The New Norm
Active-duty veterans serving since 2003 live with a new paradigm: back-to-back extended deployments. Many have served in combat; all have endured long periods of very intense operations without enough time at home to resolve even routine personal and family problems. The standard of their exposure has shifted, requiring an expanded, enhanced, and more deliberate prevention and treatment strategy. 2
Unfortunately, despite drawdowns in Afghanistan and Iraq, ongoing global unrest may mandate that the operational tempo does not decrease significantly within the coming decade. Therefore, military leaders must become even more adept at recognizing and dealing with pressures, both in themselves and in those they lead. Proper prevention, early identification, mitigation, and intervention are all line-leader responsibilities. 3 Feeling stress is a normal human response to various situations ranging from routine to complex. Its effects can be diminished or even prevented, when leaders strive to eliminate the associated stigma. Encouraging sailors and their families to address these issues in themselves and each other increases the likelihood of preventing grievous, lasting damage.
Between 2001 and 2009, diagnosed mental disorders for the U.S. armed forces increased by almost 90 percent. 4 According to the Armed Forces Health Surveillance Center, mental disorders in 2010 accounted for more hospitalizations of U.S. service members than any other category of diagnosis. 5 Some may attribute these increases to a change in recruiting standards; however a sampling review of Navy recruiting attrition rates for the second quarter of Fiscal Year 2011 and first quarter of FY12 revealed no overall change in entry-level separations due to psychological-health issues. 6 This supports our analyses that the overwhelming effect of a decade of high operational tempo is taking a toll. Regardless, the unabated stress on our forces impacts not only sailors, but families and military units—and must be addressed.
The Issues Are Not Going Away
In the most recent Navy Behavioral Health Quick Poll, a large percentage of Navy personnel reported “some” or “a lot” of work stress. The number jumped from 58 percent in 2005 to 74 percent in 2009 and 82 percent in 2010. In 2011, the number dropped slightly to 75 percent. The data indicate that the number-one stressor among respondents is “lack of personnel to do the job.” And the largest increase in pressure was among E-7s to E-9s. Unfortunately, the most stressed are also the least likely to seek help and the most likely to expect negative consequences (stigma). 7 This illustrates not only the seriousness but also the potentially disastrous outcome of this issue: How can leaders help their shipmates if they are unable or unwilling to help themselves?
Additional Department of Defense information shows that military divorce rates in 2011 reached the highest levels since 1999; the Navy’s rate of 3.6 percent is the highest since 2004. 8 Service leaders surveyed in 2010 reported their top two concerns included job-related and personal/family-related stress. 9 These indicators may be related to recent increases in Navy suicides. Tragically, 46 active-duty sailors in 2009, 39 in 2010, and 51 in 2011 took their own lives. We must take action now, doing everything in our power to better equip sailors and their families, increase their resilience, and turn the tide.
Addressing the Problems
In 1999 the 2d Marine Division at Camp Lejeune, North Carolina, developed and fielded a new type of partnership between war-fighters and mental-health professionals, now called the Operational Stress Control and Readiness (OSCAR) program. 10 This expanded the role of division psychiatrists, making them deployable and tasking them with providing more clinical services at the battalion level. It also added a psychologist and psychiatric technicians to assist with clinical services, both “downrange” (deployed) and in garrison.
In 2007 the commanding generals of the three Marine Expeditionary Forces, concerned that a solely medical approach was not the optimum solution, convened a working group of Marine leaders, chaplains, and medical and mental health professionals to develop a new combat operational-stress model. They wanted it to be unit-leader-oriented, multidisciplinary, integrated throughout the organization, without stigma, consistent with the warrior ethos, and focused on wellness, prevention, and resilience. 11 The Marine Corps Stress Continuum Model and broader implementation of OSCAR were the immediate results, forming the foundation for a culturally successful approach in both the Marine Corps and the Navy.
For years the Fleet perspective on mental health was simple: a sailor was either “full up round” or “broken.” Today the Navy recognizes that stress affects every individual differently, and that its effects fall along a continuum:
• Stress reactions: These are normal, common, and expected responses to adversity.
• Stress injuries: More severe and persistent adverse responses.
• Stress illnesses: These persistently impact social or occupational function. To prevent long-term disability, more medical, spiritual, and/or mental-health treatment is needed. 12
This profound yet simple model has become the foundation for Navy operational-stress-control (OSC) doctrine, training, surveillance, and interventions. It closely follows the combat-and-operational-stress-control model developed by the Marine Corps. The entire spectrum of responses and outcomes is recognized, and a common language is provided with which to discuss the range of issues. Figure 1 illustrates the continuum, the fundamental idea being that stress tends to push individuals toward the yellow, orange, or red zones. The OSC goal is to use challenging situations appropriately to strengthen service members, units, and families, so that mission requirements can be met and people can be returned to the green zone as quickly as possible. All OSC actions aim for force preservation and readiness.
Continuing to gain acceptance, the model is being integrated into psychological and professional military texts. Its simplicity allows for a common understanding among mental-health professionals, military leaders, and young Marines and sailors. 13
Thinking in Practical Terms
Like physical injuries, those caused by stress are important risk indicators. They convey not only that an individual may be unable to perform normally in some situations, but also a risk of developing a more serious disorder. There are other parallels: Both physical and stress injuries normally heal over time; both heal faster and more completely with appropriate recognition and care; and neither is the sole fault of the individual. Although they can heal, both may leave their marks, signifying lasting change in the area of the injury. Sometimes the scars become places of enhanced strength, but the opposite may also occur.
It is particularly important that Navy leaders be aware of the major differences between physical and stress injuries. Psychological wounds are not visible, harder to recognize, less likely to be voluntarily reported, and burden the bearer with greater social stigma. Furthermore, looking at the model, the concept of an orange-zone stress injury bridges the gap between the all-or-nothing idea of full-up-round or broken sailors. Consistent with 21st-century scientific evidence regarding effects on the brain, body, and mind, this new zone reduces the sense of shame associated with combat and operational stress. It also provides leaders with an important marker of psychological health for operational risk management and the implementation of early intervention to restore readiness.
The CNO directed the development of a pilot program to address the problem, and in mid-2010 a new course was introduced: Navy Operational Stress Control for Leaders, based on a similar program developed for the Marine Corps. The Navy and Marine Corps Public Health Center provided support, and the course was launched using a single Navy warfare community: Navy Expeditionary Combat Command (NECC) and its subordinate units.
The goal was to provide practical and effective concepts and tools to officers and chief petty officers at their level of expertise and experience to help them mitigate problems discussed here. Taught in one day in five modules, it includes dialogue, discourse, personal stories, and discussion of the impact of stress on individuals, units, and families. In helping leaders recognize symptoms, it is intended to build balanced and informed empathy for sailors and to help navigate stress.
Leaders Training Course
Navy Operational Stress Control for Leaders provides information about the associated biology, changes in behavior and function resulting from severe or prolonged exposure, zones of the stress-continuum model, the importance of communication between caregivers and leaders, and their responsibility for navigating operational stress. The material covered has been adjusted to fit sailors’ traditions, language, and esprit de corps.
Tools are offered to develop and apply skills to reduce or eliminate stigma, provide awareness of available resources to help sailors and families, and know when and where to get more help with the problem. Case-study scenarios and role-playing are used to internalize the application of core leader functions. Also covered are how Navy OSC supports operational risk management, and risk decision-making. Among the numerous benefits of this course, an intangible but powerful one is that command leadership is in one room at the same time, having an open and honest discussion about real stress issues in a focused and personal setting.
During the initial pilot phase, courses were conducted for four operational NECC units. Having been briefed on the results, NECC’s commander directed that all operational units under his command receive the training. The course was also presented to a mixed audience of active-duty personnel and civilians at the Navy and Marine Corps Combat and Operational Stress Control conference in San Diego in April 2011; to a cadre of senior enlisted leaders at the Armed Forces Medical Symposium in Colorado Springs in May 2011; and to three U.S. Coast Guard units in August 2011.
A total of 1,355 chiefs, officers, and civilians participated in 39 classes conducted through 14 December 2011. Participants consistently expressed a statistically significant increase in their confidence and ability to identify and navigate operational stress, as shown in Figure 2. In a six-month follow-up survey conducted through 28 December 2011, 94 percent of respondents believed the course was valuable to the Navy, and 89 percent believed it would help improve mission readiness.
OSC training is a part of the overall approach designed to build and maintain a strong, healthy, tough, and fit force. Its purpose is to create a common language for discussing these issues and give sailors at all levels the needed practical tools and concepts. With an immediate impact on individual and unit readiness, its objective is to eradicate the stigma associated with psychological health and continue the tradition of leaders taking care of their sailors.
OSC concepts and tools are now being incorporated in many different types of training, from boot camp through the Senior Enlisted Academy, including Officer Candidate School, Command Leadership School, and the Naval War College. It has become part of leadership training, adjusted as careers advance and leaders mature. The ultimate goal is to deploy these concepts throughout the Fleet into all warfare enterprises.
Military leaders may not have the ability to change the operational tempo or demands of combat and military operations. But by employing the concepts and tools of OSC, they are better equipped to maintain their most important assets––their sailors—in top condition, ready to handle any challenge they encounter.
1. U.S. Marine Corps and U.S. Navy, Marine Corps Reference Publication (MCRP) 6-11C and Navy Tactics Techniques and Procedures (NTTP) 1-15M, Combat and Operational Stress Control, December 2010. The authors wish to acknowledge the contributions of Dr. Tom Gaskin, commander, U.S. Navy (Retired), for his strong leadership in the Marine Corps in the science of behavioral health, and his tireless efforts in establishing the USMC Operational Stress Control and Readiness program that laid the groundwork for the Navy OSC Leaders program.
2. J. Barrett and J. Need, “Stress-Control Strategies for the ‘New Norm,’” U.S. Naval Institute Proceedings , September 2010, p. 8.
3. W. Nash, “Operational Stress Control and Readiness (OSCAR): The United States Marine Corps Initiative to Deliver Mental Health Services to Operating Forces,” in Human Dimensions in Military Operations: Military Leaders’ Strategies for Addressing Stress and Psychological Support , RTO-MP-HFM-134, Paper 25, 25-1-25-10. (Neuilly-sur-Seine, France: RTO, 2006).
4. “Force Health: A Decade of War,” Military Times , 2010, http://militarytimes.com/projects/health/morbidity  .
5. Armed Forces Health Surveillance Center, “Hospitalizations among Members of the Active Component, U.S. Armed Forces, 2010,” Medical Surveillance Monthly Report 118, no. 4 (April 2011): pp. 8–9.
6. Naval Service Training Command, Total Attrition Rates , Recruit Training Command, Great Lakes, IL, January 2012.
7. C. Newell, K. Whittam, and Z. Uriell, 2009, 2010, and 2011 “Behavioral Health Quick Polls,” Navy Personnel Research, Studies, and Technology, Bureau of Naval Personnel, June 2009, 2010, and 2011, http://quickpolling.nprst.navy.mil/  .
8. G. Zoroya, “Military Divorce Rate at Highest Level since 1999,” USA Today , 13 December 2011.
9. R. A. Schultz, “Results of the 2010 Leadership Personal and Family Readiness Survey” (Millington, TN: Navy Personnel Research, Studies, and Technology, NPRST/BUPERS-1, manuscript in preparation).
10. USMC and USN, MCRP 6-11C and NTTP 1-15M, Combat and Operational Stress Control , December 2010.
11. J. N. Mattis, K. J. Stalder, and R. C. Zilmer, “Summary Recommendations of the TRI-MEF Conference on Combat and Operational Stress Control to the Commandant of the Marine Corps (SSEC I MEF),” TRI-MEF Combat Operational Stress Conference, Camp Pendleton, CA, September 2007.
12. USMC and USN, MCRP 6-11C and NTTP 1-15M, Combat and Operational Stress Control , December 2010.
13. W. Nash, M. Steenkamp, L. Conoscenti, and B. Litz, “The Stress Continuum Model: A Military Organizational Approach to Resilience and Recovery,” in Resilience and Mental Health: Challenges Across the Lifespan , S. Southwick, D. Charney, M. Friedman, and B. Litz, eds. (New York: Cambridge University Press, 2011, in press). W. Nash, “U.S. Marine Corps and Navy Combat and Operational Stress Continuum Model: A Tool for Leaders,” in Combat and Operational Behavioral Health (Washington, DC: Borden Institute, 2011, in press).
Captain Need is a research leader in Force Health Protection for Battelle Memorial Institute. He retired from active duty in 2003, after serving numerous tours as an operational preventive-medicine officer.
Captain Harris is a senior research scientist in deployment health for Battelle Memorial Institute. He retired from active duty in 2008, after serving for 26 years in public health and radiation protection.
Senior Chief Darnell is a principal research scientist in public health for Battelle Memorial Institute. He retired from active duty in 2003, after serving for 21 years as a Fleet Marine Force and Submarine Independent Duty Hospital Corpsman.