Bulletproofing the Psyche Preventing Mental Health
Problems in Our Military and Veterans 1st Edition
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Contents
Foreword
Charles R. Figley
Acknowledgments and Editors’ Note
Part One Framing the Issues
Chapter 1 Introduction to Military-Connected Well-Being Issues
Jennifer E. C. Lee and Sanela Dursun
Point of View—The Small Bible
Matthew J. M. Hendricks
Chapter 2 Warrior Culture: Ancient Roots, New Meaning
Kyleanne Hunter
Point of View—Armor Down: The Power of Mindfulness
Ben King
Chapter 3 Mindfulness: The Neurobehavioral Basis of Resilience
Deborah Norris and Aurora Hutchinson
Point of View—A Shift on the Mat
Laura Westley
Chapter 4 The Theory and Practice of Training for Resilience
Kate Hendricks Thomas and David L. Albright
Chapter 5 Moral Injury and Resilience in the Military
Joseph M. Currier, Jacob K. Farnsworth, Kent D. Drescher, and
Wesley H. McCormick
Part Two Current Mental Fitness Programming for Military- and
Veteran-Connected Populations
Chapter 6 Department of Defense Resilience Programming
Cate Florenz and Margaret M. Shields
Point of View—Fostering Veteran-Student Health through
Stress Management: Creating Belonging and Success in a
College Setting through the Veterans at Ease Program
Robin Carnes and Stephen Kaplan
Chapter 7 Mental Fitness and Military Veteran Women
Kelli Godfrey, Justin T. McDaniel, Lydia Davey, Sarah
Plummer Taylor, and Christine Isana Garcia
Point of View—Fitting In and Finding Me
Jessica Wilkes
Chapter 8 Learning from Example: Resilience of Service Members Who
Identify as LGBT
Katharine Bloeser and Heliana Ramirez
Chapter 9 Resilient Military Families
Charles R. McAdams III
Chapter 10 The Promotion of Well-Being in Older Veterans
Kari L. Fletcher, Mariah Rooney O’Brien, and Kamilah A.
Jones
Part Three Collaborating to Provide Mental Fitness Programming for
Military-Connected Populations
Chapter 11 Faith-Based Programming for Spiritual Fitness
Rev. Sarah A. Shirley, Rev. Elizabeth A. Alders, Howard A.
Crosby Jr., Kathleen G. Charters, and Rev. John Edgar
Caterson
Chapter 12 The Role of Individual Placement and Support (IPS) in Military
Mental Fitness
Lori L. Davis and Richard Toscano
Chapter 13 Adapting the Collective Impact Model to Veteran Services: The
Case of AmericaServes
Nicholas J. Armstrong, Gillian S. Cantor, Bonnie Chapman,
and James D. McDonough Jr.
Point of View—Setting the Bar: Mental Fitness and
Performance
Kate Germano
Chapter 14 The Way Forward
Kelsey L. Larsen and Elizabeth A. Stanley
About the Editors and Contributors
Index
Foreword
A long time ago, I was a Marine in Vietnam. My war was different from
other conflicts these days (e.g., training, equipment, enemy), but much is the
same. Warfighters have a job to do: to win, to kill, and to complete the
mission. Self-care is not on their to-do list. Not then and not now. But it
should be. We had no idea back then how stress could affect your sleep or
how you can get better sleep by controlling your stress. Common behaviors
such as drinking alcohol or other self-medicating efforts are flawed but
sometimes necessary to restore stasis. Let me return to my experiences later.
This book is about building resilience in military personnel and veterans.
It is an alternative to books that focus on the problems these men and
women face or that emphasize the negative consequences of military service
in the form of mental illness diagnoses. This book is about hope and about
the belief that with effort we are able, all of us, to develop and wear a
bulletproof psyche just as we wear a bulletproof vest into battle. We can
build up our skills, moral compass, integrating honor, mutual support, trust,
and the other tools discussed in this book that better prepare men and
women for severe conditions that persist for prolonged periods of time.
Kate Hendricks Thomas and David L. Albright know about the need for
such skills and resources to enable effective leadership, adaptability, and
creativity to get the job done, no matter what. They were able to recruit not
only the authors who are scholars, researchers, and practitioners to
contribute to this book but also writers who are military veterans, including
combat vets. This mixture of voices leads to a harmony of thoughtful
creativity and reflection about what is needed to effectively serve as a shield
from the horrors of war and its immediate and long-lasting consequences.
Such a shield would enable veterans to go through the phases of reentry to
society and to be effective and loving family members.
The aim of this book is consistent with its theme: embracing and quickly
managing the s*** by taking advantage of the innovations of the
mindfulness movement and other alternative and complementary behavioral
health practices. However, there is a cautionary note at the end of this book.
Despite the best plans and efforts, the military does what it does. New
commanders take over and do the best they can. Sometimes new leadership
ends a successful program, like the ones described in this book.
The characteristics of bulletproofing are largely the same as the concept of
mettle. Mettle is a person’s ability to cope well with difficulties or to face a
demanding situation in a spirited and resilient way. Bulletproofing the
psyche, then, like having the “right stuff,” mettle, or resilience, is about
decreasing the mental health risk factors and increasing the protective
factors. Rather than focusing on a diagnosis (e.g., posttraumatic stress
disorder, depression), the focus is on preventing and bouncing back from
traumatic events.
This book illustrates how and why resilience can be taught and trained. It
is far better than the traditional focus on mental disorders and
psychopathology. The focus is on medical prevention as well as
rehabilitation toward functioning. This is one of the reasons why many are
shifting toward favoring the World Health Organization’s nomenclature over
that of the Diagnostic and Statistical Manual. Focusing on mental illness
diagnoses such as posttraumatic stress disorder is a disservice to those who
are seeking treatment: these types of diagnoses can trigger further problems,
including feelings of shame and of failure, rather than the acknowledgment
that one is injured and requires appropriate rehabilitative care. Self-care and
social support are vital to building resilience.
Indeed, resilience arguments and evidence are becoming popular among
active-duty programs. They are more often focused on preparing warfighters
for the mental and emotional toll that are brought about by combat
operations.
But no matter their documented success, future military leaders will need
to be educated about their value and kept up-to-date on new findings in this
field. So, despite the extraordinary contributions made in this book, we
cannot count on the lessons being applied in the future. This is in line with
the recent analysis Mark Russell (former Navy Commander and the lead
psychologist treating Marines) and I published through a series of systematic
reviews of military publications and documents (cf., Russell & Figley, 2017a,
2017b, 2017c). We noted that the Department of Defense in general and
frontline psychiatry in particular are failing in their responsibility to prevent
psychiatric casualties and that there are more psychiatric casualties than
physical casualties and wartime psychiatric casualties even exceed combined
totals of personnel physically wounded and personnel killed in action.
When I returned from Vietnam, I had no idea how I had been changed by
my experiences leading Marines and fighting in war. I was fortunate that my
bulletproof vest was for mental bullets, not just metal ones. I was able to
focus my postwar rage generated in Vietnam (1965–1966) on to my academic
studies and degrees. My fortune of a loving family, intellectual and social
resources, and an emerging hate of war motivated me to try to help other
vets find and build their vests. What I have tried to convey is that this book
is about helping war fighters, during and following war, build resilience to
the war stressors.
The military has dual missions of war: fighting wars and force protection.
This requires both protecting those who fight the war and getting them
home in one piece with a plan to promote healing mentally and physically
from their war injuries.
This book provides a way forward to improve military mental health.
Collectively, we can hope that this book will be read by war planners. So far,
the war planners have not worried about a bulletproof “vest” for mental
injury, just vests to prevent physical injury. Protecting our warfighters
during and following battle must be our primary mission on a par with the
military mission. This book is an important start.
Charles R. Figley, PhD
Paul Henry Kuzweg, MD, Distinguished Chair and Professor
Tulane University
New Orleans, USA
References
Russell, M. C., & Figley, C. R. (2017a). Do the military’s frontline psychiatry/combat and operational
stress control doctrine help or harm veterans? Part one: Framing the issue. Psychological Injury
and Law, 10, 1–23. doi:10.1007/s12207–016–9278-y
Russell, M. C., & Figley, C. R. (2017b). Do the military’s frontline psychiatry/combat operational stress
control programs benefit veterans? Part two: Systematic review of the evidence. Psychological
Injury and Law, 10, 24–71.
Russell, M. C., & Figley, C. R. (2017c). Is the military’s century-old frontline psychiatry policy harmful
to veterans and their families? Part three of a systematic review. Psychological Injury and Law, 10,
72–95. doi:10.1007/s12 207-016-9280-4
Acknowledgments and Editors’ Note
We came to this project after many, many conversations about veterans’
well-being issues. Perhaps we work in this space today because our own
experiences leaving the Marine Corps and Army were not ideal—it just
wasn’t as easy to leave and reinvent as we had expected. It is easy to focus
on how things aren’t optimized for military personnel leaving the active
component, but as we chatted, we always turned back to notions of
preventing some of that transition stress. “If I’d only known to do this”
became a familiar refrain. We believe that it doesn’t have to be as hard to
reintegrate into a civilian community for tomorrow’s service members. This
project is the first of our attempts to contribute to and extend the
prevention, rehabilitation, and training conversation for military personnel
navigating that liminal space between service and civilian life and those that
support these processes.
First and foremost, we would like to thank the team of contributors who
lent their expertise, efforts, and skillful prose to this volume. Without you,
there would be no book. The research and personal experiences you shared
are an invaluable gift. We would also like to thank Charlotte Brock, a Marine
Corps veteran and freelance editor, who helped us turn early chapter drafts
into cleaner prose.
Important to mention are our partners, who provide continual support for
our activities, and our children whose enthusiasm and energy sustain us.
Finally, we are forever thankful to the service members, veterans, and their
families and communities.
Many of us return from military service meaningfully changed—
physically, mentally, emotionally, and spiritually. These changes encompass
the whole person and hold the potential to transcend whole communities.
Section one of this anthology will highlight some of these issues and discuss
the physiology of stress injury and other barriers to well-being as well as the
way that hardship can create growth and even “bulletproof the psyche.”
We hope this book contributes to larger community efforts that support
healing. We also hope it motivates a new emphasis on mental fitness
training for the active duty component. Here, rigorous evaluation of existing
outreach efforts provide the foundation upon which savvy programmers
must build. We focus in section two of this book on examining resiliency
programs making inroads with today’s veterans. Our best chance for making
a difference in both the postservice and training environments (before a
service member faces transition stress) involves designing programs from a
baseline of proven success.
To operate in training commands requires great cultural competency,
making mental fitness programming relevant to warfighters working to
maintain readiness and improve performance. The narrative must become
about mission success, not mental health treatment. It means not only trying
to understand the veteran experience but also learning the most effective
ways to communicate with different subsets of the veteran and military
populations. To train is to actively participate, and this is a wellness concept
with which service members are already familiar. Framing self-regulatory
training as a way to “bulletproof the brain” renders palatable a training
opportunity specifically designed to create more effective warriors who
possess mental endurance. Framing mental fitness training as promotion of
combat fitness, resilience, and mental endurance renders it accessible to the
military population. We’re interested in building strengths after all.
We have to speak the language of warriors who have been immersed in
combat operations for over 15 years when we talk about resiliency-
cultivation. PowerPoint presentations simply won’t cut it. By establishing
mental fitness as another component of optimal combat readiness, we
establish such training as a crucial component of mission preparedness and,
as a benefit, remove the stigma of such practices for postdeployment troops
that may be struggling with stress illnesses of varying degrees. The message
can become directive; just as Marines and soldiers learn mission essential
skills and train their bodies for arduous combat, we must adopt practices
designed to train and promote health in the mind, body, and spirit in a
holistic sense. This training doesn’t succeed in sustainable fashion in a
vacuum. Knowing the importance of social support to well-being and
generally wanting to contribute to improved quality of life for service
members require a focus on the larger community in which a warrior
operates. Social and family fitness is part of mental fitness, and we must
consider family readiness programming that is more extensive and
progressive than our current offerings.
When we consider how we could apply these basic recommendations to
military veterans seeking relief from reintegration stress or to active-duty
military preparing for it, we must consider how to make stress management
a testable metric. Biofeedback tools exist that can do this. Checking for
dehydroepiandrosterone and blood cortisol ratios or conducting periodic
blood cortisol checks can be as important as other physical standards are in
the military. Biomarkers tell us quickly whether someone is taking time to
practice balanced wellness.
Section three of this anthology will highlight the possibility of training an
individual to de-escalate his or her nervous system response as a
performance metric and discuss methods for rolling such programs out both
in the active duty component and the veteran space. This anthology’s
primary conclusion is a call to action. We can use biofeedback testing to
make resilience a performance metric for the active duty component. It turns
self-awareness and resilience into standards and motivates learning,
training, practice, and performance in our community’s culture. Our future
work involves delivery and evaluation of a theoretically based, validated
training curriculum to bulletproof the brain.
The future is exciting from clinical, training, and prevention perspectives,
and these recommendations offer tremendous promise for tomorrow’s
military personnel. Training to embrace a mental temerity training regimen
can make them better at their jobs and more resilient in their lives, both
during and after their service to our country.
Kate Hendricks Thomas and David L. Albright
Part One
Framing the Issues
Chapter 1
Introduction to Military-Connected
Well-Being Issues
Jennifer E. C. Lee and Sanela Dursun
Together, the wars in Afghanistan and Iraq are among the most hostile
conflicts seen in recent history. Since 2001, over 2.7 million U.S. troops have
been deployed in support of these operations, while over 40,000 Canadian
Armed Forces (CAF) members have been deployed in support of the mission
in Afghanistan (Ramchand, Rudavsky, Grant, Tanielian, & Jaycox, 2015;
Zamorski & Boulos, 2014). There have been more than 8,000 military
casualties among members of the coalition and over 52,000 U.S. military
personnel wounded in action for the conflicts combined (Defence Casualty
Analysis System, 2016). Furthermore, it is widely recognized that the
impacts of war go beyond the immediate fatalities and injuries. Having
faced extreme stress and hostile situations, military personnel are at
increased risk of experiencing mental health problems. These “invisible
wounds” of war have garnered a great deal of attention in recent years
(Tanielian & Jaycox, 2008), with research on the mental health impacts of
recent conflicts in Southwest Asia having surged over the past decade and a
half. A number of well-designed epidemiological studies have now
contributed to a better understanding of the overall burden of
postdeployment mental health outcomes, such as posttraumatic stress
disorder (PTSD) (Averill, Fleming, Holens, & Larsen, 2015). From the
psychological lens, research has also provided substantial insight into the
processes and mechanisms that may explain how exposure to combat stress
gives rise to mental health disorders and, ultimately, influence individuals in
the longer term. Now that an extensive body of work has developed, there is
an opportunity to integrate what is known, identify remaining gaps, and
propose promising strategies to address these. The present chapter provides
an overview of key findings in this area based on research conducted on U.S.
and Canadian military personnel deployed in support of the conflicts in
Southwest Asia since 2001, with the aim of providing a more integrative
perspective of psychosocial pathways in the course of PTSD and its sequelae.
Burden of Postdeployment Mental Health
Problems
Given the traumatic nature of combat, it is not surprising that a great deal
of research on the mental health of military personnel has focused on the
psychological impacts of trauma exposure. Despite only having been
formally recognized as a mental health condition in the third American
Psychiatric Association Diagnostic and Statistical Manual (DSM-III) in 1980
(Friedman, 2016), PTSD has evolved into one of the most commonly
researched impacts of combat exposure. As noted by Friedman (2016), the
PTSD concept represented an important shift in psychiatric theory through
the acknowledgment that etiologic factors for the disorder were outside of
the individual rather than resulting from an inherent weakness.
It is argued that the recent missions in Afghanistan and Iraq have created
a unique set of conditions for increased risk of PTSD among military
personnel (Schnurr, Lunney, Bovin, & Marx, 2009): in the United States,
these wars primarily relied on National Guard and reserve forces and
required personnel to go on multiple deployments to meet the demands of
the conflict (Galea et al., 2012); tours were longer, with shorter periods
