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Safe Passage: Astronaut Care for Exploration Missions (2001)

Chapter: 5 Behavioral Health and Performance

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Suggested Citation:"5 Behavioral Health and Performance." Institute of Medicine. 2001. Safe Passage: Astronaut Care for Exploration Missions. Washington, DC: The National Academies Press. doi: 10.17226/10218.
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5 Behavioral Health and Performance If the planet is ever terraformed, it will be done by Human Beings whose permanent residence and planetary affiliation will be Mars. The Martians will be us. Carl Sagan, Cosmos (1980, p. 135) Advances in the exploration and habitation of space environments over the last half-century have set the stage for long-duration expeditions beyond Earth orbit. A common feature of these initiatives will be extended stays by groups of humans in extraterrestrial habitats. The success of such endeav- ors depends on the behavioral health and performance effectiveness of mul- tinational microsocieties living and working continuously in confined, iso- lated, and hazardous environments for extended periods of time. The increasing durations of space missions and human habitation in space environments over the past four decades have presented a range of biomedical and behavioral challenges. These challenges have been met with remarkable success, often under adverse circumstances. The so-called hu- man element, however, remains the most complex component in the design of long-duration missions into space. The imperatives of behavioral health and performance effectiveness therefore present major challenges to mis- 137

138 SAFE PASSAGE sions that involve significant increases in the time spent and the distance traveled in space. The organization of work and living conditions in space environments must be a primary consideration in the operational requirements for such bold endeavors. Closely related considerations focus on the Earth-bound support and recovery systems interacting with the astronauts and the role of astronaut screening, selection, and training. ASTRONAUT PERFORMANCE AND GENERAL LIVING CONDITIONS Background Hundreds of humans have now participated in missions that required the occupancy of spacecraft vehicles or space stations for periods of up to several months or in some cases a year or more under generally adverse environmental and behavioral conditions. Living space is confined, food is restricted in quality and diversity, there is a lack of privacy, and facilities for personal hygiene are limited. The quality of the environment provided by artificial life-support systems, compounded by high noise levels and unpleas- ant odors, is hardly comparable to that on Earth. Weightlessness requires motor and perceptual readjustments under conditions in which disorienta- tion and motion sickness are common, at least during the initial exposure to space (SSB and NRC, 1987). Social interactions are limited, and sexual ac- tivity is constrained. Only distant and remote communication with family and friends is possible. Workloads can be demanding and stressful, with the ever-present danger of a major life-threatening system failure. All of these restrictions occur under conditions that make no provision for escape, at least during missions beyond Earth orbit. Current Practice and Knowledge Base Despite these conditions, neither the National Aeronautics and Space Administration (NASA) nor other agencies of the international space com- munity have documented behavioral health problems sufficient in magni- tude to compromise mission objectives, although they may have occurred or on other occasions have nearly reached the point of compromising the mis- sion. It has been reported (Burrows, 1998), however, that three Soviet mis- sions were aborted for reasons partly psychological. Other evidence sup-

BEHAVIORAL HEALTH AND PERFORMANCE 139 ports the assumption that emotional or social problems could develop, and over months and years, these problems could grow to the point at which they disable an astronaut and limit crew effectiveness. Such evidence comes from three sources (Box 5-1): (1) anecdotal reports from astronauts and cosmonauts, (2) summary information from NASA on the incidence of ad- verse behavioral health events during space missions, and (3) findings from analog environments such as crews aboard submarine patrols or wintering over in the Antarctic. The 1998 report, A Strategy for Research in Space Biol- ogy and Medicine in the New Century (SSB and NRC, 1998a), also indicates the importance of a number of psychosocial issues. Performance decrements are usually transient, although behavioral data from more extended missions have not been easy to access. The validity and reliability of participant self-reports, anecdotal and otherwise, as well as those of official reports, have been difficult to both access and evaluate, at least in part because of the traditional reluctance of flight-qualified indi- viduals to be forthcoming about such behavioral health events. Moreover, the extent to which available accounts are representative of astronauts’ ex- periences in general is not easily determined. The available, evidence-based data from space missions are thus clearly insufficient for the committee to make an objective evaluation or projection of the behavioral health issues likely to be involved in long-duration space missions beyond Earth orbit. However, the available database from analog settings such as undersea and polar environments (Box 5-1) may be informative, at least to some ex- BOX 5-1 Evidence of Emotional or Social Problems on Short-Duration Missions Astronaut and Cosmonaut Reports of Personal and Social Problems of Adaptation The diaries of cosmonauts and astronauts who have spent long periods of time in space describe some of the personal and social problems of adaptation that can occur during long-duration space missions. For example, cosmonaut Valentine Lebedev (1988), who usually had a relatively sunny disposition, described his mood turning distinctly sour relatively early during his 211-day space mission on Salyut 7. By the 9th day he had a conflict with his fellow crewmember (p. 39). Just over 2 months into the mission he said, “My nerves were always on edge, I get jumpy at any minor irritation.” About half way through the trip, his anxiety interfered with his sleep (p. 291). As with cosmonauts and astronauts alike, however, he kept his feelings to himself (p. 158).

140 SAFE PASSAGE BOX 5-1 Continued U.S. astronaut Jerry Linenger, who spent nearly 5 months aboard Mir with two cosmonauts, wrote that he “was astounded at how much I had underestimated the strain of living cut off from the world in an otherworldly environment” (Linenger, 2000, p. 151). Even though he had done all he could do to prepare for the mission, he experienced profound feelings of isolation and confinement as well as alienation from his crewmates (p. 152). Cosmonauts and astronauts alike agreed that the most challenging interpersonal problems were not among the crewmembers but, rather, were between the crewmem- bers in space and the mission controllers on the ground. Lebedev portrayed the largest proportion of his contacts with his ground control negatively (e.g., pp. 96, 102, and 164). For Linenger, because of communication difficulties and his perception of little support from below, his aggravation with ground controllers in both Russia and the United States reached the point that he stopped communicating with them after the first month (pp. 123–127). His feelings are summed up in the title of one of his chapters, “Cosmonauts, Da! Mission Control, Nyet!” (p. 118). It is important to recognize that no recent U.S. or Russian space missions have failed because of behavioral health problems that led to diminished performance. Some astronauts have suffered from space sickness and headaches, anxiety, anger, and depression and have faced sudden, life-threatening emergencies. So far as is known, however, all of them performed their jobs, and the missions were largely successful. Some crews may have gotten along better than others, but they worked effectively as a team when they had to. Adverse Behavioral Health Events During Space Missions NASA has accumulated data on the incidence of adverse behavioral health events from postflight medical debriefings. Among 508 crewmembers who flew a total of 4,442.8 days on board 89 space shuttle missions between 1981 and 1989, 34 “be- havioral signs and symptoms” were reported to the medical staff, the most common being anxiety and annoyance (Billica, 2000). This calculates to 0.11 per 14 person- days, or about 2.86 per person-year. Among the seven astronauts who flew on Mir from March 1995 to June 1998, however, there were only two reported psychiatric events, for a yearly occurrence of about 0.77 percent. It could be that the more experienced astronauts on Mir had fewer behavioral health symptoms than some of the crewmembers on the space shuttle missions, but this has not been documented. Also, it is difficult to know how to interpret these discrepant findings since it is not known whether the same criteria were used to diagnose the conditions. Finally, because experienced astronauts as a group are reluctant to report physical and behavioral symptoms to NASA physicians, this figure may underestimate their true incidence (Collins, 1974, 1990). Behavioral Problems in Analog Environments Data from analog settings are instructive since those who have spent considerable periods of time in isolated, confined, and harsh, dangerous environments have con- fronted many of the external stresses common to long-duration space missions. Two examples are sailors on U.S. submarine patrols and groups wintering over in the Ant- arctic. Four studies of the incidence of psychiatric disorders severe enough to cause the

BEHAVIORAL HEALTH AND PERFORMANCE 141 loss of a day of work or medical evacuation among submariners found rates per man- year ranging from approximately 0.44 to 2.8 (Wilken, 1969; Tansey et al., 1979; Dlugos et al., 1995; Thomas et al., 2000). Among men and women spending 6 months living together during an Antarctic winter, where evacuation was nearly impossible, the Australian National Antarctic Expeditions Health Register estimated the rate of mental disorders to be 2.3 percent. As with the experienced astronauts aboard Mir, the incidence of behavioral problems was dramatically less among seasoned veterans. Two hand-picked six-man crews trekked around the Lambert Glacier Basin in Antarctica for 100 days and recorded their emo- tional state twice a week. Although there was some variation in mood and occasional increased interpersonal tension, these remained within normal limits, and all completed the treks successfully (Wood et al., 1999). Additional sources of information on behavioral problems in analog environments are provided by long-duration isolation work from hyperbaric chambers and Earth- bound simulators (e.g., the European Space agency’s ISEMNI and EXEMSI projects, the Russian Space Agency’s Mir simulator studies), and the NASA-funded crewmem- ber and ground personnel interactions study that took place during the space shuttle- Mir program. Relevance of Previous Reports to Long-Duration Space Missions It is difficult to confidently predict from these anecdotal reports from astronauts and cosmonauts, previous space missions, or analog environments the likelihood of behav- ioral health problems among crews of highly selected, experienced, and well-trained astronauts on long-duration missions. The clearest difference is that the missions de- scribed above were all of shorter duration than a mission beyond Earth orbit will be. No information exists on the extent to which the individual distress and the interperson- al frictions depicted in the two autobiographies or other anecdotal accounts are repre- sentative of the problems that other space crews have had. The overwhelming majority of members of space crews have neither written nor spoken about the behavioral health problems that they might have experienced. Also, the previous space missions did not rate the severity of the symptoms, their durations, the degree of impairment, or whether the less experienced crewmembers, such as payload specialists, suffered more than the astronaut-pilots and mission specialists. The data from missions in analog environ- ments have several obvious limitations as well. These include differences in the environ- ments and the missions, crew characteristics, crew responsibilities, and levels of exter- nal support (Palinkas, 1990). Yet, there is reason to consider the possibility that the stresses of long-duration space missions could cause problems in individual and interpersonal adaptation, which could threaten mental health and the success of the mission. Numbers of astronauts have reported psychiatric symptoms associated with shorter space missions. Also, the rates of occurrence of psychiatric problems among sailors on submarine patrols and those wintering over in the Antarctic were similar to the rates of occurrence of other medical problems such as cardiovascular, genitourinary, and ear, nose and throat problems (Tansey et al., 1979; Palinkas et al., 1998; Thomas et al., 2000). Just as NASA should prepare to care for these potential physical problems in astronauts, so too should it ready itself to look after the behavioral health problems of the astronauts on long-duration space missions.

142 SAFE PASSAGE tent, with regard to the consequences of prolonged isolation and confine- ment (Gunderson, 1974a,b; Wood et al., 1999). Although the relevance of studies conducted in analog environments to long-duration space missions may vary (Stuster, 1986), they do appear useful for examination of intrapersonal and interpersonal issues. Such untoward effects as lassitude, apathy, and hygienic neglect, for example, have been reported in studies of unstructured time of variable duration with polar crews in analog environ- ments (Taylor, 1987). Among the more systematic approaches to analysis of the data from studies conducted in analog environments is a reported content analysis of diaries from polar expedition leaders that ranked the salience of behavioral issues (Stuster, 1996). Of the 22 categories ranked, “group interaction” was found to be the most salient, followed by “outside communication,” “workload,” and “recreation/leisure.” More structured studies with recruits from the Australian National Antarctic Research Expeditions have focused on the effects of group composition on the adaptation of individuals to a remote hazardous environment (Wood et al., 1999). The roles of group mem- bership, the degree of isolation, and selected individual characteristics were examined in relation to self-evaluation measures. The reported results indi- cate that the predominant dimensions by which the participants determined how well they were functioning within the group included work, social life, and internalized emotional state, all of which appear to play an important role in how aspects of life in isolation and confinement are evaluated. Requirements for Additional Knowledge There is an overarching need to enhance the evidence base on the orga- nization of general living conditions and performance requirements for small groups of humans in isolated and confined microsocieties. The objectives of this knowledge-seeking endeavor would be to specify the conditions under which effective work performance of the group can be generated and main- tained within the context of productive and harmonious living arrangements that satisfy both individual and group needs for life support (clean air and water, an adequate food supply, waste management and recycling, lighting, adequate clean clothing, and communications) and general living conditions (medical care, sleep and rest, privacy, exercise, social interaction and sex, leisure and recreation, housekeeping and maintenance, education, remote contacts, and useful work). Significant amounts of ground-based as well as specialized space mis-

BEHAVIORAL HEALTH AND PERFORMANCE 143 sion research and development will be necessary to generate the knowledge essential to make adequate provision for these requirements for life support and general living conditions. Engineering and Technological Interactions To some extent, systematic studies are under way on specific subsets of the list of requirements for life support and general living conditions, par- ticularly those for life support, which mainly require engineering or tech- nological solutions. Over the past decade, for example, study groups of the National Research Council have been determining spacecraft maximum al- lowable concentrations of potentially toxic chemicals in the air and water supplies of spacecraft and habitats (NRC, 1992, 2000). The interdependent nutritional (Stein et al., 1999; Lane and Schoeller, 2000) and food supply system (Hunter, 1999) challenges of long-duration space missions have also been the foci of both intramural and extramural research and development support by NASA. In the case of the food supply system, for example, food is not only a key habitability issue but also a biomedical issue, as well as an issue of engineer- ing and systems design. Considering the duration of missions beyond Earth orbit, a bioregenerative life-support system (e.g., crop growth) would be more cost-effective than the physical-chemical regenerative systems (e.g., freeze-dried storage) now in use. Bioregenerative systems, however, require the growing and processing of crops in situ, treatment of food wastes, and preparation of daily meals, all within severe constraints for which space- compatible technologies have yet to be developed. Under such conditions, the behavioral health and habitability challenge resides in the development of a bioregenerative cuisine of nutritious and appealing dishes that chiefly make up a plant-based diet with a range of choices acceptable to a histori- cally omnivorous population. Biomedical and Behavioral Interactions For the group of requirements for general living conditions, relevant intramural investigations (e.g., by NASA laboratories) and extramural in- vestigations (e.g., by the National Space Biomedical Research Institute and university laboratories) have been undertaken with a focus on human per- formance effectiveness in the technologically rich spaceflight environment. The effects of changes in circadian rhythms and sleep patterns on behavioral

144 SAFE PASSAGE health and performance, for example, continue to receive attention in both ground-based simulation studies (Kennaway and Van Dorp, 1991; Ross et al., 1995; Dinges and Van Dongen, 1999; Wright et al., 1999) and experi- ments conducted in the course of actual space missions (Monk et al., 1998; Czeisler and Wright, 1999). The results of these ongoing sleep studies indicate that a strictly sched- uled wake-sleep cycle with dim light levels comparable to those currently provided on space shuttle missions is sufficient to maintain entrainment of the human circadian pacemaker to the 24.0-hour day for most, but not all, study participants. Misalignment of the circadian rhythm results in disturbed sleep, impaired performance alertness, waking-hour melatonin secretion, and reduced levels of nocturnal secretion of growth hormone. The results of these studies suggest that during long-term missions beyond Earth orbit, the use of stronger synchronizers such as brighter lights will be necessary to entrain the longer-than-24-hour intrinsic circadian period of all humans to the 24.0-hour day and to other day lengths such as the 24.65-hour solar day of Mars. Even with appropriate alignment of the circadian period, however, ex- perience from previous space missions suggests the more likely emergence of restricted sleep patterns in the average range of 4 to 6 hours per day. With that restricted sleep comes the risk of development of cumulative homeo- static pressure across consecutive days of inadequate sleep during long-du- ration missions beyond Earth orbit. Thus, one objective of ongoing simula- tion studies is determination of the extent to which the duration of sleep per 24 hours and the use of combined “anchor sleep” plus “nap sleep” opportu- nities each day can prevent or attenuate the development of cumulative fa- tigue and performance deficits related to sleep deprivation. Interactions in the General Living Environment Behavioral health issues related to privacy and to leisure and recreational requirements have received some attention since the beginning of space mis- sions that have involved multiperson crews in orbital flights of more than a few days’ duration (Frazer, 1968; Kabanoff, 1980; Kelley and Kanas, 1994). The interaction between the structural-physical design and the personal- social organization of space environments is likely to be the most critical in leisure and recreational pursuits as well as those activities related to personal hygiene, exercise, housekeeping, and maintenance. The historical background of human space travel reflects a predomi-

BEHAVIORAL HEALTH AND PERFORMANCE 145 nantly empirical and generally successful approach to these matters. The research and development requirement, however, for evidence-based coor- dination between design engineering, habitability considerations, and be- havioral health imperatives assumes ever-increasing importance with ex- tended mission durations. Under the closed-loop conditions of such missions, for example, all waste products (including human excretions, ex- pired gases, fluids, etc.) must be repeatedly recycled. The unique behavioral health factors involved in the toleration and acceptance of such environ- mental constraints must be investigated and determined. The extent to which behavioral self-management techniques (Beck and Emery, 1985; Beck, 1993; Barlow, 1996; Cautela and Ishaq, 1996) can be expected to provide effective coping procedures for such intrapersonal challenges will depend on the de- velopment and testing of individualized self-monitoring and self-assessment methodologies of demonstrated validity and reliability. Group Interactions Perhaps the matter of highest priority in the performance and general living conditions domain is the development of an evidence-based approach to the management of harmonious and productive, small, multinational groups who must live and work together in isolated, confined, and hazard- ous environments. Although an extensive literature on the functioning of small groups in both analog environments (Helmreich, 1973; Gunderson, 1974a,b; Vinograd, 1974; Palinkas, 1990; Harrison et al., 1991; Taylor, 1991; Weybrew, 1991; Palinkas et al., 1995; Stuster, 1996) and experimental set- tings (McGrath and Altman, 1966; Emurian et al., 1981; Brady, 1990; Brady and Anderson, 1991; Duffy, 1993; Guerin, 1994; McGrath, 1997) has been generated over the past half century, the available knowledge base is defi- cient with respect to long-duration missions beyond Earth orbit in several ways. For example, findings from group studies conducted in one setting are often not applicable to groups functioning under other environmental conditions. Empirical results are typically of such limited scope that they lack practical utility and generalizability. The conditions under which such experimental observations or even observations from analog environments are made usually differ considerably from those encountered in operational spaceflight situations. The benefits and disadvantages of traditional approaches to the study of small-group dy- namics have been well documented. When observations of the behaviors of small groups are made when the groups are in their natural habitat or in an

146 SAFE PASSAGE analog environment, the generally ethnological monitoring and recording of both current and long-term events lack experimental rigor. On the other hand, data gathered on small groups in controlled experimental settings may demonstrate functional relations, but the analysis of progressive changes in external influences and the development of internal group equilibrium is often neglected (Williams, 1974; Brady, 1990; Guerin, 1994). Viewed from the perspective of groups as small social systems operating in multifactorial behavior-specific settings that comprise specific physical situations involving people, the NASA experience over the past four de- cades has been successful. Mission objectives have been completed at the level of quality desired, and the behavioral interactions among crewmembers on individual flights have enhanced (or at least have not compromised) the viability of the group as a performing unit. Importantly, crewmembers have accomplished their mission objectives without significant deterioration of their individual behavioral or biomedical well-being. Against this back- ground of generally effective group performance in the course of missions of up to a year or more in duration, the issues to be addressed now are how to promote performance effectiveness, group solidarity, and personal well-be- ing in the course of long-duration space missions beyond Earth orbit. The enhancement of this essential knowledge base must begin by identifying those features of small social systems that foster the effectiveness of groups functioning semiautonomously over extended periods of time (Hackman, 1990, 1998). First, there is a need for evidence-based information on the appropriate partitioning of authority between ground-based mission managers and the space crew in accomplishing clear, unambiguous, and engaging objectives that orient and motivate group members to achieve the overall goals (Radloff and Helmreich, 1973; Sandal et al., 1995). The key question is how legiti- mate authority can be constructive and empowering while setting directions without dictating procedural details. How can the needs of the astronauts for substantial latitude in developing, executing, monitoring, and managing their own performance strategies be best accommodated within the overall direction required? How can relations between astronauts and the authori- ties on the ground and the inevitable disputes that occur between them be managed in real time? The second challenge in fostering performance effectiveness is to create a well-composed group engaged in well-structured tasks (Nelson, 1965; Gunderson, 1966a,b; Doll and Gunderson, 1970). Collective work produc- tivity in the context of harmonious living conditions requires the right people

BEHAVIORAL HEALTH AND PERFORMANCE 147 who are correctly configured (i.e., individuals with personal and skill char- acteristics that fit the work and the setting) and who are properly trained. As subsequent sections of this chapter will confirm, the experience and knowl- edge base in NASA as well as in other public agencies related to personnel screening, selection, placement, and training is extensive. In the area of group composition and group training, however, there is a serious lack of evidence-based information on the requirements of long-duration space mis- sions. There is also a need for research on how the development of semiau- tonomous, task-oriented groups occurs over time. To complement the avail- able data on relevant individual tasks, an enhanced knowledge base on how group tasks that promote motivated and effective performance should be structured is also essential. A third requirement for effective group functioning is a supportive physical and organizational context (Noy, 1987; Stuster, 1996). The first or- der of business here is the architectural and human factors considerations that determine the extent to which individuals and groups can live and work together comfortably and productively. The organizational factors to be con- sidered include the performance consequences (i.e., reward system) for the group, the communication-information system (i.e., data access and techni- cal assistance for online decisions), and material resources (i.e., for work execution). The evidence regarding the potency and nature of these factors is clear and compelling, but the existing knowledge base on the most effec- tive delivery system for ensuring their availability to semiautonomous, re- motely located groups is in need of considerable enhancement. Such seem- ingly mundane, contextual factors represent powerful determinants of group performance effectiveness and individual behavioral integrity. There is, how- ever, little or no evidence-based information on how the operational deliv- ery and organization of these factors can be configured to optimally support the group (see the section Support and Recovery Systems later in this chap- ter). The availability of competent leadership is the fourth factor needed to understand and manage the performance effectiveness of small operational social systems. The history of leadership research, including results of inves- tigative studies on the topic, indicates that an investigative initiative must be structured to generate information that is more evidence based, trustworthy, and useable than the information from past research (McGrath, 1984, 1997). An approach that first identifies the leadership functions important to group performance effectiveness and then examines how and by whom these func- tions are best carried out seems to be indicated.

148 SAFE PASSAGE An analytical approach might begin with an examination of the func- tions best performed by the organizational managers who establish flight crews, mission objectives, and schedules (i.e., condition-creating directive functions including design, selection, group formation, and training). Fur- ther analysis would focus on the functions best performed by ground con- trol managers who work with flight crews online and in real time during a space mission (e.g., predominantly support and technologically directive functions including organizational adjustments to ensure access to re- sources). It is important that the available knowledge on ground-based lead- ership characteristics and training requirements be enhanced. Two functions are best performed by the flight crew commander operating internally as a member of the space crew: (1) fine-tuning the space crew as an operational social system and (2) coordinating the interaction between the space crew and the ground-based managers. Only after such an analysis is it possible to evaluate the required leadership functions. Despite the existence of a massive literature on the topic of leadership (Nelson, 1964a,b, 1973; Gunderson, 1966a,b; Hackman and Walton, 1986; Ginnett, 1993; Hackman, 1993; Nicholas and Penwell, 1995; Keller, 1999; Taggar et al., 1999; Boal and Hooijberg, 2000; Judge and Bono, 2000; Silverthorne, 2001), there has been a serious neglect by NASA in general of such functional approaches. Research on how various leadership functions and responsibilities should be partitioned among group and individual par- ticipants on long-duration space missions beyond Earth orbit is needed, as such ambitious undertakings will involve many different leadership roles. There is another view, perhaps best expressed by proponents of the theory of complex adaptive systems (e.g., Paul Plsek). In this view, one cannot possibly predict the performance of a complex adaptive system (in this case, a crew, a spacecraft, and a ground support team on a 3-year mis- sion). To optimize the likelihood of success, the design work should focus on the establishment of a few simple rules for crew behavior and let the crew and its leader(s) learn their way through the problems encountered on the mission on the basis of a common objective (a successful, safe mission) and powerful personal motivation (survival) (Zimmerman et al., 1998; Lewin and Regine, 2000). It is nonetheless clear that the promotion of perfor- mance effectiveness as well as social and ecological stability for small groups involved in long-duration space missions beyond Earth orbit will require evidence-based technological developments through an approach at the most fundamental scientific level. The committee prefers application of the former “we can predict” approach because it is proactive, more easily ame-

BEHAVIORAL HEALTH AND PERFORMANCE 149 nable to inclusion in astronaut training and is based upon the previous and continuously accumulating evidence. Within the context of such an enhanced database on the determinants of effectiveness of small groups, further investigations will be required to analyze potentially disruptive influences on harmonious and productive in- teractions among members of the space crew. Among these are cultural differences among members of multinational crews, differences among mem- bers of different professional and technical disciplines, issues related to the distribution of authority, and sexual interactions. In the case of sexual inter- actions, careful consideration must be given to living arrangements that ac- commodate this challenge to group cohesiveness. Use of Pairs of Transport Vehicles for Small Groups Traveling Beyond Earth Orbit Virtually all aspects of the onboard health care support system, and par- ticularly those related to behavioral health and group performance, would be enhanced, in the committee’s speculative opinion, by a long-duration space mission design that used a pair of transport vehicles. In addition to the motivational advantages of the friendly competition that would be gener- ated under such conditions, the reassuring presence of an accompanying group to support the mission would confirm the availability of a nearby resource base. To the extent that interactions between flight groups could be established and maintained—including intermittent rendezvous during the outbound voyage—general living conditions would be enriched and po- tentially disruptive within-group issues would be attenuated. Cost-benefit analyses would take into consideration the modest incremental engineering and human systems requirements, including the support, training, and re- covery requirements, over those for a single space transport vehicle beyond Earth orbit, which itself represents a major funding investment. SUPPORT AND RECOVERY SYSTEMS Background Experiences over the past several decades in space and analog settings indicate the importance of a behavioral health role in supporting both par- ticipants and ground control personnel during and upon the return from extended space missions. Monitoring of both individual and group interac-

150 SAFE PASSAGE tions has long been recognized as a potentially informative component of such exploratory or expeditionary endeavors, but the methods and proce- dures for such oversight have seldom been adequate for the task. Certainly, the behavioral health contribution to the planning and implementation of such support and intervention systems will need to be increased. As the time-distance dimension separating astronauts from their ground base in- creases, enhancement of behavioral health support systems will be required. Under such conditions, there will be a need for the development and the refinement not only of individual and group performance monitoring and assessment technologies but also of evidence-based behavioral interventions and effective countermeasures. Of at least equal importance is the role of behavioral health professionals in planning and implementing the reentry, recovery, and follow-up evaluation of astronauts returning from long-dura- tion missions in space. The present state of knowledge about support and recovery functions has mainly been derived from agencies responsible for the provisioning of various kinds of expeditionary forces (e.g., space crews, military teams, and labor groups such as those in Antarctica). Because of serious environmental hazards, uncertainties, and the need for minimal provisioning, expedition- ary efforts have always been characterized initially by an authoritarian struc- ture. Although it seems likely that space exploration will continue to be so characterized for some time, the frequent sequel to such expeditionary ini- tiatives is envisioned to be the establishment of extended or even permanent settlements with increasing autonomy and increasing needs for new ap- proaches to behavioral support. Current Practice and Knowledge Base The key element of NASA’s space mission support systems is mission control. No other area of spaceflight operations has served as well or as long as mission control, which serves as NASA’s institutional memory. Over the past four or more decades, mission control functions, which have been con- cerned with the monitoring of every aspect of every mission from the ballis- tic flights of monkeys Able and Baker to the current International Space Station (ISS) endeavor, have dominated virtually all spaceflight activities. It must be recognized that the record of safety and success that has character- ized spaceflight is due to the support of mission control. The magnitude of this investment in support functions can be gauged by even casual observa-

BEHAVIORAL HEALTH AND PERFORMANCE 151 tion of the number of individuals at Houston Flight Center computer sta- tions during the continuous monitoring of every space mission. Perhaps the most striking contrasts are those that characterize the so-called manned mis- sions, in which the number of Earth-based mission control personnel on duty can outnumber the inflight crew and passengers by more than 100 to 1. From a behavioral health perspective, the communications functions of the inflight support systems are of the utmost importance. Aside from rou- tine operational interactions, frequent communications with medical sup- port personnel are available, along with less frequent opportunities for inter- actions with sources of emotional support (e.g., family, behavioral health personnel, flight surgeons, and others). Thus far there have been few provi- sions for ensuring confidentiality in these transactions, and there are indica- tions that ongoing monitoring, at least of voice communications, may have some operational value for assessments of the behavioral status of in-flight crew members (Kanas, 1991). The Crew Status and Support Tracker ques- tionnaire, completed in flight on a weekly basis by U.S. astronauts on the Russian Mir space station, has also been used for assessment of individuals (e.g., their mood, morale, level of privacy, physical status, social interactions, and other behavioral indicators). The validity and reliability of this assess- ment procedure, however, have yet to be determined. Other features of the current support system appear to focus on behav- ioral health. For example, favorite foods and surprise presents are dis- patched with periodic supply vehicle flights. Two-way communications with Earth-based family and friends are intermittently enhanced via combined audio and video. The transmission of computer-based picture albums of spouses, children, friends, and coworkers is enthusiastically endorsed by as- tronauts and cosmonauts. E-mail and ham radio capabilities are also avail- able, along with private conferences with the NASA Behavioral Health and Performance staff. Recreational software, audiotapes, and videocassettes (and DVDs, now available on the ISS) are provided for leisure (Flynn and Holland, 2000). Over the past decade, debriefing protocols focusing on the well-being of the individual and on her or his reintegration with family and friends have been developed. Debriefing also identifies and helps to address any residual difficulties that may have developed within and between crew members, mission control, or family, friends, and coworkers. Currently, how- ever, constrained access to debriefing data limits the extent to which these procedures can be adequately evaluated.

152 SAFE PASSAGE Requirements for Additional Knowledge Ground Support and Space Mission Interactions Perhaps the most important support system exists at the interface be- tween ground crews and those in space. Disagreements between the “sent” and the ”senders” have a long history. During World War II, submariners on 60- to 90-day patrols often complained of the unrealistic orders that were sent from rear-echelon officers thousands of miles away (O’Kane, 1977). More recently, anecdotal reports suggest friction between astronauts and ground crews, particularly during missions of relatively long duration (i.e., to the ISS). The impact of friction between the sent and the sender in both space and analog environments has been described by Nicholas (1987). Friction develops because, originally, the senders were and have been exclusively responsible for the consequences of the activity, pay explicit fees, and demand absolute control over the performances of the sent. As groups are involved in longer stays in space and particularly beyond Earth orbit (or are transported to established settlements), however, the needs and aspira- tions of the sent become progressively more influential relative to the goals and objectives of the senders. Certainly, the increased time delay in the com- munication between space crews and ground personnel will require that astronauts themselves make some acute clinical judgments. Even a physician on board will not guarantee the availability of the expertise and capability needed to deal with some of the medical or behavioral issues that may arise. This changing relationship between the senders and the sent is the foun- tainhead for the development of social structure and governmental policy as manifest in empire, colony, and emergent independent states. An enhanced knowledge base on how effective human support systems can be established and maintained as well as how internal and external factors influence their operational effectiveness needs to be developed. Among the most important core functions of the ground-based support system is the maintenance of communication exchange capabilities between the astronauts and Earth-bound family, friends, and coworkers. Although these supportive interactions are both essential and heartily endorsed by all concerned, a host of unanswered questions regarding the nature of such exchanges remain (Palinkas, 1992; Kelley and Kanas, 1994). For example, family illness or death may develop during a long-duration space mission and information or the lack of such could significantly affect astronaut atti- tudes and behavior. The extent to which such activities must be enhanced or modified to provide behavioral health support for long-duration space mis-

BEHAVIORAL HEALTH AND PERFORMANCE 153 sions remains to be determined and should be part of the behavioral re- search agenda on the ISS and other analog venues. Therefore, an evidence- based approach to the design of an effective behavioral health support deliv- ery system for long-duration space missions beyond Earth orbit is needed. There is extensive military experience with this problem that may provide a useful guide to the consequences of various policies as they are being con- sidered. The interactive monitoring of long-duration space missions will depend on communication modalities and verbal interactions. The availability of automated interactive simulation technologies makes possible an experimen- tal approach to determining the most effective mix of communication mo- dalities. Technological research is needed to address constraints likely to be associated with the expected transmission time delays (with round-trip delay times estimated to be as long as 40 minutes). Postflight Support and Reintegration Despite the numerous unresolved issues described above, there have been no documented reports on the incidence among astronauts of psychi- atric problems that are directly attributable to the spaceflight experience or that have compromised mission objectives. It is nonetheless reasonable to expect that physical changes like weakness, decreased immune system func- tion, and decreased bone mineral density may add to returning astronauts’ sense of vulnerability (Box 5-2). A significant period of readjustment, in- BOX 5-2 Recovery and Reintegration After 211 days in space aboard Mir, cosmonaut Valentine Lebedev ruminated while getting ready for landing, “We are anxious; who knows why? What’s it like down there? We’re no longer accustomed to life on the ground. Our lives are attuned to this small island in space, and suddenly here we come, back to the Big World. We don’t feel comfortable with this idea” (Lebedev, 1988, p. 340). Similarly, astronaut Jerry Linenger, reflecting on his nearly 5 months in space aboard Mir with two cosmonauts, wrote that he “was astonished at how much I had underestimated the strain of living cut off from the world” (Linenger, 2000, pp. 151– 152). Even though he had done all he could do to prepare for the mission, he experi- enced profound feelings of isolation and confinement as well as alienation from his crewmates.

154 SAFE PASSAGE cluding medical and psychological follow-up, will be needed upon the re- turn to Earth. A follow-up study of individuals who wintered over in the Antarctic, for example, found a larger than expected incidence of postmission physical and psychological problems, including heart attacks and suicide (Palinkas, 2000a,b). Although these findings have not been replicated for other Ant- arctic crews or astronauts returning from long-duration missions, they high- light the importance of postmission evaluation of astronauts’ physical and mental health coupled with support and intervention where necessary. Monitoring Behavioral Health and Performance The interpersonal problems that astronaut crews can endure for short periods may become intolerable over an extended period, thereby impairing crew performance. Schisms, friction, withdrawal, competitiveness, scape- goating, and other maladaptive group behaviors are found among highly competent men and women working together in normal terrestrial settings; they can also be expected among astronaut crews. NASA should anticipate interpersonal problems that may arise and rehearse solutions that can be used to maintain crew performance. NASA spaceflight support system personnel have continued to research, develop, test, and apply environmental and biomedical monitoring technol- ogy (Mundt, 1999; Pollitt and Flynn, 1999; Schonfeld, 1999; Yost, 1999). Monitoring of behavioral health and performance, however, presents some special problems that have not been easily managed even in face-to-face settings, much less at the distances that separate Earth-bound support sys- tems from the astronauts on a mission. A range of in-flight performance evaluation issues have yet to be resolved if adequate assessments of the ef- fects of long-term space missions on human performance and behavioral health are to be provided. In bridging this gap, early developments in the analysis of verbal inter- actions, both vocal and nonvocal, have shown promise of providing effective approaches. Over the past several decades, computerized methods for evalu- ating verbal communications have been refined as potential early-warning indicators of more general performance changes. One diagnostic technique (Gottschalk and Gleser, 1969) has been refined to reflect affective changes on a series of rating scales (e.g., anxiety, hostility, and depression). The method uses computerized scoring of speech transcriptions and is under evaluation for its validity and reliability. In addition, direct voice-analysis

BEHAVIORAL HEALTH AND PERFORMANCE 155 methods have already been used in spaceflight applications (Kanas, 1991). Continued refinements in computer technology will doubtless enhance the ability to discriminate vocal changes that are indicative of disruptive interac- tions that may have adverse effects on performance (Lieberman et al., 1995; Pickett et al., 1998; Wirth et al., 2000). The feasibility of assessing the stability and precision of performance of individual crewmembers with computerized test batteries has now been demonstrated in the course of several space shuttle missions (Manzey and Lorenz, 1998; Monk et al., 1998; Brady et al., 1999; Eddy et al., 1999). For example, self-report rating scales, timing, learning, memory, and psychomo- tor components were included in a brief 20-minute performance battery scheduled recurrently during the 10-day STS-89 space shuttle mission (Brady et al., 1999). The demonstrated stability and maintained sensitivity of the indicated measures over extended time intervals confirmed their effective- ness in detecting even small-magnitude behavioral changes, that is, changes that occurred below the threshold of spaceflight duty performance decre- ments that would require intervention with a countermeasure. The Win- dows Space Flight Cognitive Assessment Tool (WinSCAT) is a computer- ized cognitive test battery that measures performance functions. It is similar to the instrument used in the STS-89 space shuttle study. The continued development of such technological approaches to the assessment of behav- ioral integrity and evaluation of the efficacies of countermeasures is essential not only to ensure the success of extended spaceflight missions but also to enhance safety and the quality of life in many applied settings (Kelly et al., 1998). The outcomes measures for these spaceflight studies were stored in onboard computers for postmission analysis. Further real-time evaluations will require online downlink capabilities in studies conducted during long- duration space missions. At least two additional assessment instruments are under development. The Space Behavioral Assessment Tool (SBAT), is a measure of mood that consists of functional components that are being adapted for inflight re- peated performance measures applications. The second assessment measure- ment under development is the Space Flight Fatigue Assessment Tool (SFAT), which is a measure of fatigue. Psychophysiological monitoring could add an important dimension to the evaluation of the behavioral status of astronauts. Bioengineering initia- tives will be required to develop more portable, noninvasive, and natural on-body instrumentation (e.g., nanotechnology) to record and downlink psychophysiological measures for the assessment of affective changes and

156 SAFE PASSAGE cognitive dysfunctions of relevance to performance integrity (Cacioppo and Tassinary, 1990). Among the more obvious candidates for such psychophysi- ological monitoring would be heart rate variability, electrocardiogram wave- form, pulse volume, facial muscle action, blink rate and magnitude, ear canal and skin surface temperatures, as well as multiple-electrode electroen- cephalogram measures. Even though monitoring technologies have focused on individual per- formance and behavioral health, there is also a need for methods and proce- dures that can be used to evaluate group interaction patterns under space- flight conditions. Standardized systems for the monitoring and evaluation of the interactions between the members of small groups are available and could be adapted for use with space-dwelling groups through the use of audio-video downlink capabilities. One such psychometrically robust instru- ment, Systematic Multiple Level Observation of Groups (SYMLOG) (Box 5-3), adapts easily to individuals of different sexes and cultures and has been demonstrated to be valid and reliable in both military and expeditionary operations (Bachman, 1988; Bales, 1999). Countermeasure Development and Implementation Substantial portions of the NASA research and development investment in life sciences have been and continue to be devoted to the development of countermeasures. In large part, the activities of the recently established Na- BOX 5-3 Systematic Multiple Level Observation of Groups Systematic Multiple Level Observation of Groups (SYMLOG) (Bales, 1999) is a method of group assessment. SYMLOG rates each group member on three continua: dominance versus submissiveness, friendliness versus unfriendliness, and being accept- ing of task orientation imposed by authority versus being nonaccepting. It also has scales for rating of the values as well as specific group behaviors. SYMLOG is psycho- metrically robust, has demonstrated validity, and is easily adapted to individuals of different sexes and cultures. It has been translated into 19 languages. This method has been shown to be effective in distinguishing average from superior naval crews and officers on active duty in the Atlantic and Pacific fleets. In April and May 2000, SYMLOG was used by a Dutch army-sponsored climb of Pumo-Ri, a 7,200- meter mountain west of Mt. Everest. On the way to the top, the behavior of a group of nine climbers was rated daily by SYMLOG for evaluation of fitness and other perfor- mance factors.

BEHAVIORAL HEALTH AND PERFORMANCE 157 tional Space Biomedical Research Institute, funded by NASA, are focused on this agenda. However, the core investigative activities—on radiation ef- fects and cardiovascular, immunological, and neurovestibular functions, among others—do not reflect a strong emphasis on behavioral health issues. The one project on human performance is devoted almost exclusively to the sleep studies cited in the Astronaut Performance and General Living Condi- tions section of this chapter. Some of the most important behavioral health and performance coun- termeasures are incorporated into NASA’s screening, selection, and training procedures. The demonstrated effectiveness of these long-practiced meth- odologies in selecting and preparing candidates for participation in space- flight operations has served NASA well by minimizing the number of occa- sions on which interventions with countermeasures were required. There continues to be a need, however, for attention to potentially dis- ruptive personal interactions among the members of groups of astronauts on space missions and between astronauts and Earth-bound support groups. Although investigations of countermeasures will necessarily focus on com- munication modalities and patterns, an experimental analysis of the most effective coaching functions and technical support interventions will likely yield useful results. It is also important that countermeasures be differen- tially adaptable for individual and group interventions. Other examples of psychosocial areas needing more attention include asthenia and other psy- chiatric syndromes (alluded to above), the displacement of negative emo- tions from crewmembers to mission control personnel, phasic changes in crew cohesion and mood over time (e.g., the “third-quarter phenomenon”), the importance of different leadership roles at different times during a mis- sion, the effects of crew size and minority status on cohesion, cultural and common-language issues, the utility of voice analysis techniques in the moni- toring of crewmember tension, and the need to reinforce positive attributes (e.g., leisure time interests, self-esteem, and creativity). Recovery and Debriefing At present, medical follow-up of returning astronauts and cosmonauts continues as long as contact can be maintained with the individuals involved. Ostensibly, the tracking procedures are in the process of being formalized into a more comprehensive data collection and management plan. If these initiatives incorporate behavioral health factors, a rich source of space mis- sion debriefing and postmission (recovery) data can be established for fur-

158 SAFE PASSAGE ther behavioral research. Attention can then be directed toward evaluation of the validity, reliability, and effectiveness of debriefing and follow-up pro- cedures aimed at facilitating successful reintegration and readjustment to family, friends, and Earth-bound living conditions. The availability of such a longitudinal set of data could also support research to improve intra- and interpersonal support and countermeasure interventions during space mis- sions. Postmission debriefings and longitudinal behavioral health monitoring also provide the opportunity to evaluate the long-term effectiveness of premission training and intramission behavioral interventions, as well as to collect data on behavioral, social, and cultural issues that may not have been obvious during the premission and intramission phases. The relative impor- tance and the long-term effects of individual and group factors and the avail- ability of individual and group support can also be assessed during a pro- longed period of follow-up. After long-duration missions astronauts should participate in a struc- tured recovery program with both physical and behavioral health compo- nents. Reintegration challenges include redefinition of astronauts’ roles and relationships within NASA as well as with their families and communities. These processes will be affected by behavioral, cultural, and organizational factors and the abilities of the sent and the senders to realign their expecta- tions of each other. Systematic study of the recovery process should be part of NASA’s research agenda to guide the care of future generations of space explorers. SCREENING, SELECTION, AND TRAINING Background Procedures for screening, selection, and training of flight personnel have a long and distinguished history among industrial nations with advanced military defense and air transport capabilities. Since its inception more than four decades ago, NASA has enjoyed ready access to the resources of the nation’s military, including access to standardized and well-validated meth- odologies for screening, selection, and training. Beginning as early as the Project Mercury initiatives of the 1960s, a remarkable record of accomplish- ment has characterized a NASA space program that owes its success in no small measure to the effectiveness of these discriminating procedures. More- over, similar programmatic approaches to screening, selection, and training

BEHAVIORAL HEALTH AND PERFORMANCE 159 have been adopted by such ISS partners as Russia, Germany, France, and Japan (Santy, 1994; Holland, 2000). Current Practice and Knowledge Base Screening and Selection As the NASA space program has grown and prospered during the past half century, well over 1,000 candidates for astronaut and associated assign- ments have been interviewed and tested, with some 350 or more of the se- lectees having participated in space missions. The current methodology in- cludes a detailed psychiatric interview that targets particular symptomatic conditions as defined by diagnostic criteria presented in the Diagnostic and Statistical Manual, 4th edition (DSM-IV) (Flynn and Holland, 2000). In ad- dition, a test battery is administered that includes questionnaires with open- ended and multiple-choice questions, focused personality scales, and a com- puterized cognitive functions evaluation (Holland, 1997). Apparently, none of the data from these intensive and extensive screen- ing procedures are used in selection determinations except to ”select out” candidates. Responsibility for ”select-in” decisions resides exclusively with the Astronaut Selection Board. The extent to which the initial interview and test data are considered in the actual astronaut selection remains unclear. There is also little indication that the extensive screening interview and test data have been systematically analyzed for their procedural validities and reliabilities or even collated to examine interrelationships between measures. Regardless of its shortcomings, the process has made important contri- butions to the successful accomplishment of mission objectives, insofar as participants on space missions have remained free of serious behavioral dis- orders, at least for relatively short-term space missions of up to a year or more. Under the present circumstances, however, there is no way of deter- mining whether the procedures currently in place will be adequate or even useful for the screening and selection of candidates for long-duration space missions beyond Earth orbit The existing knowledge base is enhanced to some extent by simulation studies that have been undertaken in polar regions, which serve as analog environments for long-duration space missions. In a study with some 600 American men spending an austral winter in Antarctica, for example, pre- test and intake interview information was found to be useful in accounting, at least in part, for the variance in individual performance measures (Palinkas

160 SAFE PASSAGE et al., 2000). In addition, recent initiatives implemented under the auspices of NASA have involved the exposure of small groups of astronaut trainees to extreme polar environments for relatively brief intervals. Although studies conducted in analog environments have long been a rich source of experiential data, there is little evidence that the systematic data collected from studies in such settings are relevant to the behavioral challenges of long-duration spaceflight. However, these simulations in ana- log environments do provide an opportunity to pretest and refine instru- ments and procedures that can be used to select individuals and to select for effective group interactions and performances. These first steps can lay the foundation for an evidence-based approach to the establishment of valid and reliable procedures for the screening and selection of individuals and small groups who will be living and working in confined microsocieties un- der isolated and hazardous spaceflight conditions. Training The training of NASA astronauts and other flight and ground support personnel is notoriously time-consuming, thorough, and highly technical. For the most part it has been effective in guaranteeing the successful accom- plishment of well-defined mission objectives. To a considerable extent, the success of the training is attributable to the involvement of well-educated, very experienced, and highly motivated selectees who are in exceptionally good health and who have a level of intelligence that is well above average. The focus of NASA’s training objectives to date has been the mastery of skills required to operate advanced spacecraft technology in the course of relatively brief, highly choreographed missions within Earth orbit. Gener- ally, these space mission assignments do not exceed a few weeks, although in selected instances several months may be involved. On such brief assign- ments, with skillful and highly trained crewmembers, individual behavioral health issues are of minor concern. Although interpersonal consultation and coaching resources are apparently available to trainees, behavioral health does not appear to be part of the formal curriculum, and access is provided only by voluntary request. Until recently, group training appears to have been introduced into the mission preparation process only after a mission has been scheduled and a space crew has been designated. Considerable lead time (often a year or more) is usually involved in group training, and the ensuing team training process may involve not only the designated crew and supernumerary back-

BEHAVIORAL HEALTH AND PERFORMANCE 161 ups but ground support personnel and monitors as well. Like individual training, group training also appears to focus on the operational aspects of the mission objectives, with little programmed attention to group function- ing per se. An individual and group training program is under develop- ment, however, with candidates for long-duration missions beyond Earth orbit specially selected as participants. The extent to which this early initia- tive will take advantage of the availability of significant behavioral health and performance inputs remains unclear. Requirements for Additional Knowledge Screening and Selection The development of effective screening, selection, and training proce- dures must be driven by performance requirements and by the general liv- ing and support system conditions under which long-duration space mis- sions will take place. The first task is a systematic analysis of the validity and reliability of screening and selection procedures as they are currently practiced, begin- ning with a descriptive collation of the data and an evaluation of the interre- lationships between the measures. Access and review of available outcomes- related data may also shed some light on the utilities of current procedures. At the very least, such an undertaking would set the stage for an evidence- based approach to screening and selection for long-duration space missions. A range of newly emerging approaches to the study of intellectual apti- tudes and personal traits should be explored for their predictive value in assessing levels of intellectual functioning in candidates for spaceflight. Al- though current screening approaches appear to involve only limited evalua- tion of cognitive function, intelligence and aptitude measures have been shown to predict performance more accurately than personality assessments. Specific constellations of abilities including a variety of aptitudes identified as “fluid intelligence” (analytical, creative, and practical intelligence) have been shown to permit individuals to solve novel tasks without using crystal- lized knowledge involving general information or vocabulary or previously developed problem-solving skills (Sternberg, 2000). Other measures of cog- nitive function have been shown to predict pilot performances related to information-processing speed and working memory (Salthouse, 1991; Hartley, 1999) as well as multiple-task attention, breaking-set, visual reason- ing, and mental rotation skills (Kane and Kay, 1992). The relevance of these

162 SAFE PASSAGE advances in cognitive function assessment to the enhancement of astronaut screening, selection, and training as well as intramission monitoring and countermeasure development resides in the results of recent studies con- ducted during both simulated and actual spaceflights (Manzey et al., 2000). Under such conditions, degradation in manual tracking ability and phasic decrements in cognitive function performance have been reported as a re- sult of fatigue and other factors. The utility of measures that provide an evaluation of personal traits as they may be related to successful participation in long-duration space mis- sions will also require careful examination. Data obtained from actual and simulated space missions, as well as submarine missions, led to the conclu- sion that individuals strongly motivated for achievement adapted to these environments better than their peers did (Sandal et al., 1999). By contrast, studies of crews that wintered over in Antarctica found that ambitious indi- viduals had lower ratings on some performance measures than peers who had more modest achievement needs (Wood et al., 1999; Palinkas, 2000a,b). Santy (1994) has also reported that selection procedures in other national space programs (e.g., those of Russia, Germany, and Japan) tend to favor candidates for longer-term space missions whose personality characteristics measure more in the middle of the motivational range. A number of promising new developments in the rapidly advancing fields of neuroscience and molecular genetics hold considerable long-range potential for the assessment, evaluation, and training of future astronauts. Neuroimaging procedures involving functional brain scans are continuing to advance knowledge of the relationship between behavioral processes in- volving both cognitive and emotional interactions on the one hand and well- specified neural systems and regional structures on the other (Damasio, 1994; Kosslyn and Koenig, 1995; Cahill et al., 1996; Alkire et al., 1998). There is reason to expect that future developments in the functional imag- ing field will provide noninvasive methodologies that could enhance the fea- sibility of both training and behavioral health monitoring applications. These probable breakthroughs could be of significant use to NASA. Four brief examples of how NASA might use these advances for screening, selection, and training are described in Box 5-4. It is also conceivable that the future of long-duration travel beyond Earth orbit will be significantly affected by the rapidly advancing field of molecu- lar medicine (see Chapter 4), to the extent that its neuroscience dimensions could differentially reflect DNA variations of relevance to adaptation to stressful behavioral and environmental situations. It is important that the

BEHAVIORAL HEALTH AND PERFORMANCE 163 BOX 5-4 Potential Uses of Neuroimaging Methods for Astronaut Selection, Training, and Intervention 1. Functional brain scans for cognitive function assessment could considerably enhance the understanding of an astronaut candidate’s neurological potential for han- dling the mental training requirements. Positron emission tomography scans find that areas of the brain illuminate when certain mental tasks related to astronaut perfor- mance are performed, with the occipital lobe lighting up when certain visuospatial tasks are performed or portions of the frontal and parietal lobe being activated during mental rotation tasks (Kosslyn and Koenig, 1995, pp. 133, 149). One screening sce- nario might include the simultaneous administration of a test of a particular aptitude (e.g., mental rotation) along with a functional brain scan that would show the extent to which particular portions of the brain were illuminated during the period that the prob- lems were being solved. 2. Functional imaging techniques show promise as means of assessing and pre- dicting potentially disruptive mood states and of perhaps monitoring and intervening to soothe potentially disruptive mood states (Damasio, 1994). Present work illustrating those portions of the brain that are differentially associated with strong feelings of sadness and happiness or of fear and anger could well lead to more accurate ways of assessing characteristics that could be used to select out or select in an astronaut, as well as whether an individual has a predisposition to mental illness. 3. Neuroimaging also may have a role in astronaut training. An example might be the use of scans as an adjunct to assessments of cognitive and affective states during simulations to assist in countermeasure development. 4. Imaging may also be useful for inflight monitoring and assessment of changes in brain function from the baseline function as a result of stress, fatigue, or possible exposure to microdoses of toxins. procedures for the screening and selection of astronauts involved in long- duration missions beyond Earth orbit be capable of validly and reliably dis- criminating effective group interaction skills and competences. Essential developments in this regard will depend on the availability of an expanded knowledge base on the requirements for harmonious and productive group functioning in the unique environment of space. Training Astronauts on long-duration space missions will confront a range of in- tra- and interpersonal challenges, the nature of which cannot be accurately determined at present. Therefore, substantive features of training must be based on continuously accumulating experiences in actual spaceflight envi- ronments and analog settings with specially designed algorithm software

164 SAFE PASSAGE packaging technologies (Lipsey, 1993; Newman, 1997). Naturalistic studies on the efficacies of specific training procedures must follow in both simu- lated and actual space mission settings. Personalized individual training approaches must also incorporate and evaluate countermeasures based on procedures for evaluation of cognitive and behavioral functioning that are adaptable for computerized administra- tion as self-assessment and supportive intervention procedures (Wolpe, 1958; Beck and Emery, 1985; Power et al., 1990; Beck, 1993; Barlow, 1996; Cautela and Ishaq, 1996; Rosen and Schulkin, 1998; Lazarus, 2000). These programs have been designed within a stress management context and have been effective when combined with a range of interventions including bio- feedback, relaxation techniques, systematic desensitization, and pharmaco- logical treatments. Empirical observations about the nature of both individual and group behaviors and about how behavior patterns influence performance effec- tiveness can guide decisions about group composition and training. Training approaches can build on experience gained in simulated flight exercises go- ing as far back as World War II (Office of Strategic Services, 1948) and, more recently, on that gained in the Cockpit Resource Management pro- grams used by airline crews. The development of strategies for conflict reso- lution should be explored as well (Fisher et al., 1994; Heifetz, 1998). Among the more recent and relevant developments with respect to train- ing for small group performance effectiveness is the distributed interactive simulation methodology. This simulation approach (Box 5-5) uses multiperson computer-generated workstation networks for selection and training in realistic environments (Pratt et al., 1997; Gillis and Hursh, 1999). This method permits the objective recording and evaluation of interpersonal interactions within and between small training groups under conditions that simulate long-duration spaceflights, as well as related ground-based moni- toring and support systems. Training for long-duration space missions must involve an integrated approach that includes ground-based monitoring and support groups spe- cifically selected to participate in such operations. NASA behavioral health personnel should be directly involved in crew selection and in training crewmembers and ground control personnel in crisis intervention and prob- lems with interpersonal functioning. In addition, appropriate assessment tools and countermeasure development will be required to address emer- gencies and technical assistance requirements under conditions that involve multinational crews and the complexities related to cultural and language

BEHAVIORAL HEALTH AND PERFORMANCE 165 BOX 5-5 Distributed Interactive Simulation Distributed interactive simulation environments have been developed and are based on multiperson computer-generated workstation networks that represent operational elements consisting of both individuals and functional groups. Such techniques involv- ing real people can be used for selection and training under conditions of simulated mission operations in a realistic environment. Participants communicate via electronic channels to exchange information, discuss work requirements, and evaluate data for decision making; exchange the outcomes of specific actions; and evaluate mission- oriented scenarios. Space mission simulations also permit inquiries of Earth-based mis- sion control for information or instructions, or both. Groups of individuals are trained to interact within the simulation environment for the purpose of engaging with assigned crewmembers and Earth-based mission control. Distributed interactive simulation methodologies with performance tasks requiring re- peated exchange of information among participants and between groups provide an automated means for the systematic monitoring and analysis of the effects of experi- mental variations on psychosocial interactions, decision making, and both individual and group performance effectiveness. The operational performance measures evaluat- ed include pattern analysis, task completion, and timing parameters. differences as well as under conditions that involve crews of mixed sexes and with command structure constraints (Kelley and Kanas, 1992; Holland et al., 1993). It is not enough to have the leader be the buffer, because the leader could be addressing specific problems or could be too involved in a task-oriented emergency. Finally, crew resource management for long-dura- tion missions also requires consideration of technical as well as nontechnical skills (e.g., corporate citizenship, interpersonal skills, and compatibility). Individual differences in personality functioning become important when the job requires corporate citizenship or the use of “people skills” (Borman et al., 1997; Hogan et al., 1998; Mount et al., 1998; Salgado, 1998). STRATEGIC RESEARCH CONSIDERATIONS The conceptual and methodological challenges associated with design- ing, establishing, and maintaining functional systems that promote perfor- mance effectiveness and social and ecological stability for small groups in- volved in long-term space missions beyond Earth orbit will need to be approached at the most fundamental scientific level. Evidence-based tech- nological developments can be facilitated by research methodologies that incorporate studies in analog settings and simulations of the environmental

166 SAFE PASSAGE conditions and behavioral interactions that will exist in space over long du- rations. The approach should be explicitly experimental and should be dic- tated by both scientific and pragmatic considerations closely approximating procedures of established effectiveness in other areas of natural science (Biglan, 1995; Lattal and Perone, 1998). Without such a database of experi- mentally derived data, the overextrapolation of proposals for ecological sys- tems and recommendations for space habitat designs (Sells and Gunderson, 1972; Singer and Vann, 1975; Maruyama, 1978) renders them incapable of ensuring the successful establishment of functional and enduring space habi- tats. The relevance of such an experimentally derived knowledge base to the success of future space ventures depends in large part on the precision with which required performances can be specified and on how effectively they can be occasioned and maintained in individuals and groups. Despite the abundance of extensively reviewed experiments with small groups con- ducted over the past several decades (McGrath, 1984, 1997), the technology needed to analyze multiple modes of communication among and between groups and group members has not been available. With the advent of computer-based communications technologies (Duffy, 1993), the interac- tions of members of small groups and decision making by small groups can now be automated in the context of distributed performance sites. An em- pirical research base has been established to evaluate the effectiveness (Pinsonneault and Kraemer, 1990) and test the assumptions (Kraemer and King, 1988; Duffy, 1993) that underlie these technological developments. Distributed communication interactions within and between space- dwelling and Earth-bound groups will be an inherent feature of long-dura- tion space missions beyond Earth orbit. The availability of automated group interaction technologies not only opens the door to the enhanced precision of performance measurements but also provides a research approach to de- termining the correct mix of group interaction-communication modalities that maximize efficiency without overcomplicating the design of the system. Research applications of such computerized distributed interactive simula- tion systems can permit the specification, with nearly exact precision, of the stream of psychosocial cues and consequences within the interactions of members of a small group. Under such conditions, systematic investigation can determine which of the many potential modes of communication and verbal interaction are most effective in advancing group stability and effi- ciency. Within the context of both analog and simulation settings, a strong case

BEHAVIORAL HEALTH AND PERFORMANCE 167 can be made for a strategy of research to address the challenges related to operational performance and general living conditions associated with long- duration spaceflights. Such a research approach will require the integration of investigative research and organizational management activities in an at- tempt to establish and pretest effective social systems within small groups under operational conditions that allow controlled experimental analyses. In this way, major applied research questions of direct relevance to enhanc- ing the knowledge base required for spaceflight beyond Earth orbit can be pursued without sacrificing methodological rigor by using the participants of primary interest. A variety of behavioral health and performance research and develop- ment opportunities dealing with performance and general living conditions, support and recovery systems, and screening, selection, and training have been described throughout this chapter. These are summarized in Box 5-6. Some will undoubtedly prove to be highly important in contributing to the success of long-duration space missions. CONCLUSION AND RECOMMENDATION Conclusion Behavioral health and performance effectiveness present major challenges to the success of missions that involve quantum increases in the time and the distance traveled beyond Earth orbit. • The available evidence-based spaceflight data are insufficient to make an objective evaluation or projection regarding the behavioral health issues that are likely to arise. • The analysis of complex individual and group habitability interac- tions that critically influence behavioral health and performance effec- tiveness in the course of long-duration missions remains to be planned and undertaken. • There is a need for more information about support delivery sys- tems at the interface between ground-based and space-dwelling groups. • In the absence of a valid and reliable analysis of the existing data- base, it is not possible to determine whether the current procedures will be adequate for the screening and selection of candidates for long-dura- tion missions. • Although the data from natural analog environments including simulation studies may be helpful, there remains a need to accumulate knowledge based on observations from systematic research observations

168 SAFE PASSAGE BOX 5-6 Behavioral Health and Performance Research and Development Opportunities Astronaut Performance, General Living Conditions, and Group Interactions 1. Enhancing the evidence base on the organization of general living conditions and performance requirements for small groups of humans in isolated and confined microsocieties over extended time intervals and developing an evidence-based ap- proach to the management of harmonious and productive, small, multinational groups whose members will have to function effectively in isolated, confined, and hazardous environments. 2. Coordinating the development of design engineering and habitability require- ments on the one hand and evidence-based behavioral health imperatives on the other. 3. Identifying and analyzing those features of small social systems that foster the effectiveness of groups functioning semiautonomously over extended periods of time. 4. Analyzing potentially disruptive group influences that adversely affect harmo- nious and productive performance interactions under the isolated, confined, and haz- ardous conditions that characterize long-duration space missions beyond Earth orbit. Support and Recovery Systems 5. Developing a technology that will provide an adequate means for assessment of the behavioral health effects of long-duration space missions and that will establish and maintain safe and productive human performance in isolated, confined, and haz- ardous environments and developing an evidence-based approach to the establish- ment and maintenance of a system for the delivery of behavioral health support and to the analysis of those internal and external factors that influence the effectiveness of the system. 6. Evaluating and enhancing communication with family, friends, and other ground personnel and onboard recreational activities as means of providing behavior- al health support for long-duration missions. 7. Evaluating the validity and reliability of performance-monitoring procedures including the Crew Status and Support Tracker, the Windows Space Flight Cognitive Assessment Tool, and the Space Behavioral Assessment Tool and the extent to which methodologies for intramission performance monitoring are enhanced by online down- link capabilities in studies conducted during long-duration missions. 8. Developing and refining procedures for effective intervention under conditions of potentially disruptive personal interactions both among astronauts and between as- tronauts and Earth-bound support components and for evaluation of the nature and extent of changes in group interaction patterns.

BEHAVIORAL HEALTH AND PERFORMANCE 169 9. Evaluating the effects of ground-based support system design factors including backup components and personnel changes on group integration and stability as they affect personal coaching and technical support functions. 10. Developing and assessing countermeasure interventions that meet the chal- lenges presented by emergencies and technical assistance requirements under condi- tions with complexities related to cultural and language differences as well as under conditions that involve crews of mixed sexes. Screening, Selection, and Training 11. Systematically analyzing and evaluating the extensive existing database on the methods and procedures for screening and selection of astronauts used over the past several decades. 12. Evaluating personality measures in the development of valid and reliable pro- cedures for the screening and selection of astronauts and determining the extent to which intelligence and aptitude measures may predict performance more accurately than the more commonly applied personality measures. 13. Developing and evaluating screening and selection procedures that validly and reliably discriminate effective group interaction skills and competences. 14. Developing and refining training technologies including automated training for the preparation of multinational space-dwelling microsocieties as well as their Earth- bound support groups including those related to the interactions of individuals and small groups in the context of distributed ground-based and space-dwelling perfor- mance sites. Data Collection, Analysis, and Monitoring 15. Incorporating and enhancing relevant behavioral health factors as an effective contribution to a more comprehensive plan for the collection and management of astro- naut health care data. 16. Developing and testing valid and reliable individualized monitoring and as- sessment procedures to enhance intrapersonal self-management. 17. Refining communication-monitoring techniques and countermeasure interven- tions for interactions within and between ground-based and space-dwelling groups. 18. Developing and refining technological approaches to the assessment of indi- vidual and group behavioral integrity as well as the efficacies of countermeasure eval- uations during long-duration space missions. 19. Establishing a systematic approach to the collection and analysis of postmis- sion (recovery), debriefing, and longitudinal follow-up astronaut health data, including data on behavioral health and performance components. 20. Planning and undertaking a systematic collation and relational analysis of the existing archives of astronaut evaluation data to develop an evidence-based approach to valid and reliable means of screening and selection of candidates for long-duration missions beyond Earth orbit.

170 SAFE PASSAGE in both natural and simulated extreme terrestrial environments and ven- ues like the International Space Station. Recommendation NASA should give priority to increasing the knowledge base of the effects of living conditions and behavioral interactions on the health and performance of individuals and groups involved in long-duration missions beyond Earth orbit. Attention should focus on • understanding group interactions in extreme, confined, and iso- lated microenvironments; • understanding the roles of sex, ethnicity, culture, and other hu- man factors on performance; • understanding potentially disruptive behaviors; • developing means of behavior monitoring and interventions; • developing evidence-based criteria for reliable means of crew selection and training and for the management of harmonious and productive crew interactions; and • training of both space-dwelling and ground-based support groups specifically selected for involvement in operations beyond Earth orbit.

NOTES

The Mir with Earth below, as photographed from the space shuttle Discovery during space shuttle mission STS-91 on June 12, 1998, during the space shuttle-Mir final fly around before bringing the last group of space shuttle-Mir astronauts back to Earth. NASA image. 172

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Safe Passage: Astronaut Care for Exploration Missions sets forth a vision for space medicine as it applies to deep space voyage. As space missions increase in duration from months to years and extend well beyond Earth's orbit, so will the attendant risks of working in these extreme and isolated environmental conditions. Hazards to astronaut health range from greater radiation exposure and loss of bone and muscle density to intensified psychological stress from living with others in a confined space. Going beyond the body of biomedical research, the report examines existing space medicine clinical and behavioral research and health care data and the policies attendant to them. It describes why not enough is known today about the dangers of prolonged travel to enable humans to venture into deep space in a safe and sane manner. The report makes a number of recommendations concerning NASA's structure for clinical and behavioral research, on the need for a comprehensive astronaut health care system and on an approach to communicating health and safety risks to astronauts, their families, and the public.

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