Q&A: How the Army handles behavioral health issues

Pfc. Bradley Manning’s mental and emotional health was an issue for his supervisors. Whether they properly handled his case was the subject of an investigation; whether they were recommended for discipline has not been publicly disclosed.

In an interview about mental health issues in the Army, Col. Rebecca I. Porter, chief of the behavioral health division of the Office of the Army’s Surgeon General, discussed the responsibilities of Army leaders in managing their troops’ mental health. Her remarks are about general practices and policies, and do not refer to any one particular soldier.

The Washington Post: What conditions would disqualify an applicant from serving in the Army?

Porter: The [application] process includes a review of whatever medical records we have available, as well as asking potential soldiers to complete questionnaires where they might disclose information. We look for past diagnoses or past treatments, or other indicators of behavioral problems. A suicide attempt would be an indicator, as would any diagnosis of a mood disorder like depression or bipolar disorder, drug abuse or dependence, or an overdose of medication or a drug in a suicide attempt.

Who is responsible for monitoring the soldier’s mental health?

Ultimately, the command is responsible for monitoring the health and well-being of its soldiers. If a commander has reason for concern, they have access to behavioral health providers [to whom they can send a soldier] for consultation or treatment.

Who is the soldier’s chain of command?

It can start with a soldier’s squad leader and go up to platoon leader and up to the company commander and battalion commander.

What are indicators of a potential problem?

A commander should be aware of things like disturbance or a change in behavior, such as a soldier being late to formation when previously the soldier was on time for formation, or a soldier becoming belligerent toward their chain of command. Other indicators: a drunken-driving incident, getting into arguments and fights. It’s a matter of the chain of command knowing their soldiers.

If the chain of command becomes aware of a change in the soldier’s behavior, he can ask the soldier to be seen at a behavioral health clinic. Or if a commander had questions about a soldier’s fitness for duty, they could do a command-directed mental health evaluation, in which case a soldier is referred for evaluation with the understanding that the behavioral health provider will provide feedback to the commander. ...

The counselor might make the recommendation to the command that the soldier engage in treatment or therapy. They could also tell the command that they believe that the soldier has conditions that make them unsuitable for continued service. They can make recommendations that the soldier be considered for a medical evaluation board. A medical evaluation board is undertaken when there appears to be a physical or behavioral health condition that would make the soldier unsuitable for continued service. The command-directed mental health evaluation can be conducted by a psychiatrist, a doctoral-level clinical psychologist or a doctoral social worker.

If a commander orders a mental health evaluation, a soldier must be notified by a judge advocate general [a military lawyer] what their rights are within the system, so that a commander cannot use a referral to mental health as a punishment.

Is a commander required to carry out the behavioral health provider’s recommendation?

It’s a recommendation. In my experience, most commanders will concur with the recommendation. ...

Sometimes, the response to the commander is that there did not appear to be any reason for limitation of duties, or it could be that there are indications that perhaps the soldiers’ duty should be limited, or in some cases it may be that the soldier appears to be in imminent risk of danger to themselves or others. Then, the soldier would be hospitalized.

What is the commander’s responsibility for recognizing signs of instability in a soldier?

In general, those who are in a soldier’s chain of command are considered to be responsible for what the soldiers do or don’t do, for their general health and welfare. ...

Even though we train soldiers to be tough and resilient, we also instill discipline in them, so that it’s not permissible to engage in physical altercations at the drop of the hat or to drink too much and drive, and that sort of thing. It’s certainly a balance for the human psyche to be able to be ready for combat but also have the discipline to function as acceptable people in society. That’s the role of the chain of command and leadership is to help soldiers negotiate that.

What is the commander’s responsibility for preventing violations of law or Army rules?

In order to hold a military commander criminally or civilly liable under the doctrine of command responsibility, the soldier has to be under the commander’s command, and the commander had to know or should have known based on the circumstances at the time that their subordinate was engaging in impermissible conduct and the commander did not do anything to prevent or punish the person engaging in that conduct.

And if a soldier who showed signs of mental distress went on to commit a violation, is there any command responsibility for failing to prevent the act?

It would depend on the circumstances, but if there’s a behavioral health provider involved, whatever guidance and recommendations the commander received about the soldier would be an important part in determining where there was a glitch in the system.

What conditions or behavioral issues are cause for discharge?

If a soldier has less than 24 months’ active-duty service, one cause for discharge for behavioral health reasons would be the diagnosis of a personality disorder that repeatedly interferes with a soldier’s ability to perform his or her duty. So, a person might experience an adjustment disorder after a divorce, but if that resolves itself after a couple of months, and the soldier does not have repeated difficulty adjusting to certain kinds of situations, then that’s not cause for separation. But if the soldier has a chronic pattern of difficulty adjusting to stress or change, then that might be cause for separation with an adjustment disorder.

At what point is emotional stress so debilitating that it would warrant not deploying a soldier overseas?

One point at which it would warrant not deploying a soldier is if it met the conditions for a medical evaluation board. If the behavior met the conditions under which a soldier should be discharged, anyway, then of course that would prevent a soldier from being deployed. Otherwise, however, if the soldier meets retention criteria and is in treatment, we generally just want the soldier to be stable — without significant symptoms — for at least three months prior to deployment. Stability is significant. There have been instances in which soldiers have wanted to deploy but they had not been stable on medication for three months, so we worked with them to get to that three-month point so they can join their unit that is already deployed.

What has the Army done to be more effective in promoting soldiers’ mental health and recognizing problems before they escalate?

Generally speaking, we have increased our efforts in highlighting for commanders what we call the art of garrison leadership. That means making sure our young leaders, who are more accustomed these days to commanding in a theater of war than they are on an installation in the continental United States, develop their garrison leadership skills to include things like being familiar with their soldiers and knowing what’s going on in their personal lives that can impact them professionally.

There is a health promotion and risk reduction task force that works under the vice chief of staff of the Army that oversees our efforts in suicide reduction.

When did you begin the effort to standardize the delivery of mental health services to soldiers?

 In February of 2010. We’re still gathering data. We had one study that looked at identifying soldiers prior to deployment who were already in treatment, and rather than just identifying them and clearing them for deployment, we took an additional step and coordinated for their care while they were deployed, assuming they were deployable. We coordinated with their brigade surgeon to assure that they had a care program while they were in theater. We had great outcomes with that. It was recently published in the American Journal of Psychiatry. In effect, what we did was stay actively engaged with those soldiers while they were deployed -in Iraq — rather than wait for them to have difficulties in theater.

What are the stress factors in a war zone?

In the theater environment, you have the increased risk of physical harm, so soldiers have to maintain a certain level of awareness of what’s happening around them. They have to be kind of up, alert all the time to possible danger. That can wear on an individual to have to be so vigilant all the time. There’s the risk of being injured.

The other thing for some soldiers is the increased stress of being separated from their family, from their at-home support system.

In addition, if the family has problems and issues at home, given increased use of e-mail and the opportunity to call home more often, soldiers often are not insulated from those problems. So there is a potential for a soldier to have the combat stress and then on top of that whatever stress their family is going through because they hear about it on almost a daily basis.

What are you doing to lessen the stigma for soldiers who might be fearful of coming forward with a mental health problem lest it jeopardize a clearance or subject them to ridicule?

Soldiers have felt they were at risk of losing a security clearance or not being considered for promotion because they have sought out behavioral health counseling. In fact, that’s not the case. What we see is it’s better if a soldier recognizes a problem to get assistance and be forthright about that, than it is to either ignore it or wait until it’s a problem and then maybe turn to a suicide attempt or lie about it on their security clearance paperwork.

What is the Army doing to improve soldiers’ mental health?

Because we have seen an increased demand for behavioral health services, we’re working to standardize the way we deliver behavioral health care in the Army. I think that we’re making good strides in soldiers feeling more comfortable in getting services when they need them. We, in fact, encourage soldiers to reach out for help early. We find that the earlier that we’re able to talk with the soldier about what’s going on from a behavioral health perspective, the more likely we are to be able to help that soldier get to a positive outcome and return to duty if that’s what they’re looking to do.

We’re working to synchronize this effort with other programs that the Army has — from the chaplains, or from the installation management command — so that we can offer the soldiers coordinated care, whether it’s for their family’s well-being or their individual well-being.

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