Invisible Battle Scars: Confronting the Stigma Associated with PTS & TBI
by Coral Anika Theill, Published in Leatherneck Magazine, October 2011
“Post-traumatic stress is not a disorder; rather it is an injury that requires treatment.”
—Gen James F. Amos, Commandant of the Marine Corps
While on active duty, Marine combat artist CWO-2 Michael D. Fay, now
retired, captured this image of a combat-exhausted LCpl Nicholas G. Ciccone
after Ciccone walked into "the freezing, gutted remains of Kandadar International
Airport" in January 2002 from a nine-day patrol with almost constant contact.
The Marine Corps is making great efforts to address the issues surrounding PTS as well as the complications from traumatic brain injury (TBI). From the Commandant of the Marine Corps through the chain of command, there is an increased awareness of these behavioral health issues and the need for reducing the stigma associated with these injuries. Research shows social stigma is the No. 1 obstacle preventing active-duty personnel and veterans from seeking help for stress-related illness.
The Marine Corps understands the necessity of “a highly resilient, psychologically fit” Corps, and leaders are increasingly proactive in educating all Marines about PTS and TBI. The Marine Corps hopes to drive change through education. From commanders through every rank, in every unit, there is training on recognizing PTS/TBI symptoms and how to act and respond appropriately. Those suffering with these injuries and their families need to know there is help.
Four years ago, the Marine Corps created the Wounded Warrior Regiment (WWR) in an effort to help all Marines
and sailors attached to Marine units, as well as their families. The WWR has a call center—the Sergeant Merlin German Wounded Warrior Call Center—that can be reached any time of day from anywhere in the world. Everyone who has examined the PTS/TBI issues agrees that speaking with trained counselors is the strongest defense. Knowing and understanding the symptoms and the signs may save a career or a life.
An excellent video, “Cover Me,” is used to train Marines about combat stress. The message for commands, for military personnel and for their families is that prevention is the best way to avoid severe PTS. Coping measures cited in the video include recognizing how you manage stress; clearing up emotional issues before deployment; developing individual ways to unload excess stress during deployment; trying to stay rested; journaling; talking to friends and to others in your unit; avoiding isolation and alienation from your squad, platoon or family; and not volunteering for redeployment before having a chance to unwind and reset your emotional system to “normal.”
The video’s purpose is to increase awareness of combat operational stress, so that military personnel and their families are able to deal openly with post-deployment issues. It addresses the effects of combat stress and states that combat stress is a normal response. Key messages in the film are taking care of each other and asking for help if needed.
The video’s title and its contents reflect the Marine Corps’ belief of “taking care of its own.” That belief is clearly demonstrated through in-depth interviews with General James T. Conway, 34th Commandant of the Marine Corps; Gen James N. Mattis, Commander, U.S. Central Command; Sergeant Major Carlton W. Kent, 16th Sergeant Major of the Marine Corps; SgtMaj Evans McBride, retired Marine Corps Forces Pacific sergeant major; and additional interviews with Marines and sailors who have experienced combat operational stress.
“Cover Me” also is about what to do if you or a comrade show signs of having difficulty managing stress. It is about supporting fellow Marines. “You would consider me crazy if I didn’t call for air support or artillery support in a fight,” Gen Mattis says in the video. “That is the way Marines fight: always supporting one another.
“Combat is a very, very challenging environment. For those of you who have fought in close fights, you know they stay with you a long time. It is critical that if you or your buddy is having a tough time, you have the guts to come in and ask for support. Just like I ask for air support when I go into a fight, you need to take care of your buddy if he is having a tough time. It is our duty to help one another through this. Marines make choices. Let’s make good choices. Support one another, support your family and take care of yourself.”
When talking about the Corps’ response to Marines suffering injuries, Lieutenant Colonel Benjamin Hermantin, who served as the officer in charge for the 2010 All-Marine Warrior Games Team, said, “Marines don’t go-it-alone; we fight together as one, a band of brothers. When a Marine has trouble fighting his own battles, physical or mental, he still has his brothers who are there to help. That doesn’t end on the battlefield.”
Unit Cohesion: Vital Psychological Protection
“Combat changes everyone. The question is how. Sometimes that change can be in the form of damage or a negative effect, and other times it can be positive; it can be ‘post-trauma growth,’ the ability to make you stronger. I believe everyone is affected somehow, but it will look different from person to person,” says Dr. Heidi Kraft, a former Navy lieutenant commander and psychologist attached to Alpha Surgical Team, Iraq, in the video “Cover Me.”
Dr. Kraft continues, “The relationships they [Marines] had with one another were just not important, but EVERYTHING. It superseded anything else that they were doing there. Marines have the unit cohesion or the sense of togetherness that manages to give them strength even in very difficult situations.
“In other situations that is very difficult. If they lose a brother or sister out there, it is a level of devastation unlike anything I have ever seen before. I think the grief of that loss is so intense and continues to be, but we compartmentalize very well when we have to get the job done. This is a really logical thing human beings do when they have been through something traumatic; they put it away, they finish the job. Then it is much later that they may experience some of the complications from the fact they avoided dealing with it.”
Dr. Jonathan Shay, M.D., Ph.D. is an author whom Gen James F. Amos, 35th Commandant of the Marine Corps, mentions when discussing unit cohesion and its importance. In his book, “Odysseus in America: Combat Trauma and the Trials of Homecoming,” Dr. Shay writes, “Social cohesion—from having trained together and traveled to the war zone together—is what keeps people physically alive and mentally sane when faced with a human enemy who really is trying to kill them.
“The malignity of the armed human enemy is not a psychological figment. Only the support of others makes it possible to face armed killers. The idea that the social connectedness and esteem of the soldier’s unit are psychologically protective is not new, and is found in the lessons learned in World War II (but then forgotten): Repeated observations indicated that the absence or inadequacy of such sustaining influences or their disruption during combat was mainly responsible for psychiatric breakdown in battle. A cohesive unit creates courage by reducing fear. The human brain codes social recognition, support, and attachment as physical safety. Cohesion both increases the ability to overcome fear (we call that courage) and reduces fear.”
War is an unspeakable horror—even “survivors” may have wounded spirits for the rest of their lives. Some people used to think that most military men and women were capable of shutting the door on what happened during war. However, not talking about it isn’t the same as being unmarked by it. Many combat veterans may find themselves again experiencing a trauma in their minds even decades after an event. This can be overwhelming and incapacitating.
Gen Conway, while on active duty as Commandant, said, “War is war, so you cannot go through this experience without being changed. Not only does it change you, but it creates a very difficult circumstance to explain to others. It can at times feel isolating when you come out of this because you cannot explain it to others. It is simply one of the manifestations of something that is so emotionally compelling that it leaves you changed forever.”
Commander Gordon Ritchie, USN, the recently transferred WWR chaplain, talked about “Band of Brothers” character Ronald Speirs, who advises a young recruit that a soldier’s survival depends on being able to function without mercy, without compassion and without remorse. “This way of thinking may be necessary in battle,” Ritchie said, “but it causes a moral and spiritual wound on the warrior’s psyche. The cruelties of war, both those witnessed and those committed, are toxic to the soul, and these invisible wounds can be harder to heal than the physical wounds of war.
“War is a ‘soul wound’ or a ‘moral wound.’ When somebody encounters a trauma, some of the assumptions about life are easily called into question. Issues of ‘good,’ of the benevolence of society, issues regarding God or the higher power, a sense of fidelity, abandonment issues, where was God, and why did this happen all come into question. Marines in combat have these questions.”
Chaplain Ritchie described the role of chaplains as “physicians of the soul.” He added, “We assist Marines and sailors in existential and philosophical areas where the scalpel and the pharmaceutical areas do not reach.”
There are many post-deployment symptoms that may be related to PTS, including agitation and anxiety, constantly being on the lookout for danger, finding it hard to adjust, being nervous in crowds, night terrors or nightmares, fights at home, flashbacks, irritability, trouble concentrating, emotional shutdown or numbness and a feeling of being disconnected from the world.
Combat veterans suffering from PTS can’t control those feelings or stop them from occurring. Traumatic events overwhelm the usual methods of coping that give people a sense of control, connection and meaning. Combat veterans can feel an overwhelming sense of powerlessness, the belief that nothing can be done to stop the flood of violence, terror, war and explosions that they experienced and witnessed.
Victoria Lemle Beckner, Ph.D., a clinical psychologist and researcher at the University of San Francisco and the San Francisco Medical Center, said in “Cover Me,” “What most people don’t realize is that when you go through an intensely stressful experience, such as engaging in combat, the brain and the body respond in a very intense physiological way. Your stress alarm system is activated which floods the body with hormones to help you deal with a threat; it increases blood sugar levels and oxygen throughout the body and can affect different areas of the brain.
“Many people feel like they shouldn’t have any response to a stress, or that it is a sign of weakness. But, in fact, you can’t control what happens chemically to your body and brain during a really traumatic or stressful event.
“Most people will experience negative symptoms for at least a few days after a serious event. If those symptoms persist for more than a couple of weeks, it is really important to get some help. The good news is that over the last decade or so, we have developed a number of short term interventions for combat stress that are proven to be very effective. We know how to help individuals tap into their natural resiliency and heal from these wounds. But the key is to get help sooner rather than later, before the symptoms and problems become entrenched.”
Laurie Giertz, WWR’s psychological health and TBI programs lead, explained: “Marines from former wars and conflicts often did not talk about combat stress injury or PTSD. PTSD is now talked about on the active-duty side a lot. That is the difference from the Vietnam era to where we are today. There are actually Marines within each of the units, each battalion, that are now trained in suicide awareness as well as PTSD.
“What is driving the change now in the mentality regarding combat-stress-related injuries and PTSD is that we have very good leadership at Headquarters Marine Corps who are passionate about this topic. That is what is creating the change.
“Our job is to advocate and get a Marine/sailor plugged into the care they need. One reason we make calls for Marines is because we are clinical, and we can talk clinical to the VA [Veterans Affairs]. We are the middle person. Many Marines who have PTSD and/or TBI do not need to leave the Marine Corps. Not everyone who has those conditions needs to be in wounded warrior programs. Some combat-stress-related injuries are temporary. Marines need to learn how to best cope
with it, move on and live with it.”
“In the past, the Marine Corps mentality was this: If I am a combat vet, I don’t want to be ever categorized as weak,” said Sheila Rosinski, a retired Marine gunnery sergeant and a licensed clinical consultant and WWR registered nurse.
“Since World War I, most Marines believed if you were not doing your job 100 percent, you were faking, you were sandbagging, or you were trying to get out of work. Marines don’t want to have anybody perceive them as being weak or weak-minded. We are slowly changing that mentality. Instead of Marines saying to another Marine, ‘Get over it,’ now more Marines are encouraging one another to seek help. The message is getting out there slowly, but it takes time to change that mentality.
“Many Marines, when they hear Wounded Warrior Regiment, think combat injured and amputation. The role of the Wounded Warrior Regiment and call centers is different. The WWR extends support through a variety of services including advocacy, resource identification and referral, information and care coordination. We are helping the Marines/sailors and veterans get into military treatment facilities and approved programs.”
Traumatic Brain Injury
In both WW I and WW II, the principal serious wounds in combat were caused by artillery. If you were hit, you were likely to be killed. That meant a lower percentage of returning troops suffered injury and lived to tell about it.
In Iraq and Afghanistan, the principal cause of serious injury is an IED or roadside bomb. Now, the chances of survival have increased because of advances in equipment, evacuation, emergency response and treatment. Military personnel are surviving extremely serious wounds; among these are far more traumatic head injuries—TBI. A person with traumatic brain injury may face a constant struggle to maintain what we call a normal life.
TBI is caused by a blow or jolt to the head or a penetrating head injury that disrupts brain function. Even mild traumatic injuries to the brain, or concussions, can leave someone unable to remember, to follow orders or to think normally. Recovery from brain injuries (concussions) is often uncomplicated and complete, but some individuals continue to experience physical, cognitive or mood difficulties.
After external or visible signs of wounds are no longer present, TBI can cause headaches; memory difficulty; problems concentrating or making decisions; problems speaking or reading; confusion; feeling tired constantly; changes in sleep patterns; dizziness or loss of balance; nausea; increased sensitivity to lights, sounds or distractions; blurred vision; and other changes in the senses. Many people recover from TBI, but some experience long-term problems with daily living.
The Invisible Scars
Marines are coming home afflicted with both PTS and TBI in numbers never seen before. Studies have estimated that about 20 percent of those returning from Iraq and Afghanistan have suffered a mild traumatic brain injury during deployment. Of those, anywhere between 5 to nearly 50 percent may suffer both PTS and lingering problems from traumatic brain injuries. Tens of thousands of Marines, soldiers, sailors and airmen may be suffering from PTS, TBI or both. They literally become different than they were; fighting an invisible internal war.
These conditions have resulted in an increased rate of veteran suicide. Other dark sides of PTS can be alcoholism, homelessness, drug abuse, depression and sometimes destructive behavior.
SgtMaj John P. Ploskonka Jr., WWR sergeant major, emphasized the importance of seeking immediate help. “Marines who go to the battleground get PTSD. The most important thing we can do for Marines who have been in combat is to help them understand that the earlier that they get help when they need it, the better off they will be. TBI is worse at the time of injury and progressively improves in time. PTSD, on the other hand, works in the opposite way. If you do not seek help for PTSD, it will get progressively worse. If you avoid dealing with it, and sometimes it is impossible at the time, you may have complications months later.
“We are alpha males and alpha females, trying to control everything in our life. Marines want a strategy while still maintaining command and control, which we call C2. A Marine will say, ‘I don’t have PTSD; I am just fine,’ but when somebody else sees the indicators, they have a duty to help their fellow Marine get help.
“We are much more proactive now in identifying those triggers and indicators of PTSD/TBI than we have ever been because we are more attuned to it now, mostly due to technology. We know PTSD is real. Presently, we are working to demystify and destigmatize PTSD/TBI in the Marine Corps.”
Editor’s note: The “Cover Me” video may be seen at
Coral Anika Theill is an author and advocate whose published works address trauma recovery and healing from post-traumatic stress and, most recently, wounded Marines, the Warrior Games and Montford Point Marines.
Invisible Battle Scars: Confronting the Stigma Associated with PTS & TBI is used as college text for the University of the Marine Corps, Quantico, Virginia and is also published in Short Rations for Marines.