Page 42 - JSOM Winter 2021

Desired Performance and to effectively select appropriate evidence-based training
There is high demand at the individual and unit level to in- and measures to counterbalance the effect of stress on perfor-
crease options for evidence-based human performance training mance and health (from training to health sustainment and
that enhances resilience to stress and targets optimal perfor- health restoration). Conceptual focus and target skills in the
mance on core occupational tasks. Pragmatically, perfor- 8 training modules (60 to 90 minutes each) closely align with
1,2
mance enhancement paradigms of intervention are culturally those in the 11 health-sustainment/restoration sessions (90 to
aligned, are incentivized socially, and carry opportunities for 120 minutes each) to allow for relatively seamless pathways
increased knowledge, skill, and individual capacity in multiple between both arms (Figure 2). The design allows for flexible
life spheres (i.e., physical, psychological, cognitive, social, and delivery at different levels (i.e., individual, group) and deploy-
spiritual). 49–51 More importantly, when thoughtfully aligned, ment within multiple settings (i.e., community-based outreach,
human performance–based protocols have the potential to re- unit-specific trainings, clinic, MTF, VA), as well as a way to es-
align motivation and expectations in regard to seeking more tablish a common language and conceptual understanding of
traditional psychological intervention, and to reduce organiza- human performance and health that can be built upon through
tional and internalized stigma by improving health literacy. 48–53 “curbside consultations.” (Additional information on the spe-
As such, they may open doors to care initiation and improve cific content of each module/session is provided in the Supple-
retention in intervention protocols. mentary Materials section.)

Environmental Analysis/Actual Performance SIT-NORCAL for Human Performance
There are few evidence-based/evidence-driven human perfor- Training module language and content is performance focused.
mance protocols in existence that are used regularly, despite Content and concepts are geared toward acquiring a neuro-
the high demand and congruence with goals and objectives in biological understanding of stress, increasing health literacy,
psychological health and resilience. 30,54 Traditional care mod- and actively adapting skill sets to countermeasure the impact
els tend to align with the medical model (i.e., targeting and re- of physical and psychological stress on multidimensional as-
solving pathology), which carries stigma, introduces concerns pects of performance. Importantly, the design of the protocol
about engaging in care (i.e., logistics, access, potentially nega- incorporates formal unit engagement processes that allow for
tive impacts on career, social, and cultural implications), and further refinements unique to a specialty code and tailoring
ultimately disincentivizes treatment-seeking and engagement to the distinct occupational, cultural, and social demands of a
in care. 51–54 unit as a best practice (discussed further in Part 2).

Cause Analysis: Closing the Gap SIT-NORCAL for Health Sustainment and Restoration:
However, studies have demonstrated that interventions that PTSD/TBI
culturally align with the warfighter experience, focus on a The human performance protocol (training modules) inter-
paradigm of performance (rather than pathology), and can be locks with the SIT-NORCAL Health Sustainment and Resto-
geared toward prevention and early intervention at the unit level ration (HSR) geared toward PTSD/TBI (full sessions) in a way
may aid in overcoming barriers frequently seen in traditional that confers a skill set for “over-recovery” when initiating the
care models by reducing organizational stigma and logistical HSR protocol. Full session language is more recovery-focused
and cultural barriers. 41,48–50 Furthermore, interventions capable but retains the human performance stance. Concepts and focus
of nimble delivery at both the unit and MTF levels may have are geared toward learning about the neurobiology of stress,
better reach and improve the knowledge, skill, and individual the impact of PTSD/TBI on health and performance, and im-
capacities of the warfighter, ultimately improving psychological proving performance and functioning in multiple spheres. Full
performance, health literacy, and treatment initiation. 41,47–50 sessions train module concepts in more depth, present material
at a slower pace, incorporate more strategies (i.e., priming,
repetition, segmenting), and include more time for practicing
SIT-NORCAL: Intervention Selection, the target skill. Additionally, techniques and skills in this arm
Design,and Development
of the protocol are intentionally designed to increase famil-
Cultural/Performance Enhancement Alignment iarity with, and confidence in, the application of skills that
All aspects (i.e., nomenclature, approach, stance, delivery) map directly onto key elements of prolonged exposure (in
were culturally aligned and designed to leverage both previous vivo training skills via adaptive exposure training) and cog-
and existing military training as explicit resources in achieving nitive processing therapy (via mental agility/flexibility train-
objectives. For example, when selecting scenarios to be used ing) when initiating “gold standard” treatments (i.e., full
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in educational elements, real-world trainee experiences were restoration) where required. Early results in naturalistic pop-
leveraged to aid in the development of adaptive and catalytic ulations at VA Northern California Healthcare System demon-
learning tools and increase salience. Moreover, values that are strated promise in closing critical gaps identified above in
common to military servicemembers across branch and era PTSD/TBI care among combat veterans, substantially reducing
were infused throughout the protocol. These included a value symptoms of PTSD and depression, while improving adaptive
in challenging oneself by engaging in rigorous training, expe- functioning. 41
riencing high-intensity demands and situations, and increasing
one’s environmental awareness and self-awareness to achieve Intervention Implementation and Maintenance
higher performance states. 48,49 Training plans, materials, and measurement systems are
designed for flexibility, incorporating a set of multimedia
Multimodal/Multidimensional Learning training materials and PowerPoint presentations with embed-
Along Multiple Pathways ded videos, discussions, pictorial representations, graphics,
Training concepts allow participants to identify themselves demonstrations, and activities for use in in vitro (in training)
more accurately on a continuum of performance and recovery, skills practice, as well as activity assignments trainees use to

40 | JSOM Volume 21, Edition 4 / Winter 2021