TACTICAL FLOATATION Helping the Highest-Stressed Operators

in the United States Air Force

JERRY V. WALKER, I I I , PH.D., ABPPBOARD-CERTIFIED COUNSELING PSYCHOLOGISTHUMAN FACTORS CONSULTANT, 363D ISRW, USAFPSYCHOLOGY SERVICES MANAGER, NEBRASKA MEDICINE

CAO 17 September 2019//UNCLASSIFIED//

The year was 2016…

• Became 1st medical officer for a large (new) military intelligence organization

• A recent (Oct 2015) psychological survey of their intel aircrew had found:• Vastly disproportionate levels of PTSD & mental health-seeking behavior

• Binge-drinking at 9x the rate compared to the rest of the Air Force

• The highest level of stress ever recorded in the history of the U.S. Air Force

• “FIX IT”

Disclosures

Presenter does not have any relevant financial or non-financial relationships to disclose relating to the content of this presentation

The views expressed in this presentation are those of the author and do not necessarily reflect the official policy or position of the Department of Defense

Ph.D., not an M.D./D.O. (not the kind of “doctor” my mother can be proud of)

Target Population: Special Ops ISR Aircrew Direct Support Operators (DSO) and Tactical Support Operators (TSO) Perform integrated intelligence operations for SOF direct action events Execute real-time duties both on the ground and in SOF aircraft Threat detection (save the aircraft), target triangulation (find the bad guys), and

support to ground SOF (protect the good guys on the ground)

Occupational requirements: Frequent deployments (~1:1) Regular combat/operational exposure Endless training and certification/re-certification (aircraft, technical systems,

foreign languages, etc.)

Systemic Stressors:- Frequent Deployments- High Operational Tempo- Low Personnel Manning

Chronic, elevated sympathetic nervous system physiological arousal

Cynicism, Depression

Role Overload,Role Conflict,

Poor Unit Cohesion

Reduced sleep quantity/quality

Seeking Help from Mental Health or Chaplain (10%)Caffeine Overuse (57%)

Occupational Stressors:- Issues w/ Leadership- High workload, long hours- Extra duties/Admin tasks

Occupational Hazards:- Frequent combat/

trauma exposure- Moral injury

Personnel Factors:- Male-dominant (81%)- 70% b/t 26-35 yrs old- 55% married, 40% w/kids

Physical Fatigue

Relationshipissues/crises

Emotional Exhaustion, Occupational Burnout Anxiety, PTSD

Increased Alcohol Use (27%)

Interrelations of Occupational Health Issues

Autonomic Nervous System (ANS)

Accessed from http://brain-bodyhealth.com/rheumatoid-arthritis-autonomic-nervous-system-imbalance/

Rothschild, B. (2017). Autonomic nervous system table (laminated card). New York, NY: W.W. Norton.

ANS Balance Ideal Steady State

Ideal Operational State

Maladaptive Chronic State

Use Big Words, You Can Sell AnythingTo pilot-test a contemporary, evidence-based neurophysiological therapeutic modality for its efficacy in reducing prolonged sympathetic nervous system arousal and thereby improve the overall physical health, mental well-being, and behavioral functioning of AD USAF personnel who have been identified as being at heightened risk for developing occupation-related combat/operational stress reactions et al. mental health, behavioral, and/or stress-induced psychophysiological conditions due to the nature, frequency, and intensity of the duties they execute in special operations intelligence, surveillance, & reconnaissance (ISR) support

TLDR: Military guys are stressed out; psychologist helps them chill out

Rationale for Use of Floatation Therapy Induction of the PNS-mediated relaxation response requires reduced sensory input and reduced bodily movements (Ben-Menachem, 1997; Bood, et al., 2006)

Floatation therapy has, within 3 -7 sessions, reduced SNS activity as measured by changes in HR, BP, and ACTH/cortisol levels (Turner & Fine, 1990)

In 12 sessions, floating can substantially reduce pain, stress, anxiety, and burnout-related depression, while improving sleep quality and optimism; effects were sustained for at least 4 months (Bood, et al., 2001; 2006)

Activating the relaxation response can reduce the need for alcohol (et al. self-medication) and/or psychoactive medication for symptom relief (Setterlind, 1990)

Bood, S. A., Sundequist, U., Kjellgren, A., Norlander, T., Nordstrom, L., et al. (2006). Eliciting the relaxation response with help of Flotation-REST (Restricted Environmental Stimulation Technique) in patients with stress-related ailments. International Journal of Stress Management, 13, 154-175.

Empirical SupportFloatation Therapy (Restricted Environmental Stimulation Therapy; REST) protocols have demonstrated*:• Increased self-reported psychological well-being (Mahoney, 1990)• Decreased burnout-related depression, improved optimism (Bood, et al., 2006)• Improved sleep quantity and quality (Ballard, 1993)• Reduced stress (Kjellgren, et al., 2001)• Reduced anxiety and muscle tension (Schulz & Kaspar, 1994)• Reduced blood pressure (Fine & Turner, 1982)• Reduction in anxiety and elimination of suicidal ideation (Martin Polanco, MD & Dan Eagle, MD)• Chronic headache and chronic pain relief (Bood, et al., 2006)

* These results are all normal behavioral, mental, and physical reactions to prolonged parasympathetic nervous system (PNS) activation. REST simply provides an extremely practical and effective environment to mediate PNS activity.

Recruitment & Study DesignParticipants were voluntary DSOs & TSOs from a single site◦ Identified and referred by their embedded independent medical technician◦ Floatation therapy contracted with local LLC◦ Services were also made available to spouses – did not comprise a substantial

proportion of the sample (23%)

Data collected from Nov 2017 – Oct 2018

NOTE: Absence of control group for comparison in this pilot study

NOTE: An a priori power analysis assuming medium effect size (.25) required at least 65 total participants – so take these results with a “grain of salt”

ParticipantsLimited demographic data available, for participant protectionN = 91 completed at least one floatation sessionAge◦ Range: 22-48 years (normally distributed)◦ Mean: 34.09 years (SD: 5.72)◦ Median: 34 years

Gender◦ Female: 35 (41%)◦ Male: 50 (59%)◦ 6 individuals did not report

Outcome Measures

Self-Ratings (0-5 scale)◦ Pain◦ Stress◦ Sleep Quality*◦ Overall Health◦ Job Satisfaction◦ Relationship Satisfaction◦ Life Satisfaction

Psychological Assessment (OQ-45.2)◦ General Psychological Symptoms (SD Subscale)◦ Interpersonal Relationship Issues (IR Subscale)◦ Issues with, or Concerns at, Work (SR Subscale)◦ Depression Symptoms (11 items, created for this

study)◦ Anxiety Symptoms (8 items, created for this study)◦ Burnout Indices (7 items, created for this study)◦ Physical Symptoms (6 items, created for this

study)

*Participants also reported avg. # of hours of sleep per night in 1-hour increments (range: 4-9 hours)

Assessed prior to each session Assessed at odd-number sessions (1, 3, 5, 7…)

Self-Selected Session Dosage# of

SessionsNumber of Participants

who Completed

1 91

2 65

3 48

4 37

5 27

6 22

7 19

8 16

9 11

… …

13 1

• For all participants:• Range = 1-13 sessions• Mean # sessions = 3.85• Median # sessions = 3

• Repeat customers trended toward higher baseline scores of distress/psych concerns

• Time between sessions (including average # days between sessions) demonstrated null relationship with outcome measure differences from baseline

• However, higher acuity participants did tend to present for services more frequently (~1-2 weeks b/t sessions)

StressOverall stress ratings decreased 60% after just the first session, and pain reduction was maintained (down 79.9% from baseline) through session #9

F(1,20) = 35.64, p<.001, ETA=.64

What people said:◦ “The stress is gone for a few days after every

session”◦ “My anger and stress just left my body”◦ “I am much more relaxed and less irritable”◦ “I’ve noticed that my overall stress level has

remained somewhat low since my last float and massage”

◦ Significantly decreases stress—most relaxed I could be”

PainGeneral physical pain ratings decreased 66% after just the first session, and initial pain reduction was maintained (down 70.3% from baseline) through session #9

F(1,20) = 17.36, p<.001, ETA=.47

What people said:◦ “Muscle tension, headache nearly gone”◦ “My shoulders are not up by my ears anymore”◦ “After session 1, I did not have another

headache for an entire week!”◦ “Helps my shoulder pain”◦ “Improvement in back pain”◦ “I haven’t had any migraines or headaches since

my last float”◦ “Relief of muscle tension”

Stress & Pain Mitigating Factor: Time Examined # of days between floatation sessions, as well as calculated a running average for # of days between sessions (beginning at session #3)

Lower average latency between floatation sessions was associated with more substantial reductions in both pain (r=.25, p<.001) and stress (r=.39, p<.001)

Furthermore, the fewer days between sessions helped maintain floatation therapy’s positive impacts on stress (r=.12, p<.05) while also reducing muscle soreness (r=.19, p<.05)

Additionally, higher frequency of floatation sessions was correlated with a reduction in maladaptive alcohol use (r=-.16, p<.05), perhaps denoting the reduced need to self-medicate pain/stress conditions with alcohol

Though participant variability precludes a definitive recommendation, it was observed that participants with an average gap of ≥2 weeks between floatation sessions benefitted less overall

SleepNo substantial statistical differences for Sleep Quality (p=.24) or Sleep Quantity (p=.38). HOWEVER:- After 3 sessions, floaters gained an extra 42 minutes of sleep each week relative to their baseline

- After 5 sessions, floaters gained an extra 2 hours, 6 minutes

- After 7 sessions, floaters gained an extra 2 hours, 44 minutes- After 9 sessions, floaters gained an extra 3 hours, 30 minutes

What people said:◦ “Better sleep” (x4)◦ “More relaxing sleep”◦ “Sleep is more restful”◦ “I can tell a huge difference in my sleep and overall body

functions”◦ “Sleep at night is very sound”◦ “It made me sleep so deep I slept past my alarm!”

Mental HealthMental health symptoms were reduced by 35% over 9 sessionsGeneral psychological issues/concerns were reduced by 32% over 9 sessions

Diminishing returns past session #7?

F(1,31) = 2.28, p=.14, ETA=.07 (SD Subscale, 7 sessions)F(1,31) = 3.33, p=.08, ETA=.10 (OQ-45 Total Score, 7 sessions)

What people said:◦ “I believe this is helping reset my baseline”◦ “I can now start ID’ing when and how stressors are

starting to influence my actions and decisions”◦ “Can recognized when I’m stressed and try to calm

down”◦ “Increased ability to cope with stress”◦ “Feel happier!”◦ “Preventative care that helps physical and

behavioral issues from becoming worse”

Depression & AnxietyDepressive symptoms* decreased by 31.9% in 7 sessions, but further reductions after this point were negligibleConversely, anxiety symptoms** showed steady, gradual reduction with each floatation session (42.7% reduction by session #9), without leveling off

*Depression Subscale comprised of OQ-45 items: 2, 3, 5, 6, 8, 9, 17, 22, 23, 41, & 42**Anxiety Subscale comprised of OQ-45 items: 10, 22, 25, 27, 29, 33, 35, & 36

F(1,31) = 3.07, p=.09, ETA=.09 (Depression Scale, 7 sessions)F(1,20) = 2.34, p=.14, ETA=.11 (Anxiety Scale, 9 sessions)

What people said:◦ “Less PTSD symptoms, less panic attacks”◦ “Improved PTSD”◦ “When I first started this program, I was

experiencing anxiety attacks and PTSD flashbacks…since starting the massage and float, I have had 0 attacks and 0 flashbacks. It works!!!”

(Inter)Personal RelationshipsRelationship issues/concerns were cut nearly in half (down 47.6%) in 7 sessions

Relationship satisfaction (0-5 scale) concordantly increased 8.9% over this same time

F(1,31) = 4.21, p<.05, ETA=.12 (IR Subscale, 7 sessions)F(1,31) = 1.04, p=.32, ETA=.03 (Rel. Sat. Scale, 7 sessions)

What people said:◦ “More patience”◦ “Tranquility, I can manage my anger a little better”◦ “Ability to remain more calm”◦ “Being able to stay calm during stressful moments”◦ “Getting to spend quiet time with my husband”◦ “Calm at home”◦ “Focus, concentration at work and home”

Job Stress/SatisfactionOccupational issues/concerns and Burnout were reduced by 27% and 26.4%, respectively, over 7 sessionsJob satisfaction (0-5 scale), however, demonstrated minimal change…

*Burnout Subscale = OQ-45 items: 4, 6, 12, 14, 21, 28, & 38 (some overlap w/ SR subscale)

What people said:◦ “I have noticed increased patience when dealing with

everyday stressors (family/work)”◦ “Came in super stressed out from [stuff] at work,

definitely feel less of that now”◦ “More relaxed outside of work”◦ “Less stress, less anxiety, calmer at work”◦ “Focus, energy, more relaxed and productive”◦ “Stress from current workday is gone after

massage/float”F(1,31) = 5.04, p<.05, ETA=.14 (Burnout Scale, 7 sessions)F(1,31) = 3.83, p=.06, ETA=.11 (SR Subscale, 7 sessions)F(1,31) = 0.11, p=.75, ETA=.00 (Job Sat. Scale, 7 sessions)

Physical Health IndicesPhysical health issues/concerns* were reduced by 27.6% over 7 sessions (but appeared to level off around this point)

Overall physical health (0-5 scale), however, demonstrated minimal change

Various objective physiological health measures (i.e. body composition, salivary cortisol, etc.) were desired as outcome variables, but $$ was the LIMFAC…we were happy just to obtain funding for the experimental services!

*Physical Symptoms Subscale comprised of OQ-45 items: 2, 9, 27, 29, 34, & 45

F(1,31) = 3.60, p=.07, ETA=.10 (Physical Symptoms Scale, 7 sessions)F(1,31) = 0.90, p=.35, ETA=.03 (Overall Health Scale, 7 sessions)

Mental ClarityNot objectively assessed

What people said:◦ “Able to break down challenges/tasks and not feel overwhelmed”◦ “Sharper decision making”◦ “Improved focus”◦ “It’s enabling me to study better and longer”◦ “Focus on tasks, quieter mind”◦ “Increased focus at work” (x2)◦ “Mental stamina”◦ “Ability to focus and perform better at work/home”

Summary of ResultsOutcome Measure

Objective Data Support?

Subjective Data Support?

Pain YES YES

Stress YES YES

Sleep SOMEWHAT YES

General MH Sxs SOMEWHAT YES

Depression SOMEWHAT YES

Anxiety (includ. PTSD)

SOMEWHAT YES

Relationships YES SOMEWHAT

Job Stress & Burnout

MAYBE UNKNOWN

Physical Health SOMEWHAT UNKNOWN

Mental Clarity UNKNOWN YES

Interpretation of Findings

3rd-Order EffectsImproved

RelationshipsReduced Occupational

BurnoutImproved Physical

HealthIncreased Mental

Clarity

2nd-Order Effects

Stress/Anxiety Reduction Reduced Depression Pain/Headache

Reduction Improved Sleep

Floatation Therapy

Reduced Physiological (SNS) Arousal Induced Relaxation (PNS) Response

Implications Float therapy appears to improve both physical and mental health indices, with concordant positive impact on personal relationships

While job satisfaction was not impacted by the intervention, perceived job capability (stress reduction, mental clarity) may have increased

In only 7-9 floatation sessions, we were able to: Cut chronic pain and stress ratings in half Substantially improve both sleep quantity and quality Enhance relationship satisfaction, and Mitigate some aspects of occupation-related mental health conditions

Caveats Small (relatively) sample size—many possible main effects only approached statistical significance

Mass deployment during the study timeline created a prolonged break in floatation therapy services for some participants

Absence of control group; inability to randomize participants to different IVs

Float therapy & Deep Tissue Massage combo?

Generalizability should be constrained to personnel performing high-stress, combat-operational duties…but the floatation modality may have appeal to other high-stress career fields

Selected ReferencesBallard, E. (1993). REST in the treatment of persistent psycho physiological insomnia. In A. F. Barabasz, & M. Barabasz (Eds.), Clinical and experimental restricted environmental stimulation

(pp. 187–203). New York: Springer-Verlag.

Bood, S. A., Sundequist, U., Kjellgren, A., Norlander, T., Nordström, L., Nordström, K., & Nordström, G. (2006). Eliciting the relaxation response with the help of Flotation-REST (Restricted Environmental Stimulation Technique) in patients with stress-related ailments. International Journal of Stress Management, 13, 154-175.

Castro, C. A., & Adler, A. B. (2000). The impact of operation tempo: Issues in measurement. Frederick, MD: U.S. Army Medical Research & Material Command.

Chappelle, W., Traut, K., Prince, L., Goodman, T., & Thompson, B. (2015). 2015 Occupational health stress screenings: 25th IS assessment and consult. Internal report, not approved for public release.

Esch, T., Fricchione, L., & Stefano, G. B. (2003). The therapeutic use of the relaxation response in stress-related diseases. Medical Science Monitor, 9, 23–34.

Fine, T. H., & Turner, J. W. (1982). The effect of brief restricted environmental stimulation therapy treatment of essential hypertension. Behavior Research Therapy, 20, 567–570.

Kalpinski, R. (2014). Client improvement in a community-based training clinic: As indicated by the OQ-45. Dissertation, Texas A&M University, 1-77.

Kjellgren, A., Sundeqvist, U., Norlander, T., & Archer, T. (2001). Effects of flotation–REST on muscle tension pain. Pain Research and Management, 6, 181–189.

Mahoney, M. J. (1990). Applications of flotation REST in personal development. In J. W. Turner, & T. H. Fine (Eds.), Restricted environmental stimulation (pp. 174–180). Ohio: Medical College of Ohio Press.

McCance, K.L., & Huether, S.E. (2018). Pathophysiology: The biological basis for disease in adults and children (8th ed.). Maryland Heights, MO: Mosby.

Selected References, continuedMinami, T., Davies, D.R., Tierney, S.C., Bettmann, J.E., McAward, S.M., Averill, L.A., Huebner, L.A., Weitzman, L.M., Benbrook, A.R., Serlin, R.C., & Wampold, B.E. (2009). Preliminary

evidence on the effectiveness of psychological treatments delivered at a university counseling center. Journal of Counseling Psychology, 56, 309-320.

Ogle, A.D., Reichwald, R., & Rutland, J.B. (2017). Remote Combat Stress Impact and Mitigation: ISR in the Kill Chain. National Security Psychology Symposium, Chantilly, VA.

Polanco, M., & Engle, D. (2017). Floatation tank as “psychedelic.” In T. Ferriss (Ed.), Tools of titans (pp. 109–121). Boston: Houghton-Mifflin-Harcourt.

Prince, L., Chappelle, W., McDonald, K., Goodman, T., Cowper, S., & Thompson, W. (2015). Reassessment of psychological distress and posttraumatic stress disorder in United States Air Force Distributed Common Ground System operators. Military Medicine, 171-178.

Reardon, L., Chappelle, W., Goodman, T., Cowper, S., Prince, L., & Thompson, W. (2015). Prevalence of Posttraumatic Stress Symptoms in United States Air Force Intelligence, Surveillance, and Reconnaissance Agency Imagery Analysts. Psychological Trauma: Theory, Research, Practice, and Policy, 8, 55-62.

Schulz, P., & Kaspar, C. H. (1994). Neuroendocrine and psychological effects of restricted environmental stimulation technique in a floatation tank. Biological Psychology, 37, 161–175.

Turner, J. W., & Fine, T. H. (1990). Restricted environmental stimulation influences plasma cortisol levels and their variability. In J. W. Turner, & T. H. Fine (Eds.), Restricted environmental stimulation (pp. 71–78). Ohio: Medical College of Ohio Press.

Wallbaum, A. B., Rzewnicki, R., Steele, H., & Sudefeld, P. (1992). Progressive muscle relaxation and restricted environmental stimulation therapy for chronic tension headache: A pilot study. International Journal of Psychosomatics, 38, 33–39.

Jerry V. Walker, III jvwalker3@gmail.com

402-559-5031 (w)