Recently on the NewsHour, health correspondent Betty Ann Bowser explored a new Army program that aims to help every man and woman in uniform build a sturdier core of mental and emotional strength.
It's not only the largest psychological program in the Army's history -- carrying a price tag of $140 million -- it's also built around some pretty controversial ideas.
Viewers submitted dozens of questions about the program, its implementation and the science behind it. Col. Marsha Lilly of the Comprehensive Soldier Fitness Public Affairs office and critic Bryant Welch, a psychotherapist, responded to a representative sample of the queries below.
But first, brush up on the background by listening to two of the nation's top psychology experts debate the merits of the program. Also, watch an online exclusive about a war widow who says the program helped her after the death of her husband in Afghanistan. Of course, you can check out the full story here.
Click any of the questions below to jump to the responses.
6: This "positive psychology" seems like a clone of cognitive behavioral therapy that has been around for decades. How is it different? And are the soldiers tested beforehand to get a baseline of "resilience" so we know if the training had an effect?
1. Viewer "Marcellefk" asks: How is the program going to be used with family members? How are family members who are not living on or near military bases supposed to get any support? (My husband was deployed while we were on exchange overseas. We have no access to American military bases). Have any studies been done to show whether the program is effective when used with family members?
ARMY COL. MARSHA LILLY: Family members have access to the Comprehensive Soldier Fitness program to help them to achieve resilience. Geographically dispersed soldiers and family members have access to the program's online training modules referred to as Comprehensive Resilience Modules (CRM). These are skills-based training videos and the success of each skill is based on the level of effort committed to practicing and mastering the skill.
The skills taught within the CRMs are proven to work on any population of people and are not soldier-specific. Studies have not been conducted to show the effectiveness of the program but evaluations and testimonials by family members indicate that this program is very well received and has made a positive impact on family members. Family members enrolled in Defense Enrollment Eligibility Reporting System (DEERS) may access the program via the Global Assessment Tool.
BRYANT WELCH, psychotherapist: There are no valid studies showing that this program will prevent psychiatric casualties for anyone. While the Army's lead-in sentence reported in its soon-to-be-released study asserts that the study documents the benefits of the program, the actual document shows that all the Army has done is have soldiers answer 100-plus questions about attitudes that have been associated with resilience, had the soldiers indoctrinated in those attitudes, and then re-tested the soldiers with the same instrument. Naturally, the soldiers respond with what they have been taught is the "healthy" attitude the second time around. This is a sophisticated sleight of hand that is being perpetrated on the public. The danger is that soldiers will be told they are now prepared to respond to the kind of terrible traumas they will encounter in combat and, if they show psychiatric symptoms, it just means they were not "fit." This has been a longstanding problem with the military, and, I am concerned it may be the ultimate long-term impact of this program. Were it not for that, the program would probably be harmless. This, however, is a very real and serious danger.
2. Viewer "John Gage" asks: What types of meditation, if any, do you teach people to help them become more aware of how their thought processes direct their behavior? And what is the role of sports, games and recreation in the lives of people recovering from PTSD? What do they do for fun? What do they consider fun?
ARMY COL. MARSHA LILLY: CSF does not recommend any particular meditation approaches at this time. CSF uses the ATC model to help soldiers understand the relationship between thoughts and behaviors. A Comprehensive Resilience Module (CRM) on Activating events, Thoughts and Consequences (ATC) is in production, it deals directly with how our thoughts and beliefs influence our actions. Sports, games, and recreation are important for the overall health and resilience of any person. The Morale Welfare and Recreation program does a very good job addressing the recreation needs within our military community.
BRYANT WELCH, psychotherapist: This program does not address people with PTSD. It is based on the unproven assumption that soldiers can be made so resilient by brief suggestions that they change their attitude that they will not succumb to the ravages of war with PTSD and other psychiatric symptoms. Most dangerously, soldiers are given the implicit message that if they do show signs of PTSD and other symptoms that it means they are "unfit." This is the position the military has taken for decades with respect to psychiatric casualties. It is a shame that they are doing this now when so many military mental health professionals are skilled and able to provide competent treatment to psychiatric victims. We are taking a step back by telling people that it is a sign they were not "fit."
3. Viewer "arcata" asks: When you present an individual with experiences he has never been trained to work with, such as his best friend losing a limb, or his entire troop being ambushed ... and he survives ... there is no positive thinking routine in existence which will relieve his trauma. Do you disagree?
ARMY COL. MARSHA LILLY: Comprehensive Soldier Fitness does not in any way pretend to be a "quick fix" solution that will completely relieve the pain and suffering of difficult combat experiences that the viewer notes above. Comprehensive Soldier Fitness instead serves as a programmatic first step toward training members of the Army community to understand how and why they think a certain way. Once people begin to understand this, they are better equipped to change -- over time -- their thoughts and actions to strategies that are positive, adaptive and desirable for both the person and the Army. This will help them handle these extremely difficult memories and experiences in a more effective way, while certainly not "relieving" all the pain and emotions that result.
BRYANT WELCH, psychotherapist: Arcata, I could not agree more. I believe this program is based on a shallow psychological understanding of trauma. Even worse, as I have said above, it gives soldiers the message that if they are having psychiatric symptoms, it means something is wrong with them. They were not fit. It's a terrible danger in a program of this nature.
4. Viewer "Pat" asks: How does the new program deal with flashbacks? They appear to be an involuntary physical response that flashes on for often unknown or non-anticipatable reasons that are unrelated to exercises toward a positive mindset.
ARMY COL. MARSHA LILLY: CSF is not designed to treat flashbacks. If a soldier is experiencing this problem, they should seek medical treatment. Flashbacks are a key component of what we call post-traumatic stress disorder. Often, these flashbacks are sudden and unexpected, and can significantly interfere with one's quality of life and are the result or outcome of experiencing a traumatic event that can and does occur in combat.
Comprehensive Soldier Fitness strives to improve the baseline resilience and psychological fitness of the Army community before traumatic events occur so that the brain has the ability to process these events in a different way so as to not lead later to "re-living" experiences through flashbacks. In this regard, Comprehensive Soldier Fitness does not offer a solution to flashbacks, but strives to prevent them by having an individual frame an event differently during and immediately after it occurs by entering the event from an improved, baseline level of psychological resilience whereby the brain does not continually re-live the event after it occurs.
BRYANT WELCH, psychotherapist: I completely agree with you, Pat. As I have said above, the psychological underpinnings of this program are quite shallow. They reflect a limited understanding of PTSD and make exaggerated claims for what the program's very limited interventions can do. More importantly, as noted, it gives our troops the message that if they are having flashbacks that it is something "unfit" about them, not the inevitable result from the ravages of war experiences.
5. Viewer "Doug" asks: I have combat PTSD from SE Asia. Over the years, I spent a lot of time reducing the symptoms and was successful in some, such as survivor's guilt. However, one of the symptoms -- hyper-vigilance -- stayed with me, to the discomfort of my friends and family. I came home from a war to find another one right here to survive. I could write for hours about the attacks on me and other vets by people and agencies in civilian life just because we were soldiers. The best methods I know how to keep myself out of trouble is Zen meditation, kindness and thoughtfulness, so I recommend this for everyone encountering this kind of prejudice. However, my question is even with Zen and Christianity: How can I achieve a better state of mind than being in survival mode all the time?
ARMY COL. MARSHA LILLY: It seems like Zen meditation and thoughtfulness is working for you. Keep doing it if it helps you cope better and live a productive life. However, there are different strokes for different folks, what works for you may not necessarily work for the next person because everyone responds differently to psychological challenges. Medical conditions should be treated by health care professionals; perhaps a health care professional should address your hyper-vigilance symptoms and recommend some of the best treatment approaches to help with recovery.
BRYANT WELCH, psychotherapist: I am sorry to hear about your experiences. As you no doubt realize, they are the product of war trauma that cannot be undone or prevented simply by telling you to think positively or some variation on that theme. Fortunately, there are many increasingly effective treatments for trauma. You are right that meditation is one of the best, but it should be supplemented with psychotherapy especially with a practitioner who is informed by current trauma treatments. In many areas, the VA is doing good work in this area. In others it is spotty. You might want to look at the recent work of Peter Levine in developing treatments for trauma like you have been through.
6. Viewer "Blynd2" asks: This "positive psychology" program seems like a clone of cognitive behavioral therapy that has been around for decades. How is it different? Are the soldiers tested beforehand to get a baseline of "resilience" so we know if the training had an effect? Some people are just naturally more resilient than others. How do we know the soldiers showing more resilience were not that way to begin with?
ARMY COL. MARSHA LILLY: A) Comprehensive Soldier Fitness is modeled after the University of Pennsylvania Resilience Program (PRP), and PRP is in fact largely based on Cognitive Behavioral Therapy.
B) Yes, all soldiers serving at the launch of CSF in October 2009 completed the Global Assessment Tool, and the vast majority completed the assessment prior to being exposed to CSF training. Additionally, all new trainees are given the Global Assessment Tool very early during their Initial Military Training (IMT, or what most people refer to as Basic Training) experience. This establishes the baseline. As the PBS report stated, CSF will publish a technical report in the next few weeks that outlines the program's effectiveness.
C) You are correct. Some people come into the Army with experiences and a mindset that helps them respond to the challenges of Army life in a more resilient way. That aside, maintaining and developing resilience is considered a life-long process, and even highly resilient people can continue to improve. Being resilient isn't a binary state ... you aren't "resilient" or "not resilient". Rather, resilience is a continuum that can change for the worse or the better over time.
BRYANT WELCH, psychotherapist: This program is not even that far along. It is untested for anyone with combat following the training. It is entirely speculative and based on some rather extraordinary leaps of faith including the assumption that the effect of war trauma is related to self-esteem problems in junior high students. That is why I am concerned that the primary impact of this limited intervention is going to give our troops the message that if they are suffering psychiatric symptoms they must simply have been "unfit." The military has long had a tendency to dismiss the significance and nature of psychiatric casualties in this fashion.
7. Viewer "Anna D." asks: I agree with Bessel van der Kolk about the shortcomings of the Comprehensive Soldier Training program in the Army. It seems not only unrealistic, but actually morally repugnant. Are soldiers being trained to not have any feelings about killing other humans? Are they being taught to think positively about acting violently?
ARMY COL. MARSHA LILLY: No, Comprehensive Soldier Fitness does not train soldiers to have positive feelings toward killing other humans and they are not taught to think positively about acting violently. On the contrary, CSF is a prevention program designed to build resilience by strengthening five dimensions: physical, social, emotional, spiritual and family. It recognizes the tremendous stress that soldiers face during wartime. Soldiers are taught mental skills to help them build resilience before encountering a traumatic event. How you go into an event may determine how you come out of that event. Soldiers are trained to regulate their emotions and energy levels to enable critical thinking and optimal performance in a garrison environment or a combat zone. CSF is not meant to preclude soldiers from having adverse feelings in response to traumatic events -- it's about instilling skills in soldiers that allows them to be better prepared to deal with adversities.
BRYANT WELCH, psychotherapist: Anna, I agree with Dr. van der Kolk as well. Apart from the moral aspects, it is simply based on shallow psychological principles when applied to the nature of war trauma. It also gives precisely the wrong message to troops. Acknowledging psychological symptoms is a sign of health; it does not mean they are not "fit." That is the real danger of this program.
8. Viewer "Shirley_Yurgoking" asks: Are any tools used to first select for personality variables and then adapt the Comprehensive Soldier Fitness training so as to be targeted to that personality? An example in our experience is using the Myers-Briggs type indicator to enable a subject to self-select, and then have succeeding training lessons branch based upon the type.
ARMY COL. MARSHA LILLY: Unlike personality measures that focus on stable traits that tend not to change a lot over time, the Global Assessment Tool instead focuses on individual psychological health states that do tend to change over time, are malleable, and are therefore more apt to be influenced by the training that CSF provides.
BRYANT WELCH, psychotherapist: Given the sophisticated nature of your question, I think you would be shocked by the limited nature of this intervention. Sergeants are trained for two weeks in "positive psychology" in the hope that they will then be qualified to run this mental health program in their unit. Giving that kind of power to someone with that limited amount of training is not only unrealistic, it is also dangerous.