Resilience Related to TBI in the Military: An Overview

Scope of the Problem

Since 2009, it is estimated that over 5,000 U.S. troops have died and 35,000 more have been wounded in action during Operation Iraqi Freedom (OIF) and Operation Enduring Free­dom (OEF) (www.defenseling.mil/news/casualty.pdf). Many of our soldiers are surviving what used to be catastrophic, life threatening injuries, but they are often left with difficult recov­eries, the majority of which are mild TBIs and post-traumatic stress disorder (PTSD). Approximately 80 percent of TBI di­agnoses are associated with closed head injuries incurred as a result of blasting or other activities not directly combat-related (Ranchand et al., 2008).

In a comprehensive review of TBI and its prevalence, RAND reports a “probable” TBI prevalence rate of 19.5 percent. How­ever, estimates have been as high as 22.8 percent for soldiers in an Army brigade combat team returning from a one year de­ployment to Iraq (Terrio et al., 2009). Moderate to severe TBIs are estimated to be around 10 percent; however, these rates are difficult to validate as the measures themselves have not always been accurate, nor has there been clarity on the diagnostic cri­teria of TBI. An additional complexity in diagnosing TBI is the overlap of PTSD symptoms that often accompany combat (Hoge, et al., 2009).

Both TBI and PTSD may be diagnostically difficult to dis­tinguish due to the shared neuroanatomical structures, similar­ity of symptoms, and the fact that service members do not of­ten seek help for fear of being pulled out of the fight and stigma surrounding mental health issues (MHAT, 2008). At the same time, policy makers have increased the focus on efforts to ad­dress the needs of these injured service members, raising the level of due diligence to take steps and incorporate procedures that screen for these problems, thus increasing the chances of over diagnosing these problems (Hoge, et al., 2009).

TBI

TBI, defined in the medical literature as a disruption in brain function that is caused by a head injury, has become known as one of the “signature wounds” of the wars in Iraq and Afghani­stan due to its high occurrence in post-deployment service members and veterans of these wars (Ranchand et al., 2008). It is also known as the “hidden” injury because service members can sustain injury to the brain without being detected and later developing symptoms that can affect a soldier’s functioning (Tanielian et al., 2008).

At the time of injury, or sometime after, TBI could be clas­sified as mild, moderate or severe.

Mild TBI may cause a brief period of unconsciousness, mild confusion or discomfort, while a more severe injury may cause longer periods of unconsciousness, nausea, vomiting, loss of coordination or other symptoms. Moderate TBI may be di­agnosed when the patient experiences a loss of consciousness for less than 24 hours, and up to one week of post-traumatic amnesia. A TBI injury may be classified as severe if it involves more than one day of unconsciousness or more than one week of amnesia (Terrio et al., 2009).

The perceived severity of the injury depends on a number of factors. Clinically, severity of TBI is measured by the Glasgow Coma Scale, seven levels of unconsciousness, and the extent of post-traumatic amnesia. TBI severity may range from “mild,” a brief change in mental status or consciousness after the injury, to “severe,” an extended period of unconsciousness or amne­sia. In addition to physical symptoms, mental health diagnoses such as PTSD, depression and anxiety are common for TBI patients, as well as substance abuse. Due to the variable nature of TBI injury and recovery, there is not one standard of care or treatment regimen for TBI; patients’ needs are diverse, de­pending on the illness severity and the presence of co-conditions (Taber and Hurley, 2010; Tanielian et al., 2008).

TBI in service members does not always come from combat, although blast injuries have received a lot of attention because of the current en­emy’s frequent use of explosives that result in blast injuries. Most of these injuries are characterized as mild TBI. In fact, however, most closed head in­juries are due to car and motorcycle accidents, training accidents and falls. These injuries can be catastrophic and result in life-changing cognitive problems in the areas of atten­tion, concentration, memory, language processing, perceptual skills, problem solving and judgment, interpersonal skills and emotional functioning. In addition, physical problems that include motor and gait difficulties, headaches, sleep problems and pain can persist, presenting a particular challenge for reha­bilitating TBI patients and their families (Adams, 1996). Mild TBI patients have shown the most complete recoveries but, for the majority of those with moderate to severe brain injuries, complete recovery of prior functioning is never achieved (Mc­Grath, 2007).

Studies have shown that patients with mild TBI can make a complete recovery with little or no medical intervention. One study noted that patients with mild TBI recovered more quick­ly when provided with information on types of symptoms to expect. Other patients need more time and resources, and the nature of those needs varies on a case-by-case basis (Deb et al., 1999; White et al., 2008). In the civilian population, four types of outcomes have been identified for patients with moderate head injuries. Approximately 60 percent of patients with mod­erate head injuries make a positive recovery; an estimated 25 percent will be left with a moderate degree of disability; death or a persistent vegetative state will be the outcome in about 7-10 percent of all cases; and the remainder of patients will have a severe degree of disability which will range from comas to needing long term care and assistance (Hoge et al., 2008; Taber and Hurley, 2010).

Resilience

There are no universally accepted scientific definitions of resil­ience, although resilience has been increasingly recognized as a distinct domain of inquiry (Cicchetti, 1989, 1993; Masten et al., 1990, 1999, 2001). The theoretical models underpinning such literature are not always explicit, but the various definitions of re­silience tend to share in common a number of features including adaptive coping, growth, strength and positive outcomes follow­ing exposure to adversity (e.g., Rolf and Johnson, 1990; Rutter, 1990; Richardson, 2002).

The point is that resilience is a multi-dimensional construct. Resilience is best understood in context of the environment as each area of adversity needs to be considered in relationship to the individual. This is due to the fact that resilience can be differ­ent things in different environments. By specifying the dynamics of the individual and his or her situation, we will better delineate the construct of what is protective and resilient. The focus of this construct is on those things that make soldiers better at what they do and how they do it within a given extreme environment or envi­ronments (Bates et al., 2010; Van Dil­len et al., 2010).

We know that certain aspects of behavior and thinking are protective and others do not pan out. This may make a service member vulnerable or not vulnerable. The individual, envi­ronment and interacting factors have shown to contribute to resiliency. In­dividual factors would include person­ality traits such as flexibility, adapt­ability, openness to experience and extraversion (Frederickson, 2001), intelligence (Masten et al., 1999), solution-focused problem solving (Garmezy, 1991), opti­mism, hope, creativity, faith, forgiveness and self-esteem (Rich­ardson, 2002). Environmental factors have included sufficient social support to help problem solve and facilitate self correc­tion (Masten et al., 1999). There has been little to no research on interactive factors that address the interactions between the individual and the environment (Masten, 2001; Curtis and Cic­chetti, 2003).

Resilience can mean different things depending on the injury. The level of functioning is limited by the degree or severity of in­jury. In the most severe cases, it is the environment that needs to be modified so the person can adapt and obtain the highest level of functioning possible. That is, the level of function at which we can achieve is variable from individual to individual and is af­fected by many other factors. As such, our environments impact us and can overwhelm even those with the best functioning, de­pending on how compromised their nervous systems are. There is no other environment more challenging and extreme than com­bat to test nervous system functioning. (Van Dillen, 2010).

Resilience and TBI

Resilience, as discussed, refers to how an individual reacts and adapts to a traumatic event, usually bouncing back to their prior level of functioning before the traumatic event. There are those who also appear to be able to take an extraordinarily difficult event and somehow find the opportunity to improve and even excel (Bartone, 2006).

Problems associated with TBIs are well documented in the literature. Studies which have followed patients beyond one year post-injury indicate that these problems can be both per­sistent and disabling (Deb, S., et al. 1999). Residual psycho­logical, emotional and cognitive deficits have prevented them from returning to pre-functional levels. However, long-term adjustment after brain injury is achievable even after severe TBI (McGrath, 2001). As a result, researchers are now beginning to examine the positive psychological outcomes after brain injury. This begs the question, in cases of TBIs where the brain itself is actually injured and rendered impaired, can those who suf­fer this kind of catastrophic injury also possess the ability to bounce back and even thrive?

Although there is a great paucity of research in this area, recent studies do suggest that those who are survivors of brain injury are capable of positive growth. In one of the first system­atic studies that examined whether people with acquired brain injury (ABI) show evidence of psychological growth and posi­tive change, they found that in fact positive growth does appear to occur over time (McGrath and Linley, 2006). Additionally, Powell et al. (2007) found that positive growth occurs later (10 years) than earlier (1-3 years) in recovery. Hawley and Jo­seph (2008) in a longitudinal study of moderate to severe TBI survivors, compared scores for up to three years after recruit­ment and found that many of these patients continued to have residual problems associated with the brain injury. However, a sub-set of the original cohort (total of 165 patients) assessed at approximately 10 years post-TBI found that scores on the Positive Changes in Outlook Questionnaire (CiOQ) indicated positive psychological growth and outlook for over half of the sample. They concluded that positive changes are not uncom­mon in TBI patients, and that injury variables and outcomes at 6 months were poor predictors of positive changes in outlook.

Resilience building can construct health behaviors and, as a result, healthier lives. Developing resilience can have substan­tial health benefits such as reduced stress and anxiety (Newman, 2005). Having good supportive relationships and maintaining an optimistic view of the world are not often associated with resilience, but tend to help patients be healthier and maybe even live longer (Anderson and Anderson, 2003). Additionally, by understanding what resilience is and its nature, we can foster it and possibly help teach it to others. Those who are resilient and rebound from adversity to their premorbid level of func­tioning, or at least to a level of functioning that is similar, will prove to be less of a social and financial drain on our system. Those who have overcome severe TBI or trauma can become productive members of society with fulfilling lives. What is in­teresting is that some people not only come back to a level of functioning that resembles their previous functioning, but may even be stronger and less prone to future problems or stressors (Newman, 2005). Some may even thrive and excel further by improving their ability to handle adversity (Carver, 1998).

As with most chronic or catastrophic injuries, rehabilita­tion and post-acute care is most effective with a holistic and positive approach (Collicutt McGrath and Linsey, 2006). It has been long known that positive affect and emotional support is vital to the rehabilitation of acquired brain injuries (ABI). Such who also appear to be able to take an extraordinarily difficult event and somehow find the opportunity to improve and even excel (Bartone, 2006).

Problems associated with TBIs are well documented in the literature. Studies which have followed patients beyond one year post-injury indicate that these problems can be both per­sistent and disabling (Deb, S., et al. 1999). Residual psycho­logical, emotional and cognitive deficits have prevented them from returning to pre-functional levels. However, long-term adjustment after brain injury is achievable even after severe TBI (McGrath, 2001). As a result, researchers are now beginning to examine the positive psychological outcomes after brain injury. This begs the question, in cases of TBIs where the brain itself is actually injured and rendered impaired, can those who suf­fer this kind of catastrophic injury also possess the ability to bounce back and even thrive?

Although there is a great paucity of research in this area, recent studies do suggest that those who are survivors of brain injury are capable of positive growth. In one of the first system­atic studies that examined whether people with acquired brain injury (ABI) show evidence of psychological growth and posi­tive change, they found that in fact positive growth does appear to occur over time (McGrath and Linley, 2006). Additionally, Powell et al. (2007) found that positive growth occurs later (10 years) than earlier (1-3 years) in recovery. Hawley and Jo­seph (2008) in a longitudinal study of moderate to severe TBI survivors, compared scores for up to three years after recruit­ment and found that many of these patients continued to have residual problems associated with the brain injury. However, a sub-set of the original cohort (total of 165 patients) assessed at approximately 10 years post-TBI found that scores on the Positive Changes in Outlook Questionnaire (CiOQ) indicated positive psychological growth and outlook for over half of the sample. They concluded that positive changes are not uncom­mon in TBI patients, and that injury variables and outcomes at 6 months were poor predictors of positive changes in outlook.

Resilience building can construct health behaviors and, as a result, healthier lives. Developing resilience can have substan­tial health benefits such as reduced stress and anxiety (Newman, 2005). Having good supportive relationships and maintaining an optimistic view of the world are not often associated with resilience, but tend to help patients be healthier and maybe even live longer (Anderson and Anderson, 2003). Additionally, by understanding what resilience is and its nature, we can foster it and possibly help teach it to others. Those who are resilient and rebound from adversity to their premorbid level of func­tioning, or at least to a level of functioning that is similar, will prove to be less of a social and financial drain on our system. Those who have overcome severe TBI or trauma can become productive members of society with fulfilling lives. What is in­teresting is that some people not only come back to a level of functioning that resembles their previous functioning, but may even be stronger and less prone to future problems or stressors (Newman, 2005). Some may even thrive and excel further by improving their ability to handle adversity (Carver, 1998).

As with most chronic or catastrophic injuries, rehabilita­tion and post-acute care is most effective with a holistic and positive approach (Collicutt McGrath and Linsey, 2006). It has been long known that positive affect and emotional support is vital to the rehabilitation of acquired brain injuries (ABI). Such treatment for mild TBI has been shown to result in recovery from injuries with fewer complications when a positive expec­tation of recovery was communicated (McGrath and Adams, 1999). A positive outcome approach with social support has also been shown to be effective with other chronic conditions (Adams, 1996; Collicutt McGrath and Linsey, 2006). In ad­dition, rehabilitation efforts that focus on the strengths of the person, build on what the patient can do, and simultaneously have social and community support, have better outcomes (McGrath, 2004). Rehabilitation psychology has always fo­cused on building resilience by identifying those elements that promote recovery of the patient.

McGrath and Adams (1999) followed a group of patients who had reported high levels of distress on an anxiety scale while in rehabilitation following their acquired brain injury. Once a positive goal-focused rehabilitation program had been implemented, reported distress levels fell and remained low for the patients. This was confirmed with observer ratings. Mc­Grath and Adams’ research was an important step in question­ing the stereotypes of acquired brain injury patients as incapa­ble of resilience due to the nature of their injury. Furthermore, McGrath and Adams found that many of the patients could be described as self-reliant and had the ability to generate positive coping responses. Also, despite cognitive and emotional infor­mation processing problems, those with acquired brain injury seem to maintain a sense of personal stability and coherence as evidenced in a study by Collicutt, McGrath and Linsey (2006) in which they found high scores on Coherence-13 Scale follow­ing acquired brain injury.

When it comes to the treatment of brain injuries from the point of injury to years after injury, focusing on the patient and what they want for themselves in the future is the most appropri­ate approach. Focusing on the past and how current problems arose because of what happened is not as productive as looking at what the patient can do to improve him or herself and invest towards the future. During the rehabilitation stages of recovery, an opportunity exists to perpetuate a positive view and tone in the recovery process. In many cases, the patient knows s/he is limited or has difficulties, but the risk of focusing on the deficits results in patients and caregivers alike becoming complacent in which negativity can ensue, thus affecting motivation and hope (McGrath and Adams, 1999; Siegert et al., 2004).

Benefits of Researching Resilience

Future treatments need to focus on generating interventions that incorporate the current research in this area. Patients may need modified psychotherapy treatments to accommodate the cogni­tive limitations, yet treatment also should incorporate the posi­tive emotional tone that comes from positive interactions and fo­cus on what the patient’s functional progress is. Instilling a sense of resilience through pursuit of meaningful goals also promotes a sense of identity (Dewey, 2002), which can give a person a sense of purpose.

It also has been assumed that people, because of their cogni­tive limitations, will not benefit from psychotherapy. However, striving with the patient to understand their sense of meaning and learning to manage stress from their environment is em­powering. It may be necessary to teach coping skills through the behavioral principles of modeling, that is to say, demonstrating the behavior that you want the patient to exhibit in specific situ­ations. Furthermore, patients that have memory problems often can and do remember the emotional context of events, yet are at times unable to make the necessary adjustments to respond posi­tively themselves. Unfortunately, brain systems that are impor­tant to self regulation of emotions can be disrupted and there­fore these behaviors have to be relearned. The point is that the patient does not want to be this way and may need ongoing help with learning to modulate his or her thinking and emotions. Of course, caregivers need to be aware of this so they do not re­inforce this behavior. Natural positive consequences of striving to regulate one’s behavior is met with its own rewards such as feeling more connections with others, improved interpersonal interactions, and learning how to control impulses that result in a sense of mastery (McGrath, 2001).

Spiritual perspectives can also be helpful especially when injuries that are catastrophic bring to light very existential-type questions. Spiritual orientation can also help with a sense of meaning and constructing purpose (Prigatano, 1989). Certain positive behaviors that are associated with spirituality include a guide or set of rules with which to live life and a philosophy of life to interpret events with purpose and meaning. In others, spirituality is simply a positive behavior and feeling that may influence a patient’s perspective and motivation.

References

Adams, N. (1996). Positive outcomes in families following TBI. Australian and New Zealand Jour­nal of Family Therapy, 17, 75-84.

American Association of Neurological Surgeons. (2006, June). TBI. Available at: http://www.neu­rosurgerytoday.org/what/patient_e/head.asp.

American Association of Neurological Surgeons. (2007). TBI. Available at: http://www.aans.org/shared_pdfs/ Guidelines_Management_2007.pdf.

Anderson, N. B., and Anderson, P. E. (2003). The Psychobiology of depression and resilience to stress: Im­plications for prevention and treatment. Annual Review of Clinical Psychology, April 2005, Vol. 1, 255-291. Bates, M., Bowles, S., Hammermaster, J., Stokes, C., Evette, Pl, Moore, M., Fritts, M., Vythlin­gam, M., Yoskick, T., Rhodes, J., Myatt, C., Westphall, R., Fautua, D., Hammer, Pl, and Burbelo, G. (2010). Psychological Fitness: A Military Demand Resource Model. Military Medicine, TO BE PUBLISHED.

Bartone, P.T. (2006). Resilience under military operational stress: Can leaders influence hardiness? Military Psychology, 18(Suppl.), S131-S148.

Carver, C. S. (1998). Resilience and thriving: Issues, models, and linkages. Journal of Social Issues, 54(2), 245-266.

Collicutt McGrath, J., and Linsey, P. A. (2006). Posttraumatic growth following acquired brain injury: A preliminary small scale study. Brain Injury, 20, 767 – 773.

Curtis and Cicchetti, (2003). Moving research on resilience into the 21st century: Theoretical and methodological considerations in examining the biological contributors to resilience. Development and Psychopathology, 15, 773-810.

Defense Centers of Excellence (DCoE), (2009). Psychological Fitness background information: For defining Total Fitness for the 21st century.

Defense Manpower Data Center. (2009, June 10). Global war on terrorism – Operation Enduring Freedom by casualty category within services: October 7, 2001 through September 5, 2009. Avail­able at: http://siadapp.dmdc.osd.mil/personnel/CAUALTY/wotsum.pdf

Defense Manpower Data Center. (2009, June 10). Global war on terrorism – Operation Iraqi Free­dom by casualty category within services: March 19, 2003 through September 5, 2009. Available at: http://siadapp.dmdc.osd.mil/personnel/CAUALTY/oif-total.pdf/

Deb, S., Lyons, I., Koutzoutkis, C., Ali, I., and McCarthy, G. (1999). Rate of psychiatric illness 1 year after TBI. American Journal of Psychiatry, 156, 374-378.

Dewey, J. (2002). Human nature and conduct. Mineola, NY: Dover.

Earvolino-Ramirez, M. (2007). Resilience: A concept analysis. Nursing Forum, 42(2), 73-82.

Feder, A., Nestler, E. J., and Charney, D. S. (2009). Psychobiological and molecular genetics of resilience. Nature Reviews, Neuroscience, 10(6), 446-457.

Frederickson, B. L. (2001). The role of positive emotions in positive psychology: The broaden-and-build theory of positive emotions. American Psychologist, 56, 218-226.

Garmezy, N. (1991). Resiliency and vulnerability to adverse developmental outcomes associated with povery. American Behavioral Scientist, 34(4), 416-430.

Hawley, C. A., and Joseph, S. (2008). Predictors of positive growth after TBI: A longitudinal study. Brain Injury, 22(5), 427-435.

Hoge, C. W., McGurk, D., Thomas, J. l., Cox, A. l., Engel, C. C., and Castro, C. A. (2008). Mild TBI in U.S. soldiers returning from Iraq. New England Journal of Medicine, 358, 453-463.

Hoge, C.W., Goldberg, H. M., and Castro, C. A. (2009). Care of war veterans with mild TBI-flawed perspectives. New England Journal of Medicine, 360(16), 1588-1591.

Masten, A., Best, K., and Garmezy, N. (1990). Resilience and development: Contributions from the study of children who overcome adversity. Development and Psychopathology, 2, 425-444.

Masten, A. S., Hubbard, J. J., Gest, S. D., Tellegen, A., Garmezy, N., and Ramirez, M. (1999). Competence in the context of adversity: Pathways to resilience and maladaption from childhood to late adolescence. Development and Psychopathology, 11, 143-169.

Masten, A. S. (2001). Ordinary magic: Resilience processes in development. American Psychologist, 56, 227-238.

McGrath, J. (2001). A study of emotionalism in patients undergoing rehabilitation following se­vere acquired brain injury. Behavioural Neurology, 12, 201-207.

McGrath, J. (2004). Beyond restoration to transformation: Positive outcomes in the rehabilitation of acquired brain injury. Clinical Rehabilitation, 18, 767-775.

McGrath, J., and Adams, L. (1999). Patient-centered goal planning: A systemic psychological therapy? Topics in Stroke Rehabilitation, 6, 43-50.

Mental Health Advisory Team (MHAT) VII. (2008). Operation Iraqi and Enduring Freedom 07-09: Iraq and Afghanistan. Operation Enduring Freedom 8: Afghanistan. Washington, DC: MHAT V.

National Institute of Neurological Disorders and Stroke. (2002). TBI: Hope through research. National Institutes of Health, NIH Publication No. 02-158.

Newman, R. (2005). APA’s Resilience Initiative. Professional Psychology: Research and Practice, 36(3), 227-229.

Operation Iraqi Freedom (OIF) U.S. Casualty Status; Operation Enduring Freedom (OEF) U.S. Casualty Status (2010, April 12). Available at: http://www.defenseling.mil/news/casualty.pdf

Parrin, P. B., Heesacker, M., Stidham, B. S., Rittman, M. R., and Gonzalez-Rothi, L. J. (2008). Structure equation modeling of the relationship between caregiver psychosocial variables and func­tioning of individuals with stroke. Rehabilitation Psychology, 53(1), 54-62.

Powell, T., Ekin-Wood, A., and Collin, C. (2007). Post-traumatic growth after head injury: A long-term follow-up. Brain Injury, 21, 31-38.

Prigatano, G. (1989). Work, love, and plan after brain injury. Bulletin of the Menninger Clinic, 53, 414-431.

Ranchand R., Karney, B. R., Calderone L. B., and Burns, R. M. (2008). Prevalence of PTSD, depression and TBI among returning service members. In: Tanielian, T., Jaycox, L.H., editors. Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. Santa Monica, CA: RAND.

Richardson, G. E. (2002). The metatheory of resilience and resiliency. Journal of Clinical Psychol­ogy, 58, 307-321.

Rolf J, Masten A, Cicchetti D, Nuechterlein K, Weintraub S, editors. Risk and protective factors in the development of psychopathology. Cambridge; New York: 1990

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1885202/

Rutter, M. (1990). Psychosocial resilience and protective mechanisms. In J. Wolf, A. S. Marten, K. H. Nuechterlein, and S. Weinstrub (Eds.), Risk and protective factors in the development of psychopa­thology, (pp. 181-214). New York: Cambridge University Press. citation

Salmond, C. H., Menon, D. K., Chatfield, D. A., Pickard, J. D., and Sahakian, B. J. (2006). Cognitive reserve as a resilience factor against depression after moderate/severe head injury. Journal of Neurotrauma, 23(7), 1049-1058.

Siegert, R., McPherson, M., and Taylor, W. (2004). Toward a cognitive-affective model of goal-setting in rehabilitation: Is self-regulation theory a key step? Disability and Rehabilitation, 26, 1175-1183.

Taber, K. H., and Hurley, R. A. (2010). OEF/OIF Deployment Related TBI. PTSD Research Quar­terly, 21 (1), 1-3.

Tanielian, T., Jaycox, L., eds. (2008). Invisible Wounds of War: Psychological and Cognitive Inju­ries, Their Consequences, and Services to Assist Recovery, RAND, pp. 126-127.

Terrio, H., Brenner, I. A., Ivins, B. J., Cho, J.M., Helmeck, K., Schwab, K., Scally, K., Bretthauer, R., and Warden, D. (2009). TBI screening; preliminary findings in a US Army Brigade Combat Team. Journal of Head Trauma Rehabilitation, 24, 14-23.

Van Dillen, T. (2010). Neuropsychological Operational Demand Resource Model (NODR): An integrative neuropsychological process model of resilience. In support of the Psychological Fitness Draft for Defining Total Fitness for the 21st Century.

Veterans Health Administration. (2009, June 9). Polytrauma-TBI (TBI) system of care. Depart­ment of Veterans Affairs, VHA Directive 2009-028. Available at: http://www1.va.gov/VHAPUB­LICATIONS/ViewPublication.asp?pub_ID=2032.

Vital, M. (2002, September). TBI: Hope through research. National Institute of Neurological Dis­orders and Stroke, Bethesda, MD. Available at: http://www.ninds.nih.gov/disorders/tbi/tbi_htr.pdf

White, B., Driver, S., and Warren, A. (2008). Considering resilience in the rehabilitation of people with traumatic disabilities. Rehabilitation Psychology, 53(1), 9-17.

About the author

Thomas A. Van Dillen is a neuropsychologist and traumatologist support­ing DCoE’s Resilience and Prevention Directorate. Previously, he served as the Service Chief of Assessment for the National Capital Region at the National Naval Medical Center (NNMC), and as the subject matter expert (SME) for the Behavioral Health and PH-TBI programs and Director of the Clinical and Translational Research Program (CTRP). His current researchfocuses on Warrior Resilience as an integrative neuropsychologi­cal process.