Although fewer than half a percent of Americans serve on active duty (compared to 12 percent during WWII) the mental health care of our soldiers, sailors, marines, coast guardsmen and airmen is a topic of great public concern. Because the need for care often exceeds the capacity of uniformed mental health providers, active duty personnel are sometimes seen by civilian psychologists. Unique challenges arise in providing those services.
Advanced knowledge of the challenges is important to doing our best for this important community. Many rules and roles differ between military and civilian health care providers. I’ll present a couple of situations that can be handled effectively if anticipated, but which can be potentially harmful if misunderstood.
Here’s one example of a conflict that arose from these differences:
A local air base sent an airman to a civilian psychologist for care. The airman described both moderate mood problems and difficulty controlling her gambling. Those concerns were effectively addressed in treatment and her mood improved significantly.
A couple of months after she ended treatment she received orders and planned to relocate. The new assignment required a high-level security clearance. As part of obtaining the clearance, the airman had to disclose all her medical and mental health care. She sent her psychologist a note asking that the doctor report only the (happily resolved) mood problems. At the same time, the military treatment facility requested the patient’s complete mental health records. What should the psychologist do?
It’s important to understand that military members are required to disclose their health condition and health care history to authorized military authorities. Along with the sacrifice of control over where they live, the hours they work and the danger they face, members of the active armed forces have relinquished privileged communication between themselves and their mental health providers.
They can’t simply “keep their treatment secret,” without violating military law. Privacy and “need-to-know” keep most of the interactions private, but commanders who assign service members to sensitive duties have access to the information necessary to make informed decisions. Civilian providers and their military patients need to have a clear understanding of the limits of confidentiality and keep the limits in mind from the beginning to the end of treatment.
By being clear about the limitations on confidentiality at the outset of an interaction, the psychologist and the patient can include preparation for the possible ramifications of disclosure as part of the treatment. In most cases, it’s not the diagnosis that interferes with selection for special duties. It’s the behaviors that arise from the disorder that are disqualifying. For example, it may not be disqualifying to have had a gambling problem, but to have large amounts of unpaid debt, a pressing need for cash and difficulty controlling the acquisition of additional debt present a far greater concern.
In another case, a soldier was referred to a civilian psychologist for psychotherapy to address post-traumatic stress. The soldier was making good progress in overcoming his symptoms but decided not to re-enlist and to separate from the Army. During the discharge process, the soldier applied for a disability compensation for problems resulting from PTSD. He also asked the psychologist to write a strong letter supporting his contention that he would probably suffer disability indefinitely, as the result of PTSD. What should the psychologist do?
In this case, the psychologist wants to help the patient and to ensure that his post-separation needs are met. The psychologist may feel torn between expressing optimism about the patient’s prognosis and writing a very gloomy prediction about the same disorder. By being clear about the role the psychologist assumes (treatment, not assessment) the chances for subsequent conflict are reduced. The psychologist can keep clear records of the symptoms, patient reports, treatment and progress without becoming entangled in selective emphasis of disability at the potential expense of the patient’s motivation to recover.
I recommend knowing, discussing and documenting limitations on privacy and privileged communication at the outset of treatment. Obtain detailed expectations about record keeping and reporting requirements from the referral source. Be clear so the patient can make a well-informed decision about the potential implications of self-disclosure.
I’ve often told military patients that it’s not likely to be the depression (or other problems) that will affect security clearance, it’s the consequences of unresolved problems or lying about those problems that is the greater concern for commanders.
Finally, providers should know that members of the armed forces have access to a very wide range of support and treatment options. In addition to vigorous psychoeducation, public health, preventive care and outreach programs, there are well-funded family advocacy, substance abuse treatment, chaplaincy, resiliency and fitness programs. Civilian providers can learn about these through their referral sources and by visiting the websites provided by their patients’ host organizations.
Timorgy S. Strongin, Ph.D., ABPP, is a retired colonel and former Air Force psychologist and medical administrator. The opinions expressed here are his alone and do not necessarily reflect the policy of the U.S. Air Force, the Department of Defense or the federal government. Comments/questions may be sent to: Natlpsych@aol.com. Include “Strongin” in the subject line.