Cost – benefit analysis of training interventions to increase resilience

1. Cost – benefit analysis of training interventions to increase resilience Victor Kallen TNO | Behavioural & Societal Sciences

2. Psycho-social outcomes associated with ‘high risk’ professions. • Resilience: The ability to recuperate from a challenge or aversive experience within a reasonable period of time, by optimal use of available (physical & mental) resources. • Associate aversive outcomes • Associated costs • Framing a calculation model: How to reduce psycho-social pressure, and what are the likely benefits.

3. Associated aversive outcomes • Post deployment (e.g. Iraq, Afghanistan) prevalence of trauma related psycho-social symptomatology and pathology considerable: • 6 – 12 % Post Traumatic Stress Disorder (PTSD) • 8 – 14% Depression / Anxiety disorders (panic; social; phobia) • + / - 10% ‘other’: e.g. conduct; substance abuse; suicide attempt, etc. • However, ‘covert’ consequences might be significantly more severe: • Sub clinical (emotional) symptoms • ‘Conduct disorders’ / problems (aggression, sensation seeking, ubstance abuse, etc.) • Significant decrease in Quality of Life (e.g. broken families) • Loss in (economic) productivity • Indirect costs for society (vandalism; extra management efforts; associated, though covert, health care costs, etc.). • All being a magnitude of overt outcomes and costs.

4. Associated costs United States (RAND, 2008): • Anno 2009: 1.6 million veterans (Iraq, Afgh.) • $4.0 - $6.2 billion two years post deployment….. • …. for the treatment of Depression and PTSD only(!) • Providing evidence based treatment for every one in need: 27% cost reduction. • However: covert costs are not incorporated, nor costs associated with other types of psychopathology (e.g. suicide, substance abuse, aggression / sensation seeking). • Bilmes & Stiglitz (2006): $700 billion – $1.2 trillion (overall Iraq) • Bilmes (2007): of which $208 - $600 billion related to treatment, care and pensions of veterans suffering from psychopathology or Traumatic Brain Injury (TBI)

5. … to compare: the Dutch police force(Anderson Elffers Felix, 2011) • Approx 55.000 employees (only a little smaller than the armed forces) • 5 – 7 % ‘Less resilient’ (overt symptoms) • 20 – 30% ‘likely to be less resilient’ (covert symptoms) • Costs: • Intervention: Mental Health; company doctor; psychological professional. • Personnel: drop-out, middle / long term absence, professional conflicts, etc. • Organisational: decreased productivity, extra mobilisation colleagues, management hours / support, etc. Intervention costs Personnelcosts (direct) Organisational costs (indirect)

6. Associated with decreased Resilience: €14 - € 20 mil. /p.a. Intervention costs Personnelcosts (direct) €109 - € 228 mil. / p.a. €98 - €295 mil. / p.a. Organisational costs (indirect) Total : €221 - €543 mil. / p.a. • Of which: • €97 - €205 mil. ‘less resilient’ category • €124 - €339 mil. ‘likely less resilient’ category

7. Framing a calculation model: How to reduce psycho-social pressure, and what are the likely benefits • Especially in high risk professions (like the military and police) reduced resilience causes significant costs, in terms of Quality of life, Health (mental & physical!), and financially, for all(!) involved. • Quite some training modules are available that are proven effective in increasing resilience on an individual level: • Psycho-education / Competence training / Exposure • Relaxation exercises • Bio- / neurofeedback • Other • Though other factors are of relevance as well… (e.g. leadership, procedures, Esprit de Corps, press policy, etc.).

8. J.R. Scheckel (2010).Preparing the human weapon system: promoting warrior resilience. • Optimal • Peak performance • Positive outlook • Sense of purpose • Embraces Challenge • Reacting • Irritable • Feeling overwhelmed • Difficulty sleeping • Inability to relax • Concentration problems • Injured • Feelings of guilt • Decreased energy • Anxiety • Loss of interest • Social Isolation • Disease • Depression and • Anxiety • Anger / Aggression • Danger for self • and / or others Mission readyStress responsePersistent StressMission ineffective Soldier, Commander, Peer-group, Family (Medical) Professionals Education & Training Risk reduction & management Combat stress Intervention Treatment & Reintegration

9. Conclusions • Psycho-social costs constitute a significant proportion of overall budgets. • Considerable percentages of these costs are covert: hard to quantify in administrative statistics. • Although quite some R&D work has yet to be done, training modules aimed at increasing resilience are being developed and integrated in military programs. • Estimates suggest that increasing resilience may reduce costs associated with psycho-social outcomes with 30 to 60% (being est. €150 – €300 mil. annually for the Dutch armed forces). • This may primarily be in the ‘Personnel’ and ‘Organisational’ costs (being economically the most prominent!). • Specified calculation models are direly needed (proposal currently under review). • Though, mind you(!): you will get highly resilient & critical personnel that won’t settle no more with just any command ()….

10. Thank you very much for being a resilient audience! victor.kallen@tno.nl