In an effort to identify and treat Marines who suffer from post-traumatic stress disorder (PTSD), the Navy and Marine Corps have developed certain protocols in recent years. Psychiatrists, nurse practitioners and psychiatric technicians deploy with and also live in regiments on the front lines with troops.

“My personal job No. 1 is trying to figure out ways to reduce suicide rates and help folks with PTSD. There are underlying health issues,” explained U.S. Navy Commander Charles Benson, psychiatrist for the 1st Marine Division operational forces at Camp Pendleton. “The whole idea is to embed mental health professions in. Our job is to get down into the batallion level … and experience the same hardships … so we’re much more approachable because they know us; they see us all the time.”

Benson, who recently returned from a tour of duty in the Middle East, coordinates the mental health program for Camp Pendleton and acts as the senior mental health provider for the 1st Marine Expeditionary Force. Another psychiatrist presides over the Naval Hospital at Camp Pendleton.

It’s all part of Operational Stress Control and Readiness (OSCAR), the mental health arm of the Marine Corps.

Of the Marine Corps’ three Marine Expeditionary Forces—the 1st Marine Logistics Group, Marine Airwing and 1st Marine Division—PTSD prevention and treatment efforts concentrate on the 1st Marine Division. This division comprises all ground troops, which bear the brunt of on-the-ground fighting, along with, to a lesser degree, the logistics group.

A large and coordinated Navy medical response addresses Marine PTSD issues, incorporating a huge number of people spread throughout the U.S. and including Navy Medicine, the Veterans Administration and the Department of Defense. The Navy provides the Marines with its medics, corpsmen and nurses.

“Marines go off and fight folks and go through a lot of traumatic stuff,” Benson said.

A normal response is to shut down emotionally. Trauma and fear trigger a Marine to fall back on training to fulfill the mission. Meanwhile, the troop files away the accompanying grief to be dealt with later.

Later, the essential grieving process can begin and the normal brain process is to reconnect and reintegrate the emotion of the event with the memories of the event, such as the death of a buddy, Benson said.

The vast majority of Marines heal with no intervention, but many factors can cause a minority to have problems reintegrating emotions with memories, said Benson.

When PTSD develops, avoidance behavior kicks in to force the mind away from events or a series of events too painful to remember. So the Marine avoids things that generate memories, such as certain activities, smells or foods. But this avoidance behavior prevents reintegration and healing.

Taking into account the time necessary to heal, PTSD usually is not seen or diagnosed until six months after the trauma or six months after the Marine comes back, whichever comes first.

Usually the Marine can sleep off combat stress, or what used to be called battle fatigue, and the Marine returns to battle. But occasionally in combat, acute stress response occurs and the Marine stops functioning and phases out.

OSCAR makes sure Marines are taught about PTSD and screened for signs of being at-risk before, during and after deployment. Marines can be at risk from extra or ongoing anxiety, mental illness, depression, ongoing PTSD from previous deployment, or from childhood experiences. So, officers look for signs of risk, and they recognize, understand and treat their Marines. If an at-risk Marine is identified, he or she won't be allowed to deploy.  

Extensive preventive measures include building a small, highly cohesive unit that trusts each other and its leaders. Marines are trained on mental health issues through a Combat Operational Stress Continuum. They learn to recognize and self-monitor using a color-coded system. Green represents one’s state of mind when sitting around relaxing. But the stress continuum progresses through yellow, orange and red, indicating intensity of problems.

OSCAR providers such as psychiatrists and psychiatric technicians expand their effectiveness by training people they call OSCAR extenders, which includes chaplains and all officers through senior levels, in mental health issues. Providers train senior mentors and peer mentors in the stress continuum. “They know the Marines and what their stresses are, so if there’s an issue they will know that and get help because they are at hand,” Benson said.

Deployed Marines have access to stress control clinics, psychiatric clinics or mental health clinics typically staffed by four providers and four psychiatric technicians. Stress often mounts after Marines return, often because of relationship problems. So, batallion officers perform a Post Deployment Health Assessment, a standardized primary medical screening, on every active duty, 30 days before they come back.

OSCAR providers help with this assessment, particularly for units in combat, to make sure the right questions are asked, and they treat anybody displaying mental health concerns right there. Or after they get back, Benson works closely with batallion medical officers to contact those Marines and help them.

Right after returning, Marines are screened again. Then, between three and six months after they get back, Marines undergo a more detailed Post Deployent Help Reassessment (PDHRA). Benson said the Post Deployment Center is very helpful. Individual and group psychotherapy are applied first. “Medications may play a role, but that’s not what we first jump to,” Benson said. “First, they go through a very thorough diagnosis. Every person—there’s no generic case. All are very specific; there are a lot of factors.

Psychotherapy is the primary means. Marines come in and talk to somebody, sometimes doing some homework. They usually resolve 60 to 70 percent of cases significantly over a period of three to six months. If their command asks them to get help, or they come through an emergency room, they are referred back and put them through the same treatment.

Benson said the 40 percent who don’t respond to psychotherapy might respond to medication, depending on what type. Marines who suffer nightmares, cannot sleep, or have trouble regulating moods (i.e., have angry outbursts) are medicated for short periods to enable them to go through psychotherapy. Benson said he was shocked when he learned how few do get medicated. “We don’t see anybody say, ‘This guy is on lots of medication.’ ”

If the PTSD is so significant it becomes a disability, options include medical retirement or referral to a Veterans Administration hospital. “Probably 20 percent, we have to go to that length,” Benson said. “But that’s usually after years of trying to treat you in the military system.” Marines no longer able to stay in their unit can be placed in a Wounded Warrior facility. He described the Mental Health Department at the Naval Hospital at Camp Pendleton as very robust, and the one at the San Diego Naval Hospital at Balboa as even more so, with a residential treatment center for intensive treatment.

Both hospitals helped OSCAR bring in extra providers and give extra screenings and help for units that see extra combat. An example is the 3rd Batallion, 5th Marine Regiment, which suffered unusually large numbers of casualties and wounded during 2010-11 deployments. “We had a conversation with every Marine,” Benson said. “If there were issues, we invited them back for another visit. We can flex additional resources.”

One of the many organizations that research PTSD and brain injuries, and look for interventions is the Naval Center for Combat Operational Stress Control, the research and education arm in San Diego. The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury in Washington, D.C., looks at the bigger picture for prevention and treatment.

Benson said Marines no longer fear retribution or job loss for seeking help. “It’s a different Marine Corps than 10 years ago even,”  he said. “We’ve come a long way. ... As a society we are [getting over the stigma], and Marines reflect that. Commands care deeply about their folks; all they care about is get the help you need. We’re still educating, but generals and senior colonels understand the major issue and suicide rates, so they are eager to help. Career issues is a nonissue.”

Camp Pendleton also provides a civilian group, Families Overcoming Under Stress (FOCUS), under the Bureau of Navy Medicine Program, with site director Dr. Larinda Morgan. Tom Babayan, lead family resiliency trainer, works with families of Marines and sailors, “because PTSD has a lot of effects not only on individuals but within the family, also. During wartime, routines and roles are disrupted. Deployments and reintegration may cause stress for children and spouses.”

With its main office in the Marine and Family Services Building, it also operates out of San Luis Rey, Wire Mountain Teen and Youth Center and San Onofre.

The focus is on the entire family, especially prevention programs to prepare families for deployment, assist families during deployment and help them with resiliency after deployment. Resiliency training teaches families not just to meet challenges but also become stronger in the face of challenges. Resiliency skills that FOCUS staff members teach include successful communication for couples and families; emotional regulation, or managing one's emotions; and creative and collaborate problem-solving. They also help families set achievable and measureable goals.

Families also learn how to deal with trauma or loss reminders, which can cause more distress. For example, a car backfiring can be a trigger or reminder that can lead to a flashback and an elevated startled response. “We find a good deal of participation,” said Babayan. “I think the resources on base and in the Marine Corps in general do a good job of supporting us.”

The FOCUS program is customized to meet specific needs of each family member and different families. It offers family consultations, family level training, small group training, and workshops. It teaches families practical skills to help them meet the challenges of multiple deployments, combat stress, and physical injury. It also builds connections with other military family providers to support a network of care for families.

FOCUS is based on programs that show positive outcomes for families facing multiple challenges, including positive impact on the emotional health of parents and children. It was developed at the UCLA Semel Institute for Neuroscience and Human Behavior, in collaboration with the National Child Traumatic Stress Network and Children’s Hospital Boston/Harvard Medical School.

The program also helps a family tell its own story. It teaches family members how to talk together and assists with problem-solving and goal-setting. Family members learn how to support each other and prepare for future challenges. See the website at focusproject.org.

Another program designed to build resiliency, facilitate recovery and support reintegration but based elsewhere is Real Warriors. At its website, realwarriors.net, troops can get help accessing benefits and contact Lest We Forget peer-to-peer advocacy groups. Families can support their service member with psychological health concerns. Veterans can learn how to support PTSD treatment.

In Transition, based in St. Louis, MO, contracts with the Department of Defense to help returning service members moving to another military installation access benefits or connect with community resources to get back into civilian life.

Other resources include SemperFiFund.org/resources/ and Military One Source, available 24 hours a day, seven days a week at 800-342-9647 or militaryonesource.com. The TriCare Crisis Line for TRIWEST Health Care Alliance site is triwest.com.

The Marine & Family Programs is available at 800-253-1624. Marines can reach Counseling Services at 760-725-9051. For the Consolidated Substance Abuse Counseling Center, call 760-725-5538 or 760-725-5539. For sexual assault, contact 760-500-1707.

Follow Camp Pendleton Patch on Twitter and Facebook.