Much of the variance in health outcomes is explained by social, environmental, and psychological/behavioral factors rather than biomedical factors. Consequently, health agencies, health plans, health systems, and others have begun to address social determinants of health (for example, social isolation, substandard housing, food deserts) to improve health outcomes. At the same time, individuals are not equally affected by social determinants. Protective factors have been shown to act as important mediators in allowing some individuals not only to “survive” adverse circumstances but to actually “thrive” and emerge from them even “stronger” than before—a concept known as resilience. Health organizations and employers are in a position to strengthen protective factors leading to resilience.
The Department of Defense (DoD) and the US Military Services, comprising the Army, Air Force, Navy, Marine Corps, as well as the National Guard can offer important insights on how to strengthen resilience. In this blog post, we will briefly describe resilience-strengthening efforts in the DoD. We also offer five critical lessons learned from those efforts that can benefit civilian organizations as they look for more effective ways to improve population health.
Resilience-Strengthening Programs In The US Military
DoD defines resilience as the ability to withstand, recover, and grow in the face of stressors and changing demands. Resilience allows individuals to adapt well in the face of adversity, trauma, tragedy, threats, or significant sources of stress. Greater resilience is associated with improved mental health, pain management, chronic disease management, and other health outcomes.
Building resilience is of importance to the military services as service members are required to always be ready to deploy anywhere at any time. The DoD, therefore, has implemented diverse programs to strengthen resilience, seeking to maximize the performance and health of more than 2.1 million service members, 730,000 civilian personnel and more than 9.4 million Tricare beneficiaries who receive care through its military treatment facilities, private-sector providers, or embedded mental health providers. These programs have been implemented in the face of increased diagnoses of adverse mental health outcomes following stressful deployments of active duty personnel. Resilience-strengthening programs attempt to teach skills to change attitudes, behaviors, or social dynamics in response to crises or stress. Specific teachable resilience skills include mindfulness, cognitive reappraisal techniques, positive command climate, and actions to promote belongingness and cohesion.
Exhibit 1 presents illustrative examples of current DoD resilience-strengthening programs targeting active duty personnel, their families, or the Reserves.
Exhibit 1: Examples of Department of Defense resilience programs
Source: Authors’ analysis; 1 Soucy J. Resilience Makes for Stronger Guard, Increases Readiness. Arlington (VA): National Guard Bureau; 2019 Mar 12.
2Lengyel JL. 2020 National Guard Bureau posture statement: implementing the national defense strategy. Arlington (VA): National Guard Bureau.
3Corsi RE. Air Force Instruction 90-506: comprehensive airman fitness (CAF). Washington (DC): United States Air Force; 2014 Apr 2.
4Department of the Army. Army regulation 350-53: comprehensive soldier and family fitness. Washington (DC): United States Army; 2014 Jun 19.
5Comprehensive Soldier and Family Fitness. About CSF2. Washington (DC): United States Army; 2016 Jul 12.
6Navy Personnel Command. Operational stress control: background. Washington (DC): United States Navy; 2016 May 12.
Five Lessons Learned From The DoD’s Resilience Programs
These lessons—learned from the DoD’s approach and programming to strengthen resilience over the past 15 years—can be instructive for the civilian sector as health agencies and organizations, employers, or others look to improve the performance and health of populations while mitigating adverse health outcomes.
Foster A Sense Of Purpose And Belonging
In the military, the concept of serving something greater than oneself (for example, one’s country) is central to its ethos. Connecting to a greater purpose can be a significant source of resiliency for active duty personnel and is continuously fostered by the military from recruitment, training, deployment, re-integration, to retirement. Having a sense of purpose is associated with greater reliance on preventive health behaviors, decreased risk of disability, and improved morbidity and mortality. Similarly, a sense of belonging protects military service members from developing depression following deployment.
Civilian health organizations and employers are just beginning to adopt programs to foster a greater sense of purpose in their patient or employee populations to achieve better health outcomes or performance. Tailored digital life coach programs, such as Kumanu, use advanced predictive models to create highly personalized and dynamic guidance, tips, insights, and messages to help people achieve greater life fulfillment through a sense of purpose. Other programs rely on immersive orientation sessions to connect with a greater sense of purpose. These sessions are subsequently continuously reinforced through story-telling and sharing of ideas in team meetings about how to fulfill one’s purpose.
Strengthen Resilience In Both Individuals As Well As In The Social Units To Which They Belong
DoD programs simultaneously focus on strengthening resilience in individuals and their social units. Unit resilience and performing as a team has demonstrated to be critical for military units to successfully accomplish their missions and to function better under considerable stress. Group cohesion has been shown to be related to fewer negative mental health outcomes in service members returning from deployment. For example, the Army’s Comprehensive Soldier and Family Fitness program provides hands-on training and self-development tools to allow families to better cope with stress.
Civilian organizations are experimenting with similar efforts to strengthen resilience of social units. For example, some hospitals focus on empowering nursing teams in high-stress environments (for example, emergency departments) through greater access to information, resources, and support. These efforts lead to stronger job satisfaction, reduced burnout, and lower levels of work-related stress. Systematically fostering social support and offering additional resources, such as peer support groups and event reviews have fostered resilience of team members in rural hospitals and other health care settings.
Instill Resilience And Mental Fitness Across The “Life Cycle”
The DoD adapts resilience programming across the “life cycle” of its active duty personnel (recruitment, training/boot camp, deployment, repeat deployment, post-deployment, and retirement from active duty service). Many mental fitness and resilience skills, such as mindfulness, meaning-making, and optimism, are flexible, scalable, and can be shaped to fit the specific needs of populations during specific phases of their “life cycle” in the military. For example, the Navy implemented a Warrior Toughness pilot program in 2018 that introduces mindfulness, visualizations, and self-talk as a regular mental fitness practice during recruit training. The Navy is now exploring ways to expand on this early introduction to mental fitness with complementary opportunities throughout the career life cycle of a sailor.
Similarly, civilians encounter different challenges across the life cycle (for example, education/training, marriage/families with newborns/young children, career progression and professional development, and retirement). Some resilience programs in the civilian sector target populations within a specific phase of their life cycle. For example, college students’ academic performance, self-reported health, and well-being benefit from interventions that encourage them to attribute perceived adversity to the college-adjustment process rather than personal deficits. For older adults, interventions that focus on increased volunteering and group exercises (for example, Tai Chi and Yoga) can improve resilience through greater social and communal interaction as well as social connectedness.
Embed Resilience Resources Within High-Stress Work Places
Embedding mental health providers and behavioral health technicians who have operational and cultural competence specific to the military breaks down mental health stigma, ensuring greater acceptance of attending to psychological health among service members and leaders. Consequently, the military services continue to grow their embedded mental health programs. A primary goal of these programs is to improve performance and readiness as opposed to solely focusing on diagnosing and treating pathology. For example, the Navy is embedding psychologists on aircraft carriers, leading to reductions in costly medical evacuations and loss of personnel during deployments. Similarly, the US Submarine Forces Command demonstrated through an embedded pilot program substantial reductions in sailors needing to be removed from submarine duty for mental health reasons. Furthermore, many embedded military resilience/mental fitness programs are effectively implemented by trained “lay” personnel rather than highly educated, credentialed mental health professionals, making program implementation more flexible and less costly.
In the civilian sector similar embedded programs have been implemented for law enforcement, and it has been suggested that they would be helpful for intensive medical care unit staff. Professional psychological services and resilience programs (for example, mindfulness training) targeting law enforcement professionals have led to greater job satisfaction, performance, retention, and improved physical and mental health.
Rely On Detailed Measurement And Sophisticated Analyses
An initial “let-a-thousand-flowers-bloom” approach to the DoD’s resilience programming has provided a rich experience base with diverse programmatic approaches. The DoD is now beginning to operationalize multiple, standardized, resilience-relevant measurable endpoints (for example, premature evacuation from deployment) to analyze the impact of resilience programs. Advanced analytic models can examine relationships between critical domains (that is, physical, medical/dental, nutritional, environmental, social, behavioral, psychological, and spiritual fitness) of the DoD’s Total Force Fitness framework and specific resilience endpoints. In a previous blog post, we described how artificial intelligence solutions such as process automation, pattern recognition, or contextual reasoning can better support outcome improvement, policy development, and performance optimization, including resilience. Moreover, by investing in the development and deployment of greater predictive analytic capabilities, the DoD should in the future be able to identify individuals and populations who would benefit the most from mental/behavioral health interventions or other resources to help them perform better and avert adverse mental health outcomes.
Outside of individual research studies or specific efforts of vendors of resilience programming, the civilian sector has not yet developed a comparable measurement, data capture, management, and analysis approach to measure the impact of resilience-enhancing efforts.
Leading The Way
The US military has a long history of informing innovations in the civilian sector including health care, dating all the way back to demonstrating the benefit of inoculations during the American Revolutionary War. The US military may have a similar opportunity to lead the civilian sector in better understanding how to promote resilience.
First, although only 1 percent of Americans serve in the US military, the demographic of the Armed Forces is broadly representative of the US population. Hence, learning more about which resilience programs impact military populations and why may allow for a generalization of the impact of resilience-enhancing efforts for the US civilian population.
Second, the diversity, reach, and planned expansion of the DoD’s resilience programs is currently unparalleled in the civilian sector. Thus, as the civilian sector is just beginning to purposefully foster resilience, it could avoid costly failed investments by systematically learning from the DoD’s broad array of programming and documented impact.
Third, interrelationships of psycho-social-biomedical factors in predicting health outcomes are complex. The DoD is in a position to understand such complex relationships due to its unique ability to access, connect, and analyze diverse longitudinal data (genetic, behavioral, biomedical, social, productivity/performance, and so forth) about active duty personnel. This unique detailed data set, when coupled with advanced analytic techniques, can comprehensively inform the impact of resilience programs on specific outcomes. In contrast, the civilian sector typically does not have the same ability to access, link, and analyze similarly diverse longitudinal data. Consequently, the DoD is in a better position to understand complex relationships of factors impacting resilience than the civilian sector in the near future.
Continuing to invest tax dollars in DoD resilience programs is not only good for active duty service men and women and their families who benefit from them. If these investments are well managed, including investments in advanced analytics to understand and predict clearly defined resilience endpoints and health outcomes, it can also broadly benefit the civilian sector. By learning what DoD programs or initiatives are particularly effective, the civilian sector can more quickly build successful efforts to strengthen resilience in all Americans.
Authors’ Note
The appearance of external hyperlinks does not constitute endorsement by the Department of the Navy of the linked websites, or the information, products, or services contained therein.
