Trauma Informed Leaders and the Behavioral Health Golden Hour

By Sgt. Michael L. Sobey

Headquarters and Headquarters Battery, 1st Armored Division

October 31, 2023

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In this instance, the Golden Hour refers to the precious 60 minutes after Soldiers are wounded, when proper medical treatment is crucial to their survival. Beyond this first hour, survivability decreases based on variety of factors (C. Cacho, personal communication, June 3, 2023 & Kotwal et. Al, 2016). Since the beginning of the Global War on Terror (GWOT) we lost a staggering number of service members due to suicide, more so than all combat operations combined.

With that in mind we must institute a behavioral health (BH) golden hour mirroring the physical response guidelines but for mental health. The U.S. Army needs to train and equip Soldiers with the knowledge and skills needed to address behavioral health (BH) issues, and we need to restructure our BH system to serve today’s Soldiers better.

What is Trauma?

Trauma is “any disturbing experience that results in significant fear, helplessness,dissociation, confusion, or other disruptive feelings intense enough to have a long-lasting negative effect on a person’s attitudes, behavior, and other aspects of functioning. (APA Dictionary of Psychology, 2015-a.).” Trauma can be categorized into two distinct groups, small t and large t.

Small t is a trauma or event that exceeds our ability or capacity to cope with both the event and daily life from an emotional disruption.

Large t is a trauma or event that has a significant impact on an individual and leaves them feeling powerless and with little control over their environment (Barbash, 2019).

Keep in mind that a small t for some can be a large t for others, and vice-versa. Trauma is unique to individuals, and we must not prematurely judge their experience or perception. This is where trauma informed leadership comes in. They are leaders who understand how to prevent and respond to trauma.

Trauma-Informed Leadership

Trauma-informed leaders recognize people, including themselves, who struggle from past and current traumatic experiences. They respond with compassion and empathy. They understand the importance of presence for themselves and their teams to help them cope and grow. They also understand their teams’ need to feel heard, protected, prepared, and seen by organizational leaders. Koloroutis and Pole (2021) show there are five needs that team members look for in leaders:

1. Hear me
2. Protect me
3. Prepare me
4. Support me
5. Care for me

These needs are in line with the tenets of the Noncommissioned Officer (NCO) Creed. “I know my Soldiers and I will always place their needs above my own,” and “my two basic responsibilities will always be uppermost in my mind, the accomplishment of my mission and the welfare of my Soldiers (NCO Creed - Army Values, n.d.).”

Why it Matters

Developing the skills to hear, protect, prepare, support and care for our Soldiers helps ensure we have lethal teams consistently at the highest state of readiness. When engaged in meaningful conversations with our Soldiers, NCOs build rapport, glean a better understanding of their lives, learn what motivates them and show compassion and empathy.

By protecting Soldiers both physically and mentally, we create an environment free of fear and intimidation from bodily and emotional harm. Preparing them to face stressful and emotionally draining situations eases the impact of trauma and gives them the skills to confront their issues.

Supporting our Soldiers, whether they are going to BH, the chaplain, pursuing an education or chasing their passions or goals, creates a workplace where innovation is welcome, and they feel valued. Self-care is a key here. If we display basic compassion and empathy toward one another, we strengthen bonds and foster trust through every echelon.

The Need to Rethink

Collectively as leaders, we must rethink our approach to interpersonal interactions. We should not leave struggling Soldiers behind; we cannot label them as lazy; we cannot hold double standards; and most of all we need to understand what is important to them so we can make sure they are taken care of.

The moment you pin chevrons on your chest, you are considered competent enough to care for America’s sons and daughters. When Soldiers are wounded in combat, we spare no effort to recover and care for them. Why is this different in garrison when it comes to BH issues?

If leaders slow down, take a tactical pause, and strive to understand the situation before responding, we show compassion and create a better environment for our Soldiers. This allows for a top-down understanding of their emotional and mental readiness and prepare them to function in high stress situations.

A Way Forward

Leaders at all levels can act as first responders to BH. We train Soldiers in Tactical Casualty Combat Care (TCCC) at the most basic level; why not expand this to BH care?

According to the Defense Health Agency (DHA) Psychological Health Center of Excellence, adjustment disorders account for 30.8% of all diagnosed mental health conditions in the U.S. military (Military Health System, 2022). For context, an adjustment disorder is defined as:

“Impairment in social or occupational functioning and unexpected severe emotional or behavioral symptoms occurring within 3 months after an individual experiences a specific identifiable stressful event, such as a divorce, business crisis, or family discord.” (APA Dictionary of Psychology, 2015.-b).”

Adjustment disorders are treatable and mostly resolvable. The U.S. Army’s existing options range from teaching Soldiers skills to cope with adjustment issues to providing adequate treatment time.

In clinical practice, differential diagnoses help rule out or detect certain psychological conditions such as adjustment disorders, acute stress disorder, post-traumatic stress disorder, mood or anxiety disorders, or personality disorder traits among other conditions (American Psychiatric Association, 2022). Adjustment disorders can fall into the small-t or high-t range depending on the person; however, as noted above they are treatable. So why don’t we train Soldiers to respond to adjustment disorders?

Leaders Recommendation

The U.S. Army needs trauma-informed leaders who foster growth, create a sense of belonging, genuinely care for Soldiers and recognize when their BH challenges enter the golden hour.

Leaders and Soldiers alike should train on fostering better environments, coping with stress and responding to it. Emotional readiness and intelligence need to be Soldier tasks at Basic Combat Training (BCT) and Advanced Individual Training (AIT). By learning these tasks, Soldiers show up to their first unit with a set of baseline skills as they transition from trainee to well-rounded operational soldiers.

Soldiers will not only understand their military occupational specialty (MOS) but will also develop their trauma-informed leadership skills. For Soldiers already at their duty stations, we must start at the ground level and add tools to their skillset which will allow them to identify and respond to golden hour BH issues.

While the Army has available programs, they may be restricted to certain grades or positions. The Basic Leaders Course (BLC) should expand to teach these skills to the next generation of NCOs and the Basic Officer Leaders Course (BOLC) should follow suit. All current NCOs and officers should be required to go through this training as well, ensuring that BH training is standardized across the formation.

Behavioral Heath Challenges

U.S. Army resources associated with Soldier mental and emotional readiness are overwhelmed. The common trend is that our BH system is at 140-160 percent capacity and backed up several weeks for intake appointments. The Behavioral System of Care (BHSOC) is strained due to a provider shortage, poor access to care, a pervasive lack of trust, and the stigma associated with the system.

Furthermore, as uniformed BH professions advance through the ranks, their time progressively becomes dominated by administrative tasks, decreasing their patient contact time. Another issue facing the Army are the large number of resources, known as resource saturation. While it’s great to have multiple resources, it can be confusing because Soldiers may not know what service is appropriate for their needs.

Recommendation

Behavioral health services across the Army are over-taxed to the point of ineffectiveness so the Army should restructure BH services and how Soldiers are cared for.

The Army should create a position much like the Sexual Assault Response Coordinator (SARC), but specifically for BH. It would be filled by an NCO operating with limited confidentiality and implemented army wide. The NCO would serve as a front-line suicide prevention resource, trainer and high-risk first responder.

Placing these positions within formations would provide unit commanders with additional resources and they would also act as trusted confidants with limited confidentiality. They would be subject matter experts on all BH resources and social programs and act as the cadre for BH programs able to direct Soldiers to the proper resources based on their respective needs. They would be advocates and liaisons for Soldiers, NCOs and officers alike.

These Soldiers should be trained to administer the Columbia Suicide Severity Rating Scale (C-SSRS) so they would understand risk factors and urgency and escalate faster care (The Lighthouse Project the Columbia Lighthouse Project, 2022). Such a position would provide important resources to our formations and serve as a BH rapid response.

The COVID-19 pandemic proved the U.S. Army can provide virtual services, including BH resources. Bolstering the Army’s virtual capabilities would provide two substantial benefits, appointments and likelihood of use.

First, reducing missed appointments (Adepoju et al., 2021). A BH appointment can take up a substantial portion of a day, especially considering driving time driving to and from the appointment, large wait times for Soldiers once on site and the appointment itself. BH care by phone in a closed office or private automobile can eliminate all that wasted time.

Second, senior leaders are more likely to use BH services because they can do so in private. There is a well-documented stigma associated with senior leaders receiving BH services and many senior leaders do not receive treatment because of this. Virtual BH sessions can give Soldiers in these positions who want to seek help relative peace of mind when receiving BH services.

Finally, the Army should assign warrant officers to the BH system. As mentioned above, when providers advance through the ranks, they have progressively less patient contact. With warrant officers providing BH treatment, the Army has a wide range of counselors whose sole function is patient contact, which helps bridge the gap between the 68X MOS, behavioral health specialist and the officer corps, and helps fill the gap between the duties of the specialists and commissioned providers.

Conclusion

Focusing on becoming trauma-informed leaders and understanding our Soldiers will help build a more lethal and ready force. The U.S. Army must think innovatively and take deliberate action to provide a training curriculum from BCT to AIT and beyond that equips the next generation of Army leaders to recognize and intervene when BH is needed.

For current leaders, the Army needs to provide training and continuity. Trauma-informed leaders are simply an extension of the obligation all leaders are expected to meet. Preserving the health and welfare of our Soldiers is not just a battlefield expectation, it is a crucial element to ensure readiness, whether in garrison or while deployed.

To reduce the strain on the Army’s BH system, the Army should explore creating a new MOS where warrant officers with proper counseling credentials and licenses serve as BH subject-matter-experts. These positions should be integrated into units and in the existing BH system to provide front line care and fill system gaps.

By implementing these proposed recommendations, the Army can truly transform the way it approaches BH emergencies and improve/save the lives of countless Soldiers in distress both on and off the battlefield.

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References

Adepoju, O. E., Chae, M., Liaw, W., Angelocci, T., Millard, P. J., & Matuk-Villazon, O. (2021). Transition to telemedicine and its impact on missed appointments in community-based clinics. Annals of Medicine, 54(1), 98–107. https://doi.org/10.1080/07853890.2021.2019826

American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed.)

APA Dictionary of Psychology. (2015.-a). https://dictionary.apa.org/trauma

APA Dictionary of Psychology. (2015.-b). https://dictionary.apa.org/adjustment-disorder

Barbash, E., PhD. (2019, October 18). Different Types of Trauma: Small “t” versus Large ‘T.’ Psychology Today. https://www.psychologytoday.com/us/blog/trauma-and-hope/201703/different-types-trauma-small-t-versus-large-t

Cacho, C, SGT USA. (2023, JUNE 03. Personal Communication [Interview]

Koloroutis, M., & Pole, M. (2021). Trauma-informed leadership and posttraumatic growth. Nursing Management, 52(12), 28–34. https://doi.org/10.1097/01.numa.0000800336.39811.a3

Kotwal, R. S., Howard, J. T., Orman, J. A., Tarpey, B. W., Bailey, J. A., Champion, H. R., Mabry, R. L., Holcomb, J. B., & Gross, K. R. (2016). The Effect of a Golden Hour Policy on the Morbidity and Mortality of Combat Casualties. JAMA Surgery, 151(1), 15. https://doi.org/10.1001/jamasurg.2015.3104

McMahon, F. (n.d.). A Soldiers Request. Association of the United States Army. https://www.ausa.org/Soldiers-request

Adjustment disorder in the military. Military Health System. 2022.). https://www.health.mil/Military-Health-Topics/Centers-of-Excellence/Psychological-Health-Center-of-Excellence/Clinicians-Corner-Blog/Adjustment-Disorder-in-the-Military

NCO Creed - Army Values. (n.d.). https://www.army.mil/values/nco.html

The Lighthouse Project The Columbia Lighthouse Project. (2022, August 23). The Columbia Lighthouse Project. https://cssrs.columbia.edu/

 

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