Strong in mind and body

Can a program that reduces depression and anxiety in children boost resilience among soldiers?

That was the belief of the U.S. Army as it rolled out its Comprehensive Soldier Fitness program to 1.1 million active-duty soldiers, reservists and members of the National Guard this fall. Developed in conjunction with several of psychology's top stars, the initiative seeks to assess and enhance soldiers' ability to cope with all of life's challenges, including the mental rigors of combat.

"We don't assume people can shoot when they come into the Army, so we teach them how to load weapons and how to aim," says Brig. Gen. Rhonda Cornum, PhD, MD, director of the Comprehensive Soldier Fitness program. "We need to attend to psychological fitness the same way we do physical performance."

The idea behind the soldier fitness program is that the response to strong adversity, like combat, is bell shaped, says Martin E.P. Seligman, PhD, director of the Positive Psychology Center at the University of Pennsylvania, who is consulting with the Pentagon on the progam's development. At the extreme end is post-traumatic stress disorder, in the middle is ordinary resilience and at the positive end is post-traumatic growth.

"The program's aim is to move the entire distribution toward the healthy end." Seligman says.

So, if more soldiers are trained to cope successfully with adverse events, fewer will go on to struggle with mental health issues, abuse drugs and alcohol or contemplate suicide after deployment. And more will find that they have developed greater leadership, maturity, and appreciation of life and family.

The initiative's biggest component is resiliency training, based on research by Seligman, as well as techniques used in the Army's "Battlemind" program, an instruction program launched in 2007 and designed to boost resilience before battle and help soldiers adjust to life back home. The program also includes self-development modules based on psychological research in four key mental fitness areas: emotional, social, spiritual and family well-being.

Seligman, among others, hopes that one consequence of the program will be a reduction in the number of service members who experience PTSD, which according to a September study by researchers from Stanford University and the Naval Postgraduate School, may eventually affect as many as 35 percent of soldiers serving in Afghanistan and Iraq (Management Science, Vol. 55, No. 9). Currently, about 7.5 percent of soldiers who deploy to a combat theater develop PTSD, but the condition is not randomly distributed. In a study published in the April 25 British Medical Journal (Vol. 338, No. 7701), military researchers found that soldiers with low levels of physical and psychological health prior to combat had two to three times the risk of symptoms or a diagnosis of PTSD after deployment, compared with those who had higher baseline mental and physical health scores. Thus, the opportunity for prevention by increasing overall health is huge, Cornum says.

If the program is able to boost resilience, increase post-traumatic growth and reduce PTSD in the Army, the possibilities for expansion are enormous, many say. Later in 2010, the program will be expanded to soldiers' spouses and families, and it could eventually be used for helping prisoners, students, employees and others improve their psychological fitness and resiliency.

"This will open up research and employment for psychologists the world over, if it works," Seligman says.

Some psychologists caution, however, that psychology shouldn't celebrate the program's success before there's evidence that it works for this population.

"There's really no simple solution," says University of Washington marital researcher John M. Gottman, PhD, who is helping develop the program's family fitness component. These problems may now be the new reality with service members continuing to face long and repeated deployments.

Teaching resilience

The military considered several programs to help address soldiers' mental health issues, before ultimately selecting Seligman's Penn Resiliency Program due to its strong evidence base. This made it highly likely to have an impact, says Cornum, who directs the $120 million Comprehensive Fitness initiative under the Army's chief of staff, Gen. George W. Casey Jr.

Seligman's research has found that the resiliency techniques can improve outlook on life among children of all ages, curb their likelihood for depression and boost grades. Twenty-one replications of the Penn program have been tested across the globe. More evidence of the program's potential came in a 2007 Behaviour Research and Therapy (Vol. 45, No. 6) study that found the techniques may also help college students reduce depression and improve their optimism and sense of well-being. (A report on the Penn Resiliency Program appears in the October 2009 Monitor.)

In the Army curriculum, developed jointly between the Army and University of Pennsylvania psychologists, mid-level leaders are taught cognitive-behavioral and social problem-solving skills based on research by Seligman, Aaron Beck, PhD, and Albert Ellis, PhD. One of the central components, Seligman says, is teaching soldiers how to identify and avoid catastrophic thinking. For soldiers, this means training them not to immediately think that if a fellow service member is late coming back from a tour of duty, he's been killed, Seligman says. Instead, the program trains soldiers to consider not just the worst scenario, but the best scenario (the soldier fell asleep and he's hitchhiking his way back), and then to arrive at the most likely scenario (he's lost and will be in trouble perhaps, but he's probably safe).

In the pilot version of the training, soldiers went through five days of lessons through video and animation-infused Power Point presentations, participant role-playing and group discussions, says Karen Reivich, PhD, co-director of the Penn Resiliency Program. They were also taught how to play to their personal strengths to build better relationships and learn the importance of active and constructive responding, a positive psychology technique characterized by expressing sincere enthusiasm and interest in a happy or exciting event a friend or partner has experienced, such as a promotion.

The Army's resilience program will be administered primarily by the Army's "teachers": its noncommissioned officers, or sergeants. In August, 50 sergeants attended a weeklong master resiliency training at Penn, and 150 more received the training last month. By fall 2010, the Army seeks to place at least one trainer in every battalion, typically each composed of 500 to 600 soldiers. Feedback evaluations suggest that most of the pilot participants saw the need for teaching resiliency, Seligman says.

"They basically gave the course a 4.8 of 5 on everything," Seligman says. "A typical comment from the sergeants was, 'We need every soldier, Army civilian and family member to receive this training.'"

Sergeants will roll the training out to their teams in small chunks—anywhere from two hours a week to one day a week, Reivich says. And as the program progresses, soldiers will also be taught new ways of thinking that can help them improve and grow personally after surviving trauma, says University of North Carolina at Charlotte psychology professor Rich Tedeschi, PhD. Since the 1980s, Tedeschi has studied the conditions that lead to post-traumatic growth. He says that post-traumatic growth can be sparked by introducing troops to ways of cognitively processing their traumatic experiences and their aftermath that emphasize a rebuilding of core beliefs and meaning, a recognition of personal strengths and an identification of purpose.

"One of the things I think people misunderstand is they think we're saying that trauma is a good thing for people, and it's certainly not," Tedeschi says. "But given that people do [experience trauma], some people change in positive ways, and there are ways we, as professionals, can facilitate this."

Ongoing learning

The Army's focus on psychological well-being will continue even after every service member is trained in resiliency. "This is not like an immunization where everyone has to get it in a three-month period and then you're done," says Cornum. "The program will be applied throughout their careers."

To measure service members' mental fitness before resiliency training, in October the Army began rolling out its Global Assessment Tool—designed primarily by University of Michigan psychologists Christopher Peterson, PhD, and Nansook Park, PhD. It confidentially assesses soldiers' mental health, character strengths, social support and relationship satisfaction, among other factors. Based on the results, the Army will recommend specific education and training in each of four psychological fitness areas. Troops are directed to Web-based self-improvement courses on emotional, social, spiritual and family issues, developed based on years of psychological research on each topic.

Bowling Green University psychology professor Kenneth Pargament, PhD, for example, has been leading the development of the Army's spiritual fitness module to help soldiers identify their core beliefs, values and aspirations and assist them in accessing resources in times of struggle, through chaplains, ritual, meaning-making or reflection and meditation. The program's emotional fitness module was developed by University of North Carolina at Chapel Hill psychologists Sara Algoe, PhD, and Barbara Fredrickson, PhD, who say their course will help dispel the idea that emotions are "touchy-feely" and show that feelings have a functional purpose to fuel resilience and foster growth. University of Washington's Gottman says the family fitness course teaches troops how staying close to loved ones when they're far away can be achieved through the use of open-ended questions and supportive comments to a spouse making decisions at home. And in the social fitness module, soldiers learn how to connect and form relationships, which research suggests makes them more effective within and outside of the service, says course designer University of Chicago psychologist John Cacioppo, PhD.

"Soldiers have experiences they can't really relate to others and that puts them at risk for a variety of physical and mental problems," Cacioppo says. "If we can improve their ability to work together and trust others, they'll be in a better position to sustain effective well-being, and they'll return to civilian life as more complete individuals."

Psychology at its best?

While the program's results likely won't be evident for several years, many are already touting the initiative as a win for the field.

"This is the largest study—1.1 million soldiers—psychology has ever been involved in, and it will yield definitive data about whether or not [resiliency and psychological fitness training] works," Seligman says. In addition, if performance among soldiers improves, these same resilience-building techniques may be expanded to other branches of the military. Other potential applications include at-risk populations in the public—to reduce school dropouts, drug abuse and violence among urban adolescents, for example.

"It's a foothold for something broader in the long term, and an opportunity for psychologists to show that they know what they're talking about," Cacioppo says.

He cautions, however, that the program must continue to be evidence-based to make a significant difference in soldiers' lives. "We have to be as attentive and rigorous and demanding of ourselves and our discipline as we've ever been," Cacioppo says.

Gottman's trepidation goes further. He's skeptical of the program's potential for far-reaching positive effects, and doesn't think the Army has gone far enough to ensure its approach is based in science. "What these soldiers deal with on a daily basis is not like common, everyday American stress," he says. "We can't hope to solve this problem with a couple of online modules."

Since the program will roll out gradually, Seligman says, the initiative will be evaluated through a "wait list" control design. Those troops under the resiliency-trained sergeants serve as the experimental group and those under the as-yet-untrained sergeants serve as the controls, and the Army's evaluation will be monitoring each group's incidence of PTSD, sick bay time and performance, he says.

No matter the outcome, Seligman says, the program will do much to build awareness of the field of positive psychology. He says it was the decision of Gen. Casey, the Army's chief of staff, to put the Comprehensive Fitness Program under the Army's operations and training group, rather than lumping it with the military's medical department.

"It's not under anyone else's roof," Seligman says. "This is our declaration of independence."

Amy Novotney is a writer in Chicago.