By Amy B. Adler, Ph.D.
Jan. 13, 2020

U.S. Army photo by Pfc. Cameron Boyd

Imagine a team of service members in the middle of a fire fight – the explosions, the smells, the flashes of light, the fear. And now imagine that one of them gets so overwhelmed by stress that they freeze. They stop functioning, and now the team is down one service member and maybe two or more, as the team has to treat the affected individual. What do we, as mental health professionals, advise teams to do in a moment like this? What procedures are in place to help address an acute combat stress reaction when it matters most: in the midst of a life-threatening situation?

Until recently, there was no specific step-by-step intervention in place to help teams manage this kind of situation. Now researchers at the Walter Reed Army Institute of Research (WRAIR) have taken a cue from an intervention developed, tested, and now mandated in the Israel Defense Forces, and created a new program called iCOVER.

iCOVER is a 6-step, peer-based intervention that can be completed in under a minute. It's designed to rapidly return individuals to a functioning state and restore them to purposeful action by activating the prefrontal cortex and helping the brain regain control. The six steps follow the acronym iCOVER:

Identify the individual experiencing an acute stress reaction.

Connect with the individual by speaking their name, making eye contact, and holding their arm.

Offer commitment by letting them know they are not alone.

Verify facts with two to three simple questions to get their thinking kickstarted ("Who is your commander?" and "What unit are you in?").

Establish an order of events to ground them in the present moment by stating what happened, what is happening, and what needs to happen in three simple sentences.

Request action of the individual to restore them to purposeful behavior.

It only takes about an hour to be trained in iCOVER, and a randomized controlled trial with U.S. soldiers and Marines published in 2019 shows that platoons can learn the steps quickly and use them correctly in realistic, live-action training scenarios. WRAIR is also studying the use of iCOVER during deployment and the results are promising.

First, service members see the utility. In a group of soldiers preparing to deploy to Afghanistan last year:

• 95 percent reported that iCOVER training was useful.
• 93 percent thought it was relevant.
• 93 percent thought the procedures were clear.

Second, soldiers' attitudes change from before to after training. For example, the number of soldiers who said they are confident they can help peers experiencing combat stress reaction increased by 23 percent.

WRAIR is also studying how often teams encounter this kind of experience. Surveys indicate that more than one in three soldiers with combat experience report that they have witnessed this kind of stress response in team members. These results signal that the firefight scenario described above is something we need to consider when preparing troops to handle the psychological intensity of combat.

Of course, questions remain. In particular, how well does iCOVER work under real-world conditions, like the firefight scenario described above? Perhaps the most useful evidence for the support of iCOVER will come from case studies, such as those reported by the Israel Defense Force in which soldiers report how these procedures were effective in a range of circumstances. Research will also try to identify the long-term implications of combat stress on the development of posttraumatic stress disorder and whether iCOVER, by restoring individuals to action, can promote healthy adjustment following potentially traumatic events.

The iCOVER training video is available on WRAIR's YouTube channel, and the complete training module with detailed trainer notes is available on request from WRAIR or the Psychological Health Center of Excellence.

Dr. Adler is acting director of the Research Transition Office at the Walter Reed Army Institute of Research. She is a clinical psychologist who has worked with the Army for more than 25 years, published more than 100 journal articles, and edited six books.