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
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Military Landscape
Special Duty Considerations
Fitness for Duty Evaluations
Fitness vs. Suitability
• Clinical Considerations
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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
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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