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Evidence-Informed Factors for Promoting Psychological Resilience in the US Military

Evidence-Informed Factors for Promoting Psychological Resilience in the US Military


Good morning welcome to the final NIH
Medicine Mind the Gap seminar of 2012 today’s featured speaker is Terry
Tanielian who will discuss the concept of psychological resilience and highlight
how the US Department of Defense has implemented programs to promote
psychological resilience in an effort to prepare troops and their families for
the challenges of deployment she will also review how these approaches have
evolved over the past several years and how the concept of total force fitness
is shaping future training and prevention efforts within the military
Mr. Tanielian is a Senior Analyst at the RAND Corporation she received an MA in
psychology from American University her areas of interest include psychological
effects of combat terrorism and disasters psychological resilience of
suicide prevention as well as access to and quality of behavioral health care
for returning veterans this Mr. Tamilian has worked on several studies on the
behavioral health related needs of returning operating Operation Enduring
Freedom Operation Iraqi Freedom veterans and their families including co-leading
landmark study invisible wounds of war Mr. Tanielian is currently leading a new
perspective longitudinal study to follow military families across a deployment
cycle and is also lead on a study to assess the veterans support programs
under welcome back veterans initiative she is serving as a co-investigator on a
large randomized control trial to examine the effectiveness of stepped
care for post-traumatic stress disorder and depression within the US Army and
has published several peer-reviewed articles and book chapters and served on
numerous working groups and expert panels for those of you joining us today
via webcast we will be live tweeting today’s lecture at NIH prevents and we
will take questions using the seminar #nihmtg thanks to the NIH community and the leadership of the Office of Disease
Prevention Acting Director Paul Coates we even do indoor enjoyed our most
successful year to date among this year’s topics speakers discussed biases
in biomedical research making progress in eliminating health inequalities and
communicating possible harms and benefits of treatment and lifestyle
we’ve done scheduling speakers for 2013 if you have speaker or topic suggestions
please feel free to tweet us use our seminar hashtag or contact me Paris
Watson at [email protected] now please join me in
welcoming terry Tanielian well thank you for that wonderful
introduction and thank you for the invitation to be here thank you for all
of those who came and thanks to those who are watching and listening on the
web I’m honored and humbled to be able to share some of the insights that we’ve
learned working with the military over the past several years about the
concepts of resilience and kind of how they’re moving and evolving to really
think about these issues over time I just want to ask I see a couple of
uniforms in the audience but before I get started I just wanted to get a sense
of how many of you have worked for the military been in the military or
familiar with the organizations and cultures of the military so a good
number so today I’m really gonna be talking about issues that have affected
the u.s. the US Army the Navy the Air Force and the Marines as well as to some
extent the Coast Guard which also former falls under the purview of the
Department of that I think it goes without saying that most
of us recognize the past decade of these complex that the United States have been
involved in an Iraq Afghanistan has placed an incredible burden and they
represent the longest period of prolonged combat to the United States
certainly in the use of the all-volunteer force we’ve seen an
unprecedented reliance upon the reserve guard of our citizens warriors if you
will we’ve deployed up close to two and a half million individuals many of them
have gone multiple times for varying lengths and they’ve accumulated numbers
and numbers of we expect our military service men and
women to perform optimally we place them in austere environments we hope and
count on them to complete their mission efficiently and effectively and to
really be able to endure a very very stressful work environment and life we
know that we can screen individuals to ensure that we get the healthiest and
most confident individuals to wear that uniform and perform those missions and
we’ve seen over the past decade billions and billions of dollars being spent to
really support those servicemen and women and their families to be able to
really indoor these dresses and perform optimally so today I hope to cover a few
topics I want to talk a little bit about resilience what is resilience we’ve
heard a lot about it we certainly have heard it in different contacts and
there’s a big hope and expectation that is going to be a solution to many of the
ailments they’re affecting our troops then I’ll talk a little bit about how
resilience is being promoted can it be promoted we’ll look to the literature to
try and understand what the evidence suggests in terms of really shaping and
promoting resilience among populations I’ll talk a little bit about what DoD
has done to implement some of those programs and their experience to date
then I want to talk a little bit about a relatively new concept called total
force fitness withs builds upon resilience and performance optimization
and is shaping some of the new programs for the services in the future and then
hopefully we can talk a little bit about the implications for non DoD settings
and populations as those of you are thinking about other at-risk groups for
stress and other problems and think about what in the military’s experience
and the resilience world may be relevant first I want to start with kind of
defining resilience and first perhaps kind of recognize that resilience is not
a synonym for health or well-being resilience in fact has several
definitions in the literature we identified 37 in fact but but some of
the most common ones are really the idea that it’s the ability to withstand
recover from and grow in the sea stressors and changing demand it’s the
ability to bounce back from a difficult experience in a healthy manner so these
two definitions really reinforce the concepts that resilience isn’t
identified or determined until an individual or a group or a family
endorsed some stress so it’s not a kind of point in time assessment of
well-being it’s a process in which they actually bounce back or can endure a
significant stressful event resilience factors are often referred to those
individual and contextual factors that facilitate resilience and in fact in
many observational studies that’s where we see various different characteristics
that have been assessed to differentiate populations that seem to do well and pop
from the populations that don’t do as well
there are some key assumptions that I think have been made in putting kind of
a lot of eggs in the basket of resilience promotion and those
assumptions are that it can be learned and that it can be enhanced if you look
to the literature where resilience was actually developed kind of from child
development there has been some belief that it’s a
personality trait where others have seen that it’s something that can be
developed and nurtured so why resilience in the military context there’s been
unprecedented attention to the post deployment mental health problems that
our troops have returned home with how these consequences then affect their
families there’s been a number of concerns about the rising rates of
suicide so we’ve seen the stress accumulate we’ve also seen the rates of
these problems rise we know that most personnel actually do well coming home
from deployment only about 20% at any given point in time of our returning
troops report symptoms consistent with diagnosis of PTSD or depression although
the suicide rates continue to rise and that is certainly an area for concern
but there is a large proportion of our force that’s deployed several times that
seem to be doing okay so what about those troops kind of can help us and
teach us a little bit more about resilience
we know as I mentioned the billions of dollars that have gone into implementing
creating and implementing programs to promote resilience they’ve really
focused on trying to enhance coping skills teach techniques that can promote
resilience and kind of develop that part Enis
and now establishing these comprehensive models for fitness and then implementing
various different holistic approaches to support those models so kind of want to
move to some of the work that we’ve been doing it ran to help the military
understand and evaluate kind of the various different efforts that they’re
focusing on and I just want to kind of put out there what our definition of
resilience is and how we’ve been approaching it it ran and it really is
this capacity to adapt successfully in the presence of risk and adversity and
so thinking about the various different programs and services that are designed
to increase in individuals of families a units and a community’s capacity to
successfully endure and persist through that risk and adversity it present this
continuum because it’s used by the Department of Defense it actually was
adapted from the US Navy and now used by the defense Centers of Excellence to
kind of indicate that you know you can understand resilience along a continuum
and they use kind of the green yellow orange red kind of differentiation
between folks that are performing optimally people that may be reacting in
the yellow zone the injured is kind of in the orange reddish and the ill would
be in the more severe end and the idea that you know they use the 3 R’s of
resilience reintegration and recovery and think about the various different
ways that they can influence resilience through different types of programs
education and training risk mitigation stress intervention and then treatment
and reintegration and that the concept of resilience isn’t just meant for
people in the optimal functioning or rare area but that’s we can think about
resilience along that continuum and promoting it for the entire population
so now I’m going to talk a little bit about what we identified in the
literature about how resilience can be promoted in 2009 we were asked to
examine resilience programs and identify or kind of retro best practices so
before you can label something your best practice you obviously need to
understand kind of they’re doing if it’s been evaluated and
there weren’t necessarily any gold standards for like the magic bullet or
the solution for what had to be done to promote resilience so we reviewed the
literature to try and understand what studies have been done to determine to
identify and promote psychological resilience and we also consulted with a
series of experts to identify what we call evidence-informed factors to
promote psychological resilience a lot of these factors come from the
literature’s that have study populations exposed to risk and adversity and
differentiate between that the group that does well on the group that doesn’t
so well we’ve seen very few gold standard RCT is randomized clinical
controlled trials to be able to you know take two groups provide an intervention
and expose them to stress to see how one does compared to the other you know
ethically that’s not necessarily something that can be implemented and
it’s just more difficult to do those types of studies so we then identified
these factors and then tried to apply them to the programs and practices and
strategies that the Department of Defense was implementing at the time to
promote resilience to identify where there perhaps are some gaps and make
suggestions for improvement we also identified some models for the
department and some of the services to think about for future program
programming and improving their own existing policies in this area first one
I talked a little bit about the the layers that we consider to kind of
interpret these studies and examine kind of the process and of building
resilience and kind of how resilience bears itself out
we used a kind of ecological approach if you think about you know you drop a
pebble in the water and it ripples out how far it ripples in the strength of
how it ripples can be modified based upon the density as well as how
supportive that environment is around it so we place the individual at the center
the family kind of as the next layer the community the unit actually is the next
level kind of there and climate and those that surround them
on their unit and then their community and their community can be their
neighborhood it can be church group it can kind of be kind of the next layer of
reinforcement so we both look to the literature to identify factors at each
of these levels as well as then looked at programs that are try to affect each
of these levels and promoting resilience so now I’m going to try and walk through
each of these levels to share with you what we learn from the literature in
terms of where the evidence and the strength of that evidence is strongest
for promoting resilience and so this here we have the individual level
resilience factors and this table is actually ordered so that those factors
that have the strongest amount of evidence from the literature or at the
top and those that come from the that the with the weakest or perhaps just
from expert insight or towards the bottom so positive coping we all know
that it’s important to kind of use positive coping techniques over negative
coping techniques you can think about help-seeking behaviors the ability to
kind of solve problems both personally as well as interpersonally in
relationships positive effect the idea of being the kind of glass half-full
optimistic having a sense of humor when you approach challenges and difficulty
kind of being active and alert positive thinking trying to kind of reframe
issues make sense out of a situation thinking about positive outcomes versus
negative outcomes again that glass half full but realism kind of mastery of the
possible knowing your self-esteem and worth having confidence self-efficacy
and can perceive control over a situation behavioral control the ability
to monitor evaluate and monitor your own emotional reactions to accomplish a goal
the issues around self-management self-regulation and kind of self
enhancement physical fitness just the ability to actually function effectively
and efficiently in various different domains and environment and then
altruism kind of a selfless concern for and for the welfare of others kind of
putting others first and so you know I think that again these are
characteristics that have been identified in populations that
to do well after being exposed to stress or experiencing something very stressful
and to the extent that they’re they’re then adopted into specific programs
we’ll talk with that about that in a couple of minutes so the next level we
have the family again and so what we’ve observed from the the literature and
kind of the experts is this the concept of emotional ties the bonding among
family members kind of the opportunity to have shared recreation and leisure
time how close-knit your family is communication kind of a very important
concept in families and and one that kind of you know allows for the sharing
of thoughts and opinions where people and families feel that they can work
together to problem-solve and manage their relationships and stress support
do you have support or do you feel comfortable and supported emotional
emotionally and drive comfort from those relationships and their families
closeness love this gets it love intimacy and attachment you know how
attached your family is nurturing this is particularly important around
parenting skills and kind of are you nurturing of the other individuals and
your family an adaptability you know how well can you adapt to changes
particularly the changes associated with military life across a deployment cycle
where tasks and roles within the family may have to change and shift across the
deployment cycle as that service member deploys or has to go away for training
other parts the family may have to take out or take out the trash you know do
other types of functions that that service member took care of you know
getting the car maintained or you know the carpooling the homework supervision
so how adaptable is the family to being able to switch these roles at the unit
level there’s been several studies that have demonstrated the importance of the
command climate and the amount of unit cohesion that can be protective in
reducing the incidence of mental health problems among those who have gone to
combat and experienced kind of stress kind of fought the idea that you can
foster this inter unit inter chené kind of the pride and support in
the mission the positive role modeling the relationship that the individuals
have with each other as well as with their command structure the
noncommissioned officer level turns out to be a very critical level of
leadership for most troops in that you know do they provide a supportive kind
of positive outlook and reinforce a good climate the amount of teamwork the
ability to work well with your fellow unit members and cohesion you know we
often hear that in a unit they work very tightly and together to kind of
accomplish their mission but also look out for their fellow service member you
know kind of the concept of I got your back you got your sex in military
language and so then the community I mean we have to recognize that the
community also is a critically important population restful experience so again you know I
think many of us can think about ourselves as part of the community that
surrounds our service members and their families and how well we interface so
these are the factors that the resilience literature has identified as
being important we also then looked at kind of well how is it best to actually
confer these types of approaches or characteristics and you know is it just
easy to tell people about it or is it about teaching techniques and so the
literature also shows us that it’s about teaching techniques and the highest
benefit seems to come from those those approaches that try to teach skills or
strategies that will allow people to have a higher positive aspect effect to
positive thinking coping again positive coping skills over negative coping
skills so negative coping skills in this way you know be thinking about things
like self medication or denial positive coping would be things that you know are
more active and healthier realism behavioral control again the techniques
that have shown to be the strongest and promoting resilience kind of a gun
that’s positive command climate there’s a lot of focus in the military about
effective leadership and are we really teaching and helping our leaders to
really lead and be supportive of their units and again this sense of
belongingness so I want to talk a little bit about the various different programs
and I put the slide up just because I’m going to start to talk about these
different things down at the bottom these type ologies of different programs
and there are several education and training kind of the concept that we
want to strengthen and prepare individuals and other groups of
audiences to be ready for enduring some stressful life experiences risk
mitigation so we know something’s happening the ability to assess they’re
being able to identify and intervene with combat stress interventions so this
is heavily focused on individuals who are going to deploy and experience or be
exposed to combat and then treatment and reintegration so kind of a treat so when
we look at the typology of education and training and look at the different
programs that are put in place we find that many of them are often implemented
as part of the pre deployment preparations the audiences may be for
the individual service member there may be activities designed for the family
designed for the children there may also be things targeted specifically at
health care providers or leaders or at different types of audiences and groups
historically these are called different things now that common term is
resilience training in years past it was considered stress inoculation you know
the idea that we could inoculate troops against stress so that they would
somehow be you know hard heed and and and ready to endure those stressful
situations methods are very greatly across these different types of programs
we see everything from briefings of PowerPoint slides that sometimes can go
on for hours and just be repeated information put up on the screen
classroom style and you know I was able to attend an event not too long ago in a
Guard unit where we were in this very stark large warehouse sitting in chairs
having slides just repeatedly shown to us to talk a little bit about wellness
and stress prevention all of they may be simulation drills and field training
exercises to prepare individuals for the types of experiences they’re going to
have and test those strategies and two other techniques that are actually
trying to use roleplay and modeling to do some problem-solving and learning of
crisis intervention skills and there’s been a large effort to kind of do these
stand down trainings to bring awareness and build that awareness among leaders
troops and families about really what to expect what they should expect across
the deployment cycle the types of experiences that they may have
themselves that they may actually observe in their loved one and what to
do about them these approaches are often universal that if you think about the
public health model these are universal approaches they’re offered to everybody
and so you’ve got groups that have potentially mixed in their level of risk
for how they might respond to these types of environments and experiences
also large settings in many many cases so risk mitigation there are many many
programs they’ve put and put in place to specifically try and reduce the risk of
certain negative outcomes this event is done primarily through workshops
presentations consulting with commands and even embedding providers within
units trying to bring as far forward individuals that can identify problems
and help mitigate them right at the forefront of the issue they specifically
target the reduction often in the incidence of psychological health
problems we see a lot of effort focused on specific problems such as domestic
violence sexual assault substance use and suicide again I mentioned these
these are kind of public health approaches that are focused on a
particular outcome but many of them incorporate the concepts of resilience
and teaching the techniques and skills that are talked about in terms of the
evidence level evidence-informed factors so combat stress interventions the idea
that we need to identify those in need and connect them to care so there are
multiple screening approaches both Universal and targeted approaches that
are used to try and identify those that may have signs and symptoms of problems
both far forward as well as when they come home we’ve used in the military has
used embedded providers within units chaplains have become a very critical
work force if you think about their role and being able to both provide a
confidential source of support but also being on the front within the unit to
recognize changes and potential problems within the individuals and units they
come in contact with we’ve deployed in theater combat stress interventions
teams individuals that have the training to kind of provide the early
interventions that might be able to provide some relief symptom reduction as
well as promote recovery and return to duty there’s been a heavy reliance in
the military on the use of gatekeepers so individuals that will be on the
frontlines potentially recognize the signs and symptoms and be there to be
able to connect individuals with health and get them
facilitated into treatment I mentioned chaplains or a critical
gatekeeper we also know NCOs or noncommissioned officers are also kind
of down at a lower level and the ability to actually try and be aware of
potential problems and connect individuals to help there’s a number of
care coordination programs that have been implemented particularly targeted
toward higher risk groups like for example the severely wounded and one
injured have a number of different support programs that are designed to
kind of help them with care coordination and make sure that they are getting the
support and help that they need and then the idea that there’s also a number of
things public education campaigns and other kind of resources and materials
that have been put out to really try and change the culture and create a culture
of help seeking and kind of change the message address kind of the concerns
around the barriers to care for about stigma and promote a culture of help
seeking and as help-seeking as a sign of strength within the military and this
has been a pretty radical and large shift over the past decade so and then
finally kind of the next typology of these different types of resilience
programs are focused on treatment and reintegration so delivering services to
those that are in need and trying to facilitate the recovery kind of trying
to prompt that bounce back you know these come in the forms of crisis
intervention the delivery of evidence-based treatment for specific
mental health problems for both servicemembers and their families so
ensuring that when we know that there are researched you know based
evidence-based effective high quality treatments getting them to the
individuals who need them this is primarily come through various different
efforts large efforts to train providers and military leaders on the appropriate
techniques to use as well as the techniques not to use that we’ve learned
from research that don’t work and perhaps can be even dangerous but then
to also expand services to non-traditional settings to think about
being able to put some of these techniques in primary care based
settings or in other outpatient settings they’ve created a number of kind of
non-medical counseling services that are available to
military servicemembers and their families that can provide some
confidential confidential care and supportive counseling but then again
linking with collaborative services we often know that individuals who are in
need don’t just need health care they may need other assistance in trying to
get adaptations made to their homes connections to help with any
transitional issues for their children as they adapt to perhaps dealing with
different and different challenges for the family but also kind of providing
support we know that one of the most vulnerable times for individuals is
during a period of transition and so helping individuals as they transition
from deployments so as they come home thinking about how we bring our troops
home and what we do during that transition period is having an effect on
their recovery and their transition back into civilian settings but also kind of
after they take that uniform off after they leave their military service this
is particularly a concern for reserving guard members who often don’t have much
time as they come home they can come home and like within 72 hours be back in
their homes and maybe you’d be back in their employment settings if their job
is still there and so trying to think about how we really help them transition
across that those periods and so again there are multiple transitions across
the deployment cycle transitioning you know through pre deployment through the
deployment out of the deployment as they come home and then as they reintegrate
and leave the military service and then really thinking about that more
long-term they may even have more transitions after that they may move you
know from one location to a different location and then there’s been efforts
to kind of really think about how we facilitate patient engagement I think
for those of you that study quality of care we know that an activated informed
an educated patient will be a kind of engaged in ensuring they get
high-quality care so how can we ensure that when those in meter and treatment
are getting services that we are putting things in place that can keep them
actively engaged and that we don’t see drop out or challenges with compliance
they’ve been a number of innovative solutions now tried again to address
some of the barriers around access to care but also to kind of keep
patients engaged in this self-management approach there have been in turbit
internet-based and smartphone approaches I don’t know if any of you have seen a
lot of the new technologies that are available from if you go to a couple of
the different web sites from the defenders of excellence the T to the
technology branch you’ll see a number of kind of online internet-based and things
that you can download to your smartphone that can that are designed to kind of
help individuals assess their own symptoms but manage their treatment and
recovery as well so as I said there are a number of different types of programs
that fall into these different categories and we tried to try and wrap
our arms around everything DoD was doing in the area of resilience so we used a
very structured approach first we had to define what we felt rose to the level of
a program a poster isn’t a program but things that were actually trying to do
interventions designed to kind of promote resilience and this was a couple
years old we did us in 2009-2010 and at that time we identified 77 resilience
programs across the DoD and services that had in their mission to promote
resilience among troops or their families there are a number I just
listed a couple here that you may have heard of battlemind training was a
series of briefings that was used at the pre-deployment and post-deployment
phases it’s been a band renamed resilience training and if this is
focused in the Army the Army Center for enhancing performance is a kind of a
performance optimization approach to help with specific techniques to help
individuals perform better think about sports psychology to some extent when
you think about this you know the use of imagery self-regulation helping building
your focus and tasks to kind of accomplish your goals and so this too
has now been folded under another program that I’ll talk about in a second
a second within the Army airman resiliency training similar to
battlemind this is a series of briefings that are delivered in large group
settings within the Air Force combat operational stress control it kind of
refers to a whole suite of different types of approaches for the Navy and the
Marines includes embedding providers low down within the units and far forward
but else konna teaching combat stress kind of
techniques to the Marines and the sailors project focus focus stands for
families overcoming under stress this is a resilience training program for
families and children within the Navy and the Marines based out of Los Angeles
but they’ve done been doing a program around a number of different
installations the real warrior campaign I mentioned that’s actually a public
education and awareness campaign it’s got several components with educational
materials both for servicemembers for families as well as health care
providers real warrior net and then comprehensive soldier fitness
comprehensive soldier fitness is now incorporated to kind of take under its
realm kind of the concepts and in trainings around battlemind as well as
the Army Center for enhancing performance but comprehensive soldier
fitness was introduced and a few years ago on this idea that we needed to take
a more holistic kind of approach to thinking about fitness that brought in
what we knew about the mind and the body there are five dimensions physical kind
of the idea that you want to perform excellently and capably in the physical
domain emotional social spiritual the importance of kind of having faith and
spirituality and kind of a belief in oneself and their mission and family so
they have five dimensions but they also then base this on five kind of pillars
if you will they use a of varied approach to try and both assess how
people are doing along these dimensions but enhance their fitness in each of
those areas they use the global assessment tool which is a survey that
individuals are asked to fill out that assesses kind of how they’re doing along
these different dimensions they train what are called master resiliency
trainers to kind of be skilled and able to help individuals develop some of
these skills and problem-solving performance enhancement is another one
of the pillars institutional training kind of helping leaders within the
institution of the army to kind of understand the importance
these concepts and then kind of the the use of modules to be able to allow
individuals where they want to improve their kind of abilities in one of these
areas to be able to take some of those modules we wanted to kind of talk a
little bit about comprehensive soldier fitness because as I transition into
total force fitness you can see that the army was thinking about some of the
tenants and comprehensive soldier fitness before and informed actually
where we went with total force fitness in the military so I mentioned these
programs and I mentioned these concepts but I think what’s important is like I
said billions of dollars have been put into these programs but we still know
very little about whether or not these techniques these strategies are
effective when we did our report in 2010 at that time very few of the programs
had been evaluated those that had been most regularly evaluated included the
Army’s programs battle mine and ASAP they had demonstrated that those that
had taken some of those to briefing and trainings had fewer symptoms of PTSD and
depression and fewer sleep problems when they came back from deployments and we
knew at the time that a SEP was doing some very rigorous randomized controlled
trials to look at program efficacy at a number of places and so now they’ve been
subsumed over comprehensive soldier fitness and comprehensive soldier
fitness itself is being evaluated and there are a number of reports that have
both come out and some ongoing efforts to kind of ensure that what is being
done as being efficacious and effective I’ll note that I think program
evaluation is critical and I think it’s important to knowledge that in an effort
to kind of rush out and have well intentions to help folks cope and
deliver these services few programs actually think about asking the question
well did it work you know or how could we do it better resources are often not
allocated for program evaluation and kind of been in the the mindset that we
just have to do something to help to try and solve these problems we can’t wait
for the data to tell us if it’s going to work before we roll it out we just have
to roll it out the programs that have done some evaluation tend to use
different types of strategies they gather satisfaction
you know using feedback and from ratings and interviews with individuals who have
participated in those programs to understand the feasibility and inform
improvement some programs actually gather information about functioning
across the number of domains typically in the emotional and behavioral health
area they ask questions about post-traumatic stress symptoms or
antisocial behavior and things like that again they also gather some clinical
data and then most of the outcomes that are measured though around these
programs have to focused on the individual level there are fewer
programs that are focused at the family and organizational level and very few
that actually assess kind of how families think things are going project
focus has done a number of valuations and they’ve had a number of reports
published about the effectiveness of their program as well again most of the
programs kind of focus at this individual and unit level again around
positive thinking kind of behavioral control and creating that positive
command client kind of helping leaders to try and understand and provide both
positive role models and reinforce the importance of taking care of yourself
family communication and belongingness are also the most commonly incorporated
factors for programs that are that are focused at the family and community
levels so now I’m going to turn to talk a little bit about total force fitness
and total force fitness is a relatively new concept it was introduced in an
instruction from the Joint Chiefs of Staff in 2011 and it really tries to
incorporate again different dimensions that focus on the mind and the body and
so we have a number of domains it’s a holistic approach it’s really an
emerging framework that’s helping to kind of organize and think about kind of
fitness in a more holistic way there are four of these dimensions that focus on
the mind psychological behavioral spiritual and social and then four that
focus really around the body the physical the medical and dental
nutritional and environmental and I’ll talk about each of these in a second
there are five tenets that really underlie this concept
that you know total Fitness really extends beyond the individual and
involves families it involves communities and involves organizations
that the family’s health plays a key role in sustained success and fitness
for the individual and for the force that that in implementing this and
assessing it and using metrics who not only must measure the positive but you
also must measure the negative outcomes and it’s links it links to the concept
of the forces fitness to the fitness of society from which service members are
drawn I think it’s important to think about you know our military is
recruiting and accessing individuals that come from the United States Society
and as that society struggles with its own challenges and issues around fitness
and health and well-being that potentially creates challenges for the
military to either try and correct or enhance or address some of those issues
as well and so this really does kind of take a societal approach and throughout
this kind of approach it really acknowledges that leadership is
absolutely crucial and if you’ve heard anything kind of about to these various
different things than the military leadership is a critical element of
almost everything that they do to support their troops and it can have
both positive and negative impact and so I think that’s an important takeaway so
what is physical fitness I think this is probably the easiest for all of us to
identify with you know it’s the ability to be able to accomplish all the aspects
of the mission while remaining healthy and uninjured
you know well-rounded fitness programs are going to have varied kind of
approaches to kind of cardio strength training building the core strength
increasing speed and agility but it also acknowledges that the union of the
appropriate amount of sleep to perform well physically and to facilitate
recovery after different events and it in in the total force fitness concept
that was outlined by the Joint Chiefs staff kind of talks about the use of
mind-body programs as being just as important as that strength training the
concepts of yoga martial arts and meditation for example you know some of
the the ways that physical fitness is often measure
we can think about strength speed agility and kind of you know the ability
to your body composition kind of your aerobic capacity kind of all the
traditional kind of biomarkers that we tend to take that we can measure kind of
on the physical persons performance so the goal of training your body to be
ready for the mission and the job this is why you see a lot of PT programs and
a lot of focus on individuals physical strength and appearance psychological
fitness again this really kind of draws from what we just talked about in the
prior segment about psychological resilience and kind of now calls it
psychological fitness this is the idea that you can integrate and optimize kind
of the mental and emotional behavioral abilities and capacities to strengthen
your resilience but optimize your performance to kind of both be able to
focus and perform but then also to perhaps strength and resilience the
ability to cope with unique mental stresses and challenges and then kind of
it also kind of presumes that without this resilience servicemembers and their
families are at risk of burnout they can put themselves at physical danger and
may be more vulnerable to stress and combat related environments in
particular some of the metrics here kind of you know think about not just the
absence of psychological symptoms but think about aspects around morale
adaptive coping techniques and kind of mental capacity as well it’s just the
absence of psychological disorders behavioral fitness this is really about
what we do to our bodies and how we behave whether or not we adopt behaviors
that support readiness and health and thinking about you know positive
behaviors increasing those increasing kind of the things that we do that are
healthy and decreasing the things that we do that perhaps are less healthy like
smoking and use of substances or risk-taking behaviors you know wearing
your seatbelt you know wearing a helmet when you ride a motor motorcycle and so
the idea that with behavioral fitness is really about making sure that
individuals are making healthy choices and how they interact
the environment spiritual fitness the concept of finding meaning purpose and
then social support this isn’t necessarily about belonging to a church
or any specific religion it’s about the the individual or groups ability to
maintain their belief system the principles and the values that they need
that will help them in times of stress and really kind of their philosophical
and human values these concepts we often think form the basis of an individual’s
character their disposition but really also kind of influence their
decision-making and their integrity at the individual and group level again
this is about values and practices and core beliefs and finding meaning in
tasks and in life and in a lot of the literature talks about the importance of
that meaning and value social fitness is the concept of building and maintaining
healthy relationships with others if you think about the ecological model it’s
kind of how the ripples out I support you at various different times of need
you know the ability to engage in social networks in a healthy way that promote
overall well-being and optimal performance
it really intertwines again that the unit the family and community levels
that the would-be individual and the idea that this really comes in the
social fitness is developed around a common sense of purpose clarity of the
values the personal level as well as within a unit the understanding and
awareness of the mission and the preparation for challenge and kind of
how this all relates together this is often measured kind of in concepts of
social cohesion social connectedness kind of tasks cohesion when groups are
assessed to the extent that they’re kind of all integrated into that social
network medical and dental fitness actually really refers more to meeting
the minimal standards and requirements that the military sets out to ensure
that individuals are deployable and that they meet the minimum requirements for
retention in the military and there are a number of them they vary across the
various different services but they basically fall into the categories of
you know are you free of disease and are you
fit and healthy to perform the specific tasks that are designated in your
occupational specialty so they employ various different screening techniques
an immunization program to kind of inoculate and immunize individuals
against particular types of diseases as well as hazards that they could be
presented with and they focus a lot on prevention and pretreatment so when they
screen individuals and they identify something if those can be treated they
will deliver services and interventions that can then bring them back up to
medical and dental readiness and again it’s focused on ensuring that the
service member is capable of completing the required training you know can they
endure the base the basic training but also other mission related training and
environments to effectively perform the requirements again we count on our force
to be able to perform effectively and we need to make sure that they can endure
that training to prepare environmental fitness kind of acknowledges and
recognizes that the environment within you and within your work has a very very
big influence on how well you can perform again you know we know that in
our bodies perform differently at different temperatures at different
altitudes noise can play affect on our ability to focus and get tasks done air
quality radiation this doesn’t just apply to the military it applies to all
of us I think we can all think about the settings in which we find ourselves
working more effectively and being able to accomplish our tasks but within the
military we also know that they may go to environments where they may be
exposed to specific hazards such as hazards that may come in
you know both exposure to toxins they can be vector borne diseases or other
contaminants and so you know there’s a focus on the use of not just the
immunizations they talked about before that can be effective and preventing
some of these consequences if they come in contact but use the use of personal
protective equipment and kind of specific adaptation and training
techniques that are required so that individuals can perform at these
different levels and be able to kind of perform their tasks and mission at
different temperatures at different altitudes again with noise and really
kind of focus if you think more kind around occupational health and
safety measures to kind of both provide that prevention and intervention where
needed in nutritional fitness which i think is also gaining more and more
recognition about being very important about the provision and consumption of
food that both in quantities and qualities and proportions that are
sufficient to preserve performance and health but thinking about making wise
choices nutritionally not only about the food that we consume but about the
supplements that we put in our body the supplements that may have positive
effects as well as the supplements that may have negative effects and there is a
for any of you that have had the opportunity to deploy to some of these
environments there’s a high reliance upon those energy drinks and the
caffeine to kind of keep folks awake trying to understand kind of how that
changes an individual body’s performance and kind of the effects that that can
have both positive and negative at the same time that there are some
nutritional supplements that we believe can offer some confer some benefit and
perhaps be protective against some challenges and stressful environments as
well so again trying to create a culture an environment where healthy food and
beverage options are an easy and appealing choice this is difficult I
think for any of us that have tried to make healthier decisions about what we
eat it’s difficult when you travel it’s difficult when there are few choices at
grocery stores or you’re in a hurry and thinking about kind of how you array
food items and grocery stores but what’s available in what’s cheap at the
exchange and you know how are we really kind of thinking about policies and
programs around promoting healthier choices and what we put in our bodies so
talk a little bit about kind of what the implications are and invite your
comments about kind of what you think the up the implications are for non DoD
settings and environments and populations I think that it comes
without saying that I think we all recognize the role and importance of
using public health approaches to trying to understand a problem use both
Universal and targeted approaches to screen detect problems and treat and
facilitate recovery but I think the importance of what we’ve
learned over the past ten years and kind of where these concepts have gone from
not just resilience promotion but else in psychological resilience and thinking
about this all is something that we need to do to train people to just deal with
stress more effectively but how we think about fitness in a more holistic way is
the importance of recognizing that there are multiple dimensions and layers that
contribute to health and performance it’s not it’s not just about how we
think about things you know it’s about some of these other dimensions it’s not
just the individual it’s their family it’s their unit it’s their community
it’s the environment that surrounds them and so these multiple layers and
dimensions are critically important to think about and how that intersects with
what we’re trying to to do particularly in the healthcare field where we’re you
know only touching individuals for a very small portion of their their life
and that the other parts of their life may have greater impact on some of their
decisions and some of some of the outcomes again you know the opportunity
that we have to think about promoting resilience and teaching techniques and
teaching skills just better decision-making skills problem-solving
skills not just for our military but what you know what about our children
and the next generation of adults and you know what are we doing to think
about how we help individuals in various different communities approach
situations and kind of make healthy decisions and support one another with
these concepts of resilience that will be helpful I think for maintaining
population health more broadly preparing specifically for disasters and
emergencies to minimize trauma there’s been a large effort and if any of you
have read the National Health security strategy the concept of resilience is
clearly and squarely in there around communities and thinking about how can
we prepare communities that may be living in regions that could be at
higher risk for some of these disasters or that may you know over time face some
of these community challenges and kind of thinking about you know building
community resilience that they can kind of prepare work together to create the
solutions and adapt successfully and again thinking about the opportunity
that after an event resilience again and some of those techniques can help foster
recovery for end Jules for the family in the community
and then again this concept of the need to measure the effectiveness continually
not only to inform continuous improvement kind of ensure that we’re
getting better more efficient and we’re ensuring effectiveness but because we
want to minimize we often have to be concerned about the costs and how well
and how long these things can be sustained in terms of the level of
effort so we want to be cost effective but I think we also want to ensure that
what we’re doing and what we’re deploying in terms of these programs
work so that we can offer folks the most hope and the most promise for being able
to cope with the very challenges that they will face and that they can
facilitate recovery transition into civilian life and you know thank them
for the service that they’ve given to our country not just them as individuals
but their family as well so think it’s critical that we always ask ourselves
the need to evaluate and as I said resilience for a long time has been
thought as the panacea if we can just make folks resilient then we won’t see
these rates of PTSD we won’t see the rise in suicide and that may be but we
have to actually start to measure whether or not some of these some of
these techniques are in fact accomplishing what we hope that they
will accomplish and if they’re making a difference not just by measuring the
absence of some of the psychological health problems but looking if they
contribute to some of the health and fitness domains that we believe they can
also be associated with and you know I’m a great believer in resilience you know
I believe it’s a concept that is important and that we need to strive for
but I maintain some healthy skepticism as well
and that I hope that we can continue to refine what we believe are techniques
that will promote resilience that will enhance fit fitness so that we can kind
of really make sure our troops and their families are given the very very very
best that we can and I thought it kind of effective and important that as I was
thinking about this talk and these concepts that I saved my tongue
on my Little Nemo drive because Nemo after all is one resilient little fish
and so you know let’s hope that we can all kind of ensure environments where
the little Nemo’s can kind of get back and endure a very traumatic experience
and for our troops I think we owe it to them to ensure that the techniques that
we employ and the strategies can help them endure the great sacrifices that
they’re making on all of our behalf so with that I’d like to open it up to
questions I’d be happy to kind of go over anything I just said and I guess
for those on the the web we would just remind you and 4:00 in the room too
please use the microphone so that folks on the web can hear you and if you have
an opportunity to send in comments online did I put that other slide up I
guess Carrie thank you system thank you for your presentation I of
resilience it’s really interesting and I heard you speak before how does your
kind of collective approach you know through the current total force fitness
or the other programs evolve or change in relationship to those who are doing
back-to-back appointments in the needs of those individuals and how you go back
and assess the needed fit shape your program again and really get to that
individual and their community family that’s a great question um you know it
Rand we aren’t delivering these programs and services we have the opportunity to
evaluate them and kind of you know look at how that’s affecting some of their
kind of approach to changing kind of techniques and you know I think it’s an
open question I think there’s been a lot of concern about the read the repeated
deployments the kind of accumulation of time spent away from families time spent
at risk for significant exposure to trauma and you know these programs are
anchored to various different parts the deployment cycle if you even start to
think about the the way that they assess you know somebody could be doing a pre
deployment screening but they’ve already deployed like you know three or four
times and so is that really pre deployment or is that post you know
three deployments and so it’s it’s hard I think to kind of think about these
things linearly because we start to get into a circle and a loop and I can’t
speak to what some of these individual programs are doing to kind of think
about that and how they change their techniques but I can say that there is a
general awareness that the accumulation of exposure is becoming more important
and the need to kind of reconsider guidelines for how we deploy individuals
both the number of times for how long how much time do we give them back home
what do we do what can we do with interventions and strategies while
they’re back home that can help reset them and kind of you know put them on a
path but prepare them that that path may be interrupted with having to go again
I’m so thinking not just about the individuals but the family so don’t have
a direct answer about specific things that are being done but that
is an ongoing challenge given the environments where we’re deploying
people multiple times any other questions Terry thank you very much the title of
your presentation is actually a little provocative because he used the term
evidence-informed Iran is one of the biggest evidence-based practice centers
that we know what was the decision he used the term informed as opposed to the
face because the strength of the evidence really isn’t there to indicate
we don’t see that a lot of the there have there had just haven’t been a lot
of research studies that have used the designs that we would use traditionally
to use the term evidence base like I said you know we don’t have the
opportunity there haven’t been a lot of RCTs done to indicate that this actually
demonstrated a real efficacious approach and so evidence informed we use to kind
of suggest that there is evidence there’s in fact you know we reviewed
hundreds and hundreds of literature the strength of evidence varies across these
different factors but a lot of its theoretical a lot of its post-event kind
of observational it’s hard to draw causal relationships between you know
some of these factors and the outcomes based upon those designs and we talked
to experts so we felt it’s safer to call it evidence informed versus evidence
based which in you know traditionally you would see in other parts of the
field where there have been a lot of RCTs that have demonstrated efficacious
now this is not unusual to this area at the end of the day people still have to
make decisions and I want Majan it in a setting like this people still have to
make decisions about what it what interventions to actually use or what
strategies for education so are you able to at least give people a sense of what
the strength of the or the experience is and to guide the military in deciding
which approach yeah with that one part of the talk in
terms of the study that we looked at we did provide very specific
recommendations at the program level we could identify the various tip of the
programs that we looked at what factors were being used if those were the
factors with a stronger level of evidence versus a lower level of
evidence and that feedback was given with the opportunity that they could
actually think about changing their approaches incorporating some of the
other factors that according to the evidence to date suggests will be have
greater potential of promoting resilience we haven’t been asked to go
back and evaluate again whether or not that’s in fact happened we’ve had a
newer study that has looked at psychological health programs more
broadly and again you know a great challenge and thinking about yes you
need to make decisions you need to deploy interventions you need to get
these services out there but how are we incorporating kind of a continuous
quality improvement model to that process to ensure that we’re always
refining strategies to focus and target and improve and so we provided pretty
program at the program level specific recommendations as well as more broadly
for the field to really think about you know should there be sets of
expectations or approaches that should be focused on more heavily than others
again I you know I think the skills development and the teaching of
techniques is different than lecturing and putting slides up and certainly
having you know rooms of people with PowerPoint slides going up while they’re
actually trying to accomplish something else which we’ve also seen happen and so
we’ve given some feedback on specific methods and techniques for how you
actually deliver the information as well yours tell me if you can hear me now so
this question is what approaches are being used for service members who’ve
left the military or guard members at home away from their units so that’s a
great question and there’s a pretty well-known program now the Yellow Ribbon
reintegration program that was implemented a few years ago specifically
designed to target and provide support services for reserve and guard after
they come back to their communities and the Ribbon Program offers a range of
different types of programs and services and each state has a different Yellow
Ribbon Program and can do things a little bit differently I can’t speak to
specifics because I haven’t studied the Yellow Ribbon Program but it does exist
it’s out there and there are a number of programs that even the services have now
tried to deploy that focus on individuals after they leave the service
and so not just thinking about people while they’re in uniform but thinking
about them as they make those transitions as well so yellow ribbon is
certainly one of the ones that’s most well known and then you know there’s
some efforts I think that have been put out by the VA obviously around you know
suicide prevention and crisis but also transition to kind of have more
welcoming hands for individuals as they come from the Department of Defense as
well hi Terry can you hear me yes okay my
name is June I have a question obviously you
mentioned that during your briefing on your overview that you have a healthy
skepticism in terms of the effectiveness of this various techniques of resilience
and earlier when you were discussing the comprehensive soldier fitness you
mentioned the physical emotional spiritual family got together that the
that there’s a training for the master resiliency for all the trainer’s did
your study by any chance go into perhaps the effectiveness of those trainers and
then the master trainers if you will and resiliency and the effect that they may
or may not have that’s a great question and no we actually did not evaluate
comprehensive soldier fitness as a program and I know that there are some
ongoing assessments that that team is doing with some partners but it is
randa’s not engaged in any of those evaluations so I can’t speak to that
question I’m sorry it’s not on behalf of the office of
disease prevention I really like to thank you for having given us a
stimulating presentation it’s very fitting fitting component of our mind
the gap series and it does challenge us to think
in different ways I the same time I’d also like to thank our other co-sponsors
of this seminar the office of dietary supplements
they’re complementary and alternative medicine the National Institute of
Mental Health they have been steady partners through
all of these seminars well I thank you very much for your
participation everybody who is here or on the on the web please follow Harris’s
suggestion that if you identify topics and speakers who you think would be
appropriate for this series we would love to hear from you and a personal
note I want to thank the Office of Disease Prevention for having let me be
their director for the last couple of years and let me be involved in
activities such as this it’s been exciting thank you thank you


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