Clinical Considerations and Readiness

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