International Military Leaders' Survey on Operational Stress

MILITARY MEDICINE. 173. 1:10-16. 2008

International Military Leaders' Survey on Operational Stress Amy B. Adier, PhD*; Paul Cawkill, MScf; Lieutenant Colonel Coen van den Bergf; MC Philippe Arvers§; Major Jose Puente^; Lieutenant Colonel Yves Cuvelier\\

ABSTRACT Despite the itnportance of military leaders in moderating the impact of deployment stressors on unit tnembers. little attention has focused on the training leaders receive in managing unit stress. As part of a NATO Research Panel (Hutnan Factors and Medicine (HFM)-()81/Research and Technology Organization Task Group (RTG)), 16 nations participated irt a needs assessment survey of military leaders who had returned from an operation within the previous 2 years. Findings from 172 leaders etiiphasized the lack of training specifically geared for leaders to address operational stress issues for unit members and their families and the need for integrated mental health support across the deployment cycle. In general, most leaders regarded stress-relaled mental health problems as normal and were supportive of help-seeking. The information obtained here was used to develop a Human Factors and Medicine -081/RTG Leader's Guide on operational stress.

INTRODUCTION Deployments are a source of potential stressors for military personnel and their families. The slressors begin at predeployment, continue through the deployment phase, and include the postdeployment period of adjustment.' Such stressors may have implications for individual job performance,the health and well-being of military personnel.' the functioning of military families.^ and the desire of military personnel to remain in the military.'* While researchers have identified individual variables that moderate the Impact of deployment-related stressors.''^ studies have also examined how leaders influence the impact of deployment stressors on unit members. For example, positive outcomes following deployment have been associated with confidence in senior leadership.** the degree to which leaders clarify goals and provide structure."* and leader acknowledg*U.S. Army Medical Research Unil-Europe, APO AE 09042. tHumati Systems Group. Defence Science & Technology Laboratory (Dstl). Famborough. Hants. GUI4 OLX U.K. :j:Netherlands Defetice Academy. Faculty of Military Sciences, Military Behavioural Sciences and Philosophy. PO Box 9O.(X)2. 4800 PA Breda. The Netherlands. ^D^partment des Facteurs Huniiiins. Pole "Psycho-sociologie des contraintes op^rationelles," Centre de Recherches du Service de Sant^ des Armies. CRSSA, BP87. 38702 La Tronche Cedex. France. •Jlnspeccion General de Sanidad-Unidad de Psicologia (Joint Medical Office. Unit of Psychology). Hospital Cenlral de la Defensa. Cli'nicas Especiales. 5^ Planta. Glorieta del Ejerciio s/n. 28047 Madrid. Spain. llDOO-SAO. Kwartier Koningin Astdd. Bruynstraat 200, 1120 NederOver-Heembeek. Brussels. Belgium. Portions of this article were presented at the 2006 NATO Research and Technology Organization-Human Factors and Medicine 134 Symposium, "Human Dimensions in Military Operations: Military Leaders' Strategies for Addressing Stress and Psychological Support," April 24-26. 2006, Brussels. Belgium and the 2006 Meeting of the International Society for Traumatic Stress Studies, November 4-7. 2(H)6. Hollywood. CA. The views of the authors do not necessarily represent their respective Department of Defence or government. This manuscript was received for review in March 2(K)7. The revised manuscript was accepted for publication In August 2007.

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ment of soldier sacrifices.'" Such findings underscore the role of leaders in moderating the impact of deployment on outcomes of importance to unit members, leaders, and Ihc military organization. Despite the importance of leaders influencing the health and well-being of unit members during deploytnent. we are aware of no systematic assessment of how loaders are trained to address operational stress issues or their satisfaction with this training. To assess leader training in mental health support across the deployment cycle, NATO's Human Factors and Medicine (HFM)-08 I/Research and Technology Organization Task Group (RTG) conducted a multinational survey of operational leaders. The NATO HFM-081/RTG "Stress and Psychological Support in Modern Military Operations" Group evolved from an exploratory team (HFM-ET016) in 2002 and was established in April 2003. The primary goal was to provide military leaders with information and practical guidelines on stress and p.sychological support to enhance effectiveness in operations. HFM-081 developed a stirvey to assess leader preferences for such guidance. Qtiestions were also asked about how leaders viewed mental health problems because stigma had been identified as an important issue for military personnel returning from deployment' although commanders seetn to have relatively tolerant attitudes toward combat stress reactions." The aim of the survey was to assess (1) what kind of support and training military units and leaders received for dealing with stress-related probletns in their unit across the deployment cycle; (2) what support and training they wanted to receive about stress-related probletns; and (3) leader attitudes toward mental health-related problems.

METHOD

Procedure Sixteen NATO and Partnership-for-Peace (PfP) nations participated in the project between June 2005 and January 2006,

MILITARY MEDICINE. Vol. 173, January 2008

Military Leaders' Survey

which included either a face-to-face interview or a postal questionnaire depending on the logistical requirements for each naiion, In all, the survey or interview took approximately 30 10 45 iiiinules to complete and was conducted in the national language of the participant. Selection for the survey wa.s based on a convenience sample although participants needed to have been in a leadership position (enlisted or officer) on operations sometime in the last 2 years. Responses were not linked with specific names or identifying infomiation and participation in the study was voluntary. Data were aggregated across nations, thereby also preserving ihe anonymity of specific nations.

Sample Of the 19 nations comprising HFM-08I/RTG. there were returns from 16 nations (Table I). Of the 172 responses, the majority (97%) of responses were from Army personnel. Ranks ranged from sergeant to colonel; 78.5% were officers. All but two participants were men. Length of service ranged frotn 3 to 35 years with a mean of 16 years (SD = 8.08). Respondents identified their primary military role as infantry (56.2%), artillery (12.4%). engineering (7,1%), or armored (6.5%). Half of the respondents had been on one deployment; 30% had been on two deployments. In all, 79% had only been on peacekeeping deployments and 16% had been on combat deployments. The majority of deployment locations included Afghanistan. Bosnia, Kosovo, and the Gulf/Iraq.

Measures All of the questions were designed specifically for this needs assessment, and a subset of questions are included in the present analysis. The questions and sample responses are presented in Table II.

TABLE I. NATO and PfP Nations Pailicipating in Survey Nation

No. Surveyed

Austria Belgium Bulgaria Canada Czech Republic Denmark France Lithuania Luxembourg The Netheriands Rumania Spain Slovakia Sweden Dnited Kingdom United States Total

10 17 11 5 10 5 17 II 10 15 10 14 10 4 9 14 172

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Psychological Support

Respondents were asked (1) what kinds of psychological training and support their unit received for psychological or stress-related problems; (2) what kinds of training and support they, as leaders, received for mental health-relaled issues; and (3) what elements of training and psychological support leaders would like to see changed. These questions were asked for each phase of the deployment cycle: predeployment, deployment, and postdeployment. Family Support Respondents were asked (1) what kinds of support and training family members received; (2) what kinds of support and training they, as leaders, received for handling family-related problems; and (3) what training and support they would like in terms managing family member stress. Again, these questions were asked for each phase of the deployment cycle. General Atdtude.f

Leaders were asked who they considered to be responsible for the psychological readiness of unit members. Leaders were also asked what they thought of unit members who had stress-related problems and unit metnbers who sought services for stress-related problems.

Analysis Strategy The goal of the data analysis was to identify common themes that bridged across the participating NATO nations. Given this goal, specific national issues were not highlighted and themes were mentioned if they were reported by at least two nations represented in the sample. Direct quotes were used, however, as illustrations. RESULTS

Psychological Support across the Deployment Cycle Predeployment

Unit Training and Support. Al least one individual from every nation in the survey reported some predeployment unit briefing, group instruction, or education related to psychological stress on operations, Nevertheless, respondents from nine different nations reported that their units received no predeployment psychological preparation. Thus, there appears to be some variability within nations as to whether units receive predeployment stress-related training. In the case of respondents from al least two nations, the lack of preparation appeared to be due to the fact that the deployment occurred on short notice. The topics of training included the psychological stages of deployment, normalizing responses and reassuring unit tiiembers about their own reactions, identifying individuals at risk for suicide, dealing with family issues, and dealing with combat stress. Respondents from five nations mentioned having training exercises that incorporated dealing with psychological stress in some fashion.

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Milifarv Leaders' Survey TABLE II. Questions and Sample Responses to the Military Leaders' Survey Survey Question Psychological support at predeployment What kind of psychological preparation did your unit receive prior to your last deployment in order to cope with any psychological or stress-related problems that might ticcur during the operation/mission?

Did you, as one of the unit leaders, receive any specific training or preparation for supporting subordinates in the event of encountering stress-related problems during the operation/mission? Are there any elements of the current predeployment psychological preparation that you would like to see changed and/or improved upon?

Psychological support during deployment What kind of psychological support did your unit receive during your last deployment in order to cope with psychological or stress-related problems thai might occur during the operation/mission? Did you. as one of the unit leaders, receive any specific support for assisting unit members if they encountered stress-related problems during the operation/mission? Are there any aspects of the psychological support provided during operations that you would like to see changed or improved upon?

Psychological suppt>rt at postdeployment Whai kind of psychological support did your unit receive after the last deployment in order to cope with psychological or stress-related problems that might occur after the operation/mission? Did you, as one of the unit leaders, receive any specific support for assisting unit members with stress-related problems following the operation/mis.sion? Are there any aspects of the psychological support provided postdeployment that you would like to see changed or improved upon?

Sample Responses "We had psychological education aboui stres,s and how to cope with it in different situations," "Just a 30 t(i 60 minute briefing on signs and symptoms of combat stress." "None. No course or training. Preparation based on personal experience." "Nothing received specific to that deployment," "Having former leaders explain, based on their experiences Irom missions, what to expect on a mission, maybe by using cases to illustrate different situations," "There is a certain need of predeployment training a! all levels. It should be aimed at dealing with the problems during the mission and effective management of the team in a conflict or crisis." "Support from comrades." "Military psychologist helped to solve individual problems." "Yes. from military leaders with higher tnilitary ranks." "A visit from a psychologist after an accident (happened once)." "It would be better if the psychologist had more practical insight concerning the work leaders do during a mission and by that be able to relate more to ihe situations leaders rnight face during a mission." "Chaplains need more training as they are first line care/counselors. One was good, the others had no training." "As part of a post-deployment reintegration period, we received a series of briefings to help cope with reunification and postdeployment stressors." 'Two surveys, Reintegration briefing," "No, Nothing for leaders." "Suicide prevention training-what to look for in soldiers." "Optimally, psychologists could be standing by at base to assist if necessary during the homecoming procedure," "Currently, when a unit returns home some personnel are immediaiely dispatched to another unit. This means they have no one to talk to about the highs and lows relating to their recent operation. You need 3 months together as a unit during posideployment,"

Military families What kind of psychological support was received by the unii family members before, during, and after the lasl deployment in order to cope with psychological or stress-related problems that might occur? When thinking of the current psychological support given to families within your nation, are there any changes/improvements you would like to see implemented?

"We received postoperation handouts on separation from family. But there was no guidance for me as a leader on how to cope with families... " "A letter and a support handbook." "I think we have it right for cohesive units/subunits, but for augmentees we are failing in our family support." "We don't target reintegration at the right time—[we target | the honeymoon phase when we first get back. They're tired and they go on block leave and then come back to work. Then 90 days later the problems become real again."

General attitudes Who do you think should t>e responsible for preparing military personnel for operational psychological readiness? What do you think of militate personnel who suffer stress-related problems on or after deployment? What do you think of military personnel who seek services for stress-related problems?

"The [Commanding Officer]—^but he needs a professional advisor to help him." "Commanders—in close cooperation with psychologists." "This is not a disease but a moment of inner crisis. They need help rather than being returned home or decommissioned." "Seeking help demonstrates courage, strength, and maturity, and demands great respect from others."

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Leader Training. Respondents from 15 of the 16 nations surveyed reported receiving no training specifically geared toward preparing leaders to handle stress-related problems in their unit. When training was mentioned, it was described as independent of deployment preparation. Respondents from eight nations reported participating in some kind of staff course or military academy course, and respondents from three nations look university courses related to stress and mental health. In terms of informal mechanisms of support, respondents from five nations reported that they relied on their own deployment experience. As one leader mentioned, he received "'nothing formal but experience. . . was good preparation." ln addition, respondents from three nations reported talking with leaders who had deployment experience. Training Recommeiuiations. There was agreement across many nations that predeployment psychological training be part of preparing unit members for deployment. The need for leader-specific Iraining was also acknowledged. Leaders identified themselves as having a unique role: they are often Ihe first lo deal with a critical incident, have to manage a leam in crisis, and have to identify psychological problems among peers. As one leader noted, it was difficult ". . . to recognize soldiers having probletns when they are Ialso| your friend." Respondents were consistent in their recommendation that the training be orienleil toward specific practical infonnalion and based on case examples. Recommendations included providing "useful tips," being "taught specific tools for handling stress," and "examples, real situations, and practical advice." It was also suggested ihat this guidance involve experienced leaders. There was a range of topics suggested for such training including psychological and physiological responses to stress, critical incident handling, trautiiatic and cotnbat stress. sytiiptoni recognition, and dealing with death. In terms of dealing with death, recommendations included "dealing with friendly fire fatalities and injuries," "mission casualties," and "lecltires on death {what lo do, follow-up, and help for the platoon)."' Respondents from many nations commented that mental health professionals needed to be available and integrated into t)r known by the unit. As one leader said. "I'd like professional advice on call, at hand lo deal with individual cases. Someone who was able, physically, to go out to the unit and help."

Leader Training. Military leaders from 10 nations generally said that they did not receive any specific support or training as leaders for assisting unit members during deployment. Five nations reported receiving only minimal support. None of the nations had respondents who consistently reported receiving support for assisting unit members dealing with stress. In the few cases where leader support was offered, it was in the form of identifying individuals with mental health problems, addressing risk of suicidal behavior, and personal support from friends. In general, such support was provided by mental health professionals, chaplains, and other leaders. Training Recommendations. There were many suggestions about ways to improve the psychological support provided during operations in an international setting. Respondents from four nation.s recommended training for working in a multinational environment, both in terms of dealing with the local culture and in terms oi' working with militaries from other nations and comtiianding foreign troops. Similarly, several respondents noted the need for a plan to overcome language barriers when psychological support was provided by someone from another nation. There were consistent concerns that the mental health professionals providing support to unit members during the deployment be adequately trained and adopt a proactive role in being integrated wilh ihe unil. It was also recommended that mental health professionals be credible in terms of knowing the unil and the military environment. Leaders also recommended that chaplains, who were considered an excellent source of support, receive more formal iraining in mental health. In addition, leaders wanted mental health professionals to be embedded with their unit or mobile so that even those units in relative isolation could access services. Leaders noted that many of the unit problems were related to home front issues, not just operational issues and mental health support needed to handle both issues. Leaders also suggested training in communication (e.g., to integrate new members into unit), peer iraining (e.g., to provide mental health support during deployment), alcohol problems, specific operations, and/or subgroups (e.g., transportation units which are not trained for combat). Several respondents recommended routine meetings with mental health professionals lo address these issues and individual assesstiient during ihe mission to identify those having problems. Two individuals from two nations remarked that mental health support was not needed or was of no interest.

During Deployment

Unit Training and Support. Respondents from 11 nations consistently reported receiving several different kinds of support during deployment. This support was provided by a range of specialists including social workers, psychiatric nurses, psychologists, chaplains, and medical professionals. Examples of this support included advice, individual consultations with targeted subgroups, and group debriefing/ defusing sessions. This support was often in response to a specific traumatic event (e.g., helicopter crash, ambush with casualties, accident involving death of a soldier). Nevertheless, leaders from four nations consistently reported receiving little, if any, formal mental health support on deployment and described receiving support from fellow unit members.

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pDstdeployment Unit Training and Support. Individuals from 14 of 16 nations reported sotne type of formal psychological support related to returning from deployment. This support included an array of mechanisms: individual interviews wilh military mental health professionals, briefs on homecoming, debriefings, surveys, and some period of time set aside for decompression. Only 2 of the 16 nations in the survey consistently reported no kind of support. Several respondent.s commented on the importance of receiving psychological support and the need to extend this support lo families. Leaders also distinguished between the need for postdeployment mental health support following a benign lour com-

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pared to a high-stress deployment. In the event of a benign tour, postdeployment psychological support was not necessarily considered critical but in the event of a high-stress deployment, it was considered to be very important. Only 1 respondent (of 172) said that mental health support was not needed postdeployment. Leader Training. The majority of respondents from 15 of the 16 nations reported that there was no specific training for leaders for managing the psychological stress of unit personnel at postdeployment. Besides I nation that had such training. 6 individual respondents from other nations reported receiving some form of briefing about postdeployment stress geared for leaders (e.g.. suicide, the signs and sytiiptoms of post-traumatic stress disorder). Thete was general agreement that military leaders were the first line of defense for identifying mental health problems in unit personnel (e.g., "It is down to the unit leader to make the lirst assessment"), but when individuals were not deployed as part of an intact unit or otherwise dispersed, providing this support was often difficult. Others described the importance of maintaining an informal network to track the adjustment of former unit members and knowing whom to contact in the event a unit metnber had a psychological problem. Training Recommendation.s. Leaders commented on the need for decompression time before reintegration (e.g,, '"to relax with the first beer without the home front"). Respondents from seven nations also suggested that psychological support be extended beyond the itiimediate postdeployment period and be provided at least 3 to 6 months postdeployment. Consistent with this theme, maintaining unit integrity for at least 3 months after homecoming was an important issue for respondents from at least four nations. Unit integrity was described as facilitating adaptation back home, ensuring unit tnembers had friends with whom to talk, and enabling leaders to assess the adjustment of their unit members more easily. Respondents from several nations mentioned the importance of informal support networks in helping individuals cope with stress during the postdeployment phase. In addition, several respondents recommended providing information on postdeployment psychological adjustment to the unit as a whole and including family members in training about the signs and symptoms of stress-related problems. Respondents from several nations recommended structured individual interviews with military personnel, especially following particularly stressful or dangerous deployments. Respondents from several nations suggested that tuilltary mental health professionals be available (e.g., standing by. meeting with unit members) during homecoming and after. Having a mental health professional identified as a resource for a unit was not enough; respondents commented that military mental health professionals need to make themselves visible and accessible. For example, mental health professionals should be present during unit social gatherings. Some respondents recommended that leaders receive support from mental health professionals in recognizing and dealing with their own stress reactions. As one respondent recommended to mental health professionals, "Talk to leaders and see how they are doing as it is pretty stressful for NCOs [noncommissioned officers] and officers." 14

Military Families Family Training and Support

Responses from 50 tnilitary leaders indicated that family members of deploying personnel received support. Families typically received information that was designed to help them have contact with one another and to assist them in navigating the military system. Respondents also reported that family members were typically briefed about what to expect in dealing with deployment and the itnpact of a deployment on military families. Leaders primarily described family suppoti during deployment as focused on facilitating communication home including phone calls, the Internet, and webcams. Communication about the unit was supported through websites, newsletters, family btiefings, and phone circles. That said, 46 respondents reported not being aware of family support or that no family support was provided. Of the 24 leaders who reported fatnily support at postdeployment, this support included reintegration briefings, homecoming meetings, group sessions with families, and clinical support for those with significant difficulties adjusting. Support and Training Recommendations

Leaders recommended contact between the unit and families be improved during the predeployment and deployment phases and that individuals not deployed as part of an intact unit be provided more support. Suggestions included conveying realistic, but not alarming, information about the mission to families, providing regular contact frotn the unit, and providing information geared to children. Respondents from a number of nations raised the issue of providing practical support to spouses, as spouses often have to deal single-handedly with family issues during the deployment. Several respondents suggested that professional statf like psychologists and chaplains be available for military families if needed. Leaders recommended thai postdeployment training for families occtir after the initial reintegration honeymoon period.

General Attitudes Responsibility for P.sychological Readiness

Leaders were asked who was responsible for the psychological readiness of unit members. The tnost common respon.se, reported by leaders from eight nations, was that commanding officers (COs) shouid be responsible. Respondents considered COs—-from platoon to battalion level—to have ultimate responsibility for the unit and the necessary experience and knowledge of the military required to know the needs of the individual and the organization as a whole. Leaders also noted that COs are in close proximity and have daily contact with their subordinates. The second most common response, mentioned by leaders from six nations, was that psychologists were responsible for

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The majority of leaders surveyed saw the presence of stressrelated problems on deployment as normal, and generally agreed that help-seeking behavior was a positive step, although other leaders disagreed. This survey was a needs assessment that relied on a convenience sample. Respondents are not necessarily representative of their nation's military leaders. Despite the potential for a bia.sed sample, this survey was the first needs assessment of its kind and included a range of ranks and Attitudes Related to Stigma deployment experiences. The approach can serve as a model Leaders were asked what they thought of unit members for conducting multinational needs assessments with other with mental health problems. Frequent comments from I 1 NATO RTGs. ensuring that programs developed are responnations reflected the perspective that stress was normal, sive to operational leaders" requests. and that everybody suflers to a certain degree, although the In addition, the results from this survey suggest the majority cope and deal with it. Some leaders from eight need for developing training programs on operational nations were less tolerant of menial health problems. They stress designed specifically for leaders. Follow-up research noted thai having stress problems could be a way unit should assess the efficacy of such programs both within members try to get out of work, could harm one's career, and across nations. As an initial step, the NATO Task ov could reflect a deficiency in predepioyment selection, Group has integrated the recommendations from the miliand that these individuals should not be allowed to deploy tary leaders' survey into "A Leader's Guide to Psychologor should be sent home. Other comments reflected the ical Support Across the Deployment Cycle."'- This guide belief that individuals suflering from stress were sick and represents the first concerted effort to target leaders with needed help. information about managing stress-related problems in Leaders were also asked what they thought of unit unit members. The guide is general enough to apply to the members who sought mental health services. Most were range of NATO and PfP nations and includes information supportive with such statements as, "It is the best/right/ on stress-related reactions, mental health and morale assmart/responsible/reasonable/sensible thing to do". Re- sessments, families, and the role of military leaders in spondents from three nations saw help-seeking as a sign of supporting unit member mental health. Throughout, firststrength, courage, and maturity. Also, several military hand accounts exemplify the issues discussed and practical leaders stated that they regarded unit members with more information is provided as highlights. The goal of such a respect and understanding when unit members acknowl- guide is to translate psychological information into a useedged their problems and recognized that they needed ful product for operational leaders and simultaneously help. The potential for stigmatization was mentioned by increase interoperability by providing NATO and PfP leadrespondents from three nations and the concern that help- ers with a common understanding of stress-related seeking behavior would lead to discharge was mentioned concerns. by respondents from two nations. the psychological readiness of the unit. Psychologists were seen as experts who had the necessary in-depth knowledge and experience relevani to this area. Medical staff was the third most common response. Approximately 50 military leaders noted that both the CO and psychologist or medic were responsible. Options receiving 10 or fewer responses included the chaplain, military personnel themselves, and personnel staff.

REFERENCES DISCUSSION Results from an international survey of experienced military leaders found that while there were national differences in terms of the degree of mental health support provided to unit members across the deployment cycle, most nations had some kind of mental health support for unit members and their families. There was greater consensus, however, that leaders were provided little training in addressing operational stress issues. The majority of leaders were interested in receiving training and preferred concrete, specific information related to recognizing and managing psychological stress on deployment. Another consistent theme from the survey was that most leaders saw themselves as responsible for the psychological readiness of their unit members and wanted to work together with militaiy mental health professionals to achieve this goal. In general, leaders also wanted military mental health professionals to be more visible and integrated with their unit.

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