Keywords

The military depends on its service members to be physically and psychologically resilient. Resilience is essential because military service demands long hours, extended time away from family and friends, frequent relocation, endurance in the face of harsh environmental conditions, performance under stress, and courage in life-threatening situations. Soldiers, sailors, airmen, and Marines who are resilient are able to adeptly respond to these challenges, quickly recover from them, and even grow from their experiences.

Most Service Members Are Resilient

While mental health problems represent one of the top reasons for medical evacuations from a deployed setting [1], the majority of service members do not report mental health problems while serving in the military or as veterans following retirement from service. Rates of PTSD are estimated at 5.5% in the overall U.S. military population and 13.2% in operational infantry units, meaning more than four in five service members (82.8–94.5%) do not meet clinical criteria for PTSD [2]. Besides PTSD, 22.3% of service members report clinical levels of depression symptoms [3], 13% report clinical levels of anxiety symptoms [3], and 15.2% report alcohol-related problems [4]. While these rates are substantial, they also suggest that approximately three in four service members have no clinically significant concerns related to mental health problems or alcohol use.

Resilience, however, is more than the absence of mental health problems. There are numerous definitions of resilience, but these definitions typically describe resilience as comprising the inherent individual attributes that enable successful adaptation, functioning, or positive change following adverse events [5, 6]. One relatively simple and straightforward definition of resilience is “the demonstration of positive adaptation in the face of adversity” ([7], p. 6). The Department of Defense similarly defines resilience as “… the ability to withstand, recover, and/or grow in the face of stressors and changing demands” [8].

The fact that militaries like the U.S. Department of Defense have definitions of resilience demonstrates that resilience is central to the concept of military culture, where service members are expected to put “mission first” and move effectively through cycles of preparation for deployment, deployment, reintegration, and recovery before preparing to deploy again. Across the different phases of this cycle, service members are expected to adapt to rapidly changing and uncertain circumstances, to subordinate themselves within a hierarchy, and to navigate volatile, uncertain, complex, and ambiguous (i.e., VUCA; [9]) environments. Although individuals may falter in the face of adversity or need help to recover, the majority of service members consider themselves to be resilient.

In one anonymous survey, for example, soldiers preparing to deploy were asked to rate their own resilience using the Self-Rated Resilience Scale ([10]; Table 3.1). While junior-ranking soldiers reported less resilience than non-commissioned officers or officers, the majority agreed that they bounced back and recovered from adversity. Table 3.1 also illustrates that service members do not uniformly describe themselves as resilient in all ways, consistent with findings from Warner et al. [11] that service members are frank in their responses on anonymous surveys.

Table 3.1 Self-rated resilience by rank category
Full size table

This frank self-appraisal is predictive of mental health. In a longitudinal study, soldier ratings of their own resilience prior to deployment was positively associated with their mental health nearly a year after they had returned from a combat deployment [12]. Moreover, soldiers who perceived themselves as highly resilient had better mental health outcomes not only because of their individual capabilities, but also because they actively reached out to others around them when they returned home. These results demonstrate that self-rated resilience is a useful marker of a service member’s ability to withstand the rigors of deployment. Clinicians can leverage this finding by asking service members to rate their own resilience and their use of social connection.

We note, however, that this high level of resilience among service members is potentially influenced by multiple personal and institutional factors. On the one hand, the military might attract service members who are resilient, who are driven to succeed under demanding circumstances, and whose personal goals and values resonate with military culture [13]. On the other hand, the military selection system might also screen for resilient individuals. Certainly, recruits must meet basic standards of mental health prior to enlistment or commissioning, and some mental health conditions preclude individuals from military service. For those who do make the cut, however, military experience and training might help them become more resilient than they were when they joined the service by further developing their existing skills, capabilities, and confidence. Although research has yet to determine which of these factors contributes most strongly to service member resilience, it is likely that service member resilience reflects some combination of these forces.

Selected Components of Resilience

Even though most service members are resilient, they still sometimes falter and need additional support. Risk associated with behavioral health symptoms range from background characteristics, such as adverse childhood experiences [14, 15], to exposure to extreme military stressors, such as combat and atrocities [16, 17]. In this chapter, we limit our focus to four biopsychosocial factors with significant implications for providing clinical care and consultation to service members: sleep, emotion regulation, social cohesion, and leadership. We selected these four because they are well established in the research literature as predictive of quality of life and mental health in the military occupational context.

Sleep

Sleep is vital for service members’ physical and psychological resilience [18], and sleep problems can signal an increased risk for subsequent mental health problems [19, 20]. Sleep disorders among service members are discussed in greater detail by Capaldi (this volume); here, we emphasize sleep as a critical foundation for understanding service member resilience. Insufficient sleep is associated with missed work [21], difficulty with cognitive tasks [22, 23], and impaired military performance [24].

Despite the importance of sleep for health, soldiers routinely report sleeping fewer than 7 h/day, the minimal recommended amount of sleep [25]. In one sample of more than 2300 soldiers, 77.2% reported sleeping 6 h or fewer per 24-h period [26]. The epidemic of insufficient sleep is embedded in a larger organizational context where sleep is regarded as something that can take a back seat to mission requirements. Efforts are underway to prioritize sleep within the military [27]. At present, however, service members may underestimate the importance of sleep for building resilience to stress and sustaining performance.

Interestingly, just being aware of the benefits of sleep can improve service members’ sleep hygiene [28]. For example, one study showed that service members do not have to have a diagnosable sleep problem to benefit from greater awareness about the importance of sleep [28]. Indeed, the more soldiers know about sleep and the more they make sleep a priority, the better their sleep health [26]. These studies suggest that clinicians should not only limit their evaluation of sleep health to screening for possible sleep disorders among service members (Capaldi, this volume), but should also provide consultation to service members regarding how they can improve sleep for improved physical and cognitive performance.

Emotion Regulation

Lack of sleep is also associated with difficulties in emotion regulation—the ability to appropriately control, manage, or express an emotional response [29]. Service members who can regulate their emotions effectively are able to function well occupationally, socially, and interpersonally. Emotion regulation does not only refer to the ability to control one’s temper—it also refers to the ability to express a range of emotions from guilt, sadness, and anxiety, to joy, love, and gratitude.

Within the military culture, emotions are typically held in check, and a certain amount of stoicism is seen as useful to endure the physical and psychological demands that are part of military service [30] (see Box 3.1 for a soldier’s description of managing emotions after coming back from a combat deployment). Accepting emotions, rather than acting on them or engaging in problem-solving, is associated with better adjustment [31], even within the context of basic combat training, where new soldiers learn the fundamentals of Army culture. Soldiers refer to this skill of acceptance by using the phrase “embrace the suck.” The correlation of acceptance with better adjustment likely reflects the fact that soldiers are confronted with stressors that are largely out of their own control, and acceptance is therefore a more useful tool—if not the only tool—to facilitate adjustment.

Box 3.1 Emotions After Combat

The [transition] from being in a combat zone to home was good and bad. Some of the good reasons were getting out of the fucking desert and heat. Being able to see my family, wear civilian clothes, be with my girl and have actual off time without being on “Stand By.” Being able to let loose a little and have some fun without worrying about being in danger. The bad reasons are always feeling like I’m forgetting something. Watching my cousins over there go insane. Feeling like someone is always behind me and not letting my guard down. Talking about my experience with others and not controlling my emotions about it. I’ve never gone through a transition like this before and I’m not a fan of it. Feeling like something’s wrong when it’s not, always in a hurry to do things. People telling me I need to relax more. I don’t feel like I did anything in Iraq. Just drive around and wait to get blown up. (Soldier 4 months after returning from Iraq)

Restricting emotional expression can be useful in the occupational context, but it can harm service members’ ability to create meaningful connections with others outside of work. The ability to express a range of emotions at the right time and place can be useful for building relationships at work, in social settings, and at home [32]. While military culture often encourages the restriction of emotional expression, there are exceptions. Most notably, military culture normalizes and permits the expression of anger. Research shows that service members may perceive anger as helpful in performing their duties (reported as helpful by 48.3% of soldiers in one study; [33]), but this perception is associated with an increased risk of mental health symptoms. Although anger is often viewed as useful or acceptable, evidence suggests that it is actually associated with poorer adjustment [34].

Clinically, service members may need to be coached to address anger in different ways. First, service members should be encouraged to regard anger as just one of many emotions—and one that may not be in their best interest to harbor, particularly at the exclusion of other emotions. Second, they should be encouraged to cultivate awareness of positive emotions, such as love, joy, and gratitude. Simple approaches like a gratitude diary have been associated with an increase in wellbeing and a decrease in anxiety (e.g., [35]). Finally, encouraging flexibility in coping responses can help encourage emotion regulation. Techniques such as mindfulness can help boost a service member’s resilience and sustain their cognitive performance (e.g., [36]), and clinical treatments, including mobile applications, have been developed to target anger in service members and veterans [37,38,39].

Social Cohesion

Numerous studies have documented the role of social connection in establishing a healthy life. Indeed, a lack of social connection is not only associated with poor mental health [40], but a 26% greater likelihood of early death [41]. Social connection lies at the heart of military culture, and serving alongside, protecting, and supporting one’s fellow service member is a revered characteristic of military service. The solidarity among soldiers is paramount to the Army profession, as manifested in the Soldier’s Creed, which states, “I am a Warrior and a member of a team” and “I will never leave a fallen comrade” ([42], p. B-3). A soldier’s connection to fellow battle buddies, or an airman’s connection to fellow wingmen, however, extends far beyond the battlefield: The friendships developed in military service can last a lifetime and serve as an important source of support in times of need ([43, 44] [see Box 3.2]).

Box 3.2 Social Cohesion and Loss

I got a tattoo … dedicated to seven men lost … so that I will always have my brothers with me. My wife actually helped me in writing out the poem for the tattoo. That helped a lot, made me feel very good inside. I am ready for another deployment and I think that’s why my transition has gone so well because I have someone that cares for me and has my back. (Soldier 4 months after returning from Iraq (reported in [45]))

Social connection is the psychological adhesive that binds service members together, transforming them from individuals into a cohesive military unit that works in seamless harmony to advance a shared mission. Unit cohesion has been found to moderate military stressors, including deployment, and individuals who are excluded from this cohesion are at increased risk for mental health problems and suicidal ideation [46]. Resilient service members, then, are those who are able to sustain relationships within and outside of the military culture.

Leadership

The importance of leaders in military culture cannot be overstated. Leaders serve a critical role in establishing shared expectations, pulling groups together, and ensuring the well-being of unit members.

However, just as military leaders can set the stage for their groups to sustain their resilience under pressure, they can also undermine it. Service members are willing to pursue a mission at great personal cost and, in exchange, they expect that the organization will take reasonable steps to ensure their well-being, care for their families, and provide them with the necessary training, equipment, and leadership [47]. When leaders fail to uphold their end of this psychological contract, the sense of betrayal can be profound. Leaders who humiliate others, have others engage in unnecessary risk, or engage in unethical behavior undermine the resilience of their teams.

Service members are likely to serve under a diverse array of leaders. Some of these leaders will likely fall short of expectations, while others will surpass them. Importantly, positive perceptions of leaders are associated with better mental health outcomes, cohesion, and perceived organizational support [48]. Clinically, that means that even as individuals may feel disappointed or even betrayed by their leaders, they may have also experienced positive leadership as well. Good leaders can serve as a great resource—and for those service members who have left military service, the lack of a leader in their life may feel like quite a void. Several studies have found that specific and clearly identifiable leader behaviors are associated with better individual adjustment. For example, platoons leaders—typically junior officers—who ask about the sleep habits of their unit members and encourage unit members to get plenty of sleep have unit members who report getting more sleep [49]. Similarly, leaders who remind unit members about the importance of the mission and encourage them to take time to physically and psychologically reset have unit members who report less emotional exhaustion, a sign of burnout [50]. Thus, clinicians who can work with leaders to encourage targeted behaviors may be able to enhance the resilience of the unit as a whole. Clinicians are encouraged to consider the role of leaders and their potential influence on service members who are seeking clinical care.

Resilience Training

Resilience building is valued within the military and taught both implicitly and explicitly. New recruits receive training designed to test their resilience and build their sense of confidence when they first enter the military, and they continue to receive informal and formal resilience training through their service. Basic training challenges new recruits to manage a great deal of new information and succeed at basic tests of military skills, including marksmanship, navigation, and combat casualty care. Once assigned to a unit, service members routinely train with their teams in increasingly realistic battlefield scenarios. In passing through various career milestones, service members become more confident and resilient at home station and on deployment.

Formal resilience training aims to ensure that all service members have the necessary mental skills for life in the military. Not all service members arrive at their first duty station with the same foundation for navigating life challenges: Notably, service members have a higher rate of adverse childhood experiences than non-military personnel [14]. As such, providing new personnel with essential resilience skills may enable them to manage the demands of military service more successfully. This proactive approach may also be a useful way for the military to reduce attrition, and thus help offset the shortage of eligible recruits [51].

In the Army, resilience training is part of a mandatory curriculum that instructs soldiers on the use of specific cognitive and behavioral skills. Launched in 2008, the Army’s Comprehensive Soldier Fitness program (CSF; [52]) comprised several resilience initiatives, including a mandatory self-assessment using the Global Assessment Tool [53] and unit-based resilience training (i.e., Master Resilience Training [MRT]; [54]). MRT provides soldiers with social, cognitive, and behavioral skills for problem solving and effective communication, and incorporates performance psychology skills such as goal setting, self-talk, and energy management [55]. CSF training was also developed for the deployment cycle, particularly post-deployment resilience training, and randomized trials of the foundational material have demonstrated the efficacy of this approach [56, 57].

Skills taught in the Army’s resilience training programs have corollaries with approaches used in clinical treatment. For example, MRT teaches soldiers to practice anxiety reduction techniques, such as deliberate breathing, and engage in cognitive restructuring to avoid thinking traps. Other skills adapted from psychological research include practicing gratitude (i.e., “Hunt-the-Good-Stuff”; [54]) and responding positively to good news (i.e., Active Constructive Responding; [58]). As the Army updates its resilience training program, certain themes are emerging. First, the goal is to have fundamental skills integrated into formal training environments and taught by expert trainers. Second, the unit-level component of resilience training is shifting to a coaching model, with the emphasis on preparing NCOs to encourage use of resilience skills at certain times and places, rather than provide classroom-based instruction on the skills themselves. Finally, additional validated training is being examined to provide units with options for including additional resilience skills that are an appropriate fit based on a unit’s particular needs.

The common language provided by these resilience skills can be leveraged in a clinical context with service members who have been exposed to formal MRT training or to whom these concepts are otherwise familiar. Table 3.2 provides examples of the kinds of resilience skills taught in the Army’s program and the foundation of these skills in the literature.

Table 3.2 Sample resilience skills and their clinical corollaries
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The Navy and Air Force have equivalent resilience-building initiatives (for an early review, see Rand’s 2011 Report by Meredith et al. [6]). Currently, the Navy has the 21st Century Sailor, which incorporates a suite of programs that addresses topics ranging from life-work balance to nutrition. While we are not aware of publications detailing the effectiveness of these efforts, Navy-specific studies have identified factors that influence resilience. For example, Burt and Barr [59] identified the influence of leadership in the resilience of Navy recruits, and the role of performance enhancement strategies such as goal setting, emotional control, and attention control in the resilience of Navy Explosive Ordnance Operators [60]. In a Rand technical report from 2010, the Air Force also examined resilience factors related to performance [61] and launched Airman Resilience Training. A program evaluation published by Rand in 2014 documented variability in training implementation and low perceived utility of the program [62]. Currently, the Air Force has materials available under the banner concept of “Air Force Resilience” (see https://www.resilience.af.mil/Prevention-Tools/ for a list of tools ranging from how to manage anxiety and legal problems to how to encourage Airmen and families to thrive) [63], and has developed Wingman Connect, training designed to improve social connectedness.

Although not the focus of the present chapter, we do note that other nations have resilience training programs as well. For example, the Canadian Forces has the Road to Mental Readiness program, although this training may have limited effect, as demonstrated in a randomized trial with recruits [64]. Similarly, the Australian Defence Force has BattleSMART [65], an integrated program that also begins with recruits as well as other training packages such as self-reflection [66]. Likewise, in the UK, the military has implemented resilience training in various forms [67, 68]. While resilience training is popular across militaries of different nations, the need for continued training development, efficacy testing, and implementation optimization remain priorities for future efforts [69, 70].

Transition and Reintegration

Transitions offer an opportunity for new opportunities, personal growth, and career development, but can also be associated with increased mental health risk (see Castro, this volume, for discussion of transition and mental health). Within the Army, about a third of soldiers who transition into new units report difficulty with transition [71] and this stress is experienced regardless of rank or marital status. Transitioning into the first unit of assignment has also been associated with increased risk of attempted suicide [72].

Transitioning out of the military may also be a challenge to resilience. As service members depart military service, they have to adapt to significant changes to their identities, social rules and roles, their sense of purpose, and their social network [73]. For instance, veterans of the conflicts in Iraq and Afghanistan report struggling to navigate the lack of structure in civilian life and feeling disconnected, unsupported, and directionless as they search for a new sense of normality in their lives [74]. The loss of team orientation and of their importance to others can undermine their ability to find meaning in civilian life. Moreover, the strengths that helped them succeed in the military can challenge their ability to adjust to civilian life if these strengths are not adapted successfully [32]. For example, a sense of duty is a core Army value and can be beneficial for employment and community participation when that sense of duty translates into being reliable, task-focused, and achievement oriented. This same strength, however, can impede adjustment and lead to psychological rigidity and impatience if not adapted carefully for the civilian context. Thus, focusing on transition itself may be valuable for clinicians to consider.

New initiatives within the Department of Defense emphasize the importance of navigating the military-to-veteran transition. Within the Army, one such initiative is the Soldier for Life program. As the program’s title suggests, the military offers a place of belonging for soldiers that transcends their specific years of service. The Marines take a similar approach in recognizing that the connection can transcend the formal transition, using the phrase “Once a Marine, always a Marine.” However, veterans differ with respect to their identification with the military following their service. When working with veterans, clinicians should discuss the influence that the military has on their understanding of resilience and the military’s impact on personal identity.

Resilience in the Clinical Context

If resilience is integral to the military culture, what role does it have in the consulting room, with clinicians, and in therapy? In this section, we review components of resilience and beliefs about resilience that may help clinicians in connecting with, understanding, and creating a treatment plan for service members and veterans.

First, it is important to remember that a service member or veteran would not have been able to complete military milestones without a foundational level of resilience.

Second, it is important to consider the individual’s place in terms of military career and deployment cycle. Where is the individual in terms of basic developmental milestones? Where is the individual in the deployment cycle? Depending on the answer, different resilience challenges are likely to be present. For example, performance anxiety may be an issue for those who are anticipating a stressful challenge like deployment, in which case performance psychology skills might be useful to supplement interventions (e.g., self-talk, goal setting, energy management). If the individual is having difficulty in the aftermath of an intense, potentially traumatic experience, other resilience skills may be useful as a supplement to traditional clinical interventions, such as those skills that build social connections. The clinician might also ask what roles, if any, unit members and leaders play in the service member’s adjustment trajectory. If the individual is transitioning out of the military, then the challenges include a wider scope of redefining oneself, one’s purpose, one’s team and one’s military family. To address these issues, clinicians may want to discuss these questions with individuals from both a practical and existential perspective, exploring what personal and organizational community supports are available to assist with transition to civilian life, and helping the service member discuss and identify goals for life after the military.

Clinical Pearls

  • Bear in mind that most service members are resilient

  • Remember resilience is deeply valued

  • Consider timing within the military career cycle

  • Address sleep problems

  • Focus on social connection

  • Build emotion regulation skills

  • Leverage preference for self-management

Third, service members may prefer self-management (see the chapter on stigma by Ivany, this volume). Rather than being reluctant to see a clinical provider because of stigma or fear of negative career consequences, service members may be reluctant because of a preference for self-care. Surveys show that soldiers prefer to engage in self-management [75, 76]. This preference does necessarily constitute a rejection of treatment. Instead, the treatment can be recast as a form of coaching—a way to help the service member strengthen their own skills and improve their functioning. Adopting a coaching role may be a better match with the service member’s preferences and values. Although this self-management preference could be viewed as defensive, being responsible for one’s self can also be considered a strength.

Fourth, tackle sleep head on. Be sure that the service member understands the value of their own sleep and the risks to emotion regulation, cognitive functioning, and physical health if sleep is limited. Sleep provides a critical basis for emotion regulation; addressing sleep first will help to promote greater resilience.

Fifth, in a similar vein, address social connection directly. Prioritize the need to cultivate a social network—one that provides meaningful social contact. And for those transitioning out of the military, a social network that can withstand the transition to civilian life.

Sixth, consider introducing mindfulness as a way to build resilience and enhance performance, given the link between self-reported mindfulness and adjustment in military personnel [77] and veterans [78]. Service members and perhaps veterans as well may be open to skills that enhance their performance and readiness. This kind of skill is also consistent with a preference for self-management. Without practice, however, this skill will not likely be valuable, and thus it is important to integrate mindfulness practice into daily routines.

Finally, it is important to take mindset into account. Individuals with what Dweck [79] calls a fixed mindset view their skills and abilities as fixed. In contrast, individuals with a growth mindset view their skills as something they can improve and change. Unsurprisingly, these two different mindsets can influence the degree to which individuals respond well under stress.

Box 3.3 relates the story of two different non-commissioned officers, with two different responses to a setback, integrating the themes highlighted throughout this chapter. When confronted with the same challenge, Staff Sergeant Ryan spirals down while Staff Sergeant Steele gains confidence. Ryan responds with sleep problems and anger, has difficulty regulating his emotions, and is bitter about what he sees as poor leadership. Instead of reaching out, he starts to isolate himself. Ryan has a fixed mindset, believing he (and likely his squad) have a certain set of skills that cannot change. This kind of mindset can prevent his growth and potentially sabotages his future success.

Box 3.3 Soldiers with Fixed and Growth Mindsets

Staff Sergeant Ryan and Staff Sergeant Steele are both squad leaders. Both recently received negative feedback from their Company’s First Sergeant in front of the entire formation about their squad’s readiness. Staff Sergeant Ryan starts ruminating about what he perceives as his failure, losing sleep, yelling at his squad out of frustration, and shutting himself off from his peers. He knows he’s tried his best to motivate his squad but it hasn’t worked and now the entire company knows. He feels embarrassed by the First Sergeant, and let down. He didn’t think being a squad leader was going to be this difficult.

Staff Sergeant Steele feels the heat too but he takes some deliberate breaths and thinks about what pieces of the problem he can control and what he can’t control, and remembers that this issue isn’t all-or-nothing. He’s had other successes before, he just has to work harder to get there this time. He reaches out to another squad leader for advice and establishes specific goals for his squad. He tells them this is an opportunity to prove themselves and when they do better, he reinforces their pride by listening to their accomplishments.

In contrast, Steele has a growth mindset. He believes that people can cultivate their talents and skills. This perspective encourages him to change his leadership approach and to believe in the ability of his squad to change as well. He uses specific resilience techniques: deliberate breathing to calm down, and thinking about what he can control. He also builds social connection both by reaching out to others and by using active constructive responding with his squad to help them savor their small successes, reinforcing their trust in him and building their resilience.

In this way, resilience can be understood as not simply a variable that impacts individual service member health and performance. It’s a capacity that impacts others, from family members to fellow unit members, creating a blueprint for the next generation.

Conclusion

Clinical approaches to providing care for military service members often focus on pathology and dysfunction. However, this perspective overlooks the fact that service members display a remarkable degree to resilience, hardiness, and fortitude in carrying out their duties, and the vast majority of service members do not meet diagnostic criteria for common psychiatric disorders. As the military continues to emphasize resilience-based training, more service members are exposed to ideas and concepts that have useful clinical corollaries that clinicians can capitalize on in treatment.

It may also be useful for clinicians to be mindful of the impact that military culture has on service members, particularly in regards to their sleep health, social relationships, and emotion management. Additionally, treatment providers working with active-duty populations should explore the positive (and negative) effect that military leadership can have on individuals seeking clinical care. Clinicians can also consider using the military culture’s emphasis on resilience as a subject of discussion in assessing an individual’s wellbeing. Finally, clinicians can consider adopting a coaching perspective in providing treatment in order to match service members’ preference for self-management.