ORIGINAL ARTICLES

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MILITARY MEDICINE, 176, 9:976, 2011

Assessment of Military Population-Based Psychological

Resilience Programs
Lt Col Brenda J. Morgan, USAF NC*; CAPT Sandra C. Garmon Bibb, NC USN (Ret.)†

ABSTRACT Active duty service members’ (ADSMs) seemingly poor adaptability to traumatic stressors is a risk to
force health. Enhancing the psychological resilience of ADSMs has become a key focus of Department of Defense (DoD)
leaders and the numbers of military programs for enhancing psychological resilience have increased. The purpose of this
article is to describe the results of an assessment conducted to determine comprehensiveness of current psychological
resilience building programs that target ADSMs. A modified six-step, population-based needs assessment was used to
evaluate resilience programs designed to meet the psychological needs of the ADSM population. The assessment results
revealed a gap in published literature regarding program outcomes. DoD leaders may benefit from targeted predictive
research that assesses program effectiveness outcomes. The necessity of including preventive, evidence-based interven-
tions in new programs, such as positive emotion interventions shown to enhance psychological resilience in civilian
samples, is also recommended.

INTRODUCTION determine the comprehensiveness of military psychological

Since 2001, approximately 1.9 million United States (U.S.)
military members have deployed to Iraq and Afghanistan.1
Stressors, such as the continuing nature of current deploy-
ments and the increased operations tempo for those members
who do not deploy, increase the risk for military members to
suffer from decreased mental health functioning (depression,
post-traumatic stress disorder [PTSD], decreased work per-
formance, increased physical illness, increased attrition).2–5
Because it has been suggested that on-going mental health
issues are rooted in one’s state of resilience, renewed sup-
port has emerged for efforts that target the fitness of military
forces through enhancement of psychological resilience.6–8
The Department of Defense (DoD) has many excellent efforts
designed to address psychological care of the active duty ser-
vice member (ADSM) population, including unit-specific
programs and interventions. However, details relating to com-
prehensiveness and effectiveness of these population-based
programs are sometimes lacking.5–8 The purpose of this arti-
cle is to describe the results of an assessment conducted to
*Graduate School of Nursing, Uniformed Services University of the
Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814.
†Department of Health Systems, Risk, and Disease Management,
Graduate School of Nursing, Uniformed Services University of the Health
Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814.
resiliency programs established since the onset of Operation
Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) and
currently in place to meet the needs of ADSMs.
BACKGROUND
Improving the psychological fitness of the total military force
requires targeting population health problems and conducting
population health studies. Population health is a “framework
for thinking about why some populations are healthier than
others, as well as the policy development, research agenda,
and resource allocation that flow from it.”9 Population health
is also the “definition and measurement of health outcomes
and their distribution, the pattern of determinants that influ-
ence such outcomes, and the policies that influence the opti-
mal balance of determinants.”10 Population health research
focuses on progressively describing, explaining, predicting,
and controlling health and health outcomes (Fig. 1).9 Even
though military population-based psychological resilience
programs are in place, clear evidence for the comprehensive-
ness and effectiveness of these programs is needed to provide
information to focus conduction of population health studies.
Once conducted, these studies can be used to inform policy
and decision making related to military population-based psy-
chological resilience programs.

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 Assessment of Military Population-Based Psychological Resilience Programs
POPULATION-BASED ASSESSMENT FRAMEWORK
A needs assessment is “practical research culminating in a
description of a specific group’s health status, as well as the ade-
quacy of resources available to that population…,”11 whereas
a population-based needs assessment is an “attempt to quan-
tify and understand a specific need within a community in an
effort to target resources effectively to address that need….”11
We used a population-based needs assessment framework to
conduct our assessment because this approach provides the
best guide for assessing the sufficiency and adequacy of resil-
ience-focused military programs within the ADSM commu-
nity. We adapted Declercq et al’s six-step, population-based
assessment approach to streamline the assessment process.11
To accommodate conduction of a review of existing psycho-
logical resiliency programs, we added programmatic review
as part of Step 3, Existing Resources. In addition, because
of the scarcity of military psychological resiliency program
outcomes research available when we conducted our assess-
FIGURE 1. Progressive purpose of population health studies. (Depiction
based on Young’s description of the trajectory of population health studies9.)
FIGURE 2. Assessment of active duty service member psychological resilience needs.
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ment, we combined Declercq et al’s Steps 5 and 6 into a single
step, renamed Synthesis of the Data (Fig. 2). An explanation
of the adapted population-based needs assessment approach is
presented in Table I. A summary of the specific questions and
findings associated with each step of the assessment is pre-
sented later in this article.
ASSESSMENT METHODOLOGY
Data Sources
Systematic reviews are conducted using “a rigorous scientific
approach to combine results from a body of original research
studies into a clinically meaningful whole.”12 An integra-
tive review of the literature is conducted to summarize “past
empirical or theoretical literature to provide a more compre-
hensive understanding of a particular phenomenon or health-
care problem.”13 Therefore, we used an integrative review
approach to ensure inclusion of published and unpublished,
as well as theoretical and empirical literature, in assessing the
comprehensiveness of military psychological resiliency pro-
grams established since the onset of OEF/OIF.
PubMed and Cumulative Index to Nursing and Allied
Health Literature bibliographic databases were queried to
identify documents addressing military psychological resil-
iency programs targeting ADSMs. Keywords such as U.S.
military programs, resilience programs, ADSM, preventive
interventions, and positive emotion (PE) were used to search
for both theoretical and empirical publications. Because of
the newness of some programs and a paucity of published
outcome studies, conferences, workgroups, the lay press,
and various DoD and military Web sites were also reviewed
to locate published, as well as nonpublished, but publicly
available, service-specific (Army, Navy, Air Force [AF])
documents. A “snowball” or “network”14 sampling process
was used to search for additional documents. For example,
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 Assessment of Military Population-Based Psychological Resilience Programs

TABLE I. Modified Population-Based Needs Assessment Steps

Population-Based Needs Assessment Modified Population-Based Needs Assessmenta

(1) Formulate the Question
(2) Review the Literature
(3) Existing Resources
(4) Question Refinement
(5) Data Collection
(6) Analyze Results
(7) Present Results
a
Developed using Declercq et al11 definitions from the Seven Step Population-Based Needs Assessment.
(1) Formulate the Question: Succinct Definition of the Problem and Population Used to Direct Approach to
Produce Outcomes From the Needs Assessment Process.
(2) Review the Literature: Used to Describe the Nature of the Problem (State of Health) in the Population of
Interest, and to Present Related Information.
(3) Existing Resources and Programs: Gap Between Needed and Available Services.
(4) Question Refinement: Based on Literature Review, Refine the Overarching Question Related to Problem and
Population.
(5) Data Synthesis: Experimental, Time Series, and Cross-Sectional Research Used to Compare Primary and/or
Secondary Data to Identify Gaps.
(6) Present Results: Data Collection and Analyses Presented to Aid Decision-Making, Setting Priorities, and
Establishing Goals/Objectives.

when gathering information about programs, the program
contact for one psychological resilience program frequently
provided referral to other pertinent program contacts. In addi-
tion, reference lists from published literature were used to
locate other relevant publications and data sources.
Application of the Assessment Process Steps
In the following section, we present an overview of the data
synthesis process and results associated with the application
of each assessment process step.
Formulation of the Question
Since 2002, PTSD prevalence for the general military popu-
lation has varied from 5% to 20%.15 In the November 2010
Medical Surveillance Monthly Report,2 statistics showed
that 9% of ADSMs self-reported PTSD symptoms and 28%
reported depressive symptoms. Despite the variation in
reports of these statistics, we felt it was important to address
the ongoing ADSM mental health concerns1,5,16,17 through the
overarching question at the center of this needs assessment
(Fig. 2): “What factors impact development and maintenance
of ADSM psychological resilience?”
Review of the Literature
Scope of the problem. Deployment-related problems, such as
mental health issues and completion of ADSM deployment
health surveys, are the focus of many military studies.1,3,15,18–21
Historically, military psychological resilience research was
service-specific; targeted the combat soldier; and/or was
treatment-oriented, rather than preventive.3,22 Although sci-
entists from all military branches have pursued psychological
resilience research, most have targeted samples in basic mili-
tary training (BMT)23–27 or military cadets,28–30 with goals that
addressed such associations as resilience factors and gradua-
tion success, attrition rates, or leadership strengths. New mili-
tary recruits are, for the most part, mentally healthy and adapt to
stressors normally, nevertheless, the intense stress exposure that
begins in BMT continues into their advanced individual train-
ing (AIT). AIT recruits have additional military and academic
requirements and may be at even greater psychological risk than
their civilian college student counterparts.31 The positive aspects
of acute stress exposure may wane in the face of inappropri-
ate coping measures and unmitigated stress.3 Left unchecked,
chronic stress exposure may weaken psychological resilience
and impact performance.3 Even the social bonds developed in
BMT that should provide a positive stress outlet for the AIT
trainee may instead lead to added peer pressure.32 Understanding
the experience of stress for the new recruit, including how to
help those having difficulty adjusting, is necessary. However,
some researchers24,33 suggest that this early training environ-
ment may not be the most conducive for interventions designed
to build psychological resilience. Instead, Cigrang et al33 pro-
posed lowering mental health discharge criteria and redirecting
saved resources to target other members later in their careers.
As stated earlier, population health studies are best focused
on describing and explaining current problems, and then,
designing evidence-based interventions that may positively
impact outcomes. Studies describing psychological resilience
protective factors have increased in both military- and civilian-
based literature. Factors targeted by Army and Navy programs
include fitness, humor, hope, unit cohesion, social support,
sense of purpose, spirituality, and optimism.22,34 In civilian
populations, there is evidence that increasing PE is associated
with improvements in these targeted areas.35,36 However, the
effectiveness of PE interventions in enlisted military popula-
tions is not yet established. To date, no studies have been con-
ducted targeting military members in the AIT environment
with interventions designed to strengthen psychological resil-
ience by increasing PE, such as gratitude. Because civilian PE
intervention studies are based in samples with similar charac-
teristics of ADSMs, the synthesis of the literature from these
studies may be useful to develop population health studies for
military settings. Therefore, in reviewing the military litera-
ture, it is important to understand how major concepts related
to enhancing psychological resilience have been conceptual-
ized in the civilian literature and how these concepts could
be operationalized in similar military settings and samples. A
synthesis of these concepts is presented below.
Resilience. Psychological resilience is defined as the abil-
ity to bounce back from, or deal with, adversity with positive

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 Assessment of Military Population-Based Psychological Resilience Programs
outcomes.37,38 In military members, psychological resilience
includes personal factors that enhance or weaken the stress
response process and impact how one copes with stressors.
Combat stress response training is recognized as one tool
for lessening the psychological impact of combat stress on
ADSMs. In 1999, guidance from DoD39 identified the impor-
tance of targeting overall force health by establishing require-
ments for comprehensive training programs.
Force health protection is defined as aiming to “…promote,
protect, improve, conserve, and restore the mental and physi-
cal well being of Service members across the full range of
military activities and operations.”40 Because the mission of
each Service is different, it is expected that one Service may
focus more heavily on combat vs. noncombat, but their efforts
should not be at the expense of certain occupations.41 Models
used to frame the various programs have been inconsistent,
although the Stress Injury Continuum is one model increas-
ingly being used by the services for assessing, training, and
treating psychological resilience.
The Navy-Marine Corps Combat and Operational Stress
Continuum (COSC), based on the Stress Injury model, pro-
vides a mechanism for tracking the military members’ cur-
rent state of resilience, and offers a means of communicating
with a common language to discuss the normal stress response
and pathological illness effect on brain, body, and mind
functioning.42 In the Stress Continuum, the range of stress
responses and outcomes are illustrated using color codes
(Red/Ill; Orange/Injured; Yellow/Reacting; Green/Ready).
There is a distinction made between combat and opera-
tional stress, where operational stress is experienced regard-
less of deployment status. In this model, military members
either suffer through the stressful situation or recover from
negative effects as quickly as possible.42 In the COSC, the
indicators of a “ready” resilient member include humor,
positive attitude, social/spiritual connection, and sense of
purpose.
Stress. How one manages stress is an integral part of one’s
state of resilience. Although no one is spared from exposure
to life’s stressors, a person’s response will be individualized
based on physical, psychosocial, and environmental factors.43
In the 2008 annual stress survey, 75% of Americans reported
experiencing moderate or severe levels of stress.44 Military and
nonmilitary populations experience similar stressors, but mili-
tary members, in times of war and peace, live and work with
the added burden of increased operations tempo, extended
family separations, deployments to austere and threatening
environments, and exposure to mutilation and death.3,20 One
DoD health survey4 assessed the elevated levels of stress in
military members—32% of the military members reported “a
lot” of occupational stress, whereas 20% reported “a lot” of
family stress.
More alarming was the young age (<21) of respondents
reporting the highest (38.8%) job-related stress and who
“met screening criteria suggesting a need for further mental
health evaluation.”4 This young age corresponds to the ages
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of those military members most psychologically vulnerable
and less likely to have developed strong, adaptive coping
skills to aid them during increased stress exposures.2,3 If, as
reported,17,45–47 predeployment mental health is strongly linked
to postdeployment PTSD, then efforts should be directed to
strengthening mental resources for our newest recruits where
as many as 15% report PTSD symptoms on accession.46
The link between stress and chronic condition morbidity
and mortality is well-studied.43,48 Personality (type, locus of
control, optimism, pessimism), social functioning (networks
and roles), past experience with stress, and coping mecha-
nisms43 are some personal factors that “affect one’s appraisal
of stressors and influence the emotional, behavioral, and
physiological responses of individuals.”43 The context within
which the individual experiences stressors may be biologi-
cal (developmental stage, appraisal), environmental (may
alter response ability), and cultural (exposures, appraisal,
response).43 In Folkman’s Stress and Coping Model,35 factors
such as meaning-focused coping and PE impact stress adap-
tation. Research has accumulated that supports the benefi-
cial effects of PE in the stress process.35 In Folkman’s model,
assisting members with adaptive coping requires a holistic
approach, mind–body–spirit.
Positive Emotions. Unlike negative emotions linked to many
stress-related diseases,49,50 a PE, or affect, is believed to relate
to well-being or happiness.51 Happier people are healthier, cope
better with illness, live longer, are more productive and engaged
workers, more persistent in problem solving, more altruis-
tic, and more positive.52,53 Folkman35 theorized that “positive
emotions might serve as ‘sustainers’ that help motivate cop-
ing, ‘breathers’ that provide momentary respite from distress,
and ‘restorers’ that replenish coping resources.” The physio-
logical means connecting PE, improved health, and a longer
life, relate to cardiovascular reactivity and recovery, such that
positive and negative emotions impact cardiovascular arousal
uniquely.54 Interventions focused on inducing PE have been
shown to affect physical and psychosocial health outcomes in
such areas as heart disease,54,55 immune functioning,56–58 pain,59
mental health,60–66 chronic disease,66–68 and cancer.69,70
According to the Broaden and Build Theory of Positive
Emotion,71 everyone’s potential for strengthened resilience
depends on certain personal and situational factors that
increase one’s range of available options when initially chal-
lenged. It is through the adaptation process that resilience is
enhanced such that PE and psychological resilience share a
reciprocal relationship of increasing personal resources for
managing life’s challenges.3,36,71–74
Description of Existing Resources
An exploration of existing ADSM military resources under-
scores the needs, and highlights research gaps, for predictive
interventions. Overall, existing resources tend to be more
focused on combat or deploying members; are not consistent
across the services; and, most importantly, are not prevention-
focused and lack effectiveness outcomes.
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From “… 2004 to 2008, documented visits for mental disor-
ders increased by more than 68%”16 and suggestions were that
injury prevention and mental health management resources
should be targeted with primary, secondary, and tertiary pre-
vention efforts.16 Several explanations have been offered for
the increase, such as, decreased stigma, increased access, and
improved diagnoses/documentation.2 Regardless, the increased
utilization is a potential strain on military resources.
A review of current and past DoD efforts to off-
set issues related to postdeployment reveals a number of
resilience-focused programs (Tables II, III). Programs recently
instituted in the Army (Table II) and Navy/Marine Corps

TABLE II. Army and Navy/Marine Corps Programs

Army Programs Intervention/Outcomes

CSF76:
Army BM82,83 Name Changed to Sustainment Resilience Training;
Mandate in 2007; BM I (Basic Combat Training); BM II (Junior
leaders), BM III (Midgrade Leaders), BM IV (Senior Leaders),
BM V (Precommand)84
CSF Army MRT79
Level I (10 Days) and Level II (14 Days) Training; Targets NCOs,
Midlevel Supervisor; Approximately 1300 Trained Since Fall 2009;
MRT Course Opened Ft Jackson, SC, 201086 MRT Mobile Team
Navy/Marine Corps Programs
Navy Boot Camp Survival Training for Navy Recruits—
A Prescription (BOOT STRAP)27
Focused New Recruits Identified as High Risk (Not for All Recruits);
Strategies to Assist Navy Recruits’ Success87 Provided Further
Evaluation of BOOT STRAP Intervention Impact on Future
Attrition Rates
Navy/Marine Combat/Operational Stress Control41,86,88,89,107
COSC (Red/Orange/Yellow/Green); Build Resilience, Identify Stress
Response, Mitigate Stress Issues; Three-Phase Development:
Phase I 2008 (OSC Awareness Pre/Postdeployment; >110K
Trained)
Phase II 2009 (Mission/Community-Specific)
Phase III 2010 (Navy Leadership Course, Curriculum
Integration); Naval Military Training Apprentice
Module Added to Technical Pipeline
Caregiver Occupational Stress Control87,90
Intervention: Cognitive and Skills-Based Training Across the Life Cycle;
Pre/Postdeployment; Classroom and Online; Targets ADSM, Warrior
Transition, Community, Spouse
Outcomes: BM Research Since 1996; Postdeployed Well-Being Increased
for Predeployment BM Trained; CSF,76,85 GAT+77,78
Intervention: Cognitive Restructuring to Manage Stress; Train-the-Trainer
Technique; Initial Development UPENN, Based on Shatte and Reivich79
Outcomes: Pending (GAT+ Scores)77,78
Intervention/Outcomes
Intervention: Mental Health Provider Uses Cognitive/Behavioral
Interventions Aimed at Coping, Such as Reframing Faulty Thinking
Patterns, Relationships, Self-Assessment of Emotional Reactivity
Outcomes: Improved Graduation Rates and Group Cohesion; Improved
Problem-Solving, Coping, Perceived Social Support26,27,87
Intervention: Formal Training Modules, Cross-Career; In-person and Web;
Introduces the Stress Continuum Model, Overview of Signs/Symptoms
of Problems Along Continuum; Predeployment Training Reinforces the
Prerequisite Online Course With Deployment Scenarios; Postdeployment
Training for Service Members and Spouses/Significant Others; Reviews
Reintegration Difficulties; Signs, Symptoms, and Resources Identified;
Builds on COSC Predeployment Training42
Outcomes: “Stress-O-Meter” Measurement Tool; Okinawa Experience
(June 2009 to April 2010)91; Assess Staff Stress Based on Continuum;
Links to Self-Care Training. Planned: Training Surveys, Focus Groups,
Behavioral Health Quick Poll, Lightening Poll, Questions for Navy-Wide
Surveys, Policy Review90

TABLE III. AF Programs

AF Program Intervention/Outcomes
CAF93: Intervention: Led by the Integrated Delivery System; Online Modules, Social
4 Pillars (Physical, Mental, Social, Spiritual) Networking Sites, etc
5 C’s—Care, Commit, Connect, Celebrate, Communicate Outcomes: Unknown
Total Force Resilience: ART94: Intervention: Assist Reintegration for Targeted High-Risk Career Fields; Assess
Tiered Approach: Effect of Deployment on Behavioral Factors in High Risk Members and
Tier 1(High-Risk Deployers): Deployment Transition Center; Families
AF Stress Inoculation Training and Research; Operational Outcomes: Unknown
Resilience in Sustained Combat; Basic Combat Convoy Course
Tier 2 (High-Risk Groups for Suicide): Landing Gear Intervention: LG-Free Standing Tailored Class; Uses Mental Health,
(LG)108 Now ART; released Oct 2008; Identify/Connect Airman & Family Readiness Center, or Chaplain Briefings; Focus Deployment
Airmen Suffering From Traumatic Stress Symptoms to Helping Environment/Stress: Typical Reactions, Reintegration, and Reunion; ART-
Agencies Module, Skill-Based Training
Outcomes: Unknown
Tier 3 Every Day Stressors and Training: Lower Risk Intervention: Computer-Based Suicide Prevention Training; Connect Airmen to
for Suicide Base Support
Outcomes: Unknown
Foundational Training: Baseline Testing of New Recruits Intervention: Lackland Behavior Questionnaire; Assess Risk and Resilience
Factors
Outcomes: Unknown

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 Assessment of Military Population-Based Psychological Resilience Programs
(Table II) have specific psychological resilience strengthening
components focused on all occupations.42,75 Outcomes support-
ing the effectiveness of these programs in military samples are
promising but incomplete. The Army Comprehensive Soldier
Fitness (CSF) program, initiated in 2008, aims to develop/
institute holistic fitness programs for performance enhance-
ment and resilience in Soldiers, families, and civilians.76 The
CSF program incorporates dimensions of strength: physical,
emotional, social, family, and spiritual.76 The four pillars of
the CSF program include: (1) Global Assessment Tool (GAT;
100 items, self-assess emotional, spiritual, social, and fam-
ily fitness)77,78; (2) comprehensive self-learning resilience
modules; (3) institutional military resilience training; and
(4) Master Resilience Training (MRT).79 The Army has a
comprehensive set of metrics planned for assessing the CSF
program outcomes.77,78 Mindfulness-based Mental Fitness
Training (MMFT),80 designed to improve attentional capac-
ity, and Provider Resilience Training81 are interventional
programs also being tested. Planned Army/Marine stud-
ies include an expressive writing intervention with post-
deployment Battlemind (BM) training (name changed to
Sustainment Resilience Training/SRT); expansion of BM
program to British, Canadian, and Dutch Soldiers; and an
in-theater debriefing program.82–84
The Navy/Marine Corps COSC (Table II) was founded on
the Stress Injury Model and U.S. Marine Corps Combat and
Operational Stress Control Doctrine.42,88,89 The COSC doc-
trine includes 3 tools: (1) Stress Continuum Model (situation),
(2) Five Core Leadership functions (mission), and (3) Combat/
Operational Stress First Aid (execution).92 Development of the
doctrine began in 2007, was adopted in 2008, further revised
in 2008–2009, and integrated into training in 2010.42
Total Force Resiliency was rolled out for the AF com-
munity in early 2010 (Table III).93,94 This AF resiliency pro-
gram, based on Army and Navy programs, is a comprehensive
means to enhance well-being.93 Airman Resilience Training
(ART), the primary AF deployment training program, is a
three-tiered, risk-targeted (PTSD, depression, anxiety, sui-
cide, etc.) psychological resilience enhancement program to
include foundational training for new recruits.75,93,94 The AF
piloted its first ART class in June 2010.94
The Air Mobility Command piloted the Comprehensive
Airman Fitness (CAF) initiative in July 2010.93 CAF, described
as a change in culture vs. just another program, includes two
principles: (1) daily positive actions (5Cs) that predict one’s
actions during challenge/stress; and (2) balancing mental,
physical, social, and spiritual fitness (4 pillars) leading one
to address the factors they can control (positive behavior and
holistic fitness).93 Even with recent work, AF efforts are still
new and there is no clear delineation of proposed metrics or
published program effectiveness research.
For an effective and fit military, DoD psychological resil-
ience programs must be comprehensive. The military litera-
ture and programmatic review reveals that, while there is a
lack of published outcomes for some service programs, DoD’s
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efforts to address the mental health resilience problems have
been sincere, including funding for research, conferences, new
resilience training/program implementation, clearing houses
to assist with identification/evaluation of resilience-building
programs/interventions, and a “top down” leadership focus.75
The Chairman of the Joint Chiefs of Staff (CJCS), looking
beyond mainstream interventions, charged subject-matter
experts with development of an instruction that views the mili-
tary member’s total fitness holistically, mind-body-spirit.7 The
instruction, Total Force Fitness (TFF), covers all DoD services
and is proposed to assist leaders in their effort to develop a
more resilient (fit) force.95 The TFF instruction is one alterna-
tive (whole-person concept) for addressing current mental
health problems exhibited by ADSMs. In the TFF model,
resilience is defined as “the ability to withstand, recover,
grow, and adapt in the face of…challenges.”5 TFF is a state
of well-being in the individual, family, and organization that
allows members to carry out the mission under all conditions.
TFF includes eight domains: social, physical, environmen-
tal, medical, spiritual, nutritional, psychological, and behav-
ioral.95 The TFF instruction, while addressing individual-level
fitness, clearly aims to affect readiness at the population level
by including families, organizations, and communities.
Refinement of the Question
The literature is replete with descriptive studies of the preva-
lence of ADSM mental health troubles and programs in place
to address problems. The Army has a long history of pro-
gram development, to include published outcomes. The Navy/
Marine Corps programs are well established and have been
expanded to include noncombat occupations across all ranks.
The AF is still in the early development and piloting phase,
yet the lack of published data regarding program effectiveness
highlights the need for outcomes-research and further devel-
opment of interventions/programs to fill the gap.
The overarching question driving this needs assessment
was re-examined based on findings from the literature review,
including the premise that the best predictor of postdeploy-
ment mental health is predeployment mental health; the lack
of published stress/resilience research in the AIT environment;
as well as the lack of published outcomes for current AF pro-
grams. The overarching question was revised to query: “Are
there sufficient and correctly designed services to address
psychological resilience in ADSMs, especially comprehen-
sive programs with a preventive focus using interventions to
increase positive emotions?”
Data Synthesis
The synthesis of the literature highlights gaps in current
program resources and provides a foundation on which to
develop interventional (predictive) population health research
studies. An assessment of service-level programs targeting
psychological resilience is summarized in Tables II and III.
Programs implemented to provide services to ADSMs that
include resilience building components are becoming more
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 Assessment of Military Population-Based Psychological Resilience Programs
prevalent in the literature.5,75 Updates to Navy/Marine Corps
COSC programs were recently presented.96 Although there
are many efforts underway, and some programs do have pre-
ventive interventions, the greatest focus is still on treatment.
Researchers have been quick to note the need to develop inter-
ventions and programs that are evidence-based using robust
(reliable and valid) metrics to assist line leaders in determin-
ing what to offer their warriors to enhance psychological
resilience.6,96
Because of the lack of published outcome data on pro-
gram effectiveness, many decisions regarding current needs
of ADSMs and the appropriate services to meet those needs is
based, in part, on the mental health data collected from man-
datory deployment health surveys. The 1998 National Defense
Authorization Act included requirements for the surveillance
of military members’ pre- and postdeployment health as a way
to provide a more reliable process of screening for deploy-
ment-related health problems.97
The DoD (DD) Form 2795 was developed to collect pre-
deployment health information and the DD Form 2796 for
postdeployment health information.97 Deployment surveys are
self-report, collect both physical and mental health informa-
tion, and include review by a provider. In 2005, the DD Form
2900, Post Deployment Health Reassessment, was added to
provide for reassessment of the seemingly late manifestation
of mental disorders 3 to 6 months postdeployment.19,97–105
Unfortunately, there is an ongoing controversy surround-
ing reliability and validity of findings from military deploy-
ment self-report tools and the appropriateness of expending
resources on what some consider self-limiting mental health
problems. Many returning deployers either do not com-
plete the required surveys or are less than truthful on their
postdeployment surveys by underreporting mental symp-
toms.19,99–101 Given the limitations, these data are still being
used by leaders to determine resource utilization, to include
program funding. What is needed, and has been proposed
by CJCS,7 is research that uses data collection based on a
common set of variables and consistent, reliable, valid met-
rics.6,103 In this way, programs could be implemented using
evidence-based interventions. Additionally, DoD lead-
ers could make recommendations for resources and fund-
ing based on findings that are generalizable to the entire
military population vs. having individual and unit-specific
outcomes.
Recommendations and Proposals
Based on this current assessment, recommendations and pro-
posals believed to lead to improved outcomes for ADSM,
their family members, the public, as well as the line leaders/
commanders, include the following:
(1) Implement programs that are prevention-focused.
(2) Implement programs that use evidence-based inter-
ventions.
(3) Implement programs that include intervention effective-
ness outcome measures.
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Copyright (c) Association of Military Surgeons of the U.S. All rights reserved.
Implementing programs with a holistic view will enhance
ADSM fitness. Comprehensive programs, to include robust
preventive efforts throughout the career life cycle, will fur-
ther the CJCS vision for TFF.8,41,85,95 In a comprehensive pro-
gram, prevention impacts all aspects of the program: planning,
implementation, and training.102 Military preventive efforts
are important103–106 and as one government report103 explains,
“psychological health involves not only the detection and
remediation of illness but also the provision of effective pre-
ventive strategies.” Using a standard evidence-based frame-
work that is preventive and that normalizes the stress response
embraces a philosophy of early intervention, decreases the
stigma of seeking care, and leads to a more psychologically
fit ADSM. To ensure that research targeting psychological fit-
ness and enhanced resilience is generalized to the larger popu-
lation, agreement is needed on the most appropriate variables
and metrics.106
CONCLUSIONS
Assessing the effectiveness of interventions should be a prior-
ity in new programs. Before policy is put forth to control or
mitigate health problems, research studies are needed that first
explain the problem, and then follow with predictive studies to
test the efficacy and effectiveness of known interventions.9
The lack of empirical evidence across many of the mili-
tary services’ resiliency programs emphasize the urgent need
for population health studies that test interventions that are
interdisciplinary, interservice, and focused across occupations
and ranks. Factors in the stress process that affect resilience in
the ADSM have been widely studied and provide support that
interventions, such as increasing PE, are effective in buffering
the effects of stress exposures in civilian samples and should
be considered when developing new programs.3,35
The debate regarding appropriate focus of DoD resources,
including new research interventions, is productive in that
it highlights the importance of targeting preventive efforts
toward improving military members’ adaptability to stressors
while minimizing the impact of poor adaptation on overall
force health. One approach to furthering this debate is to build
knowledge through needs assessment followed by interven-
tional (predictive) research that addresses the gaps. Increasing
PE is one intervention to consider for aiding military members
to appraise daily stressors from a more positive perspective,
thus decreasing perceived stress and increasing psychologi-
cal resilience.
ACKNOWLEDGMENTS
The author acknowledges the support and guidance of her dissertation
committee: Dr. Robert Emmons, Dr. Ada Sue Hinshaw, and Dr. Diane
Padden.
REFERENCES
1. Institute of Medicine (IOM): Returning home from Iraq and Afghanistan:
preliminary assessment of readjustment needs of Veterans, service
members, and their families. The National Academies Press, DC, 2010.
MILITARY MEDICINE, Vol. 176, September 2011
 Assessment of Military Population-Based Psychological Resilience Programs
Available at http://www.iom.edu/Reports/2010/ Returning-Home-from-
Iraq-and-Afghanistan-Preliminary-Assessment.aspx; accessed March 25,
2011.
2. Armed Forces Health Surveillance Center: mental health issue. MSMR
2010; 17(11): 3–16.
3. Kavanagh J: Stress and performance: a review of the literature and its
applicability to the military. RAND, Santa Monica 2005. Available at
http://www.rand.org/pubs/technical_reports/2005/RAND_TR192.pdf;
accessed March 25, 2011.
4. Hourani LL, Williams TV, Kress AM: Stress, mental health, and job
performance among active duty military personnel: findings from the
2002 Department of Defense Health-Related Behaviors Survey. Mil
Med 2006; 171: 849–56.
5. Bates M, Bowles S, Hammermeister J, et al: Psychological Fitness. Mil
Med 2010; 175(Suppl 8): 21–38.
6. Nash WP, Vasterling J, Ewing-Cobbs L, et al: Consensus recommen-
dations for common data elements for operational stress research and
surveillance: report of a federal interagency working group. Arch Phys
Med Rehabil 2010; 91: 1673–83.
7. Mullen M: On total force fitness in war and peace. Mil Med 2010;
175(Suppl 8): 1–2.
8. Land BC: Current Department of Defense Guidance for Total Force
Fitness. Mil Med 2010; 175(Suppl 8): 3–5.
9. Young T: Population Health: Concepts and Methods, Ed 2. New York,
NY, Oxford University Press, 2005.
10. Kindig D, Stoddart G: What is population health? Am J Public Health
2003; 93(3): 380–83.
11. Declercq ER, Bichell TJ, Center JK: Population-based needs assess-
ment. Bringing public health to midwifery practice. J Nurse Midwifery
1997; 42(6): 478–88.
12. Stevens KR: Systematic reviews: the heart of evidence based practice.
AACN Clin Issues 2001; 12(4): 529–38.
13. Whittemore R, Knafl K: The integrative review: updated methodology.
J Adv Nurs 2005; 52(5): 546–53.
14. Burns N, Grove S: The Practice of Nursing Research: Conduct, Cri-
tique, and Utilization, Ed 5, pp 341–365. St. Louis, Elsevier Saunders,
2005.
15. Ramchand R, Schell TL, Karney BR, Osilla KC, Burns RM, Calderone
LB: Disparate prevalence estimates of PTSD among service members
who served in Iraq and Afghanistan: possible explanations. J Trauma
Stress 2010; 23(1): 59–68.
16. Armed Forces Health Surveillance Center: Ambulatory visits among
members of active components, U.S. Armed Forces, 2008. MSMR
2009; 16(4); 16–17.
17. Armed Forces Health Surveillance Center: Relationship between the
nature and timing of mental disorders before and after deploying to
Iraq/Afghanistan, Active Component, U.S. Armed Forces, 2002-2008.
MSMR 2009; 16(2): 2–6.
18. Bliese P, Wright K, Adler A, Thomas J, Hoge C: Timing of post-combat
mental health assessments. Psychol Serv 2007; 4(3): 141–48.
19. United States Government Accountability Office (GAO): Defense
Health Care: post-deployment health reassessment documentation needs
improvement, GAO-10-56. Washington, DC: United States General
Accounting Office. Available at http://oai.dtic.mil/oai/oai?verb=get
Record&metadataPrefix=html&identifier=ADA510374, November 19,
2009; accessed March 28, 2011.
20. Hosek JR, Kavanagh J, Miller L: How Deployments Affect Service
Members (MG-432). Santa Monica, CA: RAND 2006.
21. Tanielian T: Assessing combat exposure and post-traumatic stress dis-
order in troops and estimating the costs to society: implications from
RAND Invisible Wounds of War Study (CT-321). Santa Monica, CA:
RAND, 2009. Available at http://www.rand.org/pubs/testimonies/
CT321/; accessed March 31, 2011.
22. Wald J, Taylor S, Asmundson GJ, Jang K, Stapleton J: Literature Review
of Concepts: psychological resiliency. DRDC Toronto CR 2006-073,
July 1, 2006 (No. W7711-057959/A). Toronto 2006. Available at http://
MILITARY MEDICINE, Vol. 176, September 2011
Downloaded from publications.amsus.org: AMSUS - Association of Military Surgeons of the U.S. IP: 186.145.126.068 on Aug 10, 2015.
Copyright (c) Association of Military Surgeons of the U.S. All rights reserved.
www.dtic.mil/cgi-bin/GetTRDoc?Location=U2&doc=GetTRDoc.
pdf&AD=ADA472961; accessed March 28, 2011.
23. Datel WE, Lifrak ST: Expectations, affect change, and military perfor-
mance in the Army recruit. Psychol Rep 1969; 24(3): 855–79.
24. Cigrang JA, Carbone EG, Lara A: Four-year prospective study of mili-
tary trainees returned to duty following a mental health evaluation. Mil
Med 2003; 168: 710–14.
25. Martin PD, Williamson DA, Alfonso AJ, Ryan DH: Psychological
adjustment during Army basic training. Mil Med 2006; 171: 157–60.
26. Pollack LM, Boyer CB, Betsinger K, Shafer MA: Predictors of one-
year attrition in female Marine Corps recruits. Mil Med 2009; 174:
382–91.
27. Williams A, Hagerty BM, Yousha SM, Horrocks J, Hoyle KS, Liu D:
Psychosocial effects of the BOOT STRAP intervention in Navy recruits.
Mil Med 2004; 169: 814–20.
28. Gold MA, Friedman SB: Cadet basic training: an ethnographic study of
stress and coping. Mil Med 2000; 165: 147–52.
29. Gibson D, Myers JE: Perceived stress, wellness, and mattering: a pro-
file of first-year Citadel Cadets. J Coll Stud Dev 2006; 47: 647–60.
Available at http://www2.myacpa.org; accessed March 31, 2011.
30. Matthews MD: Toward a positive military psychology. Mil Psychol
2008; 20(4): 289–98.
31. Warner CH, Warner CM, Breitbach J, Rachal J, Matuszak T, Grieger
TA: Depression in entry-level military personnel. Mil Med 2007; 172:
795–99.
32. Finch MI, Stedmon AW: The complexities of stress in the operational
military environment. In: Contemporary Ergonomics 1998: Proceedings
of the Ergonomics Society Annual Conference, Cirenster, UK, 1–3
April 1998. Edited by Hanson MA. Bristol, Taylor Francis Inc; 1998;
388–92.
33. Cigrang JA, Todd SL, Carbone EG: Stress management training for mil-
itary trainees returned to duty after a mental health evaluation: effect on
graduation rates. J Occup Health Psychol 2000; 5(1): 48–55.
34. Southwick S: Adapting to stress: lessons from the resilient. Paper pre-
sented at the 2010 Navy and Marine Corps Combat Operational Stress
Conference: Taking action, measuring results, May 18–21, 2010, San
Diego, CA. Available at http://www.med.navy.mil/sites/nmcsd/nccosc/
coscConference/Pages/2010/coscConference2010MediaDay2.aspx;
accessed March 28, 2011.
35. Folkman S: The case for positive emotions in the stress process. Anxiety
Stress Coping 2008; 21(1): 3–14.
36. Tugade MM, Fredrickson BL: Resilient individuals use positive emo-
tions to bounce back from negative emotional experiences. J Pers Soc
Psychol 2004; 86(2): 320–33.
37. Earvolino-Ramirez M: Resilience: a concept analysis. Nurs Forum
2007; 42(2): 73–82.
38. Maguen S, Turcotte DM, Peterson AL, et al: Description of risk and
resilience factors among military medical personnel before deployment
to Iraq. Mil Med 2008; 173: 1–9.
39. Department of Defense: DoD Directive 6490.5, Combat Stress Control
Programs, February 23, 1999, certified current as of November 24, 2003.
Available at http://www.dtic.mil/whs/directives/corres/pdf/649005p.
pdf; accessed April 8, 2011.
40. Department of Defense: DoD Directive 6200.04 Force Health Protection
(pp. 1–11), October 9, 2004, certified current as of April 23, 2007.
Available at http://www.dtic.mil/whs/directives/corres/pdf/620004p.
pdf; accessed April 8, 2011.
41. Rounds M: The principle challenge of realizing total force fit-
ness: changing our readiness culture. Mil Med 2010; 175(Suppl 8):
124–26.
42. Nash, W: Grow the Green, Shrink the Red: Overview of the New
DON COSC Doctrine. Paper presented at the 2010 Navy and Marine
Corps Combat Operational Stress Conference: Taking action, measur-
ing results. May 18–20, 2010, San Diego, CA. Available at http://www.
med.navy.mil/sites/nmcsd/nccosc/coscConference/Pages/2010/cosc
Conference 2010MediaDay1.aspx; accessed March 28, 2011.
983
 Assessment of Military Population-Based Psychological Resilience Programs
43. Ice GH, James GD: Conducting a field study of stress: general princi-
ples. In: Measuring Stress in Humans: A Practical Guide for the Field,
pp 1–24. Edited by Ice GH, James GD. Cambridge, NY, Cambridge
University Press, 2007.
44. American Psychological Association: Stress in America 2009: Executive
Summary. Available at http://www.apa.org/news/press/releases/stress-
exec-summary.pdf; accessed March 25, 2011.
45. LeardMann CA, Smith TC, Smith B, Wells TS, Ryan MA: Baseline self
reported functional health and vulnerability to post-traumatic stress dis-
order after combat deployment: prospective US military cohort study.
BMJ 2009; 338: b1273.
46. Stander VA, Merrill LL, Thomsen CJ, Milner JS: Posttraumatic stress
symptoms in Navy personnel: prevalence rates among recruits in basic
training. J Anxiety Disord 2007; 21(6): 860–70.
47. Larson GE, Hammer PS, Conway TL, et al: Predeployment and in-
theater diagnoses of American military personnel serving in Iraq.
Psychiatr Serv 2011; 62: 15–21.
48. Lyon BL: Stress, coping and health: a conceptual overview. In: Hand-
book of Stress, Coping, and Health: Implications for Nursing Research,
Theory, and Practice, pp 3–26. Edited by Rice VH. Thousand Oaks,
Sage Publications, 2000.
49. Kiecolt-Glaser JK, McGuire L, Robles TF, Glaser R: Emotions, mor-
bidity, and mortality: new perspectives from psychoneuroimmunology.
Annu Rev Psychol 2002; 53: 83–107.
50. Pressman SD, Cohen S: Does positive affect influence health? Psychol
Bull 2005; 131(6): 925–71.
51. Diener E, Oishi S, Lucas RE: Personality, culture, and subjective well-
being: emotional and cognitive evaluations of life. Annu Rev Psychol
2003; 54: 403–25.
52. Lyubomirsky S, King L, Diener E: The benefits of frequent positive
affect: does happiness lead to success? Psychol Bull 2005; 131(6):
803–55.
53. Steptoe A, O’Donnell K, Marmot M, Wardle J: Positive affect and
psychosocial processes related to health. Br J Psychol 2008; 99(Pt 2):
211–27.
54. Brummett BH, Boyle SH, Kuhn CM, Siegler IC, Williams RB: Positive
affect is associated with cardiovascular reactivity, norepinephrine level,
and morning rise in salivary cortisol. Psychophysiology 2009; 46(4):
862–69.
55. Ostir GV, Berges IM, Ottenbacher ME, Clow A, Ottenbacher KJ:
Associations between positive emotion and recovery of functional sta-
tus following stroke. Psychosom Med 2008; 70: 404–9.
56. Brydon L, Walker C, Wawrzyniak AJ, Chart H, Steptoe A: Dispositional
optimism and stress-induced changes in immunity and negative mood.
Brain Behav Immun 2009; 23(6): 810–16.
57. Ironson G, Hayward H: Do positive psychosocial factors predict dis-
ease progression in HIV-1? A review of the evidence. Psychosom Med
2008; 70: 546–54.
58. Moskowitz JT: Positive affect predicts lower risk of AIDS mortality.
Psychosom Med 2003; 65: 620–26.
59. Strand EB, Zautra AJ, Thoresen M, Odegard S, Uhlig T, Finset A:
Positive affect as a factor of resilience in the pain-negative affect rela-
tionship in patients with rheumatoid arthritis. J Psychosom Res 2006;
60(5): 477–84.
60. Casey LM, Oei TP, Newcombe PA: An integrated cognitive model of
panic disorder: the role of positive and negative cognitions. Clin Psychol
Rev 2004; 24(5): 529–55.
61. Chida Y, Steptoe A: Positive psychological well-being and mortality:
a quantitative review of prospective observational studies. Psychosom
Med 2008; 70: 741–56.
62. Cohen S, Pressman, S: Positive affect and health. Curr Dir Psychol Sci
2006; 15(3): 122–25.
63. Johnson DJ, Penn DL, Fredrickson BL, Meyer PS, Kring AM, Brantley
M: Loving-kindness meditation to enhance recovery from negative
symptoms of schizophrenia. J Clin Psychol 2009; 65: 499–509.
984
Downloaded from publications.amsus.org: AMSUS - Association of Military Surgeons of the U.S. IP: 186.145.126.068 on Aug 10, 2015.
Copyright (c) Association of Military Surgeons of the U.S. All rights reserved.
64. Seligman ME, Schulman P, Tryon AM: Group prevention of depression
and anxiety symptoms. Behav Res Ther 2007; 45(6): 1111–26.
65. Sin NL, Lyubomirsky S: Enhancing well-being and alleviating depres-
sive symptoms with positive psychology interventions: a practice-
friendly meta-analysis. J Clin Psychol 2009; 65(5): 467–87.
66. Hart SL, Vella L, Mohr DC: Relationships among depressive symp-
toms, benefit-finding, optimism, and positive affect in multiple sclero-
sis patients after psychotherapy for depression. Health Psychol 2008;
27(2): 230–38.
67. Moskowitz JT, Epel ES, Acree M: Positive affect uniquely predicts
lower risk of mortality in people with diabetes. Health Psychol 2008;
27(Suppl 1): S73–82.
68. Ostir GV, Berges IM, Markides KS, Ottenbacher KJ: Hypertension in
older adults and the role of positive emotions. Psychosom Med 2006;
68: 727–33.
69. Lamkin DM, Lutgendorf SK, McGinn S, et al: Positive psychosocial
factors and NKT cells in ovarian cancer patients. Brain Behav Immun
2008; 22(1): 65–73.
70. Steginga SK, Occhipinti S: Dispositional optimism as a predictor of
men’s decision-related distress after localized prostate cancer. Health
Psychol 2006; 25(2): 135–43.
71. Fredrickson BL, Tugade MM, Waugh CE, Larkin GR: What good are
positive emotions in crises? A prospective study of resilience and emo-
tions following the terrorist attacks on the United States on September
11th, 2001. J Pers Soc Psychol 2003; 84(2): 365–76.
72. Cohn MA, Fredrickson BL, Brown SL, Mikels JA, Conway AM:
Happiness unpacked: positive emotions increase life satisfaction by
building resilience. Emotion 2009; 9(3): 361–68.
73. Jackson D, Firtko A, Edenborough M: Personal resilience as a strategy
for surviving and thriving in the face of workplace adversity: a literature
review. J Adv Nurs 2007; 60(1): 1–9.
74. Ong AD, Bergeman CS, Bisconti TL, Wallace KA: Psychological resil-
ience, positive emotions, and successful adaptation to stress in later life.
J Pers Soc Psychol 2006; 91(4): 730–49.
75. Bowles SV, Bates MJ: Military organizations and programs contributing
to resilience building. Mil Med 2010; 175: 382–85.
76. Cornum R, Matthews MD, Seligman MEP: Comprehensive soldier
fitness: building resilience in a challenging institutional context. Am
Psychol 2011; 66(1): 4–9.
77. Peterson C, Park N, Castro CA: Assessment for the U.S. Army
Comprehensive Soldier Fitness program: the Global Assessment Tool.
Am Psychol 2011; 66(1): 10–18.
78. Lester PB, McBride S, Bliese PD, Adler AB: Bringing science to bear:
an empirical assessment of the Comprehensive Soldier Fitness Program.
Am Psychol 2011; 66(1): 77–81.
79. Reivich KJ, Seligman MEP, McBride S: Master Resilience Training in
the U.S. Army. Am Psychol 2011; 66(1): 25–34.
80. Stanley E, Jha A: Mind fitness: improving operational effectiveness and
building warrior resilience. Joint Force Periodical 2009; 55(4): 144–51.
Available at www.cusnc.navy.mil/ctf-ia/documents/Mind%20Fitness.
pdf; accessed March 26, 2011.
81. Landry L: Provider resiliency training (PRT): The most informative
PRT overview in the briefest time span ever. Paper presented at the
2008 U.S. Marine Corps Combat Operational Stress Conference, May
28–30, 2008, San Diego, CA. Available at http://www.usmc-mccs.org/
cosc/conference/sessions3.cfm; accessed April 7, 2011.
82. Battlemind Training Office (BTO): Battlemind Training. (n. d.).
Available at https://www.resilience.army.mil/about.html (now resil-
ience training); accessed March 25, 2011.
83. Battlemind Training Office (BTO): Battlemind Training: a history of
the development of the Army’s integrated system of mental health train-
ing. (n. d.). Available at https://www.resilience.army.mil/archives.html;
accessed March 28, 2011.
84. Adler A: Information paper: Battlemind Resilience Training Research
Accomplishments and Plans, May 2009. Available at https://www.resil
MILITARY MEDICINE, Vol. 176, September 2011
 Assessment of Military Population-Based Psychological Resilience Programs
ience.army.mil/InfoPaperBattlemind Research.doc; accessed April 7,
2011.
85. Seligman MEP, Matthews MD (editors): Special issue: Comprehensive
soldier fitness. Am Psychol 2011; 66(1): 1–86.
86. Kappler S: MRT Course Opens on Fort Jackson. Army News Service
April 9, 2010. Available at http://www.army.mil/-news/2010/04/09/37005-
class-act-mrt-course-opens-on-fort-jackson/index.html; accessed March
25, 2011.
87. Williams A, Hagerty BM, Andrei AC, Yousha SM, Hirth RA, Hoyle
KS: STARS: strategies to assist Navy recruits’ success. Mil Med 2007;
172: 942–49.
88. Tri-MEF Combat Operational Stress Control (COSC) Conference Notes,
I MEF COSC Conference, September 5–7, 2007. Available at http://
www.i-mef.usmc.mil/external/imef-01/staff_ sections_staff_secretary.jsp;
accessed April 7, 2011.
89. United States Marine Corps: Marine Corps Bulletin 6490 Combat
and Operational Stress Control Program, September 18, 2008. Available
at http://www.marines.mil/search center /Pages/Results.aspx?k=6490&s=
All%20Marines.mil%20Content; accessed April 8, 2011.
90. Westphal R: Caregiver Occupational Stress Control. Paper presented at
the 2008 USMC Combat Operational Stress Conference, August 12–14,
2008, San Diego, CA. Available at http://www.usmc-mccs.org/cosc/
conference/sessions3.cfm; accessed March 27, 2011.
91. Fisak J, Westphal R: The Okinawa Experience: The USNH Okinawa’s
Caregiver Occupational Stress Program. Paper presented at the 2010
Navy and Marine Corps Combat Operational Stress Conference: Taking
action, measuring results, May 18–22, 2010, San Diego, CA. 2010.
Available at http://www.med.navy.mil/sites/nmcsd/nccosc/coscConfer
ence/Pages/2010/coscConference2010MediaDay2.aspx; accessed March
28, 2011.
92. Nash W, Westphal R, Watson P, Litz B: Combat Operational Stress
First Aid: useful tools to promote recovery. Paper presented at the
2010 Navy and Marine Corps Combat Operational Stress Conference:
Taking action, measuring results, May 18–20, 2010, San Diego, CA.
Available at http://www.med.navy.mil/sites/nmcsd/nccosc/coscConfer
ence/Pages/2010/coscConference2010MediaDay2.aspx; accessed April
7, 2011.
93. Ferrero K: AMC officials unveil concept to strengthen force resilience.
Air Mobility Public Affairs July 7, 2010. Available at http://www.af.mil/
news/story.asp?id=123212513; accessed March 27, 2011.
94. Locquiao F: Moody hosts first-ever airmen resiliency training: Chairman
calls for better mental health programs. 23rd Wing Public Affairs June 29,
2010. Available at http://valdostadailytimes.com/moodyafb/x1671033692/
Moody-hosts-first-ever-airman-resiliency-training; accessed March 27,
2011.
95. Jonas W, O’Connor F, Duester P, Peck J, Shake C, Frost S: Why Total
Force Fitness? Mil Med 2010; 175(Suppl 8): 6–13.
96. Navy and Marine Corps 2010 Combat Operational Stress Conference:
taking action, measuring results. Available at http://www.med.navy.
MILITARY MEDICINE, Vol. 176, September 2011
Downloaded from publications.amsus.org: AMSUS - Association of Military Surgeons of the U.S. IP: 186.145.126.068 on Aug 10, 2015.
Copyright (c) Association of Military Surgeons of the U.S. All rights reserved.
mil/sites/nmcsd/nccosc/Pages/coscConference2010.aspx, May 18–20,
2010; accessed March 28, 2011.
97. Bliese P, Wright K, Thomas J, Adler A, Hoge C: Post-deployment men-
tal health screening instruments: How good are they? Available at http://
oai.dtic.mil/oai/oai?verb=getRecord&metadataPrefix=html&iden
tifier=ADA433073, December 2004; accessed March 27, 2011.
98. Wright KM, Thomas JL, Adler AB, Ness JW, Hoge CW, Castro CA:
Psychological screening procedures for deploying U.S. forces. Mil Med
2005; 170: 555–62.
99. Casscells S: Assistant Secretary of Defense for Health Affairs Memo-
randum: Implementation of revised DD Forms 2796 and 2790, March 24,
2008. Available at www.pdhealth.mil/downloads/Implementation_Of_
Revised_DDForms2796and2900.pdf; accessed March 27, 2011.
100. Greene-Shortridge TM, Britt TW, Castro CA: The stigma of mental
health problems in the military. Mil Med 2007; 172: 157–61.
101. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman
RL: Combat duty in Iraq and Afghanistan, mental health problems, and
barriers to care. N Engl J Med 2004; 351(1): 13–22.
102. Department of Defense (DoD) (1996): Evaluation Report on the
Management of Combat Stress Control in the Department of Defense.
Report no. 96-079, pp 1–53. Available at www.dodig.mil/Audit/reports/
fy96/96-079.pdf; accessed March 25, 2011.
103. Defense Health Board Task Force on Mental Health: An Achievable
Vision: Report of the Department of Defense Task Force on Mental
Health, pp 1–100. Falls Church, VA, Defense Health Board, 2007.
104. Seal KH, Bertenthal D, Miner CR, Sen S, Marmar C: Bringing the war
back home: mental health disorders among 103,788 US Veterans return-
ing from Iraq and Afghanistan seen at Department of Veterans Affairs
facilities. Arch Intern Med 2007; 167: 476–82.
105. Cardona R, Ritchie EC: Psychological screening of recruits prior to
accession in the U.S. Military. In: Textbooks of Military Medicine:
Recruit Medicine, pp 397–310. Edited by DeKoning BL, Lenhart MK,
Lounsbury DE, North RB. Office of the Surgeon General at TMM
Publications, Washington, DC, Borden Institute, Walter Reed Army
Medical Center, 2006.
106. Firth K: A survey of multidimensional health and fitness indexes. Mil
Med 2010; 175(Suppl 8): 110–17.
107. Laraway L: Operational Stress Control Update. Paper presented at the
2010 Navy and Marine Corps Combat Operational Stress Conference:
Taking action, measuring results, May 18–20, 2010, San Diego, CA;
Available at http://www.med.navy.mil/sites/nmcsd/nccosc/coscConfer
ence/Pages/2010/coscConference2010MediaDay1.aspx; accessed March
28, 2011.
108. Loftus T: Memorandum for ALMAJCOM/SG: Landing Gear: Pre and
Post Deployment Prevention Education. Available at http://airforce
medicine.afms.mil/idc/groups/public/documents/webcontent/knowl
edgejunction.hcst?functionalarea=AFSuicidePreventionPrgm&docty
pe=subpage&docname=CTB_095710&incbanner=0, April 22, 2008;
accessed March 27, 2011.
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