Managing Behavioral Health in Space
Behavioral health in space is the practical application of aerospace psychiatry and aerospace psychology techniques to positively influence the mental well-being of astronauts, cosmonauts, and their family members.
Space flight possesses unique stressors in an unforgiving environment. Behavioral health is currently ranked second to the risk of space radiation exposure as a potential impediment to a successful exploration class mission. Lessons learned have revealed that prior Russian space flight missions have been terminated early due to psychological decrement. Therefore, it is critical to have in place a comprehensive and integrated program to prevent, detect, assess, and manage behavioral health issues in human space flight.
Several human space flight missions in the 1970s, 1980s, and 1990s produced issues with behavioral health due to psychological factors. In 1974, the crew of Skylab III expressed displeasure with their excessive workload and discontinued communications for a protracted time period (Cooper 1976). In 1976, during the Soyuz- 21 mission to the Salyut-5 space station, the crew was brought home early after the cosmonauts complained of a pungent odor. No source for this odor was ever found, nor did other crews detect it. Since the crew had not been getting along, the odor may have been a psychosomatic manifestation of the intense interpersonal friction. In 1985, the crew of the Soyuz T-14 mission to Salyut-7 was brought home early because cosmonaut Vladimir Vasyutin complained that he had a prostate infection. Doctors later believed that the problem was partly psychological, perhaps a manifestation of isolation, confinement, and interpersonal conflict. The Soyuz TM-2 mission in 1987 was similarly cut short because of adverse psychosocial factors. In 1995, the first flight of the joint US-Russian space program on Mir produced psychological strain between the astronaut and cosmonauts. While the joint program brought forth psychological adversity including oral outbursts, friction between space and ground crews, depression, demoralization, motivational decline, and significant errors in task completion, there were also positive psychological ramifications. These included significant personal accomplishments, strong friendships, helping others, sharing fresh food from home, and surpassing technical and scientific expectations (Holland 1999). The behavioral difficulties within the aforementioned space missions may have been prevented if more robust and preventative behavioral services had been in place. Since those missions, first the Russian space program and then the other international partner space agencies have developed very robust programs to manage behavioral health in space missions.
Space Agencies and Their Behavioral Health Groups
To prevent and/or mitigate any adverse behavioral issues each space agency has its own Behavioral Health and Performance Group (BHP) comprised of dedicated clinical/operational psychiatrists, psychologists, and behavioral health specialists who have developed a program to manage the behavioral health of their astronauts or cosmonauts. With respect to the International Space Station (ISS) program, these groups also collectively meet annually as the Spaceflight Human Behavior and Performance Working Group (SHBPWG). Their mandate is to support the ISS Multilateral Medical Operations Panel (comprised of the space agencies’ management physicians) in coordinating input from the international partners regarding: (1) psychological adaptation and support, (2) behavioral health, (3) sleep and circadian health, (4) fatigue monitoring, and (5) human-system interface issues (Duncan et al. 2007).
Examples of issues discussed by the SHBPWG include: psychiatric/psychological selection and certification standards; content of psychological training of individual crew members and/or entire crews; in-flight behavior and performance monitoring standards; planning, provision, and coordination of preflight, in-flight, postflight behavior and performance support; astronaut work/rest schedules; and emergency support of crew members experiencing difficulties in their performance or behavior.
NASA Behavioral Health and Performance Group
The main focus of this entry will be on the United States’ National Aeronautics and Space Administration (NASA) Behavioral Health and Performance operational group’s program. The other international partner space agencies (Canadian Space Agency, European Space Agency, Japanese Space Exploration Agency, and Russian Space Agency) have very similar behavioral health services.
NASA’s biopsychosocial approach to the behavioral well-being of astronauts is an integrated, multipronged approach which addresses all aspects of the flight environment that might influence adaptation, emotional and social health, and peak mission performance. This is a systems view of behavioral support to the mission and addresses the internal state of the individual astronaut, characteristics of the mission profile (e.g., duration, habitable volume, communications, work/living environment), and maintenance of key relationships (within the crew, crew-ground, family), among other things.
Toward this end, NASA BHP Operations utilizes individuals who are trained and certified in pertinent disciplines such as psychiatry, clinical psychology, space medicine, operational psychology, industrial/organizational psychology, aviation psychology, and media and information technology. Behavioral medicine functions – such as applicant psychiatric screening, clinical diagnosis and treatment, preflight and in-flight medical assessments, crew medical officer training, and annual examinations – are primarily managed by flight surgeons who are board certified in psychiatry and by clinical psychologists who have experience with aviators. Nonmedical psychological functions – such as applicant suitability selection and procedure design, crew training for expeditionary skills, preflight and in-flight crew member and family support, in-flight monitoring – are primarily managed by clinical, operational, and industrial/organizational psychologists. Both disciplines provide postflight mission debriefings, consultation to mission management, and other related tasks. Professional duties heavily overlap, so all individuals must have extensive experience and training in operational environments. Not infrequently, BHP operational personnel will be requested to provide psychological consultation to Flight Directors, ground controllers, or to NASA management on various psychological programmatic issues such as selection, training, mission management, or other organizational issues.
Prevention of behavioral problems during human spaceflight begins with selection. Those individuals who are assessed as having a history of, or significant potential to have, a psychiatric diagnosis are disqualified during the astronaut selection process. This part of the selection process falls under the purview of behavioral medicine and is commonly called “select-out.” It is no different than other medical conditions that are potentially disqualifying, such as a history of kidney disease or high blood pressure. During astronaut selection, personality disorder features are also deemed potentially disqualifying, as are a history of overt psychiatric illness, such as a prior psychotic or major depressive episode. The NASA select-out process is extremely rigorous and consists of a battery of clinical psychological tests and an extensive, in-depth interview/examination with a psychiatrist and psychologist. Individuals who have had a history of, or are most likely to have, a psychiatric disorder are disqualified or selected-out (Harrison and Fiedler 2015; Kanas and Manzey 2008).
Applicants who are psychiatrically qualified are then assessed for suitability for NASA space missions. This aspect of selection is under the purview of operational psychology and is typically termed “select-in.” The suitability assessment is based on personal attributes derived from job analyses of the target mission profiles. A suitability rating is assigned to each interviewed applicant and is an assessment of the degree to which that applicant would make a good astronaut. Some of the factors that are considered when determining suitability include resilience, emotional stability, and teamwork skills (Galarza and Holland 1999; Kanas and Manzey 2008). The behavioral health portion of astronaut selection is only one small part of the whole astronaut process. Once an astronaut class is selected and approved by NASA headquarters, they begin training for the next 2 years as astronaut candidates (ASCANs).
Astronaut Candidate Training
There are a number of training classes given by BHP Operations to ASCANS during their 2-year candidacy period following selection. Representative classes include the courses below.
Stress Resiliency is a short review of stress management techniques and expectations of the frustrations and rewards of a career at NASA. The stress of a NASA career on family members is also discussed.
Cross-Cultural training is a 17-hour workshop that exposes US astronauts to special circumstances that can arise from multinational crew members and ground control personnel working together on a complex project such as ISS. The course addresses cultural factors, communication and negotiation styles, and work and social factors. Potential positive and negative effects of cultural differences are identified. Methods, strategies, and resources that can be used to facilitate cross-cultural challenges are described and practiced within the context of case situations.
Conflict Management is a discussion-oriented lesson that introduces a three-point cycle that drives, escalates, and de-escalates conflict. The course reviews methods for breaking the cycle at each of the three points so that conflicts are resolved in ways that preserve relationships with colleagues, friends, and family. Techniques include “rules” for fair fighting, checking the accuracy of interpreted meanings, and recognizing and managing emotions that can perpetuate conflict.
Expeditionary Skills is a 24-h, segmented practicum developed by operational psychology and conducted by current astronauts. Major “soft skills” topics, such as leadership/followership, small group living, teamwork, and self-care, are taught in conjunction with a series of technical training trips (e.g., geology) that take place in remote field locations. Senior astronauts accompany the ASCANs, discuss lessons learned from previous exploration and space expeditions, and mentor ASCANs in practicing effective expeditionary behaviors.
Unassigned Crew Training
Opportunities to practice expeditionary skills in demanding operational environments are provided by NASA after the individual has successfully completed their astronaut candidacy period and prior to their first mission assignment. These opportunities include National Outdoor Leadership School (NOLS), NASA Extreme Mission Operations (NEEMO) undersea science station missions, Cooperative Adventure for Valuing and Exercising human behavior and performance Skills (CAVES) expeditions, meteorite hunting expeditions to Antarctica, and real-time crew communication practice in high-performance jets. Unassigned crew training enables astronauts to practice the behavioral skills that will be needed when they fly in space.
NASA psychiatrists conduct an annual behavioral medicine assessment with each active astronaut on flight status. This assessment is comprised of an annual clinical interview and covers broad areas of occupational relevance, including space flight experience, workload, fatigue, sleep, peer relationships, family, challenges, goals, and future plans. These annual occupational assessments are not intended to be comprehensive psychological or psychiatric screenings for mental disorders or psychiatric illness but are intended to act as a behavioral health fitness check in conjunction with the annual physical examinations that all astronauts annually undergo.
At any time during an astronaut’s career, he or she may receive clinical care from behavioral medicine providers. If needed, the astronaut and/or their family members may be referred to private behavioral health clinicians for consultation or treatment.
Family Support Office
The BHP Family Support Office (FSO) acts for astronauts and their family members by liaising with the Astronaut Office, the Astronaut Spouses Group (ASG), Johnson Space Center security, Flight Medicine Clinic, Military Liaison Office, Public Affairs Office (PAO), school districts, and others. An organizational FSO is needed when employee tasks include deployments or hazardous duties that affect employee families. The FSO personnel assist with all family issues and concerns in a confidential manner. They also connect and communicate with families so that they are informed and ready in the event of an emergency. To support families in their readiness preparations, the FSO provides publications, newsletters, email notices, training and educational classes, and specialized seminars. The FSO was created along the same standards and models used by Family Support Offices in the US Department of Defense to address the unique challenges that face astronauts and their families during astronaut training cycles and flight assignments (Sipes and Vander Ark 2005). As several astronauts have noted, the FSO provides the support that enables them to more easily concentrate on their work in space because they believe that their family needs are being addressed by BHP and FSO personnel (Stuster 2010).
Once an astronaut is assigned to a specific mission, there are a number of training courses provided to the assigned astronaut. The topics of the training are aligned with the internationally agreed upon behavioral competencies (Besonne et al. 2007; Kanas and Manzey 2008). A sample of these courses is provided below.
Crew Medical Officer training is provided by BHP behavioral medicine specialists to individual astronauts who are assigned the role of Crew Medical Officer. This training provides an overview of potential psychiatric symptoms and disorders that might be seen during a space mission. Discussion includes the therapeutic clinical response and resources that are available on the ISS should a crew member exhibit seriously disordered behavior. The focus of this training is on overt psychiatric symptoms or illness as opposed to behaviors that fall within the norm for persons who are living and working in stressful circumstances.
Psychological Factors of Extended Space Flight are conducted by an operational psychology provider and discusses psychological, social, and work-related factors that are driven by mission and environmental demands, such as volume and nature of the vehicle or habitat, mission duration, and technical aspects. It also identifies the principle environmental, interpersonal, and programmatic factors that can impair psychological health and performance during extended confinement. Crew members are provided lessons learned from previous missions during the preflight, in-flight and postflight phases. The manifestations of various psychological factors are discussed, as well as the procedures that are used to manage any contingencies. A separate, subsequent discussion is held between the astronaut and the BHP specialists that focus upon the unique characteristics of the upcoming mission, the tasks and crew, and those of his or her family situation. Mitigating strategies and procedures are also discussed.
Crew and Family Psychological Support Familiarization, and Psychological Support Planning is conducted through classes and through personal, informal meetings between operational psychology specialists, and crew members and their families. Crew members are briefed on the psychological support program that is established to help normalize conditions for the crew members and their families and maintain connectedness between them. Support is available to assist crew members and their families during the preflight, in-flight, and postflight phases of the mission. Each crew member identifies his or her desired in-flight support resources, and a tailored program is designed from the options that are currently available.
Practical Planning for Long Duration Missions is a class conducted by the FSO, which encourages crews and family members to consider important personal arrangements before long-duration missions. This class stresses critical actions (e.g., wills, emergency contact information), reviews lessons learned pertaining to these, and provides tools and checklists to help simplify the personal preparation process. The BHP FSO offers this class in conjunction with the Astronaut Office. Spouses, significant others, and other key family members may attend this event at the crew member’s discretion.
Preflight behavioral assessments conducted between the astronaut and behavioral medicine providers cover a wide range of topics such as: mission readiness; workload and fatigue; family and personal relationships; crew training concerns; management issues; mood and anxiety; personal mission goals, desires, challenges, and risks; family concerns; and preferred notification if any emergencies occur on Earth. These assessments are to prevent or mitigate any foreseen behavioral issues before the astronaut flies on their assigned mission.
In-flight Tracking and Discussions
Private Psychological Conferences (PPCs) are conducted via videoconferencing between behavioral health specialists and the astronaut every 2 weeks. These cover a range of operationally relevant behavioral health topics such as: sleep (duration and quality); circadian dysrhythmia (including sleep shifts); fatigue; workload; individual and crew morale; crew-ground relationships; mood and cognition; family and personal relationships; environmental and habitability issues (including food); and any preparation for upcoming important events such as extra vehicular activities (EVAs) or space vehicle captures using the robotic arm. The PPC is an abbreviated check for any behavioral health issues before they become problematic and is an opportunity for the astronaut and the behavioral health specialists to discuss concerns and strategies in a private setting. It is augmented by on-demand email and telephone contact capability between the astronaut and BHP. The PPC occurs in addition to weekly private medical conferences between the astronaut and crew surgeon that focuses on medical issues. The behavioral health specialists also have regular contact with the crew member’s family members during the mission.
In-Flight Psychological Support Services
Providing crew members with the opportunity to keep regular contact with their families is important for maintaining crew member behavioral health (Kanas and Manzey 2008; Stuster 2010). Private Family Conferences are conducted via video between crew members and their families from within the privacy and comfort of the family home normally every weekend. The Internet protocol (IP) telephone is an additional link between a crew member and that crew member’s family and friends. The crew member can call home when Ku-band coverage is available. The NASA tracking and data relay satellite uses Ku-band to communicate with the ISS. Some astronauts have actively embraced other social media including blogging, tweeting, and posting to Facebook and Instagram.
Crew Discretionary Events are videoconferences for morale purposes and are arranged by the operational psychology specialists that link an astronaut with celebrities of their choice on Earth. The crew Webpage, the IP telephone, and real-time email can help crew members feel more connected to events on Earth. The Crew Webpage, which is updated frequently each week for each crew member, is specifically tailored and, thus, provides that crew member with a gateway to personal news selections, videos, music, and photographs.
Providing choices of leisure activities for crew members is another tool that can prevent behavioral health distress. Before flight, crew members request movies, music, and electronic books that will later be uploaded to them. Even leisure equipment can be requested; for example, in response to the request of various ISS crew members, several musical instruments, including a keyboard and guitar, are now on board the station. Astronauts have stated that they frequently use movies and music to accompany their required daily exercise regimens. In addition to its physical benefits, exercise also is an effective countermeasure for maintaining positive mood (Stuster 2010). The PPCs, which are conducted every 2 weeks, comprise an opportunity – in addition to email and IP phone – for the crew member to request any modifications to their in-flight support plan.
Post Flight Assessments and Debriefings
Two types of postflight debriefings are conducted which review the mission retrospectively. Behavioral medicine and operational psychology providers focus on topics such as the level of personal satisfaction, greatest challenges, frustrations, and joys during the mission; retrospect review of fatigue level prior to critical events such as extra vehicular ctivities; family reintegration issues; and postflight mood, anxiety, and cognition. In addition, other subjects covered may include the crew member’s short- and long-term career plans, what worked and did not work from a BHP standpoint, and what behavioral health services may need improvement or change. These postflight areas of focus allow the providers to continue or implement any postflight clinical services that may be indicated and to improve the services for future missions. A debriefing by in-flight support coordinators is also conducted which retrospectively focuses on the specific in-flight support procedures provided to the astronaut and family. Topics include the scheduling and technical coordination of family audio-video communications, daily news, morale items, and Crew Care Packages. In particular, the astronaut and their spouse will be asked what BHP services could be improved or changed (Kanas and Manzey 2008).
After the astronaut has completed their mission in space, behavioral health services continue with the astronaut on “as needed basis” and also during the annual behavioral health examinations. At the NASA career termination point, there will ultimately be an “exit planning” interview with the astronaut. Topics in this interview may include expectations in the transition, future plans with their family, and lessons learned from other astronauts who left NASA.
In conclusion, managing behavioral health during human spaceflight is critical for successful mission completion. However, the successful development of a comprehensive an integrated behavioral health program for human spaceflight spans from astronaut selection until retirement. The space mission itself is a capstone of the entire program and cannot be addressed in isolation. The NASA behavioral health services listed above are the product of lessons learned not only from early exploration expeditions on Earth but also from 50+ years of international space flight missions. We need to heed lessons from the past and continually evolve the behavioral health and performance program to prevent, detect, assess, and manage behavioral health in future human space flight missions, including those that will ultimately travel into deep space.
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