Why is the world's largest organization of psychologists so aggressively promoting a new, massive, and untested military program? The APA's enthusiasm for mandatory "resilience training" for all U.S. soldiers is troubling on many counts.
The January 2011 issue of the American Psychologist, the American Psychological Association's (APA) flagship journal, is devoted entirely to 13 articles that detail and celebrate the virtues of a new U.S. Army-APA collaboration. Built around positive psychology and with key contributions from former APA president Martin Seligman and his colleagues, Comprehensive Soldier Fitness (CSF) is a $125 million resilience training initiative designed to reduce and prevent the adverse psychological consequences of combat for our soldiers and veterans. While these are undoubtedly worthy aspirations, the special issue is nevertheless troubling in several important respects: the authors of the articles, all of whom are involved in the CSF program, offer very little discussion of conceptual and ethical considerations; the special issue does not provide a forum for any independent critical or cautionary voices whatsoever; and through this format, the APA itself has adopted a jingoistic cheerleading stance toward a research project about which many crucial questions should be posed. We discuss these and related concerns below.
At the outset, we want to be clear that we are not questioning the valuable role that talented and dedicated psychologists play in the military, nor certainly the importance of providing our soldiers and veterans with the best care possible. As long as our country has a military, our soldiers should be prepared to face the hazards and horrors they may experience. Military service is highly stressful, and psychological challenges and difficulties understandably arise frequently. These issues are created or exacerbated by a wide range of features characteristic of military life, such as separation from family, frequent relocations, and especially deployment to combat zones with ongoing threats of injury and death and exposure to acts of unspeakable violence. The stress of repeated tours of duty, including witnessing the loss of lives of comrades and civilians, can produce extensive emotional and behavioral consequences that persist long after soldiers return home. They include heightened risk of suicide, posttraumatic stress disorder (PTSD), substance abuse, and family violence.
Conceptual and Empirical Concerns
Although its advocates prefer to describe Comprehensive Soldier Fitness as a training program, it is indisputably a research project of enormous size and scope, one in which a million soldiers are required to participate. Reivich, Seligman, and McBride write in one of the special issue articles, "We hypothesize that these skills will enhance soldiers' ability to handle adversity, prevent depression and anxiety, prevent PTSD, and enhance overall well-being and performance" (p. 26, emphasis added). This is the very core of the entire CSF program, yet it is merely a hypothesis -- a tentative explanation or prediction that can only be confirmed through further research.
There seems to be reluctance and inconsistency among the CSF promoters in acknowledging that CSF is "research" and therefore should entail certain protections routinely granted to those who participate in research studies. Seligman explained to the APA's Monitor on Psychology, "This is the largest study -- 1.1 million soldiers -- psychology has ever been involved in" (a "study" is a common synonym for "research project"). Butwhen asked during an NPR interview whether CSF would be "the largest-ever experiment," Brig. Gen. Cornum, who oversees the program, responded, "Well, we're not describing it as an experiment. We're describing it as training." Despite the fact that CSF is incontrovertibly a research study, standard and important questions about experimental interventions like CSF are neither asked nor answered in the special issue. This neglect is all the more troubling given that the program is so massive and expensive, and the stakes are so high.
It is highly unusual for the effectiveness of such a huge and consequential intervention program not to be convincingly demonstrated first in carefully conducted randomized controlled trials -- before being rolled out under less controlled conditions. Such preliminary studies are far from a mere formality. The literature on prevention interventions is full of well-intentioned efforts that either failed to have positive effects or, even worse, had harmful consequences for those receiving them. For instance, in the 1990s the DARE (Drug Abuse Resistance Education) substance abuse prevention program was administered in thousands of elementary schools across the U.S., at a cost of many hundreds of millions of dollars. Yet evaluations of DARE rarely found the desired effects in regard to reducing young people's later substance use (e.g., see this and this summary). In response, DARE was modified in the last decade; however, subsequent evaluation found that the revised program actually increased later alcohol and cigarette use in those who received it compared to controls.
Similarly, criminal justice researcher Joan McCord has demonstrated how well-meaning programs have caused actual harm. She conducted a 30-year follow-up of a classic delinquency prevention program. Those participants randomly selected for intervention, but not matched controls, were provided with extensive enrichment, including mentoring, counseling, and summer camp. Among the matched pairs who differed in outcomes decades later, those who received the intensive assistance were more likely to have been convicted of serious street crimes; were more frequently given a diagnosis of alcoholism, schizophrenia, or manic depression; and on average died five years younger. Other studies of criminal justice interventions have also uncovered unanticipated, deleterious effects. Given this well known record, it is especially concerning when a major intervention is rolled out for thousands -- or hundreds of thousands -- without careful prior examination, including an investigation of potential negative effects. The special issue of the American Psychologist gives no indication that preliminary studies of CSF were conducted.
Also problematic, the CSF program is adapted primarily from the Penn Resiliency Program (PRP) where interventions were focused on dramatically different, non-military populations. Even with these groups, a 2009 meta-analysis of 17 controlled studies reveals that the PRP program has been only modestly and inconsistently effective. PRP produced small reductions in mild self-reported depressive symptoms, but it did so only in children already identified as at high risk for depression and not for those from the general population. Nor did PRP interventions reduce symptoms more than comparison prevention programs based on other principles, raising questions as to whether PRP's effects are related to the "resilience" theory undergirding the program. Further, like many experimental programs, PRP had better outcomes when administered by highly trained research staff than when given by staff recruited from the community. This raises doubts as to how effectively the CSF program will be administered by non-commissioned officers who are required to serve as "Master Resilience Trainers."
Regardless of how one evaluates prior PRP research, PRP's effects when targeting middle-school students, college students, and adult groups can hardly be considered generalizable to the challenges and experiences that routinely face our soldiers in combat, including those that regularly trigger PTSD. In an inadequate attempt to bridge this gap rhetorically, CSF proponents describe PTSD as "a nasty combination of depressive and anxiety symptoms" (Reivich, Seligman, & McBride, p. 26). In fact, PTSD involves a far more complicated cluster of severe symptoms in response to a specific traumatic event, including flashbacks, partial amnesia, difficulty sleeping, personality changes, outbursts of anger, hypervigilance, avoidance, and emotional numbing.
We also believe that other key aspects of Comprehensive Soldier Fitness should have received explicit discussion in this special issue. It is standard practice for an independent and unbiased ethics review committee (an "institutional review board" or "IRB") to evaluate the ethical issues arising from a research project prior to its implementation. This review and approval process may in fact have occurred for CSF, but the manner in which the principals blur "research" and "training" leads us to wish for much greater clarity here. This process is even more critical given that the soldiers apparently have no informed consent protections -- they are all required to participate in the CSF program. Such research violates the Nuremberg Code developed during the post-World War II trials of Nazi doctors. That code begins by stating:
The voluntary consent of the human subject is absolutely essential.
This means that the person involved should have legal capacity to give consent; should be so situated as to be able to exercise free power of choice, without the intervention of any element of force, fraud, deceit, duress, over-reaching, or other ulterior form of constraint or coercion; and should have sufficient knowledge and comprehension of the elements of the subject matter involved as to enable him to make an understanding and enlightened decision.
Disturbingly, however, this mandatory participation in a research study does not violate Section 8.05 of the APA's own Ethics Code, which allows for the suspension of informed consent "where otherwise permitted by law or federal or institutional regulations." Despite the APA's stance, we should never forget that the velvet glove of authoritarian planning, no matter how well intended, is no substitute for the protected freedoms of individuals to make their own choices, mistakes, and dissenting judgments. Respect for informed consent is more, not less, important in total environments like the military where individual dissent is often severely discouraged and often punished.
More broadly, the 13 articles fail to explore potential ethical concerns related to the uncertain effects of the CSF training itself. In fact, the only question of this sort raised in the special issue -- by Tedeschi and McNally in one article and by Lester, McBride, Bliese, and Adler in another -- is whether it might be unethical to withhold the CSF training from soldiers. Certainly, there are other ethical quandaries that require serious discussion if the CSF program's effectiveness is to be appropriately evaluated. For example, might the training actually cause harm? Might soldiers who have been trained to resiliently view combat as a growth opportunity be more likely to ignore or under-estimate real dangers, thereby placing themselves, their comrades, or civilians at heightened risk of harm?