In a 2 – 4 page paper, you will explore the common post-deployment problems

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in a 2 – 4 page paper, you will explore the common post-deployment problems that Moore and Kennedy have addressed, with citations. Additionally, identify and describe the tasks that need to occur post-deployment (Meichenbaum) and five post-deployment programs (Greenberg and Meichenbaum). I have provided the reading material attached. Please cite all papers. Common problems include relationships, PTSD, substance abuse etc.

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67 • ways to bolster resilience across the deployment cycle Research and practice (pp. 291–310). Mahwah, NJ: Erlbaum. Tedeschi, R. G., & McNally, R. J. (2011). Can we facilitate posttraumatic growth in combat veterans? American Psychologist, 66, 19–24. 67 325 Zoellner, T., & Maercker, A. (2006). Posttraumatic growth in clinical psychology: A critical review and introduction of a two component model. Clinical Psychology Review, 26, 626–653. WAYS TO BOLSTER RESILIENCE ACROSS THE DEPLOYMENT CYCLE Copyright © 2013. Oxford University Press, Incorporated. All rights reserved. Donald Meichenbaum Since the terrorist attacks of September 11, 2001, over 2 million individuals have been deployed to Iraq and Afghanistan, with nearly 800,000 who have been deployed multiple times. There is a linear relationship between the number of fire fights (direct combat experiences), the number of deployments, and the severity of psychiatric symptoms returning service members experience. The rate of posttraumatic stress disorder (PTSD) and related psychiatric disorders among veterans who have served in recent combat, however, is only in the range of 10 to 18% (Nash, Krantz, Stein, Westphal, & Litz, 2011). This means that somewhere between 80 to 90% of returning service members are impacted by their combat experiences, but most evidence some level of resilience. Such evidence of resilience is not unique to military personnel. Bonanno (2004) documented that the upper level of post-trauma disorders following traumatic victimizing experiences is approximately 30%. In fact, resilience is the normative response to trauma experiences, whether the traumatic events are a natural disaster or due to accidents, illness, losses, or intentional human design—terrorist attacks, childhood sexual abuse, rape, domestic violence, and the like (Meichenbaum, 2006). Such evidence of resilience, or the ability to “bounce back,” the ability to continue forward and maintain equilibrium in the face of chronic adversity, the ability to live with ongoing fear and uncertainty, and the ability to adapt to the difficult and challenging life experiences is more the rule than the exception, more common than rare. Moreover, resilience is not a sign of exceptional strength, but a fundamental feature of normal coping, or what Masten (2001) characterizes as “ordinary magic.” Research has continually demonstrated from the time of World War I that veterans, as a group, resume normal lives and most (70%+) appraise the impact of their military service on their present lives as “mainly positive” and “highly important.” The majority of military spouses believe that deployment had strengthened their marriage, contributed to the development of new skills, as well as to a sense of independence and self-reliance. The children of military families are also typically resilient, even after experiencing significant trauma and family deaths (Sheppard, Malatras, & Israel, 2010; Wiens & Boss, 2006). Military Psychologists' Desk Reference, edited by Bret A. Moore, and Jeffrey E. Barnett, Oxford University Press, Incorporated, 2013. ProQuest Ebook Central, Created from adler on 2018-10-16 06:02:34. Copyright © 2013. Oxford University Press, Incorporated. All rights reserved. 326 part iv • clinical theory, research, and practice For example, studies of aviators who were shot down, imprisoned, and tortured for years by the North Vietnamese indicated that some 61% reported that the imprisonment had produced favorable changes, increasing their self-confidence, and teaching them to value the truly important things in life (Adler, Bliese, & Castro, 2011; Meichenbaum, 2011). Military organizations have been proactive and effective in putting into place a whole host of intervention programs designed to bolster resilience across the entire deployment cycle. Table 67.1, which was adapted from Pincus, House, Christensen, and Adler (2001), provides an illustrative (not exhaustive) list of resilience-bolstering interventions that have been developed. These programs may be implemented at the universal (primary), selected (secondary), or indicated (tertiary) levels, which, respectively, provide services for all service members and their families; for those identified as being in need or at high risk; and for those requiring more immediate and comprehensive services. These intervention programs require organizational policies and support that are designed to reduce risk, as in the case of sexual harassment and sexual assaults, reporting practices, and mental health services for victimized service members, or programs that are designed to provide stress inoculation training before deployment (Meichenbaum 2006; 2009). Whealin, Ruzek, and Southwick (2008) highlighted that such preparatory universal intervention programs should: 1. make future potential stressors more predictable so that when they occur, exposed individuals will perceive themselves to be more in control and more self-efficacious; 2. encourage more positive cognitive appraisals of potential stressful events by providing practice and mastery training; 3. teach emotion-regulation, stress management, and social problem-solving skills. Each of these military-based interventions incorporates the “building blocks,” or factors that research indicates are the prerequisites of resilience. In considering these components, it is important to keep in mind that post-trauma stress and resilience can coexist. Positive and negative emotions may co-occur, operating side-by-side following exposure to traumatic events. In fact, service members may be resilient in one domain of their lives, but not in other domains, or at one time in their lives and not at other times. Resilience is a dynamic, fluid process that develops over time, and its expression may be a slow developmental progression. There are multiple pathways to resilience, with no single dominant factor, or “magic bullet” that determines it. Rather resilience-engendering activities need to be practiced and replenished on a regular basis, so that such coping responses become automatic and incorporated into one’s repertoire. Moreover, one can think of not only resilient individuals, but also resilient families, communities, and resilient combat units. Strong unit cohesion that nurtures trust and high morale within the unit, a sense of connection and belongingness and perceived support, and units that have competent and concerned military leadership that instills confidence provide protective factors that promote resilience within their unit. Besides unit cohesion, some other resilienceengendering factors include social supports (“band of brothers/sisters,” peer and family supports); stress management techniques and proactive, as compared to avoidant, coping style; cognitive flexibility and an optimistic future orientation; 3:1 ratio of positive to negative emotions; and having a resilient-oriented mind-set. Meichenbaum (2012) has enumerated specific ways to bolster resilient behaviors in six domains of life—physical, interpersonal, emotional, cognitive, behavioral, and spiritual. The US Army Comprehensive Soldier Fitness (CSF) Program (see American Psychologist, January 2011—Volume 66, Number 1, and trains master resilience trainers, who are deployed in large organizational units on ways that service members can bolster personal strengths, control negative emotions, adopt a resilient mind-set and enhance relationships with loved ones. A major feature of CSF is the way it provides service members with individualized feedback, using the Global Assessment Tool (GAT) that can guide self-paced training Military Psychologists' Desk Reference, edited by Bret A. Moore, and Jeffrey E. Barnett, Oxford University Press, Incorporated, 2013. ProQuest Ebook Central, Created from adler on 2018-10-16 06:02:34. 67 • ways to bolster resilience across the deployment cycle 327 table 67.1. Stages of Deployment and Illustrative Resilience-Bolstering Interventions Stage PREDEPLOYMENT The notification of deployment to the point of departure. SUSTAINMENT From the end of the first month through to the final month of deployment. REDEPLOYMENT Month preceding homecoming to home arrival Copyright © 2013. Oxford University Press, Incorporated. All rights reserved. POSTDEPLOYMENT Arrival home to 6 months. Tasks Possible Interventions Service member and family preparation, accompanying responsibilities and reactions 1. Military training program 2. Comprehensive Soldier Fitness Program (CFP) 3. Battlemind Programs (War Resiliency Programs) for service members and spouses. 4. Family Readiness campaigns that establish both patterns of communication and service members’ ongoing presence in the family. 5. Family Organizational Plans Handle a variety of deployments and home-front stressors. 1. 2. 3. 4. 5. Initial readjustment, altered routines, altered family responsibilities, communication. 1. 2. 3. 4. Renegotiate roles, Establish new routines. Cope with injuries, losses and postcombat reactions. 1. Yellow Ribbon Reintegration Program. 2. Coming Together around Military Families (CTAMF). 3. Families Overcoming under Stress Combat Injury (FOCUS-CI) 4. Sesame Street Workshop—Talk, Listen, Connect. Also bibliotherapy for children. 5. Army couples’ expressive writing project. 6. Evidence-based treatment programs for PTSD, substance abuse, couples therapy. 7. Telehealth programs. Mental Health Advisory Teams (MHAT) Trauma Risk Management Programs (TRIM) Small Unit After-Action Reviews Battlemind Debriefing Combat and Operational Stress, First Aid and Control (COSC), (PIE’s interventions, Proximity, Immediacy, Expectation) 6. Navy and Marine Corps Combat Intervention Programs 7. Bereavement groups, Memorial and ceremonial services 8. Provide Work-rest cycles, Sleep management, Substance abuse programs, R&R Prepare for reintegration stressors. Information about resources and services. Address barriers to help- seeking. Educate about Web-based resources (e.g., Military One Source) (Stage Model Adapted from Pincus et al., 2001) modules. While initial results of the CSF have been promising, a more complete evaluation of this $120 million initiative is now underway (Nash et al., 2011). At the military family level for Active Duty service members, Wiens and Boss (2006) have enumerated a number of protective factors including access to comprehensive health care, educational services, legal assistance, consistent employment, and a host of on-base and online organizations that have been specifically created to provide support to families, as well as high levels of community supports. For the families of National Guard members, because of their geographical dispersement, additional out-reach intervention programs have been established such as the Yellow Ribbon program, Military One Source, (; http://www.militaryonesource. com), and the like. The importance of such intervention efforts is underscored by the findings that married service members are three times more likely than single service members to meet diagnostic criteria for PTSD and 2.7 Military Psychologists' Desk Reference, edited by Bret A. Moore, and Jeffrey E. Barnett, Oxford University Press, Incorporated, 2013. ProQuest Ebook Central, Created from adler on 2018-10-16 06:02:34. 328 part iv • clinical theory, research, and practice times more likely to be clinically depressed. Deployed soldiers report that home-front stressors are a major contributor to their levels of stress when deployed (Adler et al., 2011). Resilience-engendering programs need to take these risk and protective factors into account and reduce the barriers such as stigma associated with help-seeking, as well as practical barriers (transportation, child care, easier access) (Meichenbaum, 2009). Copyright © 2013. Oxford University Press, Incorporated. All rights reserved. RECOMMENDATIONS Finally, it is worth highlighting that the present assessment approach for returning service members is designed to identify the self-reported presence of psychiatric symptoms on the postdeployment health assessment (PDHA) and postdeployment health reassessment (PDHRA). Given that the normative reaction to deployment is resilience, it would be useful to systematically and routinely assess for what “signs of resilience” returning service members and their families evidence. For example, see the Posttraumatic Growth Inventory ( cfm). In what ways has the exposure to combat and related deployment activities actually strengthened individuals, families and contributed to their growth? There is a need to convey an explicit message to all service members and their families that as a result of deployment they are likely to become more resilient. That which gets assessed, usually gets attended to and highlighted (Meichenbaum, 2011, 2012). References Adler, A. B., Bliese, P. D., & Castro, C. A. (Eds.). (2011). Deployment psychology: Evidence-based strategies to promote mental health in the military. Washington, DC: American Psychological Association. Bonanno, G. A. (2004). Loss, trauma, and human resilience: Have we underestimated the human capacity to thrive after extremely aversive events. American Psychologist, 59, 20–28. Masten, A. S. (2001). Ordinary magic: Resilienceprocesses in development.American Psychologist, 56, 227–238. Meichenbaum, D. (2006). Resilience and posttraumatic growth: A constructive narrative perspective. In L. G. Calhoun & R. G. Tedeschi (Eds.), Handbook of posttraumatic growth (pp. 355–368). Mahwah, NJ: Erlbaum. Meichenbaum, D. (2009). Core psychotherapeutic tasks with returning soldiers: A case conceptualization approach. In S. Morgillo Freeman, B. A. Moore, & A. Freeman (Eds.), Living and surviving in harm’s way: A psychological treatment for pre- and post-deployment of military personnel (pp. 193–210) New York, NY: Routledge. Meichenbaum, D. (2011). Resiliency building as a means to prevent PTSD and related adjustment problems in military personnel. In B. Moore & W. E. Penk (Eds.), Treating PTSD in military personnel (pp. 325–344). New York, NY: Guilford Press. Meichenbaum, D. (2012). Roadmap to resilience: A guide for military, trauma victims, and their families. Clearwater, FL: Institute. Nash, W., Krantz, L., Stein, P., Westphal, R. J., & Litz, B. (2011). Comprehensive soldier fitness, battlemind, and the stress continuum model: Military organizational approaches to prevention. In J. I. Ruzek, P. P. Schnurr, J. J. Vasterling, & M. J. Friedman (Eds.), Caring for veterans with deployment-related stress disorders: Iraq, Afghanistan, and beyond (pp. 193–214). Washington, DC: American Psychological Association. Pincus, S. H., House, R., Christenson, J., & Adler, L. E. (2001). The emotional cycle of deployment: A military family perspective. U.S. Army Medical Department Journal, 4/5/6, 15–23. Sheppard, S. C., Malatras, J. W., & Israel, A. C. (2010). The impact of deployment on U.S. Military families. American Psychologist, 65, 599–609. Whealin, J. M., Ruzek, J. I., & Southwick, S. (2008). Cognitive-behavioral theory and preparation for professionals at risk for trauma exposure. Trauma, Violence, and Abuse, 9, 100–113. Wiens, T. W., & Boss, P. (2006). Maintaining family resiliency before, during, and after military separation. In C. A. Castro, A. D. Adler, & C. A. Britt (Eds.), Military life: The psychology of serving in peace and combat (Vol. 3, pp. 13–38). Bridgeport, CT: Praeger Security International. Military Psychologists' Desk Reference, edited by Bret A. Moore, and Jeffrey E. Barnett, Oxford University Press, Incorporated, 2013. ProQuest Ebook Central, Created from adler on 2018-10-16 06:02:34. Copyright American Psychological Association. Not for further distribution. 7 Fostering Resilience Across the Deployment Cycle Neil Greenberg The previous chapter in this volume focused on building resilience before one encounters extraordinary demands of deployment, and earlier chapters address the importance of cohesion, morale, and leadership in fostering resilience. This chapter reviews additional opportunities to build resilience across the deployment cycle while acknowledging a number of important gaps in the available empirical evidence. Focusing attention on building resilience around the deployment cycle has intuitive advantages: First, it could provide “just in time” training prior to deployment, where it will be needed most. If the effects of resilience training are in part transient (Seligman & Fowler, 2011), offering such training close to when it will be needed may be most effective. Predeployment training and exercises also provide an opportunity to immediately apply and reinforce resilience through practice of what is learned in resilience training (Reivich, Seligman, & McBride, 2011). Finally, The composition of this chapter would not have been possible without the expert advice and guidance from Dr. Mark Zamorski, whose input is highly appreciated. Building Psychological Resilience in Military Personnel: Theory and Practice, R. R. Sinclair and T. W. Britt (Editors) Copyright © 2013 by the American Psychological Association. All rights reserved. 137 resource-intensive interventions could be provided only to those who are actually likely to deploy in the near future, as opposed to the larger military population. Copyright American Psychological Association. Not for further distribution. The Predeployment Period The predeployment period provides a number of potential opportunities to foster resilience. This section concentrates on two possible mechanisms: predeployment mental health screening and predeployment mental health briefings. Predeployment Psychological Screening Although predeployment psychological screening does not promote resilience per se, it aims to achieve the same end (i.e., limiting the psychological impact of deployment). Because there are measurable psychological factors associated with resilience, “screening in” personnel who report more of those factors might lead to a more resilient deployed force. Specific military groups, such as snipers (Girard & Scholtz, 2005) and Special Forces (Burwell, 1999), already use this approach, and advocates of screening might argue that if screening works for these groups, it should work for the general military population. However, this view may be too simplistic. Predeployment psychological screening could theoretically serve two distinct purposes. First, it could ensure adequate performance while deployed by weeding out those who will be unable to respond to the demands of deployment. Second, it could ensure long-term mental health after return by preventing nonresilient individuals from deploying. While both purposes are valuable aims, they often get conflated. Some authors have argued that assuring performance while deployed will optimize favorable long-term mental health (Grossman & Christensen, 2004). Although an important minority of service members will succumb to mental health problems as a result of their deployment (Institute of Medicine, 2000), most of these individuals apparently performed adequately while deployed, as evidenced by the low rates of repatriation (Ritchie, 2007; Rundell, 2006). Good operational performance is thus not sufficient to ensure good long-term mental health. World War II–era data are often cited as evidence that screening for psychological vulnerability is ineffective (E. Jones, Hyams, & Wessely, 2003). However, the applicability of this finding to current times is limited because of scientific advances in many relevant areas over the past 60 years. Moreover, that (and other) research has focused exclusively on short-term performance 138       neil greenberg Copyright American Psychological Association. Not for further distribution. as an outcome, and psychological screening to predict military performance is likely always to be weak relative to other screening and selection mechanisms such as routine supervision and evaluation during realistic training. The potential value of screening to predict long-term mental health is harder to dismiss out of hand. In research settings (where confidentiality and freedom from consequences of disclosure are ensured), predeployment impaired well-being is a modest predictor of postdeployment well-being (Leardmann, Smith, Smith, Wells, & Ryan, 2009; Rona et al., 2006; Sandweiss et al., 2011). Practical experience with predeployment screening for the prevention of deployment-related mental health problems has, however, been largely disappointing. For example, evaluation of an intensive predeployment screening process examined more than 5,000 Canadian personnel preparing for a peacekeeping deployment to Kabul, Afghanistan (Zamorski, Galvin, & Humeniuk, 2007). Less than 1% of those screened were deferred from deployment because very few reported problems; estimated predeployment prevalence rates of mental health problems were unrealistically low (Zamorski, Uppal, Boddam, & Gendron, 2006). Data from a recent U.K. study (Hacker Hughes et al., 2005) also showed that very few members reported problems during predeployment screening, and a recent U.S. study showed that there was substantial underreporting of recent mental health care use on predeployment screening forms (Nevin, 2009). In a U.S. screening trial, a higher proportion (21%) reported problems during predeployment screening (Wright et al., 2005). However, after a more detailed clinical evaluation, very few of those with positive screening tests were judged to have a problem serious enough to require deferral of deployment. This observation invites three possible explanations. The screening instruments might have been overly sensitive, but this seems unlikely because the tests used were reasonably specific. It is also possible that the screening tests accurately identified those with mental health problems, but these problems were not severe enough to have precluded deployment. Finally, it is possible that the operational imperative made it difficult to make the right decision with respect to deployment. This hypothesis is supported by the finding that many of those who initially screened positive were deemed to have “misunderstood” the question after further questioning. Although the available data do not indicate which of these explanations is correct, it is clear that in some contexts service members are willing to disclose psychological symptoms during predeployment screening. This refutes the criticism that screening cannot work simply because no one will disclose (Rona, Hyams, & Wessely, 2005). It does not, however, address the question as to whether the “right” people will disclose: Some of those who disclose might be healthy people who are simply unmotivated, and some of those who fail to disclose might be ill people who are motivated to deploy. fostering resilience across the deployment cycle      139 Three factors conspire to make screening for psychological vulnerabilities ineffective in real-world circumstances: 77 Copyright American Psychological Association. Not for further distribution. 77 77 The association between self-reported premorbid psychological factors and long-term mental health is modest (Brewin, 2005; Brewin, Andrews, & Valentine, 2000; Rona et al., 2006; Vogt, Proctor, King, King, & Vasterling, 2008). Routinely used screening tests are transparent and hence subject to reporting bias. These tests may thus better reflect motivation to deploy than fitness to deploy and might also be influenced by stigma-related concerns. Finally, the prevalence of adverse mental health outcomes is, in most cases, modest. Researchers are trying to identify that small fraction of people in the general military population who might become ill as a direct result of their deployment and go on to have long-term disability; this prevalence rate will be well below the 15% to 20% of combat troops who disclose symptoms shortly after their return (Hoge et al., 2004). Epidemiological longitudinal data from the United States showed that only 4% of service members deployed to Afghanistan or Iraq had new-onset posttraumatic stress disorder (PTSD; Smith et al., 2008); many of these individuals will go on to recover more or less fully. In a time of high operational tempo, commanders will be understandably intolerant of false positives and will reasonably demand that burdensome screening prevent a significant fraction of postdeployment mental health problems. The inescapable trade-off between sensitivity and specificity makes these competing goals: Highly sensitive screening tests correctly identify a large fraction of nonresilient individuals, but they result in large numbers of false positives (i.e., resilient individuals being identified as nonresilient). Highly specific tests correctly identify almost all resilient individuals, but they result in large numbers of false negatives (i.e., nonresilient individuals being misidentified as resilient). False positives are particularly problematic when the prevalence of the outcome (nonresilience) is low. A screening process with 80% sensitivity (a sensitive test is able to detect all real cases) and 80% specificity (a completely specific test does not have to provide any false positives) implies an odds ratio of 16, which is huge in epidemiological terms. Such a process would prevent 80% of cases. However, at an outcome prevalence rate of 5% it would also preclude the deployment of 23% of the cohort, and five out of six of those excluded would be false positives. Faking would worsen this performance. These concerns notwithstanding, one recent study comparing an intensive predeployment screening process in one Army division with a conven140       neil greenberg Copyright American Psychological Association. Not for further distribution. tional approach in a similar division preparing for a similar deployment showed that though only 0.7% were precluded from deployment and only 0.9% deployed with “additional requirements,” those screened more intensively had dramatically more favorable mental health outcomes (Warner, Appenzeller, Parker, Warner, & Hoge, 2011). For example, they received care for psychiatric disorders while deployed at far lower rates (2.9% vs. 13.2%). The mismatch between the low deferral rate and the substantial apparent impacts on mental health could reflect ancillary benefits of the screening (and subsequent targeted care) or significant underlying differences between the two divisions. Although encouraging enough to warrant further investigation, this evidence is not strong enough to drive systematic changes in screening policy. Predeployment Briefings Deploying troops are often briefed about psychological matters, with the intention of helping to maintain their psychological health. These briefings presumably include education about the nature of traumatic stress, mechanisms for coping with separation from family and dealing with culture shock, and education about how to seek care if needed and related topics. The evaluation of the effectiveness of these briefings is very limited: In the United Kingdom, an opportunistic, nonrandomized study found no evidence that predeployment mental health briefings had any effect on long-term subsequent mental health status (Sharpley, Fear, Greenberg, Jones, & Wessely, 2008). However, studies that have examined the impact of such briefings while troops are deployed show a somewhat different picture. A study of U.S. soldiers who received a specific predeployment briefing package called Battlemind felt significantly more prepared for dealing with combat stress and were also much less likely to report mental health symptoms while deployed (U.S. Office of the Surgeon General, 2008). A U.K. study found similarly that troops who had received predeployment briefing were less likely to report mental health problems while deployed than troops who had not. However, in both studies, assignment to the predeployment briefing condition was not random, and the apparent benefit may be due to factors other than the training itself. During Deployment As alluded to in Chapter 4 of this volume, the tools of morale, cohesion, good leadership, and effective training work their magic during deployment to mitigate distress and enhance performance. Given that most service members appear to manage their distress well enough to perform adequately while fostering resilience across the deployment cycle      141 Copyright American Psychological Association. Not for further distribution. deployed, these tools appear to be largely working as they should and are all that are needed for the majority of service members. This crucial aspect of operational stress management should not be medicalized: Military leaders need to be squarely in charge of helping those under their command perform under the extreme but foreseeable demands of deployment; this requires that leaders find ways of preventing, recognizing, and managing distress in their subordinates (Britt, Davison, Bliese, & Castro, 2004). But there will always be an important minority for whom these important tools will not be enough. Mental Health Problems During Deployment Symptoms of mental health problems are common in personnel deployed on combat operations. The richest data come from the U.S. Army Mental Health Advisory Team (MHAT) reports and the U.K. Operational Mental Health Needs Evaluation (OMHNE). Over the past 5 years, between 13% and 19% of U.S. personnel surveyed during deployment have reported symptoms of anxiety, depression, or acute traumatic stress (U.S. Office of the Surgeon General, 2008); similar figures have been found in deployed populations of U.K. troops (Mulligan et al., 2010). Not surprisingly, mental health problems influence performance while deployed. Substantial fractions of frontline combat troops reported that stress or emotional problems limited their ability to do their job (15%), made them work less carefully (23%), or made their supervisor concerned (13%; U.S. Office of the Surgeon General, 2008). Those who reported mental health symptoms were also substantially more likely to report having committed unethical behavior while deployed (U.S. Office of the Surgeon General, 2006). Barriers to Mental Health Care on Deployed Operations Service members commonly report barriers to accessing mental health care while deployed, due to attitudinal, geographic, and logistical factors. These include stigma, fear of career impact, unsupportive leadership, lack of trust in mental health providers, geographical isolation, difficulty getting time off work, and difficulty getting appointments. As a result, only 40% of respondents who reported problems had actually sought care (U.S. Office of the Surgeon General, 2006). Building Resilience During Deployment by Facilitating Mental Health Care and Support One strategy to build resilience (or more properly to restore it) involves overcoming the barriers to mental health care while deployed. To this end, 142       neil greenberg Copyright American Psychological Association. Not for further distribution. the United States (Ritchie, 2007; U.S. Office of the Surgeon General, 2008), Canada, and the United Kingdom (McAllister, Blair, & Philpott, 2004) all deploy mental health clinicians on major operations. The ratio of providers to deployed personnel varies: Estimates include 1:2,500–4,000 in the United Kingdom (Fertout et al., 2011), 1:700 in the United States (U.S. Office of the Surgeon General, 2008), and 1:500–600 in Canada (Lt. Col. R. Jetly, personal communication, November 26, 2008).The United States has modestly increased the number of deployed mental health providers over the past few years (U.S. Office of the Surgeon General, 2003, 2006), and this has been associated with significant increase (29% vs. 40%) in the fraction of those with symptoms who had sought care in theater (U.S. Office of the Surgeon General, 2003, 2006). This favorable trend cannot be reliably attributed to an increase in the number of providers, because other system-level changes (e.g., greater emphasis on mental health training) occurred at the same time. But it would be wrong to assume that the responsibility for the mental health of personnel lies with mental health professionals. Rather, it is better to conceptualize an individual’s resilience to withstand the operational environment as coming from a number of sources, including the unit in which he or she serves. Within the U.K. Armed Forces, for instance, the psychological welfare of troops is, doctrinally, a chain of command responsibility (Greenberg, Jones, Jones, Fear, & Wessely, 2011).The role of clinicians is to support the unit imperative to maintain personnel’s health. Peers are another potential source of nonprofessional support. Service members are much more likely to turn to a peer for help than to a mental health provider or chaplain, both on deployment (U.S. Office of the Surgeon General, 2003) and afterward (Greenberg et al., 2003). The U.K. Royal Marines have attempted to leverage this through their Trauma Risk Management (TRiM) program, which trains nonmedical personnel in psychological risk assessment and referral (Greenberg, Cawkill, & Sharpley, 2005). Although one aim of the TRiM program is to reduce stigma, the randomized evaluation study did not confirm widespread stigma change 12 to 18 months after TRiM training (Gould, Greenberg, & Hetherton, 2007); nor did it influence the primary outcome of psychological well-being. It was, however, well accepted and appeared to show some benefits in terms of organizational functioning (Greenberg & Langston, 2007). It may be that the study did not continue for long enough or that the personnel surveyed (sailors aboard ship) had too little trauma exposure to see any benefits (Greenberg & Langston, 2007). Although some enthusiasm about the potential of nonprofessionals to extend and complement the care of professionals is appropriate, this approach has potential risks; if service members are encouraged to seek such help, military organizations must ensure that the nonprofessional guidance given is sound. The preference for service members to turn to peers for help with fostering resilience across the deployment cycle      143 Copyright American Psychological Association. Not for further distribution. psychosocial problems should be taken with a grain of salt; just because they might prefer nonprofessional care does not mean that this is what they need. The limited social distance between peers is both an asset and a potential liability here; it might be hard for a peer to do the right thing and tell his buddy that he or she needs some professional help. If those with potentially serious problems are inappropriately reassured, genuine harm may occur. Because of their stronger confidentiality protections and their direct integration into military units, military chaplains are presumed to bridge the void between the desires for help of distressed service members and their concerns about what might happen if they sought it out. A similar role can be played by a number of other military personnel, such as welfare officers, trusted leaders, and indeed medical staff, though confidentiality protection may not be as strong as it is with chaplains. Critical Incident Stress Debriefing Critical Incident Stress Debriefing (CISD) was initially a group-level intervention designed to meet psychological needs in the aftermath of a “critical incident,” such as a serious automobile accident, a fire, or a natural disaster. CISD can be provided by trained laypersons or by mental health professionals and is intended to follow a rigid, seven-step process over 2 to 3 hours (Mitchell & Everly, 2001). CISD was implemented widely in some military organizations; until recently, the Canadian military required that CISD occur after each and every “critical incident” (Department of National Defence, 1994). Formal evaluation of CISD shows that although it is well received by nearly all participants (Mitchell & Everly, 2001), there is no beneficial effect on PTSD or depression, and some studies have suggested the potential for harm (McNally, Bryant, & Ehlers, 2003; Rose, Bisson, & Wessely, 2003; van Emmerik, Kamphuis, Hulsbosch, & Emmelkamp, 2002). But these studies have been criticized by CISD proponents, who have pointed out that the protocol used, the target population, the context, and the outcomes measured differed from those intended by its developers (Bisson, Brayne, Ochberg, & Everly, 2007). Randomized trials of psychological debriefing in military populations have been recently reported. In U.S. peacekeepers with limited trauma exposure, CISD did not promote (or retard) recovery compared with a conventional stress education lecture; soldiers did evaluate CISD more favorably (Adler et al., 2008). Subsequent work with U.S. personnel returning from a demanding combat deployment showed that in comparison with a conventional stress lecture, a modified form of group CISD facilitated recovery in a number of domains (Adler, Bliese, McGurk, Hoge, & Castro, 2009); benefits 144       neil greenberg were seen only in those who had more exposure to traumatic events while deployed. These results are encouraging, but additional validation is needed before CISD is widely implemented as standard practice for service members during or after deployment. Copyright American Psychological Association. Not for further distribution. Cognitive Behavioral Therapy In traumatized civilians with acute stress disorder or acute PTSD, shortterm, trauma-focused cognitive behavioral therapy (CBT) dramatically hastens recovery and (far less dramatically) decreases the fraction afflicted with PTSD 1 year later compared with supportive psychotherapy (Ehlers & Clark, 2003; McNally et al., 2003; National Collaborating Centre for Mental Health, 2005). Short-term CBT should be applied only to those who have significant posttrauma symptoms lasting more than a few weeks (McNally et al., 2003; National Collaborating Centre for Mental Health, 2005). Of note, simple provision of an educational handout appears ineffective (Ehlers et al., 2003; Scholes, Turpin, & Mason, 2007; Turpin, Downs, & Mason, 2005). There are no similar CBT studies in military personnel, and there would be numerous logistical barriers to delivering CBT while deployed. Nevertheless, the promise of being able to shorten the duration of symptoms (and, presumably, of dysfunction) is appealing, even if the effects on long-term PTSD prove to be limited. The Postdeployment Period Although coming home from a difficult deployment is generally a huge relief, many service members find parts of this process difficult, particularly in the first weeks to months after return (Adler et al., 2009; Adler, Zamorski, & Britt, 2011). Redeploying service members experiencing transition difficulties or reintegration problems represent a heterogeneous group. Some are fundamentally healthy people having more or less normal reactions to major changes in their physical and social environment. In addition, there are some individuals with minor psychosocial difficulties or with self-limiting distress. Finally, there is an important minority with a broad range of diagnosable deployment-related mental health problems. These three groups map roughly to Bonanno’s (2004) concept of resistance, resilience, and recovery after traumatic events. Each group has different needs. The first (resistant) group does not need professional help. The second (resilient) group might benefit from watchful waiting or perhaps some education or supportive therapy. The third (ill) group needs formal mental health care. Educational programming has to tell those in the first two groups to fostering resilience across the deployment cycle      145 Copyright American Psychological Association. Not for further distribution. worry less and those in the last group to worry more about their mental health. An additional challenge is that the needs of individuals within a given group will also vary substantially, due to differences in personality, deployment and other life experiences, the timing relative to return from deployment, and the social environment. The central challenge of the postdeployment period is to find ways to match programs to the diverse and changing needs of this heterogeneous population. Decompression and Reintegration Programs There is a strong consensus that the early phases of reintegration after a difficult deployment are associated with at least some discomfort in many returning service members (Adler et al., 2009, 2011). Some authors (Fontana & Rosenheck, 1994) have suggested that in addition to being temporarily unpleasant, negative reintegration experiences may be potentially toxic, in the sense that they cause mental health problems. This argument is grounded in homecoming experience of U.S. veterans of the Vietnam War (Shay, 2002), and it is supported by the observation that negative homecoming experiences were strongly associated with current psychopathology (Fontana & Rosenheck, 1994). However, this research is bias prone, relying largely on cross-sectional surveys done years after the end of the war. Even when one ignores the very real risk of recall bias, reliably interpreting the direction of causation here is impossible. Although it is plausible that negative homecoming experiences resulted in later mental health problems, it is virtually certain that those who had mental health problems had more difficult homecoming experiences because they were mentally ill at the time or because a common substrate (e.g., negative affectivity) confers susceptibility to negative homecoming experiences as well as mental health problems. Notwithstanding Fontana and Rosenheck’s (1994) audacious assertion that theirs is a “causal” model, no amount of theoretical rigor or statistical wizardry can exclude these important sources of bias in cross-sectional research done years after the events of interest. The best longitudinal research on this topic in U.S. soldiers returning from Iraq showed that transition problems and mental health problems are indeed separate (though correlated) constructs; transition problems alone shortly after return did not independently predict later mental health problems (Adler et al., 2011). Whether transition experiences are simply unpleasant or truly toxic, military organizations have taken an interest in making transition easier for service members and their families, through third-location decompression (TLD) programs, educational programming, and a graded return to home life once home. 146       neil greenberg Copyright American Psychological Association. Not for further distribution. Third-Location Decompression Programs In the past, the gradual winding down of hostilities and the long return home by sea meant that the transition home occurred more gradually, in theory permitting redeploying service members to deal with some of the challenging aspects of the reintegration process sequentially rather than simultaneously. TLD programs attempt to achieve the same result by providing returning service members a brief pause in a restful location on the way home. This usually involves some educational programming (Garber & Zamorski, 2012; Hacker Hughes et al., 2008), making it difficult to disentangle the benefits of such programming from the nonspecific rest and recreation benefits of the decompression per se. The stated purpose of Canada’s TLD program is to make the reintegration process easier for redeploying personnel and their families; the program is not framed as a preventive measure against PTSD. Since the program’s inception in 2006, more than 20,000 service members returning from a combat and peace support mission in Kandahar Province, Afghanistan, have spent 5 days in a hotel in Cyprus, receiving 3 to 4 hours of educational programming (including a version of the U.S. Battlemind program; Adler et al., 2009).The main focus of the program, however, is rest and recreation. Support for the TLD concept among Canadian participants is high, with 95% agreeing that “some form of TLD is a good idea” (Garber & Zamorski, 2012, p. 397). Overall satisfaction with the program as a whole is also high, with 81% finding it valuable and 83% recommending it for future rotations to Afghanistan. Educational programming is well received, with 74% being satisfied at the end of the program. Approximately 1,800 participants from two TLD rotations were resurveyed 6 months after return; satisfaction was, if anything, higher with the passage of time (Garber & Zamorski, 2012).The most consistently identified benefits of the program were that it had made the reintegration process easier (74%) and that it had helped participants realize that there was nothing wrong with getting help for mental health problems (75%); this is also a central message of the Battlemind program (Adler et al., 2009). Other nations have reported favorable responses to their TLD programs, even though the content of these programs differs substantially (Garber & Zamorski, 2012; Hacker Hughes et al., 2008). For example, satisfaction is high with the U.K. program, which takes place within a restricted number of military-only areas in Cyprus and lasts a mere 36 hours (N. Jones, Burdett, Wessely, & Greenberg, 2011). Although a definitive randomized trial has not been conducted, there are strong data to suggest that TLD programs are well received by redeploying service members and are perceived to have made the reintegration process easier for them. Whether this level of evidence is sufficient to sustain a TLD program fostering resilience across the deployment cycle      147 depends on how it is framed. If it is conceptualized as a medical intervention to prevent mental health problems, stronger evidence of efficacy (e.g., a randomized trial) might be required. If it is instead cast as a human resources benefit (e.g., midtour leave), the consistently favorable evaluation of TLD may suffice. Copyright American Psychological Association. Not for further distribution. Postdeployment Educational Programs These educational programs aim to help returning service members better understand the reintegration process, to normalize it, to make sense of the confusing ambivalence that characterizes it, and to help service members prevent conflicts and problems by enhancing adaptive coping (Adler et al., 2009). There is generally also some discussion of warning signs of mental health problems and how to access care if needed. The evaluation of nearly all such programs consists (at most) of brief user acceptability ratings immediately afterward rather than careful assessment of the target outcomes of easier reintegration or prevention of mental health problems. An exception to this is an observational study from the United Kingdom that showed that nonreceipt of a homecoming brief was indeed associated with poorer mental health (Iversen et al., 2008). This study also showed that only those who viewed the briefing as being helpful showed evidence of benefit, suggesting that the quality of the briefing matters. A randomized controlled trial of a novel psychoeducational approach (Battlemind; Adler et al., 2009) showed favorable acceptability ratings and evidence of modest efficacy several months later across several psychosocial outcomes, though only in those who had heavy combat exposure. The program (particularly the video version) is strongly rooted in American culture (accents, idioms, settings) and the American experience in Operation Enduring Freedom in Afghanistan. But, as noted previously, Canadians (including Francophone Canadians) also found the program valuable, and a high-quality U.K. trial of Battlemind versus standard psychoeducation briefings, delivered during decompression, found that those in the Battlemind group were less likely to misuse alcohol than those in the control arm 4 to 8 months after receiving the brief (Mulligan et al., 2012). The U.S. Marine Corps uses a different educational paradigm, called the Warrior Transition Program (U.S. Marine Corps, 2008).The program is said to have high user acceptability ratings (Hawes, 2003), though the single qualitative evaluation of the program showed decidedly uneven satisfaction (Buchanan, 2005).There are no published evaluations of its mental health impact. Graded Return to Work The last commonly used approach to easing the reintegration process consists of human resources policies that make the return to home life a 148       neil greenberg Copyright American Psychological Association. Not for further distribution. little more gradual once the service member is home. The central feature of these policies is several days to several weeks of work before commencing postdeployment leave; this is used for various tasks related to wrapping up the deployment (e.g., cleaning and returning equipment, medical exams, paperwork). There has been only limited evaluation of these approaches; researchers in the United Kingdom (Academic Centre for Defence Mental Health, 2009) showed no association between completion of a heterogeneous set of decompression/reintegration interventions and postdeployment mental health status. Australia reported a small study on the outcomes of service members who, for various reasons, happened to complete a TLD program, a reintegration program (along the lines of the above), both, or neither (Field, 2005). Reasonable satisfaction was found with the interventions, though those who had both TLD and reintegration valued the decompression portion more highly. There was no difference in distress scores 6 months after their return. One consistent comment on reintegration policies in general is that reservists and individual reinforcements from other bases object to having to spend additional time away from their families when the reintegration approach occurs at a base far from their home (Academic Centre for Defence Mental Health, 2009; Field, 2005). Postdeployment Screening Postdeployment mental health screening is widely performed but highly controversial. This section reviews the theoretical rationale for screening, the findings of mental health screening programs in both military and nonmilitary settings, and the remaining uncertainties and controversies in this important area. The argument for postdeployment mental health screening is as follows: Mental health problems are highly prevalent and are leading causes of disability, impaired productivity, and impaired well-being (Demyttenaere et al., 2004). Mental health problems are thus of interest to any large employer, but they are of particular interest to the military for three reasons. First, they can be a consequence of military activities, so the military has a due-diligence or duty of care requirement to minimize these problems to the extent possible. Second, they can cause deficits in areas such as memory, concentration, judgment, reasoning, and goal-directed behavior, which can influence operational safety and effectiveness. Finally, they are strong risk factors for separation from military service (Creamer et al., 2006; Hoge et al., 2002, 2005) and this at a time when most military forces are experiencing unusual pressures for retention of experienced staff. As alluded to above, some deployments are associated with an increased risk of a broad range of mental health problems, particularly PTSD, depression, fostering resilience across the deployment cycle      149 Copyright American Psychological Association. Not for further distribution. and their comorbidities (Institute of Medicine, 2000). Effective treatments for many common mental health problems exist, but only a minority of those who could benefit from care actually receive care (Fikretoglu, Guay, Pedlar, & Brunet, 2008; Hoge et al., 2004; Sareen et al., 2007). Many barriers have been identified to explain this gap (Fikretoglu et al., 2008; Hoge et al., 2004; Sareen et al., 2007), but one of the most important appears to be that many mentally ill individuals do not appear to realize they have a problem for which they need help. This problem may account for approximately 90% of unmet need (Fikretoglu et al., 2008). Widely available, brief screening tests with acceptable performance characteristics exist (Brown, Leonard, Saunders, & Papasouliotis, 2001; Löwe, Kroenke, & Gräfe, 2005; Ouimette, Wade, Prins, & Schohn, 2008), and some have been cross-validated in military populations and even in the postdeployment context (Bliese, Wright, Adler, Thomas, & Hoge, 2004). Initially, there was concern that few personnel would disclose their problems. The experience, though, has been otherwise. In the United States, 27% of soldiers returning from Iraq disclosed symptoms suggestive of one or more psychosocial problems on their 3- to 6-month postdeployment screening (Milliken, Auchterlonie, & Hoge, 2007); in Canada, 12% of service members who returned from deployment in support of the mission in Afghanistan have reported symptoms suggestive of one or more common mental health problems (Zamorski, 2011). The issue of deception during postdeployment screening was directly explored by a randomized trial that showed that anonymous screening resulted in only slightly higher rates of reported symptoms, and it was the least affected individuals who were most likely to under­ report (Thomas, Bliese, Adler, & Wright, 2004). However, a more recent study showed larger differences (McLay et al., 2008). Some have argued that even if problems are identified by screening, stigma, lack of confidence in the military, or other barriers will prevent those identified during screening from actually accessing care (Rona et al., 2005). This is not the case in the United States; 35% of U.S. Iraq and Afghanistan returnees sought formal care for a mental health problem in the first year after their return (Hoge, Auchterlonie, & Milliken, 2006). The largest fraction of individuals who did seek care consisted of those for whom no follow-up had been recommended during the screening; they disproportionately sought care in the first month after screening, suggesting that it may have influenced later care seeking in those who did not initially disclose problems or who refused care. U.S. surveys have also shown substantial levels of support for mental health screening among the rank and file (Warner, Appenzeller, Mullen, Warner, & Grieger, 2008). In Canada, 30% of a large, diverse cohort of previously deployed personnel sought specialty mental health care over an 150       neil greenberg Copyright American Psychological Association. Not for further distribution. average of 4.5 years after their return (Boulos & Zamorski, 2011). The unique contribution of screening to this high rate of care seeking is unclear and is difficult to assess without a randomized trial. For screening to work, the system must have the capacity to deliver a sufficient volume of high-quality care, should individuals present for it. This is a major problem in the United States (U.S. Department of Defense Task Force on Mental Health, 2007): Iraq returnees seeking mental health care in the first year after return received only 3 visits each, on average, including primary care visits (Hoge et al., 2006). This seems unlikely to be sufficient to meet the likely substantial clinical needs of this population, approximately 17% of which reported symptoms suggestive of PTSD (Milliken et al., 2007). In Canada, however, service members with mental health problems were significantly more likely than their general population counterparts to have received mental health care in the previous 12 months (Zamorski et al., 2006). This suggests that although service members may have special barriers to care, special access to care can overcome them. Proponents of screening also point to high-quality studies that show that screening for depression and high-risk drinking can be effective in primary care settings, although only if certain conditions are met (U.S. Preventive Services Task Force, 2004). This has led several national groups to recommend such screening (U.S. Preventive Services Task Force, 2004). Screening for PTSD has also been shown to be superior to usual care in adults with serious physical trauma (Zatzick et al., 2004). There is preliminary evidence of benefit for screening in the primary care setting for unexplained physical symptoms (Dickinson et al., 2003), which are common after some deployments (Hyams, Wignall, & Roswell, 1996). The weakest link in the chain of evidence supporting postdeployment screening is the uncertainty about whether earlier treatment results in a more favorable long-term outcome. Certainly, early treatment should be able to truncate the period of suffering, which can be prolonged. In 2002, Canadian Forces members with service-related PTSD had a median delay between symptom onset and initiation of treatment of 5.5 years (Fikretoglu, Brunet, Guay, & Pedlar, 2007). Whether early treatment is truly easier or more likely to result in remission is unclear. In general terms, screening programs may also have harmful effects, which should be considered in their evaluation (U.S. Preventive Services Task Force, 2004). In the context of cancer screening, false positives can understandably cause worry, and there is evidence that such worry may persist even after the definitive test is reassuring (Brewer, Salz, & Lillie, 2007). Although harm is, in theory, a possible effect with mental health screening, none of the high-quality trials have shown any evidence of such effects (U.S. fostering resilience across the deployment cycle      151 Copyright American Psychological Association. Not for further distribution. Preventive Services Task Force, 2004). However, some have argued that labeling false positives as being “unwell” may bring with it the possibility of stigmatization (Rona et al., 2005), with all of its negative effects. The criticism of postdeployment screening that is hardest to dismiss is that it is wasteful. The same resources devoted to screening might be better applied elsewhere. Cost–benefit analysis requires information on costs and benefits, neither of which are known here. Some have proposed that screening has ancillary benefits, such as providing reassurance, encouragement, and advice. Postdeployment screening also provides useful health surveillance data. These ancillary benefits should be explicitly evaluated if they are to be used to justify screening. If a screening program is implemented, when should it be timed relative to redeployment? In returning service members after a difficult deployment, the apparent prevalence of mental health problems appears to have a steady, almost linear increase, at least over the first year after return (Hoge, 2006; Hoge et al., 2006; Zamorski, 2011). Screening immediately after deployment identifies many individuals who have what appear to be self-limiting problems but misses many who will develop problems later (Milliken et al., 2007). On the other hand, screening later misses an opportunity to intervene early for those with early onset disorders. Some nations hedge their bets and screen both immediately after deployment and again 3 to 6 months later, but the incremental value of this approach is uncertain. In Canada, screening occurs only once, 3 to 6 months after return, but mechanisms other than screening are getting at least some of those with early onset problems into care. For example, more than half of those with symptoms of depression or of PTSD were already in care at the time of their screening (Zamorski, 2011). The United Kingdom experimented with screening for mental disorders in the general military population (i.e., not specifically after return from a deployment) using a brief postal questionnaire (Rona, Jones, French, Hooper, & Wessely, 2004). The survey was completed by 67% of those invited, and the 27% who had one or more positive screening tests received a letter inviting them to follow up with their military general practitioner; a random sample of those who screened negative were also encouraged to follow up. Overall, less than 30% of those invited actually did so. Those who screened positive were significantly less likely to follow up than those who screened negative. Qualitative research (French, Rona, Jones, & Wessely, 2004) on potential barriers to follow-up identified the key theme as being “lack of confidence” in the military and in its health care system. Although the design of the U.K. study was very thoughtful and rigorous, the design of the screening program itself was less so. Those studies that have shown value in mental health screening have used a much more intensive 152       neil greenberg Copyright American Psychological Association. Not for further distribution. approach, including a face-to-face encounter with a primary care clinician at the time of screening, more clinically oriented screening tests, informing the provider of the results of the tests, and systematic efforts to ensure follow-up (U.S. Preventive Services Task Force, 2004). It is also possible that different results would be seen in a system in which service members had greater confidence in the military and its health care system. It is particularly noteworthy that other postdeployment screening studies have shown that those who screen positive are more likely to follow up (Hoge et al., 2006; Milliken et al., 2007) rather than less likely, as seen in the U.K. study (Rona et al., 2004). This suggests that the propensity to seek care after screening depends on the screening process itself and the context in which it is applied. In summary, as with predeployment screening and TLD programs, randomized trials should be done to assess the value of postdeployment screening. Nevertheless, there is growing evidence to refute the common criticisms that useful screening tests do not exist, that service members will not disclose their problems, or that they will fail to seek help if they do (Rona et al., 2005). There are randomized trial data for screening for depression, problem drinking, and PTSD in other settings that cannot be summarily dismissed just because they are from a different context. Whether the existing evidence is strong enough to sustain a postdeployment screening program is a matter about which reasonable minds might differ. Moreover, what works in one country and context may not work in others. In particular, the prevalence rate of postdeployment mental health problems must be high enough in the screened population to justify the effort and to minimize the burden of false positives. Admittedly, the foregoing section on screening may not appear to be directly related to building resilience per se. But it does reflect the reality that until such time as resilience can be reliably ensured, mechanisms must be in place to help those in whom resilience mechanisms fail. An imperfect but growing evidence base supports postdeployment screening. This discussion of the postdeployment period began with pointing out that one of the main challenges of building resilience during this period is the diversity of human needs in a mixed population of resistant, resilient, and ill individuals. The strongest philosophical appeal of postdeployment screening is that it is based on an individual assessment of needs and individual targeting of interventions. Other Potentially Promising Interventions The positive psychology literature that shows that some remarkably simple interventions that focus attention on the positive aspects of life and on personal strengths can result in sustained improvements in well-being; these benefits accrue to both mentally ill and mentally well individuals (Seligman, Steen, Park, & Peterson, 2005). Such interventions might provide a useful fostering resilience across the deployment cycle      153 Copyright American Psychological Association. Not for further distribution. tool to offer to everyone returning from a deployment. Expressive writing about emotional experiences also shows significant and consistent efficacy with remarkably little effort or professional involvement. Benefits are again seen in those with and without mental health problems (Pennebaker, 1997, 1999; van Emmerik, Kamphuis, & Emmelkamp, 2008); some investigators are exploring the potential value of this tool in soldiers returning from combat deployments (Baddeley & Pennebaker, 2011). Computer-based interventions (particularly those delivered via the Internet) also show promise in a broad range of mood and anxiety disorders (Andersson et al., 2005; Carlbring et al., 2005, 2007), including PTSD (Knaevelsrud & Maercker, 2007; Litz, Engel, Bryant, & Papa, 2007). Conclusion The topic for this chapter unfortunately did not lend itself to theoretical coherence. Instead of forcing these observations about a diverse group of interventions into some unfamiliar framework, we use this Conclusion to highlight some themes about military resilience that might not otherwise emerge in this book. Do Whatever It Takes to Keep Service Members Well Military operations obviously require physically and mentally fit service members. This book deals largely with trying to understand the psychological processes that underlie resilience. This focus on psychological processes is valid in that it is clear that these are important predictors of resilience, if not the true mechanisms by which resilience occurs. But military organizations are not interested in psychological processes per se; they are interested instead in accomplishing their military mission, and they will do whatever it takes to keep service members healthy and functional in order to ensure readiness, operational effectiveness, and force sustainability. “Whatever it takes” could be a psychoeducational intervention, a pill, a screening program, a human resources policy. Military leaders are presumably interested in whatever is most effective and efficient, not whatever is most interesting or theoretically coherent. Short-Term Performance Versus Long-Term Mental Health In the section on predeployment screening, the two facets of resilience were described. Both short-term performance and long-term mental health are important, but the two may require different approaches and will require differ154       neil greenberg ent evaluation strategies. Interventions that enhance performance may be valuable, but one cannot assume that they will improve long-term mental health. Copyright American Psychological Association. Not for further distribution. Resilience-Building Interventions Must Be Evidence Based Theory should guide the development of interventions, but theory alone is not enough to establish their effectiveness. Many theoretically attractive approaches have proven to be useless or even harmful (e.g., some applications of CISD). Randomized controlled trials will often be required to establish efficacy, particularly if the intervention is resource intensive, if there are risks involved, or if the outcomes are health related. Of course, observational data may still provide practical guidance. For example, if predeployment psychoeducation is to be provided, it makes sense to use the Battlemind program as a template, given the encouraging results seen in nonrandomized trials. Finally, the content of evidence-based interventions (e.g., short-term CBT) may inform the development of new interventions (e.g., group psychoeducation), but the efficacy of these new interventions cannot be assumed. The Importance of Context Although fundamental psychological processes do not differ substantially from country to country or from deployment to deployment, the military and societal contexts clearly do. The differential effect of interventions such as postdeployment Battlemind and debriefing according to combat exposure suggests that this is an essential part of this context. Thus, interventions that work in one context may not work in another. The effectiveness of postdeployment screening, for example, hinges on service members disclosing their problems, seeking care, and receiving effective care once it is sought; differences in these areas may explain differences in the deployment-related screening experiences of different countries. Thus, even where programs of proven efficacy exist, implementation into new contexts will require adaptation and validation. The Importance of Content It should be clear from the mixed results reported in this chapter that some interventions appear to work better than others. Although context matters, the content of the intervention itself and the precise way it is delivered are also paramount. Thus, it is misleading to say that “postdeployment mental health briefings don’t work” or “debriefing is ineffective.” The evident U.S. success with these two interventions is likely related to the care with which the interventions were developed and implemented. fostering resilience across the deployment cycle      155 Copyright American Psychological Association. Not for further distribution. Different People Need Different Things at Different Times People differ. Service members are likely to be almost as diverse as the host population from which they are drawn. Needs are also likely to vary across the deployment cycle. Accordingly, it is likely that different strategies will be needed to address the different needs of different individuals and that these will have to be appropriately timed. Group psychoeducation will thus always be a blunt tool that will never meet the needs of everyone all the time. One-on-one interventions such as screening or short-term CBT may overcome this limitation, but these are often resource intensive. The challenge is to find the most efficient ways possible to leverage the benefits of such precious one-on-one time with service members. Positive psychology interventions, expressive writing, and computer-based interventions are appealing because little or no professional time may be required in their application. In addition, such interventions can be applied at the individual level, when and where they are needed. Service Members Are People, Too Much is made of the important differences between work and culture in the military and in the general population. Such differences certainly exist, but it seems likely that when it comes to fundamental psychological processes, human needs, learning, and effective care, service members think and act first and foremost as human beings. For this reason, high-quality research evidence from the civilian setting, such as that on screening for depression, cannot be dismissed out of hand. Finding the Right Mix of Professional and Nonprofessional “Care” The responsibility for resilience is shared among leaders, health professionals, and service members themselves. Each has something essential to offer, and the right mix will depend on the task at hand and the context in which it occurs. Using less costly and more widely available trained unit personnel in lieu of clinicians for triage and support (à la TRiM) is appealing, but military organizations must take steps to ensure that this is effective and safe. The Need to Have Reasonable Expectations Finally, it is important that commanders and researchers do not lose track of what they are up against, in that building resilience is like trying to ensure performance of difficult and morally troubling tasks in an extreme environment at great personal risk. And they are trying to ensure that the 156       neil greenberg Copyright American Psychological Association. Not for further distribution. mental health of those who are asked to do these things remains sound. This is no small task. The ability of military forces to intervene is limited by some important knowledge gaps. For example, what psychological processes truly result in the phenomenon of resilience, as opposed to being merely associated with it? Which of these are amenable to change? And what is the best way of achieving this? Until these knowledge gaps are closed, those who are working in the field of resilience have to have reasonable expectations as to the efficacy of the possible interventions. All who work in this field have to accept that servicerelated mental health problems will inevitably occur in a certain fraction of those exposed to significant adversity—science simply lacks the technology to reliably prevent these problems. For this reason, there is a need to be careful not to oversell the various resilience-building programs, while at the same time celebrating and promoting those small successes that are found. References Academic Centre for Defence Mental Health. (2009). UK Decompression Survey final report. London, England: Kings College. Adler, A. B., Bliese, P. D., McGurk, D., Hoge, C. W., & Castro, C. A. (2009). Battlemind debriefing and Battlemind training as early interventions with soldiers returning from Iraq: Randomization by platoon. Journal of Consulting and Clinical Psychology, 77, 928–940. doi:10.1037/a0016877 Adler, A. B., Litz, B. T., Castro, C. A., Suvak, M., Thomas, J. L., Burrell, L., . . . Bliese, P. D. (2008). A group randomized trial of critical incident stress debriefing provided to U.S. peacekeepers. Journal of Traumatic Stress, 21, 253–263. doi:10.1002/jts.20342 Adler, A. B., Zamorski, M. A., & Britt, T. W. (2011). The psychology of transition: Adapting to home after deployment. 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T., Jones, N., Alvarez, H., Hull, L., Naumann, U., . . . Greenberg, N. (2012). Postdeployment Battlemind training for the U.K. Armed Forces: A cluster randomized controlled trial. Journal of Consulting and Clinical Psychology, 80, 331–341. doi:10.1037/a0027664 Mulligan, K., Jones, N., Woodhead, C., Davies, M., Wessely, S., & Greenberg, N. (2010). Mental health of UK military personnel while on deployment in Iraq. British Journal of Psychiatry, 197, 405–410. doi:10.1192/bjp.bp.110.077263 National Collaborating Centre for Mental Health. (2005). Post-traumatic stress disorder: The management of PTSD in adults and children in primary and secondary care (National Clinical Practice Guideline No. 26). Trowbridge, England: Cromwell Press. Nevin, R. L. (2009). Low validity of self-report in identifying recent mental health diagnosis among U.S. service members completing Predeployment Health Assessment (PreDHA) and deployed to Afghanistan, 2007: A retrospective cohort study. 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Retrieved from cgi-bin/virtcdlib/index.cgi/6468753/FID1/start.pdf van Emmerik, A. A., Kamphuis, J. H., & Emmelkamp, P. M. (2008). Treating acute stress disorder and posttraumatic stress disorder with cognitive behavioral therapy or structured writing therapy: A randomized controlled trial. Psychotherapy and Psychosomatics, 77, 93–100. doi:10.1159/000112886 van Emmerik, A. A., Kamphuis, J. H., Hulsbosch, A. M., & Emmelkamp, P. M. (2002). Single session debriefing after psychological trauma: A meta-analysis. Lancet, 360, 766–771. doi:10.1016/S0140-6736(02)09897-5 Vogt, D. S., Proctor, S. P., King, D. W., King, L. A., & Vasterling, J. J. (2008). Validation of scales from the Deployment Risk and Resilience Inventory in a sample of Operation Iraqi Freedom veterans. Assessment, 15, 391–403. doi:10.1177/1073191108316030 Warner, C. H., Appenzeller, G. N., Mullen, K., Warner, C. M., & Grieger, T. (2008). Soldier attitudes toward mental health screening and seeking care upon return from combat. Military Medicine, 173, 563–569. 164       neil greenberg Copyright American Psychological Association. Not for further distribution. Warner, C. H., Appenzeller, G. N., Parker, J. R., Warner, C. M., & Hoge, C. W. (2011). American Journal of Psychiatry, 168, 378–385. doi:10.1176/appi.ajp. 2010.10091303 Wright, K. M., Thomas, J. L., Adler, A. B., Ness, J. W., Hoge, C. W., & Castro, C. A. (2005). Psychological screening procedures for deploying U.S. forces. Military Medicine, 170, 555–562. Zamorski, M. A. (2011). Report on the findings of the enhanced postdeployment screening of those returning from Op ARCHER/Task Force Afghanistan as of 11 February 2011. Ottawa, Ontario, Canada: Department of National Defence. Zamorski, M. A., Galvin, M. A., & Humeniuk, T. W. (2007, October). Findings of an intensive predeployment screening program for Canadian Forces members deployed to Afghanistan in 2003–2005. Redeployment Paper presented at Wounds of War: Lowering Suicide Risk in Returning Troops, NATO Advanced Research Workshop, Klopeiner See, Austria. Zamorski, M. A., Uppal, S., Boddam, R., & Gendron, F. (2006, November). The prevalence of mental health problems in the Canadian armed forces: Comparison with the Canadian general population. Poster session presented at the meeting of the Canadian Psychiatric Association, Toronto, Ontario, Canada. Zatzick, D., Roy-Byrne, P., Russo, J., Rivara, F., Droesch, R., Wagner, A., . . . Katon, W. (2004). A randomized effectiveness trial of stepped collaborative care for acutely injured trauma survivors. Archives of General Psychiatry, 61, 498–506. doi:10.1001/archpsyc.61.5.498 fostering resilience across the deployment cycle      165 CHAPTER 3 Copyright © 2010. American Psychological Association. All rights reserved. I CAN’T #&$%! SLEEP! Sleep problems are a common issue that many service members are forced to deal with after returning from a deployment. For some, the problem may be falling asleep. For others, the problem may be staying asleep. Some may experience disturbing dreams about things they witnessed while on deployment. Whether you have a difficult time reaching that peaceful slumber or completing a few hours of uninterrupted rest or wake up thinking you need to respond to some unidentifiable threat, sleep difficulties can create a tremendous amount of stress and aggravation for you. Let’s take the case of PFC J., who recently returned home after finishing a 12-month tour to Iraq. Ever since his return, he’s noticed that it takes him 2 to 3 hours to fall asleep. This in itself is not that big of a deal. However, considering that he rarely gets to bed before midnight and has an 0530 formation every morning, the sleep deprivation is starting to take a toll. For example, he is noticing that he can’t concentrate and remember things as well as he used to. He finds himself falling asleep at inappropriate times, like...
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Common Post-Deployment Problems

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Common Post Deployment Problems
Deployment is a demanding activity for the soldier and has major social, economic
and psychological side effects for the victims and the closely affiliated people. Developing
resilience after the program is a major challenge for majority of the soldiers. The attributes
that help to build resilience includes cohesion, morale and proper leadership strategy. The
development of resilience begins from the pre-deployment period to facilitate potential
opportunities to avoid the negative side effects that soldiers experience after deployment
(Greenberg, 2013). The objective of the study focuses on the analysis of the post-deployment
problems among the military soldiers and the programs involved to help address the problem.
Tasks and Responsibilities that Occur During Post Deployment
The session of the post deployment commonly takes place after the military
responsibilities upon arrival at home. Between the points of arrival in around 6 months it is
usually challenging for the soldiers to adjust to normal life. In this session, the soldiers and
the family members are involved in activities like the renegotiation of roles and in other
situations the establishment of new routines. In the ...

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