Page 40 - JSOM Winter 2021

challenges managing physiological arousal) builds tolerance in providing performance enhancement training. Training ef-
and a skill set that can “inoculate” the trainee to more signif- forts were found to be sporadic, resulting in SIT not being
icant stressors, thereby reducing the negative impact of stress used to its full potential among high-intensity/high-risk occu-
psychologically and physically, thus increasing resilience and pa tional groups. More importantly, researchers isolated the
performance in the face of stressors. challenges that were limiting the integration of SIT more
formally and deliberately for human performance, 30–32 which
Traditional SIT protocols incorporate an interlocking tripha- mirrored those identified with SIT protocols in the clinical
sic design: Phase I (Education/Conceptualization), Phase II context. 40,41 These challenges included a lack of core content,
(Skills Acquisition and Rehearsal), and Phase III (Application manualization, and measurement capability (which was lim-
and Follow-Through). 29,30 Targets of a specific intervention iting reproducibility), as well as formalized processes for de-
are identified; then education and skill elements are carefully ployment in group settings. Recommendations were made to
30
selected for each phase. Skills and training elements are then overcome these limitations; those most salient to the current
scaffolded to confer a rapidly enhancing skill set, with each project included:
skill building upon the others, culminating in exposure in sim-
ulations and/or real-world applications to solidify target skills 1. Develop curricula for SIT with an emphasis on core skills
in relevant environments. 29,30 that facilitate performance enhancement.
2. Identify opportunities to integrate common stressors from
Psychological Performance Enhancement Context downrange experiences.
In 2014, a large-scale review of modern stress theories and for- 3. Ensure that applicable skills are mastered before exposure
malized state-of-the-art strategies being utilized by US Military to stressful conditions.
assets examined SIT and stress exposure training (a similar 4. Continue to provide sufficient opportunities to practice
paradigm). The RAND Study (Project Air Force), Enhanc- new coping skills under “real” performance conditions.
ing Performance Under Stress: Stress Inoculation Training 5. Consider supporting SIT with virtual reality technology.
for Battlefield Airmen, outlined a body of evidence demon- 6. Continue efforts to identify valid screening tools to predict
30
strating the efficacy of SIT in the human performance context success in stressful conditions.
among military personnel in multiple high-risk/high-intensity 7. Develop measures to support the evaluation of screening
occupational specialties. Training targets included enhancing tools and SIT.
stress tolerance, managing physiological arousal, increasing 8. Provide information to increase awareness of support ser-
complex adaptive skill sets, and improving general function- vices for mental health.
ing, performance, and resilience to stress. 31–39
Development of SIT-NORCAL
Key findings demonstrated that individuals can be trained to This project was undertaken in direct response to the recom-
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effectively minimize the destructive effects of stress on human mendations of the RAND study. The resulting protocol is
performance: (1) Through formalized training and stepwise, a unique, culturally congruent psychological performance en-
structured exposure to stressors, individuals can cultivate nec- hancement and health sustainment (i.e., evidence-based treat-
essary skills and countermeasures (i.e., can be “inoculated” ment) hybrid, designed specifically for warfighters and combat
against the adverse impact of physical and psychological veterans. SIT-NORCAL is a manualized but flexible protocol
stress), thereby improving optimal performance capability delivered on a continuum that interlocks evidence-based psy-
under a range of stressful conditions. (2) Formalized educa- chological performance enhancement techniques with key ele-
tion, skills training, and focused exposure to occupationally ments from “gold standard” psychological health interventions
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relevant stressors are important core components for prepar- for PTSD (i.e., cognitive processing therapy and prolonged
ing military personnel in high-risk/high-intensity occupational exposure). This protocol can be delivered in both individual
specialties to perform well under stress. 30 and group formats, and directly targets Neuropsychological
Optimization and Repair of Cognitive flexibility and agility
Clinical Context (i.e., thinking skills) and Affect regulation (i.e., emotional
While a far greater number of studies have established the control/physiological control skills), using enhanced Learning
potential of SIT in human performance enhancement appli- science methods (NORCAL) to speed efficiency in acquisition
cations, SIT has also been recognized by the Veterans Ad- and recall of task- and goal-relevant skill sets.
30
ministration (VA) and Department of Defense (DoD) as a
second-line treatment for PTSD. Preliminary investigations
40
on forms of SIT have suggested potential promise in overcom- Methods
ing barriers to treatment initiation, reducing the symptoms of Initial content and process elements of the SIT-NORCAL pro-
posttraumatic stress among combat veterans 31,40,41 and enhanc- tocol were configured for performance enhancement and battle-
ing resilience against PTSD and stress disorders among mil- field applications via phased education among both individuals
itary personnel. 31,32 This combined body of literature makes and groups of US Air Force personnel in special tactics (combat
SIT an ideal paradigm for configuration as an evidence-based/ controllers, joint terminal attack controllers, tactical air control
evidence-driven human performance and health sustainment party) and first response personnel (combat medics) from 2010
hybrid. to 2013. Subject matter experts from multiple specialty fields
were consulted in regard to initial material designs: operational
Implementation (Content and Process Challenges) psychology (n = 2), clinical psychology (n = 1), and neuropsy-
Despite being a well-established, well-accepted strategy, the chology (n = 2). Formal study of the efficacy of SIT-NORCAL
RAND study identified that instructors providing training in as a health sustainment and restoration (i.e., treatment) proto-
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SIT techniques to airmen were mostly offering skills ad hoc, col began in 2013, when it was revised and expanded for appli-
and there was usually very limited support from psychologists cations among combat veterans with PTSD and TBI.

38 | JSOM Volume 21, Edition 4 / Winter 2021