By Hamid R. Tavakoli, MD, FAPA, FACLP
Head, Consultation-Liaison Psychiatry
Naval Medical Center Portsmouth
Portsmouth, Virginia, USA
and Landon L. Van Dell, MD, LCDR, MC, USN
Associate Program Director, Psychiatry Residency
Naval Medical Center San Diego
San Diego, California, USA
This work received no funding. The authors have no conflicts of interest.
Disclaimer
The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.
Copyright Statement
We are military members and employees of Department of the Navy, Department of Defense and the United States Government. This work was prepared as part of our official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties.
INTRODUCTION
All U.S. military branches – the Army, Navy, Marine Corps or Air Force – have a set of core values. As psychiatrists who treat active-duty military members, we often return to the core values that we, and all members of the armed forces, are taught during military training. We often observed time and again that the same skills that are successful in the armed forces, coined these skills the Warrior Psychotherapy Elements, which, when encouraged, can cause a paradigm shift in the individual, and conceivably a community and a nation. In the following we will briefly review the essence of Warrior Psychotherapy and highlight its most pertinent elements that can be taught and instilled in treatment settings to give strength to those combating life problems. Warrior Psychotherapy underscores the positive impact of these values, which we believe are often overlooked, perhaps more so now than ever in the past. Its elements can be the building blocks needed not just to restore emotional health and functioning, but to live satisfied and fulfilled lives – to live the best life possible.
WARRIOR PSYCHOTHERAPY
The most sophisticated entity in the universe is the human brain. Embedded amongst its abundant connections and powerfully integrated functions, we have our complex behaviors and emotions. These complex mental functions lead us to productive and content lives, but occasionally they can go astray and do the opposite. In the midst of these suboptimal brain performances and mental malfunctions (referred to as disorders), we deteriorate and become impaired. Such disturbances bring about suffering not just for us, but also for our loved ones and our communities. The essence of medicine, through its art and science, is to alleviate human suffering. Psychiatry is a medical discipline that focuses on such suffering by diagnosing and treating mental disorders. General forms of treatment are either pharmacology or psychotherapy.
Many forms of specific psychotherapies can be found, but if one takes a broad view of psychotherapies, they are either psychodynamic or cognitive-behavioral in nature. Psychodynamic psychotherapy is rooted in psychoanalysis and Freudian themes of unconscious conflicts, past experiences and their meaning.1 Cognitive-behavioral psychotherapy challenges automatic patterns of thinking and negative thoughts that lead to mood disturbance.2 Deriving from these two main schools of thought, in this article we introduce a different type of psychotherapy, termed “Warrior Psychotherapy.”
Adjustment disorder is a mental health diagnosis that outlines a group of symptoms developed in response to stressful or traumatic events. The response is often exaggerated, causing social disruption and suffering, though typically short-term. Adjustment disorders are very common within the military, as individuals are frequently stressed, sometimes purposefully. They are additionally put in unpleasant enviornments, far from home, without typical comforts. Despite this, service members are expected to meet high standards of performance. When an adjustment disorder develops, the nature of work within the armed forces becomes a difficult hurdle to manage, and the service member will often not meet suitability standards. Adjustment disorders can at times be successfully treated with medications and traditional therapy methods. However, without the removal of military environments, they will very frequently recur. Warrior Psychotherapy is designed to specifically target acute adjustment disorders and resist the development of future symptoms. The hope is that a person can learn to tolerate a stressful situation and continue to succeed.
The method of Warrior Psychotherapy is to gain meaning, and then face up to life’s problems, not just to function, but go beyond functioning (analogous to utopic view of health in psychoanalysis).3 Warrior Psychotherapy is a type of therapy that reinforces qualities and traits in a patient that are similar to a warrior. By encouraging and instilling such characteristics, the patient’s suffering and emotional disturbance will be better tolerated or alleviated. The belief here is that life is a battle, and we face adversity, setbacks and losses, similar to a military member in combat.
We conceptualized nine of the most significant elements of Warrior Psychotherapy that can be taught to patients in combating life problems. It is our opinion that these elements are the building blocks needed not just to restore emotional health and functioning, but to live the best life possible. These are specific characteristics from our military branches of service that teach the service member how to overcome challenges when deployed or in combat. The same can be taught to the general public to overcome emotional negativity and turmoil in civilian life. When these Warrior Psychotherapy Elements are fostered, encouraged, and shaped by the physician or other treatment providers, they can cause a paradigm shift resulting in optimal functioning.
HONOR
One of three United States Navy Core Values is honor, with the other two being courage and commitment.4 Honor can mean many things – reputation, glory, recognition, kindness, pride and so on. Ultimately, honor is the highest form of self-respect. Every day begins and ends with this pursuit. Having integrity, especially with oneself, is an integral part of self-respect. A person of honor does not lie, steal, cheat, or take advantage of another. These practices are destructive and lead to chaotic life experiences, anxiety and suffering. Any sense of self-respect is damaged with such acts. For example, denial, perhaps the most pathological on the list of unhealthy defense mechanisms, is basically lying to oneself – the antithesis of integrity; hence self-respect; hence honor.
Honor involves both mind and body. In the military, in order for you to be mission essential, you must maintain physical readiness. Your body is the tool required to carry out life’s missions. For mission success, that tool cannot be abused, rather it should be finely tuned and ready for obstacles.In a sense, a clear conscience and a healthy body is the essence of honor. If you cannot honor and respect yourself, you cannot properly appreciate and love your family, friends, fellow humans, or the world around you.
MORALITY
Morality is a system of values held by a person, or society. However, morality is more than just right or wrong. The question is why? Why be moral? Why do the right thing, even when no one is looking? The answer lies in having faith. Faith here does not have to be linked to any religious institutions. Effectively, faith is a belief in something beyond yourself. For many, faith can be a trust in God and a system of religious beliefs. But faith can be many things. It is not necessary to practice your faith within a formal organization with rituals and traditions. Keep in mind, faith is neither blind nor thoughtless. It requires study and effort. It does not antagonize the pursuit of truth.
Morality, and with it, faith, are crucial in the military where recognizing the interconnectedness of all tasks and jobs helps keep focus on the overall mission. A sense of belonging to something far greater than an individual can propel the motivations and actions of service members, whether they are on the battlefield or behind a desk at an office. As treatment providers, we have to help those whose purpose is lost, no matter the stage of their illness or life circumstance. Patients often need guidance and encouragement to realize their roles in the workplace, in their relationships, in their families, and their communities; morality and faith can renew the much needed vigor and hope.
EXCELLENCE
One of three United States Air Force Core Values is Excellence in All We Do. The other two being Integrity First and Service Before Self.5 The aim of this element is never perfection – a concept that is an illusion and never attainable. Rather, it is for continued improvement. It is the pursuit of continued improvement through performances and accomplishments. Every citizen has the right to pursue happiness, as declared by our nation’s Founding Fathers. Along the same framework, whether in personal or community pursuits, we must strive for excellence. We must aim to improve, to think better, to act better, to become better, each and every day.
This element of Warrior Psychotherapy highlights why the goal of mere “functioning” can be a hazardous concept; a concept that lowers expectations of ourselves and our brains. As stated in the beginning of this article, our brains are extremely powerful, and excellence happens in the pursuit, never finishing, never achieving perfection, but rather striving to be better in perpetuity.
PROBLEM-SOLVING BEHAVIOR
Personality disorders, regardless of cluster type, are generally defined by chronic maladaptive coping mechanisms and immature psychological defenses. At the core, the shared common feature of these pathologies is a recurrent and inflexible pattern to problem-solving. These individuals are more prone to adjustment difficulties, although anyone can face significant distress or impairment when struggling to problem solve. Some, often times, have abundant solutions, but none that work to resolve or alleviate their life stressors. Problem solving skills that are taught during officer training school can be applied beyond the military and leadership schools. Acronyms can at times be helpful. The acronym is: Real Good Leaders Test Several Ideas. Life has obstacles and every individual will be stressed frequently. This is one of several useful approaches that focus on finding the best possible solution to any obstacle, problem, or life stressor. In such a mindset, individuals are the leaders of their own lives and minds. Recall the poem “Invictus” by William Ernest Henley (1875): “I am the Master of my Fate, the Captain of my Soul.”
COURAGE
Courage is the second US Navy Core Value. Very important to note: Courage is not fearlessness. Whether in the office, battlefield, sports arena, etc., many individuals question their heart. The fear to move forward can surround failure, pain, embarrasement or any number of unpleasant consequences. But any or all of these unpleasant consquences can be key to the puzzle of improvement. Failure is necessary to learn. Tension and pain are required to strengthen muscle. Embarrasment can often be the initial effect felt from delivering new or better ideas. In other words, fear is okay and adaptive. There is no courage without fear, otherwise it would be recklessness. We must learn to be comfortable challenging ourselves. It takes true mettle to buy into the idea that failure is a part of life, and we learn and grow from it. Eleanor Roosevelt said, “People grow through experience if they meet life honestly and courageously. This is how character is built.” This idea is constantly instilled in service members. The same mentality of courage, to move forward despite pain and obstacles, can be taught to any person.
TOUGHNESS
Toughness means many things. Similar to courage, which often occurs in settings of fear, toughness happens within many settings of physical and psychological stress. Grit and tenacity of purpose are essential for toughness. It is the resistance of hopelessness and the rejection of giving up. This is not a fixed quality, but rather can be cultivated through conscious and focused practice.
Maintaining control is indeed often necessary for success. However, how does one deal with a situation when control is out of our hands? Do we give-in or give-up? Toughness could play out as the former but never the latter. Remaining resolute in dire circumstances would never involve giving up. For example, a patient has terminal lung cancer. Giving in to this diagnosis is the most psychologically healthy option. If continued treatment cannot end with resolution of the terminal diagnosis, does a healthy-minded patient wither away and give up because the outcome is inevitable? This giving up behavior leads to demoralization and depression.6 It takes grit and stoicism to give in and accept this uncomfortable position, while maintaining the aspects of life that can still be controlled – a stark difference from giving up. Another example would be an outnumbered team of special operatives in a foreign land whose position was discovered. These individuals are trained to never contemplate the idea of giving up, but rather give in to the terribleness of their situation and fight against the odds. That much they can control.
Ultimately, it takes determination, grit, and tenacity to resist hopelessness in the setting of physical and psychological stress. It takes toughness to avoid giving up when the balance of control is not ideal. This concept does not only apply to the stress of warfare, but also to the stress of finances, health problems, heartbreak, or any number of difficulties throughout life.
SITUATIONAL AWARENESS
Significant effort is made to improve the ability of military units and individual warriors to rapidly develop and maintain situational awareness. Situational awareness stems from understanding factors that influence any condition. Likewise in the civilian world, situational awareness may mean understanding what your boss needs, what your family wants, what you have in the fridge to make for dinner tonight. What is the goal for this meeting? For this week? For the next 5 years? What is your mission today? Tomorrow? Next year? How do you define your mission success?
Awareness of the details and steps required to achieve on a day-to-day basis are important elements akin to situational awareness in the military or civilian world. Similarly, situational awareness requires understanding the resources available, understanding the priorities of those around you and understanding how you fit into a larger picture.
FLEXIBILITY AND ADAPTABILITY
President Dwight Eisenhower once said, “Plans are nothing. Planning is everything.” Typically, with an acute stressor – for example, a deadline – a person has a plan but will either have to be flexible with their schedule to complete the project, or risk being late. The plan changes. Once the stressor resolves, the schedule can return to normal. However, if this is a chronic and repeated stressor, the situation may require a permanently adapted schedule. Perhaps they can delegate tasks so that the timeline to each deadline is not so ruthless. Either way, the plan changes and continued planning is necessary for success. The hallmark of those suffering from personality disorders is that they have chronic maladaptive coping styles when faced with stress and are inflexible in their approach to life’s problems. This rigid style will inevitably lead to adjustment problems and suffering when faced with changing environments or increased stress. To be adaptive and flexible are the opposite of disordered personality traits. To recognize and practice these elements, to be flexible and to adapt, becomes indispensable.
COMMUNICATION
Communication, simply defined, is a connection between people or groups of people that allows for the exchange of thoughts, feelings and ideas. Ideally, communication leads to mutual understanding. While the concept of communication is simple, it cannot be thought of as simplistic, as the application of communication is complex. There are several components to communication, including content of what is being communicated, the context of the situation, the way the content is delivered (e.g., tone of voice and body language), the method by which communication is transmitted (e.g., in person, by phone, email, teleconferencing, etc.), the relationship between the people or groups of people, how the information is perceived or understood and the effect of the information being communicated.
The ability to communicate intentions or decisions effectively to others is a vital skill within the military setting and beyond. There are significant repercussions that could result if communication is poor, and it requires empathy and respect to avoid these setbacks.
Human beings are social, yet communication can go awry in so many ways that, in some cases, people choose to isolate. The importance of human connectivity is highlighted by the fact that perceived loneliness has been shown to be a risk factor for mortality and suffering. We have seen this play out very clearly in our world during the COVID-19 pandemic. Thus, the way we communicate with others and foster human connections, is vital to our health. This element must be practiced and fostered within the therapeutic setting.
CONCLUSION
Warrior Psychotherapy focuses on building upon certain character traits and reinforcing behaviors that lead to successful management of life stressors. This method is most clinically relevant for treating acute adjustment disorders and preventing future symptoms. These techniques will serve the general public just as effectively as they do our active duty service members. With proper guidance through psychotherapy, these warrior elements can serve to not only return patients to mere functioning, but they will have the opportunity to reach optimal functioning. Much like a warrior’s mentality, healthy minds strive for improvement, find solutions to problems, learn from failures, adapt, and ultimately, never give up.
REFERENCES:
- Gabbard, G.O. (2014). Psychodynamic Psychiatry in Clinical Practice. 5th Edition. American Psychiatric Publishing, Inc.
- Wright, J.H., Brown, G.K., Thase, M.E., Basco, M.R. (2017). Learning Cognitive-Behavior Therapy. 2nd Edition. American Psychiatric Publishing, Inc.
- Sadock, B.J., Sadock, V.A., Ruiz, P. (2015). Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 11th Edition. Wolters Kluwer.
- McComas, L., Kristenson, J.D. (2019). Naval Officer’s Guide. 13th Edition. Naval Insititute Press.
- Benton, J.C. (2008). Air Force Officer’s Guide. 35th Edition. Stackpole Books.
- Wise, T.N., Biondi, M., Costantini, A. (2013). Psycho-Oncology. American Psychiatric Publishing, Inc.
Table 1. Warrior Psychotherapy Elements
| ELEMENT | ASSOCIATED CONCEPT | END GOAL |
| Honor | Derivative of all other warrior beliefs | The highest form of self respect |
| Morality | Foundation of ethical code | To believe in something beyond yourself – faith. |
| Excellence | Never perfection, but the “pursuit“ to be better | Motivation for self-improvement |
| Problem Solving Behavior | Structured problem solving | Selecting effective solutions |
| Courage | Moving forward. Having fear is ok. | Grow from adversity |
| Toughness | The difference between giving up vs. giving in | Struggle against helplessness and hopelessness. |
| Situational Awareness | Pragmatic understanding of conditions for mission success | Gain awareness and insight |
| Flexibility and Adaptability | Oppostite of personality disorder traits: Inflexibility and Maladaptive coping | When plans fail, make new plans |
| Communication | Connection | Empathy and understanding |
Table 2. Problem-Solving Behavior
| Real Good Leaders Test Several Ideas | |
| Recognize | … the problem (the most important step) |
| Gather Data | facts – observed truths criteria – boundaries, e.g. time definitions – explanations assumptions |
| List | possible solutions |
| Test | a solution listed |
| Select | the best solution |
| Implement | re-do process with another listed solution if ineffective |
