.net or send 

a text message to 838255.

For emergencies call 

9-1-1 or go to your nearest 

Emergency Room. 
26 Coping with Stress Issues

Positive coping

Reminder: recovery is a process.

� Stressors will not simply 

disappear; plan how you will 

respond and take control.

� Many others face similar stressrelated issues; you are not alone. 

Others can offer support through 

their experiences.

� Practice relaxation methods (see 

pages 8-9 and 12-13).

Coping with the symptoms of 

stress:

Unwanted distressing memories, 

images, or thoughts

� It’s natural to have memories of the 

combat or operational stress.

� Discuss this with a trusted person.

� Remember that reminders of 

combat or operational stress often 

lessen with time.

Sudden feelings of anxiety 

or panic

Stress reactions often include heart 

pounding and feeling light-headed 

compounded by rapid breathing. 

� These reactions are not of 

themselves dangerous. 

� The accompanying scary thoughts 

are what make these reactions so 

upsetting.

� Slowing down breathing may help.

� It will soon pass.

� Responding in positive ways will 

help it happen less often.

Feeling like the combat or 

operational stress is happening 

again (flashbacks) 

Reminder: this is common after 

combat or operational stress.

� Note current surroundings.

� Remind yourself that you are safe. 

The combat or operational stress 

happened in the past - not in the 

present.

� Get up and move around. 

Reestablish the present with 

simple tasks like drinking water or 

washing hands.

� Call a trusted person to talk.

� Discuss with a counselor or doctor. 

Dreams and nightmares related to 

the combat or operational stress

Reminder: this is a dream and not real 

danger.

� Orient to the present by getting up 

from bed.

� Engage in a pleasant, calming

activity like listening to music.

� Talk to someone if possible.

� Discuss with your doctor. Certain 

medications can be helpful.

Difficulty falling or staying asleep

� Keep to a regular bedtime routine.

� Avoid heavy exercise for several 

hours just before going to bed.

� Avoid using your sleeping area for 

activities beyond sleep or sex.

� Avoid alcohol, tobacco and 

caffeine.

� Do not lie in bed thinking or 

worrying. Get up and enjoy 

something soothing or pleasant. 

Read a book, do a quiet hobby.

Irritability, anger and rage

� Walk away from the situation to 

take time out to think and cool off. 

� Use daily exercise to reduce body 

tension and relieve stress.

� Don’t stay angry: it increases stress 

and can cause health problems

� If you blow up at family members 

or friends, find time as soon as 

possible to talk about it. Let them 

know what you are doing to cope 

with your reactions. 

� Talk to a counselor or doctor about 

anger. Take classes in managing it.

Difficulty concentrating or staying 

focused

� Slow down for better focus. 

� Write things down; lists may be 

helpful. 

� Break tasks into smaller chunks.

� Plan a realistic number of events 

or tasks for each day.

Trouble feeling or expressing 

positive emotions

This is a common reaction to combat 

or operational stress.

� Continue enjoyable activities even 

if initially difficult.

� Show loved ones you care in 

various ways: write a card, leave a 

small gift or phone someone and 

say hello.

� Try different methods to see which 

are most helpful. As other skills, it 

is improved with practice.

Negative coping

Some common behaviors don’t help 

and may make a situation worse in 

the long run.

Substance abuse is taking drugs or 

alcohol to feel better. This might be to 

escape problems, help sleep or ease 

stress symptoms. Substance abuse 

can lead to bad decisions that risk 

relationships, employment and health 

(See pages 20-21 for mitigating 

strategies).

Avoiding others

� Fear of social situations can lead 

to avoiding others. Social support 

is part of healthy coping.

� If distanced from others, problems 

may seem to build up and cause 

more negative thoughts, sadness 

and fear, reinforcing a sense of 

aloneness. 

� Take part in social activities even 

if it doesn’t sound good initially. 

It will increase chances of feeling 

good and having fun.

Staying always on guard may seem 

reasonable after experiencing combat 

or operational stress, this only 

causes more stress, fearfulness and 

drains energy (See pages 12-13 for 

mitigating strategies).

Avoiding reminders of the combat 

or operational stress by shutting out 

Coping with stress issues
feelings may seem reasonable but 

doesn’t work because the effort takes 

a lot of energy and prevents progress 

in coping. 

Anger and violent behavior

� Anger may cause a loss of temper 

and reckless actions. It can 

distance people who may try to 

help. 

� It’s natural to feel angry after going 

through combat or operational 

stress. Uncontrollable anger and 

violent behavior can cause other 

problems and reduce access 

to help by alienating people 

(See pages 16-17 for mitigating 

strategies). 

Dangerous behavior

� It is common to try coping with 

risky or dangerous activities, such 

as driving too fast or starting 

fights. This can cause injury to self 

or others. 

� Smoking is dangerous to health. 

� Overeating to relieve stress can 

cause weight gain which can also 

compromise health. 

Working too much

� Work is a good thing for learning 

new things, interacting with 

others, and gaining confidence 

but too much can be a form of 

avoidance. 

� It may lead to putting off seeking 

help by diverting attention. 

� It reduces time with family and 

friends and their support.

� It can impact sleep and eating 

right, both important to recovery. 

Stigma

is negative views about things 

people don’t know much about, 

such as mental health. Everyone 

has a role in reducing stigma.

Stigma occurs when others think:

� Stress injuries and illnesses can’t 

be treated.

� Stress is someone’s fault or is 

something to get over. 

� It is contagious.

� Stress injuries make people 

dangerous.

� Stress injuries and illnesses 

aren’t real.

Stigmas can keep someone from 

seeking or receiving treatment. 

Leaving stress untreated allows it to 

become worse.

You have control of how you are 

viewed. Actions and treatment 

of others will influence people’s 

attitudes about stress injuries and 

illnesses. When people understand 

health injuries, they are more likely 

to rise above negative views. Self 

respect is an important part of 

recovery. 

Peer Support

Others who have experienced 

combat or operational stress are 

good sources of understanding 

and support. Contact with others 

who have had similar experiences 

will reduce isolation and distrust 

of others. OSCAR Team Members 

are trained Marines, many with 

similar experiences. Veterans may 

find benefit in joining a veterans’ 

organization. 

It may be hard to join a peer support 

group. It may not seem useful 

or it may be difficult to trust new 

people. It can be a great relief to 

take positive action and learn that 

others are dealing with the same 

issues. Working with others can also 

develop into friendship in time.

“It’s okay 

to not be 

okay.” 

— General James F. Amos

Commandant of the 

Marine Corps

Managing Combat & Operational Stress A Handbook for Marines & Families 27

U.S. Marine Corps photo by Cpl Michael Petersheim
28 For Friends and Family

Effective 

communication 

is important 

� Focus on making communication 

as non-confrontational as 

possible ... this can be easier 

said than done during a stressful 

transition period.

�	Make time for the family to talk 

together, including any children. 

Even “too young” children 

respond to company and 

conversation.

�	Be respectful to each other when 

discussing issues, especially in 

front of children.

Ways you can help

Learn as much as you can about 

stress issues. Knowing how stress 

affects people may help you 

understand what your Marine is 

going through. The more you know, 

the better you and your family can 

handle stress issues.

Tell your Marine you want to listen

and that you also understand if he 

or she doesn’t feel like talking. Let 

your Marine talk about the combat 

or operational stress event at his or 

her own pace.

Offer to go to doctor visits with 

your Marine. You can help keep 

track of medicine and therapy, and 

you can be there for support.

Plan family activities together, like 

having dinner or going to a movie.

Do physical activities together 

like taking a walk, going for a bike 

ride, or some other things you enjoy. 

Exercise is important for health and 

helps clear your mind.

Encourage contact with family and 

close friends. A support system will 

help your Marine get through difficult 

changes and stressful times.

Your Marine may not 

want your help. If this 

happens, keep in mind 

that withdrawal can be a 

symptom of stress. Give 

your Marine space, but 

tell him or her that you will 

always be ready to help. 

Offer support and 

safety

Just being there for 

your Marine can be a 

tremendous comfort. It 

can help your Marine avoid 

the isolation that often 

comes with combat and 

operational stress. Some 

other ways to offer support:

If your Marine wants 

to talk about his or her 

experiences, be there to 

listen. Believe what your 

Marine tells you. Don’t 

minimize what he or she 

has been through.

Avoid trying to solve your Marine’s 

problems or telling him or her what 

to do. Reassure your Marine that 

you care about him or her no matter 

what.

Respect your loved one’s wishes.

Allow your Marine to make his or her 

own decisions. It can help him or her 

to feel in control again. Additionally, 

your loved one may need a lot 

of time to heal from combat or 

operational stress, and may not feel 

like participating in some activities.

Suggest sources of help.

Encourage your Marine to get the 

help he or she needs — but don’t 

force it. You can help your Marine 

find healthcare providers, mental 

health professionals or a treatment 

program. You should also encourage 

him or her to maintain friendships, 

stay in touch with other family 

members or join a self-help group 

(see pages 30-32 for more sources 

of help).

Relationship 

maintenance

The best thing for the relationship is 

to make time for each other. This can 

be as simple as setting aside a few 

hours as a couple once a week. If 

you need to get a babysitter, do so. 

Make an effort to foster intimacy and 

closeness. 

Spouses may experience several 

emotions, from relief to gratitude 

to irritation. Being left alone for a 

long time and forced to become 

very independent can lead to 

frustration at the loss of privacy or 

independence they didn’t realize 

they wanted before their Marine left. 

This may also cause feelings of guilt 

along with the sense of relief their 

Marine is alive, safe and home.

For friends 

 and family

Personal growth links:

•	 Joesgoals.com

•	 Posttraumatic growth inventory

•	 milblogging.com 

“It is critical that we work together 

to prevent stress issues and reach 

out to any fellow Marine who is 

showing signs of stress. We must 

ensure every Marine understands 

that seeking help for these issues 

is not a sign of weakness. The 

negative impact of stress is an 

invisible enemy we can’t afford to 

ignore.” 

— Sergeant Major Michael P. Barrett, 

Sergeant Major of the Marine Corps
Prior to deployment, there was a 

whirlwind of emotion to manage. At 

some point during the deployment, 

it normalized as the routine 

developed with day-to-day life 

and everyone became used to 

their Marine being gone. Now that 

the Marine is back, the whirlwind 

begins again.

Any Marine can have an adverse 

reaction to stress.

Even very experienced Marines can 

be affected. That’s why all friends 

and family members should stay 

alert for stress reactions in their 

Marines.

Get counseling if needed.

Your Marine’s reaction to combat 

or operational stress can seriously 

affect your relationship. For 

example, you may:

�	Be fearful of talking about the 

triggering event.

�	Have difficulty talking to your 

loved one.

�	Feel emotionally cut off from him 

or her.

�	Be discouraged that your loved 

one has not recovered from the 

stress.

Marital or family counseling can 

help you and your Marine deal 

with these issues together. Even if 

he or she does not want to go to 

counseling, get help for yourself.

To find a mental health professional 

or counselor who can help you 

cope with your Marine’s combat 

or operational stress, contact your 

Marine and Family Services Center, 

your chaplain or other spiritual 

counselor, your base health clinic, 

a VA facility, or a private mental 

health professional or clinic (see

pages 30-32 for more sources of 

help).

Maintain routines

This can give you, your family and 

your Marine a sense of order and 

comfort in that some things have 

returned to normal. For example, 

if you usually have dinner together 

every night, stick to that routine as 

much as possible.

Be kind to yourself

It is easy to neglect yourself if you 

are taking care of others. But to 

most effectively help others, you 

need to take care of your own 

needs.

�	Eat healthy foods and get 

enough exercise. Talk to your 

health-care provider before 

starting an exercise program.

�	Relax, rest and get enough 

sleep. Keep in touch with 

friends. Do things you enjoy.

Managing Combat & Operational Stress A Handbook for Marines & Families 29

How to create a better 

family climate

•	 Talk to each other.

•	 Be kind and thoughtful even when it isn’t easy.

•	 Spend time together, such as eating dinner 

together and doing other fun activities like games 

and outings.

•	 Make your relationship a priority and focus on the 

present while paying attention to your children.

•	 Focus on the positive by capitalizing on strengths 

and cheerfully compensating for any weaker 

areas to create a sense of being a team.

•	 Focus on relaxing and creating a sense of 

normalcy through routine tasks.

•	 Keep interactions upbeat when parting even if you 

have a disagreement.

•	 Remember quality of time spent together is more 

important than the quantity of time.

U.S. Marine Corps photo by Lance Cpl Jacob Barber
Sources of help 

 and information

Operational Stress 

Control & Readiness 

(OSCAR) teams

OSCAR is Marine-led training that 

builds teams of Marine leaders, 

medical and religious ministry 

personnel and Mental Health 

Professionals who work together 

to provide a network of support 

within each battalion-level unit. 

OSCAR teams serve as known, 

easily approachable immediate 

points of contact, noticing small 

changes in behavior and taking 

action early on stress-related issues; 

encouraging those who need help 

to get it. Providing early intervention 

as appropriate, OSCAR teams help 

Marines maintain full readiness. 

OSCAR Team Training occurs across 

the total force supporting Marines in 

theater, in garrison, and at home.

OSCAR Mentor/Team Members

Identify, support, and advise their 

fellow Marines on stress-related 

issues to help prevent stress from 

becoming a more serious issue.

OSCAR Extenders 

Provide counseling and referral as 

required. They are medical personnel 

including medical officers and 

corpsmen and religious ministry 

personnel including chaplains 

and religious program specialists 

assigned to Marine Corps 

commands.

OSCAR Mental Health Professionals 

Provide follow on in-depth mental 

health care. They are assigned to 

some Marine Corps commands and 

are available at most installation 

medical treatment facilities (MTF).

DSTRESS

is anonymous and open 24/7/365, 

providing counseling services (on 

various topics) to Marines, attached 

Sailors, and family members who 

speak with “one of their own.”

�	Voice/Text (domestic and 

international) 1-877-476-7734 

�	Okinawa (DSN) 645-7734; (local 

cell or local land line) 098-970-

7734; (US based VOIP) 1-877-

476-7734 

�	MCAS Iwakun (DSN) 645-7734; 

(local cell or local land line) 098-

970-7734

�	www.dstressline.com

Marine Corps Family 

Services 

Offers classes, information, referral, 

and counseling on a wide range of 

topics. They are located on Marine 

Corps facilities.

�	East of the Mississippi River: 

(800) 336-4663

� West of the Mississippi River: 

(800) 253-1624 

Military OneSource

Available to assist service members 

and families throughout the 

deployment cycle, on any topic, 24/7.

�	CONUS: (800) 342-9647; 

OCONUS: (country access 

code) (800) 342-9647 (dial all 11 

numbers); 

International: (800) 464-8107.

�	www.militaryonesource.com

Defense Centers of 

Excellence (DCoE) 

Outreach Center

provides 24/7 information and 

resources about resilience, recovery 

and reintegration.

�	(866) 966-1020

�	E-mail: resources@dcoeoutreach.

org

� www.dcoe.health.mil/24-7help.

aspx 

National Guard 

Support Center

Assists National Guard and other 

reserve service members.

�	www.jointservicessupport.org

Veterans Affairs

Healthcare information, VA medical 

center facility locator and benefits 

assistance for veterans.

�	(877) WAR-VETS (927-8387)

�	VA facility locator: www2.va.gov/

directory/guide/home.asp. Each 

VA medical center and many VA 

clinics have stress injury and PTS 

specialists. 

�	VA PTSD program locator: 

www2.va.gov/directory/guide/

PTSD_flsh.asp?isFlash=1

American Red Cross

provides confidential counseling, 

guidance, information, referrals 

and other services at offices on 

Marine Corps installations and their 

worldwide network of chapters.

�	Active-duty service members can 

call (877) 272-7337.

30 Sources of Help

Region Locations Phone Numbers

Atlantic HQ Co., H&S BN, 4th MLG (Marietta, GA) 678-655-7177 / 679-688-7179

Mid West 24th Marine Regiment (Kansas City, MO) 816-843-3675 / 816-843-3678

North East 25th Marine Regiment (Devens, MA) 978-796-2306 / 978-796-3633

North West 4th LSB, H&S Co. (Ft. Lewis, WA) 253-477-2611 / 253-477-2612

South HQ, MARFORRES (New Orleans) 504-678-6188 / 504-678-6186

South West 23rd Marine Regiment (San Bruno, CA) 650-244-9806, ext. 1007 / ext. 1503

Psychological Health Outreach Program (PHOP)

Assists Navy and Marine Corps reservists with psycological health services.
U.S. Air Force photo by Sgt Elyssa Quesada

Psychotherapy, medication and self-help 

techniques can help ease depression. If you feel 

depressed, seek treatment from a healthcare 

provider or mental health professional. In the past 

month, how much have you been bothered by any 

of the issues below?

` Feeling down, depressed or hopeless?

` Little interest or pleasure in doing things?

` If you have consistently had either of these 

issues in the past month, you should be 

evaluated by a health care professional.

Depression is treatable

Stress issues are 

manageable.

With treatment, most Marines and veterans with 

combat and operational stress issues can move on 

to full, satisfying lives. Generally, symptoms lessen 

over time.

Some may experience continuing flare-ups of their 

symptoms — for example, when they are exposed 

to a situation or an event that reminds them of 

combat or operational stress. Daily management of 

symptoms becomes easier with practice.

Managing Combat Operational Stress A Handbook for Marines & Families 31

Marines, attached Sailors, 

and families call: 

Anonymous DSTRESS Line at

1-877-476-7734 and online chat 

at www.dstressline.com. 

Veterans or Service members

and families call: 

Confidential Military Crisis Line 

at 1-800-273-8255 and press 1, 

use the online chat at 

www.veteranscrisisline.net or 

send a text message to 838255.

For emergencies call 

9-1-1 or go to your nearest 

Emergency Room. 
32 

Real Warriors Campaign

Real stories of strength and hope 

along with other useful news and 

information to build warrior and 

family resilience to support return 

and transition. Sponsored by DCoE.

�	www.realwarriors.net

Afterdeployment.org

Information and self-guided 

solutions for dealing with health 

and wellness, stress, relationship 

problems, children and deployment, 

conflict at work, anger, living with 

physical injuries, sleep problems, 

depression, posttraumatic stress 

and war memories, alcohol and 

drug abuse and spiritual guidance 

and fitness.

�	www.afterdeployment.org

Military Pathways

provides free, anonymous mental 

health and alcohol self-assessments 

for service members (including the 

National Guard and Reserve) and 

families, available online and over 

the phone. The self-assessments 

help create a picture of how an 

individual is feeling and whether 

they could benefit from talking to a 

health professional.

�	www.militarymentalhealth.org

HQMC Combat & 

Operational Stress 

Control (COSC)

assists commanders and leaders 

in maintaining their warfighting 

capabilities by addressing the 

impacts of stress. COSC activities 

enhance force preservation, 

readiness and the long-term 

health and well-being of Marines 

and their families. COSC efforts 

include OSCAR, Deployment Cycle 

Training (DCT), and COSC plans, 

policies, tools and resources. These 

initiatives prevent, identify, and 

manage combat and operational 

stress-related issues and increase 

access to mental health care by 

breaking stigma; raising awareness; 

providing education and resources 

to support Marines. COSC is the 

lead for all matters pertaining to 

combat and operational stress 

control in the Marine Corps. 

�	www.manpower.usmc.mil/cosc 

Behavioral Health 

Information Network 

(BHIN)

is an information clearing house, 

providing the latest information, 

tools and resources related to 

behavioral health, free for Marines, 

Sailors and families. Sponsored by 

HQMC Behavioral Health.

� www.usmc-mccs.org/bhin

Human Performance 

Resource Center 

(HPRC)

Addresses the mind-body 

connection in wellness and 

recovery.

�	http://HPRC-online.org

32 Sources of Help

U.S. Marine Corps photo by Cpl. Tyler Main

Marines, attached Sailors, 

and families call: 

Anonymous DSTRESS Line at

1-877-476-7734 and online chat 

at www.dstressline.com. 

Veterans or Service members

and families call: 

Confidential Military Crisis Line 

at 1-800-273-8255 and press 1, 

use the online chat at 

www.veteranscrisisline.net or 

send a text message to 838255.

For emergencies call 

9-1-1 or go to your nearest 

Emergency Room. 
U.S. Marine Corps photo by Sgt Pete Thibodeau

Even the most motivated and well-trained Marines 

can find themselves challenged by combat and 

operational stress. Some Marines can overcome 

these problems on their own and some are going to 

need help. Early intervention is key. 
For more information:

Combat & Operational Stress Control

www.manpower.usmc.mil/cosc