Expanding the Toolkit for Medics in Combat:
Operational Resilience Training

Andreas Espetvedt Nordstrand^a,c, Haakon Gabrielsen Engen^a,Amy B. Adler^b

^a Joint Medical Services, Norwegian Armed Forces, Oslo, Norway

^b Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research

^c Department of Psychology, Norwegian University of Science and Technology (NTNU), Trondheim, Norway

Background

Soldiers in combat are confronted with extreme stressors and yet are still required to function. Nowhere is this more evident today than in Ukraine, following Russia’s full-scale invasion in February 2022. Since that time, hundreds of thousands of Ukrainians have been fighting on the frontlines, enduring combat stress and constant threat. Both acute and accumulated combat stress exposure can precipitate a transitory, but debilitating psychological condition often referred to as combat and operational stress reactions (or COSR) [6]. The negative impact of COSRs can affect both individuals, units, and the mission, with initial Ukrainian reports indicating that 25 % of officers and 33 % of soldiers struggle to psychologically adapt to combat conditions on the frontlines [2][5]. Although few medical providers are available near the frontline to address the mental stress of combat, combat medics offer one way to provide service members with mental health support.

Against this backdrop, Ukraine asked for mental skills training to be integrated into military training that Ukrainian medics receive in Europe. Thus, when the Norwegian Armed Forces began training combat medics in the spring of 2023 as part of Operation Elisiv, they integrated material that addresses mental skills. This material is known as Operational Resilience Training (ORT). This training has been designed to equip medics with best-practice tools for managing mental health.

Operational Resilience Training (ORT)

Collaborative development

The ORT program was developed through collaboration between the Norwegian Armed Forces Medical Services (FSAN) and the Walter Reed Army Institute of Research (WRAIR) [1]. WRAIR is one of the world’s leading institutions for military health research with years of experience in developing resilience and mental health training products and establishing empirical evidence for their utility. FSAN and WRAIR have also been collaborating on resilience topics since 2018 [3][4].^,Thus, when mental health experts in Norway were tasked with training Ukrainian medics, they reached out to WRAIR for support. Together, they adjusted existing WRAIR training products for the Ukrainian context and co-developed new training modules that were not yet established. In pulling each of these modules under the umbrella of ORT, the development team also generated a mental health continuum graphic that medics could use to quickly categorize individuals in terms of their mental health readiness and identify which operational resilience skills might be applied to help shift themselves or unit members towards optimal readiness.

Stress bucket metaphor

These resilience skills are at the heart of ORT, which provides education and techniques for medics across a wide range of topics. For each topic, there is an emphasis on how this information can be used to sustain the medics’ own resilience and how the medics can use this information with unit members. There is also an underlying metaphor that helps explain and integrate the variety of concepts: the stress bucket (Figure 1). The stress bucket is used as a metaphor to explain how stress accumulates in an individual. The stress bucket fills up with all types of stress that a soldier accumulates in war, from separation from family, intense uncertainty, and lack of sleep, to physical danger and the emotional toll of witnessing human suffering.

Fig. 1: Stress Bucket Metaphor

The metaphor is useful to help soldiers understand that when the stress bucket becomes too full, it overflows, leading to various stress reactions. Such stress reactions may manifest themselves as apathy, confusion, irritability, or panic-like anxiety. At their most extreme, these symptoms can render a soldier temporarily unable to function effectively in combat. Along the frontlines in Ukraine, this inability to function is dangerous and a critical challenge for medics to address. Understanding how soldiers face and handle stress at the frontline has been a major driving force behind ORT.

To prevent the stress bucket from overflowing, it can be helpful to understand what contributes to stress as well as what tools can “open the tap” and release some of that stress. ORT focuses on providing soldiers with simple, effective, evidence-based strategies for managing the stress bucket, both individually and as a part of their unit. These resilience-building strategies focus on four themes: supporting health-promoting behaviors such as sleep; practicing emotion regulation; maintaining a sense of meaning and supportive self-talk; and facilitating cohesive teams. Each of these themes can be strengthened through practice – they represent trainable skills – and they are reinforced across multiple modules.

ORT modules

The ORT modules range from addressing clinical concerns to sustaining resilience. In terms of clinical concerns, the modules start with acknowledging combat stressors, describing mental health problems, and identifying how medics can use listening skills and reframing to support unit members. Then the modules take a deeper dive into dealing with acute stress reactions, addressing grief, and learning about mental skills that can assist soldiers who are tasked with managing human remains. The modules also address the importance of sleep, introduce numerous performance enhancement skills, and present practical methods for building and maintaining unit cohesion.

In the performance enhancement module, for example, one practical tip medics are taught is how to use “5, 5, 5,” a technique based on the concept of temporal distancing in which individuals learn how to place a negative experience into perspective by asking themselves how they will think about the event 5 weeks, 5 months, and 5 years from now. In another example, they learn “distraction by design.” In this technique, individuals distract themselves from negative experiences as a way to rapidly calm down their body after combat. There are three types of distractions that are introduced: alternating attentional focus by listening to different sounds, engaging in arithmetic, and imagining how they would build their dream house. In the cohesion-building module, for example, practical tips include reviewing rules of engagement for managing unit conflict and considering how to use indirect and direct action to reach out to a unit member who is becoming socially disconnected.

Training beyond the classroom

Beyond the classroom portion of the training, ORT has developed an innovative approach by bringing the students outside of the classroom to practice first in a field environment and then in the context of an operationally-relevant high-stress scenario. For example, medics are directed to enter a building where they encounter what appear to be human remains and one of their teammates freezes in an acute stress reaction. This scenario gives them a chance to leverage their ORT skills to respond quickly and get their teammate back to functioning while also managing their own stress levels.

First year experience and outlook

Feedback from more than 300 medics who have completed ORT has been positive. ORT evaluations showed that approximately 99 % of participants felt the training was both relevant and important. Results from pre- and post-training surveys also showed a substantial increase in the confidence of medics in managing their own stress and the stress reactions of unit members [1]. These findings are especially encouraging considering that most students were coming straight from the frontline and had combat experience and were thus in a position to assess the degree to which ORT was value added.

Since launching in the spring of 2023, the ORT material has also been delivered to NATO working groups and been shared with NATO partners directly. In the fall of 2023, for example, ORT was shared with the Sanitätsdienst of the Bundeswehr and it has become a core part of the European Union Military Assistance Mission (EUMAM) program for training Combat Medics. Similarly, ORT is being employed by the US combat stress control team training Ukrainians in Europe. The fact that ORT is being adopted by various countries speaks to the degree to which military counterparts recognize the advantage of taking a comprehensive view of resilience, focusing on practical skills, and integrating training into scenarios. In addition, ORT is being considered for adaptation by other militaries to use with their own personnel, including Norway.

ORT represents a significant development in medical training, military psychology, and mental health. By providing medics with tools to understand and manage stress, ORT is aiming to contribute to the mental resilience of Ukrainian soldiers fighting under extreme conditions. The program is built on a holistic understanding of health, where physical and mental well-being are integrated components of a soldier’s ability to carry out their mission.

References

1. Iversen P, Adler A: US, Norway partner to help stressed Ukrainian troops. Army magazine 2023; 73 (12). , last access October 7, 2024. mehr lesen
2. Kokun O, Pischko I, Lozinska N:.Military personnel’s stress reactivity during pre-deployment in a war zone. Psychology, Health & Medicine 29023; 28(8): 2341-2352. mehr lesen
3. Nordstrand AE, Anyan F, Bøe HJ, Hjemdal O, Noll LK., Reichelt JG, Forbes D, Adler AB:Problematic anger among military personnel after combat deployment: prevalence and risk factors. BMC Psychology 2024;12(1),451. mehr lesen
4. Nordstrand AE, Barger SD, Tvedt MA, Gjerstad CL, Engen HG, Adler AB: A Novel Intervention for Acute Stress Reaction: Exploring the Feasibility of ReSTART Among Norwegian Soldiers. European Journal of Psychotraumatology 2024; 15(1): 2400011. < https://doi.org/10.1080/20008066.2024.2400011>, last access October 7, 2024 mehr lesen
5. Prykhodko I I, Bielai SV, Hrynzovskyi AM, Zhelaho AМ, Hodlevskyi SO, Kalashchenko SI: (2020). Medical and psychological aspects of safety and adaptation of military personnel to extreme conditions. Wiadomości Lekarskie 2020; 73 (4): 679-683. mehr lesen
6. Solomon Z: From the frontline to the homefront: The experience of Israeli veterans. Frontiers in Psychiatry 2020; 11, , last access October 7, 2024. mehr lesen

Disclaimer

Material has been reviewed by the Walter Reed Army Institute of Research. There is no objection to its presentation and/or publication. The opinions or assertions contained herein are the private views of the author, and are not to be construed as official, or as reflecting true views of the Department of the Army or the Department of Defense.

For the Authors

Commander Andreas Espetvedt Nordstrand, Ph.D.
Norwegian Armed Forces Joint Medical Service
Grev Wedels Plass 2, Oslo, Norway
E-Mail: aespetvedt@mil.no