Breaking the Stigma of Behavioral Healthcare
By Lt. Col. Paul Dean and Lt. Col. Jeffrey McNeil
Originally published in the April-June 2012 edition of Special Warfare
LTG Mulholland directed the USASOC Staff to conduct a review of policies and procedures relating to behavioral health (BH) stigma issues across the command. The review was comprehensive and included focus groups from all of the tribes, as well as subject matter expert input. Feedback from across the tribes is critical in developing effective strategies to establish an environment that encourages and supports our ARSOF warriors to seek necessary behavioral health services.
To the men and women of Army Special Operations,
Earlier this month, I tasked my staff to conduct a review of policies and procedures relating to behavioral health stigma issues across the command. The purpose of the review was to ensure that there were no existing policies or procedures within the U.S. Army Special Operations Command that inadvertently conflict with our intent that our Soldiers be able to seek behavioral-health assistance without fear of stigma or negative consequence. The review was comprehensive and included focus groups with all of the ARSOF tribes, as well as subject-matter expert input. I appreciate feedback from our tribes as we work to establish an environment that encourages and supports our ARSOF warriors to seek necessary behavioral health services.
There are a few primary lessons I have drawn from the review and feedback (more detail can be found below):
Behavioral Health Misperception: We often associate BH with severe psychological problems, mental illness or, in some instances, the place to go when someone wants to complain about things they cannot change. The truth is very different. Behavioral-health support is similar to physical therapy, physical training, medical treatment, marksmanship training or a variety of other activities we engage in to maintain a high state of health and readiness, as well as enhance our performance. Behavioral health employs a full range of techniques and methods to enhance our mental performance resulting in increased individual performance, relationship improvement and overall effectiveness and quality of life. How we think and talk about this aspect of wellness is important, as it helps shape the way we think about the topic. Therefore, we will increasingly talk about optimized mental performance as the norm.
I have asked each of our tribes to establish programs to educate the force on behavioral health and optimized mental performance. All of our leaders will treat SOF warriors that seek BH services or optimized mental performance with respect and dignity, as we do for those being treated for medical conditions.
Confidentiality/ Privacy: There was significant concern expressed about the amount of information shared with unit leadership with respect to behavioral-health treatment. The fear of disclosure and loss of privacy is the single most prevalent factor in reluctance to seek BH care.
It is a leader’s responsibility to take care of his or her people and a leader’s awareness of their Soldiers that are genuinely at risk is important. However, I have directed that SOF warriors have the ability to access optimized mental-performance services or routine behavioral-health support without fear of being tracked or stigmatized.
Career Implications: There is a pervasive concern that seeking BH support will negatively impact a SOF Soldier’s career, including their security clearance. In order to address this concern, I directed my G2 to conduct a thorough review of security policies and consulted with subject-matter experts in security-clearance adjudication and behavioral-health policies. The clear message is that the only real negative impact on security clearance or job opportunities is overt severe or chronic maladaptive behavioral or legal issues. In many cases, these can be prevented if a Soldier seeks behavioral health or other support early in the process.
I have issued instructions to all unit commanders to initiate changes to command policies (formal and informal) to ensure no negative repercussions will result from warriors seeking routine behavioral health or optimized mental-performance support. Leaders will lead from the front on this issue.
Accessibility: Another very common theme was frustration in seeking care at medical-treatment facilities for a variety of reasons. It is clear to me that our units need accessible providers who truly understand the SOF culture, are willing to work with our warriors on a health-based model rather than a mental illness one, and are embedded in the organizations they serve. I am pursing several lines of operation, including growth of assigned BH professional staff through the Army’s force-design process and the U.S. Special Operations Command’s Preservation of the Force and Families effort to increase the number of operational psychologists and other embedded behavioral-health providers for USASOC. Until we can grow our specialty assets, I encourage you to consider the multiple avenues of mental-performance enhancement and BH support that are available, including operational psychologists, unit chaplains, licensed clinical providers, MFLC, Military One Source, TRICARE, TRICARE network providers and our military treatment facilities.
I directed all of the command teams to develop and implement action plans based on internal results from this stigma review. To you, the men and women of the world’s finest force, I ask that you, first and foremost, be there to care for the Soldier on your left and right; and secondly, to help us better understand what needs to be done for the force and our families.
Strength and Honor,
Based on feedback from USASOC Soldiers and our SME’s, the primary factors and perceptions related to BH stigma/ barriers to care include: (1) Confidentiality and fear of being labeled, (2) Negative impact on career, (3) Self/ peer perceptions, (4) Accessibility of quality BH care, and (5) Command climate.
The best practices to mitigate BH stigma include several lines of effort. Most importantly, the emphasis needs to be on Warrior Mental Performance Enhancement, rather than the traditional BH model. It is also critical that we increase the number of embedded BH providers, expand BH education/training initiatives, and continue to explore multiple avenues for Soldiers to access quality BH care. Ultimately, USASOC leaders need to both communicate the value of warrior performance enhancement and establish sustainable programs that support the mental health of the force.
All policies and procedures related to BH treatment were reviewed. There were no identified USASOC, SOCOM, DA or DoD policies that directly contribute to stigmatizing Soldiers for seeking BH treatment. Current DA and DoD policies focus more on privacy for service members who seek treatment. However, some leaders still want programs or procedures that identify high risk individuals. The procedures must balance the command need to know with the importance of privacy and confidentiality. Ultimately, Soldiers that are being seen for routine BH counseling or consultation should not be identified as “high risk.”
Primary Stigma Factors and Barriers to Care
A. Confidentiality & Fear of Being Labeled. The single most pervasive concern of our USASOC warriors is that their BH information will not remain confidential and will result in stigmatization. As one USASOC Soldier put it, “Everything in SF Group is based on reputation.” Our SOF warriors don’t want to stand out negatively or give reasons to doubt their ability, and some Soldiers reported feeling embarrassment and shame for being seen entering a BH clinic or office.
It is a leader’s responsibility to take care of his people as well as being aware of risks to mission and risks to the force. We need to ensure that service members have the ability to seek self-improvement, optimize mental performance, and pursue routine behavioral health consultation and counseling without fear of being tracked or stigmatized.
There are also practical steps that can be implemented to address concerns of confidentiality and privacy. The BH clinic or office needs to be in an area that maximizes privacy. Soldiers should be given the flexibility to attend appointments in civilian clothes or take other reasonable steps to ensure they are comfortable in seeking BH care. BH clinics or offices should be located away from HQ and main work areas, and even separate from other medical clinics to remove stigma and barriers. Another option is the establishment of off-site clinics. Ultimately, it is most important for our SL’s to foster a command culture that closely guards confidential medical or BH information.
B. Negative Impact on Career. One prominent concern of our warriors is that they will be removed from their team if they seek BH assistance and consequently lose their support system. Respondents cited potential impact on OER/NCOER’s, promotions, future military courses, flight status and loss of special duty pay. One officer stated that he thought medical/BH records were reviewed at promotion boards. While this is erroneous, it does contribute to stigma. Some soldiers are convinced leaders unofficially make negative career decisions about Soldiers who have sought BH services or advice.
BH treatment rarely harms soldier’s careers; however, the inevitable results of not seeking help - DUI, domestic violence, and disciplinary problems – do damage careers. In many cases, these adverse impacts can be prevented if a Soldier seeks behavioral health or other support earlier in the process. Therefore, our leaders must make realistic and conscious efforts to ensure that 1) Soldiers willing to seek self-improvement through behavioral health resources suffer no negative repercussions, and 2) lead by example by demonstrating willingness to personally seek self-improvement.
There is also a pervasive concern that seeking BH treatment will negatively impact a SOF Soldier’s security clearance. USASOC conducted a thorough evaluation of security policies, consultated with senior security clearance adjudicators, and reviewed BH policies. The clear take-away message is the only real negative impact on security clearance or job opportunities is overt maladaptive behavioral or legal issues rather than simply seeking behavioral health services. The belief that seeking BH treatment will result in security clearance revocation continues to be a strong deterrent for BH treatment. In one small poll of SOF Soldiers, only 10% realized there was any change in this policy that allowed individuals not to report counseling related to adjustment from combat. Please see attached G-2 information paper that describes this in detail.
C. Self/ Peer Perceptions. Seeking BH treatment is perceived to contradict the cultural norm of self-reliance and may contribute to the stigma that those seeking BH treatment are perceived as “dependent.” Across the force there is perception that seeking behavioral health services indicates a personal weakness and that our peers will also see us as less self-reliant.
However, seeking consultation and counseling is actually a sign of resilience, and is a critical part of the self-improvement process for many of our warriors. Just as we seek appropriate medical care for our physical injuries suffered in combat or training, we must also seek behavioral health to maintain and enhance warrior performance. Similarly, we do not consider our weapons “weak” by continually performing preventive maintenance on them or tweaking their performance through careful modifications. Humans are no different. Effective warriors seek self-improvement. Effective leaders support such behavior and lead by example.
D. Accessibility of Quality BH Care. Most of the participants reported that they generally trust BH providers and believed that BH treatments can be effective. However, there is a reported lack of “SOF Cultured Providers,” and this can make the SOF Soldier feel misunderstood, disconnected, and less trusting. One very common theme was frustration in seeking care at medical treatment facilities for a variety of reasons. Long delays for appointments and unfamiliar providers present real barriers to care. Soldiers reported they generally are more likely to seek services from someone they are familiar with.
It is clear that our units need accessible providers that truly understand the SOF culture and are embedded in the organization they serve. CG, USASOC is pursuing several lines of operation (Army TAA 14-18 and SOCOM’s Preservation of the Force and Families effort) to increase the number of Operational Psychologists and other embedded behavioral health providers for USASOC. Until we can grow our specialty assets, you should consider the multiple avenues of BH support that are currently available, including Operational Psychologists, Unit Chaplains, Licensed Clinical Providers, MFLC, Military One Source, TRICARE and our Military Treatment Facilities.
A significant number of USASOC Soldiers assume BH providers are quick to prescribe medication or to diagnose severe psychiatric diagnoses such as PTSD resulting in career ending administrative action and embarrassment. The reality is most trusted SOF oriented BH providers understand the impact of severe psychiatric diagnoses and carefully discuss these issues with the Soldiers they see and carefully consider their concerns. Several Soldiers expressed preferences for approaches that emphasize education, skill development, and incorporating social support. The use of embedded providers who better understand the unit’s mission and culture will be able to make comprehensive assessments, provide education on mental health resources and judicious referrals for psychiatric treatment as necessary. Our operational psychologists and embedded providers should continue to monitor the quality of care being received by our Soldiers.
E. Abuse of the BH System. There is a common belief that some of our Soldier’s are using mental problems as a get out of jail free card. This real or perceived abuse of the system increases stigma, as BH treatment is associated with escaping responsibility and poor performance. As a result, soldiers with genuine needs may then avoid getting help altogether.
Military discipline is fundamental to the integrity of our BH system. Leaders need to consistently hold Soldiers accountable for their actions, while still ensuring they are afforded all necessary behavioral health services.
F. Command Climate. Senior Leaders (SL’s) can contribute directly or indirectly to BH stigma. Based on feedback from the tribes, this is certainly the exception, as USASOC leaders are reportedly providing a supportive environment for their Soldiers seeking BH care. However, there are some examples cited of negative comments concerning Soldiers seeking BH care, a general lack of knowledge of the BH system, and some isolated incidents of Soldiers being removed from teams because they were seeking BH treatment.
A prominent theme across the tribes was the importance of SL’s engaging Soldiers to lay the foundation for any BH messaging. SL’s should educate Soldiers on the importance of seeking mental performance improvement or BH care early and the risk of waiting until there is real impact on their career related to legal/ethical/moral breaches. It is also critical for leaders to demonstrate to Soldiers that they are invested in their well-being. Across the tribes, this deliberate focus on Soldiers getting the help they need appears to have a positive impact and serves to mitigate BH stigma. The most powerful impact was from SL’s discussing personal counseling/BH treatment and how it benefited them. The strongest Leaders lead from the front. One specific recommendation from an NCO was to establish a unit panel of SL’s to answer Soldier’s questions and discuss concerns.
Many USASOC Soldiers are unaware of the processes in place to ask for help and many of our SL’s do not understand the BH system, especially policies and procedures related to confidentiality and reporting requirements. Operational Psychologists and embedded BH providers should provide education for leadership on BH policies, limits of confidentiality, recognition of risk indicators, and how to handle Soldiers with BH concerns.
In addition, the issue of planned force reduction should also be addressed by senior leaders. Especially amongst our support Soldiers, there is a fear that seeking BH care may give leadership a reason to cut them as part of the force reduction. Leaders should remind Soldiers that misconduct will continue to negatively impact a soldier’s career, seeking self-improvement will not. Lastly, our CSC/CSU’s need to establish and cultivate legitimate opportunities to reset, and these positions should not in themselves be stigmatizing.
Best Practices for Mitigating BH Stigma
A. Re-branding Behavioral Health. We best serve our soldiers by shifting the focus from Behavioral Health to an optimized mental performance model for SOF warriors. It is imperative that we begin to focus on proactive, health focused, optimized mental performance, rather than the medical illness/model. This approach will focus on enhancing the strengths of our warriors, rather than the model of treating illness, which in itself increases stigma. We assess and select our warriors because of their resilience and mental abilities, and our programs need to emphasize the need to maintain and enhance the mental readiness of our warriors to the same dedicated degree we currently work to enhance our combat skills, physical performance and endurance, and MOS skills. With a comprehensive approach, an optimized performance approach offers warriors access to a full range of physical, psychological, spiritual and family services uniquely shaped to optimize mental performance and attitudes, improve marital and family relationships, and enhance quality of life. How this is applied will depend on each of our tribes’ unique culture and mission sets.
Optimized mental performance programs are conducted by operational psychologists and incorporate elements of behavioral science, learning theory, sports psychology, neuropsychology, and personality assessment to improve mental performance. PE may include individual or group training to enhance memory/concentration, situational awareness, mental flexibility, influence and persuasion, operating in ambiguous environment, team interpersonal dynamics, and leadership development. For example, one SF Group Psychologist has initiated performance psychology, leader development, and team dynamics instruction with some ODAs in order to enhance performance, build rapport, and increase familiarity.
Resilience programs are also based on an optimized mental performance model. One SF Group Resiliency Team developed a unique leader based resiliency program comprised of leader training (recognizing resilience vulnerabilities and methods to overcome these vulnerabilities), leader screening tool, and screening procedures. The program is based on the concept that issues are most effectively managed at the lowest level possible where leaders know their Soldiers best. Leaders are in a better position to effectively screen their Soldiers for issues and address those issues with professionals providing tailored and specific consultation and support as needed throughout the process.
B. Operational Psychology and Embedded BH Providers. The best practice model for our units includes an Operational Psychologist working as a Special Staff Officer working hand in hand with dedicated BH provider(s) who directly work under the Unit Surgeon. Our organizations that use this model have the least amount of BH stigma and the highest utilization of BH resources.
(1) Operational Psychologists: Operational psychologists provide support to a wide range of missions as a deployed asset and in garrison. This support includes A&S, HUMINT support, and SERE. The visibility of the operational psychologist in non-stigmatizing events can provide opportunities for short-term consultation, performance enhancement, or even counseling and is an ideal entry point for Soldiers to seek assistance. Specifically, significant interaction with operational psychologists at A&S and other training venues was cited by our SOF warriors as mitigating stigma. Also, operational psychologists routinely provide performance feedback on strengths and vulnerabilities based on A&S packets, and this creates an excellent venue to de-stigmatize and encourage self-improvement in the soldier.
(2) Embedded SOF BH Providers: Embedded providers have better understanding of cultural context, organizational pressures and resources and have habitual relationships with unit members. This can be a dedicated medical provider serving in medical clinic or an off-site clinic serving Soldiers. Placing uniform providers in civilian clothes while providing care can also decrease apprehension to seek BH care.
C. Chaplain Partnership with BH. Unit Chaplains are seen as well integrated and respected across USASOC. They continue to serve as the most prevalent point of entry for behavioral health concerns and counseling for many Soldiers. Cross training between group psychologist and chaplains can increase chaplain BH referral skills and enhance psychologist’s access to Soldiers. Marital counseling and retreats provided by Chaplains are seen as excellent resources, and the inclusion of embedded BH providers can enhance these already successful programs.
D. BH Education Initiatives. Operational psychologists and embedded BH providers should develop innovative approaches to educating soldiers about performance enhancement, BH resources and accessing care. These resources can reside on the portal for BH FAQ’s or in a library with informational and self-help resources. All of these programs need to address the SOF warrior’s need for professional and personal development. In crafting these programs, developers need to keep in mind the strong dislike for approaches that seemed canned, programmatic, or “Big Army.”
Operational psychologists and BH providers can also provide BH training to serve as force multipliers. For example, integration of BH topics into 18D non-trauma modules has been an effective way to enhance existing support systems for ARSOF warriors.
E. Mandatory Assessments and Briefings. Mandatory briefings and assessments can be good opportunities for SOF warriors to seek BH assistance. While these programs initially may meet resistance, the feedback from the tribes is that they are beneficial because they serve as “cover” for those Soldiers that would not otherwise engage an operational psychologist or BH provider. At one of our CSU’s, a 3 year re-look program is generally seen positively and has the positive effect of operational psychologists increased visibility and encourages personal development through psychological assessment feedback and performance enhancement.
F. Providing Multiple Avenues for BH Assistance. There are several sources of BH support, including embedded BH providers, MFLC, Army One Source, MTF’s and Tricare network providers.
Across the tribes there are many factors contributing to BH stigma and significant barriers to care. There are changes that can be made in the short-term to mitigate stigma, such as increased resources, accessibility and optimized mental performance programs. However, genuine long-term change requires strong leadership to establish a command climate that supports our SOF warriors as they seek mental performance enhancement, personal development and behavioral health support.
Lt. Col. Paul Dean is the director of Psychological Applications and the command psychologist for USASOC. He also serves as the operational psychology consultant to the U.S. Army Surgeon General. He has spent more than 10 years in special operations, including his last assignment as the command psychologist at the Joint Special Operations Command. He has deployed multiple times in support of a variety of joint special-operations task forces. Dean holds bachelor’s, master’s and doctoral degrees in psychology from the University of Southern Mississippi.
Lt. Col. Jeffrey McNeil is the deputy command psychologist for USASOC. In his previous assignments, he has spent more than 10 years as an operational psychologist for special-operations units. He has participated in several deployment operations with various joint special-operations task forces. McNeil’s most recent assignments have been the chief psychologist, Combat Applications Group and the regiment psychologist for 160th Special Operations Aviation Regiment. He holds a bachelor’s degree in political science from Michigan State University, a master’s in national security and strategic studies from the Naval War College and a Ph.D. in counseling psychology from Western Michigan University.