MILITARY MEDICINE, 183, 9/10:e603, 2018

Effectiveness of Acceptance and Commitment Therapy

in Increasing Resilience and Reducing Attrition of Injured
US Navy Recruits
LCDR Christopher J. Udell, MSC, USN; Julie L. Ruddy, PsyD; Philip M. Procento, BA

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ABSTRACT Introduction: US Navy recruits who have injuries preventing them from participating in intense physi-
cal conditioning are pulled out of boot camp training and receive treatment that includes daily physical therapy, pain
medications, and psychoeducational groups. Graduation from boot camp for these recruits requires not only recovering
from their injuries but also passing a required Physical Fitness Assessment consisting of a timed 1.5-mile run, curl-ups,
and push-ups. About 50–60% of these recruits will eventually be separated out and sent home. The purpose of this
study is to examine the effectiveness of an Acceptance and Commitment Therapy (ACT)-based program called
Mindfulness for Pain and Performance Enhancement (MPPE). This treatment program was designed to help recruits
effectively handle pain and assist them in improving their physical performance in the service of recovery, boot camp
completion, and entrance into the Navy. Materials and Methods: This study was approved by the Edward Hines VA
Hospital/Captain James A. Lovell Federal Health Care Center Institutional Review Board and the Naval Services
Training Command. Treatment was voluntary and a total of 373 recruits enrolled in one of the 32 cycles of MPPE
administered. Attrition was 35.1% (131 recruits). The control group comprised 310 recruits who did not enroll in
MPPE. Recruits continued to receive standard treatment services (e.g., physical therapy, medical interventions, and
psychoeducational groups) while participating in MPPE. Chi-square tests and one-way analysis of variance were used
to analyze comparisons among treatment, control, and attrition groups on demographic, clinical, and boot camp train-
ing variables. Paired sample t-tests and Cohen’s d effect sizes were computed to assess change on treatment outcome
measures. Logistic regression was performed to identify demographic, clinical, and boot camp training variables pre-
dictive of graduation. Results: All of the pre- to post-treatment outcome measures were significant and Cohen’s d effect
sizes ranged from 0.41 to 0.84. Effect size changes were small for anxiety and experiential avoidance; moderate for
pain acceptance, mindfulness, cognitive inflexibility, and depression; and large for pain reduction. Treatment comple-
ters graduated at a higher rate (58.3%) than attrites (34.4%) or controls (45.5%). Based on a logistic regression model,
variables predictive of graduation included MPPE completion, age, and reported pain rating. Conclusion: MPPE is a
six-session, 2-wk-long Acceptance and Commitment Therapy-based approach to pain and physical performance that
was added to existing treatment services. Results supported the use of this program for helping recruits recover from
injuries and successfully pass physical training requirements for graduation. Recruits were not randomly assigned to
treatment, thus limiting the interpretation of outcomes. Incorporating this treatment earlier in boot camp training and
making it available to more recruits (i.e., not only injured recruits) may further reduce attrition and contribute to greater
resiliency of sailors within the US Navy fleet.

INTRODUCTION run, curl-ups, and push-ups. Recruits with injuries or medical

Basic training at the Naval Recruit Training Command at
Great Lakes, IL, is 8 wk long and involves rigorous physical
exercise. Graduation is dependent on passing a Physical
Fitness Assessment (PFA), consisting of a timed 1.5-mile
Captain James A Lovell Federal Health Care Center, USS Tranquillity
Bldg 1007, Recruit Evaluation Unit, 3420 Illinoi St., Great Lakes, IL 60088.
The views expressed in this article are those of the authors’ and do not
reflect the official policy or position of the Department of Defense,
Department of the Navy, or the US Government. The authors have no con-
flict of interest to declare. This material is the result of work supported with
resources and the use of facilities at the Recruit Training Command, Great
Lakes, IL. We would like to thank the recruits who volunteered for their par-
ticipation in this study. We would also like to thank the Recruit Division
Commanders and Recruit Training Command Special Programs Division for
their support.
doi: 10.1093/milmed/usx109
Published by Oxford University Press on behalf of the Association of
Military Surgeons of the United States 2018. This work is written by (a) US
Government employee(s) and is in the public domain in the US.
conditions interfering with physical training are pulled out
and receive physical therapy, medical, and mental health ser-
vices. The length of time on hold from training can range
from a week to a few months; 50–60% are ultimately sepa-
rated (i.e., sent home.) Factors believed to contribute to this
rate of separation include recruits’ interpretations of and
reactions to pain sensations, expectations of treatment, lack
of physical endurance, and inadequate resilience to stress.
Acceptance and Commitment Therapy (ACT) is a
mindfulness-based therapy that teaches psychological flexibility
or the ability to be in the present moment with full awareness
and openness to experience while taking action guided by val-
ues.1 Although most forms of treatment for pain advocate for
elimination or avoidance of pain, the focus in ACT is on devel-
oping greater awareness for and non-judgmental acceptance of
physical and emotional pain and to reduce the interference of
pain in everyday value-driven activities. ACT for chronic pain
is empirically supported by randomized control trials,2–7 partially

MILITARY MEDICINE, Vol. 183, September/October 2018 e603

 Effectiveness of ACT in Increasing Resilience and Reducing Attrition of Injured US Navy Recruits
controlled trials,8,9 and effectiveness studies,10–15 but there are
no published treatment studies on acute pain (e.g., lasting 2–6
wk) or subacute pain (e.g., lasting 7–12 wk). Laboratory
studies on ACT16–18 and mindfulness19–22 using experimen-
tally induced pain to reproduce conditions of acute pain found
increased acceptance from mindfulness-based approaches rela-
tive to control focused strategies. However, the experience of
brief pain in a laboratory setting differs in many ways from
pain that arises in the aftermath of a stress fracture or dislo-
cated limb. Acute/subacute pain will not become chronic pain
for many people, but one’s response could potentially affect
onset of chronic pain.
US Navy recruits undergoing rigorous physical training
are at a risk of becoming overwhelmed by negative thoughts,
emotions, and bodily states. The pressure of completing
physical training requirements in order to graduate elevates
the tendency to over-evaluate and attempt to avoid, reduce,
or eliminate emotional and physical discomfort. As recruits
become preoccupied with negative thoughts and unwanted
sensations, they are at greater risk to engage in behaviors
that diminish physical performance. In contrast, observing
and allowing uncomfortable internal experiences, flexibly
shifting attention into the present moment, and taking
value consistent action (e.g., engaging in physical training)
may improve physical performance. Sports psychology
has seen an increase in empirically supported mindfulness
and acceptance approaches to enhancing athletic perfor-
mance.23–31
There are no published studies on psychological treatment
for pain or performance enhancement in Navy recruits. There
are two primary aims in the current study. The first aim is to
examine the effectiveness of an ACT-based treatment program
using measures of pain, acceptance, mindfulness, cognitive
inflexibility, experiential avoidance, depression, and anxiety.
The second aim is to demonstrate that recruits who completed
treatment were significantly more likely to recover, graduate,
and become sailors.
METHOD
Procedures
This study was approved by the Edward Hines VA Hospital/
Captain James A. Lovell Federal Health Care Center
Institutional Review Board and the Naval Services Training
Command. Data were gathered through retrospective record
review and a waiver of informed consent was approved.
Recruits who cannot participate in physical exercise due to
pain are medically evaluated and, if necessary, pulled from
training and transferred to the Recruit Convalescent Unit
(RCU) for rehabilitation. Rehabilitation in the RCU consists
of progression through four phases of physical therapy.
Weight-bearing exercises increase with progression through
each phase. Recruits in phases III and IV participate in
supervised weight-conditioning exercises and walk (phase
III) or run (phase IV) on a track. Successful completion of a
e604
PFA monitored by physical therapy staff is required to leave
the RCU and return to training. Upon returning to training,
recruits who were on hold in the RCU must still complete a
final PFA in order to graduate from boot camp.
In some cases, recruits complete training but have not yet
passed a final PFA to graduate. These recruits are moved to
the Fitness Improvement Training (FIT) program. Recruits
in FIT participate in intense physical training daily and
attempt PFAs 3 d a week. Some recruits in FIT are trans-
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ferred to the RCU after an injury is discovered.
During the time frame of the study, all recruits received stan-
dard treatment services provided to recruits in the RCU. These
included group and individual physical therapy described above,
advanced exercise and conditioning machines, TENS units,
analgesics, pain medications, etc. Standard treatment also
included voluntary participation in stand-alone psychoeduca-
tional groups held one to two times (60-min sessions) a day.
These groups were conducted by psychiatric technicians, clini-
cal psychologists, and psychiatric nurse practitioners. Topics
included cognitive skills, goal setting, stress management,
problem solving, and relaxation training.
Intervention
The primary investigator, with over 10 years of experience
developing and leading ACT-based treatment programs, cre-
ated the treatment protocol for this study. The protocol,
named Mindfulness for Pain and Performance Enhancement
(MPPE), was designed for recruits in the RCU, taking into
account factors particular to a recruit training environment.
Emphasis was placed on condensing treatment while still
incorporating evidence-based ACT concepts and skills. The
final product was a six-session program held 3 d a week,
1.5-h-long sessions. A brief outline of the protocol is as
follows:
− Session 1: Psychoeducation on pain; discussion of fusion
and avoidance responses to pain.
− Session 2: Examine the effectiveness of attempts to con-
trol emotional and physical pain and the costs to living from
these attempts.
− Session 3: Concepts and application of mindfulness; exer-
cises include mindfulness with silly putty and breathing
meditation.
− Session 4: Cognitive fusion and its impact on physical
performance; practice meditative and non-meditative defu-
sion exercises.
− Session 5: Observing self and willingness to experience
pain or discomfort; body scan and mindfulness exercises for
cultivating greater acceptance of unwanted bodily sensations
during physical exercise.
− Session 6: Values and committed action; emphasis on
task-focus versus outcome-focus in physical performance
(e.g., value-driven actions taken in the present moment with-
out preoccupation with evaluation or results).
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 Effectiveness of ACT in Increasing Resilience and Reducing Attrition of Injured US Navy Recruits
One-hour-long booster sessions were offered twice a
week to all recruits who completed MPPE to provide oppor-
tunities for practice of experiential exercises and to assist
with obstacles to daily application. All treatment groups
were administered by the primary investigator (CJU) and co-
facilitated by psychiatric technicians. Any recruit in the
RCU was eligible to participate in MPPE at any time while
in the RCU. MPPE was intentionally scheduled at a time
when it did not conflict with standard treatment services. A
new treatment cycle began approximately every 2 wk.
Measures
Pain Rating System
The PRS32 is a five-item measure of pain. Rated on a scale
of 0 (not at all) to 10 (extreme), items include current and
past week level of pain, interference attributed to pain, irrita-
bility associated with pain, and discouragement stemming
from pain. Internal consistency in the present sample was
good (α = 0.83).
Chronic Pain Acceptance Questionnaire-8
The Chronic Pain Acceptance Questionnaire-833 is an eight-
item measure of pain acceptance. There are two underlying
factors of activity engagement and pain willingness. Each
scale contains four items rated on a scale of 0 (never true) to
6 (always true). A single total score was calculated from
summing both scales. Higher scores indicate greater pain
acceptance. Internal consistency in the present sample was
acceptable (α = 0.76).
Cognitive and Affective Mindfulness Scale-Revised
The Cognitive and Affective Mindfulness Scale-Revised34 is a
10-item measure of concentration, awareness, distractibility,
and acceptance of unwanted or uncomfortable emotions. Items
are rated on a scale of 1 (rarely/not at all) to 4 (almost always).
Internal consistency in the present sample was good (α = 0.85).
Cognitive Fusion Questionnaire
The CFQ35 is a seven-item measure of the tendency to
become attached to, controlled by, and distressed by uncom-
fortable thoughts. Items are rated on a scale of 1 (never true)
to 7 (always true). Higher total scores mean greater cognitive
inflexibility. Initial validation indicated that the CFQ corre-
lated highly with measures of acceptance and action, mind-
fulness, depression, and anxiety. Internal consistency in the
present sample was excellent (α = 0.92).
Acceptance and Action Questionnaire-2
The AAQ-236 is a seven-item measure of experiential avoid-
ance and psychological inflexibility. Items are rated on a
scale of 1 (never true) to 7 (always true). Higher total scores
reflect less acceptance of uncomfortable internal experiences
and allowing these experiences to control behavior. The
AAQ-2 correlates well with measures of depression, anxiety,
MILITARY MEDICINE, Vol. 183, September/October 2018
and thought suppression. Internal consistency in the present
sample was excellent (α = 0.91).
Patient Health Questionnaire-9
The PHQ-937 is a nine-item measure of depression severity.
Items were based on criteria for major depressive disorder in
the Diagnostic and Statistical Manual of Mental Disorders –
Fourth Edition, Text Revision (DSM-IV-TR). Items are rated
on a scale of 0 (not at all) to 3 (nearly everyday). The PHQ-9
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correlates strongly with measures of depression including the
Beck Depression Inventory-II38 and Center for Epidemiologic
Studies Depression Scale.39,40 Internal consistency in the pres-
ent sample was good (α = 0.84).
Generalized Anxiety Disorder Seven-Item
The GAD-741 is a measure of general anxiety disorder symp-
toms. Items are rated on a scale of 0 (not at all) to 3 (nearly
everyday). Higher scores indicate greater severity of anxiety
symptoms. At initial development, the GAD-7 demonstrated
solid internal consistency and correlated strongly with other
measures of anxiety such as the Beck Anxiety Inventory.42
Internal consistency in the present sample was good (α = 0.89).
Data Analysis
Differences among the treatment, attrition, and control groups
on demographic, clinical, and boot camp training variables
were analyzed using chi-square tests and one-way analysis of
variance with Scheffe’s post hoc test or Welch’s analysis of
variance with Games Howell post hoc test. For chi-square tests,
adjusted standardized residuals were used to measure the
strength of differences between observed and expected values.
Residuals greater than ±2 were considered significant.43,44
Independent sample t-tests were computed to examine differ-
ences between treatment completers and attrites on all outcome
measures. Pre- to post-changes on the outcome measures were
analyzed using paired sample t-tests. Within-subject Cohen’s d
effect sizes were calculated to measure the magnitude of
change and 95% confidence intervals (CI) were also computed.
Paired sample t-tests and within-subject Cohen’s d effect sizes
were also run separately for treatment completers who gradu-
ated versus those who were separated to evaluate whether
greater treatment gains were associated with successful boot
camp completion. Logistic regression was performed to exam-
ine which independent variables were most predictive of gradu-
ation. Nagelkerke R2 was used to measure the overall model fit
and odds ratios (OR) were examined to identify variables sig-
nificantly predictive of graduation.
RESULTS
Sample Characteristics
All recruits in the RCU between July and November 2014, and
between April 2015 and July 2016, were included in the study.
A total of 373 recruits participated in one of the 32 MPPE
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 Effectiveness of ACT in Increasing Resilience and Reducing Attrition of Injured US Navy Recruits

cycles conducted during this time frame. Recruits who com-
pleted at least four of the six sessions were defined as comple-
ters. The treatment group was composed of 242 recruits who
attended 5.3 sessions on average. Attrition was 35.1% (n =
131); they attended 2.4 sessions on average. Of the 131 attrites,
22 (16.8%) were medically separated, 18 (14.6%) were medi-
cally cleared back to training, five (3.8%) attended only half of
the sessions, and 86 (65.6%) withdrew.
Recruits in the RCU during this time frame who did not
Hispanic, 5.0% Asian, and 4.1% other. Males (n = 348;
51.0%) and females (n = 335; 49.0%) were fairly evenly
represented. However, there was a higher percentage of males
in the treatment group (58.3%) than in attrition (48.1%) or
control (46.5%) groups, χ2 (2, n = 683) = 8.12, p < 0.02.
There were no significant differences among groups on week
of training at time of transfer to RCU, transfer from FIT, or
pain ratings (i.e., pain rated on a scale of 0–10; see Table I).
Significant main effects were found for length of time in RCU
[F(2, 680) = 22.62, p < 0.001] and number of psychoeduca-

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participate in treatment were included in the control group
only if they had been in the RCU long enough to have had
the opportunity to participate in one of the treatment cycles
(e.g., in the RCU longer than 2 wk) and transferred at a time
when they could (e.g., not during the middle of a cycle).
During the time frame of the study, 387 recruits did not par-
ticipate in MPPE. Of these recruits, 58 (75.3%) were medi-
cally separated 9.7 d after transfer; 19 (24.7%) were
medically cleared back to training 10.5 d after transfer. The
remaining 310 recruits comprised the control group.
There were no significant differences among groups on age
and race. Average age was 20.9 yr. According to chart review,
race was 59.6% Caucasian, 24.0% African-American, 7.3%
tional groups attended [Welch’s F(2, 300.40) = 46.25, p <
0.001]. Treatment completers were in the RCU significantly
longer and attended significantly more psychoeducational
groups than attrites and controls.
Distribution of Injuries/Conditions
Recruits were moved to the RCU for injuries and conditions
that were categorized into skeletal, muscle/tendon/ligament/
joint (MTLJ), pain (e.g., no underlying medical condition or
injury), headaches/vestibular, pulmonary/cardiovascular, stomach/
intestinal, iron deficiency anemia, and medical other (see

TABLE I. Comparisons Among Treatment, Attrition, and Control Groups on Length of Time in Recruit Training Command & RCU,
Week of Training at Transfer to RCU, Transfer from FIT, Attendance in Psychoeducational Groups, and Pain Ratings.

Treatment (n = 242) Attrition (n = 131) Control (n = 310)

Length of time in RCU (d) 64.5 48.3 50.1
Week of training at transfer to RCU 4.6 4.6 4.7
Transfer from FIT 27.3% 38.2% 31.9%
Psychoeducational group attendance 6.8 3.6 2.3
Pain ratings (range on 10- point scale) 0.56–4.6 1.0–4.9 0.7–4.5

TABLE II. Distribution of Injuries and Medical Conditions for Recruits in the RCU.

Treatment (n = 242) Attrition (n = 131) Control (n = 310)

Skeletal 157 (64.9%) 69 (52.7%) 164 (52.9%)
Stress fracture 128 (52.9%) 58 (44.3%) 134 (43.2%)
Nondisplaced fracture (lower body) 12 (5.0%) 6 (4.6%) 11 (3.6%)
Dislocation (upper body) 5 (2.1%) 3 (2.3%) 9 (2.9%)
Nondisplaced fracture (upper body) 4 (1.7%) 1 (0.8%) 5 (1.6%)
Displaced fracture 3 (1.2%) 0 (0%) 1 (0.3%)
Other 5 (2.0%) 1 (0.8%) 4 (1.3%)
MTLJ 63 (26.0%) 46 (34.4%) 98 (31.6%)
Sprain (lower body) 14 (5.8%) 5 (3.8%) 17 (5.5%)
Strain (lower body) 7 (2.9%) 5 (3.8%) 16 (5.2%)
Shin splints 10 (4.1%) 13 (9.9%) 21 (6.8%)
Tendonitis (lower body) 12 (5.0%) 5 (3.8%) 6 (1.9%)
Patellofemoral syndrome 10 (4.1%) 6 (4.6%) 12 (3.9%)
Iliotibial band friction syndrome 3 (1.2%) 4 (3.1%) 11 (3.6%)
Strain (upper body) 0 (0%) 1 (0.8%) 8 (2.6%)
Other 7 (2.9%) 7 (5.5%) 7 (2.2%)
Pain 11 (4.5%) 11 (8.4%) 24 (7.8%)
Headache/vestibular 3 (1.2%) 1 (0.8%) 2 (0.6%)
Pulmonary/cardiovascular 5 (2.1%) 0 (0%) 10 (3.2%)
Stomach/intestinal 3 (1.2%) 1 (0.8%) 7 (2.3%)
Iron deficiency anemia 0 (0%) 0 (0%) 5 (1.6%)
Medical other 0 (0%) 3 (2.3%) 0 (0%)

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 Effectiveness of ACT in Increasing Resilience and Reducing Attrition of Injured US Navy Recruits

Table II). Skeletal, MTLJ, and pain accounted for 94.1% of all
transfers. A chi-square analysis limited to these three catego-
ries approached significance, χ2 (4, n = 643) = 9.02, p = 0.06.
Skeletal injuries accounted for the largest percentage of trans-
fers to the RCU. However, a significantly greater percentage
of treatment completers (64.9%) had skeletal injuries compared
with attrites (52.7%) and controls (52.9%). There were no
other significant differences among groups on injury/condition
classification.
recruits (M = 5.3) and separated recruits (M = 4.5), t (231) =
1.19, p > 0.05.
Graduation Rate and Reasons for Separation
There were 327 (47.8%) recruits graduated and 356 (52.2%)
separated. Table IV shows the distribution of injuries and con-
ditions for which separations were made. The most common
reason for separation was MTLJ injuries (26.1%), followed by
skeletal injuries (22.8%), pain (21.1%), and mental disorders

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Pre-treatment Differences and Pre- to Post-
treatment Changes
There were significant differences between treatment com-
pleters and attrites on two pre-treatment measures. On the
PRS, completers (mean [M] = 15.98, standard deviation
[SD] = 10.20) scored lower than attrites (M = 18.51, SD =
11.34), t (371) = 2.20, p < 0.05, d = 0.23. Completers (M =
6.74, SD = 5.06) also scored lower than attrites on the PHQ-
9 (M = 7.98, SD = 5.97), t (231.9) = 2.07, p < 0.05, d =
0.23 (degrees of freedom on the PHQ-9 were adjusted due to
unequal variances).
All treatment measures produced significant effects (see
Table III). Pre- to post-effect sizes with 95% CI were as fol-
lows: pain (d = 0.84, CI = 0.66–0.95), pain acceptance (d =
0.64, CI = 0.51–0.78), mindfulness (d = 0.60, CI = 0.47–0.74),
cognitive fusion (d = 0.63, CI = 0.48–0.76), experiential avoid-
ance (d = 0.48, CI = 0.34–0.61), depression (d = 0.54, CI =
0.39–0.66), and anxiety (d = 0.41, CI = 0.27–0.54).
Compared with recruits who were later separated, recruits
who later graduated reported greater improvement on pain,
mindfulness, depression, and anxiety; less improvement on
pain acceptance and cognitive fusion; and equivalent improve-
ment on experiential avoidance. There was no significant dif-
ference in booster session attendance between graduated
(primarily adjustment disorders; 14.3%). Excluding separation
classifications that had low cell counts, there was not a signifi-
cant association between group (treatment, control, or attrite)
and reason for separation, χ2 (8, n = 309) = 10.16, p > 0.05.
Variables Predictive of Graduation
Table V presents the associations between demographic, clini-
cal, and boot camp training variables and final outcome of
graduation. Continuous variables were dichotomized into cate-
gories using a median split. Treatment was significant, with
completers graduating at a higher rate (58.3%) than attrites
(34.4%) or controls (45.5%). Males and recruits over age 20 yr
were significantly more likely to graduate. Recruits moved to
the RCU before the sixth week in training did better than those
who were not moved until week 6 or later. Recruits who were
transferred from FIT were especially at risk for separation
(70.2%). There was a significant relationship between gradua-
tion and condition/injury at transfer to the RCU, with MTLJ
injuries most associated with separation. Recruits reporting
average pain greater than 3 on a 10-point scale were signifi-
cantly more likely to be separated. Attendance in psychoeduca-
tion groups and length of time spent in the RCU were not
predictive of graduation.
All of the predictor variables from Table V were entered
into a logistic regression model; continuous variables were

TABLE III. Means and SD of Treatment Measures for All Treatment Completers and for Treatment Completers Who Either Graduated
or Separated.

Total (n = 242) Graduated (n = 141) Separated (n = 101)

Pre M Post M Pre M Post M Pre M Post M
Measure (SD) (SD) t d (SD) (SD) t d (SD) (SD) t d
PRS 16.0 8.9 12.57 0.84 13.0 5.8 10.06 0.95 20.2 13.2 7.60 0.76
(10.2) (7.9) (9.5) (5.2) (9.7) (9.0)
CPAQ-8 28.6 33.0 −10.02 0.64 30.0 34.2 −7.27 0.62 26.7 31.4 −6.91 0.69
(7.3) (7.5) (7.3) (7.5) (6.9) (7.2)
CAMS-R 28.3 30.9 −9.38 0.60 28.8 31.5 −7.48 0.62 27.5 30.0 −5.67 0.57
(5.4) (5.9) (5.4) (5.7) (5.4) (6.0)
CFQ 24.7 20.0 9.67 0.63 23.2 18.4 7.22 0.61 26.9 22.2 6.42 0.64
(9.9) (9.0) (9.2) (8.7) (10.5) (9.0)
AAQ-2 18.8 15.7 7.39 0.48 17.1 14.1 5.70 0.47 21.2 17.9 4.71 0.47
(9.3) (8.3) (8.2) (7.5) (10.2) (8.9)
PHQ-9 6.7 4.4 8.22 0.54 5.7 3.2 7.07 0.62 8.2 6.0 4.54 0.44
(5.1) (4.4) (4.6) (3.3) (5.4) (5.2)
GAD-7 5.6 3.9 6.32 0.41 4.5 2.9 5.13 0.45 7.0 5.3 3.83 0.37
(5.1) (4.5) (4.4) (3.5) (5.7) (5.4)

PRS, Pain Rating Scale; CPAQ-8, Chronic Pain Acceptance Questionnaire-8; CAMS-R, Cognitive and Affective Mindfulness Scale-Revised; CFQ, Cognitive Fusion
Questionnaire; AAQ-2, Acceptance and Action Questionnaire-2; PHQ-9, Patient Health Questionnaire-9; GAD-7, Generalized Anxiety Disorder-7. All p values < 0.001.

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 Effectiveness of ACT in Increasing Resilience and Reducing Attrition of Injured US Navy Recruits

TABLE IV. Comparisons Among Treatment, Attrition, and Control Groups on Reason for Separation.

Classification Treatment (n = 101) Attrition (n = 86) Control (n = 169)

Skeletal 25 (24.8%) 19 (22.1%) 37 (21.9%)
Segmental dysfunction 8 (7.9%) 6 (7.0%) 8 (4.7%)
Stress fracture 7 (6.9%) 5 (5.8%) 8 (4.7%)
Osteopenia/osteoporosis 5 (5.0%) 4 (4.7%) 13 (7.7%)
Nondisplaced fracture (lower) 0 (0.0%) 1 (1.2%) 2 (1.2%)
Limb/back deformity 4 (4.0%) 1 (1.2%) 6 (3.6%)
Other 1 (1.0%) 2 (2.4%) 0 (0.0%)
MTLJ 29 (28.7%) 22 (25.6%) 42 (24.9%)

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Shin splints 9 (7.9%) 6 (7.0%) 17 (10.1%)
Tendonitis 6 (5.9%) 1 (1.2%) 2 (1.2%)
Patellofemoral dysfunction 5 (5.0%) 6 (7.0%) 10 (5.9%)
Osteoarthritis/osteochondrosis 2 (2.0%) 3 (3.5%) 3 (1.8%)
IT band friction syndrome 2 (2.0%) 2 (2.3%) 0 (0.0%)
Other 5 (5.0%) 4 (4.7%) 10 (6.0%)
Pain 21 (20.8%) 21 (24.4%) 33 (19.5%)
Headache/vestibular 4 (4.0%) 1 (1.2%) 9 (5.3%)
Pulmonary/cardiovascular 1 (1.0%) 2 (2.3%) 4 (2.4%)
Stomach/intestinal 0 (0.0%) 0 (0.0%) 2 (1.2%)
Iron deficiency anemia 0 (0.0%) 1 (1.2%) 3 (1.8%)
Medical other 3 (3.0%) 2 (2.3%) 2 (1.2%)
Mental disorder 12 (11.9%) 15 (17.4%) 24 (14.2%)
PFA failure 6 (5.9%) 3 (3.5%) 13 (7.7%)

TABLE V. Association Between Predictor Variables and Final Outcome of Graduation or Separation.

Final Outcome
Graduated Separated
Variable n = 327 (47.8%) n = 356 (52.2%) df, χ2 p
Group 2, 20.78 <0.001
Treatment 141 (58.3%) 101 (41.7%)
Attrition 45 (34.4%) 86 (65.6%)
Control 141 (45.5%) 169 (54.5%)
Gender 1, 8.83 <0.01
Male 186 (53.4%) 162 (46.6%)
Female 141 (42.1%) 194 (57.9%)
Age 1, 12.06 <0.01
18–20 181 (42.7%) 243 (57.3%)
> 20 146 (56.4%) 113 (43.6%)
Week of training 1, 23.06 <0.001
Before sixth week 197 (56.9%) 149 (43.1%)
From sixth week 130 (38.6%) 207 (61.4%)
FIT 1, 41.24 <0.001
Yes 64 (29.8%) 151 (70.2%)
No 263 (56.2%) 205 (43.8%)
Reason for transfer to RCU 3, 16.17 <0.01
Skeletal 208 (53.3%) 182 (46.7%)
MTLJ 78 (37.7%) 129 (62.3%)
Pain 18 (39.1%) 28 (60.9%)
Other 23 (57.5%) 17 (42.5%)
Average pain rating 1, 72.17 <0.001
0–3 221 (63.9%) 125 (36.1)
4–10 106 (31.5%) 231 (68.5%)
Psychoeducation groups 1, 1.60 >0.05
0 to 2 groups 183 (50.1%) 182 (49.9%)
More than two groups 144 (45.3%) 174 (54.7%)
Time in RCU 1, 1.74 >0.05
Up to 52 d 158 (45.4%) 190 (54.6%)
Over 52 d 169 (50.4%) 166 (49.6%)

e608 MILITARY MEDICINE, Vol. 183, September/October 2018

 Effectiveness of ACT in Increasing Resilience and Reducing Attrition of Injured US Navy Recruits
not dichotomized for the model. This model accounted for
31% of the variance in graduation rates [χ2(12) = 179.13,
p < 0.001, Nagelkerke R2 = 0.31] and correctly classified
71.5% of cases. Only four of these variables made a unique
statistically significant contribution to the model: age (p <
0.01; OR 1.07; 95% CI 1.02–1.13), not transferred from FIT
(p < 0.001; OR 2.51; 95% CI 1.58–3.98), MPPE completion
compared with dropping out (p < 0.001; OR 2.63; 95% CI
1.55–4.44) or not participating at all (p < 0.001; OR 1.95;
95% CI 1.28–2.98) and average pain rating (p < 0.001; OR
0.52; 95% CI 0.45–0.60).
DISCUSSION
Findings from this study provide support for MPPE, an ACT-
based treatment program designed to help recruits more effec-
tively handle pain, and improve their performance on physical
fitness tests required for entrance into the Navy. MPPE was
added to already existing services that included daily physical
therapy, medical interventions (e.g., pain medications and sur-
gery), and psychoeducational groups. Treatment was only 2
wk long, yet produced significant improvements on all out-
come measures, with effect sizes of large for pain reduction,
medium for pain acceptance, mindfulness, cognitive inflexibil-
ity, and depression and small for experiential avoidance and
anxiety.
The current study was unique in that there are no published
studies on mindfulness and acceptance-based treatment for
people in the acute or subacute phases of pain following an
injury. Although participants in ACT for chronic pain studies
report duration of pain generally ranging from 110 to 155 years,
recruits commonly entered MPPE within 1–4 wk of their inju-
ries. The treatment sample in this study also differed from par-
ticipants in ACT for chronic pain trials on factors such as age
(i.e., average age in the current study was 21 yr), motivation
(e.g., receiving treatment that could help them graduate), and
the absence or reduced incidence of disqualifying medical and
mental health conditions.
The current study shared similarities with mindfulness
and acceptance-based approaches to athletic performance
enhancement. Sappington and Longshore’s31 systematic
review supported use of these approaches based on subjec-
tive measures of mindfulness, cognitive flexibility, experien-
tial acceptance, and anxiety. There was mixed evidence,
however, on objective measures of athletic performance such
as running25,29 and archery.27,29
The most important aim of the current study was to dem-
onstrate that MPPE can contribute to higher graduation rates.
Graduation required not only recovering from an injury/med-
ical condition but also successfully completing a medical
PFA and a final PFA. This was the objective performance
measure for the current study. Treatment completers gradu-
ated at a higher rate (58.3%) than controls (45.5%) and
attrites (34.4%). A chi-square analysis found a significant
relationship (p < 0.001) between treatment completion and
MILITARY MEDICINE, Vol. 183, September/October 2018
graduation (adjusted standardized residual cells for treatment
completers were ±4.0). Treatment completion was also a sig-
nificant predictor of graduation in a logistic regression
model. Yet, there was not much differentiation on pre- to
post-outcome measures between treatment completers who
graduated and those who were separated. Moreover, there
were no significant differences in booster session attendance.
Gender was not a significant predictor in the logistic
regression model. There were significantly more males than
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females among treatment completers compared with attrites
and controls. However, both males (63.8%) and females
(50.5%) in the treatment group graduated at higher rates
compared with attrites (males: 38.0%; females: 30.9%) and
controls (males: 50.0%; females: 41.6%).
Among recruits coming to the RCU from FIT, 70% were
later separated. Many recruits come to boot camp in unsatis-
factory physical shape. The FIT program was designed to
assist those recruits in passing a PFA. FIT was not intended
for injured recruits. Unfortunately, injuries may not be dis-
covered until recruits are in FIT.
There were no significant differences among treatment
completers, attrites, and controls on the injuries and condi-
tions that put them in RCU, except for skeletal injuries that
were more frequent for completers. Injury/condition classifi-
cations requiring transfer to the RCU were not significantly
predictive in the logistic regression model; average pain rat-
ing was. Lowest and highest pain ratings were collected on
medical visits for all recruits during their time in the RCU.
Treatment completers, attrites, and controls were comparable
on these ranges. Yet, treatment produced a large effect size
in pain reduction. Recruits could enter MPPE any time while
in the RCU, so the lowest and highest pain ratings they
reported during medical appointments could have been
before, during, or after their participation in MPPE. Also,
whereas pain ratings collected on medical visits were limited
to physical pain, the PRS used in MPPE includes items on
emotional pain associated with physical pain.
MPPE was not the only psychological treatment offered
to recruits in the RCU. Psychoeducational group participation
was not significantly associated with graduation, but recruits
who attended two or fewer groups were more likely to gradu-
ate than those who attended more than two. Psychoeducational
groups were stand-alone sessions designed to help recruits
handle stress they were experiencing while in the RCU. The
purpose of these groups was not specifically to help recruits
effectively respond to physical pain or to enhance physical per-
formance. Treatment completers were significantly more likely
to attend these groups, but completers who later graduated
attended fewer (6.3) sessions than completers who were later
separated (7.5).
There are several limitations of this study. First, it was not a
randomized control trial. There could be particular characteris-
tics about those recruits who chose to participate in treatment
that might limit the conclusions drawn. Recruits who entered
treatment may have already had higher pain tolerance, greater
e609
 Effectiveness of ACT in Increasing Resilience and Reducing Attrition of Injured US Navy Recruits
resiliency, or stronger motivation to pass the PFA and graduate.
Second, no outcome measures were administered to the control
group. Comparisons with the control group could only be made
on demographics, select clinical variables (e.g., injury/medical
condition diagnoses, pain ratings, and psychoeducational group
attendance), and boot camp training variables (e.g., time in
RCU and transfer from FIT). Improvement on outcome mea-
sures may not have been attributable to MPPE but to factors
not examined. Third, the attrition rate was a fairly high 35.1%.
MPPE was scheduled at a time when recruits generally did not
have other obligations, and much of this attrition (65.6%) came
from recruits who voluntarily stopped attending after the sec-
ond session. There was no follow-up with those recruits to ask
them why they stopped coming. But those recruits who
dropped out may have been distinctly different from the recruits
who stayed on unknown factors predictive of graduation.
In conclusion, Naval recruits with injuries and medical con-
ditions are at risk of getting separated from boot camp if they
cannot recover from injuries or medical conditions and success-
fully pass a PFA required for graduation. The current study
represents the first time that a behavioral intervention was
implemented to assist these recruits and reduce attrition.
Results from this study provided support for the use of a mind-
fulness and acceptance-based treatment program designed to
help recruits effectively respond to pain and enhance physical
performance to recover, graduate from basic training, and
become sailors. Introducing this program to recruits earlier in
training and before transfer to the RCU would allow more
recruits to benefit and could yield an even greater impact on
both recruit attrition and resiliency of sailors in the fleet.
FUNDING
This research received no specific grant from any funding agency in the
public, commercial, or not-for-profit sectors.
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