Clinical Considerations and Readiness

Disclaimer

• Information and opinions expressed by Maj Dhillon and other military/government employees providing lectures are not intended/should not be taken as representing the policies and views of the Department of Defense, its component services, or the US Government.

Overview• Readiness

– Military Landscape– Special Duty Considerations– Fitness for Duty Evaluations– Fitness vs. Suitability

• Clinical Considerations – Your Role: Occupational Mental Health– Who is your client?– Ethics– What are the needs of the organization?– Your responsibility to the patient– Your responsibility to the organization

Readiness

Military Landscape

• It’s all about mobility• Primary job plus…– Operate in austere env where med svcs scarce– Stand post, defend post

• Needs of the msn • Limited personnel; virtually impossible to get

replacements in critically manned jobs• Mobility disposition after each appt

Special Duty Considerations• Flyers:

– Disposition submitted to flight surgeon• Submits aeromedical disposition

– RTFS, DNIF, RTCS, DNIC

• Special Operators– Embedded Psych to address issues and keep CC apprised of status

• PRP– Personnel Reliability Program in AF– Those working with Nuclear weapons– Stringent requirements for certification– Strict medical care

• Ex. Cant take OTC meds with out physician authorization• Documents stored separate from other members• Reporting medical status up special chain to CC preserving confidentiality, msn

essential, need to know

Fitness for Duty Evaluations

• Evals: job clearance, security clearance, special school, admin sep, conscientious objector, VA, malingering, forensics

• Commander Directed Evaluation (CDE)– Emergent– Non-emergent– Outcomes: RTD, RTD w tx, MEB, Admin Discharge– Conducted only by Doctoral lvl providers

CDE

• Can only be ordered by mbr’s CC• DoD Directive (DoDD) 6490.1 Mental Health Evaluations of

Members of the Armed Forces• DoD Instruction (DoDI) 6490.4 Requirements for Mental

Health Evaluations of Members of the Armed Forces• Air Force Instruction (AFI) 44-172 Medical Operations,

Mental Health• Navy: SECNAVIST 6320.24A Mental Health Evaluations of

Members of the Armed Forces• Army: MEDCOM Regulation 40-38 Command Directed

Mental Health Evaluations

CDE

• Emergent– Svc mbr believed to be in imminent danger to self

or others– Protective measures taken to protect mbr and/or

others– Mbr not informed of rights until practical and then

given written order for eval– Usually hospitalization and mbr’s consent vs.

involuntary hospitalization at issue

CDE

• Non Emergent CDE– No immediate safety concerns suspected– CC consults with CDE POC about appropriate options and

circumstances warranting referral• Unpredictable behavior; repeat misconduct, lability, acting out,

odd behavior; job learning probs; illegal beh; non responsive to unit discipline; somatic complaints impact unit msn; CC seeking discharge from svc for mbr

– Answers if MH condition explains situation– Is condition amenable to treatment?– Can mbr handle a weapon, have access to classified info, be

deployed, be suitable for continued svc?

CDE

• Once proceeding, MH provider gathers collateral info from CC and medical records

• CC orders mbr to appear for CDE verbally and in writing.– Mbr gets 2 business days to seek legal counsel

• When meeting with mbr, informed consent:– Purpose of eval, not mbr’s provider, consultant for CC, lack of

confidentiality, possible outcomes– Clinical interview, psych testing

• After eval completed, 1 business day to report findings and medical recommendation to CC verbally

CDE

• Recommendations– RTD—No MH issue– RTD with MH tx—Fitness Issue– Refer for MEB—Fitness Issue– Recommend Administrative Discharge—Suitability

Issue

Fitness vs. Suitability

• Fitness: Does the mbr have a condition amenable to treatment? – Axis I– Handled by Medical Board process

• Suitability: Does mbr have a persistent pervasive character presentation not amenable to reasonable treatment that can significantly interfere with mbr’s ability to function effectively in a military environment? – Axis II– Handled by Legal department

Clinical Considerations

Your Role: Occupational Mental Health

• Military setting: Obligation to mission requirements, ability to function effectively in the military environment

• Civilian setting: Obligation to patient first• When Axis I or Axis II dx made, fitness and

suitability for duty determination required– Guidelines for decisions dictated by policy

Rank Dynamics in Treatment

• Most junior svc mbrs aware of rank– Ingrained in training– As pts, some sit at attention, highly formal, not

relaxed, detracts from developing alliance• Resolve by clinician behavior, body language, and

addressing issue casually

Rank Dynamics in Treatment

– As clinicians, some discomfort about confronting higher ranking pt; asking and discussing super private info• Resolved by developing rapport, good working alliance,

and building pt’s confidence in provider

– As MH techs, lower confidence starting out since they don’t have rank or pro qualifications providers do• All staff in MTF incl MHTs work under the authority of

the medical group CC who’s usually an O-6

Who is your client?

• For therapy—patient is your client– Msn impacting issues reported to CC

• For CC directed evaluations—CC and svc branch are the clients

• For duty evaluations, assessment/selection, special schools, security clearances—military branch is your client, make recommendations for the good of the service

Ethics

• Confidentiality– Must apply APA ethics code in context of mil instructions, federal

and state laws– Mandatory civilian and mil reporting requirements

• Pt informed verbally and in writing prior to svcs

– Rights/Interests of individual weighed against group’s• Significant factor in Stigma• Mission Impact• CC need to know

– CC has responsibility to know whereabouts of troops• Usually no more detail than “at a medical appt”• Will not disclose whether mbr is a pt in clinic or not unless msn impacting

issue present or pt gives consent

Ethics

• Mission Impact– ~50% who have seen a mil MHP and ~66% who

have not, believe there is negative career impact– Generally pt case surveys show overwhelming

majority do not have career impact• Small percentage that does usually CC referred or

waited until problem was severe to seek help

Ethics

• Multiple Relationships– Limited MH assets– Small/ remote locations– Address with pt how to handle encounters outside

of med setting to preserve confidentiality– Be a professional at all times• Case in point: pt is also CC of another pt

Ethics

• Multiculturalism– Population as diverse as US– Non-citizens serving – Allied country services– Spouses, dependents– Overcome dearth of knowledge of a particular

culture by learning from pt

What are the needs of the organization?

• Quick effective treatment– 6-25 sessions– Focused goals related to functioning, symptom

specific– Deployments, PCS, training interfere w treatment– Must be possible to cont care w another provider– Care transfer process to ensure continuity of care

• Minimal interruption to operations• Healthy capable force

Provider Responsibility

• To patient– Effective goal directed treatment– Sound empirically validated treatment– Improve functioning to enable optimal msn

accomplishment– Transparency regarding any CC notifications• Accomplish with pt in office

– Enable pt autonomy—become their own therapist– Build pt self-efficacy

Provider Responsibility

• To Organization– Brief, empirically validated tx– Consult with CC on msn impact issues• Problem Solve to assist CC

– Develop favorable relationship with CC• Stigma from CC that providers will not notify them PRN

– Foster a professional image of MH providers/career field

Recap• Readiness

– Military Landscape– Special Duty Considerations– Fitness for Duty Evaluations– Fitness vs. Suitability

• Clinical Considerations – Your Role: Occupational Mental Health– Who is your client?– Ethics– What are the needs of the organization?– Your responsibility to the patient– Your responsibility to the organization