Air University

Steven L. Kwast, Lieutenant General, Commander and President

Air Command and Staff College

Thomas H. Deale, Brigadier General, Commandant

Bart R. Kessler, PhD, Dean of Distance Learning

Robert J. Smith, Jr., Colonel, PhD, Dean of Resident Programs

Michelle E. Ewy, Lieutenant Colonel, PhD, Director of Research

Liza D. Dillard, Major, Series Editor

Gregory F. Intoccia, PhD, Essay Advisor

Selection Committee

Kristopher J. Kripchak, Major

Michael K. Hills, Lieutenant Colonel, PhD

Barbara Salera, PhD

Jonathan K. Zartman, PhD

Please send inquiries or comments to

Editor

The Wright Flyer Papers

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E-mail: acsc.der.researchorgmailbox@us.af.mil
AIR UNIVERSITY 

AIR COMMAND AND STAFF COLLEGE

Fiscal and Operational Impacts 

of Standardizing US Military 

Resiliency Programs to Minimize 

Post-traumatic Stress Disorder

James E. McDonald

Lieutenant Colonel, ANG

Wright Flyer Paper No. 55

Air University Press 

Air Force Research Institute 

Maxwell Air Force Base, Alabama 36112-6026
Project Editor

Jeanne K. Shamburger

Published by Air University Press in April 2016

Disclaimer

Opinions, conclusions, and recommendations expressed or implied within are solely those of the 

author and do not necessarily represent the views of 

the Air Command and Staff College, the Air Force 

Research Institute, Air University, the United States 

Air Force, the Department of Defense, or any other 

US government agency. Cleared for public release: 

distribution unlimited.

This Wright Flyer Paper and others in the series are 

available electronically at the AU Press website: 

http://aupress.au.af.mil.

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iii

Contents

List of Illustrations v

Foreword vii

About the Author ix

Preface xi

Acknowledgments xiii

Abstract xv

Introduction 1

Methodology 3

Combat Stress and Post-traumatic Stress Disorder 4

Implementation of Resiliency Training 7

Analysis and Findings 11

Conclusion 17

Summary 21

Appendix 25

Abbreviations 29

Bibliography 31

v

Illustrations

Figure

1 Annual PTSD diagnoses for all services (2000–2013) 6

2 Number of Soldiers physically wounded 12 

versus diagnosed with PTSD (2001–7)

3 Total Force Fitness model 18

4 Examples of services’ prevention campaigns 21

vii

Foreword

It is my great pleasure to present another issue of the Wright Flyer 

Papers. Through this series, Air Command and Staff College (ACSC) 

presents a sampling of exemplary research produced by our residence and 

distance-learning students. This series has long showcased the kind of 

visionary thinking that drove the aspirations and activities of the earliest 

aviation pioneers. This year’s selection of essays admirably extends that 

tradition. As the series title indicates, these papers aim to present cuttingedge, actionable knowledge—research that addresses some of the most 

complex security and defense challenges facing us today.

Recently, the Wright Flyer Papers transitioned to an exclusively electronic publication format. It is our hope that our migration from print 

editions to an electronic-only format will fire even greater intellectual 

debate among Airmen and fellow members of the profession of arms as 

the series reaches a growing global audience. By publishing these papers 

via the Air University Press website, ACSC hopes not only to reach more 

readers but also to support Air Force–wide efforts to conserve resources. 

In this spirit, we invite you to peruse past and current issues of the Wright 

Flyer Papers at http://aupress.maxwell.af.mil/papers_all.asp?cat=wright.

Thank you for supporting the Wright Flyer Papers and our efforts to 

disseminate outstanding ACSC student research for the benefit of our Air 

Force and war fighters everywhere. We trust that what follows will stimulate thinking, invite debate, and further encourage today’s air, space, and 

cyber war fighters in their continuing search for innovative and improved 

ways to defend our nation and way of life.

THOMAS H. DEALE

Brigadier General, USAF

Commandant

ix

About the Author

Lt Col James McDonald, Air National Guard, is currently the command and control officer for Federal Emergency Management Agency 

Region IX (California, Arizona, Nevada, Hawaii, Guam, Pacific Islands, 

and more than 150 sovereign tribal entities). He has been a police officer 

for the Los Angeles Police Department for the past 19 years, working 

with every bureau in the city. Past assignments include street patrol officer; staff positions in the Department Operations Center, Civil Rights 

Integrity Division, and Planning and Research Division; and training officer. Colonel McDonald deployed to Iraq in support of Operation Iraqi 

Freedom and served as squadron commander and staff officer in security 

forces, communications, and logistics. He holds a bachelor of science degree in adult education from Southern Illinois University–Carbondale 

and a master’s degree in military operational art and science with a concentration in joint warfare from Air University, Maxwell AFB, Alabama. 

This paper received the Air Force Surgeon General’s Award. 

xi

Preface

This study came about as a result of my deployment to Iraq in 2007. I 

was in charge of more than 150 Airmen at Kirkuk Regional Air Base next 

to a city of nearly a million people. The Iraqi police academy’s campus in 

downtown Kirkuk had been attacked and blown up half-a-dozen times 

by terrorists, so the solution was to move the school about 100 meters 

from our main gate. Since I was in charge of all entry to and exit from the 

base, my Airmen and I were under constant threat while deployed. In 

addition, my base area was bombed, rocketed, mortared, and shot at 

more than 20 times during my deployment—an average of once or twice 

a week. This situation was further compounded by daily shootings and 

improvised explosive devices deployed “outside the wire,” but in close 

proximity to us, that killed and injured hundreds of personnel, resulting 

in the loss of 17 US military members from my base while I was stationed 

there. I will never forget seeking immediate shelter, checking on the welfare of my troops at their posts during “Alarm Red,” or witnessing casualties being transported to medical facilities on base. 

The morning after I returned home, a neighboring farmer discharged 

a shotgun (I’m sure at birds or squirrels), and I awoke on my hands and 

knees crouched next to my bed, wondering where the nice bedspread had 

come from and how it had replaced the US-issue wool blanket. Six 

months later as I was driving through Los Angeles, a construction worker 

activated a jackhammer, and I swerved my vehicle in an evasive maneuver, grabbed for my (nonexistent) M-4 firearm, and for a second I saw the 

tan hood of my deployed Humvee through the front windshield. That 

very same day I started reading about post-traumatic stress disorder 

(PTSD) to find out what to expect next and to determine if I were perhaps going crazy. 

Although there is a mountain of information about causes and treatment of PTSD, I was amazed that very little is in place to prepare today’s 

warriors for what to expect, reassure them that they are not alone in their 

experience, and provide them with a road map to recovery. Researching 

my symptoms and talking about my experience with other military 

members, friends, and family, I worked through my issues and have even 

come to appreciate my journey. I have realized a personal perspective of 

resiliency and growth as a result of my experience. Over the past seven 

years, I have come to the conclusion that PTSD (or combat stress reaction) is a normal response to abnormal events.

xiii

Acknowledgments

I want to thank my thesis advisor, Dr. Gregory Intoccia, for his advice, 

patience, and help in the final phase of this endeavor. I am also grateful to 

Dr. Kate Ksobiech for bearing with me during the most painful part of 

this process—the research proposal phase. Her repeated rejection of 

every proposal I submitted forced me to reconsider my topic and bring 

the scope from “too broad, too broad” to narrowing my focus down to 

one that was attainable. 

I would also like to thank my classmates and friends for their comments, edits, and suggestions. Much appreciation to my cousin for discussing this subject with me at length over pizza at his dinner table.

I am eternally grateful to the leadership in the Air Force and California Air National Guard that has given me such remarkable opportunities. 

You have transformed a young punk rocker who joined the military for 

the G.I. Bill and a pair of combat boots into someone who now looks in 

the mirror and thinks, “Oh, no—I am ‘the MAN’!!!” Timing is truly 

everything, and I have cherished every moment.

Above all, I wish to extend the greatest amount of gratitude to a “sisterin-arms,” my amazing wife. You are my rock and the best military leader 

I have ever known. You have been a shining example and will always be 

the “General” at home!

Abstract

For hundreds of years, adverse psychological effects of war on human 

beings have been recognized, and efforts have been made to heal or lessen 

the symptoms. Today, much of the concentrated efforts toward combat 

stress reaction focus on reactive medicinal and psychological treatment, 

yet relatively little attention has been dedicated to preemptive measures. 

Within the past six years, the military has implemented nearly a dozen 

separate programs aimed at decreasing the rates of post-traumatic stress 

disorder (PTSD) and suicide. The purpose of this paper is to evaluate the 

current resiliency training programs used by the military and to recommend improvements. 

The broad conclusion is that since the US military began research 

for improving PTSD treatment more than 10 years ago and implemented various resiliency programs, to date there is no universal, comprehensive program content or delivery framework on either matter. 

Combat and tactical training are taught exclusively from resiliency 

training. Organizations are independently managed and operated with 

little or no collaboration.

A key recommendation is that standardization should occur in the 

following four areas: training scope, training content, training delivery, 

and consolidation of organizations. A comprehensive model may be 

adopted and integrated to standardize purpose and format. Standardized 

training content and delivery would ensure proven subject matter and 

provide more consistent evaluation and metrics. Centralized platforms 

for consolidation could lower administrative costs while increasing communication and oversight of best practices. Taking action to standardize 

and consolidate resiliency programs would result in saving lives and millions of dollars in treatment, disability, and retraining costs.

xv

1

Introduction

An abnormal reaction to an abnormal situation is normal 

behavior.

—Victor Frankl

Man’s Search for Meaning

Post-traumatic stress disorder (PTSD) is a term coined to describe 

symptoms that occur in the aftermath of mental trauma experienced 

during combat. These symptoms include recurring nightmares, flashbacks, reactions to triggers such as loud noises, and hypervigilance.1

Military veterans who experience PTSD also are susceptible to other destructive behaviors such as self-medication—the use of drugs and/or alcohol to alleviate PTSD symptoms—which can often lead to substance 

abuse. Negative thoughts—another result of PTSD—can lead to irritability, depression, and suicide.2

Although combat stress reaction (CSR) has been recognized and labeled for hundreds of years, in the last 30 years the US military has experienced a sharp increase in reported episodes and corresponding treatment. Disability and deaths by suicide due to PTSD have seen a further 

dramatic rise in the past 10 years.3

 The US Army formally implemented a 

preventive program for PTSD in 2009, with other military branches following suit with their own versions of resiliency programs. Since that 

time, the Army has boasted a mild reversal of this rising trend of new 

PTSD cases in its personnel.4

 Implementing preventive measures such as 

social support, deliberately not avoiding hardship, adequate sleep, a nutritious diet, fitness, and other healthy coping techniques have shown to 

be effective in lowering the rate of long-term PTSD.5

To be clear, the terms prevention and resilience—when used by the 

psychological community in reference to CSR/PTSD—are slightly different in meaning from the more common definitions of each. MerriamWebster defines prevention as “to stop or hinder something from happening.”6

 In the context of this study, however, prevention translates to 

minimizing stress and maximizing resilience in combat situations. Prevention is a misleading substitute for resilience to PTSD and will be used 

in this study to refer only to proactive measures taken toward PTSD.

The medical definition of emotional resilience is “an ability to recover 

from or adjust easily to misfortune or change.”7

 In the research material 

concerning PTSD, resilience is used to describe the mental state of those 

who experience trauma yet achieve the most complete recovery possible 

in the least amount of time. This term is a shortened variation of the more 

technically correct term high resilience. The military generally uses both 
2

resilience and resiliency when discussing the prevention of, and positive 

recovery from, PTSD. When referring to training programs, military 

documents and articles most often use the term resiliency training. 

Resiliency is much more common than once thought. There is evidence not only of the personality trait of “natural hardiness” but also of 

an individual’s ability to learn to be resilient.8 Both the military’s philosophy of taking care of service members and its fiscal responsibility demand that military leadership at least consider options for minimizing 

mental trauma to service members while saving money on reactive treatment. Some critics question whether PTSD is preventable at all.9

 They 

challenge the validity of the military’s research results and assert that, 

even if valid, the impact is negligible.10 However, even a small reduction 

in PTSD equates to millions of dollars of cost savings per year. In addition, benefits such as improved morale and higher retention may be realized. While these side effects could be considered intangibles on the surface, they directly result in reduced retraining costs and increased job 

performance. The scope of this study is limited to measurable fiscal and 

operational impacts.

The concept that training could lower the occurrence of PTSD and 

speed recovery through resilience poses the following question: given the 

considerable treatment and disability costs of PTSD, how can the comparison and standardization of best practices among all military branches’ 

existing PTSD resiliency programs result in a significant reduction in 

long-term costs by lowering PTSD occurrences? An analysis of the preventive programs in each branch of the military that addresses PTSD and 

associated symptoms through resiliency reveals a need for benchmarking 

and consistency of procedures. Standardization would result in a more 

all-inclusive program, better statistics for tracking and benchmarking, 

administrative cost savings, and, most likely, a significant reduction in 

PTSD occurrences.

Research has shown resilience to be an effective deterrent to PTSD. 

Standardization of resiliency programs through review and use of best 

practices; consolidation of administrative management and oversight; 

and consistent, complete implementation of services to all military 

branches could save the United States millions of dollars in annual treatment and disability costs. It can be argued that standardization may not 

be practical since military branches are not the same. For instance, 

ground forces (Army and Marines) have traditionally had a higher rate of 

PTSD than the Navy or Air Force. Specifically, based on government estimates of diagnosed PTSD and suicide, the Army’s rate is approximately 

four times as high as that of the Air Force.11 However, the success in other 
3

areas where similar efforts have been integrated into a joint force concept 

encourages optimism regarding the expected results of standardization.

Methodology

This study reviews the current status of resiliency programs in the US 

military, evaluates their effectiveness, explores the possibility of standardization, makes key recommendations, and projects expected benefits. The research indicates that current treatment methods and costs are 

not sustainable. The study highlights the difference between activity and 

productivity and urges a fundamental shift in the approach toward 

PTSD.12

This research uses the evaluation methodology as its framework. First, 

the study assesses the military’s annual baseline numbers and cost trends 

of treatment for PTSD. Included in the cost are average treatments per 

year and average payments per year in disability benefits for PTSD. This 

study also evaluates other less-calculable financial considerations, such 

as training costs not only to replace service members suffering from 

PTSD with new recruits but also to retrain PTSD-diagnosed service 

members. One benchmark used is the research results of the Army’s 

Comprehensive Soldier Fitness Program, in place since 2009. To project 

possible cost savings of such a program for the total force, this study estimated the program’s effect on the current rate of PTSD. It then extrapolated this success into cost savings in treatment and disability if training 

is standardized across the total force. The study also explores the benefits 

of standardizing content and delivery of training. The projected effect on 

lowering PTSD and related symptoms could become greater as the services identify best practices and further modify programs to incorporate 

benchmarks—for example, if a portion of the Navy’s program generates 

better results than a commensurate part of the Army’s program.

Other cost savings options to consider are not only consolidating existing programs across services into a centralized organization but also 

reducing duplication of effort within each military branch. Some 

branches have several programs simultaneously focusing on resilience. 

Also, discontinuing separate administration of resiliency programs in 

each branch and integrating them into a joint administrative operation 

would decrease overlapping positions. Besides enhancing communication and standardization of the program, joint integration would significantly lower the administrative cost of management, tracking, evaluation, and oversight versus performing these functions via separate 

organizational structures.
4

Combat Stress and Post-traumatic Stress Disorder

The battlefield is cold. It is the lonesomest place which men 

share together.

—S. L. A. Marshall

Men against Fire

History of Combat Stress Reaction in War

Adverse psychological effects of war on human beings have been acknowledged for hundreds of years, even as far back as medieval times.13

Expressions such as “soldier’s heart,” “shell shock,” “battle fatigue,” and 

“war neurosis” are American predecessors to the current popular terms 

of post-traumatic stress disorder or PTSD.

14 These terms are used by doctors, psychologists, governmental agencies such as the US Department of 

Veterans Affairs (VA), journalists, and victims to describe the dysfunctional symptoms that significantly compromise reintegration into a full 

and productive life. This level of dysfunction is reportedly experienced by 

as many as 30 to 40 percent of military personnel who have been in a war 

zone.15 Nearly 20 percent of service members who return from deployment to Iraq and Afghanistan are officially diagnosed as suffering from 

PTSD.16

As early as 1919, doctors began to more closely observe and track shell 

shock—a psychological condition found in World War I combat veterans.17 After that war, the government looked at screening processes as a 

way to lower rates of PTSD, thinking that perhaps more “mentally 

healthy” service members would have better recovery from combat 

stress.18 No matter how healthy warriors are to begin with, certain factors 

experienced in combat simply cannot be avoided. For instance, two “potent” causes of combat-related stress in those exposed to combat are fatigue and fear—whether fear for themselves, their peers, or those for 

whom they are responsible.19 Neither factor can ever be removed from 

battlefield conditions.

The medical community has been researching long-term effects of 

traumatic stress for years. During the beginning stages of the Vietnam 

conflict, and 15 years prior to the introduction of the concept of PTSD, 

Herbert Archibald and Read Tuddenham were examining patients suffering long-term effects of combat-related stress. Scientific consensus following World War II focused on five diagnostic criteria. These included 

“(1) unusual stress; (2) previous normal personality; (3) reversibility; (4) 

possible progress to . . . [a] neurotic reaction; and (5) . . . persistent reaction.” At the time, if the patient met the criterion of a persistent reaction, 

doctors used the term combat fatigue and regarded it as a “temporary 
5

diagnosis to be used only until a more definite diagnosis is established.”20

As a result of their research, Archibald and Tuddenham argued that 

symptoms following severe traumatic stress “may persist over very long 

intervals” and may not be temporary but a permanent disability.21

Creation and Diagnosis of Post-traumatic Stress Disorder

The term post-traumatic stress disorder was first coined and published 

in 1980 by doctors hoping to legitimize pain and suffering reported by 

Vietnam veterans.22 Many Soldiers, doctors, and psychologists have 

questioned for years whether most cases currently diagnosed as PTSD 

are a mental disorder at all or, rather, “a normal response to abnormal 

events.”23 In 2011 the second-highest-ranking Army general, Peter Chiarelli, called for changing the name of PTSD from disorder to injury.24

Medal of Honor recipient Ty Carter recently insisted on a national news 

channel that “post-traumatic stress is not a disorder, it’s not a syndrome, 

it’s a natural reaction.”25 Eric Maisel, famed author of some 40 books, 

questions the very definition of the term mental disorder as listed in the 

new Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association.26 However, in direct disagreement, Matthew Friedman, a “key leader in the psychiatric community,” rejected the idea of changing the name of PTSD, stating that it 

could have “unintended negative consequences” because “it would confuse the issue and set up diagnostic distinctions for which there is no 

scientific evidence.”27 Although nearly 30 percent of individuals may 

experience PTSD symptoms after encountering a significant traumatic 

event such as combat or a terrorist attack, more than 95 percent of those 

exhibit either no symptoms at all in the aftermath or short-term symptoms that last six months or less.28

T﻿he Rising Rate of Post-traumatic Stress Disorder

In spite of the decrease in time deployed, the wars in Vietnam, Iraq, 

and Afghanistan have produced even higher levels of PTSD. Within two 

years after the start of the Iraqi War, the Defense Department identified 

higher rates of emotional difficulties in Soldiers who had both deployed 

for 12 months or more and seen extended periods of combat. In July 2005, 

the Department of Defense (DOD) announced that it needed to improve 

the ways it “prevents, identifies and treats mental illness” in service members who had deployed to Iraq or Afghanistan.29 Figure 1 depicts the 

number of PTSD diagnoses in all services from 2000 through 2013.
6

Figure 1. Annual PTSD diagnoses for all services (2000–2013). (Reproduced 

from Hannah Fischer, A Guide to U.S. Military Casualty Statistics: Operation New Dawn, Operation Iraqi Freedom, and Operation Enduring Freedom [Washington, DC: Congressional Research Service, 2014], 3.)

It is unknown exactly why today’s military is experiencing higher rates 

of PTSD. On the surface, the length of deployment seemed to be a factor, 

but historical perspective discounts this possibility. During many earlier 

wars, military members would deploy until they were injured or the war 

ended. Today, personnel are usually deployed for one year or less. An 

average deployment period for the Army is one year, between nine 

months and a year for the Navy, nine months for the Marine Corps, and 

anywhere between 60 days and one year for the Air force, depending on 

the mission. From a logistics viewpoint, shorter deployment times equate 

to increased logistics requirements (airlift) and other associated costs. 

Increasing deployment frequency by decreasing duration diverts the focus of transporting aircraft away from where they are needed in-theater. 

Too much turnover of manpower results in less experienced personnel in 

place. As identified during Vietnam, turnover lowers unit cohesion.30 Increasing the operations tempo of deployments requires processing more 

people, drastically increasing the workload of support sections such as 

personnel and finance. Further shortening deployment time periods is 

impractical.

There is speculation that the growing rate of PTSD cases has to do 

with today’s warriors transitioning rapidly from a relatively comfortable 

lifestyle into the stressful military environment and combat surroundings.31 Other possible factors include the financial reality that members 

and their families can profit from higher disability and death benefits, 
7

that the military has gotten more resources to identify and treat PTSD, 

and that it is simply better at identifying and treating PTSD today.32

T﻿he Growing Cost of Treating Post-traumatic Stress Disorder

More Gulf War veterans now collect VA disability than do Vietnam 

War veterans. In 2010 1.14 million Gulf War veterans overtook the 1.1 

million Vietnam veterans collecting disability. Vietnam disability recipients due to PTSD still outnumber Gulf War PTSD cases by 33 percent, 

and the $17 billion in disability payments to Vietnam veterans is 50 percent more than the $11 billion paid to Gulf War veterans.33 Using Vietnam War veteran PTSD patients as a model, however, experts anticipate 

that the number of Gulf War PTSD disability recipients will likely continue to grow.34 That growing number is also combined with the increase 

in cost per existing PTSD cases as disabilities worsen over time. The 

problem is that associated costs will continue to rise due not only to 

cost-of-living increases or inflation adjustments but also to the sheer 

number of newly affected veterans being added to the roster of existing 

affected veterans.

Implementation of Resiliency Training

Shift from Reactive to Proactive

Since 2009 all military branches have at least partially implemented 

programs aimed at preventing PTSD and suicide. Moreover, in 2011, the 

chairman of the Joint Chiefs of Staff (CJCS) issued an instruction delivering a “framework” for “total force fitness.”35 Nevertheless, as of 2014, 

there has been no apparent effort to standardize delivery of such a program. In September 2010 a resiliency workshop was held at Andrews 

AFB, Maryland, attended by representatives from 30 major commands, 

Headquarters Air Force, and sister services.36 Although participants developed many recommendations, none have yet been implemented. Of 

all the military branches, including respective Guard and Reserve components, the US Army’s Comprehensive Soldier and Family Fitness 

(CSF2) program is the most established. In 2009 the Army implemented 

Master Resilience Training (MRT), based on materials developed by the 

University of Pennsylvania and focused on prevention and resilience.37

The Army has invested heavily in this program, with a start-up cost of 

$125 million and more than 900,000 of its service members trained.38 It 

has also conducted the most follow-up research to measure effectiveness. 

To date the Army has surveyed and posted results of more than 22,000 

military personnel who have undergone training.39
8

The outcome has been slightly positive, with a 1 to 2 percent margin of 

improvement in those units that have adopted the CSF2 program over 

units not yet participating. These results have been questioned as to their 

veracity, even by professionals who believe in the notion of human emotional resilience.40 Still others point out that the margin of error is often 2 

percent in most polls, which could explain a 1 to 2 percent change in rate. 

Nevertheless, it is hard to dispute the sheer numbers of those surveyed. 

Other outside sources document that new PTSD cases and symptoms 

such as depression, low morale, and suicide have been slowing in the 

Army. This data seems to support the CSF2 findings.

While the DSM details the negative aspects of exposure to “an overwhelmingly traumatic event,” the concept of resiliency balances negative 

side effects with positive outcomes as well.41 The US military is now looking at shifting focus from intervention to prevention and from illness to 

wellness.42 To validate the effectiveness of prevention, the military must 

explore and prove the theory of resiliency—the idea that prepared service 

members can recover from combat more quickly and completely. It is not 

uncommon for individuals to go through trauma such as combat yet 

achieve an even higher level of physical and emotional fitness—a phenomenon called post-traumatic growth. Many principles that make up 

the rubric of post-traumatic growth were utilized in the Army’s resiliency 

program.43

Existing US Military Resiliency Programs

Army. The Army’s CSF2 program is the flagship of the existing military resiliency programs addressing PTSD. The Army announced that it 

would provide four pillars (emotional, social, physical, and spiritual) of 

fitness in 2008 as “comprehensive Soldier fitness,” and after an investment 

of $125 million, that service launched the program in 2009.44 It subsequently added family as a fifth pillar and modified the name from CSF to 

CSF2. Its training has been delivered through in-person and onlinecourse platforms. The training websites and presentations are the most 

standardized of the programs currently available in any military branch. 

The Army’s resiliency training has also been the most widely and uniformly distributed of any of the US military branches.

Marine Corps. The Marine Corps runs several resiliency programs 

simultaneously. While leadership seems to be aware of each of the programs, they do not operate jointly. The Marine Corps conducts an independent study of how Marines respond to stress in its Research, Assessment, Performance, Training Optimization, and Resilience (RAPTOR) 

program, which reviews present-day combat training methods and 
9

studies lessons learned for future training operations to advise commanders of best methods observed.45 The Behavioral Health Program 

centers largely on unit commanders and the Chaplain Corps.46 The biggest component of this program is its Behavioral Health Information 

Network and the Marine Corps Fitness Improvement Tool (MCFIT), 

which assigns a coordinator to each unit commander. According to the 

Marine Corps commander’s guide, “The coordinator for phase one of the 

MCFIT can be any Marine in the unit; however, a unit’s Religious Ministry Team is recommended for the task. Care should be taken to avoid the 

coordinator being any lower than a Sergeant.”47 The Marine Corps has 

also recently adopted the Navy’s Operational Stress Control (OSC) and 

modified it to become the Combat Operational Stress Control (COSC) 

program. Some of the more recent websites give the title as Operational 

Stress Control and Resiliency (OSCAR), indicating a possible upgrade in 

the name and content of the program. This program differs from the Marine Corps’s 2007 initiative Operational Stress Control and Readiness 

(also OSCAR), which attempts to identify and treat problems in the combat zone. The more recent OSCAR focuses on resiliency while the earlier 

OSCAR relied heavily on prescribing antidepressant medication.48

Navy. The Navy’s OSC program was implemented in 2009, delivering 

“stress training” to naval leadership in two courses: Navy OSC for Leaders 

(NAV-OSC Lead) and Deckplate Leader OSC (DPL-OSC). These courses 

are a vital part of any command’s efforts to foster a supportive climate, 

whether preparing for deployment or trying to strengthen readiness and 

cohesion. As of March 2014, NAV-OSC Lead had been delivered to 9,000 

Sailors, and DPL-OSC had been taught to 12,000 Sailors. The Navy also 

offers the Families OverComing under Stress (FOCUS) program, delivering resiliency training to families.49

Air Force. The Air Force Comprehensive Airman Fitness (CAF) program, loosely based on the Army’s CSF2 program, is comprehensive in 

name only. Instead of being truly all-inclusive of PTSD and related symptoms, it focuses its four pillars (mental, physical, social, and spiritual) almost exclusively on suicide prevention. The program also lacks consistency in thorough delivery of training—some bases provide CAF training 

while others do not. Bases that have documented CAF involvement are 

from several commands and in different states. There does not seem to be 

a uniform pattern of who is conducting CAF training. One can only 

speculate that a decision to have CAF training on base is due to a wing/

base commander’s exposure to the program through education or a reaction to an incident. Some bases have combined training into existing 

Wingman Day, Safety Day, and Suicide Prevention training programs.50
10

No evidence exists of any Air Force Reserve or Air National Guard units 

providing CAF training.

Coast Guard. In addition to the main four military branches, the US 

Coast Guard (although it falls under the Navy during wartime) also has 

access to Department of Homeland Security (DHS) resiliency training. 

The Coast Guard recently changed the name of its previous program 

from DHS Together Resilience Training to Building Resilience and Preventing Suicide in the Coast Guard. This is an annual e-learning training 

course, again, predominately focused on the prevention of suicide and 

largely ignoring other symptoms of PTSD.

Reserve components (joint). The Yellow Ribbon Reintegration Program, other than having a presentation from the Psychological Health 

Program (PHP), is a purely reactive effort that provides financial, relationship, and military benefit information. This information is presented 

after service members return from deployment. It is not preventive in 

nature except perhaps if a member has returned from deployment and 

retains information for future deployments.

National Guard. The National Guard Bureau has even joined the fray 

with its PHP. This program establishes a state director of psychological 

health (DPH) at each of the 54 joint force headquarters nationwide, as 

well as a unit DPH at every Army and Air National Guard unit. The PHP 

“provides National Guard–oriented mental health training throughout 

the full spectrum of the deployment cycle,” including the identification of 

nonmilitary resources available before and after active-duty military service (civilian status).51 The state director also works with the Guard and 

Reserve’s Yellow Ribbon Reintegration Program, yet another framework 

that fits resiliency into its format.

Centralized agencies. Several national and international medical organizations currently have a relationship with the US military: the American Psychiatric Association, American Psychological Association, American Red Cross, National Institute of Mental Health, and VA, among 

others.52 One centralized organization, the Defense Centers of Excellence 

for Psychological Health and Traumatic Brain Injury (DCoE), interacts 

with the Department of Veterans Affairs and has been involved in response to the mental health and fitness of service members.53 Congress 

established the DCoE in November 2007 due to the findings of six congressionally mandated reports.54 The reports highlighted an immediate 

need for high-level health care for US service members—regardless of 

branch, component, status, or geographic location.55

The DCoE is comprised of six components: the Center for Deployment 

Psychology, Center for the Study of Traumatic Stress, Defense and Veterans Brain Injury Center, Deployment Health Clinical Center, National 
11

Center for Telehealth and Technology, and National Intrepid Center for 

Excellence.56 Initially, most of its efforts were concentrated on reactive 

treatments for PTSD and traumatic brain injury (TBI). It was involved 

with the joint workshop on resilience in September 2010. Despite being 

technically a nongovernmental organization, the DCoE interacted with 

the military to address PTSD and TBI. The DOD approved realignment 

of the DCoE to the US Army in January 2013 under DOD Directive 

6000.17E, Executive Agent (EA) for the Defense Centers of Excellence for 

Psychological Health and Traumatic Brain Injury.

57 It is unclear why the 

DOD opted to align the DCoE organization under the Army instead of 

recognizing its interaction with all branches and establishing it as a centralized organization.

Analysis and Findings

It’s fuzzy math.

—George W. Bush

Response to Al Gore

 2000 presidential debate 

Current and Projected Costs of Treatment and Disability

The growing trend of PTSD and related symptoms has seen small reversals in 2013. Since not much has changed in PTSD treatment, this 

tentative progress could be an early indication of success with resiliency 

programs. However, the overall rising rate since 2003, combined with the 

increased health-care costs, highlights the need for sustained focus on 

resilience toward PTSD. Initial investment in resiliency programs has 

been high—nearly $500 million—with the Army and Reserve components alone responsible for more than half of that bill. To put the cost in 

perspective, military health-care spending (nearly 40 percent of which is 

for PTSD treatment) soared from about $19 billion in 2000 to more than 

$50 billion by 2010 and was projected at approximately $65 billion for 

2014.58 Treatment of PTSD is 46 percent of the VA budget, averaging 

more than $900 million annually.59 This amount excludes any PTSD 

treatment related to TBI and does not include partial or full medical disability for PTSD. Experts predict that the upward trend of mental disorder will continue to grow and that continued care for PTSD (at projected 

levels) is not sustainable.60 In 2011 the VA treated 476,515 veterans with 

a primary or secondary diagnosis of PTSD.61 Figure 2 compares the number of physically wounded Soldiers with those diagnosed with PTSD 

from 2001 through 2007. 
12

PTSD IS FAR MORE COMMON THAN PHYSICAL WOUNDS

SINCE OCTOBER 2001:

1.5 MILLION

NEW VETERANS

834,467

VETS WHO’VE OBTAINED

VA HEALTH CARE

50,409

SOLDIERS WOUNDED

IN ACTION

239,174

VETS DIAGNOSED

WITH PTSD

Figure 2. Number of Soldiers physically wounded versus diagnosed with 

PTSD (2001–7). (Graph sources: Department of Veterans Affairs and DOD. 

Reproduced from Jaeah Lee, “Charts: Suicide, PTSD and the Psychological 

Toll on America’s Vets; 14 Staggering Stats about the Invisible Wounds of Iraq 

and Afghanistan,” Mother Jones, 17 January 2013, http: motherjones.com

/politics/2013/01/charts-us-veterans-ptsd-war-iraq-afghanistan.) 

PTSD carries more than one form of price tag. As author Richard Gabriel has noted, “Psychiatric breakdown remains one of the most costly 

items of war when expressed in human terms.”62 A focus on resilience is 

here to stay. Preventive measures fall in line with Pres. Barack Obama’s 

Patient Protection and Affordable Care Act of 2010 as a key component 

for the future of national health care.63

Programs Not Standardized in Scope, Content, Delivery, or Evaluation

Although the military is beginning to reap the benefits of teaching 

resilience to service members, a lack of standardization of the various 

programs remains a problem. Comparison of resiliency programs reveals 

inconsistencies in training scope, content, delivery, and evaluation of results. Standardization is essential to maximizing the effectiveness of resiliency programs. Despite grasping the importance of providing resiliency 

training to its members since 2009, the US military has not progressed in 

organizing systematic or standardized training within or among branches. 

The military branches and corresponding Guard and Reserve compo-
13

nents are content to pursue their own resolution to mental health issues 

caused by PTSD. In today’s environment of fiscal limitations, this situation cannot and must not continue.

Scope. Marine Corps, Air Force, and Coast Guard programs have 

placed more emphasis on symptoms of PTSD, such as suicide, and very 

little focus on PTSD itself as the root issue. In many respects, focusing on 

symptoms would be like a doctor advocating increasing meals as a preventive measure for patients experiencing sudden weight loss (symptom) 

from cancer instead of providing information on how to prevent the root 

problem—cancer itself. Smoking, obesity, depression, suicide, and other 

mental/physical health issues are often side effects of PTSD known as 

“comorbidity.”64 The Air Force’s CAF program is an example of narrow 

scope. Most Air Force material presented online or at each base is directed at suicide prevention. The allure of addressing suicides is that the 

military has kept accurate statistics on suicide rates for decades whereas 

other PTSD side effects are more difficult to identify and track—such as 

domestic violence, substance abuse, anger management, and other related symptoms.

Military resiliency programs over the last five years have been developed largely through trial-and-error experimentation. Most similarities 

among programs have occurred by coincidence, with no attempt at standardization to date despite the CJCS instruction providing guidance four 

years ago. One can argue that as long as Airmen are trained in the proper 

techniques for resilience and the results are effective, the rationale is unimportant. However, in the long run, this ends-justify-means attitude is 

unscientific and counterproductive to any training effort.

Content. The Army and Navy have most clearly developed programs 

that are comprehensive, closest to the Total Force Fitness model, and consistently focused on resiliency specifically to PTSD and related symptoms. The Army has targeted resiliency to PTSD as its core focus in training. The Navy has also taken steps to address PTSD through training in 

coping with stress while deployed and in daily life. Therefore, these two 

programs were reviewed for content.

Successful methods in training resiliency techniques can be taken directly from college and professional sports organizations’ programs. Yogi 

Berra famously said that professional baseball “is 90 percent mental, and 

the other half is physical.”65 Many references to sports apply equally well 

to combat: mental preparation, peak performance, flexibility when the 

opponent reacts unexpectedly, and full physical and mental recovery to 

be able to perform again in a very short time period.66 Current military 

resiliency programs urge a holistic approach to health—mental, physical, 
14

social, and spiritual. However, they do not adequately address mental 

preparedness for stress in combat and in life.

Delivery methods. Resiliency training is not incorporated into combat or tactical training courses but is taught separately. Much of resiliency 

training is computer based or occurs in a classroom environment whereas 

combat training and deployment preparation are almost always handson. Eighty-one percent of combat veterans consider training that provides “battle inoculation . . . [to be] ‘very important.’ ”67

The US Army has the most fully implemented resiliency program to 

date. Its program is largely computer based and is required annually. The 

Army supplements the online CSF2 training with certified master resilience trainers, Soldiers who have attended the US Army Master Resilience School at Fort Jackson, South Carolina. The level 1 course is 10 days 

long, and the supplemental level 2 course is an additional 5 days.68 The 

Army has master resilience trainers placed in each unit, and it has also 

trained the most service members. Research on the effectiveness of MRT 

indicates that it positively correlates with an increase in Soldiers’ emotional fitness.69 The most significant result has been an amazing reversal 

in the suicide trend, which nearly doubled from 2005 to 2010, peaked in 

2012, and experienced a dramatic decline of 19 percent in 2013.70 The 

Army has conducted the most follow-up research on its program and 

published findings as to its effectiveness. For these reasons, although still 

in its infancy, the Army’s program should be considered the standard of 

actual accomplishment.

The Navy teaches its OSC mostly through e-learning and blog-like articles on official web pages to all naval service members and their families. 

It provides additional training for naval leaders through two classroomdelivered courses. The Navy has also made an effort to embed stress control concepts into all existing education and training programs.71

Evaluation. Organizational standardization has obvious benefits. 

Probably the most critical benefit would be to use standardized evaluation metrics to objectively identify which program components work 

best by comparison. One of the most critical complaints of existing resiliency programs is that after “more than a decade of war, [there is still] a 

lack of systematic evaluation and performance measures [to gauge the 

success of resiliency programs].”72 Standardized evaluation metrics would 

more accurately identify the impact of training methods. Results could 

be more quickly compared and communicated. As a 2008 RAND study 

of resiliency programs recommended, “Each . . . should be evaluated 

carefully. . . . Only programs that demonstrate effectiveness should be 

maintained and disseminated.”73
15

What little research has been conducted to evaluate program effectiveness has been performed on individual programs, with little or no 

comparison to other programs to gauge relative effectiveness. Proper 

evaluation requires the identification of similar methods and results. Attempting to apply metrics to dissimilar programs is like comparing apples to oranges and can skew perspective.

Consolidation of Organizations

While the Army’s program may be the most inclusive in content, the 

Army’s and Air National Guard’s PHPs have made significant strides in 

jointness. The National Guard Psychological Health Program oversees 

both components of the National Guard and ensures standardized format and content. The PHP has also become a part of the Yellow Ribbon 

Reintegration Program, which is delivered to an even wider range of the 

Guard and Reserve components of all military branches.

Other than the PHP, the military currently has no centralized oversight of resiliency programs. It does not monitor individual program 

management of personnel and budgets or evaluate overall program efficiencies. Each program is independently managed and operated, with 

little or no communication with peers. Programs are funded autonomously, and although the majority of funding comes from the US military, it can come from different sources from US government and nongovernment budgets. Consolidation of program organizations would 

show improvement in several different areas.

Operations. A centralized organization would reduce costs overall by 

decreasing operational redundancies and eliminating overlapping staffing and administrative functions. Centralized operations drastically reduce duplication of effort, streamline communication, and aid in assessing and evaluating the effectiveness of programs. Other costs savings can 

be found in reducing facility lease and/or maintenance expenses. A centralized organization would facilitate training delivery. Instead of risking 

irregular coverage, training resources could be pooled and directed toward instructing personnel.

The textbook economics term for costs lowering as an organization 

grows and consolidates is increased economies of scale. Economies of scale 

are essentially cost advantages gained due to expansion. In a conventional 

business, the average cost per unit falls (to a certain point) as output increases.74 This strategy is long term because costs sometimes can be 

briefly driven up during the transition process as a result of disruptions in 

operation and learning adjustments. A consolidated organization should 

realize reductions in overhead costs as well as in capital expenditures.75
16

The larger an organization, the more stability it can achieve. Large, 

stable organizations influence other governmental and nongovernmental 

agencies and collaborating companies. This advantage is useful when 

sharing information, garnering assistance on projects, or brokering contracts. Established, centralized organizations have more negotiating 

power with suppliers. Materials and services acquisition could be centralized, putting the larger organization in a better bargaining position to 

potentially obtain better rates and services.

Oversight. A centralized organization means centralized management, which, if planned and operated properly, reduces duplication of 

effort in oversight of personnel, operations, and assets. It streamlines levels of bureaucracy, standardizing and simplifying administration. It provides oversight to all components, ensuring fair and complete distribution to military branches.

Communication. When organizations are consolidated, systems such 

as communications and information technology (data storage and access) are frequently redesigned and upgraded, making their functions 

even more efficient. Consolidated communications centers ensure more 

intraorganization communication as well as communication with customers and peer organizations. Larger voice and data communications 

systems could be planned for better compatibility, with security and redundancy measures included for preservation and protection of critical 

information.

Standardizing the existing resiliency programs would immediately 

begin to recognize cost savings by slowing or stopping existing PTSD 

rates since the Army’s rate is beginning to show signs of effectiveness. 

Leaving aside potential legal implications, it is impractical for any one 

branch of the military to shoulder the responsibility of funding and delivering training to the total force. Therefore, an existing centralized organization must be identified or a new one formed for such a purpose. Funding and manpower would be reallocated from individual branches to the 

central organization.

The current environment of separate programs exhibits not only a lack 

of communication between organizations but also a potential liability insofar as the end user may receive conflicting messages or treatment. For 

example, a California national guardsman may receive information from 

a behavioral health officer that could potentially be substantially different 

from what his unit’s DPH advocates, which could also differ from the 

information on the CSF2 website. The same member falls under no fewer 

than three different resiliency programs, which are run separately with 

no obligation to coordinate or communicate with each other.
17

Evaluation metrics. Centralized evaluation of all branches would create a research pool double the size of the results of any previous resiliency 

program study. As any poll would indicate, larger numbers create a lower 

margin of error for inaccurate or skewed results. Centralized procedures 

set standards in metrics and evaluation criteria. Common standards 

identify benchmarks—best practices that can be passed on to achieve desired results in all branches. Research would be shared and compared 

more quickly by using a common platform to transmit or exchange ideas.

Conclusion

What does not kill me, makes me stronger.

—Friedrich Nietzsche

Twilight of the Idols

Recommendations

Integration of resiliency training into combat/tactical training. Resiliency training addresses life coping skills that may be delivered to service members through computer-based training or in a classroom environment. It also is directly related to PTSD caused by exposure to trauma 

during combat. Therefore, it makes sense to incorporate training on stress 

and coping skills as part of combat and tactical training. Combat training 

and deployment preparation courses should be assessed for inclusion of 

resiliency training. Combat and tactical training should include conditions that expose service members to stress in a controlled environment. 

Specific guidance should be given on stress, associated symptoms, and 

effective coping methods. Integrating resiliency training into combat or 

tactical training would better prepare deployers for combat-related 

stress and give them the ability to experience recovery—effective stress 

inoculation.

Comprehensive scope using the Total Force Fitness framework. Although the military has made strides in implementing PTSD resiliency 

programs, they lack consistency in content. Some programs are more 

wide ranging than others. Two of the dozen or so programs specifically 

address methods to reduce long-term PTSD cases while the rest mostly 

address selected comorbidity symptoms. Programs should emulate the 

Total Force Fitness framework, addressing all identified categories in the 

model (see fig. 3). Training should not only focus on physical or spiritual 

health but also include mental preparedness. Realistic guidance on what 

to expect would be helpful to service members preparing to deploy.
18

Social support

Task cohesion

Social cohesion

Substance abuse

Hygiene

Risk mitigation

Coping

Awareness

Beliefs/Appraisals

Decision making

Engagement

Food quality

Nutrient requirements

Supplement use

Food choices

Strength

Endurance

Flexibility

Mobility

Heat/Cold

Altitude

Noise

Air quality

Access

Immunizations

Screening

Prophylaxis

Dental

Service values

Positive beliefs

Meaning making

Ethical leadership

Accommodate diversity

Social

Total Force

Fitness

Environmental

Psychological

Behavioral

Physical

Medical

Nutritional

Spiritual

Figure 3. Total Force Fitness model. (Adapted from Chairman of the Joint 

Chiefs of Staff Instruction 3405.01, Chairman’s Total Force Fitness Framework, 1 September 2011, A-2.)

Standardization by consolidating organizations under the Defense 

Centers of Excellence. The US military presently has several resiliency 

programs that do not have any centralized oversight to provide guidance 

on focus and content. Although the disparate programs have the same 

purpose and customer base, they do not communicate and sometimes do 

not know of each other’s existence. Standardization and communication 

can be best achieved by consolidating organizations. The government 

should consolidate resiliency programs in order to standardize training 

and delivery across all branches of the military, generating more complete coverage of service members and best practices from each program 

based on proven effectiveness.

Existing programs must immediately be evaluated and compared 

against each other to identify benchmarks—what works well. The other 

programs must be modified to incorporate the best training and most 
19

cost-effective means of training delivery. Programs must be delivered to 

all units—starting immediately with the branches and units that reflect a 

higher rate of PTSD and related symptoms, whether due to deployment 

and combat or not. Therefore, training should concentrate first on those 

units and then on the other career fields in a wing.

One option—utilizing the existing DCoE as a central organization for 

program consolidation—would alleviate major startup costs involved 

with building a new organization. The DCoE has recently been aligned to 

fall under the US Army. It is already familiar with mental health and fitness of military members, so a new program would experience a more 

reasonable learning curve than employing a brand new organization or 

contracting an outside organization for military purposes. The DCoE 

should be further realigned to fall under the DOD as a whole instead of 

merely one branch of the military.

Implications

An ounce of prevention is worth a pound of cure.

—Benjamin Franklin

Fiscal implications. Franklin’s argument for prevention is as pertinent to the topic at hand today as it was to fighting fires in Philadelphia 

nearly 300 years ago. Adoption of more preventive methods outlined in 

the Total Force Fitness framework could save the US military millions 

of dollars in treatment and disability costs for PTSD and related symptoms per year. Standardization of resiliency programs and integration 

into a joint or total force program would save even more millions of 

dollars per year in research, tracking, training delivery, and other administrative costs.

The obstacle at hand is getting all stakeholders—military branches, 

states, resiliency organizations, unit commanders, and end users—to 

commit to change. Many of the challenges with consolidating programs 

are political. Agreeing to give up money and control will be an ordeal. It 

may also be a struggle to get all participants to agree on the scope and 

timeline for changing their programs. Part of getting ready for transformation involves preparing against opposition arguments and having a 

plan in place for projected realignment and/or reductions. Focusing on 

the end goal is imperative: having a better, more comprehensive program 

that will produce more prepared service members who will perform 

more capably in battle and recover quickly and fully afterward.
20

These separate organizations should cease operating individually 

managed programs. Instead, they must methodically begin coordinating 

their efforts at building resilience in service members into a focused common goal. If the Army’s results were realized throughout the rest of the 

military branches, the United States could save between $10–$20 million 

per year in VA treatment alone and even more in disability payments.

Consolidated organizations and administration would result in even 

greater cost savings, possibly $100 million per year or more in management, administrative, training, and other operational costs. A few examples of viable administrative cost savings include merging the storage 

and delivery of training material (whether physical or electronic) and 

establishing regional training locations for standardized instruction, delivery, and evaluation. The military must combine separate program organizational structures into one joint administrative organization. Doing 

so would save costs in parallel levels of management and administrative 

positions while avoiding duplication of effort that may result in conflicting directions. Instead, actions could concentrate on attaining a unified 

vision/goal.

Operational implications. Planning and executing a strategy to consolidate the various existing resiliency programs under one institute would 

create a more effective and organized operation. Oversight and management of programs could be made regional instead of by military branch, 

allowing better visibility and responsiveness. Standardized communication would result in sending and receiving clear, streamlined messages 

both vertically and horizontally. More effective program management 

would lower duplication of offices and material. Printed training materials 

could be designed, ordered, and printed for use among all branches, lowering costs and overhead. Consolidated bases could share certified trainers, providing greater coverage and less unnecessary surplus.

This joint organization would be better suited to implement metrics 

tracking to compare prior levels of PTSD and related symptoms with current levels to indicate program success or need for modification. Also, the 

consolidated organization could implement metrics tracking to compare 

branches to determine the need for adjustment to address a specific requirement in a particular branch. Once needs were identified, the oversight organization would determine levels of funding/focus required per 

branch. It could adjust the content of the message to match military 

branch culture while preserving the standardization of intent and methodology (fig. 4). Such oversight would allow assessment of the effectiveness of program modifications and identification of future actions to 

maximize program efficiencies. 
21

Figure 4. Examples of services’ prevention campaigns

Summary

People are always talking about standardization, and I don’t 

like the word. There is no such thing. . . . The only constant 

thing in this world is change.

—Henry Ford

The Quotable Henry Ford

All branches of the US military are currently attempting to implement 

resiliency practices without coordinating or standardizing their respective programs. In-house research and statistics give rise to possibly biased 

findings, and lack of communication has resulted in lost opportunities to 

improve programs based on valuable lessons learned by other branches. 
22

The rising cost in treatment, together with this growing bill for resiliency 

programs, is not sustainable. Annual military budgets continue to shrink, 

and more cuts are inevitable. Such cuts could be unevenly meted out, 

creating inequality in branches’ programs. Distributing cuts evenly across 

the board would result in program inefficiency.

The US military’s philosophy of taking care of service members while 

ensuring fiscal responsibility demands the aggressive pursuit of minimizing mental trauma to military personnel at a lower cost. Program standardization and consolidation would save fiscal resources and maintain 

or even increase program effectiveness. Timing is everything, and there 

is no time like the present. Ten years ago, the military identified the need 

to further improve its programs in addressing PTSD. For the past six 

years, the military has concentrated on prevention by developing various 

resiliency programs. The time to consolidate these programs and standardize methods of training and delivery is now.

Notes

(All notes appear in shortened form. For full details, see the appropriate entry in the 

bibliography.)

1. US Department of Veterans Affairs, “Symptoms of PTSD.” 

2. Ibid.

3. Williamson and Mulhall, Invisible Wounds, 6.

4. Zarembo, “Prevent Psychological Problems.”

5. Ghaemi, First-Rate Madness, 124; and Herman, Trauma and Recovery, 47.

6. Merriam-Webster, s.v. “prevention,” accessed 1 April 2014, http://www.merriam-web

ster.com/dictionary/prevention.

7. Merriam-Webster Medical Dictionary, s.v. “resilience,” accessed 1 April 2014, http://

www.merriam-webster.com/medical/resilience.

8. Kobasa, Maddi, and Kahn, “Hardiness and Health,” 168–77; and Bonanno, “Loss, 

Trauma, and Human Resilience,” 20–28.

9. Kime, “Panel: Scant Evidence.” 

10. Sagalyn, “Health Experts Question Army Report.” 

11. Blakeley and Jansen, Post-traumatic Stress Disorder, 27.

12. Johnson, Who Moved My Cheese?, 11.

13. Sohn, “Medieval Knights May Have Had PTSD.”

14. Friedman, “Past Names for PTSD.”

15. Baldwin and Weeks, “Research Brings Hope for Veterans.”

16. Engelhard et al., “Vulnerability Associations and Symptoms,” 25; and Giordano, 

“Pain and Psychopathology,” 34–42.

17. Stretch, “Follow-Up Studies of Veterans,” 457–76.

18. Jones, Hyams, and Wessely, “Screening for Vulnerability,” 40–46.

19. Wells, “Group Cohesion and Morale,” 61.

20. Archibald and Tuddenham, “Persistent Stress Reaction,” 475.

21. Ibid.

22. Jaffe, “New Name for PTSD.” 

23. Van der Kolk, McFarlane, and Weisaeth, Traumatic Stress, 78.
23

24. Sagalyn, “Changing Name of PTSD.”

25. Timm, “PTSD Is Not a Disorder.”

26. Maisel, “New Definition.”

27. Sagalyn, “Doctor Rejects Name Change.” 

28. Galea et al., “Trends,” 514–24.

29. Miles, “Officials Report Progress,” 118.

30. Kirkland, “Postcombat Reentry,” 302.

31. Hedges, Know about War, 115–16.

32. Spiegel, “Treatment Costs Soar”; and Grossman and Christensen, On Combat, 294.

33. Gordon et al., Enhancing Assessments, 17–19.

34. Ibid.

35. CJCS Instruction 3405.01, Chairman’s Total Force Fitness Framework. 

36. Borda, “Air Force Resiliency Program,” 7.

37. Casey, “Comprehensive Soldier Fitness,” 1–3.

38. Reivich, Seligman, and McBride, “Master Resilience Training,” 25–34.

39. Lester et al., Comprehensive Soldier Fitness Program, 1.

40. Soldz and Eidelson, “Call for Retraction.” 

41. American Psychiatric Association, Diagnostic and Statistical Manual.

42. Chiarelli to leaders and scholars, letter.

43. Joseph, “Client-Centred Therapy,” 101; and Calhoun, Tedeschi, and Park, Posttraumatic Growth.

44. Lester et al., Comprehensive Soldier Fitness Program, 3. 

45. Calaway, “Resiliency Training.” 

46. Torpy, “Spirituality and Spiritual Fitness.” 

47. US Marine Corps, “(MCFIT) Commander’s Guide,” 4.

48. Caplan, Johnny and Jane, 120.

49. Operational Stress Control, “What’s Next?”

50. Hubenthal, “Building Resilience.” 

51. National Guard Bureau, Psychological Health Program website, “Program Goals.”

52. US Department of Veterans Affairs, “PTSD.”

53. Defense Centers of Excellence (DCoE) for Psychological Health and Traumatic 

Brain Injury, official website, 2014.

54. DCoE, Annual Report 2012, 9.

55. DCoE, Annual Report 2009, 9.

56. Ibid., 38.

57. DCoE, Annual Report 2012, 15.

58. Keifer, “Admiral Mike Mullen.” 

59. Congressional Budget Office, Treatment of PTSD, 18, 20.

60. Dunn, “Experts: PTSD Growing Issue”; and Keifer, “Admiral Mike Mullen.” 

61. US Department of Veterans Affairs, “VA PTSD Program Quick Facts.” 

62. Gabriel, No More Heroes.

63. White House, “Affordable Care Act,” 1–11.

64. “309.81: Posttraumatic Stress Disorder (PTSD),” in American Psychiatric Association, Diagnostic and Statistical Manual. 

65. Asken, Grossman, and Christensen, Warrior Mindset, 23.

66. Ibid., 42.

67. Holmes, Acts of War, 53.

68. “U.S. Army Master Resilience School.” 

69. Lester et al., Comprehensive Soldier Fitness Program, 15.
24

70. Zarembo, “Programs to Prevent Psychological Problems”; Briggs, “Military Suicide 

Rate”; and Zoroya, “Suicides in the Army.”

71. Cragg, “Navy Program.” 

72. Denning, Meisners, and Warner, Preventing Psychological Disorders.

73. Tanielian and Jaycox, Invisible Wounds of War, 452.

74. Sullivan and Sheffrin, Economics, 157.

75. Nordmeyer, “Benefits of Organizational Consolidation?”
25

Appendix

Military Resiliency Programs as of 2014

Branch Program Title Program Information

Army Comprehensive Soldier and 

Family Fitness (CSF2)

Primary focus: Post-traumatic 

stress disorder (PTSD) and 

related symptoms

Website: http://csf2.army.mil/

Start-up year: 2009

Air Force Comprehensive Airman Fitness 

(CAF)

Primary focus: Suicide 

prevention

Website: No central website 

available

Start-up year: 2010

Navy Operational Stress Control 

(OSC)

Primary focus: Stress 

continuum and stress 

management

Website: http://navynavstress

.com/

Start-up year: 2009

Marine Corps Behavioral Health Information 

Network

Primary focus: Community 

counseling and suicide 

prevention

Website: http://bhin.usmc-mccs

.org/

(no longer available to the 

public)

Start-up year: 2010
26

Branch Program Title Program Information

Marine Corps Combat Operational Stress 

Control (COSC)

Primary focus: Spiritual health 

(Chaplain Corps) and PTSD 

continuum

Website: 

http://www.med.navy.mil/sites

/nmcsd/nccosc/Pages/welcome

.aspx

Start-up year: 2011

Marine Corps Operational Stress 

Control and Readiness 

(OSCAR) Teams

Primary focus: Mental health 

professional peer-to-peer 

support / “Stress First-Aid”

Website: No central website 

available 

Information website: 

http://www.med.navy.mil

/bumed/comms/MEDNEWS

/Pages/OperationalStress

ControlandReadiness.aspx

Start-up year: 2012

Marine Corps Research, Assessment, 

Performance, Training

 Optimization and Resilience 

(RAPTOR)

Primary focus: Resiliency 

research program

Website: No central website 

available 

Information website: 

http://www.imef.marines.mil

/News/NewsArticleDisplay

/tabid/3963/Article/534868

/resiliency-training-raptor

-program-prepares-deploying

-marines.aspx

Start-up year: 2011

Coast Guard DHS Together Employee and 

Organizational Resilience

Primary focus: Organizational 

resilience, particularly to 

workplace violence

Website: 

http://www.dhs.gov/dhstogether

-employee-and-organizational

-resilience

Start-up year: 2010
27

Branch Program Title Program Information

Coast Guard Building Resilience and 

Preventing Suicide in the 

Coast Guard

Primary focus: Suicide 

prevention

Website: No central website 

available

Information website: 

http://www.uscg.mil/d7/sect

Jacksonville/training/MAN

DATED%20TRAINING%20

LIST%20UPDATED%20

20MAR13.pdf

Start-up year: 2013

Army / 

Air Guard

Psychological Health Program 

(PHP)

Primary focus: Mental health 

support (“five pillars of 

wellness”)

Website: https://www.joint

servicessupport.org/php/

Start-up year: 2010

Air Force /

Marine Corps

Deployment Transition Center

Ramstein AFB, Germany 

Primary focus: Reintegration 

program

Website: http://www.ramstein

.af.mil/deploymenttransition

center.asp

Start-up year: 2010

Joint Reserve 

Services

Yellow Ribbon Reintegration 

Program

Primary focus: Reintegration 

program; later, inclusion of 

PHP

Websites: http://www.yellow

ribbon.mil/

https://www.jointservicessupport

.org/yrrp/Default.aspx

Information website: 

http://www.militaryonesource

.mil/deployment?content_id

=266643

Start-up year: 2008
28

Branch Program Title Program Information

Army / Air 

National Guard:

Indiana

California

Michigan

Georgia

Behavioral Health Services

(Star Behavioral Health 

Providers)

Primary focus: Understanding 

and treating military members; 

mostly reactive

Websites: http://starproviders

.org/providers/states/indiana

/collaborators-page-id-5

http://www.calguard.ca.gov/BH

Start-up year: 2011

Department of 

Defense

Defense Centers of Excellence 

for Psychological Health and 

Traumatic Brain Injury (DCoE)

Primary focus: Reintegration 

program; later, inclusion of 

PHP

Websites: http://www.dcoe.mil

Start-up year: 2007

Joint Chiefs of 

Staff

Total Force Fitness Framework Primary focus: Standardized 

resiliency structure

Websites: No central website 

available

Start-up year: 2010
29

Abbreviations

CAF Comprehensive Airman Fitness

CJCS chairman of the Joint Chiefs of Staff

COSC Combat Operational Stress Control

CSF2 Comprehensive Soldier and Family Fitness

CSR combat stress reaction

DCoE Defense Centers of Excellence for Psychological 

Health and Traumatic Brain Injury

DHS Department of Homeland Security

DOD Department of Defense

DPH director of psychological health

DPL-OSC Deckplate Leader OSC

DSM Diagnostic and Statistical Manual of Mental Disorders

FOCUS Families OverComing under Stress

MCFIT Marine Corps Fitness Improvement Tool

MRT Master Resilience Training

NAV-OSC Lead Navy OSC for Leaders

OSC Operational Stress Control

OSCAR Operational Stress Control and Resiliency

PHP Psychological Health Program

PTSD post-traumatic stress disorder

RAPTOR Research, Assessment, Performance, Training Optimization, and Resilience 

TBI traumatic brain injury

VA Veterans Affairs

31

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