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The stress continuum model: A military organizational approach to resilience and recovery

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Abstract

Resilience in the face of adversity is vital for military service members to survive potential threats to their own lives and safety and to accomplish assigned missions, often for the sake of others’ survival and welfare. The ability of service members to bounce back from operational stress may also determine how successfully they reintegrate with their families and communities after returning from deployment, whether they can continue to work in military professions, and whether they develop potentially disabling mental disorders or other serious behavioral problems. Military organizations have long traditions of selecting, training, and sustaining service members to endure intense and persistent operational stress without losing their abilities to function on the battlefield, but other indices of resilience have only recently attracted the sustained interest of the military. As military organizations develop programs to promote a broader spectrum of desired stress outcomes, they are faced with a choice between expecting traditional resilience-building methods to meet untraditional objectives and creating entirely novel approaches to resilience. Academic interest in the psychological, biological, social, and personality-trait differences associated with successful adaptation to combat and operational experiences has increased rapidly since the late 1990s. Underlying recent studies in this area has been the assumption that the incidence of various mental health and functional problems associated with combat and operational experiences might be reduced if modifiable risk and resilience factors could be identified and then targeted in military prevention programs. Unfortunately, research and translational programs to enhance resilience in members of the armed services have, so far, been limited by the lack of a unified or paradigmatic approach to conceptualizing the military and extra-military processes and functions that may lead to resilient outcomes, and even by the lack of a consensus definition of resilience. Uniform methods of measuring resilience processes or outcomes also do not yet exist. The little empirical research that has been conducted in the military has significant internal and external validity problems, greatly limiting their power to inform prevention or intervention practices, which is the basic goal of resilience research.
Chapter
Section
238
Resilience and Mental Health: Challenges Across the Lifespan, ed. Steven M. Southwick, Brett T. Litz, Dennis Charney, and
Matthew J. Friedman. Published by Cambridge University Press. Copyright © Cambridge University Press 2011.
Specifi c challenges
Section 4
1 6 The stress continuum model: a military
organizational approach to resilience
and recovery
William P. Nash, Maria Steenkamp, Lauren Conoscenti, and Brett T. Litz
Introduction
Resilience in the face of adversity is vital for military
service members to survive potential threats to their
own lives and safety and to accomplish assigned mis-
sions, o en for the sake of others’ survival and welfare.
e ability of service members to bounce back from
operational stress may also determine how successfully
they reintegrate with their families and communities
a er returning from deployment, whether they can
continue to work in military professions, and whether
they develop potentially disabling mental disorders or
other serious behavioral problems. Military organiza-
tions have long traditions of selecting, training, and
sustaining service members to endure intense and per-
sistent operational stress without losing their abilities
to functi on on the battle eld, but other indices of resili-
ence have only recently attracted the sustained inter-
est of the military. As military organizations develop
programs to promote a broader spectrum of desired
stress outcomes, they are faced with a choice between
expecting traditional resilience-building methods to
meet untraditional objectives and creating entirely
novel approaches to resilience.
Academic interest in the psychological, biological,
social, and personality-trait di erences associated
with successful adaptation to combat and operational
experiences has increased rapidly since the late 1990s.
Underlying recent studies in this area has been the
assumption that the incidence of various mental health
and functional problems associated with combat and
operational experiences might be reduced if modi-
able risk and resilience factors could be identi ed
and then targeted in military prevention programs.
Unfortunately, research and translational programs
to enhance resilience in membersof the armed ser-
vices have, so far, been limited by the lack of a uni ed
or paradigmatic approach to conceptualizing the mili-
tary and extra-military processes and functions that
may lead to resilient outcomes, and even by the lack of
a consensus de nition of resilience. Uniform methods
of measuring resilience processes or outcomes also do
not yet exist.  e little empirical research that has been
conducted in the military has signi cant internal and
external validity problems, greatly limiting their power
to inform prevention or intervention practices, which
is the basic goal of resilience research.
To promote clarity about the concept of resilience in
the military, and to foster future research, this chapter
begins by considering the concept of resilience in the
military as comprising of di erent classes of positive
stress outcome.  e chapter then considers potential
metrics for each and brie y surveys existing evidence
that the military has been successful at developing and
sustaining each aspect of resilience in its service mem-
bers.  e goal is to identify the greatest ongoing chal-
lenges for military resilience program development.
One recently developed, evidence-informed approach
to promoting resilience and recovery is then described
that speci cally emphasizes military ecological val-
idity: the Combat and Operational Stress Control
(COSC) program in the US Marine Corps and its par-
allel in the US Navy, the Operational Stress Control
(OSC) program.  e rationale, conceptual framework,
and intervention strategies common to both programs
are outlined.  e chapter concludes with a call for well-
designed outcome studies of programs that attempt to
ll the current gaps in military resilience programs .
Military resilience challenges
Almost any mission with which a military unit may
be tasked – whether assaulting an opposing military
force, countering a civilian insurgency, conducting
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Chapter 16: The stress continuum model
239
Troops in battle who are disabled by stress, even brie y,
or who lose their ability to remain calm and make
rational decisions in the face of chaos lose operational
e ectiveness and may quickly become physical cas-
ualties. Some of the historically highest physical cas-
ualty rates have been experienced by ground combat
units engaged in disorganized and panicked retreats.
Similarly, the success of western nations and deployed
military units to prevail in modern, asymmetrical war-
fare against non-governmental insurgencies or terror-
ist groups depends on their abilities to remain focused
on constructively “winning the hearts and minds” of
populations even while repeatedly enduring attacks
from within the population’s ranks – attacks that have
great potential to provoke terror, horror, helplessness,
rage, and a desire to seek vengeance rather than to build
hospitals, schools, and sewage systems.  e weapons of
global terrorism, including the growing threat of rogue
nuclear incidents, directly target the resilience of soci-
eties and their governments.
At the unit level, the desired outcomes of oper-
ational resilience include mission e ectiveness, readi-
ness, and force preservation. At the individual level,
the simplest desired outcome is to avoid becoming a
stress casualty (i.e., being incapacitated) by continu-
ing to maintain at least the minimum required abil-
ity to function in assigned operational military roles.
Stated more positively, the objectives of individual
and unit-level operational resilience are performance
enhancement despite hardships and losses, and the
development and maintenance of the time-honored
military traits of courage, fortitude, and valor (e.g.,
Moran, 1967 [originally published 1945]). Operational
resilience has been so central to the e ectiveness of
ghting forces that methods for promoting it have
been in existence since ancient times. In the Roman
army (Phang, 2008 ), for example, the goal of all train-
ing and discipline was to develop virtus (courage in
battle) without ferocia (madness), and animus (con -
dence) and impetus (enthusiasm) without excessive ira
(anger).  e same warrior ideal of controlled aggres-
sion, summoned by external authority but restrained
by internal moral values, can be found in military
cultures throughout history (French, 2003 ). Much
the same tools are available to the military today as
were in use in ancient times to promote operational
resilience: pre-induction selection, tough and realistic
training, the building of unit cohesion through shared
successes in the face of shared hardships, and engaged
leadership (Nash et al ., 2011 ).
peacekeeping, or providing humanitarian assistance in
the wake of a disaster – can expose service members
to mortal danger, loss, and moral compromise with an
intensity and relentlessness hard to imagine in most
other settings (e.g., Litz, 2007 ; Nash, 2007 a; Litz et al .,
2009 ). Returning from deployment exposes service
members to an entirely di erent set of adaptive chal-
lenges, some of which may be just as overwhelming
as those experienced during deployment. Examples
include the stress of coming home to a broken family,
a lost civilian job, or  nancial ruin. Both during and
a er deployment to an operational theater, service
members face the challenge of mourning losses,  nd-
ing meaning in experiences that seem senseless, and
making peace with enduring memories of death and
destruction. Resilience challenges for military service
members and the organizations that support them,
therefore, arguably encompass at least three broad
forms: (1) operational resilience , which may be de ned
as the ability to maintain occupational role function-
ing and psychological performance during operational
deployments despite stressor exposures, and perhaps
despite internal distress and con ict (see Litz, 2005 );
(2) post-deployment resilience , which may be de ned
as the ability to reacquire and maintain e ective role
functioning in largely non-military settings a er
returning from deployment, and so again to be a pro-
ductive member of a family and civilian society; and
(3) psychological resilience , which may be de ned as
the ability to adapt physically, mentally, and spiritually
to operational stressor exposures, and the sometimes
lasting changes they engender, without developing a
signi cant mental disorder or behavioral problem.
ough obviously interrelated, these three broad
resilience challenges in the military have very di er-
ent historical and scienti c bases, and they depend
on di erent methods for promotion and metrics for
assessment. Each will now be brie y described in its
historical and scienti c context.
Operational resilience
Extreme stress is not an incidental byproduct of armed
con ict but rather one of its central features and imme-
diate objectives. Success in traditional warfare has
o en been determined by which side possesses the
greater ability to endure and continue  ghting despite
the potentially overwhelming challenges and hard-
ships each side intentionally in icts upon the other
(von Clausewitz, 1982 [orginally published 1832]).
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240
Section 4: Specifi c challenges
American Civil War soldiers and veterans (Dean, 1997 ).
e ancient Greeks understood that war – particularly
the brutal, close-up variety they practiced – could
darken the psyches of surviving veterans with a miasma
(pollution) that was di cult, at best, to wash away, and
that could result in illness, death, or the destruction of
families long a er the war had ended (Meagher, 2006 ).
Like many other ancient Greek insights, however, this
understanding of the post-deployment consequences
of combat stress was somehow forgotten, only to be
slowly and painfully rediscovered over the past cen-
tury.  e world was shocked by the murders over six
weeks in 2002 of four military wives by their active
duty husbands at Fort Bragg, North Carolina, home of
the army’s special operations command (Starr, 2002 ).
ree of the four assailants had recently returned from
combat operations in Afghanistan.
Unlike the military’s approach to operational resili-
ence, tools for promoting post-deployment resilience
have changed considerably over the centuries. Public
puri cation rites and rituals to remove the stain of war
have long been used to promote reintegration into civil
society a er war. In ancient Greece, public perform-
ances of dramas of homecoming, written for audi-
ences of veterans by playwrights who, like Sophocles
and Euripides, were veterans themselves, may have
been crucial for the socialization of returning warriors
(Meagher, 2006 ). In the USA, organized programs to
promote post-deployment resilience have only recently
become a priority. Troops returning from the US Civil
War, World War I, and the Vietnam War were notori-
ously le to fend for themselves to too great an extent
unless they quali ed for government-supplied  nancial
or medical assistance. Despite the myriad of readjust-
ment problems experienced by Vietnam combat vet-
erans, US military services only  rst implemented
ongoing programs to promote post-deployment resili-
ence, such as “Warrior Transition” in the Marine Corps
and “Battlemind” in the US Army, in the wake of the
Fort Bragg murders in 2002. Both Warrior Transition
and Battlemind, as initially conceived, are single-
session psychoeducational classes delivered to service
members immediately before or a er they return from
a theater of war (see Nash et al ., 2011 ). Another method
in use by the military to promote post- deployment
resilience is a brief “decompression” period in a loca-
tion intermediate between war zone and home, such
as the “ ird Location Decompression” currently
employed by Canadian forces (Marin, 2004 ), among
others. Perhaps most important for post-deployment
At its most basic level, operational resilience is easy
to measure in service members because the primary
target outcome is simple and easy to quantify over the
xed period of observation of each deployment. Most
simply, operational resilience may be quanti ed as the
inverse of the incidence of disabling combat or oper-
ational stress casualties in a deployed force. A deployed
unit that has su ered a 10% stress casualty rate may be
said to be 90% operationally resilient. At the less basic
level of optimum individual performance despite stress
load, metrics for operational resilience are less clear
and simple, and may not be easily collected.
How successful has the military been at promot-
ing operational resilience in its service members and
units? Using the simple metric of the rates of stress
casualties requiring medical evacuation, the US mili-
tary has enjoyed considerable and sustained success
in promoting operational resilience. A er World War
II, when as many as 10% of all troops were disabled by
“battle fatigue” or some mental health diagnosis, stress
casualties rates fell to approximately 3.7% during the
Korean War, and as low as 1.2% in Vietnam (Nash,
2007 b). Shorter and more predictable tour lengths and
generally lower physical casualty rates were credited
for some of this apparent improvement in operational
resilience over time. According to the 2005 report of
the US Army Mental Health Advisory Team (MHAT;
the MHAT-II report), the last annual MHAT report to
include stress-casualty data, behavioral health diagno-
ses accounted for 7.1% of all medical evacuations from
Iraq (527 of 7415) between March and September 2003
(the initial invasion), and 6.0% of all medical evacua-
tions from Iraq during the same months the following
year (Mental Health Advisory Team, 2005). Given that
approximately 181 356 soldiers deployed to Iraq during
2003 (Hoge et al ., 2006 ), the stress casualty rate among
the personel during the initial invasion of Iraq was only
527 (0.29%). By any standard, the modern US military
may be considered highly successful at promoting and
maintaining operational resilience.
Post-deployment resilience
It is likely that returning service members and veterans
have always faced signi cant challenges readapting to
civilian life, and that operational stress has always fol-
lowed them home to their families and communities
a er they have participated in armed con ict.  ese
challenges are clearly described in ancient Greek tra-
gedies (Shay, 1994 , 2002 ) and in the diaries and letters of
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Chapter 16: The stress continuum model
241
from both operational and post-deployment resilience
because the methods available for promoting it, and the
possible metrics for assessing it, may be very di erent.
Observable post-exposure behaviors, for example, may
be very poor indicators of levels of psychological resili-
ence because even extreme distress may be invisible
to all but the most intimate of social contacts, and the
impacts of physical, psychological, social, or spiritual
changes resulting from stressor exposures may be long
delayed. By de nition, psychological resilience is more
than merely meeting minimum standards of behav-
ior during circumscribed periods of time. To a much
greater extent than operational or post-deployment
resilience, psychological resilience must be viewed as a
process rather than a state or trait, and studied longitu-
dinally rather in cross-section.
e military has only recently focused its resilience-
building e orts on the promotion of psychological
resilience, at least in part because of its long tradition
of viewing the qualities that contribute to operational
resilience as su cient to also ensure long-term psy-
chological health and well-being in service members
a er they returned home. In the traditional warrior
ethos, qualities like courage and fortitude have been
seen as the primary, if not sole, determinants of psy-
chological resilience as well as resilience on the battle-
eld.  e logical  ip-side of this belief has been that
those who lacked psychological resilience a er return-
ing from a theater of war must also have been lacking
in courage and fortitude (Nash, 2007 b). Such attitudes
might lead to the conclusion that stress disorders such
as post-traumatic stress disorder (PTSD) are not legit-
imate illnesses or injuries, even among those who pro-
vide healthcare in the military. In a recent survey of a
self-selected but large sample of convenience of 310
army healthcare providers at Fort Hood, Texas, 18%
endorsed having little or no con dence that PTSD was
a “real illness caused by military service” (Stahl, 2009 ).
Regardless of attitudes and traditional beliefs, the
goal of psychological resilience programs must be to
prevent long-term psychological distress or dysfunc-
tion and, instead, to encourage psychological health,
strength, and well-being.  ese are the clear goals set
for US military psychological health programs by the
Department of Defense Task Force on Mental Health,
chartered by Congress in 2006. In its report back to
Congress in 2007, the Task Force established four over-
arching goals for military psychological health pro-
grams: (1) build a culture of support for psychological
health in the military; (2) ensure the availability to
resilience is the provision by military organizations
of ongoing support for its own service members and
veterans by peers and leaders, as well as a full range of
social and health programs. Notable in this regard is
the US Marine Corps’ Marine for Life program ( http://
www.m4l.usmc.mil) .
Metrics suggesting a lack or de ciency of post-
deployment resilience may be drawn from the rates of
occurrence of a number of objective post- deployment
behaviors. Examples include post-deployment vehicle
accidents, substance misuse or abuse, family violence,
divorce, and post-deployment suicide. How suc-
cessful has the US military been at promoting post-
deployment resilience indexed this way? A survey of
recent news articles on the subject gives anecdotal evi-
dence that a lot more work needs to be done in this area.
For example, in an eerie echo of the 2002 Fort Bragg
murders, three female soldiers were killed in 2008 by
their military husbands or boyfriends, also at Fort
Bragg (Burleigh, 2008 ). A series of homicides at Fort
Carson, Colorado, between November 2008 and May
2009, triggered an epidemiological investigation (US
Army Center for Health Promotion and Preventive
Medicine, 2009 ). Less anecdotal evidence for a cur-
rent gap in post-deployment resilience promotion also
comes from the news media, o en quoting govern-
ment reports, regarding the rising rates in the military
of suicide, substance abuse, domestic violence, and
divorce (e.g., Anon, 2009 ; Stewart, 2009 ; Tyson, 2009 ).
Unfortunately, data regarding the prevalence of these
post-deployment problems in military populations are
sparse in the current professional medical and psycho-
logical literature. Nevertheless, it is clear that current
gaps exist in the promotion of post-deployment resili-
ence in the military .
Psychological resilience
Psychological resilience, as de ned here, is most closely
related to the concept of resilience commonly found
in the mental health literature – that is, the ability to
maintain a stable, healthy level of psychological and
physical functioning despite exposure to losses, poten-
tially traumatic events, or other extreme stressors (e.g.,
Bonanno, 2004 ). Since levels of psychological and phys-
ical functioning must strongly in uence behaviors and
role performance both during and a er deployment,
psychological resilience is fundamental to the other
two aspects of resilience discussed above. But psycho-
logical resilience deserves to be discussed separately
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242
Section 4: Specifi c challenges
for use in the US Navy as the OSC program (Marine
Corps Combat Development Command & Navy
Warfare Development Command, 2010 ). Although
these two service-speci c programs di er somewhat,
they share common goals, guiding assumptions, core
concepts, and tools for intervention.  e presentation
of the program is structured in a way that we feel can
lead to measurement strategies, testable predictions,
and empirical research, and can hopefully serve as a
model for the  eld.
Program overview and goals
e COSC and OSC programs are comprehensive,
system-wide occupational stress management pro-
grams whose primary goal is to promote resilience of all
the three types described above, including operational
resilience during deployments, post-deployment
resilience a er returning, and psychological resilience
throughout military careers and beyond.  erefore,
COSC and OSC target wellness and the prevention of
mental disorders rather than the enhancement of per-
formance. A secondary goal for these programs is to
provide a common language and framework to inte-
grate all resilience and recovery e orts within US Navy
and Marine Corps units under the leadership of military
commanders and their chains of command.  e COSC
and OSC have been developed and implemented step-
wise, beginning approximately in 1999 .
Guiding assumptions and rationale
e following are the key underlying assumptions and
the rationales that guide the COSC and OSC programs,
along with the rationale for each.
Assumption 1 . e stress states lie along a broad
spectrum for members of the military services,
from wellness and thriving, at one end, to illness
and disability, at the other, with important
intermediate stress states signaling varying levels
of risk for role impairment and long-term mental
disorders.  ere are many more possible stress
outcomes than the extreme states of a iction or
resistance. Furthermore, stress states are not  xed
over time but evolve as trajectories.
Rationale . Epidemiological research has o en
focused on dichotomous outcomes from stressor
exposures, such as the presence or absence of
PTSD, for example. However, when symptom
burden among stress-exposed service members
and veterans is assessed using continuous rather
service members and their families of a full continuum
of excellent care; (3) provide su cient resources to
achieve these ends; and (4) empower line military lead-
ers to plan and coordinate integrated prevention, iden-
ti cation, and treatment e orts (US Department of
Defense Task Force on Mental Health, 2007 ).
How well has the military met the psychological
resilience challenge? Does the low rate of battle eld
combat stress casualties during the current con icts
in Iraq and Afghanistan signal a low rate of mental
disorders among its veterans? According to recent epi-
demiological studies, psychological resilience remains
a signi cant problem for the military.  e rate of PTSD
among service members and veterans who have served
in the wars in Iraq and Afghanistan is in the range
10–18%, and the prevalence does not diminish over
time (Litz & Schlenger, 2009 ). In addition, PTSD is but
one of many adverse mental health outcomes possible
in those exposed to combat; others include depressive,
anxiety, and substance use disorders. Another source of
data regarding psychological resilience in the military
are the reports of the US Army’s MHAT teams, char-
tered by the Army Surgeon General every year since
2003 to assess the mental health of soldiers currently
deployed to Iraq and Afghanistan.  e MHAT stud-
ies have reported that among US Army soldiers cur-
rently deployed to Iraq, the prevalence of signi cant
mental disorder symptoms, whether of post-traumatic
stress, depression, or anxiety, has varied from a low of
12.6% in 2005 to a high of 20% in 2007 (Mental Health
Advisory Team, 2003 , 2005 , 2006 a, 2006 b, 2008 , 2009 ).
Year-to-year variations correlated well with recent lev-
els of combat exposure and other risk factors rather
than in response to institutional resilience building or
other intervention programs .
The US Navy and Marine Corps
approach to resilience and recovery
Every military service branch has responded to the
resilience challenges described above by developing
and  elding new programs designed to reduce the
rates of adverse stress outcomes and, instead, to pro-
mote wellness and optimal performance. Rather than
survey these myriad new programs, none of which has
yet been proven e ective by well-designed outcome or
program-evaluation studies, we turn now to a descrip-
tion of one particular approach to resilience and recov-
ery that was recently developed in the US Marine
Corps as its COSC program, and subsequently adapted
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Chapter 16: The stress continuum model
243
e ectiveness of indicated prevention interventions,
which target individual subclinical distress and
dysfunction, rather than selective or universal
prevention interventions targeting high-risk
groups or entire populations, respectively (Feldner
et al ., 2007 ). Furthermore, since even so-called
resilient individuals o en experience at least brief
periods of subclinical distress and dysfunction in
the a ermath of trauma or loss (Bonanno, 2004 ),
and early symptom burden is a marker of risk for
future pathology (Shalev, 2002 ), recovery may be
more relevant to prevention e orts than resilience.
Assumption 4 . Whereas certain aspects of resilience
are determined by pre-existing individual traits
and capabilities, promoting resilience of all
types throughout the lives and careers of service
members and their families is only possible by
leveraging all available systemic resources , including
those in the physical, psychological, social, and
spiritual domains. One of the resources that is
most crucial for the promotion and maintenance
of resilience in military units and families is
their organic leadership.  e responsibility for
resilience and recovery programs in the military
resides with line leaders at all levels; it cannot be
delegated to medical, mental health, or religious
ministry personnel.
Rationale . e early literature on resilience correlated
the ability to bounce back quickly from adversity
with individual risk and protective factors such as
age, gender, ethnicity, and enduring personality
traits such as hardiness (Kobasa
et al ., 1982 ; Ta et al ., 1999 ). However, evidence
has accrued that positive outcomes in the face
of adversity depend on complex interactions
between the individual and the environment, with
signi cant roles played by availability of resources
and social systems such as families, communities,
and cultures (e.g., Ta et al ., 1999 ; Waller, 2001 ;
Hobfoll et al ., 2009 ).
Core concept: the stress continuum model
A prerequisite for implementing an organization-wide
e ort in the military to promote resilience and recov-
ery, and to prevent adverse stress outcomes, is a lan-
guage and classi cation system for stress that can be
employed equally by military leaders, service members,
chaplains, family members, and medical and mental
than dichotomous measures, it is clear that levels
of clinical and subclinical distress and dysfunction
are distributed broadly at any point in time
(Shalev, 2002 ; Bonanno et al ., 2006 ), and that
symptoms change along identi able trajectories as
time progresses (e.g., Bonanno, 2004 ; Dickstein
et al ., 2010).
Assumption 2. Regardless of how strong, capable,
and well prepared someone is prior to stressor
exposure, anyone can be stressed beyond their
adaptive capacity . Given su cient exposure to
stressors, many individuals will express at least
subclinical distress and dysfunction, even though
few will develop chronic mental disorders.
Rationale . Pre-exposure preparation programs have
not yet been found to e ectively prevent adverse
stress outcomes such as PTSD in trauma-exposed
individuals (Whealin et al ., 2008 ). In studies of
risk and resilience factors for PTSD, among the
greatest determinants of mental health outcomes
hav e been the c umul ative burden of stresso r
exposures (e.g., Bonanno et al ., 2007 ; King et al .,
2008 ) and peri-exposure psychological processes
(Ozer et al ., 2003 ), rather than pre-exposure
factors.  e nding by army researchers in World
War II that every soldier had a breaking point
de ned by duration of continuous exposure to
combat (Appel & Beebe, 1946 ) has been echoed
by the  ndings of recent researchers that the risk
for mental disorder symptoms increases with each
month of deployment (Mental Health Advisory
Team, 2008 ).
Assumption 3 . To be maximally e ective, mental
disorder prevention programs in the military
must intervene not only before service members
are exposed to potentially toxic stressors, but also
a er they develop even subclinical levels of distress
or dysfunction in the context of trauma, loss, or
other extreme stress. In order to provide targeted
interventions for symptomatic individuals,
prevention must also include e ective methods
for identifying who, at any given moment, is
symptomatic. Military psychological health
programs must promote both resilience and
recovery .
Rationale . Using the nomenclature endorsed by the
Institute of Medicine Committee on Prevention
of Mental Disorders (Mrazek & Haggerty,
1994 ), the greatest evidence exists to support the
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244
Section 4: Specifi c challenges
increase individuals’ resistance to hardship and adver-
sity may be said to “grow the green zone” for them: that
is, increase the range of stress challenges that they are
able to endure without becoming distressed or dys-
functional in any signi cant way. Military training,
social cohesion, and leadership are also engineered
to enhance the ability of service members to bounce
quickly back to the green zone once the source of per-
turbing stress has been removed.
Attributes and behaviors characteristic of the green
zone include high levels of physical and cognitive per-
formance, remaining calm and steady both physically
and emotionally, sustained con dence in oneself and
others, and behaving ethically and morally. Other green
zone characteristics include receiving adequate and
restful sleep, maintaining proper nutrition and phys-
ical  tness, retaining a sense of humor, and remaining
engaged socially and spiritually.
e green zone is the zone of stress resistance rather
than stress resilience, in that green zone stress, by def-
inition, causes only minimal changes in perceived
distress and functional abilities. Individuals in the
green zone do not need to bounce back because they
are not signi cantly bent. erein lies the limitation
of the green zone, and the reason that military train-
ing intentionally and repeatedly stresses service mem-
bers well beyond their levels of green zone comfort. As
with physical training in preparation for athletic com-
petition, training must repeatedly and increasingly
challenge individuals slightly beyond their current
capacities in order to develop greater strength, power,
and endurance.
Reacting: the yellow zone
e yellow zone is the zone of mild and temporary
distress or changes in functioning owing to stress . By
de nition, yellow zone stress reactions are always tem-
porary and reversible since yellow zone stress does
not signi cantly exceed individuals’ coping capaci-
ties. Each individual’s yellow zone, therefore, is de ned
by their current level of resilience in body, mind, and
spirit – their current ability to bounce back from hard-
ship and adversity of various levels of intensity. It is
crucial for service members to acquire and maintain
broad yellow zone stress capacities because the yellow
zone is where most operational challenges are met.
Hence, military training repeatedly and intentionally
pushes service members into their yellow zones. While
preparing for a war zone deployment, entire military
units are led through yellow zone training challenges
health professionals. Every member of the organiza-
tion must hold a similar concept of the stress states
to be promoted or prevented, and each must share a
similar understanding of the words used to describe
these states. Such commonalities of language and con-
ception are not easily achieved among the many stake-
holders of resilience and stress prevention in a military
organization, given the many cultural, educational,
and professional di erences that divide them. To
meet this challenge, the commanding generals of the
US Marine Corps’ three air–ground–logistics Marine
Expeditionary Forces (MEFs) convened a working
group in 2007 consisting of Marine leaders, chap-
lains, and medical and mental health professionals.
e charter for this Tri-MEF COSC Working Group
charged it with developing a multidisciplinary but
leader- oriented, organization-wide, stigma-reducing
approach to resilience, wellness, and prevention that
was consistent with both the warrior ethos and current
science.  e result of the Working Group’s delibera-
tions was the combat and operational stress continuum
model, a heuristic that divided the spectrum of possible
stress states into four color-coded zones designated
green (ready), yellow (reacting), orange (injured),
and red (ill). Although the boundaries between these
four stress zones are neither sharp nor easily de ned
by available metrics, the conceptual de nition of each
zone was believed by the multidisciplinary members of
the Tri-MEF Working Group to have strong face valid-
ity and be consistent with current evidence and theory
(Nash, 2011). Importantly, the line Marine leaders that
commissioned the Tri-MEF Working Group saw the
continuum model as a way to integrate and coordinate
the resilience e orts of line commanders and caregivers
throughout the organization, throughout unit deploy-
ment cycles and througout the careers of individual
service members. What follows is a brief description of
the four zones of the model.
Ready: the green zone
e green zone is the zone of adaptive coping, optimal
functioning, and personal well-being . e green zone is
not the absence of stress, for the lives of marines, sailors,
and their family members are seldom without stress,
but rather its e ective mastery without the experience
of signi cant distress or impairment in physical, social,
or occupational functioning.  e ability to remain in
the green zone under stress, and to return quickly to
it once a ected by stress, are two crucial aspects of
resilience. Training and experiences of mastery that
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Chapter 16: The stress continuum model
245
cumulative stresses of military operations. Some individ-
uals may have behavioral disorders that existed prior to
deployment or disorders that were  rst present during
deployment, and need BH intervention beyond the inter-
ventions for COSR.
Implied in this de nition of COSR is the conceptu-
alization of combat stress, dating back to the early years
of World War I, as not genuine expressions of injury or
illness induced by stress but rather as always temporary
and reversible, except in those individuals weakened by
pre-existing disorders of character or mental function-
ing (see Lerner, 2003 ).  e same symptoms of distress
or dysfunction, if experienced somewhere other than
in a theater of war, might be conceived very di erently,
and might receive very di erent treatment. In fact, the
same symptoms as those considered a normal COSR
during deployment might be diagnosed and treated as
PTSD if they were still evident a er the deployment
ended.
e orange zone of “stress injury” was established
to address some of the drawbacks of the traditional
view of combat stress as essentially all yellow zone, no
matter how disabling. In particular, a stress zone was
needed that represented subclinical or pre-clinical lev-
els of distress or dysfunction interposed between the
yellow zone of normal, necessary, and transient stress
reactions and the more severe and diagnosable mental
disorders (the red zone). Without a stress zone between
normal and disordered, there could be no target for the
early indicated prevention interventions that might
spell the di erence between recover and chronic dis-
ability. Also, the traditional view of psychological
resilience as determined solely by the same qualities
necessary for functional operational resilience, such as
courage and fortitude, has increased the stigma associ-
ated with being damaged by the stress of military ser-
vice, and erected barriers of shame and denial between
injury and care (Nash et al ., 2009 ).
Orange zone stress is de ned as more persistent and
severe distress or dysfunction resulting from stressors
that exceed, in intensity or duration, the functional lim-
its of individuals’ biological, psychological, social, and
spiritual coping machinery. Whereas yellow zone stress
represents a bending under force, orange zone stress is
conceived to represent a literal wound in the body, mind,
or spirit caused by stress. If one conceives of an injury
as a disruption in normal integrity that resulting in a
decrement in normal functioning, then the evidence in
support of the concept of literal, rather than  gurative,
injuries under stress comes from many sources. For
of ever-increasing di culty. Like athletes, war ght-
ers seek to  nish their training regimens at near-peak
capacity.
As de ned, yellow zone stress causes subjective dis-
tress, decrements in functioning, or both. Subjective
distress in the yellow zone may include emotions of
anxiety, fear, anger, or sadness. Yellow zone cognitions
may include worrying or fantasies of either quitting
or retaliating against those who are in icting current
stressors. Changes in physical functioning in the yellow
zone may include high levels of physiological arousal,
causing a rapid heart rate and breathing, sweating, and
tremulousness.  ey may also include diarrhea, nausea,
or other physical symptoms of strain. Cognitive changes
in the yellow zone are those associated with very high
and sustained levels of physiological arousal, such as
distractibility, poorly sustained attention, slowed recall,
and poor problem solving. Behaviors characteristic of
the yellow zone may include irritability, di culty fall-
ing asleep, or changes in appetite, levels of enjoyment,
motivation, enthusiasm, or social connectedness.
e de ning characteristics of yellow zone distress
and changes in functioning are that they are always
mild and temporary, and they always disappear com-
pletely once the source of stress is no longer present.
Yellow zone stress is, by de nition, a level of stress to
which a particular individual is resilient and, therefore,
able to rebound from without incurring lasting dam-
age to body, mind, or spirit. Yellow zone stress does
not leave a mental or emotional scar. Of course, as each
individual endures repeated challenges over time, and
as resources for resilience are depleted, yellow zone
capacities may dwindle and resilience may be progres-
sively lost.
Injured: the orange zone
e orange zone represents the  rst signi cant depart-
ure in the stress continuum model from more trad-
itional views of combat and operational stress, which
tended to conceive of any and all experiences of distress
or dysfunction in the context of military operations as
normal and transient, regardless of severity or persist-
ence. For example, the COSC doctrinal publication
FM4–02–51 de nes “combat and operational stress
reaction” (COSR) as follows (US Army, 2006, p. 1–5):
is term can be applied to any stress reaction in the mili-
tary unit environment. Many reactions look like symp-
toms of mental illness (such as panic, extreme anxiety,
depression, hallucinations), but they are only transi-
ent reactions to the traumatic stress of combat and the
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246
Section 4: Specifi c challenges
mental disorders, they can only be diagnosed by health
professionals. Nevertheless, commanders, unit leaders,
peers, and family members can and should be aware of
the characteristic symptoms of stress illnesses so that
they can identify them and make appropriate referrals
as soon as possible.  e most widely recognized stress
illness is PTSD, but well-recognized mental disorders
arising from stressor exposures in vulnerable individ-
uals include depressive and anxiety disorders, and sub-
stance abuse and dependence .
The ve core leader functions for
psychological health
e combat and operational stress continuum model
described above is broad in its scope, encompassing
all conceivable responses and outcomes to stress, both
for service members and their families. Clearly, no one
group of individuals can manage the entire stress con-
tinuum as de ned. At le end of the continuum – the
green and yellow zones – the activities of line leaders
predominate to promote resiliency. Here, universal and
selective prevention are paramount. At the far right of
the continuum, the red zone is the purview of medical
and mental health professionals, supported by chap-
lains and other social and spiritual support personnel.
Individual service members and family members bear
responsibility for maintaining their own psychological
health across the stress continuum, including build-
ing their own resiliency, managing their own stress
reactions, and recognizing and getting help for stress
injuries and illnesses when needed. To promote resili-
ence, recovery, and reintegration across the stress con-
tinuum, leaders in the US Marine Corps and Navy have
developed and promulgated a set of  ve core leader
functions for psychological health: (1) strengthen, (2)
mitigate, (3) identify, (4) treat, and (5) reintegrate.
Strengthen
e rst core function for leaders is to strengthen ser-
vice members before they are exposed to operational
stressors. Individuals enter military service with a set
of pre-existing strengths and vulnerabilities based
on genetics, prior life experiences, personality style,
family supports, and a host of other factors that may
be largely immutable. However, centuries of experi-
ence in military organizations, as well as a number of
research studies, have demonstrated that commanders
of military units can do much to enhance the resilience
of unit members and their families through a number
example, a disruption of sustaining attachments caused
by the death of someone or something cherished may
result in at least short-term, if not enduring, changes
in self-concept and relationship to the world (Papa
et al ., 2008 ; Prigerson et al ., 2009 ). Similarly, to the
extent internalized cognitive schemata form the struc-
ture of personality and other mental functioning,
events that violate deeply held assumptions, beliefs, or
values can cause enduring psychological, social, and
spiritual dysfunction (Jano -Bulman, 1992 ; Litz et al .,
2009 ). ere is also accruing evidence from both
pre-clinical and clinical studies that severe stress can
cause a number of lasting changes in brain structure
and function (e.g., Bremner, 2006 ; Heim & Nemero ,
2009 ; Martin et al ., 2009 ). High levels of cortisol in the
brain seen in stress have been implicated in the loss of
glutamate neurons in the prefrontal cortex and hippo-
campus in circuits important for the control of physio-
logical arousal, emotion, and cognition; these circuits
act through metabolic pathways similar to those
changed in head trauma, stroke, and a wide variety of
degenerative brain diseases (Kruman & Mattson, 1999 ;
McEwen, 2000 , 2008 ; Giza & Hovda, 2001 ).
Although the clinical literature has not yet eluci-
dated the causes and e ects of orange zone stress, the
lessons of history teach that there are at least four dis-
tinct yet overlapping sources of stress injury: (1) life
threat, (2) loss, (3) moral compromise, and (4) cumu-
lative wear and tear.  e stress continuum model, as
employed by the OSC and COSC programs, alerts
leaders and caregivers to the possibility of orange zone
stress in the wake of speci c events that are potentially
traumatic, potentially morally injurious, or involve the
loss of cherished persons or things. It also draws atten-
tion to cumulative stress, from all sources over months
or years, as a fourth possible source of stress injury.
Orange zone stress is a subclinical and pre-clinical
state from which most individuals are expected to
recover (e.g., Shalev, 2002 ). However, the orange zone
is also a marker of risk, both for possible failure of role
performance (loss of operational resilience) and future
mental disorders or behavioral problems (loss of psy-
chological resilience).  e risk indexed by orange zone
stress is conceived to persist for an inde nite period of
time a er acute distress and dysfunction fade.
Ill: the red zone
e red zone is the zone of diagnosable mental disor-
ders arising in individuals exposed to combat or other
operational stressors. Because red zone illnesses are
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Chapter 16: The stress continuum model
247
facing line leaders hoping to strengthen their unit
members through training is to deliver training that
is adequately tough and realistic without making it so
tough that it in icts orange zone injuries on the train-
ing  eld. Another challenge is to recognize the limits
of pre-exposure universal prevention interventions.
Military psychological health programs must also
provide selective interventions for yellow zone stress
reactions, and indicated interventions for orange zone
stress injuries.
Mitigate
e second core function is to mitigate stressors
throughout deployment cycles in order to reduce the
stress burden placed on service members and their
families. Optimal mitigation of stress requires balan-
cing competing priorities. On one the hand is the need
to intentionally subject service members to stress in
order to train and toughen them, and to accomplish
assigned missions while deployed. On the other hand
are the imperatives to reduce or eliminate stressors that
are not essential to training or mission accomplishment
and to ensure adequate sleep, rest, and restoration to
allow recovery between challenges. Resilience, courage,
and fortitude can be likened to leaky buckets that are
constantly being drained by stress. To keep them from
running dry, these buckets must be frequently re lled
through the provision of all necessary physical, psy-
chological, social, and spiritual resources. Mitigation
activities include physical interventions such as ensur-
ing adequate sleep, rest, and nutrition, and maintain-
ing physical health and  tness.  ey also can include
social and spiritual replenishment activities such as
shared successes, recreation, religious practices, and
a er-action reviews as a means by which leaders can
reinforce ethical standards and give meaning to sacri-
ces and losses. Given the correlation between length
of deployment and stress, the most important mitiga-
tion strategies may be simply limiting the duration of
deployments and increasing the length of dwell time
between deployments.
Identify
Since even the best pre- and peri-exposure prevention
e orts cannot eliminate all signi cant post-exposure
distress and dysfunction, e ective psychological health
promotion requires continuous monitoring of stres-
sors and stress outcomes. Operational leaders must
know the individuals in their units, including their spe-
ci c strengths and weaknesses, and the nature of the
of universal prevention interventions.  ese interven-
tions fall into the three broad categories of training,
unit cohesion, and leadership.
Tough, realistic training develops physical and
mental strength and endurance, enhances war ghters
con dence in their ability as individuals and as mem-
bers of units to cope with the challenges they will face,
and inoculates them to the stressors they will encoun-
ter. Exactly how pre-exposure to stress enhances resili-
ence is not well understood, but emerging evidence
suggests that both psychological and biological mecha-
nisms are involved. Well-trained ser vice members have
lower heart rates and higher levels of neuropeptide Y, a
neurotransmitter that promote calmness in the face of
severe stress (Morgan et al ., 2000 ; Eaton et al ., 2007 ).
ey also face familiar challenges with greater con -
dence and less anxiety-induced loss of mental focus or
dissociation (Morgan et al ., 2001 ).
Unit cohesion, de ned broadly as mutual trust and
support in a social group, is developed through shar-
ing adversity over time in a group with a stable mem-
bership. Two-way communication, both horizontally
among peers and vertically between leaders and sub-
ordinates, is essential to unit cohesion. Most leaders
know how to build cohesive units given enough time
and unit stability, but a too-common challenge is to try
to maintain unit cohesion in the face of rotations into
and out of the unit, including casualties and combat
replacements. Certainly, the unit rotation policies cur-
rently practiced in the US military are more conducive
to unit cohesi on than the individual rotations common
during the Vietnam era, but individual augmentees and
members of reserve or National Guard units may still
be disadvantaged regarding this important ingredient
to strengthening.
Although complex and multifaceted, leadership is
an essential factor for the strengthening of unit mem-
bers and families. Leaders strengthen unit members by
teaching and inspiring them, keeping them focused on
mission essentials, instilling con dence, and providing
a model of ethical and moral behavior. Another cru-
cial way in which leaders enhance the resilience of their
unit members is by providing a resource of courage
and fortitude on which unit members can draw during
times of challenge (Moran, 1967 ).
Military organizations in the USA are currently
investing a great deal in new methods to augment
pre-exposure strengthening through enhanced  t-
ness, neurocognitive training, and stress inoculation
using sensory immersion trainers. One challenge
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248
Section 4: Specifi c challenges
e rst continuous aid action, check , is merely the
imperative to assess and reassess individuals exposed
to potential orange zone stressors, in order to recognize
current stress zone, needs, and risks.  e check action
takes into account two critical components of the stress
continuum model: the di erential risks posed by the
four zones of the stress continuum, and the trajectories
over which symptoms change over time.  ere are few
settings in which longitudinal assessment is as easy to
perform by involved leaders, caregivers, and peers as
in military units, given the closeness and involvement
that characterizes such organizations.  e second con-
tinuous aid action, coordinate , makes maximum use
of the extended support system intrinsic to military
organizations by connecting those in need with avail-
able resources.
e two primary aid actions, cover and calm , are
tools for acute crisis response. Cover means to get to
cover, or to make safe, whatever that may require. Calm
actions target physiological arousal, emotional inten-
sity, and cognitive disorganization. Primary aid is sel-
dom required, but when it is needed, the need is acute.
erefore, everyone at every level of the organiza-
tion should be trained in both verbal and non-verbal
actions for primary aid.
Secondary aid actions are designed to promote
recovery and healing from orange zone stress over a
longer period of time, and they are intended to be per-
formed mostly by senior leaders and caregivers, since
they require the greatest communication skills, author-
ity, and responsibility.  e connect action of COSFA
merely means to promote social support, especially
from peers and family members, in the a ermath of
orange zone stress.  e competence action includes all
mentoring, teaching, and counseling activities geared
toward the recovery of functional skills in all important
areas, including self-care, social interacting, and occu-
pational performance.  e nal secondary aid action,
con dence , targets obstacles to self-esteem and hope in
the wake of orange zone stress, particularly high lev-
els of guilt, shame, or blame. Restoration of con dence
o en depends on more realistic self-appraisal, but it
also may require forgiveness of self and others for per-
ceived failures .
e treatment function of the COSC and OSC pro-
grams also encompasses referral, consultation, and
case management to ensure higher levels of care are
obtained when they are needed. Finally, this treatment
function challenges leaders at all levels to remove the
obstacles to care posed by stigma in all its forms.
challenges they face both in the unit and in their home
lives. Leaders must recognize when individuals’ con -
dence in themselves or their peers or leaders is shaken,
or when units have lost cohesion because of casualties,
changes in leadership, or challenges to the unit. Most
importantly, every unit leader must know which stress
zone each unit member is in at every moment, day to
day. Service members cannot be depended upon to
recognize their own stress reactions, injuries, and ill-
nesses, particularly while deployed to operational set-
tings.  e external focus of their attention and their
denial of discomfort, necessary to thrive in an arduous
environment, make it di cult for them to recognize
their own stress states. In addition, stigma can be an
insurmountable barrier to admitting stress problems,
once recognized, to someone else. E ective indicated
prevention depends on leaders, caregivers, peers, and
family members recognizing orange zone stress in
others. For this reason, education and training on stress
zone identi cation is a orded to all personnel groups
in the US Navy and Marine Corps at various points in
their careers, particularly before and a er operational
deployments.
Treat
e fourth leader function for psychological health
promotion is to treat orange and red zone stress once
identi ed.  e operative verb, “treat,” may imply clin-
ical care provided by a licensed medical or mental
health professional. But in the context of the OSC and
COSC programs, what is meant is not clinical care but
intervention of any kind, at any level. Viewed in this
way, the treatment function is the responsibility of
everyone in the organization, since e ective interven-
tions for subclinical states may be provided by almost
anyone trained to provide such help.
T o ll the gap in intervention strategies lying
between routine leadership and clinical mental health-
care, the US Navy and Marine Corps developed a set
of indicated prevention tools targeting orange zone
stress in operational environments.  is interven-
tion is known as combat and operational stress  rst aid
(COSFA) and provides evidence-informed strategies
to promote recovery (see Hobfoll et al ., 2007 ) in the
hands of line leaders, non-mental healthcaregivers,
and others (Nash et al ., 2008 ). e COSFA intervention
includes seven actions, divided into three levels of care:
(1) continuous aid (check and coordinate), (2) primary
aid (cover and calm), and (3) secondary aid (connect,
competence, and con dence).
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Chapter 16: The stress continuum model
249
ere is a broad need for program evaluation
research across the spectrum of resilience training
e orts in the military. We argue that useful research
can only come from cogent and well-articulated con-
ceptual frameworks. We urge decision makers, devel-
opers, and researchers to lay out the goals, assumptions,
and rationale for each component of their respective
models, as we have done in this chapter.  is will help
to address the big challenges in the  eld, which are to
operationally de ne resilience; to gain a consensus
about what “pre-clinical” states of distress or dysfunc-
tion entail, and how to measure these states; to agree
on the key constructs of interest and to derive or cull
measures of various predictor variables and outcomes;
to conduct longitudinal research so that causal infer-
ences can be generated about risk and resilience factors
in the military; and to use this information to conduct
ongoing program evaluation.
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Reintegrate
e  nal leader function for psychological health,
reintegrate, seeks to conserve precious personnel
resources by returning individuals to duty as soon and
as completely as possible as they recover and heal from
stress.  e reintegration imperative challenges military
line leaders and medical support personnel to continu-
ously monitor the functional capacities and self-con -
dence of service members as they recover, and to apply
rational standards to decisions regarding  tness for
duty and worldwide deployability. For stress-a ected
individuals to be e ectively reintegrated into their units,
stigma must be continuously addressed, and the con -
dence of both the stress-a ected person and their peers
and small unit leaders must be restored.  is process
may take months to bring to successful conclusion. In
those cases in which substantial recovery and return to
full duty is not anticipated, the challenge for operational
commanders is to assist service members as they transi-
tion to civilian life and Veterans A a i r s c a r e .
Conclusions
e US Navy and Marine Corps have developed paral-
lel programs (COSC and OSC) to promote resiliency
and recovery in their members, not only to preserve
operational functional capacities but also to promote
post-deployment functioning and long-term health
and well-being.  e conceptual foundation for these
programs is as the combat and operational stress con-
tinuum model, a heuristic that promotes communica-
tion and integration of resilience and recovery e orts
throughout the organization.  e model classi es
stress states in four color-coded stress zones, each rep-
resenting a di erent level of risk for failure of role per-
formance and a future mental disorder. Leaders in the
US Navy and Marine Corps bear responsibility for sev-
eral core functions necessary to promote psychological
health across the stress continuum. Unique to these
programs and the stress continuum model on which
they are based is a major focus on identifying subclin-
ical or pre-clinical stress injuries in order to apply indi-
cated prevention interventions when needed.
Although the COSC and OSC programs were
devised based on available evidence, the programs have
yet to be proven e ective by well-designed outcome or
program evaluation studies. Program evaluation stud-
ies are needed to validate the major components of
these programs, including the stress continuum model,
the core leader functions, and COSFA.
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... Peritraumatic reactions in battle are representative of extraordinary stress challenges for service members, who are faced with pervasive loss, life threat, extreme physical discomfort and moral conflicts, witnessing death, and overcoming fear (Bruner and Woll 2011). However, during combat, the primary importance of these reactions lies in potential interference with maintenance of operational resilience, including mission effectiveness and optimal performance (Nash et al. 2011b). Thus, the valid assessment of relevant behavioral, emotional, cognitive, and physiological peritraumatic information is the greatest challenge in combat-related, mental health research, since technologies do not yet exist for continuous monitoring of physiological arousal in a war zone. ...
... This is particularly appealing because a number of aspects of peritraumatic distress, such as panic, freezing, or blind rage, are manifested in outwardly observable behaviors on the battlefield. During combat, the primary importance of these reactions lies in potential interference with maintenance of operational resilience, including mission effectiveness and optimal performance, as well as the potential harbinger of emergence of PTSD (Nash et al. 2011b). The PBQ-OR is proven a reliable, valid, and applicable observer-rating instrument for globally assessing different underlying dimensions of combat-related peritraumatic symptoms in active duty service members by imbedded corpsman and medics, and behaviors observed show a high correlation to various PTSD-specific symptoms at post-deployment. ...
Chapter
The postwar fiscal burden for treatment of posttraumatic stress disorder (PTSD) and PTSD-related mental, physical, and social outcomes can be high, and the liability can persist for decades post-armistice. Thus, any advancement in early detection and prevention of PTSD promise substantial benefits. There is strong confirmation that peritraumatic stress reactions are robust posttrauma predictors of PTSD development. This fact provides evidence to warrant training for the recognition and evaluation of peritraumatic stress. However, although instruments for measuring peritraumatic symptoms exist, they were not specifically developed to assess combat-related peritraumatic reactions and may insufficiently capture the wide range of possible reactions in the immediate aftermath of a combat-related trauma. In addition, these measures also all rely on subjective, retrospective self-report. To redress this problem, we developed the Peritraumatic Behavior Questionnaire (PBQ). The ultimate goal was to generate a military-specific observer-rating scale for corpsman and medics in theater to facilitate the early detection of combat-related peritraumatic distress symptoms in actively deployed service members and to unify underlying peritraumatic symptom dimensions to reliably assess combat-related peritraumatic reactions as a general construct. Before assessing an observer-rated version of the PBQ (PBQ – Observer Rated, PBQ-OR), we initially investigated the psychometric and predictive properties of the self-rated PBQ version (PBQ – Self Report, PBQ-SR). We considered that the establishment of good psychometric properties for the SR version would be important before introducing the additional complexities of observer ratings. Here we report the development of the PBQ and summarize the recently reported psychometric properties of the PBQ-SR, as well as our findings and conclusions from the in-theater evaluation procedure of the PBQ-OR. Our data confirm the ability of the PBQ to unify the underlying peritraumatic symptom dimensions and reliably assess combat-related peritraumatic reactions as a general construct. Both PBQ-SR and PBQ-OR showed high correlation to various PTSD-specific as well as PTSD-related symptoms and demonstrated promise as a potential standard screening measure in military clinical practice.
... Any cross-sectional assessment of stress, impact, and needs is inadequate to plan, implement, and evaluate public health programs to prevent psychological and behavioral health problems (Nash et al., 2015). The challenge is to conduct ongoing surveillance at the local level to identify and help those who need resources to bounce back (Nash et al., 2012). Third, COVID-19 stressors have acute and chronic components. ...
... The military has created a heuristic model, which clinicians can use to conceptualize individuals exposed to high magnitude pandemic-related stressors. The model, depicted in Fig. 2, can help care-providers identify the states of mind and body that require indicated prevention (Nash et al., 2012;Watson et al., 2011). This model distinguishes normal stress (yellow zone), defined as transient distress and impairment, from potentially toxic, persistent, and impairing distress (orange zone), defined as persistently impairing distress. ...
Article
The COVID-19 pandemic has universally threatened the building blocks of mental health, well-being, and quality of life, namely, expectations of safety, connectedness, hope, and individual and societal efficacy. Consequently, unprecedently large numbers of individuals are significantly stressed and many are at risk for relapse of mental health problems, exacerbations of existing mental and behavioral health problems, and new onset clinical problems. Because of the scope of the problem, a population-based public health perspective is needed, which in the context of disasters has well-established theories and prevention approaches. Public health approaches to disasters and pandemics focus on preventing subclinical problems from becoming clinical disorders, in comparison to clinical care approaches that focus on treating established disorders. Fortunately, specialty care clinicians who typically think about assessing and treating established disorders have the training and clinical competencies to deliver prevention-focused interventions. This paper is designed to help specialty care clinicians who use cognitive-behavioral strategies to understand the biopsychosocial impacts and resource deficits associated with COVID-19-related stressors and the public health perspective to address them. We also provide ways clinicians can help people who are suffering from significant stress and resource deficits bounce back and regain functioning. We describe psychological first aid, stress management, repeated ecological assessment, writing about stressors, problem-solving, and behavioral activation approaches to assist individuals at risk for enduring stress-linked problems.
... Identifying reliable profiles of risk is especially important in light of the fact that attempts at universal prevention of PTSD in the military, which entails targeting all service members regardless of role, symptom burden, or degree of exposure to warzone stressors, have limited effectiveness (Steenkamp, Nash, & Litz, 2013). Consequently, attention has shifted to deploying indicated prevention strategies that target service members with early or pre-clinical levels of symptoms and impairment (Nash, Steenkamp, Conoscenti, & Litz, 2011). Distinguishing those symptomatic service members who are likely to recover on their own from those who require scarce intervention resources is hindered, however, by a lack of research on the prognosis of various PTSD symptom presentations over time. ...
... These findings are consistent with prior LCA findings based on selfreported PTSD symptoms in this cohort that found greater symptom heterogeneity soon after deployment (Hebenstreit, Madden, & Maguen, 2014). Across the deployment cycle, the numbers of symptoms endorsed at a clinically significant level decreased and the sizes of less symptomatic classes increased, indicating a general trend towards wellness over time, a finding that is consistent with other recent studies of service members deployed to Iraq or Afghanistan (Nash et al., 2011;Steenkamp et al., 2013). ...
Article
Our objective was to examine symptom-level changes in the course in posttraumatic stress disorder (PTSD) across the deployment cycle among combat-exposed Marines, and to determine the degree to which combat exposure and post-deployment stressor exposure predicted PTSD symptom profile transitions. We examined PTSD symptoms in a cohort of U.S. Marines (N = 892) recruited for the Marine Resiliency Study (MRS). Marines deployed as one battalion infantry unit to Afghanistan in 2010 and were assessed pre-deployment and one, five, and eight months post-deployment. We employed latent transition analysis (LTA) to examine Marines' movement across PTSD symptom profiles, determined by latent class analysis (LCA). LCAs revealed a 3-class solution one month pre-deployment, a 4-class solution at five months post-deployment, and a 3-class solution at eight months post-deployment. LTA revealed notable movement between classes over time, which depended chiefly on pre-deployment symptom presentation. Marines who reported few pre-deployment symptoms either maintained these low levels or returned to low levels by eight months. Marines who reported a moderate number of symptoms at pre-deployment had variable outcomes; 50% had reductions by eight months, and those who reported numbing symptoms at five months post-deployment tended to report more symptoms at eight months. Marines who reported more PTSD symptoms prior to deployment retained more symptoms eight months post-deployment. Combat exposure and post-deployment stressor exposure predicted profile transitions. Examining transitions between latent class membership over time revealed prognostic information about Marines' eight-month PTSD outcomes. The extent of pre-deployment PTSD symptoms was particularly informative of likely PTSD outcomes.
... Resilient individuals may recover following exposure to a traumatic event to their preexposure levels and, in some cases, even advance beyond (e.g., posttraumatic growth) (Rutten et al., 2013). Longterm psychological resilience in military populations has been defined as the ability to adapt emotionally to combat stressors without developing lasting negative outcomes (Nash, Steenkamp, Conoscenti, & Litz, 2011). This resilience has been considered a protective factor for alleviating the risk of developing chronic, traumarelated conditions among returning Veterans (Litz, 2014). ...
Article
Problems with social functioning are common following combat deployment, and these may be greater among individuals with a history of traumatic brain injury (TBI). The present investigation examined the impact of mild TBI (mTBI), deployment-related characteristics, and resilience on perceived participation limitations among combat Veterans. This was a cross-sectional study of 143 participants with a history of at least one deployment-related mTBI (TBI group) and 80 without a history of lifetime TBI (Comparison group). Self-report measures of participation, resilience, posttraumatic stress disorder (PTSD) symptoms, and combat exposure were administered. In addition, each participant completed a structured interview to assess lifetime TBI history. The groups did not differ in basic demographics, but significant differences were found for perceived limitations in participation, the presence of PTSD symptoms, and intensity of combat exposure. A stepwise model indicated a significant effect of resilience on reported limitations in participation (adjusted R² = 0.61). Individuals with higher resiliency reported a higher degree of social participation, and this effect was stronger in the TBI group. Deployment-related characteristics, including intensity of combat exposure, did not have a significant effect (adjusted R² = 0.28) on social participation. The role of resilience should be recognized within post-deployment transition and rehabilitation programs.
... 20 Consistent with this perspective, we also view observations of stress reactions in the current pandemic as congruent with the Stress Continuum Model (Figure 1), initially developed to describe stress reactions in military personnel. 17 Describing four zones ranging from green to red, the Stress Continuum Model emphasizes the importance of viewing stress reactions on a continuum, from normal readiness and expectable consequences, to more persistent and extreme imbalance in the red zone such as PTSD and major depression. The model underscores that stress reactivity may cycle between zones and emphasizes the importance of providing appropriate level interventions to meet the needs of individuals where they are. ...
Article
Full-text available
Oncology health-care workers (HCWs) are facing substantial stressors during the current coronavirus disease 2019 (COVID-19) pandemic, resulting in a wide range of acute stress responses. To appropriately meet the growing mental health needs of HCWs, it is imperative to differentiate expectable stress responses from post-traumatic stress disorder and mental illness, as traditional mental health interventions may pathologize healthy stress reactions and risk retraumatizing HCWs under acute duress. Further, HCWs are experiencing protracted forms of acute stress as the pandemic continues, including moral injury, and require mental health interventions that are flexible and can adapt as the acuity of stressors changes. Previously developed frameworks to support people experiencing acute stress, such as Psychological First Aid, are particularly relevant for HCWs in the ongoing pandemic. Acute stress interventions like Psychological First Aid are guided by the Stress Continuum Model, which conceptualizes stress reactions on a continuum, from a zone of normal readiness and expectable consequences, to a zone of more persistent and extreme reactions such as post-traumatic stress disorder and major depression. Key principles of the Stress Continuum Model include the expectation that emotional reactivity does not lead to psychiatric problems, that interventions need to be appropriately targeted to symptoms along the stress continuum, and that people will return to normal recovery. Various core actions to reduce acute stress include delivering practical assistance, reducing arousal, mobilizing support, and providing targeted collaborative services. This non-pathologizing approach offers a valuable framework for delivering both individual and organizational-level interventions during the COVID-19 pandemic.
... 20 Consistent with this perspective, we also view observations of stress reactions in the current pandemic as congruent with the Stress Continuum Model (Figure 1), initially developed to describe stress reactions in military personnel. 17 Describing four zones ranging from green to red, the Stress Continuum Model emphasizes the importance of viewing stress reactions on a continuum, from normal readiness and expectable consequences, to more persistent and extreme imbalance in the red zone such as PTSD and major depression. The model underscores that stress reactivity may cycle between zones and emphasizes the importance of providing appropriate level interventions to meet the needs of individuals where they are. ...
Article
Full-text available
Oncology health-care workers (HCWs) are facing substantial stressors during the current coronavirus disease 2019 (COVID-19) pandemic, resulting in a wide range of acute stress responses. To appropriately meet the growing mental health needs of HCWs, it is imperative to differentiate expectable stress responses from post-traumatic stress disorder and mental illness, as traditional mental health interventions may pathologize healthy stress reactions and risk retraumatizing HCWs under acute duress. Further, HCWs are experiencing protracted forms of acute stress as the pandemic continues, including moral injury, and require mental health interventions that are flexible and can adapt as the acuity of stressors changes. Previously developed frameworks to support people experiencing acute stress, such as Psychological First Aid, are particularly relevant for HCWs in the ongoing pandemic. Acute stress interventions like Psychological First Aid are guided by the Stress Continuum Model, which conceptualizes stress reactions on a continuum, from a zone of normal readiness and expectable consequences, to a zone of more persistent and extreme reactions such as post-traumatic stress disorder and major depression. Key principles of the Stress Continuum Model include the expectation that emotional reactivity does not lead to psychiatric problems, that interventions need to be appropriately targeted to symptoms along the stress continuum, and that people will return to normal recovery. Various core actions to reduce acute stress include delivering practical assistance, reducing arousal, mobilizing support, and providing targeted collaborative services. This non-pathologizing approach offers a valuable framework for delivering both individual and organizational-level interventions during the COVID-19 pandemic.
... The result of the working group's deliberations was the combat and operational Stress Continuum Model, a heuristic that divided the spectrum of possible stress states into four color-coded zones designated green (ready), yellow (reacting), orange (injured), and red (ill). [17] The two overarching objectives of the Stress Continuum Model are to create and preserve a ready force and to promote the long-term health and well-being of the naval personnel and their family members. These two objectives are interrelated and are recognized as of paramount strategic importance since the mission of the Navy is to win wars and to return good citizens to civilian life after those wars are fought. ...
Article
Full-text available
Stress is unavoidable and encountered in many shapes and sizes. Being in a state of peaceful happiness may seem like an unachievable goal. Serving in the Armed Forces brings unique challenges during peacetime, in addition to the harmful mental and physical effects of service during war. The prolonged periods of separation from family, the very threat to life and limb, the imminence of physical danger, and the likelihood of the loss of a close colleague make the Armed Forces environment, especially in combat, inherently stressful. The lethality of the modern conflicts is potentially greater, and the way that conflicts are waged is more asymmetrical when compared with the wars of an earlier era. The Navy has its own unique set of stressors. Naval operations across the entire range of conflict expose naval personnel to a multitude of stressors. These stressors can lead to varied negative mental health consequences for the service personnel as well as their families. Increased deployments entail other stressful changes in the naval units as well, such as an increased number and intensity of training exercises, planning sessions, and equipment inspections, all of which increase the workload and pace of operations. Through this article, we briefly review the literature on this subject, emphasizing on stress and its types and stressors in Armed Forces, particularly the Navy. The article also dwells on early recognition of stress and timely intervention through the Stress Continuum Model.
... The military often puts service members in high stress environments, both physically and psychologically, where sleep deprivation is common (Grossman & Christensen, 2008;Lieberman et al., 2005;Nindl et al., 2002). In light of the conceptualization of stress as operating on a continuum (Nash, Steenkamp, Conoscenti, & Litz, 2011), perceived stress should be included as an indicator of overall mental health and wellbeing. ...
Article
Full-text available
http://www.tandfonline.com/eprint/M9WRrzyK5TnpJT4m6zqy/full The goal of this study was to examine the relationship between sleep issues, mental health (perceived stress, posttraumatic stress disorder [PTSD] symptoms, and depressive symptoms), and suicidal ideation (SI) in a sample of military service members (N = 891) using mediation analyses. Sleep issues were related to SI, stress, PTSD, and depressive symptoms. PTSD, perceived stress, and depressive symptoms mediated the relationship between sleep issues and SI; after accounting for mental health symptoms, sleep no longer had a direct effect on SI. Our findings suggest that sleep issues may operate as a risk factor for mental health issues and SI.
Article
The role of military leaders to promote resilience has never been more relevant. The following case highlights a Navy Nurse Corps Officer’s challenges with deployment stressors and building resilience during a ship-based Global Health Engagement. The case also highlights a follow-on project to enhance the resilience of deployed service members.
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en The most robust finding of moral injury (MI) research thus far—that past exposure to potentially morally injurious events predicts current symptoms of posttraumatic stress disorder (PTSD)—challenges conceptions that trauma is exclusively the result of fear-evoking brushes with death or sexual assault. It also calls into question the applicability to MI of treatments for PTSD grounded in the fear model of trauma. In the current article, two divergent theoretical models that have been applied to the understanding and treatment of moral injury are compared: the stress–appraisal–coping model and the stress injury model. Attention is drawn to the differences between how these models conceptualize stress and distress, including psychological trauma, and to their potential implications for the sustainment of mental health stigma, especially in military and veteran populations. Resumen es Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Desentrañando dos modelos para comprender el daño moral: Comentario para el número especial de Journal of Traumatic Stress sobre daño moral DOS MODELOS PARA ENTENDER EL DAÑO MORAL El hallazgo más robusto de la investigación sobre daño moral (DM) hasta el momento – que plantea que la exposición pasada a eventos potencialmente dañinos morales predice los síntomas actuales del trastorno de estrés postraumático (TEPT) - desafía las concepciones de que el trauma es exclusivamente el resultado de una estructura del miedo asociado con la muerte o el asalto sexual. También pone en duda la aplicabilidad del DM en los tratamientos para el TEPT basados en el modelo de miedo del trauma. En el artículo actual, se comparan dos modelos teóricos divergentes que se han aplicado a la comprensión y el tratamiento del daño moral: el modelo de estrés-evaluación-afrontamiento y el modelo de daño por estrés. Se destaca acerca de las diferencias entre cómo estos modelos conceptualizan el estrés y la angustia, incluido el trauma psicológico, y sus posibles implicaciones para el mantenimiento del estigma asociado a la salud mental, especialmente en las poblaciones de militares y veteranos. 抽象 zh Traditional and Simplified Chinese Abstracts by the Asian Society for Traumatic Stress Studies (AsianSTSS) 簡體及繁體中文撮要由亞洲創傷心理研究學會翻譯 Unpacking Two Models for Understanding Moral Injury: Commentary for Journal of Traumatic Stress Special Issue on Moral Injury Traditional Chinese 標題: 說明兩個用以理解道德創傷的模型:創傷壓力期刊道德創傷特刊評論 撮要: 有關道德創傷(MI)的研究,最主要的發現為過去經歷潛在的道德創傷事件,可預測當前的創傷後壓力症(PTSD)症狀。然而,亦有說法指創傷只屬經歷死亡或性侵犯的威脅產生恐懼所致。以上兩種說法有所矛盾。此外,基於創傷的恐懼模型而生的PTSD療法是否適用於治療MI,亦成疑問。本文比較兩種不同、用以理解和治療MI的理論模型:壓力−評價−適應模型,及壓力受創模型。我們特別留意兩個模型如何概念化壓力與悲痛,當中包括心理創傷,以及兩個模型特別在現役及退役軍人中,潛在使心理健康污名持續的可能。 Simplified Chinese 标题: 说明两个用以理解道德创伤的模型:创伤压力期刊道德创伤特刊评论 撮要: 有关道德创伤(MI)的研究,最主要的发现为过去经历潜在的道德创伤事件,可预测当前的创伤后压力症(PTSD)症状。然而,亦有说法指创伤只属经历死亡或性侵犯的威胁产生恐惧所致。以上两种说法有所矛盾。此外,基于创伤的恐惧模型而生的PTSD疗法是否适用于治疗MI,亦成疑问。本文比较两种不同、用以理解和治疗MI的理论模型:压力−评价−适应模型,及压力受创模型。我们特别留意两个模型如何概念化压力与悲痛,当中包括心理创伤,以及两个模型特别在现役及退役军人中,潜在使心理健康污名持续的可能。
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A review of 2,647 studies of posttraumatic stress disorder (PTSD) yielded 476 potential candidates for a meta-analysis of predictors of PTSD or of its symptoms. From these, 68 studies met criteria for inclusion in a meta-analysis of 7 predictors: (a) prior trauma, (b) prior psychological adjustment, (c) family history of psychopathology, (d) perceived life threat during the trauma, (e) posttrauma social support, (f) peritraumatic emotional responses, and (g) peritraumatic dissociation. All yielded significant effect sizes, with family history, prior trauma, and prior adjustment the smallest (weighted r = .17) and peritraumatic dissociation the largest (weighted r = .35). The results suggest that peritraumatic psychological processes, not prior characteristics, are the strongest predictors of PTSD.
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In this book, Sara Phang explores the ideals and realities of Roman military discipline, which regulated the behavior of soldiers in combat and their punishment, as well as economic aspects of their service, including compensation and other benefits, work, and consumption. This thematically organized study analyzes these aspects of discipline, using both literary and documentary sources. Phang emphasizes social and cultural conflicts in the Roman army. Contrary to the impression that Roman emperors "bought" their soldiers and indulged them, discipline restrained such behavior and legitimized and stabilized the imperial power. Phang argues that emperors and aristocratic commanders gained prestige from imposing discipline, while displaying leadership in person and a willingness to compromise with a restive soldiery.