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.
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.
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.
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.
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.