43

Preparation for Deployment: Improving Resilience

Chapter 3

PREPARATION FOR DEPLOYMENT: 

IMPROVING RESILIENCE

PATRICIA WATSON, PhD*; BRETT LITZ, PhD†; STEVEN SOUTHWICK, MD‡; and ELSPETH CAMERON 

RITCHIE, MD, MPH§

INTRODUCTION

THEORETICAL MODELS OF STRESS, TRAUMA, AND RESILIENCE

Stress

Trauma

Resilience

EVALUATING RESILIENCE OUTCOMES

MEASUREMENT OF RESILIENCE FACTORS IN THE MILITARY

INTERVENTIONS FOR BUILDING RESILIENCE AND PREPAREDNESS

Toughening Responses to Stress

Building Strengths Through Training Programs 

Building Resilience Through Self-Help Programs 

Teaching Skills Commonly Utilized During Survival Situations 

Reinforcing Skills Through Military Training 

SUGGESTIONS FOR FUTURE RESEARCH ON RESILIENCE

SUMMARY

*Assistant Professor, Dartmouth Medical School, 1 Rope Ferry Road, Hanover, New Hampshire 03755-1404; Senior Educational Specialist, Executive 

Division, Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, White River Junction, Vermont 

†

Professor, Department of Psychiatry, Boston University School of Medicine, 77 East Concord Street, Boston, Massachusetts 02118; Associate Director, 

Behavioral Sciences Division, Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, White River Junction, Vermont

‡

Professor, Department of Psychiatry, Yale University School of Medicine and Yale Child Study Center, 333 Cedar Street, New Haven, Connecticut 06510; 

Adjunct Professor, Department of Psychiatry, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, New York 10029; Deputy Director, 

Clinical Neurosciences Division, Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, White River Junction, Vermont

§

Colonel, US Army (Retired); formerly, Psychiatry Consultant to The Surgeon General, US Army, and Director, Behavioral Health Proponency, Office 

of The Surgeon General, Falls Church, Virginia; currently, Chief Clinical Officer, District of Columbia Department of Mental Health, 64 New York 

Avenue NE, 4th Floor, Washington, DC 20002
44

Combat and Operational Behavioral Health

INTRODUCTION

With ongoing military operations in Afghanistan 

and Iraq involving multiple deployments for military 

personnel, there is growing interest in preparatory 

training activities that can increase service members’ 

resilience to the stress of deployment. Service members 

are trained in numerous ways that promote adaptation 

to the stress, strain, and sacrifices of deployments. For 

example, physical fitness training, mission preparation, specialty role training, experiences that promote 

confidence in leaders and trust in peers, and messages 

that emphasize the purpose and function of mission 

goals are necessary ingredients to successful navigation of various deployment demands. It is not known 

whether these standard training activities enhance coping capabilities in the face of severe mission demands 

and traumas. Nor is it known whether existing training regimens effect risk for stress injuries and mental 

health difficulties linked to deployment stress. Finally, 

no systematic research has been conducted to date 

on preparedness interventions specifically designed 

to build psychological resilience and prevent the development of posttraumatic stress disorder (PTSD) in 

military personnel. 

The lack of empirical literature to support unit 

preparedness interventions is compounded by the 

lack of an accepted or unified conceptual framework 

that defines the necessary and sufficient ingredients 

for resilience in the face of trauma. In addition, because most research on combat stress has been crosssectional, little is known about risk, protective, and 

vulnerability factors, and the mechanisms, processes, 

and pathways of influence through which they exert 

their influence on trajectories of adaptation to deployment stress.1

 Unfortunately, the constructs used 

to define resilience are often extrapolated loosely or 

interchangeably. Furthermore, research in resilience, 

hardiness, coping self-efficacy, and biological components of resilience has been conducted within the 

areas of developmental pathology, trauma, and positive psychology, with little cross-referencing among 

these disciplines.2

Because of the high probability of exposure to severe 

stress and the extensive motivation to retain a ready 

and fit fighting force, the military is a natural laboratory to study the effectiveness of resilience-building 

strategies. What few findings do exist from the adult 

literature on resilience often come from studies of 

men in combat. These studies suggest that resilience 

is related to an ability to bond with a group with a 

common mission, a high value placed on altruism, the 

capacity to tolerate high levels of fear and still perform 

effectively, and psychobiological factors related to a 

low tendency to dissociate.3

 This chapter will extrapolate from theoretical models about resilience as well 

as related fields investigating stress, traumatic stress, 

and recovery from trauma. The goal is to generate an 

agenda for resilience training that can be examined in 

future research.

THEORETICAL MODELS OF STRESS, TRAUMA, AND RESILIENCE

It is necessary to first define theoretical models and 

core constructs related to stress, trauma, and resilience, 

as well as the implication of these models for preparation and early intervention. 

Stress

Research on posttrauma mental health belongs to 

the broader field of stress research. Stress theory generally assumes that external demands (the traumatic 

event as primary stressor) evoke responses that draw on 

internal and external resources. Loss of resources, either 

concrete (social, financial) or symbolic (beliefs, expectations) may, as secondary stressors, significantly impact 

the recovery trajectory.4

 Survivors’ own responses 

(anxiety, insomnia, depression) may additionally tax 

overall resources, becoming tertiary stressors.5

 With 

sufficient infusion of resources and the passage of 

time, recovery is the expected outcome of time-limited 

exposure to a stressor (with great variation depending 

on the intensity and duration of the stressor6

). Stress 

management typically involves identifying and ameliorating those factors that interfere with recovery (lack 

of supportive others, ongoing stressors, maladaptive 

beliefs), and providing the resources that help support, 

organize, and make a plan for survivors.7

Trauma 

There is no single cause of maladaptive responses to 

trauma. Traumatic stress theories often draw on psychological and biological research that has identified 

and mapped processes distinctly reactive to traumatic 

stress.8,9 These findings support the proposition that 

when traumatic responses are overwhelming, uncontrollable, and involve extreme physiological arousal, 

they may consolidate the link between fear and traumatic recall, leading to avoidance, repeated recall, and 

ultimately to PTSD. Additional adversity, such as that 

often seen in the aftermath of extended deployments, 
45

Preparation for Deployment: Improving Resilience

can create a chain of mutually reinforcing reactions that 

may be present forever in a person’s memory.

Ehlers and Clark’s10 cognitive model of trauma suggests that preventive interventions focus on reframing 

negative appraisals of posttraumatic reactions, help 

individuals to distinguish between past and present 

threat, and help them process intrusive recollections. 

Specifically, 

	 •	 Individuals are at higher risk for persistent

PTSD when they make excessively negative 

appraisals of the trauma and exhibit disturbed 

memory processes such as poor elaboration 

and contextualization, strong associative 

memory, and strong perceptual priming. 

If individuals appraise their reactions to 

trauma negatively, they are at risk for enduring PTSD.11 Therefore, helping individuals to 

reframe their reactions in a more neutral or 

positive light should reduce the likelihood of 

long-term PTSD.

	 •	 Because a central process in PTSD is an inability to distinguish past trauma associations 

of threat with current conditions, Ehlers and 

Clark advocate interventions that assist with 

contextual discrimination of past and present 

circumstances via cognitive therapy.

Intrusive recollections are natural responses to severe and salient life events. Processing (sharing, articulating in a therapeutic manner) incongruous, intrusive, 

distressful, and unremitting recollections, as well as 

examining and correcting the cognitive and behavioral 

responses to them, are the unique factors that should be 

addressed by trauma interventions above and beyond 

stress and negative affect management.12

Recovery following traumatic stress is promoted by 

individually chosen disclosure and social support; the 

perception that the social milieu accepts one’s reactions 

and welcomes disclosure; seeing oneself as a hero or 

survivor rather than victim; a sense of relationship with 

“God,” a higher power, or some philosophical sense 

of meaning; and trauma-focused treatment that helps 

reframe negative reactions, process intrusive recollections, and assist in distinguishing past from present 

threat.13 Posttrauma social support and relatively fewer 

posttrauma negative events may serve as protective 

factors mediating posttrauma recovery.14,15

Resilience

The American Psychological Association Task Force 

on Promoting Resilience in Response to Terrorism 

defines resilience as “the process of adapting well in 

the face of adversity, trauma, tragedy, threats, or even 

significant sources of stress.”16 It cites many studies 

showing that the primary factors in resilience are (a) 

caring relationships within and outside the family 

that create love and trust, provide role models, and 

encourage and reassure; (b) the capacity to make realistic plans and implement them; (c) self-confidence; (d) 

communication and problem-solving skills; and (e) the 

capacity to manage emotions. It is generally accepted 

that resilience is common and derives from the basic 

human ability to adapt to new situations.17 

Most research on resilience comes from developmental psychopathology, where initially researchers 

tried to identify general characteristics associated 

with resilient recovery from stressors.18 These general 

characteristics included hardiness, efficacy (both self 

and collective), and neurobiological components of 

resilience. 

Hardiness

Research with hardy individuals suggests that 

they have various personal attributes that may foster 

resilience. They report seeking help and building large 

support networks, reframe their experiences more 

positively (difficulties as leading to benefits); believe 

they can change a stressor or recover from its detrimental effects; endorse focusing selectively on the positive 

effects of severe life challenges; view themselves as 

controlling their fate; are committed to meaningful 

goals; view stress as a surmountable challenge; are less 

likely to endorse behavioral disengagement, denial, 

mental disengagement, and use of alcohol to confront 

stress; and are more likely to describe themselves as 

problem solvers.19–21 

Maddi and Kobasa22 studied healthy executives to 

discern the methods they used to increase “mental 

toughness.” They found hardy people were committed to their work (they have a mission they believe 

in), have a sense of control over what happens in their 

life, and zestfully seek and take on challenges, feeling 

they will learn from the experiences. They seldom 

get sick. 

Coping Self-Efficacy

A sense of being able to be effective in the world 

is the foundation of human agency (the power to 

originate actions for a given purpose).23 Unless people 

believe they can produce desired results and forestall 

detrimental ones by their actions, they have little incentive to act or to persevere in the face of difficulties. 

It is partly on the basis of efficacy beliefs that people 

choose what challenges to undertake, how much effort 
46

Combat and Operational Behavioral Health

to expend in the endeavor, how long to persevere in 

the face of obstacles and failures, and whether failures 

are motivating or demoralizing. Benight and Bandura24

recommended that individuals be taught to set achievable goals, which will enable them to have repeated 

success experiences as well as to establish a sense of 

environmental control, thus increasing their resilience. 

Moreover, teaching new problem-solving skills can 

increase an individual’s sense of coping efficacy. A 

strong sense of coping efficacy, in turn, reduces vulnerability to stress and depression in taxing situations 

and strengthens resiliency to adversity.

Collective Efficacy

Social cognitive theory extends the conception of 

individual efficacy to “collective agency,”25 which is 

particularly relevant to the military. People’s shared 

belief in their collective power to produce desired 

results is a key ingredient of collective agency. The findings taken as a whole demonstrate that the stronger 

the perceived collective efficacy, the higher the group’s 

members aspirations and motivational investment in 

their undertakings, the stronger their staying power in 

the face of impediments and setbacks, the higher their 

morale and resilience to stressors, and the greater their 

performance accomplishments. Both at the societal and 

individual level of analysis, a strong perceived efficacy 

fosters high group effort and performance attainments. 

Military leaders’ efforts to shape collective efficacy 

require merging diverse self-interests in support of 

common core values and goals.

Military communities play a proactive role in the 

resilience-building process by planning and constructing environmental conditions to promote preparedness, leadership, and support.23,25 Social resources, such 

as social support, socioeconomic status, and access to 

services, have shown strong effects on mental health 

and played a variety of roles in the stress process.26

Mediational analyses show that social support provides its benefits to the extent that it raises perceived 

self-efficacy to manage environmental demands.27

However, beyond receiving positive social support, 

a number of research studies indicate that it is not positive social support, but negative social support, that 

affects recovery. Dunmore, Clark, and Ehlers28 reported 

that perception of negative social interactions, rather 

than perceived positive support, predicts chronic 

PTSD. It would appear that the military would benefit 

from programs that build and maintain buddy support 

(including conflict resolution), model and reinforce 

social support, and teach strategies for providing support and understanding to those service members, for 

whatever reason, who express dissatisfaction or show 

signs of disengagement and withdrawal. 

Neurobiological Factors

Neurobiological factors play a central role in the 

capacity to tolerate stress and trauma. Twin studies 

have found that overall heritability of PTSD ranges 

from 28% to 33%.29 DNA (deoxyribonucleic acid) 

studies have found that a variety of gene polymorphisms contribute to stress reactivity and possibly the 

development of trauma-associated psychopathology. 

Examples include differences in sympathetic nervous 

system activity (polymorphism of the α-2C-adrenergic 

receptor gene),30 cortisol release in response to psychosocial stress (glucocorticoid receptor gene variant),31

and serotonin metabolism (polymorphism of the 

serotonin transporter gene).32

The role of serotonin metabolism in stress reactivity 

was studied by Caspi,32 who found that a functional 

polymorphism in the promoter region of the serotonin transporter gene moderated the influence of 

stressful life events on the likelihood of developing 

depression. Among individuals who had experienced 

childhood maltreatment, those with two long alleles 

were significantly less likely to develop depression 

than those with two short alleles. Thus two long 

alleles appear to protect against trauma-related psychopathology while two short alleles are associated 

with vulnerability to trauma. Of note, it appears that 

environmental factors can serve a protective role even 

among those with a genetic vulnerability. Kauffman33

recently found that strong social support protected 

against the development of depression in traumatized foster children, even among those with genetic 

vulnerability (ie, two short alleles of the serotonin 

transporter gene). 

A wide variety of hormones, neurotransmitters, 

and neuropeptides that are known to be activated by 

stress and trauma are also thought to be associated 

with resilience. In a comprehensive literature review, 

Charney3

 highlighted eleven neurochemicals that appear to have particular relevance to the neurobiology 

of resilience. The evidence posits that resilient individuals will score in the highest range for measures 

of dehydroepiandrosterone (DHEA), neuropeptide 

Y (NPY), galanin, testosterone, serotonin (5-HT1a), 

and benzodiazepine receptor function. These same 

resilient individuals will score in the lowest range 

for hypothalamic-pituitary-adrenocortical (HPA) 

axis, corticotropin-releasing hormone, and locuscaeruleus-norepinephrine activity. The findings are 

opposite for those individuals vulnerable to stress. For 

example, NPY is an amino acid that helps to maintain 

sympathetic nervous system reactivity within an 
47

Preparation for Deployment: Improving Resilience

optimal range. Under conditions of danger, the sympathetic nervous system (SNS) releases epinephrine 

and norepinephrine (NE) as part of the fight–flight 

response. During these high-stress situations, NPY is 

also released and helps to inhibit continued release of 

NE so that the SNS does not overshoot and possibly 

contribute to anxiety, hypervigilance, and fear. High 

levels of NPY during extreme training stress have been 

associated with adaptive performance in Special Forces 

soldiers. It is likely that robust increases in NE are held 

in check by similarly robust increases in NPY among 

these highly resilient soldiers.3,34,35

Galanin and DHEA are two other neurochemicals 

that may enhance resilience by containing or modulating the stress response.3

 For example, cortisol is released during stressful situations and helps to mobilize 

energy stores and increase arousal, selective attention, 

vigilance, and consolidation of emotional memory, all 

of which tend to be adaptive. However, when cortisol remains chronically high and unchecked, it can 

have toxic effects on the body and brain.36,37 DHEA, 

which is released with cortisol, helps to lower levels 

of cortisol, and thus has protective effects.35 Like NPY, 

high DHEA-to-cortisol ratio has been associated with 

better performance in Special Forces soldiers during 

high-stress training exercises and may play a role in 

modulating psychological, physiological, and behavioral responses to stress. 

It is likely that individual neurobiological factors 

by themselves have relatively limited impact on stress 

resilience. However, in accordance with a model of allostasis,38 the additive effects of multiple neurobiological factors may have a substantial effect on resilience. 

Thus, Charney3 hypothesized that resilient individuals 

might be those with relatively high stress-induced 

NPY, galanin, DHEA, and testosterone, and relatively 

low stress-induced SNS and HPA-axis activation. 

Numerous brain regions and neural pathways involved in the processing and regulation of fear, learning, memory, reward, emotion, motivation, and social 

behavior are also undoubtedly involved in resilience to 

stress. For example, resilience may be associated with 

optimal stimulation or inhibition of prefrontal corticalamygdala circuitry, which would facilitate appropriate 

and adaptive responses to stressors. Similarly, the capacity for mutual cooperation, social bonding, positive 

emotions, and hope in the face of adversity, all of which 

have been associated with resilience, may be dependent on well-functioning reward circuitry involving 

the nucleus accumbens dopamine system.3,34

It is likely that relevant neurotransmitter and hormone systems, as well as neural pathways, can be 

modified by experience. Developmental studies have 

shown that early experiences with stress can have 

long-term effects on behavioral and neurobiological 

responses to future fear and stress.38 Thus, uncontrollable or overwhelming stress during infancy can 

cause exaggerated emotional, SNS, and HPA-axis responsiveness to future stressors even into adulthood. 

Mild-to-moderate stressors that are controllable can 

have a “steeling” or stress inoculating effect, where the 

organism becomes less reactive to future stressors.39

Although attention and arousal are necessary for survival, going outside an optimal range has detrimental 

biological effects. During stress, multiple cortical and 

subcortical brain regions (including sensory, motor, prefrontal and cingulate cortex, hippocampus, 

amygdala, thalamus, striatum, midbrain, and brain 

stem monoaminergic nuclei and hypothalamus) 

become activated. Communication between these regions facilitates evaluation of, psychomotor response 

to, and memory for stress-related events. Although 

arousal may be life saving, it has been hypothesized 

that excessive and sustained arousal following trauma 

may increase the likelihood of developing PTSD.5,40,41

Numerous animal studies have shown that extended 

and excessive states of alarm and arousal may contribute to stress sensitization and long-term potentiation,42

both of which likely contribute to trauma-related 

psychopathology. 

Understanding and working with biological components of resilience is an area with great potential for 

intervention. Based on the neurobiological findings on 

use-dependent neuroplasticity, it is likely that certain 

preparation and training regimes will alter relevant 

neural and neurotransmitter systems that are involved 

in resilience to stress. These include training to regulate 

emotions, face fear, dispute and reappraise negative 

cognitions, find positive meaning in adversity, help 

others in need, and attract social support. 

Defining Resilience 

Resilience is generally considered to be “multidimensional,”18 with different characteristics 

expressed variably across many areas of the individual’s life (eg, occupation and social). These 

“resilient trajectories” may be uneven.18,43 For example, an individual may function adequately in 

work settings following a trauma but suffer from 

interpersonal numbing or withdrawal. Furthermore, 

the expression of resilience is influenced by context: 

the quality of the stressor, the individual’s traits, and 

the surrounding culture.43 Many researchers in this 

area conclude that resilience is not a fixed attribute 

but a type of “functional trajectory” dependent on 

circumstances and individual variations (eg, vulnerability and protective mechanisms) in response to 
48

Combat and Operational Behavioral Health

risk. If circumstances change, resilience trajectories 

can change.18,44

Multidimensional analysis indicates that resilient 

behavior in one domain may extract a price in another; 

for example, competence in work domains may involve emotional detachment from family problems,45,46

and at-risk individuals with exemplary behavior may 

experience internal distress.47,48 Finally, there has been 

some acknowledgment that the factors that bolster 

resilience may not be adaptive in all domains (ie, sociopathy and narcissism13). 

Experts in the field of resilience hold that all plans 

for research and intervention should clearly define 

resilience as a state, not a trait.18 Therefore, they recommend avoiding the term “resiliency,” with its connotation of a trait. Rather, it is recommended to use the 

phrase “resilient trajectory or adaptation,” explaining 

that these trajectories vary across situations and within 

individuals at different times.18

Indeed, resilience is both a process and an outcome. There are resilient outcomes (eg, in the face of 

enormous combat traumas, a service member does 

not develop any mental health problem or significant 

problems functioning) and there are resilient processes 

(mechanisms that create resilient outcomes), which 

change over the life-course, as demands, circumstances, and service members change. The goal of 

resilience training is to promote or augment existing 

personal and social resources and create new resources 

that contribute to adaptation.

EVALUATING RESILIENCE OUTCOMES

Three things are necessary to evaluate resilience as 

an outcome: (1) the nature of the exposure to trauma; 

(2) the prevalence of symptoms and problems, with 

an emphasis on the degree of subjective distress and 

suffering; and (3) functional capacities in diverse areas 

(eg, work, leisure, self-care, relationships). However 

resilience is operationalized, successful adaptation or 

recovery from deployment trauma within and across 

service members is dependent on the nature of the 

trauma and the extent of exposure to war-zone events. 

It is inappropriate to compare resilience across individuals without accounting for variability in exposure 

to trauma. In the case of severe and extensive war-zone 

trauma, resilience should not be narrowly defined as 

the absence of posttraumatic mental health disorders, 

such as PTSD. Service members will report a variety 

of symptoms reflecting the enduring psychological 

impact of their deployment experiences. What should 

define resilience is not the mere absence of symptoms, 

but the degree of subjective distress caused by these 

problems and, more importantly, the extent to which 

their functioning is compromised.49

In terms of studying resilience as a process, measures need to be developed to evaluate individual 

differences in protective factors and processes, so 

that studies can test potential mechanisms mediating 

exposure to trauma and outcome. Other goals would 

be to describe the prevalence of various resilience 

indicators in a given trauma context across time and 

to evaluate the efficacy of interventions designed to 

promote resilience. What mechanisms or processes 

facilitate resilience at a given posttraumatic interval? 

One way to look at resilience is that resources and 

strengths in the individual and in the group’s culture 

(eg, a cohesive and supportive squad in the military) 

outweigh the influence of liabilities and weaknesses. 

In this context, individual and social resources are 

used to: (a) manage posttraumatic demands; (b) find 

meaning, purpose, and hope; (c) reduce or eliminate 

current adversities and stressors; and (d) derive 

positive feelings from various repertoires of activities (eg, work, leisure). In research on resilience, it is 

particularly important to recognize that the process of 

resilience lies in both the individual and in the environment (and the transaction of the two). A thorough 

evaluation of resilience resources should take into account social-demographic factors, current adversities, 

social networks, and intimate relationships. 

MEASUREMENT OF RESILIENCE FACTORS IN THE MILITARY

The Deployment Risk and Resilience Inventory 

(DRRI)50,51 treats resilience as an unfolding process and 

multidimensional construct, with the individual, exposure characteristics, and the social milieu (within the 

military and in the home) seen as equally important. It 

was developed based on literature review, survey and 

focus group input, and confirmatory factor analysis, to 

assess risk and resilience variables that are related to 

health and well-being following military deployments. 

The DRRI assesses risk and resilience in 14 domains, 

divided into prewar factors, war-zone factors, and 

postwar factors.

Prewar Factors:

1. Childhood family environment (cohesion, 

closeness of family)

2. Prior stressors (exposure to highly stressful 
49

Preparation for Deployment: Improving Resilience

or traumatic events)

War-Zone Factors:

3. Preparedness (perceived preparedness, 

including belief in quality and quantity of 

equipment, supplies, and training)

4. Combat (exposure to objective warfare experiences)

5. Aftermath of battle (observing or handling 

remains, dealing with prisoners of war, 

exposure to devastated communities and 

refugees)

6. Perceived threat (subjective fear for one’s 

safety and well-being in war zone)

7. Difficult living and working environment 

(day-to-day pressures, discomfort, deprivation)

8. Concerns about life and family disruptions 

(career-related concerns, family concerns)

9. Sexual harassment (exposure to unwanted 

sexual touching or verbal conduct)

10. General harassment (harassment on basis of 

biological sex or minority status)

11. War-zone social support (assistance and 

encouragement from leaders, other unit 

members)

12. Nuclear, biological, and chemical exposures

Postwar Factors:

13. Postwar social support (emotional sustenance and instrumental assistance from 

family, friends, coworkers and employers, 

community)

14. Postwar stressors (general stressful events 

such as accidents, illness; reintegration issues 

such as job interruption, difficulties reestablishing roles)

Because the DRRI is specifically geared to evaluate 

adaptation to deployment stress and trauma, and is 

psychometrically sound, its broad use is recommended. However, the DRRI does not measure individual 

differences in psychological resilience, which is also 

an important personal resource. Prior to enlistment, 

all service members possess varying degrees of an 

innate and acquired capacity to manage serious life 

challenges and threats effectively (resilience). Unfortunately, there is no “gold standard” method of 

evaluating resilience as a individual characteristic, 

which should not be surprising because there is no 

unified conceptual or definitional framework. One 

measure that has been found to have adequate content 

coverage is the Connor-Davidson Resilience Scale,52

which is a 25-item questionnaire tapping attitudes 

about coping with adversity (eg, “having to cope 

with stress makes me stronger”). Items require respondents to indicate their degree of endorsement on 

a five-point scale ranging from not true at all to true 

nearly all the time. Connor and Davidson reported 

a Cronbach’s alpha of .89 in a validation sample of 

general population subjects, which shows that this 

instrument is highly likely to elicit consistent and 

reliable response even if questions were replaced with 

other similar questions.

The National Center for PTSD is developing a measure called the Response to Stressful Experiences Scale, 

which seeks to measure resilience. The scale has been 

structured to cover the following putative mechanisms 

of resilience:

	 • Behavioral. The actions (active or passive) 

an individual exhibits in response to an intense life stressor that facilitate a return to 

psychological baseline functioning or to psychological growth, including actions aimed at 

marshalling social support. 

	 • Emotional. The degree of effectiveness regarding how to use one’s emotions to achieve 

one’s goals. This is accomplished by managing emotional reactions in a flexible, situationappropriate manner.

	 • Cognitive. Conscious thoughts, perceptions, 

and expectations aimed at adapting to, or 

overcoming, stressful situations by orienting 

one’s beliefs when useful, to include a realistic 

and accepting stance about personal vulnerability, the likelihood of future risks, and the 

ability to achieve personal growth. 

It is hoped that by measuring multiple domains, 

a more useful and accurate level of resilience can be 

obtained.

INTERVENTIONS FOR BUILDING RESILIENCE AND PREPAREDNESS

It could be argued that the military continuously 

fosters resilience in service members from recruitment and basic training to retirement. It is beyond 

the scope of this chapter to catalog and operationally 

define all the resilience-building efforts in the lifespan 

of a service member. Instead, this discussion will focus on efforts that occur or should be considered to 

lessen the mental health impact of various deployment 
50

Combat and Operational Behavioral Health

hardships, adversities, and serious traumas (primary 

prevention). 

It is unclear at present whether preparation is likely 

to inoculate individuals fully against severe trauma. A 

number of strategies extrapolated from different fields 

are described as possible components of preparation 

and prevention. One factor that needs consideration 

is that preparation requires motivation, foresight, and 

time and energy, which may not be realistic and cost 

effective under all circumstances. If preparedness is 

not feasible, research suggests that preventing resource 

loss is more efficient in promoting recovery than attempting to introduce additional resources following a 

traumatic event.6 Other programs designed to prepare 

individuals are discussed next. 

Toughening Responses to Stress

Can individuals become better prepared for deployment and combat? The literature on “toughness” suggests that under certain conditions, repeated episodes 

of challenge or threat followed by recovery periods 

(eg, aerobic exercise and working in cold environments) can “toughen” the neuroendocrine system’s 

response to stress. People who undertook programs of 

aerobic training, for instance, were subsequently more 

energetic and more emotionally stable than they were 

before such an experience.53 Better performance and 

learning in even complex tasks was associated with 

greater adrenergic responsiveness in humans. 

Toughness is less relevant, however, to situations 

experienced as harm or loss, where negative outcomes already have occurred, or where instrumental 

coping is considered useless (eg, one can overwhelm 

organisms with excessively intense, extended, or unexpected training; even a single episode of a traumatic 

stressor can overwhelm). Combining unpredictability 

with great severity may overwhelm the organism’s 

capacity to recover, leading to weakness rather than 

toughness.54

Building Strengths Through Training Programs 

A recent expert panel reached consensus that any 

intervention program designed for situations of ongoing threat should incorporate elements designed to 

foster hope, safety, efficacy, calming, and connectedness.55 Learned optimism and positive psychology 

models56,57 incorporate many of these components to 

build strengths in people at risk. The components they 

apply to strength building and prevention include: 

instilling hope; building buffering strengths (ie, interpersonal skill, optimism, perseverance, capacity 

for pleasure, and purpose); narration, or the telling of 

stories about one’s life to another; and disputing (the 

skill of recognizing one’s own catastrophic and exaggerated thinking and effectively disputing it). 

Seligman has found that such training is selfreinforcing and prevents depression and anxiety in 

children and adults. This training is unique in that 

it focuses on building strength rather than repairing 

damage. Seligman’s intervention programs are called 

“training programs” rather than therapy, and yet they 

have similar beneficial effects as psychotherapy.57–59 

Building Resilience Through Self-Help Programs 

The American Psychological Association has recently placed an online module on building resilience 

on its self-help Web site.16 Leading researchers in the 

field of resilience and posttraumatic growth formed 

the committee that created the module. The Web site 

explicates basic self-help steps for improving resilience, based on empirical and consensus information: 

increasing social support, optimism, realistic appraisal 

and goal setting, emotional and social balance, and a 

mix of both problem-focused and emotion-focused 

coping. Because literature on adult learning suggests 

that self-paced instruction is important to successful 

mastery of material, this dissemination strategy may 

be highly effective in assisting soldiers with their own 

recovery course, particularly those who are worried 

about stigma involved with seeking assistance, and 

whose schedules are busy. 

Teaching Skills Commonly Utilized During Survival Situations 

Another approach to training resilience is to interview those who have survived highly stressful circumstances to gain an understanding of common factors 

that are helpful in survival. For instance, a recent case 

study60 illustrates that the use of problem-solving 

techniques in trauma survivors enabled them to retain 

a sense of efficacy and control during life-threatening 

situations. Examples of strategies employed by survivors include the following: 

	 •	 recalling and practicing skills from previous

education about the situation they were in (ie, 

safety and breathing);

	 •	 having confidence in friends to help;

	 •	 analyzing everything closely, and demanding

results;

	 •	 dismissing thoughts of death as unconstructive; 

	 •	 concentrating on how to pacify the person

making the threat; 

	 •	 feeling a sense of control;

	 •	 remaining calm;
51

Preparation for Deployment: Improving Resilience

	 •	 thinking of loved ones;

	 •	 prayer;

	 •	 concentrating on positive coping actions;

and

	 •	 not letting sounds or sights distract them.

Basic survival skills have been delineated by Gonzales,61 who conducted case studies and interviews with 

hundreds of people who had survived life-threatening 

situations. The following list includes the six factors 

that are commonly observed across those who survived dangerous situations.

1. Knowing as much as you can about the situation ahead of time, keeping in mind that the 

forces may be so large (or fast) that they are 

difficult to imagine.

2. Being adaptive and flexible, based on a true 

reading of the environment, and changing 

behavior accordingly.

3. Quickly organizing, setting up routines, and 

instituting discipline; breaking down very 

large jobs into small, manageable tasks; setting attainable goals and developing shortterm plans to achieve them; and dealing with 

what is within your power from moment to 

moment and leaving the rest behind.

4. Knowing your abilities and not over- or underestimating them.

5. Being able to assess and stop if it is clear 

that the environment does not support going forward, no matter how much you have 

planned; being realistic about goals and timeframe, then being content with just being in 

the process.

6. Cultivating a positive mental attitude by:

	 •	 Realizing that life is not always fair.

	 •	 Having fortitude, patience, courtesy, modesty, decorum, and the will (in the worst of 

situations) to do your best.

	 •	 Celebrating successes, and taking joy in

completing tasks, even small ones.

	 •	 Creating an ongoing feeling of motivation, preventing hopelessness, and giving 

yourself small breaks from the stress of the 

situation.

	 •	 Being determined to be careful and do your

best, and becoming convinced that you will 

succeed.

	 •	 Not becoming discouraged by setbacks; accepting that the environment is constantly 

changing; picking yourself up and starting 

the entire process over again, if necessary, 

in manageable steps; and embracing the 

world in which you find yourself and seeing opportunity in adversity.

Military personnel may be better prepared for 

deployment stresses if they have specific information to help them master life-threatening situations 

and are instructed in how to use this as part of their 

problem-solving strategy. In addition to teaching 

skills for specific situations, it may be important to 

prepare individuals to cope with unexpected situations 

where they may feel confused, bewildered, or helpless. Bell’s62 resilience program seeks to address these 

issues through the use of esoteric training principles, 

including meditation exercises that develop steadiness, 

clarity, pliancy, mindfulness, and emotional endurance. These principles, however, have not been tested 

in situations of traumatic stress.

Reinforcing Skills Through Military Training 

Military training focuses on preparation of personnel for battle or other chaotic and disastrous situations. 

The US military strives to prepare its soldiers for 

potential exposure to combat, operations other than 

war, and the stresses of deployment in many ways. 

In combat units, there are many hours devoted to 

field training exercises (some quite long), to include 

exposure to live fire, with reduced sleep, at a high pace 

of operations. Those trained at the Suvival, Evasion, 

Resistance, and Escape (SERE) schools undergo extremely stressful mock captures and interrogations at 

a simulated prisoner-of-war camp. Training in nuclear, 

biological, and chemical warfare is also standard, 

including maintenance of the gas mask and donning 

the mask within 9 seconds. Especially overseas, there 

are exercises in wearing the chemical protective suit 

for long periods of time while performing one’s job. 

The constant repetition and standardized measures of 

mastery are intended to foster a sense of control for the 

service member, at the same time sending the message 

that “we are prepared for anything that may come our 

way down range.” 

Unit cohesiveness is another critical protective factor in war. Spiegel63 speculated that it was regard for 

comrades, respect for leaders, concern for the reputation of the group, and an urge to ensure the success of 

the unit that kept soldiers fighting in World War II.64

Furthermore, he identified that when individual’s decompensated it was often after a change in the soldier’s 

relation to the group.63 During the Vietnam War, it was 

observed that ultimately this unit cohesiveness does 

not represent an altruism born of interpersonal attraction but rather the realization that a soldier’s survival 

depended upon his ability to make others willing to 

help him in his own time of need.65 This cohesiveness 

can extend throughout an entire organization, with the 
52

Combat and Operational Behavioral Health

unit serving as an extension of individual pride. The 

soldier’s self-esteem becomes linked to the reputation 

of the unit, providing additional motivation. In other 

words, an individual’s identity is not just about self 

but also incorporates a collective identity that, when 

well developed, is a protective factor.

Physical fitness is also an essential component of 

military training. Throughout their career, service 

members must take a physical fitness test twice a year. 

This ensures that service members maintain at least a 

reasonable degree of physical fitness, despite having 

many other taskings. In the elite units, physical training is a high priority. In addition to preparing soldiers 

for the physical exertion necessary in battle, physical 

fitness has also been strongly linked to reductions in 

stress, anxiety, and depression.66

Drills and exercises are another component of 

preparedness and building resilience. In the Navy, 

for example, the drills may be centered on reacting to 

fires, the ship sinking, “man overboard,” and other 

mishaps. These exercises utilize the constructs of stress 

inoculation, which in the civilian world takes the form 

of cognitive-behavioral methods to anticipate and 

diminish responses to anxiety-provoking events, with 

the aim of reducing the response to a perceived threat.67

Beyond enhancing cognitive knowledge, exercises in 

the military encourage bonding and a sense of mastery 

about disaster. Some of the military survivors of the 

September 11, 2001, attack on the Pentagon believed 

that previous drills prepared them for the chaos of the 

exit, while civilian employees complained that they 

were underprepared.68

Despite the potential benefit of stress inoculation 

and drills, recent experience has shown that many 

military members are not prepared for the sights and 

smells of civilian casualties, nor the experience of handling the bodies of their friends or the enemy. For example, after the USS Iowa explosion, when shipmates 

handled the bodies of their friends, several developed 

PTSD symptoms.69 The US Army has developed a 

pamphlet, Just the Facts . . . Dealing With the Stress of 

Recovering Human Dead Bodies, to provide guidance on 

how troops should handle remains in order to reduce 

stress levels.70 What is not currently known, however, is 

the best assortment and intensity of stimuli to prepare 

people, rather than oversensitize them.

In the military, leadership is always emphasized. 

Military leaders are taught to foster hardiness, unit 

cohesion, and morale by “leading by example”; facilitating open communication regarding how missions 

are planned; stating how mistakes or failures are corrected and learned from; seeking out (and creating if 

necessary) meaningful and challenging group tasks; 

remaining aware of the basic needs of the team (to 

include the need for rest); and providing opportunities 

for all individuals to make use of their unique coping 

skills (to include prayer or writing letters home). A 

study conducted with a group of Norwegian navy 

officer cadets demonstrated that units that increased 

significantly in cohesion after a stressful exercise also 

rated their leaders as better skilled and more caring 

and concerned compared to units that did not increase 

in cohesion. Individuals who see their leaders as more 

effective and concerned, even when these leaders 

are under extreme stress, are in turn more likely to 

interpret the experience positively. For group tasks, 

this positive interpretation is reflected in increased 

group cohesion. 

Another component to which the US military pays 

particular attention in preparation for deployment 

is the “state of affairs at home,” because emotional 

support has been shown to affect the impact of deployment.71 Data from the Israeli Defence Forces, 

for example, show that 30% of their casualties in the 

Lebanon War were caused by combat stress reactions. 

The Israeli Defence Forces found that soldiers who 

had experienced certain marital discord or stress in 

personal relationships were at high risk of suffering 

combat stress reactions.72 Recently, the US Army has 

developed a vigorous deployment cycle support 

plan called Battlemind73 to help reintegrate returning soldiers into their families and society, especially 

those who have been wounded. The Navy and Marine 

Corps have developed a multifaceted program centered around acknowledgement that stress reactions, 

injuries, and illness fall on a dimensional combat and 

operational stress continnum, with efforts to intervene 

with both service members and their families early in 

the continuum to reduce long-term problems.74–76

Finally, the military has been increasingly sensitive 

to properly recognizing the deceased. Following the 

attack of the USS Cole the leadership made a concerted 

effort to ensure that the deceased were given a proper 

military burial and that the survivors were allowed to 

pay their respects. By putting the crew to work to ensure 

a proper burial, the leader was giving the crew back a 

sense of control, sending the message to the survivors 

that each life is valuable and will be treated with due 

dignity, especially in death, and beginning the mourning 

process for those more closely linked to those lost.77

SUGGESTIONS FOR FUTURE RESEARCH ON RESILIENCE 

Primary prevention and training prior to stressful 

military situations often involves interventions such 

as teaching problem-solving skills or toughening 

exercises like those in military training. This form of 
53

Preparation for Deployment: Improving Resilience

stress inoculation is designed to foster “resistance.” 

However, by its nature traumatic stress is unpredictable and uncontrollable. Therefore, although stress 

resistance is related to specific or probable stressors, 

traumatic stress preparation should be geared more toward preparing individuals for the unexpected, when 

they may not yet understand what is going on, when 

conditions are new, and when they may feel confused, 

bewildered, or helpless. 

Another strategy seeks to enhance resilience by 

teaching certain factors that have worked for others 

following traumatic or stressful situations, such as 

social support and self-efficacy or positively changing 

beliefs or actions. This approach may involve building 

restorative, replenishing activities into the posttrauma 

schedule, having individuals try to find what might 

restore their inherent capacity to thrive, and raising 

awareness about the cost and benefit of denial at different phases postincident. Programs need to prepare for 

active outreach and assistance for weeks and months 

following deployment. 

It is important to keep in mind that what works for 

individuals in one context may not work for the same 

or other groups in others. A sensible research strategy 

for maximizing resilient trajectories before, during, and 

after deployment would be multidisciplinary, multifaceted, and sensitive to the context of the event, as well 

as to differential exposure and response. There is also 

a strong need to partner clinicians and researchers in 

designing and evaluating programs. 

It is also important to remain cautious in any statement regarding what interventions can accomplish 

toward prevention of long-term functional and symptomatic impact. For example, it is unknown whether 

interventions are associated with significant improvements in functioning. Additionally, care should be 

taken to include the preferences of soldiers when an 

intervention is planned. Research on service utilization indicates that the majority of individuals exposed 

to a traumatic event will not choose to seek mental 

health services, and therefore a careful study of what 

interventions are acceptable and supportive of natural 

recovery trajectories may be called for prior to strong 

recommendations for any mental health intervention. 

A more acceptable intervention than individual crisis 

response might be to provide a “resilience training 

model” that is implemented as part of basic training for 

all military personnel, as well as providing family and 

friends with the tools necessary for helping loved ones 

more effectively process traumatic or enduring stress.

SUMMARY

This chapter has extrapolated from theoretical 

models about resilience, as well as related fields 

investigating stress, traumatic stress, and recovery 

from trauma, to generate an agenda for resilience 

training that can be examined in future research. The 

construct of resilience represents a dynamic process 

involving protective and vulnerability factors in different risk contexts and developmental stages, and 

thus is an area of considerable interest and importance to the military. However, the lack of empirical 

literature to support unit preparedness interventions 

is compounded by the lack of an accepted or unified 

conceptual framework that defines the necessary 

and sufficient ingredients for resilience in the face of 

trauma or resilience-building interventions to prepare 

soldiers for deployment.

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