Since the beginning of Operation Enduring Freedom and Operation Iraqi Freedom, more than two million United States troops have been deployed. The operational tempo associated with these conflicts, in conjunction with extended and multiple deployments, exposure to nontraditional combat (for example, urban settings and use of improvised explosive devices), and shortened dwell-time between deployments, has placed unprecedented stress on service members as well as their families.1-3

With the complex, varied, and prolonged operational demands of these missions, it is crucial that the military continue to develop and refine strategies for promoting and sustaining the health and resilience of service members. A systems perspective on health and resilience seeks to establish good functioning and balance across all body systems (for example, homeostasis and harmony) through integration of beneficial health and mind body practices.

There are many promising integrative practices (also referred to as mind-body practices) for regulating stress via the autonomic nervous system (the ANS). Many of the practices now being reviewed are focused on integrative mind-body techniques designed to help regulate and manage stress, emotions, and arousal (such as strategies for lowering anxiety when it is too high, or for increasing arousal when it is too low). Routine pharmaceutical and psychological interventions are often a last resort for helping people manage stress and their emotions.

Consideration of the spectrum of mind-body approaches to help mediate and manage stress before it becomes too intense to self-manage provides a preventative approach to strengthening resilience and prevention of psychological health difficulties. 

Many integrative mind-body techniques have already been used in military contexts, and can be incorporated into existing resilience promoting programs or trainings, based on their popularity and interest within military and veterans hospital settings.

Integrative mind-body techniques are broadly categorized as falling within three domains of integrative practice: (1) breath exercises; (2) body-based tension modulation exercises, and (3) mindfulness, meditation, and guided imagery techniques. No technique provides an absolute or assured benefit. Some work well in combination with other integrative and conventional techniques, and some will be effective in some individuals and not others. 

It is worth noting that while most integrative techniques are primarily focused on as stress management and prevention focused interventions, integrative mind-body practices have also been gaining increased attention in the military as potential augmentative treatment strategies in a number of conditions, including post-traumatic stress disorder (PTSD) and chronic pain.4-5

Breathwork

Research suggests that breathing can be affected by experiences and circumstances. When faced with a distressing moment, the body can become over-activated and breathing can become more rapid and shallow.

Fortunately, breathing is controllable. Breathing exercises have been used to help manage emotions and regulate stress, as well as increase energy and maintain optimal arousal needed for greater focus and performance. Because breathing exercises can be quickly learned and provide immediate feelings of relief, they can be easily incorporated into existing trainings or treatments. 

For example, stress-reduction breath techniques can be easily incorporated into pre-deployment as well as mission trainings, and breathing exercises are a standard component of most manualized treatments for PTSD and other anxiety disorders.5

Body-Based Tension Modulation Practices

Body-based practices have become increasingly popular in both military and civilian settings. Stress and anxiety are reflected physically in many ways. Techniques such as yoga and tension-manipulation have been studied for their effects on stress and anxiety.

Research suggests that these techniques can have positive effects on stress management and anxiety disorders, such as post-traumatic stress (PTS). These techniques are considered to work to reverse stress postures and regulate stress hormones. It is also believed that posture and tension release techniques specifically balance nervous system functions.

Further research is needed to gain a better understanding of the ways in which specific tension exercises and yoga postures might differentially affect mood and arousal.

Mental Focus Practices (Mindfulness, Meditation & Guided Imagery)

Mindfulness practice is regarded as a potential means for greater relaxation, attention control, working memory functioning and lessening of distressing thoughts. Several meta-analytic reviews indicate that routine mindfulness practice can reduce symptoms of depression and anxiety. Additionally, recent research indicates that mindfulness may be helpful to promote feelings of well being and for increasing attention control and cognitive flexibility.

There is a need for more rigorous randomized clinical trials in the area of mindfulness to prove beneficial findings conclusive. In particular, there is a need to compare the potentially effective components of popular mindfulness techniques to one another as well as to compare mindfulness to other more traditional approaches to therapy and wellness enhancement (e.g., exercise, therapy and psychopharmacology).

Related to mental practices, guided imagery is regarded as potentially effective for managing stress, anxiety, and depression as well as for pain management and performance enhancement. While studies investigating the use of guided imagery across these areas appear promising, on the whole, many studies examined combined imagery techniques with other interventions such as hypnosis, cognitive behavioral therapy, and relaxation techniques, which make it difficult to definitively conclude that guided imagery was an active component in improvement.

Mind-Body Programs

A confluence of techniques for regulating the ANS may prove to be more effective than one integrative mind-body skill in isolation. Several are offered in a non clinical context for military populations, as delivered from the Center for Mind Body Medicine and the Benson Henry Institute for Mind Body Medicine at Massachusetts General Hospital.

Integrative mind-body programs offer the user the opportunity to access a host of approaches typically within one location, making scheduling and access easier. Although the two programs reviewed share a common theme and some similarities in approach, a critical review reveals distinct differences in application.  

Biofeedback

Because the ANS regulates a number of biological processes, measuring biological functions regulated by the ANS can provide an indicator of arousal levels and feedback that might be used to regulate as well as monitor arousal. Portable biofeedback tools are available to measure and monitor ANS functions, in particular heart rate variability (HRV). HRV reflects the healthy alternating balance of sympathetic and parasympathetic effects as increased HRV is associated with improved cognitive performance. Individuals can be trained to increase the degree of HRV and biofeedback devices could be important tools for training individuals to regulate various aspects of ANS functioning.

Results

The results of current studies suggest that integrative practices designed to regulate the ANS and improve mood, stress regulation, and arousal are promising. However, in order for these and other related practices to achieve greater recognition and use in the mainstream military health community, there is a need to compare the relative effectiveness of techniques (independently or as augmentative strategies), to each other, as well as to other more mainstream stress and energy management practices, such as exercise, counseling, or psychopharmacology.

Finally, there is a need for more studies that examine promising integrative practices within the context of “real world” military operational settings.
 

Notes

1. Belasco A. The Cost of Iraq, Afghanistan, and Other Global War on Terror Operations Since 9/11. In: Service CR, ed. Washington, D.C. 2007.

2.  Bruner EF. "Military Forces: What is the appropriate size for the United States?" in Service CR, ed. Washington, D.C. 2006.

3.  Hosek J, Kavanagh JE, Miller LL. "How Deployments Affect Servicemembers." Santa Monica, CA: RAND Corporation; 2006.

4.  Force PMT. "Pain Management Task Force: Providing a Standardized DoD and VHA Vision and Approach to Pain managment to Optimize the Care fo Warriors and their Families" in: DoD V, ed. Washington, DC: The Office of the Army Surgeon General; 2010.

5.  The Department of Veterans Affairs (VA) and Department of Defense (DoD) Post Traumatic Stress Clinical Practice Guidelines, in: The Office of Quality and Performance; Quality Management Division USA, MEDCOM, ed. 2 ed. Washington, DC. 2010.