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By Amanda McCabe, Psy.D.

As behavioral health providers who work with military service members, we hear the term ‘readiness’ often and may wonder what it means and how it could impact our work with our military clients. Generally speaking, readiness refers to the military’s capability to do its job, whether that’s during training, combat operations, or humanitarian missions. In order to ensure that the military can meet its missions, commanders need to know if their service members are able to deploy or work in an austere environment for an extended period of time. For example, work in an austere environment might look like a unit getting called up on an urgent tasker to respond to the wildfires on Maui. The commander for the unit would need to know, in a timely manner, who is available to deploy and who may not be available due to medical or behavioral health reasons. Another example of an austere environment, is a National Guard member or Reservist who has to perform their annual training for two to four weeks at a remote training location. There will be further discussion below on the different types of austere environments in which service members may work.

To maintain visibility of personnel who are ready and able to work in austere environments, readiness assessments are conducted by military providers, including behavioral health providers, at routine appointments. An example of this can be seen when a service member meets with their physician for symptoms of a cold; the physician treats the service member and also conducts a routine readiness assessment. Readiness assessments can also be done systematically to prepare for upcoming missions. Prior to deployment, the members of an entire unit undergo a medical screen or examination. During these assessments, providers will evaluate if there are any medical or behavioral health reasons that a person cannot currently perform their job deployed and also at home, oftentimes referred to in the military as in garrison. However, before we discuss the elements of a readiness evaluation, let's learn more about their benefits, answering the essential question, why does the military require these readiness assessments?

1. Early Identification of Potential Issues

Aside from ensuring an operationally effective force, regular readiness assessments allow for the early detection of issues that could impair a service member's ability to perform their duties in the long term. This includes physical injuries, mental health concerns, and personal circumstances that may affect a person’s focus or performance. Early identification enables timely intervention, whether it’s through medical treatment, counseling, or support services, helping to prevent minor issues from escalating into major problems that could impact the individual or their unit. An example of such a situation is a service member who fractured their wrist and cannot take part in attending the weekly range exercise for risk of further damaging their arm. Another example is a service member who has a parent who’s been diagnosed with a terminal illness and is requesting a compassionate reassignment in order to live close to that parent to be able to assist with their medical care. A final example, pertaining to behavioral health, highlights the importance of a walk-in clinic, which can help identify preliminary signs of stressors that arise due to a pending month-long training exercise. Early identification and targeted treatment allow stressors to stay at the “problem” level without escalating to a diagnosable behavioral health condition. Identifying medical concerns or behavioral health problems at the lowest level prevents issues becoming chronic and recalcitrant to treatment.

2. Ensuring Access to Care

Assessing readiness regularly allows the military to identify the needs of service members and ensure that they are sent only to locations that have the resources available to support them. service members train and deploy throughout the year in austere environments and it is imperative to ensure that the service member will have access to any needed care wherever they go. Austere environments can look like a multitude of situations. For example, Navy personnel can expect to serve sea duty, and be on the water for months at a time. Internet capabilities, mail, and medical resources, beyond a typical physician or behavioral health therapist, may be limited. Submariners often have limited access to the internet, fresh food, and communication with the outside world. Reservists and National Guard members have to conduct extended annual training that usually occurs at a remote site with limited electricity, internet, hot food and all with significant exposure to the elements for weeks at a time. Reservists and National Guard members do this annual training while trying to balance a civilian job oftentimes simultaneously. Active Duty members not only have the potential to deploy, but experience multiple training exercises throughout the year, which can lead to being gone for months at a time. They can also be moved, or PCSed (Permanent Change of Station), to different locations around the world that have limited resources. Therefore, it is imperative that the military ensures that they are not sending service members to areas or exercises that would aggravate their medical and behavioral health needs or the Military needs to ensure that the necessary medical and behavioral health resources are available at the next location, whether that is a PCS, deployment, or extended training exercise.

To look at an example of the Military ensuring resources for its service members, an example of an overseas move makes a great illustration. For instance, OCONUS assignments (a location Outside of the CONtinental United States) often have limited physical and behavioral health services. Therefore, service members undergo medical screenings prior to assignments to ensure the needed medical resources are available at their next duty station. One OCONUS location, South Korea, has less extensive behavioral health services available in the community due to language barriers, as such there are no partial hospitalization or residential programs within the country to send service members in need. This is an extremely limiting factor when considering the behavioral health options for service members, therefore, people who require more than routine outpatient behavioral health services would not be moved to an OCONUS assignment until they had completed treatment and demonstrated stabilization. To further illustrate, the example of a service member receiving orders to move to South Korea within three months is used. If this service member is currently undergoing significant behavioral health treatment, beyond the scope of outpatient services, their move may be delayed a month or two to allow their condition to stabilize or complete treatment. There are also times when orders are completely rescinded because the necessary treatment is not available at the next duty location. Regular readiness assessments allow service members to identify their treatment needs and move and train to only locations that maintain those required services.

3. Ensuring Long-Term Health and Sustainability

Military service is demanding, both physically and mentally. Continuous readiness assessments are essential for ensuring that the demands placed on service members do not exceed their capabilities, leading to burnout or long-term health issues. By monitoring physical and mental health, the military can provide necessary support, such as rest periods, medical care, or behavioral health counseling, which helps to sustain the force over the long term. This approach not only protects the well-being of service members but also preserves the effectiveness of the military force as a whole. If a service member’s medical needs, to include behavioral health, have been identified as becoming complex or chronic, medical retirement with access to VA (Veterans Affairs) and DoD (Department of Defense) services will be considered.

Conclusion

Continually assessing the readiness of military service members is a fundamental aspect of maintaining a capable, resilient, and effective force. It ensures operational success through early identification of issues and maintains access to care thereby protecting the well-being of service members. As the nature of global challenges continues to evolve, the importance of readiness assessments will only grow, ensuring that military forces are prepared to meet the demands of future conflicts.

Click here for Part 2: "Overview of Military Readiness Assessments"
Click here for Part 3: "Private Sector Providers and Readiness"

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Amanda McCabe, Psy.D., is a Military Behavioral Health Psychologist with the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. In this capacity, she develops and delivers training on a variety of evidence-based therapies. Prior to the CDP, Dr. McCabe served as a clinical psychologist in the Army from 2013 to 2024.

By Diana Dolan, Ph.D., CBSM, DBSM,

If you have insomnia, you have a number of different behavioral treatment options available. These options offer effective, long-term benefits without the need for sleep aids or ongoing medication. However, you may not know where to go to look for them or which is the right fit for you. In this article, let’s unpack and compare these options to get started.

Considering behavioral treatment for insomnia is a wise choice; after all, it’s widely considered the gold standard treatment (Schutte-Rodin et al, 2008; Qaseem et al, 2016, Edinger et al, 2021) and is recommended by VA/DoD clinical practice guidelines (Department of Veterans Affairs, 2019). The continuum of options ranges from self-help all the way to individually tailored treatment with a trained behavioral sleep medicine clinician.

Step 1: Self-Help

The least intensive treatment option is via self-help. This can be unguided, such as via reading books and attempting to track your own sleep and implement the strategies described. Examples of this approach include the “Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain” workbook by Colleen Carney, Ph.D. and Rachel Manber, Ph.D., recognized experts in the field, or “The Insomnia Workbook: A Comprehensive Guide to Getting the Sleep You Need” by Stephanie Silberman, Ph.D. and Charles Morin, Ph.D., also well-known sleep psychologists. Both books cost between $20-25.

Self-help can also be guided such as via apps that provide feedback on your sleep inputs and suggested changes. Some examples of this include the Insomnia Coach app developed by the VA (https://mobile.va.gov/app/insomnia-coach) and the Path to Better Sleep website hosted by the VA (https://www.veterantraining.va.gov/sleep/index.asp) that offers four modules, including a self-check, psychoeducation, and a walkthrough of Cognitive Behavioral Therapy of Insomnia (CBT-I) for self-implementation. Both are offered for no cost. Some apps even offer a sort of coaching model, where you may receive occasional contact from a person who reviews your app data (usually this is someone without advanced training in behavioral health or sleep medicine).

Outcome data suggest self-help approaches can indeed be helpful, but may fit better for those who approach them already motivated and committed to adhering to the guidance they learn, and may not be as long lasting as more intensive options (Gao et al, 2022).

Step 2: Structured Clinician-Guided Treatment

This category includes treatment with a provider who may or may not have specialized training in behavioral sleep medicine, but is following an evidence-based protocol, with individuals who are expected to largely independently implement changes with only some guidance. For example, CBT-I in a group setting is guided and has a relatively short time commitment. CBT-I group usually ranges from four to six appointments lasting 60 to 90 minutes each, for a total in-person range of four to six hours. Group sizes are usually up to about seven people, allowing individuals to get to know each other and receive support in making changes, with a cost less than that of specialty individual care at the next level up.

Another low-time commitment option is Brief Behavioral Treatment of Insomnia, or BBTI, typically offered individually. BBTI can be implemented by a paraprofessional or nurse, or by a therapist such as a clinical social worker or psychologist. While BBTI does require active effort to make changes in sleep-related behavior, it can be offered in easily accessible locations, such as a primary care or other medical clinic, and involves five contacts lasting an average of 30 minutes each, for a total in-person commitment of only two to three hours. The cost can vary, but would typically be at one’s usual medical visit copay or is covered for those receiving BBTI in DoD military treatment facilities. Full disclaimer, I both offer and train other providers in BBTI including ongoing consultation and I believe it is a helpful treatment to the majority of those who adhere to the plan, although some may have unhelpful sleep-relevant beliefs that need to be addressed outside of the protocol or may require additional appointments.

Outcome data suggests both of these options not only last longer than self-help options, but result in more noticeable improvement (Koffel, Koffel, & Gehrman, 2015; Gao et al, 2022). Clinician-guided treatment at this next step up above self-help may fit better for those who would like to improve their sleep and are willing to build on a proivded plan, but prefer scheduled access to an identified provider who gives information, encouragement and support for problem-solving any questions that may arise.

Step 3: Specialty Level Treatment

At the highest level of stepped care would be full implementation of the gold standard treatment, individual CBT-I. Clinicians who provide CBT-I may range from those who have initial training in the basics of the CBT-I protocol and offer straightforward implementation with some appropriate adaptations as needed, all the way to experienced clinicians who specialize in behavioral sleep medicine and offer treatments not only for insomnia but for nightmares, circadian rhythm disorders, adjunctive obstructive sleep apnea and narcolepsy support and more. While CBT-I training is open to providers of many backgrounds (see https://cbti.directory/ for a list of self-identified CBT-I trained clinicians), a Diplomat in Behavioral Sleep Medicine is the board credential denoting expertise available for this specialty area (see https://www.bsmcredential.org/index.php/bsm-diplomates for the roster).

The gold standard for a reason, CBT-I interventions are specifically tailored to address each individual’s unique relevant contributors and any comorbid mental or medical health concerns with a detailed plan and flexible appointment range, resulting in long lasting outcomes even in more complex situations (Gao et al, 2022). While this kind of approach would benefit anyone with insomnia, those who are not yet sure about making changes around their sleep, those who want to more collaboratively develop a plan or have more ongoing face to face support, and those who want a provider who can simultaneously weave in factors such as decreased mood, anxiety and trauma would do well at this step.

A helpful note to keep in mind about the stepped care model is that if one step does not sufficiently address insomnia symptoms, it does not mean that behavioral treatment has failed. Rather, it indicates that a higher step would be more appropriate. Even within a step as noted, differential levels of intensity exist. For those debating options, I encourage you to give the most readily accessible one a try for a starting point. You may feel more comfortable trying an intervention knowing options still remain if needed. Generally, the different steps can all have good outcomes, but the wild card is you. If you are motivated to make changes in your behavior in order to sleep better in the long run, you will get out what you put in – so go for it!

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Diana Dolan, Ph.D., CBSM, DBSM, is a clinical psychologist serving as an Assistant Director of Training & Education with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland..

References

Baglioni, C., Espie, C.A., Altena, E., Gavriloff, D., Jernelov, S., Holzinger, B., … & Riemann, D. (2023).
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 Department of Veterans Affairs & Department of Defense (2019). VA/DoD clinical practice guideline for
      the management of chronic insomnia and obstructive sleep apnea.
      https://www.healthquality.va.gov/guidelines/CD/insomnia/VADoDSleepCPGFinal508.pdf
 Edinger, J. D., Arnedt, J. T., Bertisch, S. M., Carney, C. E., Harrington, J. J., Lichstein, K. L., … & Martin, J. L.
      (2021). Behavioral and psychological treatments for chronic insomnia disorder in adults: An
      American Academy of sleep medicine clinical practice guideline. Journal of Clinical Sleep
      Medicine, 17(2), 255–262. https://doi.org/10.5664/jcsm.8986
 Gao, Y., Ge, L., Liu, M., Niu, M., Chen, Y., Sun, Y., ... & Tian, J. (2022). Comparative efficacy and
      acceptability of cognitive behavioral therapy delivery formats for insomnia in adults: A
      systematic review and network meta-analysis. Sleep Medicine Reviews, 64, 101648.
     https://doi.org/10.1016/j.smrv.2022.101648
 Koffel, E.A., Koffel, J.B., Gehrman, P.R. (2015). A meta-analysis of group cognitive behavioral therapy for
      insomnia. Sleep Medicine Reviews 19: 6-16.
 Qaseem, A., Kansagara, D., Forciea, M.A., Cooke, M., & Denberg, T.D. (2016). Management of chronic
      insomnia disorder in adults: a clinical practice guideline from the American College of Physicians.
      Annals of Internal Medicine 165(2): 125-133.
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      evaluation and management of chronic insomnia in adults. Journal of Clinical Sleep Medicine
      4(5): 487-504.

By Timothy Rogers, Ph.D.

According to the 2023 match statistics from the Association of Psychology Postdoctoral and Internship Centers (APPIC) there are 774 internship sites and a total of 3,620 accredited internship positions. The US military offers nine accredited internships sites and a total of 58 internship positions across the different branches, representing 1% of the overall training opportunities for those seeking to complete their doctoral psychology training requirements. With so many options available, why should someone focus on the 1% offered by the U.S. military?

That is a fair question. I would like to provide a response based on my experience as a former military psychology intern, as well as other experiences I have had from different professional roles. When applying to internships, I applied to the VA, college counseling centers, forensic settings, as well as military internship sites. During the course of my doctoral program, I worked in a range of clinical settings which resulted in applying to a variety of internship sites. I ended up going on over 10 interviews in different states to look at various training programs. As a result of this process, one of the things that stood out to me very clearly was the abundance of training opportunities that the military provided. In particular, the number of different clinical rotations and amount of evidence based treatments you could receive training in seemed to exceed what other training programs had to offer. Additionally, I liked the idea that the military internship program would not only help me to learn how to be an excellent psychologist, but I would also learn how to be an effective leader as an officer.

As I progressed in my career, I also had the fortunate opportunity to serve as an Associate Program Director for one of the military psychology internship sites. As part of my responsibilities, I would go over the program evaluation data completed by faculty members, current interns and those who graduated from our program. When examining the results, graduates from military internship programs would consistently note that compared to their peers they received more training (e.g., amount of supervision, training in diverse clinical topics). This feedback resonated with my own experience as a former military psychology intern, and even why I ranked military internships at the top of my list was because of the training opportunities that these internships provided.

In addition to being a former military intern, and serving as an Associate Program Director, I have also had the opportunity to visit different military internship sites as an APA Commission of Accreditation internship site visitor. As a site visitor, you have to review every aspect of a training program to examine the extent to which the program is adhering to relevant accreditation standards. It is a very in-depth process that culminates with an in-person visit to the site and interviews with everyone involved in the program (e.g., faculty members, program leadership, administrative support personnel, current interns, and graduates). Every site visit I have made to a military internship program has reinforced my understanding of the amazing opportunities afforded to students to develop their clinical skills as future psychologists and grow in leadership skills.

If you are interested in learning more about military psychology internships, the Center for Deployment Psychology holds trainings twice a year to talk about career pathways. You can find out more information on our website at: https://deploymentpsych.org/pathways-to-military-careers. We also have a section on our website dedicated to providing information about requirements to join the military, military health careers for psychologists and social workers, as well as general information (e.g., benefits associated with military service).

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Timothy Rogers, Ph.D., is an Assistant Director of Online Training, Technology and Telehealth for the Center for Deployment Psychology (CDP) at the Uniformed Services University for the Health Sciences in Bethesda, Maryland.

By Debra Nofziger, Psy.D.

I recently sat in on a discussion with Ukrainian providers who were discussing how to handle provider burnout. These were primarily providers who are directly working with fighting troops or providers who work with families who evacuated and have loved ones fighting. One of the providers shared feeling helpless when it comes to being able to help, from a behavioral health perspective, people who are experiencing ongoing war. This feeling was quickly confirmed by the other providers on the call. It got me thinking of the difference between working with patients after an event versus working with patients during an ongoing traumatic/war situation.

From my experience, there is definitely a difference with how to approach behavioral health care. In a combat situation, you can’t “fix” what is wrong. I’d go as far to say that you can’t “treat” them, unless you pull them out of the combat environment. They are in an ongoing life-and-death situation where they are repeatedly exposed to traumatizing experiences. It is similar, if not the same, to helping a patient who is in an ongoing abusive environment. I believe feeling helpless is normal for providers in these cases, given they know that the person they are working with is going to keep experiencing trauma. So how do we as providers cope with our sense of helplessness, knowing that whatever we do our patients are simply going to walk right back into their life-and-death struggle?

I believe the answer is centered around the idea of “finding peace”. When I was embedded with a forward deployed unit during my time in Iraq, I quickly discovered that I couldn’t fix what was “wrong” with those individuals who sought me out. They were experiencing understandable stress that was unfathomable. Depression, extreme grief, and trauma reactions were expected. But what I could do was help them find a sense of peace around whatever they were struggling with, which is what I honestly believe they were looking for in the first place. They didn't want me to “fix” them. They were simply seeking a sense of peace with their turmoil.

My job was to help them find that peace and whatever that meant. Focusing on how to help bring some sense of peace is what I did to combat my own sense of helplessness. I remember thinking how messed up it was, that my job was to keep them together enough so they could get back into the fighting. My job was weapon’s repair, not treating them to get back to actual mental health in the conventional way. I constantly reminded myself, though, that my goal in combat was to actually help them survive to make it home. I’d deal with the fallout of combat and “treatment” then.

What do I mean by helping patients find peace during an ongoing struggle? I found that a sense of peace can be found for a variety of reasons, traumatic experiences and what they discover they are capable of during war being common ones. Sometimes warfighters struggle to understand why they acted a certain way during an incident. Helping them understand their actions in reference to the fight/flight response, their emotional mindset, their training, or simple mission needs and the need to do whatever it takes to save their comrades can go a long way with helping them find peace with their actions. I then normalized their emotional reaction to it, pointing out that their struggle with their actions and what they witness is proof that their humanity and “soul” remains intact. I think this is a common concern that warfighters struggle with – that they are losing their sense of humanity and soul. The look of relief I’ve seen after this discussion is how I know that I’ve helped that person have a bit of peace around this worry of theirs.

Often, I found warfighters struggling with how “senseless” the deaths and overall destruction was, knowing that it wasn’t over and they would continue to experience these things. I remember how disheartened I felt with this came up, because in a very real sense they were right. This is one area where how I dealt with it during combat is close to how I deal with it now, after the fact. The key to finding peace in this case is to help them create meaning from the situation. For example, if someone died, instead of focusing on the senselessness of the death, how do they honor that person’s legacy and make it so their life and possibly death is not meaningless? What was important to the deceased? How did they impact the world in a positive way? How can the individual honor them and continue the deceased’s legacy in the world? I’ve had patients, for example, find ways to comfort others in the way the deceased used to, or volunteer for organizations that were important to the deceased. Regarding the senselessness of the overall war situation and things they see not involving death of a comrade, I help them consider how they can engage in reparation. Perhaps this meant a specific kindness to a civilian in the combat zone. Or more internal, personal actions such as saying a prayer for those negatively impacted.

I also remember helping soldiers find peace regarding their mindset, specifically around being okay with dying. What do I mean by “being okay with dying”? It is important during combat for warfighters to accept that they might die and, in fact, be okay with that fact. Having this mindset allows them to not only do what is needed during combat, but also helps them cope with the anxiety and fear about possible death. This mindset, however, can create conflict between being “okay” to die but knowing they have family back home who need them. One gentleman I talked to was struggling with how he could be okay to die when he had children back home who would miss him if he were gone. We talked awhile about how he had already impacted his children’s lives and his legacy with them, regardless if he returned home or not. He in particular sticks in my mind because I distinctly remember wondering at some point in our discussion if I was helping him at all, feeling helpless as a provider. But then, at the end, he thanked me, stating that our talk had helped a lot. That helped me so much in my discovery about the importance of helping them find peace.

Another soldier I recall talking to in the warzone was angry about what he perceived were the political reasons we were in Iraq in the first place. We know from research that soldiers can really struggle if they do not support the reason for the mission, so it is important to help them find peace on this topic. How did I do it? This soldier came in yelling about the politics, the stupidity of it all, and wondering why he continued to go out on convoys every day “just to get blown up”. He argued that he shouldn’t be going out to fight anymore for the political reasons he cited. I pushed right back at him, stating that it wasn’t about politics and the reason he went out there every day was because there was no way he was going to let his guys go out there without him. He calmed right down, stating I was right. I had refocused the purpose of why he fought from politics to thinking about his colleagues and doing what he could to protect them. A key saying with the military is that the reason they fight is because of the person to their left and to their right. No warfighter in the history of warfare has ever fought for a political cause – politics is just what gets them to a location, but it isn’t why they fight. They fight for each other. Period. So if you have a person struggling with the mission reason, refocus them onto their comrades. In this, they will find peace for why they fight.

Helping warfighters find peace isn’t always about what is happening in the combat zone. Sometimes what is weighing heavily on them has to do with things back home. In those cases, it was a lot like the therapy I’d do outside a warzone, if not exactly the same. But it had a different spin on how important it was – in a warzone it can be very dangerous if a soldier’s mind is being distracted by concerns at home. And if some of their depression or stress can be “fixed” because it isn’t related to ongoing war/trauma, then it feels even more important to remove that load given the expected emotional stress that war creates. It is like being able to lighten the load where you can, so that the added load won’t tip them over the edge.

One soldier I worked a lot with while deployed struggled with his connection with his wife. They had a lot of problems in their relationship, and he honestly didn’t know if he still loved her. We worked a lot on understanding his struggles with attachment in general and how this impacted his marital relationship. We also worked on communication skills, so he could better talk with his wife about their problems. When he came back from R&R (a two-week “vacation” from combat), he reported having talked with his wife and working a lot of their difficulties out. For the first time, he was looking forward to the end of deployment and returning home, excited to continue working on his marriage. His actual quote – “I don’t know if we will make it, but I know I love my wife and I’m going to try.” I remember this quote with tears, because two days after he said this, he died. I struggled a lot afterwards with how I felt about this. Yes, it was horribly sad that he never got home, but it was more than that. I finally realized that there was an emotion I don’t think we have an English word for, combining grief and satisfaction, perhaps? I realized that the day he died, he knew he loved his wife and she loved him. Remembering his smile, I know that in this, at least, he knew peace.

Focusing on helping patients find peace isn’t just about ongoing war and trauma. It is something I think we can focus on after the trauma is over as well – finding peace with their history and experiences. Nothing will “make it okay”, but they can be okay with living with it. I hope that my thoughts above will not only help providers in active combat but also those working with anyone who has experienced trauma. I truly believe that it is normal to sometimes feel helpless when working with people experiencing ongoing trauma. It is also normal to sometimes feel helpless with those not in active trauma situations, given the intensity of what patients sometimes experience. The key is to know we aren’t alone in this feeling, and to know that this sense of helplessness is probably coming from our drive to “fix” things and do a treatment that will take away a mental health diagnosis and the person’s overall struggle. When we feel helpless, we need to adjust what we are focused on. My default is to consider how to help the person find peace with their situation and experiences. I believe that much of the time, this is what they are truly looking for anyway, not to have their situation “fixed” but to be at peace with it.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Debra Nofziger, Psy.D., is a Senior Military Behavioral Health Psychologist and certified Cognitive Processing Therapy Trainer with the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.

By Allison Hannah, MSW, LCSW

Certain mottos stick with us from the moment we begin learning life skills. For me, one of the earliest was "be prepared," a principle I carried from my days as a Girl Scout into my military career. This motto emphasizes the importance of readiness and adaptability, key components of resilience. As a service member, whether we are learning how to use a map or training in high-pressure environments, the objective remains the same: develop the skills needed to perform under the most challenging conditions.

As I think about defining resilience, I often lean into the work of Daniel Siegel, MD, as he discusses resilience as a capacity to recover from adversity, adapt to challenges, and maintain a sense of stability and flexibility during stressful or difficult times (Siegel, 2020). Dr. Siegel also introduces this dynamic concept of a window of tolerance, which helps us reflect on the various degrees of adversity we can handle at different points in time (Siegel, 1999). When I reflect on resilience, I think about those skills I have developed over my lifespan to utilize during those times of high stress when I find myself outside my window of tolerance.

In the mental health field, we often hear that kids are resilient. As a child clinician in my previous role at a military treatment facility, who spent much of my time embedded in the elementary schools on and near post, I frequently heard from teachers, medical staff, and many other professionals, "military children are so resilient." This comment resonates with me as a professional and a parent of military children, especially when I see children endure challenging situations and still "bounce back." As I write this, it was only four weeks ago when my oldest daughter, 10, broke both bones in her wrist during the second soccer game of the season. Outside of the physical pains, she was devasted to learn that she would have to sit out the rest of the season for her favorite sport. However, after a day or so of lots of words of encouragement, plenty of reminders that she was allowed to feel disappointment and other challenging feelings, and a myriad of signatures from friends and supportive adults on her cast, my tween was back on the soccer field, this time standing on the sidelines cheering her team on for the next ten games of the season.

So, what about our children, especially those growing up in military families, make them so resilient? Research does not generally identify inherent traits children are born with that lead to some sort of natural resilience. Dr. Siegel’s work identifies that resilience is cultivated by developing skills in emotional regulation, self-awareness, and interpersonal support (Siegel, 2020). Easterbrooks, Ginsburg, and Lerner (2013) discuss resilience as the result of access to positive relationships and resources. As a social worker, I tend to look through a lens of systems and environments to notice if bigger contributions are at play. These thoughts lead me to reflect on the environment in which military children grow up—like supportive families, schools, and communities that may foster this resilience and the skills children may learn from their service member parent(s) and support systems. However, I am more interested in whether this resounding recognition of resilience within the average military child endures as they transition into adolescence and adulthood, especially as they may no longer have access to a military-connected community. While we often tout their resilience, it is important to ask: Is the initial resilience witnessed in childhood withstanding enough to contribute to their long-term well-being? Or do we need to be more intentional in building the skills and systems that support their mental and emotional health into their next developmental stages?

When we think of military children, the image that comes to mind often includes babies, toddlers, and elementary-aged kids. That is not surprising, given that over two-thirds of the 1.55 million military children are under the age of 11 (Department of Defense, 2022). Additionally, the programs available for military families tend to focus on young children, leaving a gap in support as these kids reach their teenage years. Yet, we know that adolescence brings new and complex challenges—emotional, social, and developmental. The most recent publication of the CDC's Youth Risk Behavior Survey shows continued upward trends among adolescents in reporting poor mental health and suicidal thoughts and behaviors (Centers for Disease Control and Prevention, 2023). How do we ensure that the resilience military children build during their early years carries them through these turbulent teenage years and beyond? This is a timely factor especially considering many teenagers whose parent(s) served have separated or retired by the time they reach adolescence, and they no longer have immediate access to a military community. What happens when these kids grow up?

For years, we have known that military life can significantly shape the lives of children, but there has been little long-term research on how military experiences specifically affect adolescent development (Tannenbaum & McMaster, 2024). That is changing with the recent launch of the Millennium Cohort Study of Adolescent Resilience(SOAR), a groundbreaking subsidiary of the larger Millennium Cohort Study. Launched in 2022, SOAR is embedded within the larger Millennium Cohort Study and is the first U.S. population-based longitudinal study to examine the well-being of military-connected youth. By following thousands of military-connected adolescents, the study will help to explore how military-specific experiences impact psychosocial development, mental health, and career aspirations; SOAR's scope and depth are unprecedented (Tannenbaum & McMaster, 2024).

SOAR's multi-informant design—surveys service members, their adolescent children (ages 11–17), and another primary parent—offers an innovative family-systems approach to understanding how military experiences shape adolescent health and development (Tannenbaum & McMaster, 2024). By collecting and linking data from all three family members, SOAR aims to bring to light data on the enduring impact of military life on adolescents' physical and mental health, academic achievement, and future aspirations. The longitudinal design of SOAR allows researchers to follow military-connected adolescents into young adulthood, offering a rare opportunity to observe changes in health, effects of the parent-adolescent relationship, and resilience over time. This type of data is crucial, as it will allow us to explore not just the immediate effects of military life on teens, but also how these experiences shape their transition into adulthood. The results from SOAR will be invaluable in helping researchers better deduce how protective factors like supportive communities and stable relationships can shape resilience. Insights gleaned from SOAR also have the potential to help us understand why some children and teens struggle more than others and how we can intervene to support those who need it most.

I am hopeful SOAR will be a game-changer for military family research, and its findings can potentially affect how we approach adolescent well-being within military and civilian families. As results begin to emerge, they have the potential to inform evidence-based interventions, policy developments, and programs designed to enhance the resilience and readiness of military families. Perhaps most of us already know that the journey of resilience does not end with childhood. As military children grow into teenagers, they need continued support to navigate the complexities of adolescence. By understanding the systems that foster resilience, acknowledging the unique challenges military teens face, and applying lessons from studies like SOAR, we will be better able to support the next generation of military-connected youth. I hope you are as excited as I am. You can check out more about this study at Study of Adolescent Resilience: A Department of Defense Research Project (millenniumcohort.org).

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Allison Hannah, MSW, LCSW, is a Military Behavioral Health Social Worker for the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.

References:
 Centers for Disease Control and Prevention. (2023). Youth risk behavior survey data summary & trends report: 2011-2023. U.S. Department of Health and Human Services. https://www.cdc.gov/healthyyouth/data/yrbs/pdf/YRBS_Data-Summary-Trends_Report2023_508.pdf
 Department of Defense. (2022). 2022 Demographics profile of the military community. https://download.militaryonesource.mil/12038/MOS/Reports/2022-demographics-report.pdf
 Easterbrooks, M. A., Ginsburg, K., & Lerner, R. M. (2013). Resilience among military youth. The Future of Children, 23(2), 99–120. https://doi.org/10.1353/foc.2013.0014
 Siegel, D. J. (1999). The developing mind: Toward a neurobiology of interpersonal experience. The Guilford Press.
 Siegel, D. J. (2020). The developing mind: How relationships and the brain interact to shape who we are (3rd ed.). The Guilford Press.
 Tannenbaum, K. and McMaster, H.S. (2024) The Study of Adolescent Resilience (SOAR): a research protocol. Front. Child Adolesc. Psychiatry 3:1346726. Doi: 10.3389/frcha.2024.1346726

Dr. Rita Brock recently shared her thoughts on moral distress and injury and COVID-19 frontline workers with me. I’m pleased to share parts of that conversation with you below. Dr. Brock has spent much of her career as an academic in philosophy and religion, obtaining her doctorate in this field in 1988. Her interests turned toward moral injury after a 2009 article by Dr. Brett Litz (see below for article citation) “grabbed me and wouldn’t let me go.” As a person who works in religion, ethics, and psychology, she understood how religions address human suffering and believed she could add to the conversation behavioral scientists were beginning to have around moral distress and injury.

Many are familiar with the 2012 book “Soul Repair: Recovering from Moral Injury after War” (citation below), coauthored by Dr. Brock. Besides this and other publications, she was also the Founding Director of the Soul Repair Center at Brite Divinity School, Texas Christian University. In 2017, Dr. Brock began her current position at the Shay Moral Injury Center at Volunteers of America which focuses on developing and implementing moral injury programs at a national level. While the Center initially focused on programs for military veterans, since COVID-19 it has expanded to developing support for front-line workers struggling with moral challenges during this devastating time.

In 2017, the Shay Moral Injury Center developed an evidence-based program called Resilience Strength Training (RST) for combat veterans struggling with moral injury. RST was developed as a peer-facilitated program to decrease the stigma many veterans have about seeking care. Results from a recently published study on the efficacy of this program show it helps veterans working through moral injury, specifically through the development of self-calming strategies, communication skills, self-esteem, improved sleep, and peer-supported communities. For more details about this study (Barth, 2020) and program, go to this link:https://doi.org/10.21061/jvs.v6i2.199. Currently, the Center is adapting the 50-hour program to an online 25-30 hour program. Since the pandemic, they have also adapted elements of the program to a one-hour online support program for COVID-19 care workers, keeping the peer-facilitated model, with the name Resilience Strength Time (ReST).

I asked Dr. Brock what about the peer-facilitated group model she believes is so effective with moral injury. One key healing agent she identified was the validation that occurs when people hear from others experiencing similar situations. People learn they are not alone with their moral struggle. Peer facilitators understand what the person is going through, thus reducing stigma and fear of judgment.

Dr. Brock added that when people have the chance to support others, it allows compassion for self to kick in: “It transforms what you think of yourself to listen to and support others.” Dr. Brock’s experience with the power of peer support groups goes back to her time with a summer camp program for high schoolers dealing with intense issues, ranging from violent crimes to family abuse. Through her work with them, she witnessed the profound impact of group leaders allowing themselves to be vulnerable and share their own experiences – “in that moment, they were peers… people who understood and (the high schoolers) could connect to.” It was this powerful connection that Dr. Brock wanted to carry forward to peer-facilitated moral injury programs to help reduce stigma and allow people to share their pain and work toward healing.

How is the Shay Moral Injury Center adjusting the RST program for COVID-19 ReST for healthcare workers?
The healthcare profession clinicians, especially nursing, have been writing about moral distress and injury faced by professionals for years. Based on this and her own experiences, Dr. Brock knew that the pandemic would place healthcare and frontline workers into a crisis situation around moral injury. In ICU settings, witnessing death is not an uncommon experience. With COVID-19, however, there is much more death, providers are more limited in how they can help, and the patients are dying alone instead of with loved ones. There are more morally challenging decisions and emotional pain involved.

Indeed, Dr. Brock believes these circumstances are similar to what medical providers face in a warzone, something most civilian providers have never experienced. Dr. Brock agrees with other moral injury specialists regarding the importance of people opening up to others who share their moral challenges. People need to talk about their pain and distress in order to process it. To help these providers, Dr. Brock and her colleagues adapted what they learned working with Veterans and the RST program. They started with peer facilitators from the existing veteran RST program and offered open-format online one-hour support group sessions that any COVID-19 healthcare worker could attend.

As the program progressed, the Center trained others to be the peer facilitators guiding the group discussions. These groups are confidential and open to the public. Participants can attend as often as they wish. To access ReST, participants just need register through the VOA/ReST website. Once registered, they are provided with a schedule of upcoming sessions which they can sign up for. Although attendance in prescheduled groups means membership will change session-to-session, arrangements can be made for the same group of people to meet each time. On Mondays at 7 pm Eastern, there is a specific group for military veterans co-facilitated by veterans.

What do you think and hope we will learn from the pandemic about moral injury/distress?
I found Dr. Brock’s answer to this question direct and profound. After reflection, she shared the following hopes for what our society will learn:

• “Moral injury isn’t limited to military Veterans.” Although we have known this, we have been unable in our society to validate this with research until recently.
• “(Moral injury) is also a collective experience.” As a society, we will need to deal with it at larger levels, both in how we recognize it and help those experiencing it.
• “How people feel morally about themselves and society affects how people behave.” This is true both when people are left to continue questioning morality and when they are able to come to an understanding that leaves their morals more strengthened.
• “Moral Injury is the excruciating remnant of goodness in people…. You can’t have a moral injury without a moral conscience.” The struggle with devastating experiences can lead a person to judge themselves or others as bad. In fact, though, to make that judgment requires an inner awareness of what is good, and that awareness is important to recovery.

What do you wish behavioral health providers understood about moral injury?
"Moral emotions like guilt, shame, remorse, humiliation, frustration, anger and all of those feelings are NOT pathologies…. They are appropriate emotions given (a person’s) experience and morals.” I discussed this truth with Dr. Brock, as well as my own observations with military patients both during and after combat deployments. I have been amazed with how many patients, let alone providers, think that the pain and grief involved with moral distress is something that needs to be “fixed” or that these emotions are evidence that there is something wrong with them. The truth is that experiencing moral distress when faced with a morally challenging situation is proof of a person’s goodness and humanity, not proof that they are “broken.” They are suffering, which is why they are feeling pain, and they suffer because they are good.

In our discussion, Dr. Brock shared her own observations of this, acknowledging that although moral injury is understandable, it becomes problematic when it takes over one’s life. Working through a moral injury does not mean the painful emotions are gone. Instead, the intensity of the emotional pain is mitigated so it no longer is in control, and the moral injury becomes a source of information about the self and situations as well as a motivator for action. There will still be emotional pain about the past, but the load is such that it can be carried. As Dr. Brock explains, “You have to sit in the fire until you burn clean (a metaphor she got from Jaques Verduin who works with men in San Quentin Prison). Then you can examine it and learn how it will inform your life.”

Since our interview, I’ve reflected a lot on that last idea and quote about sitting in the fierce fire until you burn clean of it. With the support of others who understand, it is incredible what people can and do get through. My personal fear of a ‘worst outcome’ situation is that those amazing frontline workers doing intensely difficult and emotionally painful, yet necessary, jobs feel they are alone and try to shut down or hide what they are going through. Or, worse yet, they believe they are somehow damaged or “broken” because of how their own morality causes them to feel.

Then there is the second part of Dr. Brock’s statement, that after you burn clean you can sit back, examine what happened and put what you learn into some type of proactive movement in your life, either personally or on a societal level. My sincerest hope is that our world will be able to do just that once this pandemic is under better control, if not over. I am so grateful for support programs like those offered by Dr. Brock and the peer specialists at the Shay Moral Injury Center. I believe they are exactly right about us needing to encourage people to talk about their pain with peers and professionals who can understand and support them through it. In my opinion, the ReST program and other support services like it are what our world needs right now to make sure we come out clean and wiser once this is all over.

More information about the VOA Shay Moral Injury Center and ReST programs can be found at https://www.voa.org/moral-injury-war-inside.

Interviews with Dr. Brock about her work can be found online. These include:

• From WebMD – “COVID-19 and the Threat of Moral Injury” recorded on 22 October 2020. https://www.webmd.com/coronavirus-in-context/video/rita-nakashima-brock
• Dr. Brock and ReST Facilitators explaining program: https://www.youtube.com/watch?v=P4ec31tYxFE
• From Volunteers of America, short video explaining moral injury within combat veterans: https://www.voa.org/the-war-inside
• Recorded webinar “Moral Resiliency for Medical Workers During COVID-19” produced by Volunteers of America:
  • Full webinar (2 hours): https://www.youtube.com/watch?v=wFF8wx6Oqc&list=PLOp3UYSMYFviGIrPLKa_xA_qV7xKUmD_h&index=3&t=2s
  • Shortened edited version (50 minutes): https://www.youtube.com/watch?v=wFF-8wx6Oqc&list=PLOp3UYSMYFviGIrPLKa_xA_qV7xKUmD_h&index=3&t=9s

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Rita Nakashima Brock, Rel.M., M.A., Ph.D., Rev. Dr. Rita Brock is Senior Vice President and Director of the Shay Moral Injury Center at the Volunteers of America.

Debra Nofziger, Psy.D.,is a Senior Military Internship Behavioral Health Psychologist with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. Dr. Nofziger is currently located at the Brooke Army Medical Center, TX.

References and Resources:
Barth, T. M., Lord, C. G., Thakkar, V. J., & Brock, R. N. (2020). Effects of Resilience Strength Training on Constructs Associated with Moral Injury among Veterans. Journal of Veterans Studies, 6(2), 101–113. https://doi.org/10.21061/jvs.v6i2.199
Litz B.T., Stein N., Delaney E., Lebowitz L., Nash W.P., Silva C., & Maguen S. (2009). Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695-706. https://doi.org/10.1016/j.cpr.2009.07.003
Brock, R. N. & Lettini, G. (2013). Soul repair: Recovering from moral injury after war. Beacon Press.

The last blog entry on in vivo exposure discussed some strategies to help your client be better prepared to benefit from in vivo exposure. This week I want to talk about “post-in vivo processing”. We don’t usually emphasize processing when we discuss in vivo exposure but it is just as important for in vivo exercises as it is for imaginal exposure. Post-in vivo processing is not merely a check the box activity to make sure the homework was done but instead is an opportunity for a client to reflect on the homework assignment, and extract some understanding or insight from the experience of facing fear and living to tell about it. For some, this may simply mean concluding, “It was easier than I expected it to be!” But for others, it may mean evaluating and dismantling some strongly held beliefs that have kept them “safe” from harm for a long time. Give example?

Many clients will walk into session with in vivo worksheets in hand, ready to discuss their experiences, so I like to ask about homework in the beginning of the session to capitalize on what they just accomplished. Some of my colleagues like to save the processing of homework for the end of session so they can get to the imaginal exposure immediately. Either way can be effective but make sure your client knows what to expect so they don’t feel ignored if you don’t ask about the homework right away. One strategy might be to briefly review the homework at the start of session to provide reinforcement but save the processing and problem solving until the end of session.

Did your client do the assignment?

Begin by finding out whether your client actually did the assignment. If avoidance or a complicated life is preventing him/her from doing the homework, you will spend your processing time trouble shooting those barriers. We could (and maybe we will) write an entire post on troubleshooting barriers, but for now let’s assume that your client did the in vivo assignment and is ready to show you the worksheet. This is your first piece of information to process. What does it tell you?

The most important thing it says is that your client took a step toward getting her life back. She had enough confidence in the treatment, in you, and in herself that she attempted, and perhaps successfully completed the assignment. This is accomplishment number one! She faced her fear!

Lead with the positive

While this accomplishment is certainly rewarding in and of itself, a simple word of praise at this point, from you, will not be wasted.

“You did it!”

“You took the first step. Good for you.”

So perhaps she didn’t stay in the situation as long as you had hoped. Maybe she didn’t do everything exactly as planned, but remember successive approximations from graduate school? This is the process of rewarding small movements or approximations of the target behavior, until the behavior is executed successfully. Shaping behavior in this way takes a few trials so be patient.

It’s not all good, however There may be some problematic aspects to correct for next time, but go ahead and praise what you honestly and sincerely can. Normalize distress and avoidance, and later, after you have extracted all that you can from what went well, constructively discuss the changes that are needed for the next time.

Praise as corrective information

Praise is emotionally rewarding if it is believable, sincerely given and meaningful to the one being praised. But one of the most important things about leading with a bit of praise for effort in this context is that it informs and corrects. For this purpose, it must be descriptive, specific, and timely. One of the biggest problematic beliefs in PTSD is some version of “I am weak for reacting the way I did (having PTSD),” “I should have been able to handle this by myself, ” or “I am incompetent and everyone knows it.” Your specific praise, as well as comments pointing out the evidence against these beliefs is a clear indication that you don’t buy it. On the contrary, you know the treatment is challenging, you appreciate your client’s courage and determination, and you have confidence that she will be able do it. When your praise is targeted in this way, it is not a mindless pat on the head: it actually is corrective information in action.

Broaden your repertoire

PTSD almost always includes many negative, inaccurate thoughts about the self. I hope you take every opportunity to specifically and descriptively comment on, and praise any thought and behavior of your client that disconfirms his deeply held negative beliefs. This means you are going to be praising her a lot, so increase your repertoire of responses. “Great job” is nice to hear a few times, but it starts to sound rote and insincere after awhile. Use humor where it is appropriate.. Tie your praise to the evidence. Look for ways to weave praise into your discussion without fanfare. For example, sometimes a simple statement of fact is a sneaky way to get in some covert praise on the fly.

“You are really working hard.”

“You did it.”

“I can see that you are putting a lot of effort into your homework.”

“You took that one on like nobody’s business.”

“You were like the energizer bunny this week!”

Review the Data

The data begins with the in vivo exposure recording form itself. This form is your client’s experience on paper, and when you go over it together, he can use the recorded data to recall what the experience was like in detail. Most forms use numbers – SUDs - to track the experience, but it is equally valid to use a graphical representation that gives a visual picture, if that is more meaningful for your client. Review the worksheet to get clues about where you might need to focus the discussion. For example, the SUDs data tell you how difficult the assignment was and whether it got easier, or remained distressing throughout the exercise. The number of repetitions tells you about your client’s enthusiasm, commitment to the process, and perhaps something about barriers to doing the treatment, if there are only a few or no repetitions. Perhaps there are notes on the form as well, telling you about your client’s reactions in the moment. Even a sparsely completed form is a clue for follow-up.

Let the client do the talking

While you are reviewing this rich data, resist the urge to open your mouth and start talking, unless you are going to offer praise, or clarify something you don’t understand. Instead gather the data from your client before you start offering your wisdom. Get her impressions of the experience before offering your own. You can use open-ended questions like these:

“How was this experience for you?”

“Did you learn anything new?

“Were your fears confirmed?”

“What are your thoughts?”

“What do you make of the numbers?”

“Was it as bad as you thought?”

“What kept you going? Why were you able to hang in there?”

Normalize PTSD related distress and avoidance

Chances are, even if the assignment went well, your client had some PTSD related distress or avoidance along the way. This is expected, predicted and should be treated as such. Let her know that this is par for the course. Be empathic and compassionate, but accept, and help your client accept, that distress and avoidance are part of PTSD, and confronting them is a planned part of the treatment. Emphasize the opportunity to test out problematic beliefs about distress, its alleged omnipotence, and your client’s ability to have a satisfying life even if distress is sometimes present.

E.g., “Even though it was distressing to be in such a large crowd, you were pleased to be able to attend the graduation ceremony for your daughter. “

Look for habituation, emphasize tolerance

We are always delighted when we see those SUDs numbers going down during the in vivo exercise and across repetitions of the same exercise, right? Look for it, and if you see it, ask about it. Find out how your client views the decrease. Did it get easier, or did she disengage? Did she use distraction or other safety behaviors, or did she habituate?

If the habituation seems credible, celebrate it, but don’t make it your only measure of success because not all the in vivo assignments will follow this pattern. Though some patients successfully habituate to everything on their hierarchy, others do not, and they get better anyway. Sometimes distress tolerance is as important as habituation. And it is a useful skill to highlight and develop because in the end, there will be more distress in life. Learning to tolerate and move through distressing experiences will give your client another way to take care of herself.

Finally, you get to talk

By now, your client may have worked through her experience with your support, of course, and there is nothing left to say except “great job.” But chances are you have noticed some things your client didn’t, so now is the time to ask more pointed, but still open-ended questions. Help your client deconstruct problematic beliefs by asking for more information about her views versus the new information learned in the in vivo. Look for thoughts and beliefs that maintain symptoms and focus the discussion toward these by asking about experiences during the in vivo and at other times that are contradictory.

E.g., “You say that you don’t have control of your temper, but you were able to be civil even though the clerk was rude to you and you felt very angry about it. What do you make of that?”

Now is the time process the safety behaviors or avoidance that may have interfered with learning. What triggered the avoidance? How did the safety behavior function in the exercise? Did it allow your patient to stay when he otherwise would have escaped? Did it prevent him from experiencing distress? Did it help or prevent him from testing his problematic beliefs? Is he willing to drop the safety behavior for the next assignment? Is he willing to stay longer and test the problematic beliefs that maintain avoidance?

Be patient

Resist the urge to sum it all up in a nice little package. Your client may need to do the exercise a few more times before she can come up with more helpful ways of viewing the situation. Let her have that experience. It will teach her so much more than your possibly brilliant but premature summary could do because it will include the nuances of her own life and her own reactions that you cannot possibly know. So be patient. There are times when you will lead your client more directly, but this is always a second line strategy. Let the more powerful strategy of personal experience have a chance to work first.

Do it again

Once you have sufficiently mined the experience for all that it is worth, it is time to collaborate with you client as you plan the next in vivo exercise. Is there more to learn from this item or has it been sufficiently processed? If it is still difficult, or if there are problematic beliefs or safety behaviors still at play, it is important to continue working on it. Does it need tweaking to get at other aspects of the core fear? Are there new questions that need to be tested? Will the corrective information gleaned from this experience easily generalize to other, similar activities, or do you need to change the context to encourage more generalization?You will be aiming to move up the hierarchy as you progress from session to session, but don’t get married to the original hierarchy. New situations may come up as your client gets more active and engaged with his life. Add those new situations as they arise.

While this may seem like a lot to do in homework review, it doesn’t usually take more than a few minutes, and as you model this approach each session, your client might begin processing on her own, making your job even easier. In the end, as with all your interventions, you are not only working through the traumatic experience, you are teaching your client a set of skills, and an approach to life that will serve him well in the future.

Am I the only one who has a hard time keeping my “pearls of wisdom” to myself so the client has a chance to find their own wisdom?

Am I the only one to discover that my fabulous would-be interpretation of the client’s experience was totally off the mark (whew, glad I kept my mouth shut that time!), when he found his own wisdom a few sessions later?

What have you learned helping people process their experiences in therapy?

Staff Voices: Five Strategies to Fortify Your In Vivo Work