Page 67 - JSOM Summer 2019

Gaps in the Literature Clinical Implications
Although we synthesized multiple studies of military resil- In 2017, some of the largest suicide studies in military his-
ience, a notable gap—absence, actually—of resilience research tory (namely, Army STARRS) were released 4–6,22,80 in which
for SOF is troubling. The lack of research on resilience in the one concluded that SF had nearly zero risk of suicide because
SOF community indicates poor progress in understanding SF are highly resilient due to their “rigorous selection, intense
the experiences of SOF Servicemembers, failure to link resil- training, strong unit cohesion, or psychological and biological
ience and suicide risk, inadequate measurement of incidence characteristics.” In 2018, SOF suicides tripled. Amid “his-
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of PTSD, and other predicates. Military resilience research torically heightened suicide rates,” the current US SOCOM
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overall is not of the highest evidence; resilience has not been strategy is to augment resilience through wellness programs
shown to reduce suicide risk or improve mental health out- emphasizing elite athleticism and psychosocial fitness. 82
comes; resilience research is based on specific assumptions of
what composes resilience depending on methods of measure- Other than the Hing et al. 2012 study of US Army SOF PTSD
ment; resilience studies in this population lack rigor. The so- incidence, few to no studies of mental health issues in SOF
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cial-cognitive nature of resilience appears to preclude highly exist either. Moreover, concomitant brain injuries such as as-
controlled experimental research and meta-analyses of the troglial scarring, believed due to years of exposure to heavy
same, at the apex of research hierarchies. During synthesis, weaponry, breaching, and explosives, could be causing neuro-
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we found resilience morphed conceptually from an historical pathologies in SOF similar to those reported in 2017 such as
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construct in positive psychology into a structural element used symptoms mimicking PTSD. Suicides in SOF could be equally
individually, enabling ability to withstand adversity—findings due to organic, occupational causes of neuropsychiatric symp-
proposed previously. 1 tom spectra and augmenting psychosocial resilience will ob-
viously not reverse physiologic sequelae from organic brain
Despite our admiration for and gratitude toward everyone injuries.
involved with initiatives designed to improve the lives and
experiences of Servicemembers, we note, metaphorically, From a clinical perspective, overemphasis on resilience could
that resilience initiatives were the cart, and measurement be stealing resources needed to investigate the multifaceted
research was the horse. Military resilience programs were natures of PTSD and suicide, especially in SOF. Resistance to
launched years before accompanying science, and unques- resilience-building groupthink is starting to emerge as voices
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tioned or unchallenged positive psychology paradigms heavily are being raised in opposition to deleterious and ineffective
influenced research frameworks and programmatic pillars. mental health initiatives that may be doing Servicemembers
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The interdependence between research findings confirm- more harm than good, despite the purest of intentions. As a
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ing programmatic success invites innumerable potentials population under significant stress and threat, targeted study
for bias, which must be addressed. At least, next phases of of resilience in SOF personnel is both warranted and exigent,
military resilience program evaluation should be examined especially given historically elevated suicidality, SOF-specific
by third-party investigators without potential conflicts of stressors, and occupational lethality faced by Special Opera-
interest. Military commands—the entire US Army (MRT, tions entities.
CSF), US Navy (OSCAR), US SOCOM (Preservation of the
Force and Family)—have invested heavily in resilience-build- The military’s insistence on resilience could be interpreted as
ing initiatives, and we presume researchers associated with shifting responsibility for effects of chronic physiologic and
those endeavors concurrently built considerable standing neurologic stress to Servicemembers unfairly characterized
spearheading those efforts and studying those programs’ as not being positive enough in thought or resilient if they
outcomes. succumb to PTSD or suicide to stop their suffering. In Feb-
ruary 2019, SOCOM’s spokesman appeared to perpetuate
Efforts aimed toward increasing resilience to mitigate nega- this ‘blame and shame’ narrative when in response to SOF
tive mental health sequelae continue despite resilience research suicides, he stated publicly that SOCOM resilience training
characterized as executed with poor methodologies, substan- aims to train participants toward positivity, that signs of
dard rigor, and lack of conceptual analyses. 31,79 In particular, suicidality (e.g., substance abuse, relationship problems) are
resilience is often couched within a pathogenic paradigm: causes of suicide (rather than symptomatic indicators), and
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Lack of resilience is associated with negative health outcomes, thinking happy thoughts somehow prevent suicide. “Many
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whereas the presence of resilience is proffered as a salutogenic suicides appear to be related to substance abuse, personal rela-
element leading to positive health outcomes. No evidence tionship issues or financial problems, [SOCOM] officials said
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supporting such curative claims was found. Given such con- . . . ‘SOCOM is working with researchers, for example, to
tradictions, this integrative review was warranted to deter- understand underlying thought processes that lead to suicide
mine the state of the science on resilience research through and what actions can be taken to mitigate that behavior . . .
structured and replicable methods. 36 The training we have developed is intended to teach skills that
help participants recognize inflexible, rigid thought patterns
American quantitative studies were weakened by some ab- and to substitute those patterns of thinking with more adapt-
sences of full discussion of resilience measurements’ psycho- able thoughts,’ McGraw said. The training is heavily based in

metric properties or subscale analyses. It was particularly cognitive behavior therapy, and is designed to provide benefit
difficult to evaluate military participants’ baseline or changed to any participant regardless of their risk for suicide.” 12
resilience measurements when investigators excluded norms,
historical referents, cutoff scores, and comparisons to other Recommendations
populations’ resilience. Leading researchers in military resil-
ience may have neglected elements that could enhance their We argue here that Servicemembers cannot overcome even
outcomes measurements’ rigor and ultimately, credibility. indirect indicators of PTSD and suicidality (e.g., relationship

Resilience and Suicide in SOF | 65