1. Clinical Considerations and Readiness

2. 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.

3. 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

4. Readiness

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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?

11. 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

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

13. 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

14. Clinical Considerations

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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