
==== Front
Eur J Psychotraumatol
Eur J Psychotraumatol
European Journal of Psychotraumatology
2000-8066
Taylor & Francis

39286908
2400011
10.1080/20008066.2024.2400011
Version of Record
Basic Research Article
Research Article
A novel intervention for acute stress reaction: exploring the feasibility of ReSTART among Norwegian soldiers
Una nueva intervención para la reacción aguda al estrés: exploración de la viabilidad de ReSTART entre soldados NoruegosEUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY
A. E. NORDSTRAND ET AL.
https://orcid.org/0000-0002-2012-0574
Nordstrand Andreas Espetvedt abc
Barger Steven D. b
Tvedt Morten Andreas d
Gjerstad Christer Lunde aef
Engen Haakon Gabrielsen ag
Adler Amy B. h
a Institute of Military Psychiatry, Norwegian Armed Forces Joint Medical Services, Oslo, Norway
b Department of Psychological Sciences, Northern Arizona University (NAU), Flagstaff, AZ, USA
c Department of Psychology, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
d Blå Kors Klinikk Lade, Trondheim, Norway
e Institute of Clinical Medicine, University of Oslo, Oslo, Norway
f Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
g Department of Psychology, University of Oslo, Oslo, Norway
h Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, USA
CONTACT Andreas Espetvedt Nordstrand a.e.nordstrand@gmail.com Institute of Military Psychiatry, Norwegian Armed Forces Joint Medical Services, Grev Wedels plass 2, Oslo 0015, Norway
17 9 2024
2024
17 9 2024
15 1 24000117 12 2023
2 7 2024
25 8 2024
Nova techset2 9 2024
Converted to JATS 1.2 by Nova Techset2 9 2024
© 2024 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
2024
The Author(s)
https://creativecommons.org/licenses/by-nc/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent.

ABSTRACT

Background: Soldiers in combat may experience acute stress reactions (ASRs) in response to trauma. This can disrupt function, increasing both immediate physical danger and the risk for post-trauma mental health sequelae. There are few reported strategies for managing ASRs; however, recent studies suggest a novel peer-based intervention as a promising approach.

Objectives: This study assesses the feasibility of ReSTART training, a peer-based course designed to prepare soldiers to manage ASRs. ReSTART builds on programmes established by US and Israeli militaries. The current study evaluates the ReSTART programme in a Norwegian setting, across distinct groups of soldiers, professionals and conscripts.

Methods: Participants included professional soldiers deploying to Mali and conscripts with 6 months of service, who completed the ReSTART training course and surveys administered pre- and post-training. These surveys assessed attitudes and programme acceptability. Analyses included 74 soldiers who provided complete survey responses.

Results: ReSTART training received high ratings in terms of usefulness, relevance, and importance in managing ASRs. From pre- to post-training, respondents had significant increases in positive attitudes towards ASR management and confidence in handling ASRs personally, and at the unit level; decreases in stigma-related attitudes associated with ASRs; and increased perception of leadership emphasizing ASR management.

Conclusions: ReSTART training shows potential as an effective tool when preparing soldiers to manage ASRs in high-risk environments, enhancing military units’ capacity to support each other and effectively respond to stress-induced functional disruptions. This study adds evidence supporting the utility of peer-based ASR management in operational settings and highlights the need for broader implementation and systematic evaluation.

HIGHLIGHTS

This study is the first study outside the US and Israeli context to systematically evaluate the feasibility of peer-based interventions for Acute Stress Reactions (ASRs) during combat.

Results show that a novel Norwegian Armed Forces training programme, called ReSTART, is strongly endorsed as a means to prepare soldiers for managing ASRs.

The study also demonstrates that completing ReSTART training positively impacts changes in self-confidence in ASR management, confidence in others’ ability to manage ASRs, perceptions of leadership emphasis of ASR management, and stigma related to ASRs.

This investigation represents the first investigation of how suitable training for peer-based ASR interventions is for inexperienced conscripted soldiers. Findings show that overall, ReSTART training has high suitability for both professional soldiers and conscripts with less than 6 months of service.

Findings demonstrate the utility of peer-based interventions like ReSTART in European militaries. Moreover, the study has implications for preparing inexperienced recruits such as newly mobilized Ukrainian soldiers currently being trained by NATO partners.

Antecedentes: Los soldados en combate pueden experimentar reacciones agudas al estrés (ASRs por sus siglas en ingles) en respuesta a traumas. Esto puede alterar la funcionalidad, aumentando tanto el peligro físico inmediato como el riesgo de secuelas de salud mental post traumáticas. Existen pocas estrategias reportadas para manejar las ASRs; sin embargo, estudios recientes sugieren una intervención novedosa basada en pares como un enfoque prometedor.

Objetivos: Este estudio evalúa la viabilidad del entrenamiento ReSTART, un curso basado en pares diseñado para preparar a los soldados a manejar las ASRs. ReSTART se basa en programas establecidos por los ejércitos de EE.UU. e Israel. El estudio actual evalúa el programa ReSTART en un contexto noruego, abarcando distintos grupos de soldados, tanto profesionales como conscriptos.

Método: Los participantes incluyeron soldados profesionales desplegados en Malí y conscriptos con 6 meses de servicio, quienes completaron el curso de entrenamiento ReSTART y encuestas administradas antes y después del entrenamiento. Estas encuestas evaluaron actitudes y la aceptabilidad del programa. Los análisis incluyeron a 74 soldados que proporcionaron respuestas completas a las encuestas.

Resultados: El entrenamiento ReSTART recibió altas calificaciones en términos de utilidad, relevancia e importancia en el manejo de las ASRs. Los encuestados mostraron un aumento significativo, entre el antes y el después del programa, en actitudes positivas hacia la gestión de ASRs y su confianza en manejar las ASRs tanto a nivel personal como en el nivel de unidad; disminuciones en actitudes relacionadas con el estigma de las ASRs; y una percepción aumentada de que el liderazgo enfatiza el manejo de ASRs.

Conclusiones: El entrenamiento ReSTART muestra potencial como una herramienta efectiva para preparar a los soldados a manejar las ASRs en entornos de alto riesgo, mejorando la capacidad de las unidades militares para apoyarse mutuamente y responder de manera efectiva a las disrupciones funcionales inducidas por el estrés. Este estudio aporta evidencia que respalda la utilidad del manejo de ASRs basado en pares en entornos operativos y destaca la necesidad de una implementación más amplia y una evaluación sistemática.

KEYWORDS

Acute stress reactions
peritraumatic
combat
psychological first aid
traumatic stress
pre combat training
Ukraine
operational resilience training
forward military mental health
PALABRAS CLAVE

Peri-traumático
guerra
conscriptos
estrés traumático
reacción aguda al estrés
trauma
Ucrania
entrenamiento de resiliencia
Norwegian Defence Research Establishment 10.13039/501100001199 The efforts to translate and adapt the iCOVER training programme into the Norwegian ReSTART programme was funded by Norwegian Defence Research Establishment (FFI).
==== Body
pmc1. Introduction

In the field of psychotraumatology, distinctions are commonly made between the pre-, peri-, and post-trauma phases of trauma exposure (e.g. Sayed et al., 2015). While extensive research has focused on post-trauma interventions such as PTSD treatments (e.g. Watkins et al., 2018) and pre-trauma strategies like resilience training (e.g. Joyce et al., 2018), there remains a significant gap in available mental health strategies applicable during the trauma itself. This gap is worrisome, as individuals may experience an Acute Stress Reaction (ASR) in situations with intense trauma exposure, which can both reduce immediate survivability and increase the risk of post-trauma mental health sequalae (Daniels et al., 2012; Dokkedahl & Lahav, 2023).

The International Classification of Diseases describes ASRs as a transient state that occurs in response to exposure to severely threatening or horrific incidents, common to high-stress environments such as military combat (e.g. Nordstrand et al., 2019). Within the field of military psychiatry, ASRs have been associated with various terms such as war neuroses, battle fatigue, shell shock, and more recently, combat stress reaction (CSR) and combat and operational stress reactions (COSRs). These terms often reflect specific organizational nomenclature (e.g. COSRs is a NATO-term) or historical context (e.g. use of the term shell shock in World War II). However, despite distinct labels, all of these terms cover the phenomenon of ASR, though some are more expansive in their definitions and may also include a broader scope of post-trauma reactions (Isserlin et al., 2008).

An ASR can last from seconds to days following the eliciting exposure (Matson et al., 2022) and can significantly disrupt emotional, cognitive, physical, and behavioral functioning, typically manifesting as a state where individuals appear agitated, passive, or frozen (Solomon et al., 1989; Harvey & Bryant, 2002; Adler & Gutierrez, 2022a). It is important to note that an ASR is a natural response to extreme stressors, not a psychiatric disorder, and is classified as a ‘factor influencing health status’ rather than a disorder in the ICD-11 (World Health Organization, 2019). An ASR should not be confused with acute stress disorder (ASD) or post-traumatic stress disorder (PTSD). ASD is diagnosed if an array of trauma-related symptoms last between 2 days and 4 weeks after exposure to trauma; PTSD is diagnosed if symptoms persist longer (World Health Organization, 2019). In military settings, the occurrence of ASRs not only constitutes a danger to the individual soldier, but due to the acute loss of function in afflicted personnel, the phenomenon can also put fellow soldiers at risk by compromising unit effectiveness and security on the battlefield (Adler & Gutierrez, 2022a).

The prevalence of ASRs during military operations is notably high. A recent study documented that between 17% and 24% of soldiers in battlefield settings reported experiencing a probable ASR, most of which were perceived to last five minutes or more (Adler & Gutierrez, 2022a). These figures suggest that ASRs are a common occurrence in high-risk combat environments. Importantly, the fact that these reactions are occurring on a battlefield complicates their management and raises challenges that must be addressed by training programmes aiming to deal with ASRs in operational settings.

One of the few developed tools for use during trauma exposure is a novel peer-based intervention first introduced by the Israel Defense Forces (IDF). This intervention, called YaHaLOM (Svetlitzky, Farchi, Ben Yehuda, & Adler, 2020), was further developed by the Walter Reed Army Institute of Research (WRAIR) for use in the US Army (Adler et al., 2020). The US Army approach, called iCOVER, was then translated and adapted by the Norwegian Armed Forces using the acronym ReSTART (Adler et al., 2023). Currently, several NATO countries in addition to the IDF have programmes that implement variations of this intervention in their militaries (Adler et al., 2023). These programmes, tailored to the different countries’ specific cultural and military contexts, represent an international collaborative approach to ASR management. Recently, this collaborative effort has been extended to the Armed Forces of Ukraine (AFU) through, among other initiatives, Norway’s training of Ukrainian combat medics (Iversen & Adler, 2023).

To date, studies in the US and Israel have shown that peer-based ASR intervention training has high acceptability and is associated with an increase in understanding about ASRs, confidence in managing them, and reduced stigma-related attitudes (Adler & Gutierrez, 2022b; Svetlitzky, Farchi, Ben Yehuda, Start, et al., 2020). With the current study, we aim to explore the feasibility of this type of peer-based intervention outside the US and Israeli context. Moreover, we want to investigate the suitability of training ReSTART across different soldier experience levels. Previous studies have shown how conscripted and volunteer soldiers differ significantly both in terms of psychological resilience (Swedish soldiers: Rydstedt & Österberg, 2013; Lithuanian soldiers: Rybakovaitė et al., 2023) and military occupational functioning (Korean soldiers: Park, 2021). This difference is important to consider, as research evaluating programmes such as iCOVER has been primarily limited to professional soldiers who readily absorbed and appreciated the relevance of the training (Matson et al., 2022). In the Israeli context, studies of peer-based ASR interventions have included conscripts. However, these conscripts were mostly seasoned soldiers with an average of 19 months of military service, and 75% of the sample had combat experience (Svetlitzky, Farchi, Ben Yehuda, Start, et al., 2020). An unanswered question is therefore whether similar patterns of benefit would be observed when training inexperienced conscripts at the start of foundational military training compared to more experienced and professional volunteer soldiers.

The Norwegian Armed Forces fields both inexperienced conscripts and experienced professional volunteers in their force structure, enabling such a comparison. In terms of its conscription policy, Norway has a selective conscription requirement. Each year, about 60,000 young men and women undergo obligatory medical and psychological evaluation, with about 9000 of these being selected for service based on the needs of the military and individual suitability (Kosnik, 2017). Conscripted service typically lasts 12 months. The main purpose of this system is to provide basic military training to a segment of the population so that the country can mobilize a reserve force in a national defence crisis (Kosnik, 2017). Additionally, conscripted service is an important recruitment tool, helping the Norwegian Armed Forces to identify and foster potential career military professionals.

The current study represents the first formal evaluation of a peer-based intervention training programme addressing ASRs outside the US and Israeli context. Moreover, it is the first study to compare how professional soldiers and newly conscripted inexperienced soldiers respond to training in ASR management. By comparing these two groups, this study can shed light on whether existing ASR training is beneficial for both professional and conscripted soldiers. Study results can then be used to inform future training efforts targeting newly conscripted soldiers who do not have combat experience.

2. Methods

This study was approved by the ethical review board of the Norwegian Armed Forces Joint Medical Services (NAFJMS). All participants volunteered to undertake ReSTART training and completed a written consent form to participate in the study. All procedures, data collection, storing and distribution of data were conducted in accordance with NAFJMS data governance regulations.

2.1. Study design and procedure

In 2020, the NAFJMS conducted two pilot studies in distinct Norwegian soldier populations to evaluate the feasibility of the ReSTART programme. Following the approach used by Adler and Gutierrez (2022b) when they evaluated the US Army iCOVER programme, the current study employed a pre–post design to evaluate the change in key variables among participants immediately before (T1) and after (T2) completion of ReSTART training. The course was taught by experienced military instructors who had received train-the-trainer instruction in iCOVER and who had completed ReSTART instructor certification.

2.2. Participants

The study sample (N = 74) included two distinct groups of Norwegian Armed Forces soldiers. Group 1 (n = 33) consisted of professional soldiers who underwent the ReSTART course as part of their pre-deployment training 7 weeks before participation in a 6-month UN mission (Multidimensional Integrated Stabilization Mission in Mali [MINUSMA]) conducted in 2020. Group 2 (n = 41) consisted of a cohort of conscripted soldiers, all in the same company, who had served approximately 6 months of their 12-month compulsory military service. This group received ReSTART training as part of a military medic course. Five participants who did not include their service status were excluded from the analysis. Thus, the comparison of the service status groups was unbalanced; there were unequal numbers of participants in each of the two groups. See Table 1 for demographic characteristics of the study samples. Table 1. Frequencies and percentages of the demographic characteristics of professional soldiers and conscript soldiers.

Demographic variables	Professional (n = 33)	Conscript (n = 41)	Total (N = 74)	
Age in years	 	 	 	
 18–24	3 (9.1%)	41 (100.0%)	44 (59.5%)	
 25–29	24 (72.7%)	0 (0.0%)	24 (32.4%)	
 30–39	5 (15.2%)	0 (0.0%)	5 (6.8%)	
 40+	1 (3.0%)	0 (0.0%)	1 (1.4%)	
Biological sex	 	 	 	
 Male	29 (87.9%)	25 (61.0%)	54 (73.0%)	
 Femalea	4 (12.1%)	16 (39.0%)	20 (27.0%)	
Military rank	 	 	 	
 Private	0 (0.0%)	38 (92.7%)	38 (51.4%)	
 Corporal/NCOb	25 (75.8%)	3 (7.3%)	28 (37.8%)	
 Officer	8 (24.2%)	0 (0.0%)	8 (10.8%)	
a Norway has compulsory conscription service for both male and females.

b Non-commissioned officer.

2.3. ReSTART training

The ReSTART programme emerged as result of a project aiming to translate and adapt the iCOVER training programme for use in the Norwegian Armed Forces. ReSTART is an acronym with each step corresponding to a Norwegian words: (1) Registrer ASR (Re [eng. identify ASR]), (2) Skap kontakt (S [eng. establish contact]), Tilby fellesskap (T [eng. offer community]), Avklar fakta (A [eng. establish facts]), Reetabler tidslinje (R [eng. reestablish timeline]), Tilbake til oppgave (T [eng. return to task]). The course entails students receiving 120 min of ReSTART training, including 40 min of drilling in the ReSTART procedure. The procedure contains six sequential steps, which students are expected to consistently perform in under 60 s upon completion of the training. The course covers education on the neural basis of ASRs, how to recognize an ASR, introduction to the six ReSTART steps, how to deal with non-responsive ASR-affected patients, and how to implement the procedure in an operational context. The training is conducted using a standardized package of training materials. This package includes cue-cards for practising ReSTART, instruction cards for students simulating ASRs, standardized PowerPoint slides with comprehensive instructors’ notes, and a professionally produced instructional video.

2.4. Measures

2.4.1. Demographics

Demographic information was collected at T1. Background questions included age, biological sex, military rank, and service status (i.e. conscript or professional soldier).

2.4.2. Acceptability

Perceptions of training acceptability were assessed at T2 using 10 items developed by Adler et al. (2020). The items gauged to what extent the ReSTART training was perceived as useful, relevant, important, and if the training brought the students closer together. Items were rated on a 5-point scale (1 = strongly disagree to 5 = strongly agree). Items were categorized into positive (agree or strongly agree) or negative/neutral (strongly disagree, disagree, or neither agree or disagree) response options in the analysis. Items were translated into Norwegian and back translated into English using the backwards-translation framework (Brislin, 1970).

2.4.3. Attitudes

Attitudes were assessed by the ASR attitudes scale (Adler & Gutierrez, 2022b) and administered at T1 and T2. The 14-item scale was comprised of four categories: (1) confidence managing an ASR (2 items); (2) confidence in fellow soldiers managing an ASR (3 items); (3) leadership emphasis of ASR management (5 items); and (4) stigma-related attitudes concerning ASRs (4 items). Items were rated on a 5-point scale (1 = strongly disagree to 5 = strongly agree) and summed. These items have previously been used to evaluate the iCOVER training programme (Adler & Gutierrez, 2022b). Items were translated into Norwegian and back translated into English using the backwards-translation framework (Brislin, 1970).

2.5. Data analysis

In addition to descriptive statistics, we assessed change in the four attitude domains following completion of the ReSTART training using repeated measures ANOVA with service status (conscript, professional soldier) as a between subjects factor and time (pre versus post) as a within subjects factor for each of the four attitude domains. We used Stata 18.0 (StataCorp, College Station, TX, USA) for all analyses and considered comparisons statistically significant if the two-sided p-value was ≤.05. We report standardized effect sizes for pre/post changes in attitudes aggregated across service status categories, and we used model-based marginal means and variance estimates to illustrate ANOVA results (Garofalo et al., 2022).

3. Results

3.1. Acceptability of ReSTART training

All soldiers agreed with the statements that the training taught them how to help a fellow soldier who is having difficulty functioning and that the ReSTART procedure was clear (Table 2). The training was viewed positively on other acceptability dimensions except for the question regarding receiving the training earlier and whether the training brought the unit closer together (Table 2). Table 2. Frequencies and percentages of endorsement of acceptability dimensions related to ReSTART training, among professional soldiers and conscript soldiers.

Acceptability (yes/no)	Professionals (n = 33)	Conscripts (n = 41)	Total (N = 74)	
1. The training taught me how to help a soldier who is having difficulty functioning	33 (100.0%)/0 (0%)	41 (100.0%)/0 (0%)	74 (100.0%)/0 (0%)	
2. The ReSTART procedure is clear	33 (100.0%)/0 (0%)	41 (100.0%)/0 (0%)	74 (100.0%)/0 (0%)	
3. I would recommend this training to other service members	31 (93.9%)/2 (6.1%)	41 (100.0%)/0 (0%)	72 (97.3%)/2 (2.7%)	
4. The training was relevant	32 (97.0%)/1 (3%)	38 (92.7%)/3 (7.3%)	70 (94.6%)/4 (5.4%)	
5. The video was helpful**	26 (78.8%)/7 (21.2%)	41 (100.0%)/0 (0%)	67 (90.5%)/7 (9.5%)	
6. The training was important	27 (81.8%)/6 (18.2%)	37 (90.2%)/4 (9.8%)	64 (86.5%)/10 (13.5%)	
7. The training was useful*	25 (75.8%)/8 (24.2%)	38 (92.7%)/3 (7.3%)	63 (85.1%)/11 (14.9%)	
8. The skills I learned in this training will help me be a better team member	23 (69.7%)/10 (30.3%)	36 (87.8%)/5 (12.2%)	59 (79.7%)/15 (20.3%)	
9. I wish I had this training earlier in my military career**	5 (15.2%)/28 (84.8%)	30 (73.2%)/11 (26.8%)	35 (47.3)/39 (52.7%)	
10. The training helped bring the team closer together	3 (9.1%)/30 (90.9%)	10 (24.4%)/31 (75.6%)	13 (17.6%)/61 (82.4%)	
Note: Items sorted in descending order of agreement. Significant difference between professional soldiers and conscripts; *p < .05 **p < .01.

3.2. Attitudes towards ASR

There were statistically significant differences between pre- and post-test scores for each of the four attitude domains (Table 3). These changes reflected improvements in respondents’ confidence in their ability to manage ASRs, confidence in the unit’s ability to manage ASRs, and leadership emphasis of ASR management, and decreases in stigma surrounding ASRs. The changes following training were of large magnitude, with standardized effect sizes ranging from 0.88 to 1.50 (Figure 1). There was a main effect of service status for personal confidence ratings and a service status by ReSTART training interaction (Table 3). Professional soldiers had lower personal confidence in their ability to manage ASRs relative to conscripts prior to training but had similar confidence following training (see Figure 1, panel A). Professional soldiers had fewer positive attitudes regarding military leadership emphasis on ASRs at both time points relative to conscripts (Figure 1, panel C), but improvements in this attitude domain following ReSTART training were comparable to improvements observed among conscripts. There was a statistically significant interaction of time and service status for confidence in the unit’s ability to manage ASRs. This finding was a crossover interaction characterized by the absence of differences across service status groups before and after training, which occurred in the context of a very large overall increase in confidence following the training (Cohen’s d = 1.08). Figure 1. Changes in attitudes towards acute stress reactions before and after ReStart training by service status.

Table 3. Attitudes towards acute stress responses (ASR) by service status and completion of ReSTART training.

Variables	F valuea	p Value	
Personal confidence in managing ASR	 	 	
 Service status	6.32	.014	
 Time (pre vs. post)	217.48	<.001	
 Service status × time interaction	18.37	<.001	
Confidence in unit ability to manage ASR	 	 	
 Service status	0.05	.82	
 Time (pre vs. post)	100.00	<.001	
 Service status × time interaction	8.39	.005	
Leadership emphasis of ASR management	 	 	
 Service status	5.69	.02	
 Time (pre vs. post)	59.10	<.001	
 Service status × time interaction	0.23	.63	
Stigma regarding ASR	 	 	
 Service status	0.03	.87	
 Time (pre vs. post)	54.86	<.001	
 Service status × time interaction	0.20	.66	
Note: Repeated measures ANOVA with service status (conscript or professional soldier) as a between-group variable and time (pre/post ReSTART training) as a within-group variable. Statistically significant service status differences reflect rating differences between conscripts and professional soldiers; significant time effects reflect changes in attitudes before and after ReSTART training; service status X time interactions reflect differential changes in attitudes before and after ReSTART training between conscripts and professional soldiers.

a All F tests have (1,72) degrees of freedom.

4. Discussion

The current study represents the first systematic investigation of a peer-based intervention for managing Acute Stress Reactions (ASRs) outside the US and Israeli context. The study demonstrated the feasibility of the Norwegian Armed Forces’ ReSTART programme in two distinct groups: professional soldiers and inexperienced conscripts. In both groups, the overwhelming majority found ReSTART training to be useful, relevant, important, and instructive for intervening in ASR cases. This high level of acceptability aligns with prior studies in the US and Israel, which indicates that peer-based ASR intervention training is relevant across several cultural contexts. That the endorsements are consistent across both experienced soldiers and inexperienced conscripts confirms that the ReSTART programme can be utilized in a standardized format in a range of segments in the military.

Moreover, the results show substantial and favourable change in all four categories of ASR attitudes (i.e. personal confidence, confidence in others, leader emphasis on ASRs, and stigma attitudes). These improvements were generally consistent across conscripts and professional soldiers, with some pre-existing attitude differences observed across the service status groups. A notable finding in this regard is that the professional soldiers reported significantly lower confidence in their ability to manage an ASR at T1 compared to the conscripts, but they also experienced a larger increase in confidence between the two time points. Ultimately, both groups ended up reporting the same levels of post-training confidence. The finding may seem counterintuitive, as one might expect more experienced soldiers to have higher starting confidence in their abilities. A possible explanation may be that the experienced professional solders were more realistic in their assessment of their pre-training skills in terms of ASR management. Given that approximately half of combat soldiers have witnessed someone having this reaction (Adler & Gutierrez, 2022a), experienced troops may know either from personal experience or from secondhand reports that managing an ASR without the right tools can be difficult. Considering this interpretation of the results, the fact that both groups are equally confident after training strengthens the construct validity of the ReSTART programme.

Overall, the findings highlight the perceived effectiveness of ReSTART training in positively shifting attitudes towards ASRs and are consistent with the small but growing body of literature investigating the utility of peer-based interventions for ASR (Matson et al., 2022). Like in previous studies (Adler et al., 2020; Adler & Gutierrez, 2022b; Svetlitzky, Farchi, Ben Yehuda, & Adler, 2020; Svetlitzky, Farchi, Ben Yehuda, Start, et al., 2020; Svetlitzky, Farchi, Yehuda, et al., 2020), we found both a high degree of positive endorsements of the training and significant pre-to-post changes in ASR attitudes.

In addition, only a small proportion of participants indicated that ReSTART training helped bring their team closer together. Such results are also consistent with previous findings (Adler & Gutierrez, 2022b). As the training is not designed to boost unit cohesion, we interpret these results as indicative of the participants providing valid and considered responses to the questionnaire.

The study findings also have implications for real-world application. The minimal difference in how inexperienced conscripts and professional soldiers received and were influenced by the ReSTART course is noteworthy and relevant to ongoing military conflicts. This finding is important because it is critical to have training that can help prepare a rapid influx of new soldiers to operate in potentially traumatic conditions if a military force must suddenly expand to meet an emerging threat. As our study results indicate, peer-based programmes such as ReSTART appear to be suitable for inexperienced soldiers and offer support for using this approach in training newly conscripted soldiers.

This situation is currently the case with the Ukrainian Armed Forces (AFU), who in their ongoing struggle to defend against Russia’s full-scale invasion in 2022, are relying heavily on conscripted soldiers. As a result of the invasion, the AFU has found itself growing rapidly from approximately 196,000 soldiers to between 500,000 and 700,000 soldiers over the span of 2 years (International Institute for Strategic Studies [IISS], 2023). AFU conscripts trained in Europe by NATO countries typically receive only 6 weeks of basic military training before being given further AFU assignments (Gady & Kofman, 2023). ReSTART’s sister programme, the iCOVER protocol, is already translated into Ukrainian; however, it is not yet part of the formal AFU pre-deployment training. Accordingly, systematic implementation of training in peer-based ASR management could be an important supplement in preparing newly conscripted troops like those fighting in Ukraine (Rybinska et al., 2022).

Importantly, the rationale behind ReSTART extends beyond conventional mental health care for trauma, focusing on immediate life-saving interventions in high-risk military situations such as during active combat. Given the impracticality of conducting empirical assessments of the efficacy of ASR management techniques in a combat environment, information can be gleaned from other sources. Specifically, case reports from service members engaged in combat can provide insight into how peer-based training such as ReSTART can be implemented in real-world contexts.

Case reports obtained by Norwegian instructors during the training of AFU troops (A. E., Nordstrand & H., Engen personal communication, 16 July 2023), provide compelling convergent evidence of ReSTART’s practical utility. In one case, a Ukrainian soldier experienced multiple ASRs during a realistic training exercise. The soldier’s team medic, trained in peer-based ASR management, successfully applied the intervention, enabling the soldier to regain functionality and contribute to the team’s performance. This medic had received training in peer-based ASR management as part of an extensive course in Operational Resilience Training provided in English with simultaneous Ukrainian interpretation. Preliminary feedback from Ukrainian medics trained in peer-based ASR management and currently fighting on the frontlines, further substantiates the utility of this technique.

Although these case reports provide valuable insights, it would be beneficial to develop structured lessons-learned from militaries (such as the AFU) that are actively using these interventions at scale in combat operations. Such data could elucidate the specific conditions under which peer-based interventions are most effective. Future research would also benefit from studies in larger and more diverse military samples. Beyond providing these skills to combat soldiers, training in peer-based ASR management could be a useful part of preparing United Nations peacekeeping troops, as they also often are exposed to high-stress scenarios (Gjerstad et al., 2020). Moreover, ReSTART likely holds potential for non-military occupational contexts involving exposure to potential trauma. For example, emergency response personnel such as police, paramedics, fire-and-rescue personnel, and intensive care health care workers, are all exposed to scenarios where they must help individuals, both colleagues and civilians, experiencing ASRs. Currently, there are few, if any, training programmes readily available that are specifically adapted for managing ASRs in these occupational groups. Future research investigating the effectiveness and utility of peer-based interventions as readily deployable tools for ASR management in civilian first responder occupations could thus fill an important gap (Adler & Gutierrez, 2022a). Of note, there are likely important cultural differences that need to be accounted for when adapting peer-based ASR management training developed for combat troops into programmes for other occupational categories.

Finally, future studies should also explore how peer-based ASR management programmes can utilize technological advances such as Virtual Reality (VR) to assist in training. VR may offer opportunities to train an intervention like ReSTART in interactive paradigms, possibly increasing the scalability and quality of such training.

5. Limitations

While this study offers some insights into the feasibility and effectiveness of the ReSTART programme for managing ASRs in military settings, it is not without limitations. First, the sample size was relatively modest, which may limit generalizability of the findings. The comparison groups also had a minor imbalance in size; however, this imbalance is unlikely to have resulted in Type II error (Landsheer & van den Wittenboer, 2015). Second, the absence of a control group not exposed to training limits our ability to attribute changes in ASR attitudes to the ReSTART programme. Third, due to restrictions on survey length, the study did not assess changes in ASR knowledge. ASR knowledge is also important to assess, and future research should focus on developing standardized metrics of knowledge related to ASR. Follow-up studies could then benefit from including such metrics. Fourth, consistent with recommendations by Armstrong (2014), we did not make corrections for multiple comparisons. Thus, results should be interpreted accordingly. Fifth, the study examined short-term outcomes immediately post-training but lacked long-term follow-up data. Such data are paramount in order to evaluate the durability of the training effects and the practical application of skills in actual combat; these are critical future questions for the field. Finally, the study did not assess real-life application of ReSTART skills by soldiers.

6. Conclusions

This study marks a significant step in evaluating peer-based interventions for managing ASRs beyond the US and Israeli context, demonstrating the ReSTART programme’s broad acceptability and effectiveness among both professional soldiers and conscripts. The findings highlight the programme’s potential in positively altering attitudes towards ASRs and suggest its applicability in various military, and potentially civilian, high-stress environments. While case reports from the Ukrainian frontlines add to the programme’s real-world relevance, future research involving larger samples, diverse groups and long-term data is crucial to fully understand and optimize its utility. The current study lays the groundwork for advancing ASR management strategies in high-risk settings, underscoring the need for continued exploration and adaptation of interventions like ReSTART.

Acknowledgements

The Walter Reed Army Institute of Research (WRAIR) graciously provided training in, and access to all their training materials related to their iCOVER training programme.

Disclosure statement

The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported. Material has been reviewed by the Walter Reed Army Institute of Research.

Data availability statement

Data can be accessed by contacting the authors directly.
==== Refs
References

Adler, A. B., & Gutierrez, I. A. (2022a). Acute stress reaction in combat: Emerging evidence and peer-based interventions. Current Psychiatry Reports, 24 (4 ), 277–284. 10.1007/s11920-022-01335-2 35353322
Adler, A. B., & Gutierrez, I. A. (2022b). Preparing soldiers to manage acute stress in combat: Acceptability, knowledge and attitudes. Psychiatry, 85 (1 ), 30–37. 10.1080/00332747.2021.2021598 35138988
Adler, A. B., Gutierrez, I. A., Edge, H. M., Nordstrand, A. E., Simms, A., & Willmund, G. D. (2023). Peer-based intervention for acute stress reaction: Adaptations by five militaries. BMJ Military Health, e002344. 10.1136/military-2022-002344 37280014
Adler, A. B., Start, A. R., Milham, L., Allard, Y. S., Riddle, D., Townsend, L., & Svetlitzky, V. (2020). Rapid response to acute stress reaction: Pilot test of iCOVER training for military units. Psychological Trauma: Theory, Research, Practice, and Policy, 12 (4 ), 431. 10.1037/tra0000487 31328939
Armstrong, R. A. (2014). When to use the B onferroni correction. Ophthalmic and Physiological Optics, 34 (5 ), 502–508. 10.1111/opo.12131 24697967
Brislin, R. W. (1970). Back-translation for cross-cultural research. Journal of Cross-Cultural Psychology, 1 (3 ), 185–216. 10.1177/135910457000100301
Daniels, J. K., Coupland, N. J., Hegadoren, K. M., Rowe, B. H., Densmore, M., Neufeld, R. W., & Lanius, R. A. (2012). Neural and behavioral correlates of peritraumatic dissociation in an acutely traumatized sample. The Journal of Clinical Psychiatry, 73 (4 ), 420–426. 10.4088/JCP.10m06642 22394402
Dokkedahl, S. B., & Lahav, Y. (2023). A prospective study of the mediating role of tonic immobility and peritraumatic dissociation on the 4 DSM-5 symptom clusters of posttraumatic stress disorder. The Journal of Clinical Psychiatry, 84 (4 ), 22m14613. 10.4088/JCP.22m14613
Gady, F. S., & Kofman, M. (2023). Ukraine’s strategy of attrition. Survival, 65 (2 ), 7–22. 10.1080/00396338.2023.2193092
Garofalo, S., Giovagnoli, S., Orsoni, M., Starita, F., & Benassi, M. (2022). Interaction effect: Are you doing the right thing? PLoS One, 17 (7 ), e0271668. 10.1371/journal.pone.0271668 35857797
Gjerstad, C. L., Bøe, H. J., Falkum, E., Martinsen, E. W., Nordstrand, A. E., Tønnesen, A., Reichelt, J. G., & Lystad, J. U. (2020). Prevalence and correlates of mental health problems in Norwegian peacekeepers 18–38 years postdeployment. Journal of Traumatic Stress, 33 (5 ), 762–772. 10.1002/jts.22578 32810318
Harvey, A. G., & Bryant, R. A. (2002). Acute stress disorder: A synthesis and critique. Psychological Bulletin, 128 (6 ), 886–902. 10.1037/0033-2909.128.6.886 12405136
International Institute for Strategic Studies (IISS). (2023). The military balance 2023. Routledge. https://www.iiss.org/publications/the-military-balance/
Isserlin, L., Zerach, G., & Solomon, Z. (2008). Acute stress responses: A review and synthesis of ASD, ASR, and CSR. American Journal of Orthopsychiatry, 78 (4 ), 423–429. 10.1037/a0014304 19123763
Iversen, P., & Adler, A. B. (2023). US, Norway partner to help stressed Ukrainian troops. ARMY Magazine, 73 (12 ), https://www.ausa.org/articles/us-norway-partner-help-stressed-ukrainian-troops
Joyce, S., Shand, F., Tighe, J., Laurent, S. J., Bryant, R. A., & Harvey, S. B. (2018). Road to resilience: A systematic review and meta-analysis of resilience training programmes and interventions. BMJ Open, 8 (6 ), e017858. 10.1136/bmjopen-2017-017858
Kosnik, M. (2017). Conscription in the twenty-first century: Do reinforcements equal security? Comparative Strategy, 36 (5 ), 457–467. 10.1080/01495933.2017.1379839
Landsheer, J. A., & van den Wittenboer, G. (2015). Unbalanced 2 × 2 factorial designs and the interaction effect: A troublesome combination. PLoS One, 10 (3 ), e0121412. 10.1371/journal.pone.0121412 25807514
Matson, L. M., Adler, A. B., Quartana, P. J., Thomas, C. L., & Lowery-Gionta, E. G. (2022). Management of acute stress reactions in the military: A stepped care approach. Current Psychiatry Reports, 24 (12 ), 799–808. 10.1007/s11920-022-01388-3 36538195
Nordstrand, A. E., Bøe, H. J., Holen, A., Reichelt, J. G., Gjerstad, C. L., & Hjemdal, O. (2019). Danger- and non-danger-based stressors and their relations to posttraumatic deprecation or growth in Norwegian veterans deployed to Afghanistan. European Journal of Psychotraumatology, 10 (1 ), 1601989. 10.1080/20008198.2019.1601989 31069024
Park, Y. (2021). Conscripts or volunteers? Assessing the impact of organizational behaviors and attitudes on Korean military sector performance [Doctoral thesis, The University of Texas at Dallas]. UTD Theses and Dissertations. https://hdl.handle.net/10735.1/9779
Rybakovaitė, J., Poškus, M. S., & Lo Bue, S. (2023). Forced or free choice: Hardiness, need satisfaction, and engagement among military conscripts. Current Psychology, 42 (10 ), 7909–7919. 10.1007/s12144-021-02123-6
Rybinska, Y., Loshenko, O., Kurapov, A., Lytvyn, S., Kondratieva, V., & Ivasiv, O. (2022). Psycho-emotional state of Ukrainian soldiers before going to the frontline. BRAIN. Broad Research in Artificial Intelligence and Neuroscience, 13 (4 ), 182–195. 10.18662/brain/13.4/382
Rydstedt, L. W., & Österberg, J. (2013). Psychological characteristics of Swedish mandatory enlisted soldiers volunteering and not volunteering for international missions: An exploratory study. Psychological Reports, 112 (2 ), 678–688. 10.2466/17.02.PR0.112.2.678-688 23833893
Sayed, S., Iacoviello, B. M., & Charney, D. S. (2015). Risk factors for the development of psychopathology following trauma. Current Psychiatry Reports, 17 (8 ), 1–7. 10.1007/s11920-015-0612-y 25617038
Solomon, Z., Mikulincer, M., & Benbenishty, R. (1989). Combat stress reactions: Clinical manifestations and correlates. Military Psychology, 1 (1 ), 35–47. 10.1207/s15327876mp0101_3
Svetlitzky, V., Farchi, M., Ben Yehuda, A., & Adler, A. B. (2020). YaHaLOM: A rapid intervention for acute stress reactions in high-risk occupations. Military Behavioral Health, 8 (2 ), 232–242. 10.1080/21635781.2019.1664356
Svetlitzky, V., Farchi, M., Ben Yehuda, A., Start, A. R., Levi, O., & Adler, A. B. (2020). YaHaLOM training in the military: Assessing knowledge, confidence, and stigma. Psychological Services, 17 (2 ), 151–159. 10.1037/ser0000360 31120293
Svetlitzky, V., Farchi, M., Yehuda, A. B., & Adler, A. B. (2020). Witnessing acute stress reaction in team members: The moderating effect of peer-based training. Journal of Nervous & Mental Disease, 208 (10 ), 803–809. 10.1097/NMD.0000000000001218 32740142
Watkins, L. E., Sprang, K. R., & Rothbaum, B. O. (2018). Treating PTSD: A review of evidence-based psychotherapy interventions. Frontiers in Behavioral Neuroscience, 12 , 258. 10.3389/fnbeh.2018.00258 30450043
World Health Organization. (2019). International statistical classification of diseases and related health problems (11th revision). https://icd.who.int/en
