Resilience Training Priorities

Resilience
01/18/19 1
“Training for warfighting is our number one priority in peace and in war. Warfighting readiness is derived from tactical and
technical competence and confidence. Competence relates to the ability to fight our doctrine through tactical and technical
execution. Confidence is the individual and collective belief that we can do all things better than the adversary and the unit
possesses the trust and will to accomplish the mission.”
FM 7-0, Training the Force
“Training for warfighting is our number one priority in peace and in war. Warfighting readiness is derived from tactical and
technical competence and confidence. Competence relates to the ability to fight our doctrine through tactical and technical
execution. Confidence is the individual and collective belief that we can do all things better than the adversary and the unit
possesses the trust and will to accomplish the mission.”

ROE
1. There is no brick wall between the brain and the body. Each affects the other.
2. Correlations may be indicators, but are not always causes. Everyone sees people die;
everyone watches forensics pathology and horror/monster shows.
3. Military personnel come from the civilian community. Civilian data lags by 4-6 years and
similar problems are likely increasing there as well (32,000 civilians commit suicide/year).
4. Disease progression can be gradual with small early symptoms before large overt
symptoms.
5. PTSD may be a multi-factor syndrome; even if one factor ‘started’ the PTSD, it may
cascade into more serious dysfunction with other contributing factors.
6. A FOB-based asymmetrical war means no front line and no secure rear area (support
manpower and organization structure are based on those). How do Preventive Medicine
teams or Chaplains function?
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01/18/19 3
What is resilience?

01/18/19 4
Resilience
Resilience: The resources to withstand, recover and/or grow in the face of stressors and changing demands.
CHAMP, USUHS
Resilience: The resources to withstand, recover and/or grow in the face of stressors and changing demands.
CHAMP, USUHS
Improving the cognitive agility, flexibility, and capacity of Expeditionary Warriors (EW) by making them mentally tough,
resilient to stress, and well adapted to chaotic, irregular environments. USMC R&D
Improving the cognitive agility, flexibility, and capacity of Expeditionary Warriors (EW) by making them mentally tough,
resilient to stress, and well adapted to chaotic, irregular environments. USMC R&D
“Teamwork is 70% of combat performance.” COL Mike Malone
When hurt or distressed, resilient people expect to find a way to have things turn out well. They feel self-
reliant and have a learning/coping reaction. Albert Siebert, Ph.D., The Survivor Personality.
When hurt or distressed, resilient people expect to find a way to have things turn out well. They feel self-
reliant and have a learning/coping reaction. Albert Siebert, Ph.D., The Survivor Personality.
Resilience is the process of adapting well in the face of adversity, trauma, tragedy, threats, or even significant
sources of stress …. It means ‘bouncing back’ from difficult experiences. APA, The Road To Resilience.
Resilience is the process of adapting well in the face of adversity, trauma, tragedy, threats, or even significant
sources of stress …. It means ‘bouncing back’ from difficult experiences. APA, The Road To Resilience.
The United States Olympic Committee found that human performance at elite levels is heavily dependent upon
intangible, mental factors, i.e. confidence despite setbacks, concentration amidst distractions, and composure
during times of stress.
The United States Olympic Committee found that human performance at elite levels is heavily dependent upon
intangible, mental factors, i.e. confidence despite setbacks, concentration amidst distractions, and composure
during times of stress.
Battlemind – the Soldier’s inner strength to face fear and adversity in combat with courage. It is “Soldier-speak” for
hardiness and resilience. www.battlemind.org
Battlemind – the Soldier’s inner strength to face fear and adversity in combat with courage. It is “Soldier-speak” for
hardiness and resilience. www.battlemind.org
Time management, command of the basics, skill mastery, combat focus, visualization, repetition, and the use of job
aids to be the most critical training that prepared Soldiers for efficient and effective task accomplishment under life-
threatening, fast-paced, and stressful conditions. ARI – Infantry Forces Research Unit
Time management, command of the basics, skill mastery, combat focus, visualization, repetition, and the use of job
aids to be the most critical training that prepared Soldiers for efficient and effective task accomplishment under life-
threatening, fast-paced, and stressful conditions. ARI – Infantry Forces Research Unit
Resilience - the process of adapting in the face of adversity, trauma, tragedy, threats, or other significant sources of distress
(combat). COL Cornum
Resilience - the process of adapting in the face of adversity, trauma, tragedy, threats, or other significant sources of distress
(combat). COL Cornum

5
BATTLEMIND
www.battlemind.org
Battlemind – the Soldier’s inner strength to face fear and adversity in combat with
courage. It is “Soldier-speak” for hardiness and resilience…
Key components include:
– Self-confidence
• Take calculated risks
• Handle future challenges
– Mental toughness
• Overcome obstacles or setbacks
• Maintain positive thoughts during times of adversity and challenge.
01/18/19
COMMANDERS - through good training and good leadership - enhance resilience in Soldiers
and units. COL Cornum

American Psychological Association
Post Traumatic Growth Potential:
• Relating to Others: People who experience trauma typically develop stronger bonds
with loved ones, reestablish relationships, and/or gain more compassion for others.
• New Possibilities: People who experience trauma may notice they are making
choices in a more conscious manner, according to a plan. May be more likely to
change things that need changing.
• Personal Strength: People who experience trauma often express greater self-
reliance, and feel more able to accept how things turn out. Find increased personal
strength that may help get them through hardships they encounter in the future.
• Spiritual Change: People who experience trauma may reevaluate spiritual beliefs,
associate more with a community of similar believers, or reconnect with their spiritual
roots.
• Appreciation of Life: People who experience trauma typically describe greater
appreciation of life. Some explain this as trying to live each day more fully. Some may
rethink their values and priorities about what is important in their life.
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01/18/19 7
What degrades resilience?

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• 40% come from ‘non-traditional’ homes without two consistent parenting figures.
• 19% of HS students had seriously considered attempting suicide during a 12 month
period.
• 8% of HS students reported making a suicide attempt in the preceding 12 month
period.
• 40% come from ‘non-traditional’ homes without two consistent parenting figures.
• 19% of HS students had seriously considered attempting suicide during a 12 month
period.
• 8% of HS students reported making a suicide attempt in the preceding 12 month
period.
Source: Charles W. Hoge, COL, MC, Chief, Department of Psychiatry and Behavioral Sciences, WRAIR
Civilian PopulationCivilian Population
• ≅400,000 adolescents and young adults were treated for self-inflicted injuries in 2006
• children and adolescents hospitalizations for depression….. increased by 27 percent
between 1997 and 2007.
• ≅20 percent of individuals self-injure at least once, and about 11 percent self-injure
repeatedly (in high school and college).
Source: Theodore Beauchaine, Associate Professor of Psychology, Director, Child and Adolescent Adjustment Project,
University of Washington.

Motor Vehicle
Crash 31%
Suicide 14%
Other Causes 23%
HIV Infection 2%
Other Injuries 9%
Homicide 21%
- Behaviors that result in unintentional and intentional injuries
- Alcohol and drug abuse
- Sexual behaviors that result in HIV infection, other STDs, and unintended pregnancy
Leading Causes of Mortality
Among 15-24 Year-olds
Leading Causes of Mortality
Among 15-24 Year-olds
Source: CDC 901/18/19

10
*Wolfe, J. (1996-2000). Adaptation to First-Term Enlistment Among Women in the Marine Corps. DAMD 17-95-1-5047.
1. More ACE factors increase risk.
2. Associated high-risk behaviors (sex,
drugs, smoking, etc.)
3. Associated impacts (health, disease,
poor job performance, depression,
etc.).
4. Diminished brain development.
5. Treatable.
Adverse Childhood Experiences (ACE)Adverse Childhood Experiences (ACE)
USMC
Sample
National
Samples
Men Women Men Women
Child
physical
26.7 38.3 3.2 4.8
Child
sexual
14.7 51.0* 3-16 12-27
Table shows only 2 factors.
Having 3+ factors does increase risk somewhat, but
does not automatically mean all are ruined.
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Alcohol abuse 23.5% 33.0%
Mental illness 17.5% 21.1%
Battered mother 11.9% 6.8%
Exposures Civilian* Army Infantry*
Childhood Abuse Civilian Army Infantry
Psychological 10.0% 20.0%
Physical 4.9% 13.8%
Sexual 19.3% 3.8%
Adverse Childhood Experiences (ACE)
are Common in Civilian and Military Populations
Adverse Childhood Experiences (ACE)
are Common in Civilian and Military Populations
• Data from civilian population from CDC ACE study (n=9,508).
• Infantry population based on AC combat unit (n=4,602)(WRAIR OIF /OEF behavioral health research project).
• Source: Charles W. Hoge, COL, MC, Chief, Department of Psychiatry and Behavioral Sciences, WRAIR
Note: Data does not
adjust for differences in
population
demographics.

12
WWII had very high Combat Stress casualties.WWII had very high Combat Stress casualties.
Causes:
• Physical exhaustion.
• Inadequate food.
• Inadequate equipment.
• Severe cold/heat.
• Poor rotation policies (>180 days in combat).
• Limited doctrine/Lessons Learned.
• Poor training.
• High casualty rates.
• Hospitalizing Soldiers and sending them home with disability benefits.
Causes:
• Physical exhaustion.
• Inadequate food.
• Inadequate equipment.
• Severe cold/heat.
• Poor rotation policies (>180 days in combat).
• Limited doctrine/Lessons Learned.
• Poor training.
• High casualty rates.
• Hospitalizing Soldiers and sending them home with disability benefits.
Sources:
• GEN DePuy, “Oral History”
• Ambrose, “Citizen Soldiers.”
• FM 6-22.5, Combat Stress01/18/19

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The Dark Side
AttitudesAttitudes
1. G1 Insist-Assist Study showed leaders’ attitudes affected attrition rates.
a. “High Attrition Leaders” believe they were ‘gate guarders.’
b. “Low Attrition Leaders” believed they were developing Soldiers.
2. Emotional Events (‘high fear events,’ ‘food deprivation’, ‘sleep deprivation,’ ‘extreme PT,’ etc.) may be
mis-perceived by some as preparing Soldiers for war, or strengthening them to cope with stress.
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Mefloquine and mental health problems among U.S. military personnel. R. L. Nevin (13 January
2010). http://www.bmj.com/
To reduce the risk of serious adverse events including anxiety, paranoia, depression,
hallucinations, and psychosis, mefloquine is contraindicated among those with certain prevalent
neuropsychiatric disorders.
Among the 4,505 to whom mefloquine was prescribed in this study, 155 (3.4%) had documented
contraindications. Among those with documented contraindications, mefloquine was indeed
inappropriately prescribed to 1 in 7.
The U.S. package insert cautions that “during prophylactic use, if psychiatric symptoms such as acute
anxiety, depression, restlessness or confusion occur, these may be considered prodromal to a more
serious event. In these cases, the drug must be discontinued".
Given that approximately 3.4% of those prescribed mefloquine in this study had evidence of psychiatric
symptoms even prior to beginning prophylactic use, and may have been exposed to mefloquine for the
duration of combat deployments lasting as long as 15 months, it is reasonable to conclude that this
inappropriate prescribing may have led to a number of "more serious" events within this population.
It seems reasonable to conclude that the inappropriate prescribing of mefloquine to those at risk of
serious adverse events must in some measure be contributory to the current burden of serious mental
health disorders among U.S. military personnel.
Unintended Side-EffectsUnintended Side-Effects

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What contributes to resilience?

1. Connect with family and friends. Stay connected with your family and friends who care about you and will listen to
you; they will help you stay strong. Write letters so you’ll get letters. Call, text, or e-mail friends and family whenever
authorized.2. Keep things in balance. You can change how you feel about events. Try to see events as opportunities. Is this
event really the “end of the world?” One way to calm yourself is to: take three deep breaths, tense all your muscles for a ten-
count, then relax (It helps). Learn what triggers you getting upset, then mentally practice a more effective future response.
Somebody call you a name you don’t like? Practice making a joke out of it.
3. Value change. Change is part of growing up and becoming an adult. Change can have a positive impact on you. Your
attitude can help you find the “silver lining in the cloud.” You may have sore muscles when you exercise, for example, but
you’ll also be getting stronger every week.
4. Keep your eye on your goals. Develop small goals within your big goals. What's one thing you can do better
today? Whatever you want to be in life, you’ll have to spend hundreds of hours learning your new skills. There will be days
when you feel frustrated or things seem impossible. Think about where you want to go in life. Whether you want to get a
good job or go to college, your short time in the current situation helps you get to that goal.
5. Take positive corrective action. Take positive action to fix the problem. Even if the issue is not immediately
solvable, doing positive things for yourself also helps. Write a letter, talk to somebody, etc. Even making a “To Do” list
helps. Go for a run. One positive action is to ask for help. The Army has resources who can help with problems (talk to
your NCO).6. Grow from experiences. You may find you’ve gotten stronger from a struggle; that working hard and overcoming
obstacles makes you feel better about yourself. How can you do better next time? Make a mistake (and we all make
mistakes)? How can you fix it?
7. Believe in yourself. Say positive things about yourself. “I’m a survivor.” “I can adapt, overcome, or improvise to win
in a tough situation.” “I like learning new things.” Develop confidence in your ability to solve problems. Just as an
example, you are one of the brightest and best Americans who are able to serve the Nation.
8. Take care of you. An “empty pitcher can’t pour milk.” Sleep, food, and water are critical to thinking clearly. Avoid
making an important decision when you’re tired, hungry, angry, or sad. Not hungry? Don’t like the new food? Eat
something you do like. Eat something anyway. Guess what? Your food tastes will change in a few days.
9. Ask for help. People make sacrifices for things or people they believe in, just like your parents did for you. What do
you believe in? Go to church. Develop your spirituality; pray or meditate. Talk to your Battle Buddy. No one is alone in
the Army; there are Chaplains, counselors, doctors, or experts in some area (pay, family resources, etc.) who can help.
The team is stronger than the individual.
Building Resilience
Modified from the APA Resilience paper. 1601/18/19

Building Resilience:
APA factors that support the development of resilience
• Influence of at least one (1) supportive person
• Presence of hope and optimism in the face of adversity
• Pleasant, active, social, nurturing, competitive personality
• Problem-solving skills with eagerness to learn and succeed
• View of self as victor instead of victim
• Has something (friend, hobby, interest) that can distract
• COL Cornum’s factors that support developing resilience:
– Prior experiences/ training- Soldier has confidence
– History of success- Soldier expects to do well in new activities
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01/18/19 18
High-fidelity
team-based
targeted training
Warrior Team
RESILIENCE
Nutrition
Skill sets
Health
Environmental
Fatigue
Optimum
man-machine interface
Support
ARI – Infantry Forces Research Unit, found time management, command of the basics, skill mastery, combat focus,
visualization, repetition, and the use of job aids to be the most critical training that prepared Soldiers for efficient and effective
task accomplishment under life-threatening, fast-paced, and stressful conditions.

Warrior Team
RESILIENCE
Warrior Team
RESILIENCE
01/18/19 19
High-fidelity Team-based
Targeted Training
•Collective-based resident training
•Unit-level CTC
•Warrior Team PT
•Warrior Team Marksmanship
•Adaptive thinking (ARI)
•Positive leadership model
Targeted Training
•Unit-level CTC
•Warrior Team PT
•Adaptive thinking (ARI)
•Positive leadership model
Nutrition
• Comprehensive testing program
• Evidence-based diet
• Access within OPTEMPO
• Warrior bar & drink
• Wet combat rations R&D
Nutrition
Resilience Skills
•Success Profiler R&D
•Embedded resilience in training
Resilience Skills
Health
•Integrated medicine policy
•Comprehensive blood- tissue testing
(NAHANES +)
•Injury RM Program
•Enhanced HCP musculo-skeletal treat
skills (see USMC SMIP)
•Mefloquine R&D
•Multi-disciplinary rehabilitation doctrine
(TRADOC copy)
•ACE screening R&D
•Boot engineering stds R&D
Health
(NAHANES +)
•Mefloquine R&D
(TRADOC copy)
Environmental
• Rapid acclimatization training
• Chilled IV + supplements R&D
• Soldier-wearable digital WBGT R&D
• Microclimate hat-vest (ongoing)
• Outdoor evaporative cooling R&D
• CONEX-based force (see brief)
• Anti-inflammatory diet (see nutrition)
Environmental
Fatigue
• Rotation policies (CONOPS)
• Modified load (see load brief)
• Mancart R&D (see Harman et al)
• Hot resupply R&D
• Sleep restore R&D
Fatigue
Optimum Soldier-machine
interface
•Optical sight with Range Finder, auto
up-down, auto ballistic drop/range and
predictive lead.
Optimum Soldier-machine
interface
•Optical sight with Range Finder, auto
predictive lead.
Support
•CONEX-Based Force
•MWR-DFAC-Commissary-AAFES/BX-
Ed Svcs family programs
•Deployed spouse education program
Support
•CONEX-Based Force
•MWR-DFAC-Commissary-AAFES/BX-
Ed Svcs family programs
•Deployed spouse education program

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Warrior Team ResilienceWarrior Team Resilience
01/18/19
We’ve been here before
We’ve done this before
We know how to do this well
We have confidence in ourselves and our leaders
Our team can win
Targeted Training
•Unit-level CTC
•Warrior Team PT
•Adaptive Thinking (ARI)
•Positive Leadership
Targeted Training
•Unit-level CTC
•Warrior Team PT
•Adaptive Thinking (ARI)
•Positive Leadership

Teamwork: Soldier-Collective Task IntegrationTeamwork: Soldier-Collective Task Integration
• As much as 70% of unit performance can be teamwork.
• Train Soldier tasks in collective context.
• Provide CTC-like capabilities by level in IMT & units.
• Design training courses backwards from collective tasks.
• Create joint, combined, and multi-national training opportunities.
• If the organization goes to war (e.g. Red Cross, CIA, AAFES/BX, MWR, etc.),
it should participate in the training base as appropriate by level.
01/18/19 21

Prepare, support, and sustain FSOPrepare, support, and sustain FSO
Train Modular Force for Full Spectrum Operations (FSO)
• Teamwork: Soldier-Collective Warrior Task Integration
• Cultural awareness and languages
• Positive Leadership
• Adaptive Thinking
• Tools: Combat Leader’s Guide
• Warrior Team Fitness
• Warrior Team Marksmanship
01/18/19 22

http://www.uxb.com/products/training/ratpac.cfm
Onsite, mission-specific training:
CONEX-Based MOUT/ Unit-Based Combat Training Centers)
http://www.militarywraps.com/

Warrior Team Fitness
Phase 2: Warrior Team Phase
Reverse course as 4-Soldier litter carry with sandbag casualty
Trains teamwork, strength, and skill
Scored on both time and doctrinal process
Aerobic: Combat loaded march to time & distance standard with military events enroute (react to
ambush, etc.)
2.5 ton
Mount
(Option:
ambulance load)
low
wall
cross
dry
gulch
cross
high
wall
cross
3 sec burst
up-down
assault
4 soldier
litter
carry
low crawl
C4
pit
C4
pit
laser
target
Not to
scale
Strength
Stamina
Skill
Speed
Spirit
Suppleness
Teamwork
01/18/19 24

Warrior Team MarksmanshipWarrior Team Marksmanship
• Strong issue that affects confidence.
• Integrated rifle-optics-ammunition-targets-training strategy
• Targets:
• Simple, deployable targets (kill-reset)
• Rocking or moving
• Physiologically-based kill zone scoring
• Shoot-back targets (Simunition©)
• Ballistic mass requiring multiple hits
• Fire and maneuver CTC-like ranges
• Possible high-low standards/equipment mix by MOS
Body armor, helmet, rifle, and vehicle interfaces
can be critical
01/18/19 25
Does combat look like this?

Warrior Team MarksmanshipWarrior Team Marksmanship
DETECT-DECIDE-DESTROY
26
• The Fire Team fighting range should be a slice of combat terrain, scenarios, target mix
(aspect, distances, behavior), and teamwork. Shooting accuracy, speed, lethality,
weapon handling, and positional awareness are all worked into a ‘crawl-walk-run’
training matrix.
• Even today’s KD ranges should be an accurate slice of the defensive perimeter with
correct fighting positions, obstacles, etc.
• Always do it right so Soldiers see it right.
grenade
throw
low
wall
cross
high
wall
cross
3 sec up-down
assault
Friendly
target
Range
not to
scale
AK47 & RPG
targets
4-shot
kill
Muzzle-flash
targets
Shoot-through
Cover target
The Fire Team fighting range presents multiple targets and scenarios
that require accuracy, fire & movement, teamwork, tactics, and problem
solving.
Targets can pop-up, move, and simulate shooting back.
High
targets
C4 pit
C4 pit
Civilian
Don’t Shoot
target
Fire Team
Start Point

no TLAC training and no
OIF/OEF experience
no TLAC training and
OIF/OEF experience
TLAC training (with classroom instructor) but no
OIF/OEF experience
Training critical thinking works!
Source: ARI
Adaptive ThinkingAdaptive Thinking
01/18/19 27
Expert Patterns of Battlefield
Thinking
 Keep a focus on mission
accomplishment and higher
commander's intent.
 Model a thinking enemy.
 Consider effects of terrain.
 Use all elements/systems
available.
 Include considerations of timing.
 Exhibit visualizations that are
dynamic and proactive.
 Consider contingencies and
remain flexible.
 Consider how your fight fits into
the bigger picture from friendly and
enemy perspectives.

Positive LeadershipPositive Leadership
USMA Peak Performance
Model:
Training the Warrior
Pentathlete
Peak
Performance
Attention
Control
Cognitive
Foundation
s
Goal
Setting
Visualizatio
n =
Stress &
Energy
Mgmt
ARI – Infantry Forces Research Unit United States Olympic Committee 1998
The most critical training that prepared Soldiers for
efficient and effective task accomplishment under life-
threatening, fast-paced, and stressful conditions are:
• Time management
• Command of the basics
• skill mastery
• Combat focus
• Visualization
• Repetition, and
• Use of job aids
Human performance at elite levels is heavily dependent
upon intangible, mental factors, i.e.
• Confidence despite setbacks,
• Concentration amidst distractions,
• Composure during times of stress.
Physical
Technical
Tactical
Mental
Emotional
Self Regulating
Instinctive
Adaptive
Agile
Mental Effort
Warrior
Mindset
Build confidence
Control attention
Recover energy
‘See’ the battlefield
Combat PT
8-Step AAR
Rote Repetition
Self critical
Analytical
Judgmental
Physical effort
01/18/19 28

29
IET OES NCOES WOES UNIT By Compo MANUALS
FUTURE SOLDIER TRAINING
PROGRAM
Perform Pre-BCT Battle
Stress/Battlemind CM
TSP
Video on web
Poster 1
ROTC PRE-COMMISSIONING
Basic Officer Leader Course
(BOLC I)
Perform Battle Stress/Battlemind
CM
TSP
DVD
Future Soldier Guide
BCT/OSUT 1-3
Perform BCT Battle
BOLC 2
Implement Battle
TSP
DVD
Poster 2
WOCS
CM
Annual Trng (AR 350-1)
DL-based interactive video
SMCT x
OSUT 4-6/AIT
Perform OEF/OIF Battle
Stress/Battlemind Programs
BOLC 3
Implement Battle
WOBC
MEL 7
Implement Battle
PCC
Implement Battle
Warrior Leaders Course (WLC)
(former PLDC)
Implement Battle
PCC
Implement Battle
SMCT Y
CPT CAREER CRSE
Implement Battle
BNOC
Implement Battle
WOAC
MEL 6
Implement Battle
PRE-DEPLOYMENT
CM
ANOC
Implement Battle
POST-DEPLOYMENT
CM
Small-Group
Intermediate Level Education
(ILE)
(formerly CGSC)
Supervise Battle
Battlestaff NCO
Implement Battle
WOSC
MEL 4
Implement Battle
PROF DEV ANNUAL
Implement Battle
First SGT
Implement Battle
WAR COLLEGE
Supervise Battle
SMC
Supervise Battle
WOSSC
MEL 1
Supervise Battle
Integrated Battlemind, Resilience, Combat Stress, Suicide Prevention, CONOPS,
& Helping Resources Training Strategy By Level (TBD)
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01/18/19 3001/18/19
Warrior Team ResilienceWarrior Team Resilience Optimum Soldier-Machine
Interface
• Optical sight with Range Finder, auto
predictive lead.
Optimum Soldier-Machine
Interface
• Optical sight with Range Finder, auto
predictive lead.
High Pay-off: Optical Smart Sight
• laser rangefinder
• auto uphill-downhill adjustment
• auto ballistic drop/range
• predictive lead
• Night Vision compatible
• add-on modular magnifier
• BOIP TBD
80% of enemy casualties are from
small arms fire.
30% of the force does 80+% of the
shooting.
Successful performance = confidence
475m

31
Why adjustability?
• The more these two folks at left contort themselves to
conform to one weapon, the less performance you’ll
see in combat (even if they shoot well in BRM).
• The array of equipment options (weapon accessories,
uniform, coats, gloves, arm/knee pads, LBE, IBA,
helmet, etc.) requires a high degree of adjustability.
01/18/19
Optimum Soldier-Machine InterfaceOptimum Soldier-Machine Interface

Eye Dominance
Right-handed-left eye dominant 28.6%
Left-handed-right eye dominant 3.9%
Cross-dominant Total 32.5%
Rengstorff, 1967
Why shift to optical sights?
• Multi-spectrum combat. Illumination/designation/sensing by energy spectrum band.
• Human eye can only focus in one plane (not 3 planes for the iron peep sight).
• Easy to train. Easy to remember.
• Faster engagements (put dot on target; shoot).
• Increased accuracy (especially at longer ranges), lead on moving targets.
• Increased situational awareness (better view of target area).
• Bypasses eye dominance issue.
• Better performance with goggles, gas masks, etc.
3201/18/19

33
M16A2 zeroed at 250m in hot weather.
Why optical sights?
• Human eye only focuses in one plane.
• Peep sight field of view is narrow & tends to
obscure the target.
• Optical sight yields wide view and can
provide ranging reference points.
• Ex. Imagine you’re shooting at an enemy Soldier at
500m.
• If you shoot center of mass, you’ll hit 45 inches low
(3.75 feet).
• How does the shooter apply Kentucky windage at
500M with the peep sight?
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01/18/19 34
If you elevate the sight 45” above the target……

01/18/19 35
Fast walking target (approx 4 mph) = 3 POA = 27” at 300
m
Running target (approx 9 mph) = 6.9 POA = 62” at 300 m
Source: USMC

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Now line the lead up in shadow or at dusk or dawn.

37
Lead the Moving Target:
• 25 yds:
– 9 mph = 4.5” lead
– 4 mph = 2” lead
– Bad speed and range estimate can still hit target lethal area
• 50 yds:
– Bad speed and range estimate can miss target lethal area
• 100 yds:
– 9 mph = 18” lead
– Misjudge speed by 3 mph misses target.
– Misjudge range by 25 yds misses target.
Data source: USMC

M16A2 10-Round Shot Group Extreme Spread
100 300200 400 500 550 600 700 800
M4A1/ACOG 4x W/ MK 262 MOD 1 10-Round Group Extreme Spread
100 300200 400 500 550 600 700 800
An optical sight and accurate ammunition makes a big difference*
* Firing was done from the shoulder on a bench01/18/19 38Source: NSWC

39
Warrior Team ResilienceWarrior Team Resilience Fatigue
Fatigue
01/18/19
Reducing Fatigue

01/18/19 40
In fact we have always done better by a mule than by a man. We were careful not to load the mule with
more than a third of his weight.”
The Soldier’s Load and the Mobility of a Nation, 1950, COL S.L.A. Marshall
Reducing Fatigue
Combat Load: The minimum mission-essential equipment, as determined by the commander responsible for carrying
out the mission, required for Soldiers to fight and survive immediate combat operations. The combat load is the
essential load carried by Soldiers in forward subunits or the load that accompanies Soldiers other than fighting
loads. (FM 21-18)
Fighting Load: The fighting load includes bayonet, weapon, clothing, helmet, and LBE, and a reduced amount of
ammunition. Keep under 48 pounds when cross-loading small unit equipment. (FM 21-18)
Approach March Load: The approach march load includes clothing, weapon, basic load of ammunition, LBE, small
assault pack, or lightly loaded rucksack or poncho roll. A limit of 72 pounds should be enforced. (FM 21-18)
Emergency Approach March Loads: Circumstances could require Soldiers to carry loads heavier than 72 pounds such
as approach marches through terrain impassable to vehicles or where ground/air transportation resources are not
available. Therefore, larger rucksacks must be carried. These emergency approach march loads can be carried
easily by well-conditioned Soldiers. When the mission demands that Soldiers be employed as porters, loads of up to
120 pounds can be carried for several days over distances of 20 km a day. Although loads of up to 150 pounds are
feasible, the Soldier could become fatigued or even injured. If possible, contact with the enemy should be avoided
since march speeds will be slow. (FM 21-18)
“A load of 62 pounds or 40% of the body weight starts to collapse the venous return system.”
Dr. Vogel
Combat Load definitions are based on United States Army Field Manual 21-18, FOOT MARCHES, 1 June 1990.

In 1987, the U.S. Army Development and Employment Agency proposed five approaches for improving soldier mobility:
1. Develop lighter weight components. However, technical developments were expected to reduce loads only by 6%
overall (126).
NOTE: Modifying the load to reduce the load or reduce energy cost might include: standardizing/consolidating batteries (see
Wilcox Ind modified M4), solar battery charger, water filter pumps, reengineering the mortar base plate to be lighter & fold, etc.).
2. Soldier load planning model. This was a computer program that aided commanders in tailoring loads through a risk
analysis based on the mission, enemy, terrain, troops and time (METT-T).
3. Development of specialized load-carrying equipment. This included such things as hand carts and all-terrain vehicles.
NOTE: Offloading could include better hot resupply in danger areas.
NOTE: Compared to body carriage, energy cost was reduced by 88% when a 50-kg load was pushed in a cart on a smooth
surface (43).
• Pulled carts (rather than pushed) appear to be easier to control on uneven terrain and also result in considerable energy
cost savings (42).
• A specially designed combat load cart that was pulled by soldiers using a hip belt resulted in faster march speeds than
moving the same loads with a rucksack. Over mixed terrain (paved road, dirt road, field, and rough trail), 34-kg and 61-kg
loads were moved 22% and 44% faster over a 3.2-km distance (48). This combat load cart, specifically developed for
military operations, is available in the US Army.
4. Reevaluation of current doctrine that might affect load carriage. An example of this was an increased emphasis on
marksmanship to reduce ammunition loads.
NOTE: Caseless or aluminum cases would reduce ammo wt. Optical sights add weight, but improve accuracy (as does better
training).
5. Development of special physical training programs to condition soldiers to develop more physical capability for load
carriage.
NOTE: Include a loaded march to time & distance std option vice running in PT program.
NOTE : Select Soldiers big and strong enough to carry the load (load is a function of % body weight).
‘Reducing Fatigue’ History
01/18/19 41

01/18/19 42
The training program proved effective.
•The weight of boxes the -women could lift to three different heights improved
between 30% and 47%.
•After training, the average box- weight the women could lift onto a truck was 118
pounds, 81% of the Army male value.
•The number of 40-pound boxes the women could lift onto a truck in 10 minutes
increased from 106 to 140.
•The number of 40-pound boxes that could be lifted off the ground, carried 25 feet
and placed onto a truck increased from 53 to 62.
•Vertical jump and standing long jump distance increased 20% and 15%
respectively.
•The speed at which a 75 pound backpack could be carried over a 2- mile mixed-
terrain course increased from 3.4 to 4.4 miles per hour.
•Before the training, only 24% of the women could qualify for 'very heavy' Army
jobs; after the training, 78% could qualify.
Effects of a Specifically Designed Physical Conditioning Program on the Load Carriage and Lifting
Performance of Female Soldiers. Everett Harman et al. USARIEM.

01/18/19 43
The Modern Warrior’s Combat Load - Dismounted Operations in Afghanistan April - May 2003, LTC Charles E.LTC Charles E.
DeanDean, CALL
Inf. Rifle Co. Avg. Pounds
Avg. % Body
Weight
High Load High %
Average
Fighting Load
(<48 lbs.)
63.08 35.27% 81.38 44.46%
Average
Approach March
Load (<72 lbs.)
101.31 56.74% 127.24 78.26%
Average
Emergency
Approach March
Load (120 lbs.)
131.74 77.82% 149.30 90.49%

44
Degrading sleep degrades learning, mood, and health.
Prof Mary Carskadon, Brown University
http://www.sleepfoundation.org/hottopics/index.php?secid=18
SleepSleep
1. Teens need 8.5-9.25 hours of sleep each night. By mid 20s: 8 hrs.
2. Natural biological sleep period 11 pm – 8 am (Melatonin secretion).
3. 0400-0600 is peak time for subjective sleepiness.
Inadequate sleep:
• Decreases:
– Vigilance
– Cognitive performance
• Inconsistent logical reasoning skills
• Reduced short-term memory
• Slower learning rate
• Poor judgment
– Grades
– Negative mood (depressive symptoms)
– Immunity (more disease)
• Increases risk re:
– Stimulant or alcohol use
– Accidents, injury, and death
– Stress hormone levels
Adequate sleep:
• Improves:
– Test scores
– Knowledge Retention
– Disease resistance
– Morale
• Decreases:
– Discipline problems
– Depression
– Attrition
01/18/19

01/18/19 4801/18/19
Warrior Team ResilienceWarrior Team Resilience Environmental
Environmental

01/18/19 4901/18/19
Warrior Team ResilienceWarrior Team Resilience Support
• CONEX-Based Force
• MWR-DFAC-Commissary-
AAFES/BX-Ed Svcs family programs
• Deployed spouse education program
Support
• CONEX-Based Force
• MWR-DFAC-Commissary-
AAFES/BX-Ed Svcs family programs
• Deployed spouse education program

12/23/09 50
1. The ‘one box’ storage/shipping/functional container system concept enhances mission capabilities,
meets world-wide shipping/ logistics standards (transportable via standard cargo container ships, cargo
planes, helicopters, trucks or rail.), and saves significant time and resources.
2. It creates a nearly “instant” FOB, hospital, hospital ship, etc. capability. Requires no foundation.
3. Saves time and resources. Equipment/supplies are no longer packed/unpacked, loaded/unloaded, et.
multiple times/places.
4. The conceptual basic military box (TBD) should be rust-proof, self-leveling, have standard interior wall
interfaces for modular interior equipment, and have standard electrical/water/cable runs. Can be pre-
insulated and solar power equipped.
5. Units are tough. Units can resist winds up to 100 mph without anchoring; and with anchoring, they can
resist winds up to 175 mph. Can be stacked 30 high.
6. Armored/insulated onsite with local materials (e.g. Hesco barriers; see BU slide).
7. Units can pre-load supplies/equipment (weapons, ammo, rations, beds, etc.) in the squad ‘box,’ for
example, to support the first 30-60 mission days.
8. Saving energy & labor is a force multiplier that saves transport costs and reduces exposure to the
enemy (each FOB is basically an ‘island’ that imports everything).

01/18/19 51
What contributes to
resilience?
Support

01/18/19 52
Amount of support makes a differenceAmount of support makes a difference
Influencers
Chaplain
Medics
Friends
Leaders
Family
Team

01/18/19 53
MWRMWR
CommissaryCommissary
Education
Services
Education
Services
AAFES/BXAAFES/BX
Red CrossRed Cross
ACS?ACS?
The Invisible Enemy: Boredom

01/18/19 54
Combat Chaplain: Force Multiplier
• Chaplains are critical assets.
• Commander’s forward sensor.
• Positive group sessions
• Try this: Observe USMC Boot Camp Sunday session
• Resilience message
• Singing & music
• Real-time on-the-ground ‘therapy.’
• Find work-arounds to legal issues (e.g. morale
class vice church service).

01/18/19 5501/18/19
Warrior Team ResilienceWarrior Team Resilience Nutrition
Nutrition

• Body iron stores were low pre-BCT (56%) and
decreased further by graduation (84%)
• Iron Anemia was correlated with poor PT
performance
• B vitamin levels were low normal pre-BCT and
“decreased significantly over BCT.”
• Menu was adequate in energy, but inadequate in
B6, folic acid, calcium, magnesium, iron, and zinc.
• Started Soldier Fueling Program.
Source: “Health, Performance, and Nutritional Status of U.S. Army Women during Basic Combat Training,” (1995)
(ADA302042)
NOTE: Study BCT menu governed by the 1985 AR 40-25
1/26/10 56
Army BCT Female NutritionArmy BCT Female Nutrition

NOTE: 22% of schools sell name-brand FAST FOOD
Environment
School
Source: Public Policy Analysis & Education Center for Middle Childhood, Adolescent & Young Adult Health

• Vending machine accessibility:
– Elementary Schools 26%
– Middle Schools 62%
– High schools 95%
• Vending machine offerings tend to be:
– High in fats, sugar and sodium.
– Devoid of daily recommended nutrients found in
fruits, vegetables, grains and proteins.
Environment
School

*1966-1970 – Adolescent data are for ages 12-17, not ages 12-19.
Source: CDC, 2004d

Naval Female Recruits Calcium and Vitamin D StudyNaval Female Recruits Calcium and Vitamin D Study
• Stress fractures occur in 0.2-5.2 % of male recruits and 1.6-21.0% of female recruits.
• Calcium Balance is compromised
− Ca deficient diet upon entry in BT.
Minimum recommended Ca 1,000mg/d
Average Ca intake 19 – 30 yrs 600-700mg/d
Median Ca intake of women during BT 700-900mg/d
− High Ca losses occur in sweat during strenuous activity. Study with collegiate basketball players Klesges, et al.
1996.
• Sample size:
− Enrolled 4,647
− Discharged from Navy 355
− Withdrew from study 1,001
− Completed 2,803
• Treatment:
− Randomized, Double Blind, Placebo Controlled
− 2,000 mg Calcium & 800 IU Vit D
• Results: Supplemented group had a 20% lower incidence of stress fractures
than the control group.
Naval Institute for Dental and Biomedical Research
1/26/10 62

01/18/19 6301/18/19
Warrior Team ResilienceWarrior Team Resilience Resilience Skills
Resilience Skills

01/18/19 6501/18/19
Warrior Team ResilienceWarrior Team Resilience Health
(NAHANES +)
•Mefloquine R&D
(TRADOC copy)
Health
(NAHANES +)
•Mefloquine R&D
(TRADOC copy)

• Recruits enter the system with undiagnosed health issues (e.g. dental
status, osteopenia, depression, alcoholism, etc.).
• Recruits/Soldiers may be under-nourished, affecting performance, injury
rates, attrition, and costs.
• High injury rates affect deployability, manpower levels, attrition, future
injury rates, and costs.
• No comprehensive life cycle monitoring system means no evidence-
based feedback process to build an investment strategy.
1/26/10 66
Total Force Plus Life-Cycle Health Readiness System:
Why Do We Need a Comprehensive Life Cycle System? *
Total Force Plus Life-Cycle Health Readiness System:
Why Do We Need a Comprehensive Life Cycle System? *
* See references in Notes
VA 2010 budget request is nearly $113 billion
“By mid-December, more than 25,803 American service members had been evacuated from Iraq since the war began
nearly three years ago, according to Pentagon officials. Nearly 80 percent of them were shipped out because of
routine illnesses and injuries unrelated to combat.”

IDENTIFY HAZARDS / ASSESSS HAZARDS / DEVELOP CONTROLS / IMPLEMENT CONTROLS / SUPERVISE-EVALUATE
26
1. In 2003 CHPPM collected pedometer data on 10 BCT companies for entire BCT cycles at
Ft. Jackson.
2. Average daily distance for the 63 days was 11.7+_4.4 km/day (M+_SD).
3. During the 3-day FTX, daily distances were 16.2+_9.7 km/day.
4. Overuse injuries are a dose-response relationship: more miles equals more injuries.
Mileage, Mileage, MileageMileage, Mileage, Mileage

Quantitative Ultrasound Screen (QUS) re Stress Fractures in Female Army
Recruits
Quantitative Ultrasound Screen (QUS) re Stress Fractures in Female Army
Recruits
68
12/23/09
• QUS calcaneal measurements on 4,139 female Army recruits at Basic Training (BT)
start.
• The incidence of stress fractures were 4.7%.
• The highest risk of stress fracture was found in white women in Q1 of SOS who
smoked and didn’t exercise (RR, 14.4).
• The combination of QUS measurements with evaluation of individual risk factors can
identify recruits who are at the very highest risk of stress fracture.
Note:
1.The bone strength ‘gold standard’ is Bone Geometry (USARIEM) (Peripheral quantitative computed
tomography (pQCT)).
2.The U.S.-adapted W.H.O. FRAX (fracture prediction) algorithm is available on the NOF website
(www.NOF.org) and atwww.shef.ac.uk/FRAX

Naval Female Recruits Calcium and Vitamin D StudyNaval Female Recruits Calcium and Vitamin D Study
• Stress fractures occur in 0.2-5.2 % of male recruits and 1.6-21.0% of female recruits.
• Calcium Balance is compromised
− Ca deficient diet upon entry in BT.
Minimum recommended Ca 1,000mg/d
Average Ca intake 19 – 30 yrs 600-700mg/d
Median Ca intake of women during BT 700-900mg/d
− High Ca losses occur in sweat during strenuous activity. Study with collegiate basketball players Klesges, et al.
1996.
• Sample size:
− Enrolled 4,647
− Discharged from Navy 355
− Withdrew from study 1,001
− Completed 2,803
• Treatment:
− Randomized, Double Blind, Placebo Controlled
− 2,000 mg Calcium & 800 IU Vit D
• Results: Supplemented group had a 20% lower incidence of stress fractures
than the control group.
Naval Institute for Dental and Biomedical Research
1/26/10 69

70
1. New Clinical Practice Guideline for Hip Pain.
2. Early effective management works:
a. Finding early avoids the fracture.
b. 75% Increase in FNF detection
Source: CPT Short, MAH, FJ ATC
Femoral Neck FractureFemoral Neck Fracture
1. Small numbers, but high costs.
2. No visibility at DA level.
3. 100% Medical Board.
4. Lifetime of treatment.
1/26/10

71
Prehabilitation
1. Females are at risk for knee injuries
2. Balancing quad-ham muscles reduces
knee injuries by 80%.
Pre-training Post-training
1/26/10
Sportsmetrics
TM
: the Key to Prevention of Serious Knee Ligament Injuries in Female Athletes, Catherine Walsh, M.S., Women’s Program
Manager Cincinnati Sportsmedicine Research and Education Foundation
Untrained
Females
Trained
Females
Males
Injury Incidence/
1,000 Player
Exposures
*p< .05
Results: All Sports; All Knee Injuries per 1,000 Athlete Exposures

72
• Treat Marines forward as Warrior Athletes.
• Sports Medicine Physicians.
• Certified Athletic Trainers (ATC’s)
– Contracted civilians who work for USMC commands.
– GREEN ASSETS (NCAA model)
– Aligned with SMART rehab clinic operations
– Clinically supervised by Navy Sports Medicine MDs when dealing with injuries
– Emphasis on prevention, education, and treatment
– Collect/enter injury data into TIMS (injury database)
• 3 trainers for Parris Island (GIT)/1 ATC for San Diego.
• 3 Athletic Training Room (ATRs) for Parris Island
1/26/10
RESULTS
+ Increased Paris Island grad rate (female 68.3% to 74.7%)
+ Increase in BCT Return to Full Duty (RTFD) rates from
rehab:
+ male 55.5% to 64.3%
+ female 37.5% to 52.2%
+ Increase in BCT recycle grad rates (female 63.5% to 75%).
– Decrease in BCT rehab discharge rates (male 13%; female
24%)
– Decreased musculo-skeletal discharges at Infantry School
(see chart at left).
– Decreased attrition at OCS
− male 8.7% to 3.8%
− female 18.1% to 5.9%)
+ Greater cadre knowledge
+ Critical feedback on sources of injuries leading to fixes.
+ Conservative estimate of $3.5M in cost avoidance and
$2.9M in Return on Investment in FY04 vs.. FY03.
Fix Forward: USMC SMIP Athletic Trainer InitiativeFix Forward: USMC SMIP Athletic Trainer Initiative

73
Admiral Nelson 11 March 1804 to Dr. Mosely:
“The greatest thing in all military service is health; and you will agree with me that it is easier for an
officer to keep men healthy than it is for a physician to cure them”.
Admiral Nelson 11 March 1804 to Dr. Mosely:
“The greatest thing in all military service is health; and you will agree with me that it is easier for an
officer to keep men healthy than it is for a physician to cure them”.
• BCT (CHPPM)
– Males: 19-37% are injured in a 9-wk cycle
– Females: 42-67% are injured in a 9-wk cycle
• Most injuries are overuse, compared to traumatic
– Males: 75%
– Females: 78%
• Most injuries involve the lower extremity (low back, pelvis, hip
and leg)*
– Males: 83%
– Females: 87%
• Activities associated with injuries in BCT
– Weight bearing activity; predominantly running, marching,
walking
1/26/10

74
• BCT grads arrived at AIT with high injury rates (approx. 28% men; 48%
women).
• PT running was the primary cause of musculoskeletal injuries.
• Changing the running program
– Reduced Clinic Visits - 36.5%
– Reduced Profiles - 48.6%
– No difference in APFT Scores
– Reduced APFT retakes - 50%
– Saved 612 limited duty days/week/BN
AMEDDC&S
Operation Aegis
Injury Control
If implemented at all IET/AIT sites:
$9M/yr & 1.5M limited duty days/yr Potential
Savings
1/26/10

75
0%
20%
40%
60%
80%
100%
1994 1995 1996 1997 1998 1999
Uninjured
1,834 Injuries
Prevented
Injured
Results for Army Basic Training: Injury
0%
20%
40%
60%
80%
100%
1994 1995 1996 1997 1998 1999
Training
Successes
Discharged
1,260 Discharges Prevented
Results for Army Basic Training: Attrition
Defence Injury Prevention Program (DIPP)
Australian Department Of DefenceAustralian Department Of Defence
Defence Injury Prevention Program (DIPP)
Australian Department Of DefenceAustralian Department Of Defence
1. Reducing injuries reduced attrition: 70% reduction over 4 years in rates of injury
and attrition
2. Gives CDRs the tools; harnesses Commander’s knowledge and skills working together
to address their own injury problems.
3. 95% reduction in pelvic stress fracture rates in female recruits.
1/26/10

Hypothesis Description Strength COA
Stress-
Cortisol
Overload
• Inhibits the uptake of glucose by the hippocampus.
Hippocampal neurons don’t have enough energy to
function.
• Inhibits neurotransmitters; nerve cells can’t
communicate with one another. People under heavy
stress find it hard to concentrate and think clearly.
• Affects the limbic system (hypothalamus, thalamus,
hippocampus, amygdala and the pituitary gland);
governs emotion, hunger, thirst, body temperature,
sleep, sexuality and memory.
• Excess cortisol kills neurons over time by too much
calcium influx into the cells.
TBD
• Resilience & Anti-stress
training.
• Vitamin C (titrate to std)
test.
• CONOPS
countermeasures.
• Re-balancing blood
chemistry & drug research.
Cytokine
Overload
• Hot environment causes inflammatory response.
• Worsened by inadequate hydration, diet, and cooling.
• First symptom is brain/behavior/thinking dysfunction.
Strong
• Cooling
• Anti-inflammatory diet
• Anti-inflammatory Warrior
electrolyte drink
01/18/19 76

Sleep
Deprivation
• Worsens information processing, judgment, and mood
(WRAIR).
• Can present as temporary psychosis (Combat
Exhaustion).
• May lead to other problems (alcohol/drug abuse, risk-
taking, poor diet, etc.).
Strong
• CONOPS
countermeasures.
• Rest.
• Sleep restoration/re-
balancing blood chemistry
& drug research.
Skill Deficit
• Recruits come in with a wide variety of backgrounds
and skill sets.
• JROTC uses the Success Profiler test and training.
http://www.conovercompany.com/products/successe/
• In CDC Adverse Childhood Experience (ACE) study,
2/3 were high-risk while 1/3 were successful. Delta
was largely an adult mentor who provided resilience
skills.
Strong
• Evaluate Success Profiler
dx test and training
longitudinally, especially in
high-risk groups.
• Bibliography available.
• See Success OPORD brief
• Chaplain combat-style
support in IET and units.
Bio-chemical
Deficiencies
• Thyroid deficiency, especially in middle-aged women
(>35), causes fatigue, depression, memory loss, etc.
• Cholesterol imbalances affect health and thinking.
− 1/5 of children have high cholesterol.
− Some 18 y/o RVN dead had 50% arterial occlusion.
Strong
• Comprehensive blood
chemistry.
• Improved autopsy.
• Re-balancing blood
chemistry & drug treatment
research.
01/18/19 77

Nutritional
Deficiencies
• Severe nutritional deficiencies (B, C) linked to psychoses
(Pellagra, Beri Beri, Scurvy).
• Iron, vitamin Bs, iodine, vitamin D, calcium, omega 3s, et al
deficiencies affect health, thinking, and mood.
• Military diet inadequate (USARIEM; Lappe Navy).
• Mediterranean Diet linked to health and mood.
• Diet linked to adolescent behavior problems (Oliver;
Schauss)
• Alkaline diet (+ vegetables) linked to effective nutrient
uptake.
Strong
chemistry testing at entry
and career sampling.
• Evidence-based diet.
• Supplements titrated to
effective serum levels.
Incoming
Pathology
•Mental health is not objectively screened for at entry.
•CDC ACE study documents 2/3 child abuse survivors are at
high risk. PET scans show under-developed corpus
callosum (see also Harlow studies). These survivors may
join the military at higher rates (Wolfe, J. (1996-2000).
Adaptation to First-Term Enlistment Among Women in the
Marine Corps. DAMD 17-95-1-5047)
•Child abuse survivors have lower levels of the NR3C1 gene
expression, which affects ability to cope with stress (Nature
Neuroscience).
•PTSD vulnerability (poor physiological response to stress;
remain hypervigilant neuro-endocrinologically after stressors).
Strong
• Screening research.
01/18/19 78

Toxins
• Average person may have over 100
toxins/contaminants in their bodies. Some strongly
interfere with the Krebs Cycle (Schauss).
• Heavy metal poisoning (e.g. lead) symptoms:
− Aggressive behavior
− Difficulty sleeping
− Headaches
− Irritability
− Combat Arms, range, and munitions personnel may be
at risk for lead poisoning (M4 blows vaporized lead
back into the shooter’s face).
− Serum testing may be inaccurate (lead sequestered in
bone).
− Families can get secondary poisoning.
• Mefloquine (malaria pill) causes anxiety, paranoia,
depression, hallucinations, and psychosis in certain at-
risk populations.
• Smoking
− Contaminates body with polonium, formaldehyde,
cadmium, cyanide, arsenic, benzene, lead, nicotine,
and carbon monoxide.
− Linked to undiagnosed depression and linked to 2x
higher PTSD vulnerability (Rasmusson A).
TBD
chemistry testing.
• Improved ammunition and
range safety.
• Improved lead testing.
• Improved Mefloquine Rx
controls and/or improved
malaria pill.
• Improved stop smoking
interventions, including
rebalancing blood
chemistry.
01/18/19 79

01/18/19 80
Compensation
Neurosis
•Combat Exhaustion Soldiers in WWII evacuated for
mental symptoms became chronic and untreatable.
•TDRL psych patients show disease recovery before
upcoming evaluations.
•Monetary payments do not treat disease and may make
recovery difficult.
Strong
• Improved objective dx
criteria.
• Aggressive multi-
disciplinary vocational-
rehabilitation.
• Multi-disciplinary
rehabilitation doctrine.

What Next?
01/18/19 81
• A large number of variables can be narrowed down by cost and an
assessment of the variable’s contribution to the PTSD incidence
variance.
• The ideal would be to sample one cohort for everything.
• Rank-order the variables and conduct intervention trials.

01/18/19 82
BU

01/18/19 83
Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery
(RAND)
• One in five Iraq and Afghanistan veterans suffer from PTSD or major depression.
• Effective treatments documented in the scientific literature — evidence-based care — are available for PTSD and major depression.
Delivery of such care to all veterans with PTSD or major depression would pay for itself within two years, or even save money, by
improving productivity and reducing medical and mortality costs.
• Nearly 20 percent of military service members who have returned from Iraq and Afghanistan — 300,000 in all — report symptoms of
post traumatic stress disorder or major depression, yet only slightly more than half have sought treatment (as of 2008).
• About 19 percent of returning service members report that they experienced a possible traumatic brain injury while deployed, with 7
percent reporting both a probable brain injury and current PTSD or major depression.
• Estimate that PTSD and depression among returning service members will cost the nation as much as $6.2 billion in the two years
following deployment — an amount that includes both direct medical care and costs for lost productivity and suicide. Investing in more
high-quality treatment could save close to $2 billion within two years by substantially reducing those indirect costs.
• Estimates the societal costs of PTSD and major depression for two years after deployment range from about $6,000 to more than
$25,000 per case. Depending whether the economic cost of suicide is included, the RAND study estimates the total society costs of
the conditions for two years range from $4 billion to $6.2 billion.
• Women, Hispanics and enlisted personnel all were more likely to report symptoms of PTSD and major depressions, but the single
best predictor of PTSD and depression was exposure to combat trauma while deployed.
PTSD

“Training for warfighting is our number one priority in peace and in war. Warfighting readiness is derived
from tactical and technical competence and confidence. Competence relates to the ability to fight our
doctrine through tactical and technical execution. Confidence is the individual and collective belief that we
can do all things better than the adversary and the unit possesses the trust and will to accomplish the
mission.”
“Training for warfighting is our number one priority in peace and in war. Warfighting readiness is derived
from tactical and technical competence and confidence. Competence relates to the ability to fight our
doctrine through tactical and technical execution. Confidence is the individual and collective belief that we
can do all things better than the adversary and the unit possesses the trust and will to accomplish the
mission.”
Victory Starts Here
The Human Dimension in Full Spectrum
Operations
Recruit-Access-Train-Retain-Develop
3c01/18/19 87

01/18/19 88
• WWII had very high Combat Stress casualties.
• Causes: Physical exhaustion, inadequate food, inadequate
equipment, severe cold, poor rotation policies, limited
doctrine/Lessons Learned, poor training, high casualty rates.
(DePuy, “Oral History,” Ambrose, “Citizen Soldiers.”).
• Finding: Hospitalizing soldiers and sending them home with
disability benefits created permanent disabilities that were
essentially untreatable.
• Treatment:
• Maintain the expectation of returning to duty.
• Fix forward (4R: rest, replenishment, reassurance, restore
confidence).
• Maintain unit contact.
• It works.
• Example:
Israelis put Combat Stress casualties through BCT; recovered
• WWII had very high Combat Stress casualties.
• Causes: Physical exhaustion, inadequate food, inadequate
equipment, severe cold, poor rotation policies, limited
doctrine/Lessons Learned, poor training, high casualty rates.
(DePuy, “Oral History,” Ambrose, “Citizen Soldiers.”).
• Finding: Hospitalizing soldiers and sending them home with
disability benefits created permanent disabilities that were
essentially untreatable.
• Treatment:
• Maintain the expectation of returning to duty.
• Fix forward (4R: rest, replenishment, reassurance, restore
confidence).
• Maintain unit contact.
• It works.
• Example:
Israelis put Combat Stress casualties through BCT; recovered

What Commanders and Medics do:
• Recovery - the act of regaining or returning toward a normal or
healthy state. MEDICS make diagnoses, prescribe therapies, and
enhance recovery.
• Resilience - the process of adapting in the face of adversity, trauma,
tragedy, threats, or other significant sources of distress (combat).
COMMANDERS - through good training and good leadership -
enhance resilience in Soldiers and units.
01/18/19 89

01/18/19 90
What increases
resilience?
The Invisible Enemy:
Boredom

Resilience Training Priorities

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Editor's Notes