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US Army Occupational Therapy: Promoting Optimal Performance

Chapter 22

US ARMY OCCUPATIONAL THERAPY: 

PROMOTING OPTIMAL PERFORMANCE

MARY W. ERICKSON, MAOL, OTR/L*; TERESA L.BRININGER, PhD, CHT, OTR/L†; SHARON M. NEWTON, OTR/L, MHS‡

; AMY M. MATTILA, MS, MBA§; and JAMES P. BURNS, OTR/L, MOT¥

INTRODUCTION

OCCUPATIONAL THERAPY IN WORLD WAR II

ARMY OCCUPATIONAL THERAPY IN THE 21ST CENTURY

Army Occupational Therapy Credentials and Training

Role of Occupational Therapy Assistants

Overview of Occupational Therapy Services in Combat and Operational Stress 

Control 

AN INTEGRATED ARMY RESERVE REGIONAL COMBAT AND OPERATIONAL 

STRESS CONTROL PROGRAM 

OCCUPATIONAL THERAPY IN SUPPORT OF OPERATION IRAQI FREEDOM 

DETAINEE HEALTHCARE

PEAK PERFORMANCE TRAINING IN OCCUPATIONAL THERAPY

OCCUPATIONAL THERAPY IN THE WARRIOR TRANSITION UNIT

The Comprehensive Transition Plan

Work Reintegration Programs

Occupational Therapy’s Focus in Work Reintegration

OCCUPATIONAL THERAPY ON THE HOME FRONT

SUMMARY

*Colonel, Individual Mobilization Augmentee, US Army Reserve; Chief, Occupational Therapy, Reintegration Branch Chief for the Proponency Office 

for Rehabilitation and Reintegration, Office of The Surgeon General, Falls Church, Virginia

†

Lieutenant Colonel, Medical Specialist Corps, US Army ; Deputy for Rehabilitation and Reintegration, Telemedicine and Advanced Technology Research 

Center, Medical Research and Materiel Command, 504 Scott Street, Building 722, Room 30, Fort Detrick, Maryland 21702

‡

Lieutenant Colonel, Medical Specialist Corps, US Army; Command Inspector General, 30th Medical Command, CMR 442, APO AE 09042; formerly 

Theater Consultant for Combat and Operational Stress Control, Iraq

§

Captain, Medical Specialist Corps, US Army; Chief, Department of Occupational Therapy, Reynolds Army Community Hospital, 4301 Wilson Street, 

Fort Sill, Oklahoma 73503; formerly, Chief, Occupational Therapy, 254th Medical Detachment (Combat Operational Stress Control), Germany

¥

Major, Medical Specialist Corps, US Army; Occupational Therapist, Department of Orthopaedics and Rehabilitation, Building 2, Room 3J04, Walter 

Reed Army Medical Center, 6900 Georgia Avenue NW, Washington, DC 20307-5001; formerly, Chief Occupational Therapist, Department of Surgery, 

Fort Jackson, South Carolina
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Combat and Operational Behavioral Health

INTRODUCTION

Occupational therapy (OT) utilizes engagement in 

meaningful occupation (purposeful everyday tasks 

and activities that “occupy” one’s time) to facilitate 

function and achieve a healthy and balanced lifestyle.1,2

Early history records the use of activity, music, and 

games to assist with the recovery of mental health. 

In 172 ce, Galan wrote: “Employment is nature’s best 

physician and is essential to human happiness.”3 The 

profession grew out of the moral treatment movement of the early 19th century, with a focus on compassion and occupation using manual labor such as 

agriculture, sewing, and tailoring to treat the insane.4

The founders of OT in the United States came from a 

variety of backgrounds including psychiatry, social 

work, and architecture. Adolf Meyer, a psychiatrist, 

observed human behavior and habit in relation to the 

environment, writing 

the whole of human organization has its shape in a 

kind of rhythm...work and play and rest and sleep, 

which our organism must be able to balance even under difficulty. The only way to attain actual balance in 

all of this is actual doing, actual practice, a program 

of wholesome living as the basis of wholesome feeling and thinking and fancy of interests.5

During the 20th century, OT became closely aligned 

with treating wounded soldiers and sailors in response 

to the two world wars.6(p158),7 Then, as now, the profession’s foundation is the belief that occupation, or 

purposeful activity, is vital to regaining or maintaining 

the health of the entire person. This purposeful activity 

is graded according to the individual’s ability. Furthermore, the philosophies of OT and treating service 

members with combat or operational stress reactions 

go hand-in-hand.6

The use of OT in the US military dates to World 

War I, when the US Civil Service Commission (precursor to the Office of Personnel Management) called 

for individuals trained in OT and other professions 

such as teachers and artists to serve as reconstruction 

aides in military hospitals. Early in 1918, the Surgeon 

General’s Office began recruiting reconstruction 

aides to work with and treat service members who 

were wounded or suffered from battle neurosis to 

return to the battlefield. In February of that year, 

the Army’s first trial of OT, occurring at Walter 

Reed Hospital, demonstrated its value in treating 

both the mind and the body of the wounded service 

member using occupation in the form of treatment: 

physically, to improve upper extremity function; 

and psychologically, to help prevent depression, 

control attention, and calm the wounded.3(pp159–160)

By June 1918 the first OTs arrived at Base Hospital 

117 in France, serving as civilians in the American 

Expeditionary Forces.3

During World War I, OT was established in Army 

hospitals for the reconditioning of convalescent 

soldiers by the Division of Physical Reconstruction 

within the Office of The Surgeon General, established 

in January 1918. Its intent was “through the use of 

mental and manual work, to restore to complete or 

maximum possible function, any military person 

disabled in line of duty.”7(p70) The overall goal of the 

reconditioning program was to return soldiers to military duty in the highest state of physical and mental 

fitness in the shortest possible time. If disqualified for 

further military service, the aim of reconditioning was 

to return the soldier to civilian life in the best possible 

physical condition, “well oriented in the responsibilities of citizenship and prepared to adjust successfully 

to social and vocational pursuits.”8(p329) The mission 

was accomplished by a coordinated program of educational reconditioning, physical reconditioning, and 

occupational therapy.

OCCUPATIONAL THERAPY IN WORLD WAR II

During World War II, OT grew in breadth and 

scope of practice in both physical medicine and 

neuropsychiatry. Programs developed to treat the 

physical and psychological injuries incorporated 

educational reconditioning, activity-based workshops, 

industrial therapy, and recreational therapy. OT 

carried out within physical medicine addressed “the 

restoration of physical function to impaired joints and 

muscles...seeking (1) improvement of the general 

physical condition, (2) the development of work 

tolerance through graded activity, and (3) stimulation 

of mental acuity through interesting occupation.”8(p344)

Occupational therapists’ observations of behavior, 

attitude, and reactions of patients were extremely 

valuable to the medical team and were reported during 

interdisciplinary staff conferences. These regularly 

scheduled meetings helped staff to plan and adjust 

the overall treatment program as needed.

OT in the neuropsychiatric section was placed under the immediate direction of the psychiatrist. The 

goals of OT within neuropsychiatry were “(1) to guide 

mental attitudes into healthy channels, (2) to promote 

a desire to get well, (3) to restore self-confidence and 

a sense of security, (4) to substitute encouragement 
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US Army Occupational Therapy: Promoting Optimal Performance

for discouragement, (5) to establish and maintain 

good work habits and (6) to afford opportunity for 

socialization.”8(p348) General treatment principles used 

with neuropsychiatric patients included (a) quiet, 

soothing work to help calm patients; (b) noisy, active 

work to discharge tension; (c) responsible work to 

promote self-confidence; (d) simple, easily completed 

tasks for encouragement; (e) interesting, colorful 

work for stimulation; (f) absorbing, detailed tasks 

for improving concentration; and (g) group work for 

socialization.

OT’s role in educational reconditioning included 

identifying the service members’ goals and interests 

and providing valuable information for the establishment of individualized treatment programs. Essential 

components of the educational reconditioning program included OT laboratory shops that provided 

practical experience for patients following the completion of academic courses sponsored by the educational 

reconditioning program in fields such as photography, 

radio, electricity, and motor mechanics. The “noisy” 

shop was used for patients who needed to discharge 

tensions through work. Activities in the noisy shop 

included carpentry, metalworking, work with plastics, 

and printing. The “quiet” shop was used for patients 

who were easily distracted or disturbed by noise and 

included activities such as weaving, leatherworking, 

ceramics, and art. Patients confined to the ward participated in OT through the use of small handicrafts 

carried out under close supervision. 

An industrial therapy program also emerged during 

World War II, in which occupational therapists organized therapeutic “industrial” assignments involving 

hospital maintenance. The program included identifying available job assignments by gathering information 

on each job title, duties required, physical and mental 

requirements, and work standards. The program 

successfully provided participants a balanced work 

program, helped maintenance personnel complete 

daily tasks, and provided therapeutic activity for a 

large number of patients while requiring few trained 

supervisors. It was designed as a transitional program 

to meet the work requirements of patients who had 

progressed beyond the need for specific therapy but 

could not yet return to full duty. The work activities 

improved 

general physical ability including muscle tone, 

strength, and joint motion, to combat the effects of 

prolonged hospitalization, to increase work tolerance, to re-establish work habits counteracting the 

effect of periods of mental and physical idleness and 

to stimulate mental alertness.8(p352)

Job task analysis was an essential component in the 

World War II reconditioning program. Occupational 

therapists analyzed jobs from both a physical and a 

psychological perspective, and subsequently identified 

a variety of job opportunities. Work areas utilized for 

reconditioning included the utility shop, motor pool, 

warehouse, post office, laundry, mess hall, supply 

department, administrative office, medical laboratory, 

photographic laboratory, orthopaedic shop, messenger 

service, drafting, landscaping, and gardening. The 

patients’ clinical appointments and medical consultations took precedence over industrial work assignments, and high standards were maintained: work 

projects were not allowed to deteriorate into a source 

of “cheap labor,” and the therapists ensured that the 

job task was appropriate for the soldiers’ physical and 

mental capabilities.

Another OT effort was a recreational (or “diversional”) program used “to divert the patient’s mind 

from thinking of himself constantly, to provide for 

the constructive use of leisure time, to furnish opportunity for self-expression, to stimulate interests and 

sustain morale, to conserve initiative and maintain 

good work habits, to promote socialization by group 

activities and to improve general physical fitness by 

stimulating the appetite and the circulation.”8(pp353–354)

The Arts and Skills Corps, composed of craftspeople 

recruited and organized by the Red Cross; the “Gray 

Ladies,” a group of volunteers assigned to hospital 

OT departments; and Women’s Army Corps assistants 

expanded the reach of OT to include minor crafts 

such as model making, art, wood and soap carving, 

plastics, leatherwork, ceramics, fly-tying, and weaving. Shop programs included photography, radio 

and electrical work, motor mechanics, and the use of 

power equipment.8(p355) In 1947, the Army established 

the Women’s Medical Specialist Corps under Public Law 36, 80th Congress, giving OTs a permanent 

military status. In 1955 the name was changed to the 

Army Medical Specialists Corps under Public Law 

294, 84th Congress, reflecting the inclusion of men 

in the corps.7(pp5,402) Current Army OT policies and 

practices are built on the foundations established in 

World War II.

ARMY OCCUPATIONAL THERAPY IN THE 21ST CENTURY

Serving throughout the world in times of war and 

peace, Army occupational therapists (OTs, military 

occupational specialty [MOS] 65A) and military occupational therapy assistants (OTAs, MOS 68WN3) 
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Combat and Operational Behavioral Health

currently number over 200 in strength. The mission 

of OT in today’s Army is to promote soldier readiness, healthy living, and optimal performance among 

all Department of Defense (DoD) beneficiaries using 

OT principles and practices (Exhibit 22-1). Army OTs 

incorporate best clinical practices and strive to deliver 

them in a timely and cost-efficient manner.9

Today, Army OT practitioners function as human 

performance experts whose innovative programs and 

services help to optimize soldier performance and 

readiness in both field and garrison settings. OTs treat a 

wide range of conditions with many soldiers impacted 

by both physical and psychological injuries. In addition to the behavioral health role of OT in combat and 

operational stress control (COSC) efforts, OTs provide 

neuromusculoskeletal evaluation and rehabilitation 

with an emphasis on the upper extremity; inpatient 

and outpatient rehabilitation, including specialty 

areas such as cognitive rehabilitation, community 

reintegration, driving rehabilitation, and burn care; 

neurology and orthopaedics; ergonomics, including 

the development of strategies to prevent injuries and 

decrease human and economic costs of injuries in 

the DoD; peak performance training; use of assistive 

EXHIBIT 22-1

US ARMY OCCUPATIONAL THERAPY SCOPE OF PRACTICE

The unique role of occupational therapy (OT) emphasizes the enhancing of each individual’s performance in his or 

her various life roles (ie, soldier, worker, parent, student, and retiree). Occupational therapy’s services are designed 

to respond to soldier, patient, family, and military organizational needs and expectations. Army OT helps prevent 

dysfunction, promotes and develops healthy lifestyles, and facilitates adaptation and recovery. Army OT helps the 

wounded, injured, or ill adapt daily occupations and routines in the areas of self-care, home management, community participation, education, work, and/or leisure activities. New Army OT initiatives include standardization of 

a military-specific Functional Capacity Evaluation, driving rehabilitation including the use of driving simulation, 

animal-assisted therapy, warrior goal-setting training, and use of a toolkit to evaluate and treat concussion/mild 

traumatic brain injury. 

Occupational therapy’s scope in the provision of services encompasses the following:

• Military readiness. All services provided to the soldier population target optimized effective performance, 

prevention, and expeditious return to duty following medical or psychological conditions.

• Priority of care is directed to the soldier to assist in maintaining his or her highest level of performance and 

ensure fitness to fight.

• Prevention and wellness. Includes screening and health promotion interventions to maintain and promote 

effective performance of soldiers and Department of Defense beneficiaries.

• Combat stress prevention and intervention in the combat environment and in stability and support operations.

• Unit consultation to promote psychosocial well-being, including ergonomic evaluation, training, and worksite analysis; identification of and ergonomic intervention for conditions where the etiology is physical or 

stress-related.

• Support of humanitarian missions in the primary care role for upper extremity neuromuscular screening 

or stress prevention and intervention.

• Direct patient care may include but is not limited to basic and advanced self-care (activities of daily living) 

evaluation and training. Training emphasizes regaining and sustaining functional performance while developing and improving diverse, complex skills including problem-solving and decision-making capabilities.

• Psychosocial treatment with emphasis on functional performance in various life roles through insight development, skill acquisition, education, and treatment programs.

• Work reintegration, including ergonomic analysis, fit-for-duty programs, and injury prevention and training 

that keep workers on the job, reduce costs, and improve productivity. Programs that promote work behaviors for improved physical and psychological performance include stress, coping, and life skills education 

programs.

• Evaluation and treatment of upper extremity conditions, including upper extremity neuromusculoskeletal 

evaluations in support of the orthopaedic physician.

• Orthotic (splint) fabrication. Adaptive technology evaluation and recommendations for, or fabrication of, 

equipment.

• Developmental pediatric evaluation and treatment (at specified treatment facilities).
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US Army Occupational Therapy: Promoting Optimal Performance

technology; and work reintegration programs within 

warrior transition units (WTUs). Recognizing the psychological as well as functional value of early return 

to wearing the uniform following injury, OTs helped 

develop the Army’s Wounded Warrior Clothing Support Program in 2008, which authorizes the wear of 

uniforms with adaptations/modifications prescribed 

by OTs or other rehabilitation specialists. Additionally, 

Army OTs serve in dedicated research positions as well 

as academic appointments. 

Emerging OT practice areas include pilot programs 

in brigade combat teams to treat individuals with 

traumatic brain injury, animal-assisted therapy and 

animal-assisted activities in COSC units, and servicedog training programs. Creative partnerships with 

501(c)(3) (nonprofit) organizations have produced 

successful service-dog training programs. For instance, 

initial service-dog training may be conducted within 

a civilian prison with specialized service-dog skills 

training conducted as part of a WTU work therapy 

program to prepare future service dogs to meet the 

unique needs of wounded soldiers. OTs are involved 

in a growing use of therapeutic riding programs as 

well. An integrated process team consisting of OTs, 

veterinarians, and behavioral health specialists is 

addressing principles and standards, and updating 

policies related to the human-animal bond.

Army Occupational Therapy Credentials and 

Training

Army OT practitioners, who serve in command 

and executive positions throughout the Army Medical 

Department, must be versatile, competent leaders to 

successfully operate and manage clinic operations in 

both deployed and garrison environments. Army OTs 

are credentialed healthcare providers and, as commissioned officers, they require National Board for Certification in Occupational Therapy (NBCOT) registration 

and a current, active, valid, and unrestricted OT license 

from a US state or jurisdiction. Currently, OT recruits 

entering the Army with a master’s degree in OT will 

be able to earn a doctorate of science in occupational 

therapy (DSCOT). The DSCOT program and the enlisted 68WN3 OTA program are taught at the Army 

Medical Department Center and School at Fort Sam 

Houston in San Antonio, Texas. As of 2010, Army OTAs 

are required to obtain NBCOT national certification 

and state licensure. Civilian OTs working within a military setting must be registered by NBCOT and licensed 

according to the regulatory requirements of the state in 

which they are practicing.9

 Civilian OTAs are required 

to take the NBCOT examination and be credentialed as 

a certified occupational therapy assistant (COTA) with 

licensure according to the regulatory requirements of 

the state in which they are practicing. 

Role of Occupational Therapy Assistants

OTAs are specialists who bring the perspective 

of the enlisted soldier to the therapeutic process by 

assisting the supervising OT in evaluating a service 

member’s occupational performance; conducting initial occupational performance history interviews and 

mental status evaluations; using observation to gather 

data as part of task-performance skill assessments; and 

implementing OT interventions under the supervision 

of a credentialed OT. OTAs coordinate, set up, and 

oversee work hardening sites; lead OT groups; and 

monitor, facilitate, and supervise therapeutic activities. 

The OTA supervises combat and operational stress 

reaction casualties, provides status updates for these 

casualties, and conducts classes on selected stressrelated topics. OTAs assist in all COSC functional areas 

including unit needs assessments and traumatic event 

management in the deployed environment. 

Overview of Occupational Therapy Services in 

Combat and Operational Stress Control 

The role of the OT practitioner in Army COSC is to 

evaluate occupational performance and implement 

interventions to enhance that performance.6

 OT’s 

unique core skills are aimed at keeping soldiers able 

to perform their mission and include

• analysis of jobs and job tasks for underlying 

requisites (required subtasks, performance 

standards, equipment used, the social and 

physical work environment, occupational 

hazards);

• assessment of occupational performance 

(functional abilities) relating to specific tasks 

and jobs;

• configuration of a therapeutic, structured environment in which skills can be developed;

• analysis, selection, and application of occupations (activities) as therapeutic media; and

• the ability to match the individual to tasks he 

or she can successfully perform.2(p22),6,7

Army OTs evaluate soldier performance across the 

spectrum of occupational areas including activities 

of daily living, work, education, leisure, and social 

participation. The OT, or a COSC team member under 

the guidance of the OT, selects therapeutic occupations 

(purposeful activities) based on the soldier’s current 

functional ability that support maintaining the sol-
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Combat and Operational Behavioral Health

dier’s military identity, enhances the soldier’s sense 

of competence, and restores confidence. OTs perform 

task analysis and functional assessments, structure a 

therapeutic environment, provide occupation-based 

treatment, and match soldiers’ abilities to the tasks or 

jobs they can perform. OTs also identify and evaluate mental and physical stressors, stress reactions, 

and cognitive function. They subsequently develop 

a treatment plan, which often includes teaching prevention, adaptive coping, and psychosocial skills. 

Additionally, they utilize therapeutic media and 

therapeutic use of self within individual and group 

settings to enhance environmental adaptation and 

maximize treatment.10(pp3–8) Army OTs integrate their 

diverse training in upper extremity orthopaedics, 

rehabilitation, ergonomics, and COSC techniques to 

identify areas of need for both individual soldiers 

and organizational units. Functional assessments 

include analysis of skills required by the soldier’s 

MOS, identification of tasks the soldier can perform, 

and synthesis of therapeutic occupations. Interventions such as “work hardening for Warriors” involve 

occupation-based treatment that matches the soldier’s 

functional ability with therapeutic occupations that he 

or she can perform. 

OT groups engage in work activities, cognitive and 

sensorimotor activities, activities that parallel taskperformance skills, cooperative activities, expressive 

arts, and exercise. Psychoeducational training may 

include selected common and collective soldier tasks 

or life skills such as stress management, relaxation 

skills, sleep hygiene, anger management, communication skills, problem solving, assertiveness training, 

and time management. Therapeutic activities of daily 

living may include personal hygiene and uniform 

maintenance; work/productive activities may include military-relevant tasks such as vehicle or site 

maintenance; and social and leisure activities may 

include cooperative or competitive sports, games, 

ceremonies, or celebrations. Therapeutic occupations 

are graded to offer challenges that are “just right” for 

each individual, leading to successful performance that 

instills competence and confidence. The soldier then 

gradually improves his or her functional capacity and 

ability to return to duty.10(pp10–12)

OT personnel also provide services as members of 

fitness teams and preventive teams in the delivery of 

behavioral health services in a deployed setting. The 

OT’s role in a preventive team is the same as the other 

team members: providing outreach services through 

establishing rapport with supported units and leaders, assessing unit needs, and making regular contacts 

with supported units. An OT approaches these tasks 

from a unique perspective of assessing and addressing 

functional performance. The OT evaluates a soldier’s 

current level of functional performance in a deployed 

environment. OTs also assess how psychological and 

cognitive function impacts task performance. They 

draw from a battery of standardized assessments that 

can help identify the presence of a combat and operational stress reaction, behavioral health problem, or 

traumatic brain injury. Collaborating with the rest of 

the team, the OT assimilates this information in determining the appropriate interventions, referrals, or 

other necessary action. For example, the OT may find 

that the best intervention is to restructure the soldier’s 

job or environment to ensure successful completion of 

a task. Interventions often involve educating both the 

soldiers and their leaders. 

Observation is one of the tools the OT uses to assess function. Observation can be especially valuable 

while conducting outreach visits. While performing 

“walk-abouts” within the area of operation, OTs work 

alongside soldiers and use their expertise to help them 

retain the functional ability to perform their mission. 

By working alongside soldiers, OTs can observe how 

each soldier is functioning and assess the mental or 

physical demands required to complete a particular 

job. Using this knowledge, the OT can begin to identify 

potential problems in task performance and intervene before problems escalate. For example, during 

Operation Iraqi Freedom (OIF) I (2003), an OT on the 

preventive team helped prepare and serve a meal in 

a mobile kitchen trailer. The OT talked casually with 

soldiers preparing the meal, getting a better idea of 

how they were dealing with the stress of operations. 

Additional stressors quickly presented themselves: 

working in a hot, crowded kitchen and dealing with 

large numbers of flies. Even the manner in which the 

food on the serving line was placed created physical stress. The OT provided suggestions for a more 

efficient and safer order of food trays, and adjusted 

the height of a work surface for one of the soldiers so 

she could more easily reach it. An added bonus was 

getting a glimpse into the basic cognitive function and 

general mood of hundreds of soldiers as they filed 

past the serving line. 

The OT’s observation skills are helpful when performing a unit needs assessment through evaluating 

the occupational performance needs of individuals 

in the unit. OTs identify component factors that are 

essential to successful performance. They may also 

assess the behavioral health training needs of soldiers, 

leaders, the unit ministry team, and other medical 

personnel within the unit. This may lead to additional 

interventions to enhance occupational performance 

and the development of plans to meet the future COSC 

needs of soldiers and units based on prevention and 
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US Army Occupational Therapy: Promoting Optimal Performance

early intervention. 

To enhance the provision of COSC services, 

Army OT practitioners utilize their background 

and training in upper extremity orthopaedics, rehabilitation, and ergonomics in both garrison and 

theater. Since the early 1980s, OTs have proposed 

and participated in programs designed to promote 

the soldier’s job performance in garrison.6(p56) Occupational therapists have been included in missions 

to Bosnia-Herzegovina, Peru, and Russia, to name a 

few. The global war on terror continues to provide 

opportunities for OTs to utilize their unique skills to 

promote the health and welfare of service members. 

OTs have deployed to Afghanistan and Guantanamo 

Bay in support of Operation Enduring Freedom. In 

the Iraq and Afghanistan theaters of operations, they 

offer OT services to US and Coalition military members, national security forces and civilians, and the 

detainee population. OT practitioners within WTUs 

help meet the needs of injured, ill, and wounded 

soldiers through a focus on life skills training and 

work reintegration. OT personnel were also involved 

in the development of regional Army Reserve COSC 

programs on the home front.

An Integrated Army Reserve Regional Combat and Operational Stress

 Control Program

Identifying the need for home-front support as large 

numbers of Army Reserve soldiers began to deploy in 

2003, the commanding general from the 88th Regional 

Readiness Command (RRC) initiated a COSC program 

for Army Reserve soldiers and their families within 

a six-state region in the upper Midwest (Minnesota, 

Wisconsin, Ohio, Michigan, Indiana, and Illinois). 

Two COSC officers from the 785th Medical Company 

(Combat Stress Control) were mobilized (an OT and 

a social work officer) to initiate a deployment cycle 

support program. From the inception of the program, 

the team used an interdisciplinary psychoeducational 

approach to help build resiliency and coping skills in 

soldiers and their families (Figure 22-1; Table 22-1). 

When available, Reserve component behavioral health 

specialists within the region augmented the team to 

provide local support. In 2005, a psychiatric nurse was 

mobilized to enhance the capabilities of the 88th RRC 

COSC team.

The COSC team established a strong working relationship with the other RRC elements that had direct 

roles in preparing and supporting deploying soldiers 

and their families. Program staff brought together 

representatives from family readiness groups; the 

chaplain’s, public affairs, and casualty affairs offices; 

and the RRC leadership to establish an integrated approach to meet the comprehensive needs of soldiers 

and families. A multilevel needs assessment was conducted to identify capabilities, needs, and resources for 

soldiers, leaders, and families throughout the region. 

The implementation of an integrated operational stress 

management program was seen as an essential element in producing secure and resilient soldiers with 

families prepared to withstand the rigors of military 

separation, combat operations, and the more routine 

stressors common to the military lifestyle. The COSC 

team explained to unit leaders that its mission is to 

keep their soldiers with them, doing their jobs through 

Military Joint Service Civilian

2003 2004 2005 2006

3,500

3,000

2,500

2,000

1,500

1,000

500

0

Figure 22-1. 88th Regional Readiness Command educational 

stress briefings, numbers of participants, 2003–2007.

programs designed to promote resiliency in the workplace, the family, and the community. 

Through a series of meetings and site visits a plan 

of operation emerged. The plan included the provision of information to leaders, soldiers, and family 

members as well as other regional military and civilian 

organizations. The team’s goal was rapid response: to 

provide soldiers and their families with educational, 

spiritual, and psychological resources to strengthen the 

basic bonds essential to high morale and good order. 

The expected outcomes included mission-capable soldiers and self-reliant families who were stress resilient, 

confident, secure, supported, and healthy (physically, 
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Combat and Operational Behavioral Health

TABLE 22-1

88TH REGIONAL READINESS COMMAND COMBAT AND OPERATIONAL STRESS CONTROL PROGRAM: 

ACTIVITY SUMMARY, APRIL 2003–DECEMBER 2006

COSC Briefings* Individual Counseling

Mobilization (soldiers/families) 13,398 Soldier/family and stress/PTSD issues 2,363

Midcycle (families) 4,826 Bereavement support (ie, funeral, follow-up, etc) 496

Homecoming (families/friends) 13,839 Well-being (acupuncture and therapeutic massage) 1,901

Reconstitution support (first postdeployment drill) 8,541 PREP couples’ support† 934

SRP training 28,247 Marriage/relationship‡ 228

Educational stress briefings

Community groups 6,045

Military groups 7,548

Other military (NG, Navy, etc) 2,258

*Number of participants

†

Marriage retreat. No program participation in 2006

‡

Single soldier retreat

COSC: combat and operational stress control

NG: National Guard

PREP: Prevention and Relationship Enhancement Program 

PTSD: posttraumatic stress disorder

SRP: Soldier Readiness Program

emotionally, psychologically, and spiritually). Soldiers 

departing for extended missions would have confidence that their families were prepared and supported, 

and would be more likely to resist the debilitating 

effects of long-term operational stress. Families who 

knew their soldiers had a solid base of preparation and 

training would feel more secure sending them out to 

serve and would be more likely to support a soldier’s 

decision to make the Army a career. Outcome measures 

were based on assessments of physical, social, and environmental factors with direct and indirect feedback 

from soldiers, family members, and leaders. Metrics 

included the number of training sessions conducted, 

attendees at each, individual consultations and followup referrals, and requests for further information and 

training sessions, as well as feedback on the effectiveness of the educational material including handouts, 

presentations, and resources provided.

Training (including informational briefings), command consultation and support, and referral were core 

features of the program. Crisis intervention, sexual 

assault prevention and advocacy programs, suicide 

prevention training and briefings, and grief-counseling 

support were also incorporated. Family stress support 

services included community outreach programs and 

collaborative programs with other branches of the 

military. For instance, Army Reserve family readiness 

groups (FRGs) “adopted” family members of service 

members from other components of the military who 

were living within their local area. 

Training for leaders and soldiers included prevention, identification, and management of combat and 

high-intensity training stressors and battle-fatigue–

related injuries (Exhibit 22-2). The training covered 

stress reduction techniques, predeployment “hardening,” anger management, suicide prevention, sexual 

assault prevention training, first responder (unit level) 

training in combat stress control, and buddy aid. 

The team provided briefings for soldiers and family 

members, addressing predeployment stressors and 

coping techniques, midcycle issues related to rest and 

recuperation visits by soldiers halfway through their 

deployment, redeployment (reunification) stressors 

and coping techniques, and reconstitution issues including reestablishing family roles and relationships, 

anger management, operational stress reactions, traumatic brain injury, and posttraumatic stress disorder. 

Family stress support services included direct and 

indirect (consultation support) services to help families 

develop stress coping skills, address couple dynamics, 

deal with children’s issues, and prepare for reunification. The team worked closely with FRGs following the 

loss or severe injury of unit members. Linking FRGs 

with Reserve combat stress control assets and other 

military, veteran, and community-based resources was 

a significant part of the COSC team’s role.

A well-being program was established at the RRC 

Headquarters to provide a variety of self-care services 

teaching leaders, soldiers, and contract personnel ways 

to build personal coping skills and resiliency. Inte-
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EXHIBIT 22-2

88TH REGIONAL READINESS COMMAND COMBAT AND OPERATIONAL STRESS CONTROL 

TEAM FIRST RESPONDER TRAINING

1. MISSION. The Combat Operational Stress Control Team (COSC) of the 88th Regional Readiness Command 

Surgeon’s office will conduct Operational Stress Control First Responder Training for Command-designated 

representatives from subordinate units in support of Department of Defense Directive 6490.5 (Combat Stress 

Control [CSC] Programs) JP-1-02, Force Protection.

2. EXECUTION.

 a. Intent: Prepare Soldiers/leaders within the USAR in basic principles of Combat Operational Stress Control 

to enhance force protection and improve Soldier readiness in support of Contingency Operations. Embedding 

Soldiers and FRG representatives knowledgeable in COSC into each unit will enhance early recognition, intervention/referral with stress issues that often result in problems that may affect unit efficiency and degrade 

the quality of life of soldiers and their families. It is assumed that this trained group of first responders will 

maintain contact with a COSC team and their commands on a regular and as-needed basis.

 b. Concept of Training. Conduct 21⁄2-day course with training consisting of Power Point slide presentations, 

video, handouts and role-playing to familiarize non-medical Soldiers with concepts of operational stress 

and battle fatigue. A team consisting of operational stress control personnel and chaplains will conduct the 

training. Both a pre- and a post-test will be administered in order to evaluate the effectiveness of the training. 

(Training Annex W)

3. CONCEPT OF OPERATIONS. To train the participants in the following topics.

 a. Basic combat operational stress principles

 b. Emotional cycles of deployment

 c. Identifying and responding to individuals with suicidal and homicidal behaviors

 d. Recognizing and responding to:

• aggression

• domestic violence

• depression

• posttraumatic stress disorder

• combat stress reactions and battle fatigue

• methods of deescalating potentially dangerous situations

• sexual assault prevention and identifying sexual harassment

 e. Available military, VA, civilian and other resources—how to access and use them

COSC: combat and operational stress control 

USAR: US Army Reserves

VA: Department of Veterans Affairs

Data source: 88th Regional Readiness Command Headquarters, Surgeon’s Office, Fort Snelling, Minnesota. 

grative healthcare providers from the civilian sector 

volunteered their services to provide a variety of selfcare techniques including seated chair massage, acupuncture, guided imagery, healing touch, reflexology, 

Reiki, aroma therapy, and relaxation skills training. 

Information on a variety of stress management topics was provided in the form of brochures, handouts, 

computer disks, and posters. Topics included but were 

not limited to information on stress and anger management, sleep hygiene, communication skills, parenting, 

transitioning, suicide prevention, brain injury, and 

posttraumatic stress, with resources from Military 

OneSource, the Brain Injury Association, Veterans 

Affairs (VA), chaplains, and the Public Health Command (Provisional), formerly the US Army’s Center for 

Health Promotion and Preventive Medicine. Personnel 

who participated in the program reported decreased 

pain and stress levels and increased awareness of stress 

management techniques.

The 88th RRC sustained the highest number of 

Army Reserve soldiers killed in action during the 

early part of the war. The COSC team worked closely 
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Combat and Operational Behavioral Health

with chaplains, public affairs staff, and casualty affairs 

personnel to establish strong support networks for 

grieving families, units, and communities. The team 

addressed the topic of grief and loss at the leadership, 

FRG, and soldier level. Frequently accompanying the 

chaplain, public affairs office, and the funeral honors team, the COSC officer provided support to the 

family, unit leadership, and other unit members and 

their families, as well as the honors team. In specific 

instances, COSC team members met with FRGs to provide bereavement support and education on ways to 

deal with loss. For instance, while five sisters anxiously 

awaited the beginning of their brother’s memorial service, the OT taught them some simple relaxation skills 

for self-calming. The family reported later how much 

those simple techniques helped them get through that 

difficult time. During a funeral, one of the honors team 

members was having a hard time standing still for 

his 20-minute rotation. A few minutes spent helping 

him refocus and practice some simple breathing techniques allowed him to successfully manage the task. 

In another case, the COSC team provided bereavement 

support for family members during an FRG meeting 

following the battlefield death of one of the soldiers. 

They discussed factors involved in grief and loss including the associated fear of having a loved one still 

in harm’s way, taught self-care techniques for adults 

and children, and explained how to locate resources 

for additional support. Following the educational part 

of the meeting, families shared a potluck meal, local 

massage therapists provided “pro bono” seated chair 

massage, and families participated in structured leisure 

activities while socially engaging with one another 

within a safe environment. The COSC team provided 

one-on-one consultation support during this time. 

Throughout the remainder of the unit’s deployment 

the team provided periodic support to the FRG.

Located in a predominately civilian region, outreach 

to civilian organizations within the 88th RRC was vital 

to help the community understand the unique and 

changing culture of the citizen soldier (the next-door 

neighbor, coworker, or church member serving as a 

Reservist). A concerted effort was launched in partnership with the National Guard, VA, and veterans’ 

service organizations to address the reintegration of 

soldiers into the workplace and community following their return home. Briefings were prepared to 

meet the individual needs of employers, community 

groups, and faith-based groups. For instance, OT staff 

developed briefing material to alert leaders, units, and 

care providers about the impact of traumatic brain 

injury, combat stress reactions, and posttraumatic 

stress disorder. 

Community outreach presentations on a regional, 

state, and national level also provided training and 

workshops for civilian healthcare workers. Law enforcement training was provided through interagency 

partnerships. State-based postdeployment healthcare 

collaborations were supported by the COSC teams 

in Wisconsin, Ohio (Ohio Cares), and Minnesota 

(postdeployment collaboration with the VA, DoD, 

and community health professionals). The team provided training for both Minnesota and North Dakota 

county veterans’ service officers, helping the officers 

to understand the changing culture and needs of redeployed soldiers and refer them to the appropriate 

level of services.

College and university presentations focused on the 

needs of returning combat veterans in the classroom, 

the needs of families and friends of a combat veterans, 

and resources available to returning veterans. The state 

of Minnesota allocated funds for the state college and 

university consortium to establish campus-based veterans’ transition centers. Veterans were encouraged to 

utilize the services of these centers to identify “battle 

buddies” as they returned to college living and to focus 

on formation of attitudes and behaviors to promote 

success in their college experience. A county library 

donated thousands of books for deploying troops at 

Soldier Readiness Processing centers as well as their 

families to provide constructive diversion from deployment cycle stress. Exhibit 22-3 describes the types of 

soldier and family briefings provided throughout the 

deployment cycle.

Occupational Therapy in Support of Operation Iraqi Freedom

Detainee Healthcare

US Army combat support hospitals are responsible 

for providing quality healthcare with dignity and respect to Iraqi civilians as well as detained insurgents. 

Individuals with acute injuries can be admitted day 

and night in an intensive combat environment. Patients on detained status are required to live in the 

theater internment facility while they receive medical 

treatment. A dynamic and multifaceted rehabilitation 

program is necessary not only for the improvement 

of patients’ performance in all areas of occupation, 

but also to enhance their functional outcomes. The 

goal is for the patient to achieve a functional level 

sufficient for discharge in a facility with a rapid 

turnover rate.

Patients admitted to a combat support hospital 

have often sustained polytrauma, which can include 
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US Army Occupational Therapy: Promoting Optimal Performance

EXHIBIT 22-3

88TH REGIONAL READINESS COMMAND COMBAT AND OPERATIONAL STRESS CONTROL 

TEAM DEPLOYMENT CYCLE SUPPORT BRIEFINGS

Deployment cycle support briefings are the single most important mechanism for establishing rapport with soldiers and family members. Through these briefings, soldiers and family members learn about the effects of chronic 

stress on the body and on performance. A significant element in all the presentations is improving communication 

skills: a factual presentation of the negative results of poor communication is given, followed by suggestions for 

developing positive communication skills. Effects of the deployment cycle on children and significant others are 

also presented.

Soldier readiness processing briefings consist of 30-minute slide presentation that alerts soldiers to the need to 

prepare themselves and their families for deployment. Briefings discuss preparation in terms of Preventative Maintenance Checks and Services (PMCS; a routine personal self-care program to maintain mission capability) and stress 

the need to start working on communication skills and problems before the soldier is mobilized.

Premobilization briefings consist of a 45-minute slide presentation describing the ramp-up to deployment and 

the effect this process has on soldiers, their spouses and significant others, and the children. Handouts are used to 

reinforce the briefings.

Mid-cycle briefings are presented to members of a family readiness group. The loosely structured briefings are 

used to answer questions and allay fears that have become burdens to family members and children, and may include one-on-one talks with individuals with specific questions. Most of the issues revolve around communication. 

Handouts are used to reinforce the briefings.

Demobilization briefings are ideally presented to family members and interested others 2 to 4 weeks before the 

soldiers return home; however, they are usually presented the same day the soldiers return. The slide presentations 

used at homecoming try to cover a range of issues from readjustment of roles to intimacy issues. Handouts are used 

to reinforce the material.

Reconstitution briefings are directed sessions of teaching followed by small group and one-on-one discussions on 

issues that have come up since the soldiers’ return. Issues include operational stress reactions, posttraumatic stress 

reactions, and marital and parenting problems. A slide presentation can be used to present issues, but often this briefing takes the form of a more relaxed and unstructured conversation. Handouts are used to reinforce the material.

Data source: 88th Regional Readiness Command Headquarters, Surgeon’s Office, Fort Snelling, Minnesota.

many orthopaedic or neurological deficits. OT staff 

members critically observe and analyze patients to 

determine a baseline performance for motor, cognitive, and communication skills. OTs and OTAs then 

work with patients to reconcile the changes to their 

bodies by empowering them to establish new habits, 

routines, and roles to maximize performance during 

daily activities. The model of human occupation frame 

of reference provides theoretical guidance to OT staff 

working with detainees, aimed at enabling inpatients 

to make order out of the disorder that they are experiencing.11 Active involvement in improving health 

and learned wellness are two key constructs of the 

model that are directly applied to detainee healthcare. 

Detainees may not readily expect to take an active approach in their own recovery process; therefore, adding 

a patient education piece to other aspects of healthcare 

service delivery is an important aspect of recovery. 

Patients must cope with the transition from the status 

of “detained patient” to an ordinary “detainee” upon 

discharge. Detainees are expected to perform the activities of daily living requirements independently in 

the internment facility.

Cultural differences bring particular challenges to 

detainee care. Many detained patients do not speak 

English, necessitating interpreters. In addition, gender 

roles within the Muslim culture are significantly different than Americans are accustomed to; for example, 

the expectation of taking direction from primarily 

female nurses can pose difficulty for male patients 

raised in a male-dominated society. If a detainee is 

having difficulty complying with medical instructions from staff, the OT may become involved. The 

therapist would work with the detainee to facilitate 

understanding of the benefits of inpatient care using 

the listen, learn, and comply approach: the OT explains 
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Combat and Operational Behavioral Health

Peak Performance training in Occupational Therapy

The concept of peak performance, developed 

originally at the US Military Academy’s Center for Enhanced Performance and currently used by Army OTs, 

is derived from “mental toughness training to develop 

the Army pentathlete.”12 It is based on the principle 

that Army leaders must be self-aware, mentally agile, 

and adaptive. Peak performance has been described 

as “sports psychology taken to the battlefield” in that 

the core components rely on human performance and 

behavior, but the thought–performance interaction 

is essential in successfully completing warrior tasks. 

A mental imagery research study found that mental 

imagery (imagining squeezing an immobilized hand 

without performing any movement) might be of benefit in preventing strength loss during immobilization.13

OTs have successfully utilized peak performance training with Operation Iraqi Freedom/Enduring Freedom 

patients, specifically in combat stress casualties or 

those diagnosed with posttraumatic stress disorder. 

Peak performance techniques decrease recovery time 

and prepare individuals for success both physically 

and mentally in returning to their respective areas of 

expertise. The OT uses peak performance concepts 

to help maximize soldiers’ physical, mental, and 

emotional performance during periods of temporary 

or permanent life changes following illness or injury. 

Through their knowledge of human factors, occupational performance, and occupational adaptation, OTs 

help soldiers build their performance capabilities in 

overcoming physical, cognitive, and emotional challenges posed by illness or injury. 

The five core foundations of peak performance are 

(1) a cognitive foundation, (2) attention control, (3) 

goal setting, (4) stress and energy management, and 

(5) visualization and imagery. Improving skills related 

to each of the five components ultimately leads to 

optimizing mental agility and performance. An example of an effective therapeutic intervention derived 

from peak performance training is the use of guided 

imagery and relaxation. Guided imagery involves 

using a series of thoughts or suggestions to direct a 

person’s mental focus toward a more relaxed state. 

Nightingale14 suggested various ways that imagery 

could be used for counseling, such as motivation by 

imagining a positive future, insight through exploration of possibilities, and problem solving. In warrior 

training and rehabilitation programs, OT services are 

conducted by an OT and an OTA. The OTA conducts 

the group program and implements orthopaedic treatments, while the OT completes individual evaluations 

and treatment sessions.

Peak performance training has been implemented 

in the form of group intervention, 1 hour per week for 

6 weeks. The OT staff facilitates a group addressing 

the following six topics: (1) goal setting, (2) stress and 

energy management, (3) visualization and imagery, 

(4) confidence, (5) attention control, and (6) anger 

management. To foster esprit de corps, the soldiers in 

the program develop a unit creed while participating. 

Group interventions focus on enhancing the thought–

performance interaction to maximize performance 

outcomes. For example, one group might focus on 

recognizing physiological changes such as skin temperature, heart rate, and muscle tension while experiencing both physical and mental stressors to allow 

participants to experience physical manifestations of 

stress. Participants would then implement steps to 

enhance performance in this stressful environment. 

Both negative and positive self-fulfilling prophecies 

can ultimately affect performance on any given event, 

not only during the training but also in many settings throughout soldiers’ lives. These core areas are 

essential to enhancing soldier performance and can 

ultimately be applied to either battlefield or garrison 

environments. 

Individual peak performance training augments 

group topics to develop the skills necessary for successful performance. Soldiers can choose goal setting 

and/or stress management for their care plan. During 

goal setting, the soldier develops personal goals ranging from graduating from the Warrior Training and 

Rehabilitation Program (WTRP) to military retirement. 

In the goal-setting session, soldiers identify the reasons 

for participating in any given event, what they want 

to accomplish, and most importantly, how they will 

achieve their goals. The end result is energy, persistence, 

and a prime selection of strategies for achieving each 

person’s goals.12 Ultimately a personalized “goal sheet” 

is developed and kept with participants at all times. The 

stress management option involves the use of Freeze 

Framer, a computerized biofeedback program, or a 

relaxation plan. Individual peak performance intervention can either be self-referred or command-referred if 

the soldier is not adapting well to WTRP.

that it is the patient’s responsibility to listen to directives put forth by the staff to maximize the benefit of 

multidisciplinary healthcare. For patients to take responsibility for the personal management of their own 

health, patient education about the injury or illness is 

imperative. Patient compliance is necessary because 

the staff must meet the needs of the other patients in 

a timely manner. 
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The stress and energy management model in peak 

performance is based on a concept called “grip and 

gravity,”12 based on identifying things individuals 

cannot control (gravity), and redirecting focus to 

things individuals have the ability to control (grip). 

In a setting where many injured soldiers feel out of 

control, future plans, current situations, attitudes, 

and perceptions will always be within their “grip” 

forces. Once the soldier has grasped the concept of 

taking control over his or her own life, biofeedback 

and relaxation techniques can be introduced into the 

treatment plan.

Biofeedback tools are used to teach soldiers how 

to recognize physiological changes (such as heart 

rate and breathing patterns) that occur with stress 

and make the necessary changes to reduce the magnitude of the stress response. By using biofeedback 

instruments, the soldier gains increased awareness 

and sensitivity to internal stress responses. The 

ultimate goal of this treatment is for the soldiers to 

recognize internal cues of stress without the aid of 

the instrument, and implement the steps to regain 

control. This reemphasizes the thought–performance 

interaction concept discussed during the group 

intervention. Equipment required for this program 

includes a computerized biofeedback instrument for 

treatment sessions and a relaxation chamber, which 

allows for optimal relaxation positioning and control 

of environmental stimuli during the intervention. 

The biofeedback equipment has been shown to improve overall physical speed and accuracy, enhance 

problem-focused coping skills, sustain concentration, 

and manage stress and anger.12

Using the peak performance model and its inherent mental agility intervention can improve soldiers’ 

satisfaction with themselves, their careers, and their 

families. With dedicated work and intervention, it can 

facilitate patients’ return to the unit without removal 

from theater or return to garrison duty. When utilized 

in the garrison setting, peak performance training at 

WTRP enabled soldiers’ return to duty earlier when 

compared to programs that do not incorporate peak 

performance concepts. Soldiers also reported increased 

satisfaction in their own outcomes as well as a decrease 

in negative thoughts. Overall, the peak performance 

program integrates psychological, cognitive, and 

physiological concepts to enhance performance and 

promote positive attitudes among soldiers both in 

theater and in garrison. 

Case Study 22-1: SGT JS, an infantryman, was initially 

seen by OT for an upper extremity injury following his return 

from Operation Iraqi Freedom. The therapist noticed that 

JS was having difficulty dealing with issues related to his 

deployment, specifically with anger and depression. He was 

referred to a community mental health social worker and a 

posttraumatic stress disorder group, which met once a week 

for 6 weeks. He decided immediately that his goal was to 

work on anger management, specifically when it came to his 

relationship with his wife. In a group-learning environment, 

he acquired many of the skills of the peak performance 

model, including energy management and goal setting. 

SGT JS also attended OT for one-on-one intervention for 

8 weeks, incorporating a biofeedback heart rate program, 

guided imagery, and progressive muscle relaxation to gain 

control and composure when dealing with stressful situations. SGT JS reported an increase in confidence, increased 

satisfaction with his marriage since his return, and an overall 

increase in well being after attending the group and one-onone sessions.

Occupational Therapy in the Warrior Transition Unit

Since World War I, OT’s philosophy of matching 

interventions to the soldier’s ability has been an 

integral part of the effort to help those wounded in 

combat return to work. It was thought that wounded 

soldiers should be “restored to trades appropriate to 

their abilities, interest, and background.”3(p152) Contributions did not end with direct care. Early OTs 

were also instrumental in setting national policy, 

contributing to the passage of the Soldiers Rehabilitation Act in June 1918.3(p158) Similar involvement 

continues today, with OT personnel instrumental 

in the formation of the Army’s Proponency Office 

for Rehabilitation and Reintegration in May 2007, 

the development of the Comprehensive Transition 

Plan, and the development of the role of OT within 

WTUs. 

The goal of a WTU is to promote soldiers’ abilities to 

return to the force or transition to a productive civilian 

life. OT helps individuals regain, develop, or master 

everyday skills to live independent, productive, and 

satisfying lives.15 Within the WTU, OT’s primary role is 

to address life-skills needs and coordinate work reintegration, thus assisting soldiers to return to productive 

living. Work includes activities needed for engaging 

in paid employment or volunteer activities.16(p341) Occupation refers to the everyday activities of life that are 

named, organized, and given value and meaning by 

individuals and a culture. “Occupation is everything 

people do to occupy themselves including looking 

after themselves, enjoying life and contributing to the 

social and economic fabric of their communities.”17(p34)

Work reintegration is defined as a program that provides a structured environment with participation in 

vocationally related activities. The participant must 
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be medically stable and have a goal of competitive 

employment.18

The Comprehensive Transition Plan

The desired outcome is for each participant to be 

a successful soldier or successful veteran, physically 

and mentally strengthened, vocationally enabled, with 

a life-care plan established, able to maintain relationships, and proud of his or her military service.19 Each 

soldier’s comprehensive transition plan is an individualized, multiphased process with overlapping 

boundaries. The reception phase is generally 1 week in 

duration. Upon arrival at the WTU, soldiers are greeted 

with a unit welcome and orientation that delineates 

the expectation that they will actively participate in 

their own healing process. They are educated on the 

overall mission statement that will be inculcated into 

their daily life within the WTU: 

I am a warrior in transition. My job is to heal as I transition back to duty or continue serving the nation as 

a veteran in my community. This is not a status, but a 

mission. I will succeed in this mission because I AM 

A WARRIOR AND I AM ARMY STRONG. 

The soldier is issued a “Warrior Toolkit” that includes the soldier mission statement, orientation materials, and life-skills material designed to encourage 

self-empowerment in the healing process. 

Next comes the assessment and goal-setting phase, 

which generally lasts a month. During this initial 

period, soldiers undergo assessments for behavioral 

health risk; pain, sleep, and safety (including cognitive awareness, mobility, vision, and hearing tests); 

and requirements for housing assistance, medical 

supplies, family needs, and nutrition management. 

The staff members also appraise the soldier’s level 

of function, vocational goals, skills, abilities, health 

maintenance and lifestyle, and the initiation/sustainment of rehabilitation. At the same time, the 

soldier’s goal-setting phase begins with a focus on 

the development of positive life skills and habits. The 

soldier works with the nurse case manager, primary 

care manager (a physician or physician’s assistant), 

squad leader, OT personnel, social work, and unit 

ministry teams to develop goals for improvement in 

body, mind, and spirit. OTs have a leadership role in 

warrior goal-setting training. Functional independence and mobility goals are established, including 

accessing transportation resources. Vocational, educational, social, leisure, and recreation goals are also 

established during this phase. Intrapersonal goals 

are identified to enhance self-esteem, responsibility 

to self, interpersonal relationships, and community 

responsibility.

Next, during the active rehabilitation phase, the 

soldier works toward attaining specific goals. This 

phase is divided into four tiers based on the soldier’s 

abilities, and a training calendar is established to help 

reset the soldier. Tier assignment levels include tier A 

(medical recovery/rest) for soldiers who are placed 

on quarters. Soldiers in tier A are generally unable to 

participate in any physical, mental, relationship, or 

spiritual strengthening programs. Tier B (basic reset) 

consists of soldiers who spend their training day in rehabilitation basics. These soldiers are actively engaged 

in medical appointments; group or individual therapy 

to improve strength, range of motion, or endurance; 

programs and classes in nutrition or weight management; classes in life skills; or classes and workshops 

on relationships. Tier B includes programs that every 

warrior in transition needs to build basic skills and 

strengths as well as individualized programs to address unique circumstances.

Tier C (advanced reset) follows completion of the 

basic skills program. These soldiers spend part of their 

duty day in vocational or educational activities, but 

still require significant time for activities specifically 

designed to rehabilitate their body, mind, and spirit. 

Tier C generally involves interventions targeted at 

addressing a specific goal. Tier D (life reset) is focused 

on vocational, educational, family, and community 

pursuits. Soldiers in this tier must have completed 

tier B basics. They spend the majority of their duty 

day in vocational or educational activities, but still 

require ongoing medical treatment or rehabilitation. 

Throughout the active rehabilitation phase, a mandatory review of progress and reassessment occurs on a 

regular basis, with the soldier actively participating in 

multidisciplinary team meetings coordinated by the 

nurse case manager.

The final transition preparation phase, which may 

last up to 90 days, occurs once each individual’s disposition decision has been made. During this phase, the 

soldier undergoes final preparation for the expected 

disposition. Details regarding return to home, family, 

and community living as well as ongoing vocational 

or educational pursuits after they leave the WTU 

are addressed and coordinated to assure a smooth 

transition. 

Work Reintegration Programs

The objectives of a work reintegration program involve returning the soldier to the role of worker either 

in a military or civilian capacity. This is done through 

promoting, improving, conserving, and restoring the 
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US Army Occupational Therapy: Promoting Optimal Performance

skills, abilities, and aptitudes of soldiers through both 

vocational and avocational reintegration services. A 

soldier-centered work reintegration program pursues 

these goals for the soldier in transition. The program 

focuses on the behavioral, psychosocial, vocational, 

avocational, and educational needs of the soldier using techniques to facilitate independence and empowerment. The work reintegration program involves 

collaboration with military and civilian communities 

to set up safe work sites that promote quality work 

performance and enhance the quality of the service 

member’s everyday life. The soldier actively participates in the work reintegration program, developing 

an understanding of how the services provided can 

positively impact his or her ability to function in a 

work environment. 

The program also incorporates collaboration with 

appropriate professionals and community members 

to minimize impairment, maximize independent 

function, and enhance the quality of life of the service 

member in transition. Through the use of performance 

indicators, the work reintegration program measures 

the effectiveness of services provided along the continuum of care. OTs assist service members to develop 

and attain realistic short-term and long-term goals that 

reflect their interests in vocational and avocational 

pursuits. Service members benefit from this program 

by increasing the likelihood of attaining their personal 

goals, while the community benefits by reacquiring 

responsible and competent workers.

Occupational Therapy’s Focus in Work 

Reintegration

The director of the work reintegration program is 

a registered and licensed OT who is qualified in both 

OT and work reintegration. Certified OTAs provide 

support in areas including screening, programming, 

life skills training, work-site development and coordination, and networking with internal and external 

resources to assure a well-balanced program aimed at 

returning soldiers to productive living. OT personnel 

work closely with other WTU staff to develop and 

implement the work reintegration program, which 

the OT is then responsible for overseeing. OTs are 

located in proximity to the WTU to facilitate communication with the cadre and increase interactions 

with participants. The OT and COTAs should be allocated appropriate space to develop and conduct a 

successful work reintegration program. Responsibilities of the OT assigned to the WTU include but are 

not limited to:

• working closely with OTs at the medical treatment facility to ensure continuity of care;

• developing and implementing standard operating procedures that support the overall 

goals and objectives of the work reintegration 

program;

• assessing limitations that prevent or delay return to work and providing recommendations 

for modifications and equipment needs;

• working closely with case mangers in coordinating vocational training, job skills training, 

and work placement;

• conducting visits to work sites to ensure job 

appropriateness and verifying that the participant is performing the agreed-upon job 

tasks;

• developing collaborations within the community to determine resources and to prevent 

duplication of services;

• working closely with other WTU staff to ensure continuity of care and accountability;

• establishing specific quantifiable standards 

to measure the work reintegration program 

success; and

• supervising the COTA personnel assigned to 

the WTU.

All soldiers assigned to the WTU undergo a comprehensive evaluation by the OT to determine eligibility 

and placement in the work reintegration program. 

Tools used by the OT may include a vocational interest survey, vocational aptitude assessment, career assessment tests, life skills assessments, cognitive skills 

assessments, occupational performance assessments, 

functional capacity evaluations, a driving evaluation in 

a simulator, and an evaluation of firearm performance 

in a simulator. All soldiers in transition also should be 

evaluated by the OT within 1 to 2 weeks of in-processing to determine if they are eligible to participate in 

the work reintegration program. Soldiers eligible for 

the program will be assigned a meaningful job within 

the limits of their physical profile and commensurate 

with their grade. Work internships are being developed 

in collaboration with the VA and 501(c)(3) (nonprofit) 

organizations to provide work experiences in areas of 

potential career fields. Each work reintegration program should maintain a file on each work site including a job description with work hours, dress code (if 

civilian), point of contact, memorandum of agreement, 

and the physical, cognitive, and psychosocial requirements of the job. 

OTs collaborate with unit training personnel to 

help develop a structured daily schedule for each 

participant consisting of life skills development, work 

preparation, education, training, and structured duty 
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assignments to prepare soldiers for return to functional living. Activities are matched to the individual’s 

needs and abilities and may include (a) stress management, (b) anger management, (c) assertiveness/

communication skills training, (d) functional activities, (e) soldier basic skill training, (f) MOS training, 

(g) problem-solving and goal-setting skills training, 

(h) financial management skills training, (i) time 

management skills training, and (j) work readiness 

skills—work habits, values, interests, skills, and vocational exploration.

The supervisor at each work reintegration site 

provides weekly progress reports to the OT. In addition, the OT conducts at least bimonthly follow-ups 

to reassess each participant for continuance of the 

current work placement. The OT also decides what 

type of follow-up is needed when participants leave 

the unit. By the day of discharge/transition, written 

recommendations are given to providers in the continuum of care and other stakeholders as appropriate. 

Depending on the needs of the soldier, the written 

recommendations address: 

• medical issues relevant to job placement;

• functional issues relevant to job performance;

• psychological issues relevant to job placement;

• significant abilities, relevant aptitude scores; 

• areas for growth;

• identification of additional training if needed; 

and

• available community integration services, including local, regional, provincial, or national 

consumer organizations.

The work reintegration program includes a data collection system for performance indicators—collected 

initially and reevaluated over time—to measure the effectiveness of services provided across the continuum, 

including the number of WTU soldiers who were discharged from the military, who returned to duty, who 

received a permanent job placement, and who enrolled 

in school. Program staff also record satisfaction of the 

job site from the participant and family members. 

Occupational Therapy on the Home Front

The emotional cycle of deployment affects not only 

soldiers, but also their families, employers, coworkers, schools, and the surrounding community.20 The 

role of OT on the home front involves building skills 

to withstand the stress of deployment separation as 

well as focusing on habit training to assist soldiers 

and their families in the reintegration process. Incorporating rituals and traditions that can carry over 

throughout the deployment may provide a sense of 

consistency and order during a chaotic time. A psychoeducational approach using a resiliency model to 

enhance life skills in predeploying soldiers and their 

families may act as a protective measure in preparing them to overcome the hardships of deployment 

separation.

Returning combat troops and their families 

frequently report increased levels of anxiety and 

risk-taking behaviors when the soldier resumes 

driving at home.21 This may be due to the retention of automatic combat driving behaviors that 

were overlearned to help the soldier survive in a 

hostile environment. Although appropriate on the 

battlefield, automatic combat driving behaviors do 

not mesh well with local traffic laws at home. OT 

personnel assess the physical, cognitive, and behavioral components of driving to help soldiers safely 

perform this daily living skill. Awareness training 

and specific interventions are useful in managing 

maladaptive postcombat driving behaviors. Using 

a consultative approach, occupational therapists 

collaborated with Military OneSource to develop 

a handout for service members and their families, 

providing awareness of and tips for managing postcombat driving behaviors. An article published in 

a national newsletter for traffic court judges also 

helped to increase the judges’ awareness of these 

issues when returning soldiers have pending legal 

action in the traffic court system.21,22

A collaborative relationship between an academic 

institution and an Army OT resulted in the development of postdeployment driving reintegration tools. 

Research conducted by OT faculty and students at 

the University of Minnesota described postcombat 

soldier driving responses and identified specific 

interventions that effectively enhance driving safety. 

In consultation with the Proponency Office for Rehabilitation and Reintegration, the student/faculty team 

incorporated survey results, focus groups, and oneto-one interviews to develop informational brochures 

for soldiers and family members. The brochures 

address postcombat driving on the American road 

and include suggestions to help returning soldiers 

drive safely at home. In addition, the OT academic 

researcher developed clinician training for OTs working in military settings to help standardize the use of 

driving simulation.
373

US Army Occupational Therapy: Promoting Optimal Performance

SUMMARY

REFERENCES

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Army OTs are human performance experts and dedicated leaders whose innovative programs and services 

help optimize soldier performance and readiness in 

theater and garrison. Providing a functional approach 

to healing through doing, OTs match the individual’s 

interests, skills, and abilities with activities that have 

meaning and purpose, along with a “just right” challenge. A focus on occupational performance helps to 

restore soldier confidence and competence. Life skills 

components of OT promote functional independence, 

which enhances future quality of life and productivity. 

Participation in work and productive activities promotes 

a sense of mastery, a positive self-identity, and a responsibility to take control over one’s future. Bridging the gap 

between medical care and military performance training, 

OTs help unit leaders retain their soldiers through assessing physical, social, and environmental factors and 

recommending interventions to enhance unit climate 

and living conditions. 

The practice of OT has been essential in the rehabilitation of military personnel since World War I. OTs 

use a variety of strategies to enhance occupational 

performance, a key factor in retention of the soldier 

who has sustained a physical or psychological injury. 

They also assess the soldier’s performance and help 

the service member gain the skills and resilience to 

remain functional whether returning to the battlefield 

or transitioning to the civilian community. OTs provide 

a vital link to practical living and a more satisfactory 

life through occupational engagement and enhancement of physical, psychological, cognitive, and social 

aspects of performance. 
374

Combat and Operational Behavioral Health

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