Stress is a common factor in tactical fast-paced scenarios such as in firefighting, law enforcement, and military—especially among Special Operations Forces (SOF) units who are routinely required to operate outside the wire (i.e., in hostile enemy territory) in isolated, confined, and extreme (ICE) environments (albeit seldom such environment is long-duration by choice).
Human performance is inherently subjected to increasing levels of adverse effects due to several types of stressors—such as fatigue, noise, temperature (e.g., extreme heat or cold), high task or acute time-limited load—leading to negatively affected cognitive processes, which may subsequently affect the quality of attention, effective decision-making, information processing, situation awareness, one’s physical or mental well-being and overall mission success. In general, the underlying factors of decreased performance in ICE environments (i.e., astronauts or Antarctic expeditioners) include diverse range of stressor such as fatigue, sleep deprivation, acquired or inherent ability to cope with stress, perception of the risks associated with the physical environment, disruptions of circadian rhythms, and separation from a known social environment. Further, external medical help is usually unavailable in long-duration exploration missions when communication might be disrupted or when message transmission could take extended period of time (such as in space missions). This added isolation requires that cosmonauts can adapt to new and developing issues in all aspects of their mission, including mental health.
ICE environments in military settings can be characterized primarily by intensity in terms of life-threatening conditions (high-risk violent environment), mission complexity, isolation (may occur through unplanned enemy action, retrograde, terrain disorientation, or other environmental conditions), confinement (military captivity), and pace of operation (speed of performance and the tasks that need to be performed). Previous empirical work has shown that individuals who successfully develop the cognitive and situational skills that can help manage anxiety in a high-stress environment have an ability to withstand stress. Though cognitive skills and specific personality traits in some have been found to facilitate higher levels of performance under stress more naturally than in others, there is also sufficient evidence that resilience competencies can be developed and changed to mitigate the adverse effects of stress on performance, thereby reducing the likelihood of negative outcomes. The incorporation of both physical and psychological competencies—adaptability, concentration, perseverance, and overall tolerance to stress—via specialized training would be expected to positively affect the mission readiness of special force personnel in several ways, including enhanced situational and behavioral performance under stress, reduced attrition during basic and advanced training, and increased trainee retention. The organic development of such competencies within special forces fall under stress inoculation training (SIT) or stress exposure training (SET).
Despite the existence of various standards for pre-combat training under stress, considerably less attention has been placed on developing competencies (i.e., behavioral and cognitive skills) that facilitate successful performance in ICE environments. Technology, such as virtual reality (VR) or virtual simulation, shows promise as an emerging health safeguard tool to provide an alternative effective platform to support additional pre-combat stress inoculation training in special forces, specifically focusing on ICE environments.
Stress inoculation training and stress exposure training
Stress inoculation training, or SIT, is one of various stress interference cognitive-behavioral therapies in the current use by organizations, both civilian and military, as a comprehensive approach to improve performance success rates under a wide range of stressful settings. Originated from several clinical psychology research disciplines, general stress inoculation training is designed to establish effective tolerance to stress through physical and cognitive skill training by providing appropriate levels of exposure to stressful stimuli in intense yet controlled environments. Empirical work has shown that individuals that are put through carefully designed realistic stressor frameworks in order to develop personal ways on how to deal with such situations, will acquire the confidence (or perception of confidence) to overcome increased levels of physical and psychological loads in the future.
Generally, as proposed by Donald Meichenbaum, known for his role in the development of cognitive behavioral therapy (CBT) and for his contributions to the treatment of post-traumatic stress, stress inoculation training comprises of three phases consisting of conceptual education, skills acquisition and consolidation (physical capacities, motor skills, and cognitive abilities), and application and follow-through.
In the conceptual education phase, the goal is two-fold: building a relationship between the trainer and trainee; and guiding an individual by increasing their understanding and perception of his or her stress response and overall existing coping skills. Various models of coping have been proposed and used to help the individual understand how maladaptive coping behaviors, like cognitive distortion, can negatively influence their stress levels. Clinical methodologies such as self-monitoring and modeling are used to help the patient become more adaptive to overcome their stressors while raising self-control and confidence. The person might be asked to build a list that differentiates between their stressors and their stress-induced exercises so that coping models can be adjusted accordingly. This stage is key in showing the individual that it is possible to provide an answer to his/her psychological triggers. This can include control of autonomic arousal, confidence-building, and basic mental skills such as the link between performance and psychological states, goal-setting, attention control, visualization, self-talk, and compartmentalization.
In the skills acquisition and consolidation phase, the goal is establish the coping techniques so they can be implemented in the next phase to regulate negative reactions and increase control over physiological responses. Some general skills in this phase can include l relaxation training, cognitive restructuring, emotional self-regulation, problem-solving, and communication skills. In general, the individual will develop a wide spectrum of personal techniques which they can then draw from in order to apply when coping with a stressful situation.
In the application and follow-through phase, the goal is subject an individual to increasing levels of a particular stressor and practices applying the techniques they have developed to mitigate his or her stress response. Employing incremental exposure of one’s to stress, or systematic desensitization, leads subsequently to the individual’s ability of becoming more resilient towards stress. This can be established via modifying the levels of motor pattern complexity, program complexity, and physiological stress in the form of increased intensity, volume, and density.
Military organizations, SOF included, began to adapt the general structure of SIT in demonstrated considerable improvements in personnel performance. Originally designed by Driskell and Johnston (1998), stress exposure training, or SET, is a comprehensive approach for developing stress resilient skills and performance in high demand training applications. However, instead of cognitive-behavioral pathological therapy, SET provides an integrative and preemptive structure for normal training populations. Similarly to SIT, SET comprises of three analogous phases consisting of information provision, skill acquisition and application and practice.
In the information phase, the goal is acquire initial information on the human stress response and what overall nature of stressors participants should expect to encounter. In the skills acquisition phase, the goal is develop and refine physical, behavioral, technical, and cognitive skills. Along with specific skills training, successful tactical training and operational effectiveness requires physical fitness training. Physical fitness not only creates a foundation for task performance, it also builds two key qualities: resilience and toughness. Resilience is the ability to successfully tolerate and recover from traumatic or stressful events. It includes a range of physical, behavioral, social, and psychological factors. In the application and practice phase, the goal is putting previous preparatory phase to practice by testing skills under conditions that approximate the operational environment and that gradually attain the level of stress expected.
A research conducted twenty-four Marines who had a diagnosis of PTSD pre- and post-deployment involved PRESIT, a program also known as pre-deployment stress inoculation training as a preventive way to help deploying military personnel cope with combat-related stressors. The findings showed that the PRESIT group of Marines were able to reduce their physiological arousal by breathing exercises. Moreover, the study found that those who went through PRESIT had benefited from the training in terms of their amount of PTSD and how they were able to cope with their stressors in comparison to those who did not go through PRESIT (Lee et al., 2002).
One of the common non-clinical examples of SIT used in a pre-combat training is a basic swimming exercise designed to increase water confidence, commonly known as “drown-proofing”. In this exercise, trainees must learn to swim with both their hands and their feet bound and complete a variety of swimming maneuvers. This exercise is a SIT example that “…build[s] the student’s strength and endurance; ability to follow critical instructions with emphasis on attention to details and situational awareness; ability to work through crisis and high levels of stress in the water” (Robson and Manacapilli, 2014).
In a similar manner to the clinical interventions designed to treat pathological psychiatric conditions, military personnel in SET is exposed to the stressors that could be part of a given situation, such as the mental and physical impacts of extreme fatigue or cold water conditioning, prophylactically or without developed psychiatric pathology for potential stressors and scenarios that are likely to encounter. Those stressors are progressive and cumulative—challenging enough, but not completely debilitating—with gradual build-up of anxiety. Each training activity is designed to establish the required technical skills (such as movement quality and positioning or control of stress responses), rather than hinder the development of those skills.
The aforementioned studies have shown that SIT can be implemented effectively in the military settings. However, it should be noted that SIT is not one-size-fits-all; the multitool nature of special operation units engaged in reconnaissance, search-and-rescue and direct-action missions, often under increased time pressures, draws a clear distinction between physical and cognitive performance readiness that of large-scale (requiring significant logistical planning) operations performed by air, ground or navy forces. Depending on the type of stressor (ongoing or time-limited), the resources and coping mechanisms will be different from person-to-person. An ongoing stressor is traumatic experience that can be expected to occur on a regular basis like being a first responder or a soldier in combat; a time-limited stressor, or an acute stressor, is a singular experience like surgery, occurring quickly quickly and is not likely to continue to happen. According to Meichenbaum, “SIT provides a set of general principles and clinical guidelines for treating distressed individuals, rather than a specific treatment formula or a set of “canned” interventions” (Meichenbaum, 2007). Yet the implementation of SIT in ICE environments, specifically for special operations forces training, is only at its inception today. As an early emerging area of practice, many psychological ramifications and benefits are yet to be fully examined and addressed, particularly around novel technology platforms involving virtual reality or mixed reality technologies (Riva, 2005).
Isolated, confined and extreme environments
Generally, ICEs comprise of a wide variety of geographical places that present hostile and harsh physical and psychological conditions posing risks to human health and life. A myriad of physical environments and medical specialties can be included under ICEs, for example long-duration space missions, expedition, wilderness, diving, jungle, desert, cave and others. In these missions, a small group of scientists, astronauts and explorers chose to participate and being willingly exposed to such environments. Substantial body of research has discussed coping mechanisms by the use of emerging technology tools, specifically focusing on cognitive performance and stress resilience development that could be linked or affected by ICE environments. Specifically, through the use of VR, researchers have reported that astronauts were able to gain access to continuous psychiatric monitoring, cognitive exercise, timely training, and sensory stimulation to mitigate monotony of the working environment. Moreover, such technology tools can provide practical answers to psychosocial adaptation by enabling cooperative and leisurely activities for team members to play together to keep internal morale and collaboration while relieving stress and tension between its members.
Virtual reality and virtual simulation tools
The advancements in computer technologies and display technologies powered by graphics processing units (GPUs) have facilitated the emergence of systems capable of isolating a user from the real surrounding environment to simulate a computer-generated one, known as “virtual reality” experiences. More specifically, displays and environmental sensors create the illusion of being in a digitally rendered environment, either by using a head-mounted display device or entering into a computer-automated room where images are present all around; accessory outputs like spacial audio and handheld feedback controllers (or any other visual, auditory, tactile, vibratory, vestibular, and olfactory stimuli) can also further contribute to the increased levels of user’s immersion or presence in a non-physical world. Presence in the context of virtual reality applications is defined by Steuer (1992) as the “sense of being there” (as cited by Riva, 2008) or the sense of being physically present in a different world that surrounds the individual. Originally as a niche tool within the digital toolbox competing with a myriad of attention-economy products in the entertainment space, VR’s digital simulations have become realistic enough to enable use cases where dangerous or complex scenarios can be safely reenacted at low cost in a virtual environment—like digital therapeutics, training, planning, and design.
Virtual reality exposure therapy (VRET). Virtual reality, going beyond practical commercial tools, has also found many applications in the area of psychology assisting both researchers in studying human behavior and patients in coping with phobias, post-traumatic stress disorder (PTSD), and substance use disorders. Computer generated 3D VR environments have been used experimentally in new fields of endeavor, including experimental systems and methods for assisting users overcome their phobias via virtual reality exposure therapy (VRET). The fundamental work of Barbara Rothbaum et al., where automated psychological intervention delivered by immersive virtual reality was found to be highly effective in reducing fear of heights, was followed by a substantial body of research work including VR systems that have been developed to assist people with overcoming a fear of flying by having them participate in a controlled virtual flying environment or helping patients reduce their experience of pain such as in burn victims by refocusing their attention away from the pain by having them engage in a 3D VR environment, such as a virtual snow world. The virtual environment created in such therapies is perceived as real enough by the user to generate measured physiological response—increased heartbeat, breathing, or perspiration—of their virtual experiences to the feared stimuli in a controlled setup, offering clinical assessment, treatment and research options that are not available via traditional methods. By confronting a scenario that intently maps onto the phobia, subjects are able to diminish the avoidance behavior through the processes of habituation and extinction (Riva, 2008). Beyond helping patients with fear of heights (acrophobia) or fear of flying, to date, VRET has been successfully used to address a myriad of specific phobias like claustrophobia, fear of driving, arachnophobia (fear of spiders), social anxiety, and for PTSD in Vietnam War combat veterans. More recently, the U.S. Army has developed Full Spectrum Warrior, a real-time tactics and combat simulation video game used for VR treatment aid of PTSD in Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) combat service men and women as well as those who have served in Afghanistan.
Similarly to assist in overcoming phobias, virtual reality has emerged as a powerful new tool to help individuals with substance use disorders. Virtual experiences have been shown to present several opportunities to improve patient treatment for substance use disorder, including tobacco, alcohol or illicit drugs. Through VR, patients are able to practice recovery techniques and cope with triggers in a safe and protected environment, allowing them to maintain sobriety and avoid relapsing. Beyond a treatment platform, VR was also found to assist in studying and measuring overall human behavior and cognition, helping researchers explore human nature in the control surroundings or custom designed settings.
In a similar manner, virtual reality emerges as a promising tool to complement SIT in the military ICE settings. “VR can enhance the effect of SIT by providing vivid and customizable stimuli” (Wiederhold and Wiederhold, 2008), while uniquely manifesting in each particular special forces pre-combat ICE environment training, or can be even individually-tailored to SOF personnel.
VR in stress inoculation training
Today’s military organizations across the world—all three services (army, navy and air force)—have a long history of employing combat simulations for training exercises, playing an essential role in preparing soldiers and pilots for modern combat. VR is used often in air forces to train personnel, both aircrew and combat service support. The most well known use originated in flight simulators which were designed to train in dangerous situations without actually putting the individual or aircraft at risk (e.g., co-ordination with ground operations, emergency evacuation, aircraft control whilst under fire) and at substantially less cost. More recently, the US Air Force (USAF) has taken steps to implement a training scenario using VR that includes a visual simulation of the setting of an airfield to enable airmen to practice their role as if they were operational.
The goal of integrating VR in SIT is to enable, over time, repetitively practiced skills become automated, thereby requiring less attention to stress and being more resistant to stimuli disruption in a consequent real environment (Wiederhold and Wiederhold, 2008). It facilitates knowledge and familiarity with a stressful environment, practice task-specific and psychological, as well as build confidence in an individual’s capabilities. The U.S. Department of Defense spends an estimated $14 billion per year on Synthetic Training Environment (STE), a training that deploys digital environments to “provide a cognitive, collective, multi-echelon training and mission rehearsal capability for the operational, institutional and self-development training domains” (USAASC, 2019). This suggests that existing commercial tools could enable the SOF to move beyond traditional training simulators while improving the quality of the SIT itself, specifically designed for ICE environments.
Today, in post-combat use, VR is already implemented in aiding recovery from psychological trauma for people with of post-traumatic stress disorder and help researchers to create more objective measures of PTSD, such as with Virtual Iraq, which later was renamed to Bravemind. Bravemind is a virtual reality environment to provide prolonged exposure (PE) therapy to veterans suffering from post-traumatic stress. In this cognitive-behavioral intervention, the subject is virtually exposed to a variety of stimuli (i.e., visual, auditory, kinesthetic, and olfactory) with the goal of a subject being incrementally exposed the stressful triggers specific to him/her until adaptation to the traumatic experiences occurs. Moreover, preliminary findings suggest that in pre-deployment use such tools could be used to evaluate individuals who might be more exposed than others to the PTSD effects before combat. By teaching these coping skills preemptively, researchers hope to clinically identify and evaluate physiological reaction during the VR exposure to determine if the individual would require continued or prescribed care. Initial outcomes from open clinical trials using virtual reality have been promising, giving the therapist flexibility to expose the user only to environments he/she would be capable of confronting and processing (Wiederhold and Wiederhold, 2008). Observations in open clinical trials showed that those who were exposed to emotionally evocative scenarios and acquired coping mechanisms exhibited lower levels of anxiety than those in the control group.
It is argued that in a similar manner VR could be modified for SIT in ICE environments for SOF.
. . . such a VR tool initially developed for exposure therapy purposes, offers the potential to be “recycled” for use both in the areas of combat readiness assessment and for stress inoculation. Both of these approaches could provide measures of who might be better prepared for the emotional stress of combat. For example, novice soldiers could be pre-exposed to challenging VR combat stress scenarios delivered via hybrid VR/Real World stress inoculation training protocols as has been reported by Wiederhold & Wiederhold (2005) with combat medics. (Rizzo et al., 2006)
Researchers from a broad range of disciplines have proposed explanations that combining VR with SIT can be more effective than real world training systems, without incurring the costs of facing rare or dangerous experiences, excessive time expenditure or unique scenario adaption.
Given its ability to present immersive, realistic situations over and over again, the technology can give SOF trainers and recruiters the opportunity to potentially design expertise on conditions before they see them for the first time in real soldiers. Moreover, VR can also offer the ability to design individually-tailored scenarios to accommodate the “long tail” tactical challenges in ICE environments—psychosocial adaptation to military captivity; dealing with civilian population in the area of operation; enhancing performance that might occur due to improper case-by-case cooperation, coordination, communication, and/or psychosocial adaptation within a tactical team; and mitigating the risk of adverse cognitive or behavioural conditions and psychiatric disorders pre- and post-deployment—which more often can be encountered in the type of SOF units’ operations.
Future directions
Despite its potential benefits, the implementation and understanding of VR in the military settings is still not fully developed and focuses mainly on the general applications of SIT. By evaluating its performance in stressful environments, this writing argues that we might be able to make progress in successfully indicating physiological and psychological reactions during the VR exposure in ICE environments to determine if the individual can enhance his/her ability to cope with severe stress to ensure that the mission succeeds or survive.