Psychological Well-Being

Chapter 25
PSYCHOLOGICAL WELL-BEING

ANGELA M. YARNELL, PhD*; ERIN S. BARRY, MS†; and NEIL E. GRUNBERG, PhD‡

INTRODUCTION

DEFINITIONS
Well-Being
Psychological Fitness
Psychological Well-Being

FOUNDATIONS OF PSYCHOLOGICAL WELL-BEING

Behaviors Relevant to Psychological Well-Being
Cognitive Processes Relevant to Psychological Well-Being
Emotional Factors Relevant to Psychological Well-Being

MILITARY LIFE AND PSYCHOLOGICAL WELL-BEING

Psychological Well-Being and the Service Member
Psychological Well-Being and the Military Family

KEY INDICATORS OF PSYCHOLOGICAL WELL-BEING

Positive Affect
Mindfulness
Meaning and Purpose
Social Support
Unit Cohesion
Core Values

PSYCHOLOGICAL WELL-BEING AND THE MILITARY MEDICAL OFFICER

Role of the Military Medical Officer
Guidance to the Commander

PSYCHOLOGICAL WELL-BEING RESOURCES

SUMMARY

*Major, Medical Service Corps, US Army; Research Psychologist, Behavioral Biology Branch, Center for Military Psychiatry Neuroscience Research,
Walter Reed Army Institute of Research, Silver Spring, Maryland
†
Research Assistant Professor, Department of Military & Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
‡
Professor, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

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INTRODUCTION

The part can never be well unless the whole is well.

—Plato (circa 425–347 bce)
The highest achievement by humans is happiness.
—Aristotle (circa 384–322 bce)

The philosophies of Plato and Aristotle are relevant decide to serve are willingly signing up for a lifestyle
today for understanding the concept of psychological that includes occupational stress; the possibility of
well-being. Plato expressed the idea that a human is dangerous, life-threatening encounters; and separa-
made up of parts that contribute to a physical, psy- tions (sometimes frequent) from significant others.
chological, and spiritual whole and that all parts that These lifestyle requirements may make the people
constitute the whole must be healthy for the being to be who choose military service different from people
well. Aristotle built upon his mentor’s philosophy by who do not. Research findings aid understanding and
adding that the ultimate goal of humans is happiness. improvement of the lives of service members and their
He characterized this state as an achievement because families in all areas, including that of psychological
it requires effort. well-being.
Military service members, their families, and civil- Military medical officers (MMOs) play an impor-
ians may strive to achieve or maintain psychological tant role in identifying individual, family, and unit
well-being. However, the life of a military service opportunities to sustain or improve psychological
member involves challenges and situations that well-being among those they serve. In addition to
differ from civilian life. The US military has been caring for patients, MMOs must advise commanders
an all-volunteer force since 1973, and people who and maintain and practice self-care.

DEFINITIONS

Well-Being a positive and valued state that should be achieved to

help optimize human performance. Utilization of the
A state of health and wellness, the ability to judge three components described above help individuals
life positively,1–3 and to achieve a balance between reach that goal.
positive and negative affect.4 In general terms, well-
being refers to physical, emotional and psychological Psychological Well-Being
conditions.
Integrated concepts of well-being and psychologi-
Psychological Fitness cal fitness are crucial to understanding psychological
well-being (PWB). PWB includes the following six
Psychological fitness is one of eight components of components of positive psychological functioning6,7:
Total Force Fitness,5 and includes internal resources,
external resources, and operational outcomes. Internal 1. Positive evaluations of oneself and one’s past
resources are present to some degree within every in- life (self-acceptance).
dividual. They include awareness, levels of optimism, 2. A sense of continued growth and develop-
coping, decision-making, engagement, and active ment as a person (personal growth).
disengagement. External resources are not intrinsic 3. The belief that one’s life is purposeful and
to an individual; they originate from the environ- meaningful (purpose in life).
ment and include training, leadership, and various 4. The possession of quality relations with oth-
fitness and wellness programs. Operational outcomes ers (positive relations with others).
represent the consequences of applying internal and 5. The capacity to manage effectively one’s
external resources to a circumstance. These outcomes life and surrounding world (environmental
include quality of life, mental health, sleep, drug use, mastery).
and suicide. For example, an individual who is psy- 6. A sense of self-determination (autonomy).
chologically fit may have excellent coping skills and
seek out wellness programs to deal with challenging Approaching and achieving these components of
situations, avoid risky behaviors, and enhance qual- psychological fitness help achieve the goal or state
ity of life. Psychological fitness has been identified as of PWB.

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 Psychological Well-Being

FOUNDATIONS OF PSYCHOLOGICAL WELL-BEING

PWB is an important component of human perfor- PWB21,22 and fewer depressive symptoms,23 whereas
mance optimization. It can be discussed independent- a diet of processed or fried foods, refined grains,
ly, but it impacts and integrates with states of social sugary products, and beer is associated with poorer
and physical well-being. For example, poor PWB may outcomes.21 Comfort foods—typically, foods high in
lead to diminished social and physical well-being.8 sugar and carbohydrates—can enhance PWB acutely.
All conditions of well-being are needed for human Eating ice cream, for example, is associated with in-
balance and health. creased positive affect.24 However, too much intake of
Positive PWB is associated with biological correlates these kinds of foods can lead to excessive weight gain
that protect health,9 and the development of PWB for that may decrease PWB over time.
physicians can help them adapt to demands of the Food deprivation generally decreases PWB and is
medical profession.10 A good understanding of PWB can related to psychological distress.25 The term “hangry”
help the MMO to (1) optimally care for patients (service has been coined to describe situations in which a per-
members and families); (2) appropriately advise com- son is angry as a result of hunger. Although this word
manders with regard to how PWB of service members may be amusing, it is a fairly common phenomenon
and families impacts readiness and performance of and is possibly related to decreases in self-control as
service members; and (3) maintain and practice self-care. a result of hypoglycemia. Low glucose in the prefron-
tal cortex, the area of the brain responsible for self-
Behaviors Relevant to Psychological Well-Being control, may be related to increases in aggression and
violence.26 When the prefrontal cortex is deprived of
To understand PWB and how to achieve or help oth- energy, such as in the case of hypoglycemia from not
ers to achieve it first requires consideration of behav- eating, an individual may experience reductions in
iors, cognitions, and motivations, as well as spiritual self-control. Being hangry is an interesting emotional
factors, that contribute to PWB. These factors must be manifestation of a state of physiological need that is
integrated for each individual seeking to achieve PWB. important to consider in terms of well-being.
Behaviors that affect PWB include exercise, leisure
activities, eating, sleep, drug use, and sexual behavior. Sleep
These behaviors may have a positive or negative effect.
People spend more than a quarter of their lives
Exercise sleeping, and quality sleep affects performance and
PWB.27 Most healthy adults need 7 to 9 hours of sleep
Individuals who exercise are more satisfied with each night.28 However, most individuals, including
their lives and happier than individuals who do not military personnel, do not get enough sleep (or enough
exercise.11 Specifically, individuals who exercised two quality sleep). Lack of sleep negatively affects PWB.
to three times per week are less depressed, angry, and Chronic insufficient sleep is related to increased expe-
stressed; are more trusting; and perceived their health rience of pain (eg, body pain, back pain, and stomach
to be better compared to people who do not exercise pain) as well as compromised optimistic outlook and
much.12 Exercise is important for everyone, but may social functioning (eg, rating on friendliness, efficiency,
be especially beneficial for people with physical health and sociability).29 Getting 8 hours of sleep increases
(eg, cancer, cardiovascular diseases, arthritis, and sexu- optimistic outlook and social functioning.29
al dysfunction) and psychological problems (eg, major
depression13); pregnant women14; and teenagers.15 Drug Use
Leisure activities also enhance PWB.16 Activities
like tai chi17; yoga18; and group activities19 improve Drug use can affect PWB, whether legal (eg, alcohol,
PWB by reducing stress and anxiety, improving mood, nicotine, caffeine, or drugs prescribed to the user) or
increasing self-esteem, and reducing social isolation. illegal (eg, street drugs such as opiates, prescription
Satisfaction with leisure activities clearly correlates drug abuse, or inappropriate use of performance en-
with benefits to PWB.20 hancing drugs). Licit drugs are used by many people
to enhance PWB and to attenuate stress.30 However, it
Eating is important to understand the health risks of repeated
drug use, including physical health dangers and de-
Proper nutrition (eg, eating fruits, vegetables, lean creases in PWB when drug dependence develops and
meat, fish, and whole grains) is linked to positive during abstinence from addictive drugs (both licit

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and illicit).30 Illicit drugs also are sometimes used to optimism is used to describe the extent to which
enhance PWB acutely, but long-term effects usually people hold generally favorable expectancies for their
lead to decreases in PWB for psychobiological, social, future.37 Optimism is related to increases in PWB,38
and legal reasons. MMOs must be aware of the effects while pessimism (belief that bad things will happen
drug use has on PWB and educate commanders and in the future39) decreases PWB. Specifically, optimism
patients about these potential dangers. is related to indicators of better psychological and
physical health; responses to adversity; emotional
Sexual Behavior well-being; and relationships.37 In contrast, pessimism
is related to less life satisfaction40 and more depressive
Being sexually active is linked to better physical symptoms.40,41 The ability to generate vivid mental
health and likely to PWB. Lack of a healthy sexual re- imagery of positive future events, instead of focusing
lationship or being in an unhealthy sexual relationship on negative thoughts or “thinking traps” (eg, catastro-
is associated with poor PWB. For example, in women, phizing), results in better PWB.42
self-reported sexual dissatisfaction is correlated with Religiosity and spirituality are also related to
lower PWB.31 Further, unwanted sexual behaviors PWB.43–46 In particular, spiritual fitness enhances
(ranging from verbal comments, nonverbal com- resilience, health, and well-being.47 Spiritual fitness
munication, or uninvited touching to sexual assault) refers to domains related to the human spirit (eg, val-
have powerful and lasting negative effects on PWB. ues, feelings, aspirations) encompassed by spiritual
Of particular relevance to the military community, beliefs and practices, but is not specific to a particular
it has been reported that women who deployed to a religion or faith.48
combat zone were more likely to have experienced
sexual stressors than female service members who Resilience
did not deploy.32 In addition, sexual abuse has been
associated with decreased PWB (eg, depression and The American Psychological Association defines
poor body image).33 psychological resilience as “the process of adapting
well in the face of adversity, trauma, tragedy, threats
Cognitive Processes Relevant to Psychological or significant sources of stress.”49 Resilience factors
Well-Being represent individual or group-level variables that
contribute to a decrease in the negative reactions to
Cognitive processes include attention, awareness stressors.50,51 Individual resilience factors include ef-
or perception, thoughts, and beliefs. Cognitions both fective behavioral and cognitive coping skills. Group
affect and reflect PWB. resilience factors may relate to effective leadership
or support from the unit. An interesting analysis of
Awareness survey data collected from deployed service mem-
bers (Mental Health Advisory Team [MHAT-VI])
Awareness is an aspect of consciousness that entails indicated that although soldiers reported similar
a perception of one’s environment. The manipulation rates of combat exposure, there was little similarity
of awareness (eg, mindfulness) affects well-being. For in scores on a measure of PTSD symptoms.52 This
example, individuals who are able to balance work analysis highlights the marked variability in response
and life demands, and completely detach from work to stressor exposure experienced by individual ser-
during off hours, are more satisfied with their lives, vice members and suggests differential effects of
have less stress, and fully engage while at work.34 resilience factors.
Mindfulness, used by marines and soldiers, is associ- Resilience and resilience training are receiving
ated with decreases in perceived stress35 and increased substantial attention in the military to help service
performance.36 members prevent and recover from physical and
psychological stressors. It is noteworthy that “thriv-
Beliefs and Appraisals ing” (to grow and develop subsequent to stress such
that the individual becomes stronger53) is an ideal that
The experience of stress or negative emotions maximizes PWB. The MMO plays a key role in trans-
depends on a person’s beliefs or attitudes about lating the science behind resilience into practical and
the situation or the way in which he or she assesses applicable tools that unit commanders and individu-
or appraises the situation. For example, having an als can use to enhance their ability to deal with stress,
optimistic outlook can lead to better PWB. The term thereby enhancing PWB.

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 Psychological Well-Being

Emotional Factors Relevant to Psychological Well-

Being

Positive emotions enhance and reflect PWB,

whereas negative emotions are inversely related to
PWB. Individuals who are skilled at recognizing and
regulating their own emotions and the emotions of oth-
ers are said to be high in emotional intelligence. High
emotional intelligence is related to increased PWB.54
Emotional arousal (or stress) is related to perfor-
mance and psychological state following the classic
Yerkes-Dodson inverted U-shaped function (Figure
25-1). Some individuals seem to thrive under extreme
stress (eg, Navy SEALS and other special operations Low Medium High
forces), and the point at which the effects of stress go
from positive to negative differs from person to per-
son. Many factors seem to affect this point, including
genetics, prenatal environment, childhood stress, per- Figure 25-1. Depiction of the Yerkes-Dodson Law of Optimal
sonality, resilience, and other factors. The relationship Arousal. As one’s arousal or stress level increases, so does
between PWB and particular levels of arousal or stress, performance and hedonic (or emotional) state; however,
when stress is high and exceeds one’s coping ability, per-
therefore, depend on the individual and on situations.
formance and hedonic state decrease.
Medical professionals experience job stress and Data source: Yerkes RM, Dodson JD. The relation of strength
burnout. These demands are negatively related to of stimulus to rapidity of habit-formation. J Comp Neurol
PWB. Further, individuals who lack social support Psychol. 1908:459–482.
from supervisors and coworkers display worse PWB Adapted from: https://en.wikipedia.org/wiki/
and more unfavorable work outcomes.55 File:OriginalYerkesDodson.svg.

MILITARY LIFE AND PSYCHOLOGICAL WELL-BEING

Military service affects the PWB of service members ing may occur because of beneficial resources associated
and their families. It ultimately affects units and the with military service, including job security and financial
military community, readiness, training, and even the compensation.56 For instance, a majority of Army officers
achievement of military missions. (70%) report satisfaction with pay.57 Although many
junior soldiers (about 30%) report financial hardship,58
Psychological Well-Being and the Service Member it is not clear if these concerns predated enlistment (eg,
existing debt) or developed during military service. Free
Military researchers have investigated the psycho- financial counseling and educational services are offered
logical effects of war for decades. Modern conflicts by the military and may help soldiers improve their fi-
with increased survivability have shed new light on the nancial situations and reduce stress. Other advantageous
relationship between stressful and traumatic encoun- resources available to service members include tuition
ters and individual health and performance. There assistance, tax-free housing, subsidized childcare, free
is now a greater appreciation for this relationship, medical care, special pay, and bonuses (for retention of
and increased attention is paid to the role of mental soldiers with specific skills).
or behavioral health in readiness to fight and fitness The military culture also offers social benefits that
for duty. Greater emphasis is now placed on holistic contribute to PWB. Social support and unit cohesion
health, patient-centered care, individualized medicine, are both important determinants of PWB for service
and reduced stigma. The services now recognize that members. In addition, high levels of perceived sup-
military life affects PWB in service members and their port from the community, unit leadership, and base
families and that this impact is present in home, gar- agencies reduced service members’ concerns about
rison, deployed, and combat situations. their spouses’ ability to cope with deployment-related
Despite the stressful and often dangerous nature of stressors.59 This perception of support for the nonde-
military service, active duty military members are more ployed spouse mitigates one potential stressor on the
likely to psychologically thrive than civilians. This thriv- deployed service member.

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Fundamentals of Military Medicine

Leadership suffer from PTSD and mood-related disorders than

noninjured veterans.66 The relationship between physi-
Another key variable for PWB in the military, given cal injury and negative psychological effects may be (a)
its hierarchal structure, is leadership. Quality of life direct—physical injury may cause biological changes
in the military is highly dependent on leadership.57 that affect psychological state; (b) indirect—physical
Survey data collected from deployed service members injury may disrupt behaviors in ways that are psy-
indicate that strong leadership was significantly cor- chologically upsetting; or (c) by other means such as
related with improved morale and cohesion, fewer disrupting sleep, which can inhibit both physical and
mental health problems, and fewer ethical violations.60 psychological recovery.
Similar surveys of comparisons across 28 platoons
revealed that leaders who exhibit positive behaviors Transitions
such as clear thinking, while not displaying negative
behaviors such as showing favoritism, helped to re- Experiences during deployment have a great effect
duce effects of combat exposures.61 on how a service member transitions back into the
garrison environment. In their model of deployment-
Combat Stress to-home transition, Adler and colleagues describe the
following factors67:
Despite the benefits of military service, there are
obvious risks and potentials for poor outcomes with • deployment variables (experiences, anticipa-
regard to PWB. To a certain extent some reactions to tion of homecoming, meaningfulness);
deployment-related stressors are expected. The De- • postdeployment variables (physical, emo-
partment of the Army coined the term “combat stress tional, cognitive, and social);
reactions” to describe the physical, emotional, cogni- • quality of life (health, work, relationships);
tive, and behavioral reactions to these stressors and and
has defined it as “expected, predictable, emotional, • other reintegration moderators like decom-
intellectual, physical, and/or behavioral reactions of pression, developing a narrative, unit vari-
a Soldier who has been exposed to stressful events in ables, and anticipation of deploying again.
combat.”62 This definition normalizes the reaction to
combat-related stressors and also provides a frame- Deriving meaning from work while deployed and
work to identify and assess maladaptive responses, in garrison is particularly important for PWB. Finding
with the intention of early intervention. Of these meaning in work is associated with enhanced motiva-
various reactions, service members are most likely to tion and well-being.68 If service members find their
report physical symptoms to their medical provider. work while deployed to be meaningless, they may
These reactions represent physiological responses experience anger and resentment, leading to negative
and arousal to combat stressors. Muscle tension, sleep impacts on PWB. There may be less meaning associ-
disturbances, and headaches are physical symptoms ated with work upon return from deployment as well,
that may be reported by service members experi- for various reasons including a decrease in arousal
encing combat stress. It is imperative that medical associated with work in the postdeployment environ-
providers understand how reactions to combat stress ment. Decreases in arousal postdeployment can lead
can manifest physically and how they may present to increased risk-taking behavior. This behavior may
in patients. include unsafe driving, leading to more road accidents
and even increased death rates due to accidents in
Injury the year following deployment.69 Transition home
can be difficult for all service members, regardless of
These stressful or traumatic exposures can have their combat experience or mental health status, and
deleterious effects on PWB. In the last decade extensive should be appropriately planned, monitored, and as-
research has been done on the effects of combat on sessed. Military medical providers play a key role in
mental health, indicating increased rates of posttrau- this entire process.
matic stress disorder (PTSD), depression, anxiety, sub-
stance abuse, and other functional impairments.51,63,64 Psychological Well-Being and the Military Family
Some believe that combat-related PTSD may be an
occupational hazard of military service.65 Aside from The transition to life at home for service members
the psychological effects of stress exposures resulting with families can also have a great impact on family
from combat, service members suffer from physical relationships and on the PWB of family members. Mili-
injuries as well. Injured veterans are more likely to tary life has substantial impact on service members’

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spouses and families. Family members experience on intimate relationships and satisfaction. Marital
various stressors such as relocation, social isolation, relationships are affected by military service,79 specifi-
separation, and fear of or actual injury or death of cally in the following ways:
the service member. The stressors may positively or
negatively impact the PWB of the family member, • disproportionate work–family balance80;
depending on a number of variables. The wars in Iraq • preparing for or recent return from deploy-
and Afghanistan have brought the longest family ment81;
separations since World War II.70 More than half of all • difficulty communicating, reestablishing
combat deployments left at least one dependent fam- emotional bonds, or renegotiating roles and
ily member behind.58 These separations are difficult responsibilities82; and
for service members and their families, and family • physical or mental health concerns for one or
stability is negatively affected by prolonged separation both partners.57,83,84
because of deployment.71
Marital satisfaction is negatively correlated with
Spouse Well-Being PTSD and depression, although it is not significantly
related to combat exposure by itself, suggesting that
For female spouses, the length of separation is other factors are involved.85 MMOs should be aware
significantly associated with poor well-being.72 More of these strains on marriage and relationships unique
specifically, deployment has been related to decreases to military service and incorporate them into their
in health-promoting behaviors including exercise, practice and interactions with patients and families.
social interaction, rest, safety-related behaviors,73 and
greater perceived stress74 for the nondeployed spouses. Coping
Further, nondeployed spouses often have psycho-
pathological problems including major depression or In addition to the perception of stress, coping style
generalized anxiety disorder; emotional, alcohol, or is predictive of PWB in female military spouses of
related family problems; and functional impairment in deployed service members, and style of coping var-
work and life,75 sleep disorders, acute stress reactions, ies based on rank of spouse, whether she grew up
and adjustment disorders.76 in a military family, and experience of a previous
deployment separation.73 The ability of the spouse or
Care for Wounded Warriors family member to cope with the stress of military life
and deployment is important. In a study of spouses
In addition to the effects of family separation, the de- from an Army infantry division, problem-focused
mands associated with current wars include increased coping strategies were more frequently endorsed
survival but greater care requirements for wounded than emotion-focused coping strategies. Problem-
warriors.57 Specifically, PTSD can be a secondary focused coping refers to changing or modifying
traumatic stressor for family members. In one study, the fundamental cause of stress, whereas emotion-
PTSD symptoms reported by military members pre- focused coping refers to strategies that are effective
dicted increased symptoms in their female spouses.77 in the management of unchangeable stressors.86–88
The MMO can impact these associations by including Problem-focused coping was related to fewer depres-
family members in the treatment services for PTSD and sion symptoms, especially in instances where the
educating the family about combat-related reactions.60 individual perceived little control over the situation.89
These steps may help improve treatment outcomes for In addition, access to social networks and sources of
the service member and lessen the impact of mental social support—similar to the situation for service
health problems on the family. Education for family members—is critical for families. Support from com-
members about physical injuries (eg, traumatic brain munity and unit positively correlated with families’
injury and limb amputation) is important so they ability to adapt to stress.90 Spouses who did not meet
understand the symptoms associated with these inju- criteria for major depressive disorder or PTSD were
ries (eg, fatigue, memory loss, frustration, and angry more likely to report positive effects from deployment
outbursts) and do not blame the service member.78 (more independence, more self-confident problem
solving) than spouses who met criteria for major
Relationship Quality depressive disorder or PTSD.82
Although separations because of military service are
Given that deployment has clearly identified effects stressful and are associated with adverse psychological
on service members and their significant others’ well- health outcomes, these separations are quite different
being, it is no surprise that there are further impacts from separations during past wars because of current

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Fundamentals of Military Medicine

technology (email, phone, video call) that increase op- unlike most civilian children, live with the concern
portunities for communication and connectedness. Also, that their parent may be injured or killed during a
Internet and virtual communities may increase connected- combat deployment,94 which may lead to emotional
ness of family members to available sources of support.70 difficulties.95 Length of the parent’s deployment and
the parent’s rank (a variable that likely represents a
Employment complex set of family circumstances) are related to
PWB. There is some evidence that child neglect and
Military spouses’ employment is another important mistreatment increase for the children of enlisted
factor that affects PWB of military family members. service members during a combat deployment. 96
Working contributes to the overall satisfaction of mili- Increases in interpersonal violence in general are as-
tary spouses, providing additional compensation, per- sociated with combat deployment97 and the length
sonal fulfillment, independence, and other benefits.91 of deployment.98 It is important for the MMO to be
Unemployment can act as a chronic stressor92 and aware of these potential issues for family members,
negatively affect PWB.93 Education level of military especially children. Additionally, the MMO can assist
spouses also may play a role in better PWB. the unit command in preventing these poor outcomes
associated with military service and deployment by
Children educating them about the relationship between cer-
tain factors discussed here. For example, engaging
Children of service members also are affected by in military-sponsored activities seems to enhance
military separations. Children in military families, well-being.99

KEY INDICATORS OF PSYCHOLOGICAL WELL-BEING

Key concepts relevant to PWB include positive af- of mindfulness is extensive and instructive.103 Impor-
fect; mindfulness; purpose and meaning in life; social tantly, mindfulness can be helpful for many opera-
support; unit cohesion; and core values, which are the tional, leadership, and personal activities and is likely
heart of military service. These factors may change beneficial for enhancing resilience and overall health.103
over time and circumstances, so a clear understanding Many current military leaders use mindfulness as a
of them can be used by MMOs and the people they tool to better prepare for a dynamic and uncertain
treat to optimize PWB. future. Importantly, training in mindfulness has been
shown to serve as a preventive measure against physi-
Positive Affect cian burnout.104 It is an important concept that can and
is impacting health and performance.
Positive affect describes how much an individual
experiences positive moods such as joy, interest, and Meaning and Purpose
alertness. According to research, this concept appears
to be more beneficial with respect to health and mor- Meaning and purpose have been studied in the so-
tality relative to negative affect, in which individuals cial sciences since the late 1980s. Meaning is described
tend to experience negative emotions such as anxiety, as “making sense, order, or coherence out of one’s
sadness, fear, anger, guilt and shame, irritability, and existence” and purpose “refers to intention, some
other such feelings or states (eg, Cohen and Press- function to be fulfilled, or goals to be achieved.”105
man100). Positive affect is directly associated with Most of the literature assesses meaning and purpose
good sleep,27 serves a protective role in cardiovascular in pathological and psychopathological conditions, but
disease,101 facilitates healthy aging,102 and is proposed in some instances meaning in life has been found to
as a buffer for the impact of psychosocial risk factors. have a strong correlation with positive well-being.106

Mindfulness Social Support

Mindfulness can be conceptualized as the act of Social support involves the perception and reality
intentionally being acutely aware of what is going on of assistance and understanding provided by other
internally and externally, without reacting.35,36,103,104 people; this support can buffer or reduce stress and
Mindfulness and its underlying awareness are inher- effects of stress.107 Social support can be structural
ent personality traits as well as capabilities that can be (eg, available social ties like marital, family, or church
honed through training.103,104 Evidence for the benefits affiliations)108 or functional (ie, not just available, but

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 Psychological Well-Being

available and able to meet the person’s needs). In the

military, positive unit environments facilitate social EXHIBIT 25-1
support and help individuals cope with stress.57 Spe-
SERVICE CORE VALUES
cifically, the relationships between work stress and mo-
rale, and work stress and depression, are moderated
Service core values are shared fundamental beliefs that cross
by the quality of the social environment.109 Conversely, service boundaries, but the unique aspects of each service
the absence of social support is a risk factor for physical are reflected in the differences among their top priorities.
and psychological problems.110–113 Army
The deployed or combat environment may present • Loyalty
conditions under which service members need the • Duty
most social support because they are removed from • Respect
their usual social support networks of family and • Selfless Service
friends while facing new stressors. As a result, social • Honor
support from the unit and other available services (eg, • Integrity
buddies, effective leaders, behavioral health profes- • Personal Courage
sionals, chaplains) is crucial in the deployed setting. Air Force
Reliance on members of the unit is part of military cul- • Integrity First
ture and is key to successful integration into military • Service Before Self
life. An individual who successfully integrates into a • Excellence in All We Do
group can achieve a sense of belonging and increased Navy and Marine Corps
self-worth, which contributes to positive health out- • Honor
comes,114 whereas one who does not integrate may • Courage
• Commitment
experience negative health effects.115 Social support
buffers deleterious effects of stress on health.107 Positive
effects of social support can be reflected in neuroendo-
crine and immune response biomarkers,116,117 reduced
psychological despair,118 and increased motivation Core Values
toward self-care.119
Core values are qualities representing an indi-
Unit Cohesion vidual’s or organization’s deeply held beliefs and
fundamental driving forces. They define what an or-
Unit cohesion is similar to social support, but with ganization believes and how it resonates and appeals
specific relevance for the military. It represents the to others within the organization and throughout the
degree to which individuals are bonded to one an- external world. Core values should be part of each
other and to their higher organization. Unit cohesion military member’s belief system. Core values repre-
in the military is positively associated with readiness, sent the solid core of each person, who they are, what
performance of individuals and groups, and personal they believe, and who they should want to be going
well-being.120 Unit cohesion has been reported to mod- forward. They provide guiding principles and can be
erate the relationship between combat exposure and used as a touchstone for service members. Each of
posttraumatic stress in marines and Navy corpsmen.121 the services has its own set of core values, as do most
Belonging to a resilient group, with high morale, has individuals. These core values are extremely important
a positive impact on the well-being of the service for PWB within, across, and throughout military com-
member.114 munities (Exhibit 25-1).

PSYCHOLOGICAL WELL-BEING AND THE MILITARY MEDICAL OFFICER

Role of the Military Medical Officer Enhancing PWB may be as simple as improving
eating, sleeping, or exercising. Patients may also
The MMO plays a key role in PWB education, train- alter the way they think about an issue. This is a
ing, and evaluation for service members and their more difficult way to enhance PWB but MMOs can
families. The MMO is charged with explaining the role assist and provide guidance. Changing motivations
of behaviors, cognitions, and motivations with respect is the most difficult way to enhance PWB. If the
to PWB. The MMO should educate individual patients issues go beyond the MMO’s ability to treat (eg,
and unit commanders about factors that impact PWB. psychopathology), the MMO must refer the patient

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to the next appropriate level of care. If psychological • drug use,

and behavioral healthcare can be found in the same • bias or prejudice,
place as the MMO is providing care, then it may • stress,
be as easy as walking the patient down the hall. In • injury, and
other cases it may be more difficult for an MMO to • transitions.
easily transition the patient to psychological care.
MMOs should be aware of the referral process and Framing the threats or challenges as detractors from
available resources at each facility in which care is accomplishing unit mission or decreasing readiness
provided. are often the most successful ways to effectively com-
MMOs are also responsible for managing their municate the importance of PWB.
own well-being, by monitoring and manipulating MMOs should remind the commander that psy-
the factors discussed in this chapter. MMOs should chological fitness is a key component to overall fit-
be aware of the importance of self-care to maintain ness and readiness. Commanders can support PWB
high levels of performance and to avoid physical or among soldiers in a unit by promoting or providing
psychological burnout. A valuable complement to the following:
self-awareness is to rely on and encourage input from
significant others and trusted colleagues with regard • physical exercise;
to the MMO’s PWB. Perhaps the most valuable guide- • healthy eating;
line to optimize one’s own PWB is to remember the • sufficient sleep;
importance of balance in all aspects of professional • mindfulness;
and personal life. • optimism;
• spirituality;
Guidance to the Commander • social support;
• unit cohesion; and
The first step is to make the unit commander aware • effective leadership.
of potential threats to PWB and ways to improve PWB,
and to educate the commander about how to make It is recommended that MMOs educate unit com-
changes within the unit. Threats to PWB include the manders on specific threats and countermeasures to
following: PWB.

PSYCHOLOGICAL WELL-BEING RESOURCES

Many tools and resources are available to MMOs, • Human Performance Resource Center (http://
commanders, and soldiers and their families, ranging hprc-online.org/about-us/about-hprc).
from online support to programs on base, such as: • Family and morale, welfare and recreation
(MWR) programs on base.
• Adler AB, Bliese PD, Castro CAE, eds. Deploy- • Community service programs on base.
ment Psychology: Evidence-Based Strategies to • Defense Centers of Excellence for Psychologi-
Promote Mental Health in the Military. Wash- cal Health and Traumatic Brain Injury (http://
ington, DC: American Psychological Associa- www.dcoe.mil/).
tion; 2011 (https://www.ajol.info/index.php/ • Center for Deployment Psychology (http://
smsajms/article/viewFile/97397/86707). deploymentpsych.org/).

SUMMARY

Healing is a matter of time but it is sometimes also a motivations/emotions affect and reflect PWB. But
matter of opportunity. as Hippocrates, the “father of Western medicine,”
—Hippocrates (460 bce–370 bce) wisely advised more than 2 millennia ago, we can
wait to heal and hope to achieve well-being, or we
Psychological well-being is relevant to the lives of can take advantage of opportunities to heal. PWB is
all people, but the challenges faced by service mem- especially affected by finding opportunities to take
bers and their families underscore the importance meaningful actions. The MMO serves a key role in
of maintaining and enhancing PWB. As discussed this pursuit for service members, units, patients,
in this chapter, various behaviors, cognitions, and and self.

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