Effectiveness of Acceptance and Commitment Therapy in Increasing Resilience and Reducing Attrition of Injured US Navy Recruits

Introduction: US Navy recruits who have injuries preventing them from participating in intense physical conditioning are pulled out of boot camp training and receive treatment that includes daily physical therapy, pain medications, and psychoeducational groups. Graduation from boot camp for these recruits requires not only recovering from their injuries but also passing a required Physical Fitness Assessment consisting of a timed 1.5-mile run, curl-ups, and push-ups. About 50-60% of these recruits will eventually be separated out and sent home. The purpose of this study is to examine the effectiveness of an Acceptance and Commitment Therapy (ACT)-based program called Mindfulness for Pain and Performance Enhancement (MPPE). This treatment program was designed to help recruits effectively handle pain and assist them in improving their physical performance in the service of recovery, boot camp completion, and entrance into the Navy.

Materials and Methods: This study was approved by the Edward Hines VA Hospital/Captain James A. Lovell Federal Health Care Center Institutional Review Board and the Naval Services Training Command. Treatment was voluntary and a total of 373 recruits enrolled in one of the 32 cycles of MPPE administered. Attrition was 35.1% (131 recruits). The control group comprised 310 recruits who did not enroll in MPPE. Recruits continued to receive standard treatment services (e.g., physical therapy, medical interventions, and psychoeducational groups) while participating in MPPE. Chi-square tests and one-way analysis of variance were used to analyze comparisons among treatment, control, and attrition groups on demographic, clinical, and boot camp training variables. Paired sample t-tests and Cohen's d effect sizes were computed to assess change on treatment outcome measures. Logistic regression was performed to identify demographic, clinical, and boot camp training variables predictive of graduation.

Results: All of the pre- to post-treatment outcome measures were significant and Cohen's d effect sizes ranged from 0.41 to 0.84. Effect size changes were small for anxiety and experiential avoidance; moderate for pain acceptance, mindfulness, cognitive inflexibility, and depression; and large for pain reduction. Treatment completers graduated at a higher rate (58.3%) than attrites (34.4%) or controls (45.5%). Based on a logistic regression model, variables predictive of graduation included MPPE completion, age, and reported pain rating.

Conclusion: MPPE is a six-session, 2-wk-long Acceptance and Commitment Therapy-based approach to pain and physical performance that was added to existing treatment services. Results supported the use of this program for helping recruits recover from injuries and successfully pass physical training requirements for graduation. Recruits were not randomly assigned to treatment, thus limiting the interpretation of outcomes. Incorporating this treatment earlier in boot camp training and making it available to more recruits (i.e., not only injured recruits) may further reduce attrition and contribute to greater resiliency of sailors within the US Navy fleet.