Three Critical Considerations When Making a Clinical Mental Health Recommendation for a Service Member

Soldier fixing weapons
U.S. Navy photo by Mass Communication Specialist 2nd Class Jacob Milham
November 5, 2018

Making a clinical recommendation for an active duty service member seems like it should be pretty straightforward. You conduct a comprehensive assessment and make an informed diagnosis. If there is a clinical practice guideline (CPG) for the diagnosis, you consider the known treatments with an evidence base. Or, you consult the growing number of military evidence briefs to determine if particular treatments work in the military population and help your service member-patient choose which treatment is best for them. And, you rely on your clinical training. And then, you make your recommendations. Right?

Not so fast. When you make any clinical recommendation for a service member you must consider the following key variables or your recommendations may fall flat, cause career disruption for the service member, or even endanger others.

  1. Is the service member’s military occupation governed by any laws or military instructions pertaining to medical/mental health/substance disorder symptoms, diagnosis or treatment?

    Given that the military is a dangerous environment that requires service members to constantly function at the top of their game and individual service members to perform jobs which present a great risk to themselves and others, there are a lot of necessary regulations guiding medical, mental health and substance disorder practice. Many occupations are governed by stringent requirements above and beyond the ones that already exist for all service members. In general, any occupation or assignment involving diving, flying, submarines, weapons, overseas placement, deployment, security details, nuclear power, special operations, classified information, recruiting, recruit training and other special duties, are regulated by additional policies. It is incumbent on the provider to know the military regulations associated with any given service member-patient’s occupational specialty.

  2. Are there any logistics hurdles presented by a specific recommendation?

    Logistics challenges are a frequently cited reason that service members don’t seek treatment in the first place or don’t stay in treatment. Junior military members in particular, who may be unlikely to challenge you if you have recommended something they know can’t be accommodated, may need to be guided in a discussion about these issues to avoid treatment dropout and facilitate a workable treatment plan.

    For a population that is always on the move, considering the practicalities of your recommendations is key. Have you chosen a treatment that takes many months to complete? Will the service member be able to complete the treatment prior to leaving for deployment or other duty? If not, are they fit for deployment-related duties and/or will you be interrupting treatment at a particularly critical juncture when you pause for their deployment? Is there an effective treatment which can be completed in the time frame which can be accommodated? Is the service member best served by going on a period of limited duty or a profile in order to be effectively treated? Is the service member transferring soon?

    In addition to the challenge of frequent moves, deployments, training exercises, and other times that service members are not available, other realities can complicate treatment. Does the service member have transportation? Does the command have to provide transportation, to include using a government vehicle and driver? How far are you from the command and how much time off from work will the service member need? These are factors that must be considered for successful implementation of an effective treatment plan and the logistics may have to be worked out directly with the command.

  3. Can the service member’s command accommodate your clinical recommendation(s)? Or alternatively, is there any negative mission impact presented by your recommendation?

    The best clinical recommendations for service members take their command into account. Service members often will decline or be unable to participate in treatment if it impacts the mission (e.g., making others assume extra duties or impairing command effectiveness). Is the service member integral to a current mission? Do your recommendations render the service member mission incapable (i.e., a duty-disqualifying medication)? Is the only time you are available for appointments not possible for the command? Working with the command and thinking outside of the box increases the likelihood of positive treatment outcomes and decreases the risk that your service member-patient will drop out of treatment, experience worsening symptoms, and incur negative career impact.

    While it may seem foreign to some providers to work with the command of a service-member-patient, the command has significant resources to assist service members. Commands control everything from duty schedules, living arrangements and leave approval, to weapons handling privileges and duty assignments. A service member-patient with a command that is actively supporting any given treatment plan, is much more likely to achieve symptom resolution and to succeed in the military.

    For more information on culturally competent mental health assessment and treatment of the military population, see our Clinician’s Corner blog series and the Center for Deployment Psychology


The views expressed in Clinician's Corner blogs are solely those of the author and do not necessarily reflect the opinion of the Psychological Health Center of Excellence or Department of Defense.


Comments

  • Dr. Kennedy, this is an excellent article that really slams home hard with me. Thank you for publishing this today.

    My, "Not-so-fast" moment came well before yours does in this great article.

    When I was sent for a full Psychological Evaluation by my CO, it was approved by the major in charge of that hospital unit and assigned to a captain to perform the evaluation. The captain said, "Not so fast, there, Major! He ended up bucking it down the full Psychological Evaluation to a CPNP. He merely completed an Intake Interview V 3.0, of course, finding nothing. I was before the wrong medical officer.

    I later learned that he didn't have time for me that day because he was getting out of the Army, and it appears he was too busy setting up his own practice outside the gate. He was likely busy finding office space and other practitioners to join his new practice.

    The late Senator Robert F. Kennedy said, "Too often we excuse those who are willing to build their own lives on the shattered dreams of others." Well, I don't excuse this captain! The lack of listening to the CO, who saw something, and said something, ruined my stellar 14-year military career, and later, contributed to ending my 32-year Federal career in 2016. That captain's betrayal of me is now the subject of a four-year VA claim that is now in line for the Board of Veterans' Appeals.

    Meanwhile, his 25-year private practice appears to be doing well with several practioners onboard. Senator Kennedy was talking about people, like that captain. The U.S. Army should be ashamed of how it let this happen.

    My wish today is that no member of our Armed Forces goes through the way I was betrayed.

    Practitioners, please listen to the CO, who is on the ground with the Troops and working closely with other officers and NCOs to keep a close watch on the Troops' well-being.

    They aren't saying that they know your vocation. They are saying, essentially, "I have seen behaviors that are of concern to me. We value this person in our Command. Would you please be kind enough to do a full Psychological Evaluation so that we know what might be going on and how we can help?"

    Finally, please conduct a thorough clinical interview, according to the current regulations. Please don't skip tests or subtest that would help round out the evaluation because you are swamped and another person is waiting to see you. You can always make the examination in two parts. A complex history and complex overlapping current issues could take three to four hours to cover and test through.

    Thank you!

    Thank you.

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