6 Key Warrior Health Takeaways from the 2021 Navy SEAL Foundation Impact Forum

Each year, the Navy SEAL Foundation invites leading experts in the field of warrior health to a summit in San Diego, where care providers, veterans, service members, and nonprofits gather to absorb their wisdom and the latest cutting-edge research in this rapidly developing field.

Perhaps this year, more than ever before, the summit felt most prescient for three reasons. First, because the drawdown in Afghanistan means that we have an enormous influx of service members returning home for whom the focus is now going to be on thriving as both individuals and in families. Second, because 2021 marked the 20^th anniversary of the 9/11 attacks, culminating 20 years of active-duty service for many service members who are now choosing this time to transition into the retirement phase of their careers, during which recovery from the scars of war now comes to the forefront. And third, because we must continue to address the needs of those who are still actively deploying around the globe—particularly the members of the Special Operations community who were the specific focus of this forum.

The experts hosted by the Navy SEAL Foundation at this year’s event represented a broad swath of working backgrounds ranging from Harvard and Yale to the NFL, all of whom shared the singular focus of providing information on the most cutting-edge research on warrior health-related topics that could be just as applicable to the healthcare providers in attendance as the servicemembers and their spouses who were also present.

So, if you were unable to attend this year, what were the key takeaways? As someone whose writing work with SOF and SOF nonprofits keeps me deeply immersed in the culture and emerging needs of our service members—and particularly the Special Operations community—I found that the forum covered some well-trodden ground, but also offered a number of surprising new avenues for further inquiry. Here are a few of those surprises that really hit home.

The prognosis for people with mTBI, and even more serious forms of brain injury, is probably better than they—or their doctors—think.

Throughout the Global War on Terror (GWOT), there has been a great deal of focus in the military community on the topic of Mild Traumatic Brain Injury (mTBI) and the possibility for Chronic Traumatic Encephalopathy (CTE)—a progressive deterioration in brain tissue that is seen over time in many individuals who have experienced numerous concussive events. The question, which science is still trying to understand through the study of military service members and NFL players (two comparable populations who experience an especially large number of repeated head traumas) is why some people seem to be more vulnerable to developing CTE than others. While researchers continue to tease out these factors, some good news is emerging.

According to Dr. Ross Zafonte—Harvard Medical School Department Chair of Physical Medicine and Rehabilitation, and Clinical and Research Leader for Traumatic Brain Injury at the Red Sox Foundation and Massachusetts General Hospital Home Base Program—the good news is that most people recover better 5 years after a major brain injury than we tend to assume they will. The bad news is a mixed bag. Though there’s no way around the fact that mTBI nearly doubles the patient’s risk of developing cardiovascular, endocrine, psychiatric, and neurological issues over a lifetime, the good news is that we have the means to treat many of these conditions.

 What does this mean for our service members who have suffered from mTBI? Though there is no changing the fact that you’ve suffered head trauma, and no changing the genetics which may predispose you more or less towards developing a degenerative condition like CTE long term, there are scientifically proven ways to mitigate the negative outcomes that these circumstances might lead to.

And the steps to take are relatively simple; they just require conscientiousness and commitment. Eat a Mediterranean diet, which has been shown to help neurocognition. High vegetable intake is especially good for cognition; dietary salt is not. Fish oil is especially important for brain function, so much that you may even be able to change a chronic biomarker through fish oil supplementation. Cardiovascular exercise is key for brain health (not so much weight training, though), and all it takes is 5,000 steps a day to hit the ideal mark for these purposes. Manage blood pressure, as high blood pressure is terrible for brain vasculature. And don’t underestimate the value of good old-fashioned sleep; brain scans show that just 7 hours a night actually clear toxins from brain tissue and can up your performance the following day five-fold. If you’re in chronic pain, address it (more on that later), as inflammation in the body means inflammation in the brain. Finally, men need to have themselves checked out for low testosterone; it’s surprisingly common in this population, easy to supplement, and can make a real difference in how you feel day-to-day.

Pain and weakness are not the same things.

“Pain is weakness leaving the body.” “Pain is temporary; pride is forever.” We all know these mantras, and some have taken them to heart more than others. Central to the operator’s identity is the notion of infallibility, or something pretty darn near close to it. This is extremely problematic for providers, however, when an operator presents for medical care. In a population that stands out from the rest of us because of their ability in training to withstand what seems like superhuman levels of pain to everyone else, it can be very difficult for clinicians to understand just how much pain an operator is actually in.

Still, says Dr. Mary Alexis Iaccarino, Assistant Professor of Brain Injury Medicine at Harvard Medical School, it is critical for docs not to miss this—and just as equally critical for operators to make a concerted effort to actually communicate their symptoms to care providers. What an operator may think of as a tolerable level of daily pain to ignore is likely clinically significant, and having more of an impact on their life than they realize.

To this point: assessing TBI in operators, Dr. Iaccarino’s team found that, due to their symptoms, up to 40% didn’t feel like they were functioning well at work; 40% were not confident at all that their memory problems wouldn’t interfere with their lives; 35% were not at all satisfied with their ability to do things for their families, and 39% of the operators studied were not confident that they could keep their symptoms from interfering with their relationships. It may be possible to endure pain, but at what cost?

Dr. Iaccarino and her team at Operation Home Base work together with the team at Massachusetts General Hospital to assess and then tackle the physical and mental issues plaguing our operators from a multitude of angles: primary care, mental health care, TBI care, physical therapy, sleep medicine or CPAP, diet, exercise, cognitive intervention, and reduction in substance abuse. While this type of assessment is currently available through not just Operation Home Base in Boston, but also Emory Healthcare Veterans Program in Atlanta, Rush Road Home Program in Chicago, and UCLA Operation Mend in LA, the multifaceted approach to “whole warrior” care may be coming to your area in the near future. In the meantime, knowledge of the protocol utilized by these programs and the science behind them still offer veterans the opportunity to explore these various avenues of treatment with their care providers while advocating for their own healthcare.

Just remember: your healthcare provider doesn’t know what they don’t know. Just because you’re strong enough to live with the pain doesn’t mean that you should have to forever. Even if you just think you’re in a tiny bit of pain, speak up; what you think of as “tolerable pain” is likely clinically very significant.

If you think a treatment or therapy is going to help you, there’s a greater likelihood you’ll report that it actually did. Conversely, if you’re skeptical of your civilian care provider’s ability to make a dent in your symptoms, you’re less likely to wind up feeling better.

Dr. Gregory Stewart, Medical Director of the Professional Athlete Care Team at Tulane University—who among other things leads the NFL Benefits Neurological Care Program and NFL Player Care Foundation Healthy Body and mind Screening Program—made an interesting observation in his presentation with which I found many SOF spouses nodding their heads in agreement. While NFL players will take supplements all day, they are loath to take prescription painkillers; the same is true of many Special Operators. What’s going on here?

Much of this has to do with what Dr. Iaccarino referenced in her talk on the “Placebo and Nocebo effects.” A placebo is medicine that works because we believe it is going to, and it can be literally anything. Sharing the notable example of the WWII medic Henry Beecher, who ran out of morphine and still successfully conducted battlefield amputations administering the saline solution to patients as if it were the powerful painkiller, Dr. Iaccarino makes the powerful point that many of us are most helped by the thing that we believe is going to help us.

The suggested subconscious line of thinking for NFL players and operators? Supplements are for strong, healthy people. Supplements are for athletes and high performers; painkillers are for the sick and weak. It’s easy to see why NFL players and tactical athletes would lean more heavily in one direction than the other, even when the scientific evidence may suggest it would be more advantageous for them to do otherwise.

It is often said, in both the NFL and SOF communities, that “mindset is everything,” and it appears that this is also the case when it comes to medical treatment. Whether you lean towards trusting scientific, evidence-based therapies, or whether you’re more drawn towards experimental procedures like Hyperbaric Oxygen Therapy (HBOT) and Psychedelic Therapy, to maximize the benefits of treatment, it’s best to erase your skepticism and go into it with an open mind and wholehearted belief that it will work.

Driving home this point? A video Dr. Iaccarino showed us a video of an elderly woman who had broken her back and consented to enter into a clinical trial for treatment. Though she believed that her broken vertebrae had been cemented back into place, they in fact had not been. Still, after surgery, she returned to her active lifestyle pain-free, fully believing that they had been repaired. She was stunned to learn years later that the relief she experienced had been mental and not physical.

There is one overarching factor under your control which is measurably, scientifically proven to contribute positively your high performance, immunity, relationships, and overall life satisfaction—but it’s going to sound like sissy stuff.

All elite performers, especially in the military context, are familiar with catchphrases like “rise and grind,” “crush everything,” and “embrace the suck.” Blocking out the pain, staying laser-focused on the mission, never missing a workout, and pushing the limits daily—this is all second nature to individuals who have climbed the ranks of top-tier military units; it’s basically a requirement of the job.

What is not second nature—not part of military culture at all—is a surprising contribution that scientific research has made to the understanding of this process. While the military takes “embracing the suck” as a requisite skillset, the science of Positive Psychology posits that for maximum performance, this needs to be taken a step further. Embracing the suck is good, but cultivating a happy and grateful mindset that enables you to at least be positive about the suck (and at best be happy about it) will give you an even greater leg up on your competition.

According to Dr. Laurie Santos, professor of Psychology at Yale University, there are numerous studies making this connection clear and unmistakable: if you want to be at maximum performance, you have to focus on your mental health. Having a cheerful and happy disposition is so powerful that it can impact one’s job status, earning potential, and ability to make rapid and innovative decisions on the fly. What’s more, that same positive mood measurably impacts physical performance, as well, as people with a negative emotional style are shown to get sick at twice the rate as people with a positive emotional style (in scientific experiments controlling for all other variables).

In other words: that old “Colonel Jessup in a Few Good Men” model of the hardened soldier’s emotional style isn’t just bad for your mental health; it impacts your performance and physical health, too. So, what does Positive Psychology say about how an operator or servicemember in a high-pressure career environment can still cultivate the requisite level of happiness and wellbeing to maximize performance? Dr. Santos gives a few key research-backed suggestions:

• Be careful who you’re comparing yourself to. When you spend your life in the company of giants, it’s easy to underestimate how well you’re actually doing. In the same vein, don’t assume that you’re the only one who’s struggling/feeling bad/anxious/etc.. You’re not the only one, but allowing yourself to believe that you are is a fast track to unhappiness.
• Make time for social connections. Meaningful face time with people we care about—phones put away—is a massive predictor of happiness.
• Help others. Acts of service small or large can do wonders for our own sense of wellbeing, so much so that experiments have shown even spending $20 on someone else makes us happier than spending it on ourselves.
• Sleep. SEALs may go without it during Hell Week, but 7 hours a night is the scientific gold standard. Research subjects tested after a single week of sleep deprivation show scores that are almost indistinguishable from the clinically depressed; even after one night of lost sleep, you’re hungrier, losing brain tissue, more emotional, less focused, and even more likely to have an accident.
• Savor every moment. Be present in your world as you use your senses to soak in your surroundings. Even in unpleasant moments, this practice of witnessing brings the mind into the present moment, reduces anxiety, and ultimately cultivates happiness.
• Buy yourself time. The scientific results are in, and they show that having more money does not make us happier, but having more time does. So use your spare cash to get takeout, hire a housekeeper, and shell out for other shortcuts that make life easier; this will pay dividends down the road when it comes to your performance and wellbeing.

Sometimes, doing the opposite of what our instinct is telling us is actually the best way to move forward through adversity.

The worst moment of the worst day of the worst deployment. That one weird detail you can’t get out of your mind. The things you maybe talked about once with the guys, and never uttered a word of again. The things you’ve never even told your wife. The things you try to downplay in your mind; the nagging questions, regrets, or guilt that won’t go away.

 For so many people, the only survivable option is to follow our instinct and put it under mental lock and key. The thing about those demons, though, is that they never stay put where they’re supposed to, and if they aren’t exorcised for good at some point, they will find a way to manifest themselves, whether through physical pain, emotional anguish, substance abuse, avoidant behaviors, or relationship issues.

When this dynamic is impacting our relationships and our family life, says Dr. Kelly Graling, Clinical Director at Cognitive & Behavioral Consultants of Westchester and Manhattan, we may feel like we just want to turn our emotions off, but the challenge is that we can’t really control them. Instead, in her practice of Dialectical Behavior Therapy, Dr. Graling teaches her patients to use “Opposite to Emotion Action.” The principle? If you’re afraid, you have the urge to avoid, but this will only increase your fear—so approach. If you’re sad, you feel the urge to withdraw, but this will only deepen your sadness—so get active instead.

This principle is magnified and deepened in the practice of Prolonged Exposure (PE) therapy for PTS(D). PE practitioner Dr. Alan Peterson, himself a 21-year Air Force veteran, was deployed at the second Battle of Fallujah and most certainly has his own stories. Today, however, he is a Professor of Psychiatry & Behavioral Sciences at the University of Texas and is also the director of the STRONG STAR Consortium and the Consortium to Alleviate PTSD. Dr. Peterson’s goal, for everyone suffering from the effects of Post Traumatic Stress, is to see them reach the point where they can say “I’m a PTSD survivor,” just like cancer survivors can say. The promising thing is that this outcome is achievable, says Dr. Peterson; research is showing that PTSD can absolutely be treated into remission

To reach this end state of remission, however, Dr. Peterson says that the storytelling piece is critical. This can happen in a variety of ways, and at STRONG STAR they are looking at Prolonged Exposure Therapy (PET), Cognitive Processing Therapy (CPT), Cognitive Behavioral Couples Therapy, and Written Exposure Therapy, which have all been shown effective for treating PTS(D) in both military and civilian populations. What is important is that by some expressive means, the painful, buried story sees the light of day, where it can be turned over, examined from every angle, considered and reconsidered. As a writer who helps veterans tell their stories, I can personally testify to the therapeutic efficacy of this process. It is not selfish to share such burdens; in my experience, listeners—whether caregivers or loved ones—are unequivocally eager to help carry the weight.

There is one more thing. For some, the wounds may feel too raw to revisit under any circumstances. There is still hope, however. In these cases, says Dr. Peterson, there is some evidence that Stellate Ganglion Block treatments can measurably reduce a patient’s PTS(D) symptoms sufficiently that full benefits of the storytelling (exposure therapy) can be realized.

Science doesn’t (yet) know what it doesn’t (yet) know—and this should make you feel hopeful about the future.

If nothing else, I walked away from the Navy SEAL Foundation Impact Forum with a strong feeling of hope for the future lying dormant within all that still remains unknown. The mind is an overwhelmingly powerful tool, the limits of which could hardly be defined even by a large cohort of leaders in the field of brain science, mental health, PTS(D), and (m)TBI could. As the commitment of dedicated experts like these has shown, however, science is making progress, and we have yet barely scratched the surface.