“We all have our breaking point”

What can be done to increase the resilience of German military personnel? What does it take to survive the stresses and strains of deployment? What about acceptance of mental disorders among military personnel, and how can a professional approach help? The editorial team at “Ethics and Armed Forces” spoke with psychologist Dr. Ulrich Wesemann from the Psychotrauma Center at the Bundeswehr hospital in Berlin.

Dr. Wesemann, resilience is a complex concept. How would you define it from the point of view of psychology, in just a few words?

Resilience is commonly defined as a certain ability to resist or persevere in the face of critical situations, so it means remaining psychologically stable and not allowing the stress of the situation to affect you. Whether it is always possible to do that is another question. I see it as a continuum between two opposite poles: on the one side is resilience, the ability to endure or resist, and on the other is vulnerability – a kind of sensitivity or susceptibility. So it does not matter so much which term you use.

What is it that makes people resilient or vulnerable? Do these tend to be fixed personal characteristics – are some people more resilient and others more vulnerable – or can resilience be acquired and learned?

Both. There are various theories. Many experts assume that there is a genetic component first of all. But others take the view that resilience can be acquired. I think it is a combination of both. For example, the fact that psychotherapies are effective shows that you can influence resilience.

Could you give a rough estimate of the ratio between invariable factors and those that can be influenced?

No, the extent to which environmental or genetic factors play a role cannot be expressed as a percentage. Resilience research is a huge field, but it cannot make one hundred percent predictions. Overall, the studies that have focused more on vulnerability are stronger. So vulnerability factors seem to give better predictions. But if we say that these are basically the same as resilience, then we have to conclude that resilience research has not quite found the right influencing factors yet. You would only need to reformulate the vulnerability factors and call them resilient. For example, “sleep problems”, “physical complaints” or “depressed mood” could become “healthy sleep”, “physical wellbeing” or “balanced mood”. That would take greater account of a person’s current psychological states, which are definitely indicators of resilience.

In your view and based on your experience, what are the factors that influence resilience the most? Are they internal or external factors?

I think that locus of control is a very important factor, i.e. the perception of how much control we have over situations and events. How predictable are they, how much can we influence them? That seems to play a big role. Self-efficacy is also a very important factor. We would tend to describe these as traits, i.e. stable factors that change relatively little over time. Among the external factors, the most important is group cohesion – in the military, this is called camaraderie – and a good social fabric at home. These are the most important elements that are most likely to make people resilient.

Is the effect cumulative – in other words, does having more positive factors make you more resilient?

You cannot simply add them up, but on the other hand, it is clear that it is always better if a person has more of these factors.

What role do sport and physical exercise play in resilience? And if I may ask a personal question: What is your most important resilience resource?

I would say my family is my most important source of resilience. They give me a lot of support and strength. But actually, leisure activities – whether sport or something else – in general, a full personal life with nice things to do and good friendships, that plays a big role. A certain level of satisfaction with one’s job is also part of it: to see a purpose and enjoy going to work, having good relationships with colleagues.

So can you really predict whether someone will cope better or worse with difficulties, based on factors like these? Some people argue that resilience only becomes apparent in the actual situation in which individuals experience stress.

People who have the appropriate factors will withstand certain situations better than those who lack them. Such predictions are certainly possible, but are more appropriate when applied to a large group; they should not be applied to individuals.

And what about military personnel, who are not only exposed to potentially traumatic experiences during deployments, but also experience high stress and other adverse circumstances? Do they have a higher risk of psychological disorders as a result?

Yes, because of their job they have an increased risk of developing an occupational mental disorder. According to our studies, the most common are anxiety disorders, followed by around two percent of post-traumatic stress disorders (PTSD) and depressive episodes. The one-year incidence of mental disorders among military personnel following a deployment is higher than in the general population. If we now look at whether those affected suffered a critical event, we see that those who did have a six to seven times higher risk of developing a disorder. Without this critical event, military personnel are in a range similar to that of the ordinary population. Of course, being away from home and the conditions during deployment act as stress factors in themselves. Even if these are regarded as rather normal conditions in the military, they are still a risk factor.

So if it is really all about the deployments and what is experienced there, how do you go about preparing for them, how can you strengthen resilience in a preventive way?

This may sound a bit disappointing for psychologists, but the most important thing is the ability to act confidently, i.e. training for performance in various critical situations. What exactly happens during operations is unpredictable to some extent. But if military personnel have practiced particular military situations and acquired a certain level of confidence in their actions, this is a protective factor that also transfers to other situations. During the 2016 Christmas market attack in Berlin, for example, we saw that it was far more stressful for firefighters to take on tasks that were usually outside their area of responsibility. So there is already a whole range of factors that we can influence, e.g. through training. The next thing is good equipment. Apart from that, group cohesion is important, i.e. building camaraderie. That happens automatically during a deployment, but it can also be encouraged.

it is not about getting through all critical situations symptom-free, but finding the most professional way of dealing with them

Finally, it is useful to know about mental disorders. We have used a computer-based training program called CHARLY for this purpose. The approach behind it was called “From Hero to Pro”. That means it is not about getting through all critical situations symptom-free, but finding the most professional way of dealing with them. Destigmatization is a big topic here.

Isn’t CHARLY also a way of experiencing that some stress reduction techniques – such as breathing exercises – really work?

That’s right. Training participants rehearse critical situations in a photo-realistic way. It is an immersive experience, and they then have to calm their own excitement. So it is about emotional anticipation. If they have prepared themselves for such critical situations, then naturally they no longer seem as overwhelming as they would without preparation. The most important factor, as I said, is performance, to make sure that they really stay in control of a situation. If soldiers train their emotions to achieve this, then of course there is a much greater chance that they will get through it well.

We observed good effects from the training even during the deployment preparation stage. Those who had been prepared for deployment with CHARLY had fewer symptoms of PTSD following active service in Afghanistan (the International Security Assistance Force (ISAF) mission). So it really is an effective tool.

Is CHARLY still being used?

No, the project has ended now, and it was not designed for the whole military, but only for various task forces such as explosive ordnance disposal teams and the medical service. But of course there are also other preventive training programs in the Bundeswehr. For example, the B.E.S.S.E.R. method is currently being taught extensively. It is a form of mental first aid, which anyone can use to help people who are in psychological shock.

Do the German armed forces also carry out pre-screenings to identify certain risk factors?

The Psychological Service of the German armed forces has a screening instrument – the “mental fitness assessment” – which can be carried out individually, or also in a group setting. Every member of the military can take the test voluntarily and then receive guidance from troop psychologists. It is not intended as a selection tool, but rather to identify problems in particular areas, which can then be addressed individually. Basically to see if there are weaknesses somewhere, and what can be done about them. For example, with social skills training, sleep training, or exercises to reduce symptoms of overexcitement. This can be done in both individual and group settings. The Psychological Service is currently developing various training programs around these goals, and recently launched trainSLEEP – a self-learning tool to help you improve your sleep.

But military resilience programs have attracted a fair amount of criticism. One example is the Comprehensive Soldier and Family Fitness program in the United States. It is strongly influenced by positive psychology, and has been accused of promoting problematic attitudes, along the lines of “you just have to change your mindset, then you can handle anything”. What do you say to that? Where does the resilience concept reach its limits?

As far as I know, the U.S. program was hyped a lot at first, but was then increasingly criticized for having been hastily cobbled together and transferring things from a civilian to a military context without evaluating them properly. And of course, resilience training has its limits because we all have our breaking point. When external stress becomes too much, we all get sick – some of us faster than others. Some with a stomach ulcer, others perhaps with a depressive episode. Resilience cannot be trained to infinity.

When external stress becomes too much, we all get sick

I don’t think we’re doing too badly with our approach to “mental fitness”. We train on an individual basis, where there is a need for training. We can’t say all that much about the overall success at the moment, but I am really quite confident.

You mentioned the stigmatization of mental disorders. Being resilient and robust is part of the self-image of soldiers; people also talk about a “rescue mentality”. Is there a greater understanding of mental disorders now, also following the experiences of overseas deployments?

In the military, as in other forces and services, there is actually far more acceptance of occupational mental disorders than in the general population. Unfortunately, however, the opposite is true as far as the individual affected is concerned. Based on deployment statistics, which record all military personnel who have received psychological treatment in connection with their deployment, we see that it takes an average of three and a half years before they seek treatment for the first time – if they do at all. We assume there is a large number of unreported cases.

Last year, we were at the Interschutz trade fair in Hannover. We used a questionnaire to survey more than 1,000 personnel in other forces and services, most of them firefighters, to find out how they felt about stigmatization. In response to the hypothetical question of whether they would rather have an equivalent psychological disorder or physical illness, the majority opted for the physical illness. So the psyche still seems to be a big mystery. But there is a need for a professional approach to dealing with occupational and personal psychological stress, hence our slogan “From Hero to Pro”.

What exactly do you mean by that?

I think it is important to understand that the military, police or firefighter profession is not first and foremost about “being a rescuer”, but about doing your job well – for example, helping people. And at the same time paying attention to how you feel about work-related stress, and finding a good way to deal with it. As I said earlier, stressful situations can always arise that are overwhelming – and here a professional approach is needed in the sense of accepting help or getting help. Psychological problems are an occupational risk that should be accepted as such and taken seriously.

So more should be done to reduce stigmas, especially at the individual level?

Incidentally, it may be due to the fear of institutional stigmatization if people do not seek professional treatment

Yes, unfortunately there is still work to be done. Incidentally, it may be due to the fear of institutional stigmatization if people do not seek professional treatment. People fear poorer career opportunities, or that their superiors or colleagues will think badly of them. That is why we started establishing destigmatization programs some time ago. But they were limited to the military. Now we have developed a simple non-expert assessment questionnaire. It is designed to enable partners of Bundeswehr personnel to better assess the psychological state of the person concerned. This can serve as a basis for discussions, or as a starting point for requesting advice about other services. We hope that this will strengthen their partnership. Additionally, it could help soldiers seek support earlier. The questionnaire is still being validated. In a pilot phase, we have already been able to identify disorders quite successfully. We are now testing it on a larger scale.

Is this essentially an attempt to activate the social environment as a resilience factor?

Of course we’ll have to see whether gentle pressure from the family is enough to make someone seek treatment. But this is also just a tool to push back the stigma. After all, we do have quite good therapeutic measures to treat most mental disorders. But if those affected don’t come, it is difficult to help them; and the longer they wait for treatment, the more difficult it becomes.

So with psychological disorders too, the earlier you seek treatment, the better the chance of successful treatment?

Generally speaking, that is true, but of course not in every individual case. For example, a depressive episode may subside on its own. On the other hand, we also know that once it has occurred, the chances of another one occurring are significantly higher, so early treatment absolutely makes sense. The mental fitness assessment is also designed to work preventively, before a psychological disorder develops.

The principles of Innere Führung (leadership development and civic education) are sometimes mentioned in connection with resilience factors.^[1] How important is people-oriented leadership in general, especially in the military?

Good leadership is an extremely important factor in resilience

A recently published study showed that social support has a significant impact on psychological symptoms.^[2] Social support in this case was understood to mean not only the family, but also colleagues and superiors. We have already tried replicating the study, and found that social support during deployment, especially from superiors, is reflected in psychosomatic health. We also concluded that good leadership is an extremely important factor in resilience. Or – if it is lacking – it is a vulnerability factor.

The meaningfulness of deployment is also an important protective factor. If the soldiers don’t see a meaning in it, they are less motivated and, of course, more vulnerable when they run into difficulties.

Don’t certain value orientations also make people more susceptible to so-called moral injuries? Aren’t “morally sensitive” soldiers more easily shaken when they encounter situations during deployments that completely contradict their values?

Unfortunately you’re right about that. There are studies, for example by Professor Peter Zimmermann et al., that tend somewhat in this direction. They show that soldiers with a strong “traditional” value orientation, for example, are more susceptible to depressive symptoms in such situations. So these value orientations seem to be predictors of moral injuries. It is important to note that these are not a diagnosis in themselves, but psychological disorders can develop from them as a consequence. From the deployment statistics, we found that moral injuries have increased in recent years.

As Professor Zimmermann says, it is also a sign of a strong moral orientation if soldiers encounter problems in such situations and do not simply let the experience bounce off them. So are we faced with a dilemma that cannot be fully resolved?

That’s right. We cannot hire antisocial people for that reason, even if they might be more resilient in some situations. There is just as much a need for empathy. One solution would be to understand such value orientations as a risk factor, and then train other influencing factors. As I said, the resilience concept has many variables and possibilities. For example, the Psychological Service now offers preventive measures for dealing with moral conflicts, if needed. These are suitable for intervention at an early stage to avoid psychological disorders from developing in the first place.

Let me briefly turn to another topic. In the Ukraine war, people often speak – perhaps somewhat carelessly – of the strong resilience of the Ukrainian population. But the people there have been experiencing intense violence for over a year. What awaits this country?

We can observe this in other war contexts as well: Most of the time, the soldiers hold out until the end. But once the war comes to an end, sadly we have to expect massive psychological repercussions. Not only among military personnel, but also among the civilian population.

At the moment, the principal goal is probably to make the soldiers fit to fight again …

Unfortunately, in war the individual person does not play a major role. Rather, they are expected to function. Whether they suffer harm as a result is usually a secondary consideration as long as they don’t fail. Let us at least hope that they all receive appropriate help as early as possible.

Dr. Wesemann, thank you very much for the interview.

Questions by Rüdiger Frank.