Initial job analysis of military embedded behavioral health services: Tasks and essential competencies

Utilization of mental health personnel assigned to operational military units is an area of growth for the US military. What activities they perform, how requirements may differ from working in clinical settings, and how to select and train for these types of positions is still poorly understood. A job analysis was conducted of Air Force mental health providers and enlisted technicians embedded in special operations, intelligence, and high-risk training units. Participants rated 27 tasks on frequency, importance, difficulty, and risks, as well as the importance of 37 knowledge, skills, and abilities (KSAs), with differentiation between KSAs that may be trained versus those that must be present to be assigned to the embedded position. Tasks reflected 4 areas of activity: unit embedding/engagement, behavioral health consultation and support, performance optimization activities, and operational mission tasks. Tasks varied by professional training (psychologist, social worker, enlisted technician) and unit type. The KSAs rated as most important were ethical judgment and ability to manage complex relationships and boundaries while working outside of a clinic, strong interpersonal skills with appropriate assertiveness to advocate for safe, effective courses of action, and understanding of unit missions and organizational dynamics. Results have implications for job design, selection criteria, professional disciplines with KSAs necessary to unit-specific tasks, and training of personnel for integrated operational support positions.     

Editorial

This study examined the psychometric properties of the Outcome Questionnaire-30.2 (OQ-30.2; designed to measure patient progress throughout mental health treatment) in a sample of United States Air Force active duty basic military trainees who were evaluated for mental health concerns during the course of basic training. Findings indicate that the OQ-30.2 was internally consistent and Total scores decreased with more contact with mental health professionals. Previously reported 1- and 3-factor structures were not replicated; rather, results suggested the use of a broad 27-item general psychological distress subscale and a separate subscale of 3 critical items assessing substance use concerns. Present findings support the utility of the OQ-30.2 as a tool for repeated monitoring of patient progress in military mental health settings. Recommendations for future directions in the development of alternate calculations of the clinical cut score and reliable change index are discussed.     

Measuring Situation Awareness in Virtual Environment-Based Training

We evaluated the efficacy of a computer-based situation awareness (SA) measurement system for training dismounted infantry SA in an urban terrain virtual reality (VR) simulation. Based on past research, we hypothesized that the SA measures would be sensitive to individual (squad leader) differences, and that the frequency of specific probes would reveal differences in critical SA requirements among scenarios. Three infantry squads performed multiple trials across two different scenarios. A confederate platoon leader posed probes to squad leaders during trials and experts made ratings afterward. Results revealed squad leaders had similar responses to probes, despite differences in combat experience. Analysis of probe frequency revealed different high priority SA elements and decisions for each scenario. The SA behavior and communication ratings revealed differences among squads, which trended with experience. Measures of SA were also consistent across the test scenario as a result of similar mission types and task difficulties. We discuss the implication of our findings for future research and theory within this area.     

Ethical considerations in the management of military related concussion

Since the year 2000 over 300,000 military service members have been diagnosed with mild traumatic brain injury/concussion. Consequently, this injury has become the subject of increased awareness and study within the military healthcare environment. Although single and/or isolated concussions typically heal in a relatively rapid fashion with limited to no long-term sequelae, there is debate in the field about the impact of repeat concussion. To this end, various ethical challenges arise when managing patients with such injuries. Several papers outlining these issues with regard to athletes have been published in the sports medicine literature. However, because providers caring for military service members must make return-to-duty-decisions, practice within the military setting results in a number of unique ethical considerations. More specifically, management of service members with a history of repeat concussion and increasingly complicated recoveries, as well as the potential for premature return-to-duty are topics of concern for military health care providers. Using the American Psychological Association ethical principles and standards, the current article outlines various ethical challenges to concussion management in the military setting. The ethical principles of Beneficence and Nonmaleficence and Respect for People’s Rights and Dignity, as well as the 3 related ethical standards of Competence, Avoiding Harm, and Conflict of Interest are discussed. Policy changes are highlighted as a proximal solution to these ethical challenges.     

Confidentiality and Mental Health/Chaplaincy Collaboration

Confidentiality can both facilitate and inhibit working relationships of chaplains and mental health professionals addressing the needs of service members and veterans in the United States. Researchers conducted this study to examine opportunities for improving integration of care within the Department of Defense (DoD) and Department of Veterans Affairs (VA). Interviews were conducted with 198 chaplains and 201 mental health professionals in 33 DoD and VA facilities. Using a blended qualitative research approach, researchers identified several themes from the interviews, including recognition that integration can improve services; chaplaincy confidentiality can facilitate help seeking behavior; and mental health and chaplain confidentiality can inhibit information sharing and active participation on interdisciplinary teams. Cross-disciplinary training on confidentiality requirements and developing policies for sharing information across disciplines is recommended to address barriers to integrated service delivery.     

An Event History Analysis of First-Term Soldier Attrition

The study of attrition has largely focused on identifying demographic or biographic characteristics that predict whether soldiers complete their enlistment term. As a result, much is known about who attrites. Less is known about why soldiers attrite. This research assessed the influence of two psychological factors on U.S. Army soldier attrition: self-reported confidence that one could complete one’s term of service and ambivalence regarding the decision to enlist. The study sample consisted of first-term enlisted soldiers (N = 14,808) who were respondents to Army surveys. Results of fitting three longitudinal models indicated that confidence in being able to complete one’s term of obligation was more predictive of attrition for those reporting greater ambivalence regarding the decision to enlist. This effect was significant throughout a 3-year period. This work adds to our understanding of attrition by highlighting the role of confidence and ambivalence. Implications for strategies to reduce attrition are discussed.     

Limits to Confidentiality in U.S. Army Treatment Settings

A number of reports detail ethical concerns of behavioral health providers in the U.S. Military regarding limited confidentiality. This article provides a review of limits to confidentiality in behavioral health settings as outlined by U.S. Army regulations and Department of Defense directives. Specific limits are discussed under seven categories, including: medical treatment and oversight, command notification, threats to safety, public health purposes, judicial or administrative proceedings, law enforcement investigation, and specialized personnel programs. Specific attention is given to war crimes reporting, special duty, and command involvement. Lessons learned for best practice across service branches are provided as a collaborative model for resolving perceived conflict between the APA Ethics Code and military regulations.     

Predictors of Support for Women in Military Roles: Military Status,Gender, and Political Ideology

The repeal of combat restrictions by gender raises the importance of understanding factors related to the acceptance of women serving in the full range of military jobs. Previous research shows military affiliated cadets, especially males, are substantially less approving of women serving in military jobs, especially those involving exposure to direct combat or command positions, than are other college students. The current study extends these findings by considering political ideology in addition to gender and military affiliation, as related to attitudes toward women’s roles in the military overall and in combat roles in particular. Survey data from Service Academy cadets (n = 3,116), Reserve Officer Training Corps (ROTC) cadets (n = 1,367), and nonmilitary affiliated college students (n = 2,648), provided measures of whether a woman should or should not be allowed to serve in 9 different military job areas. In addition to overall approval, a scale for combat jobs was created from a subset of 4 of the jobs. Regression analysis indicated that once gender, political party, political position (left/right), and attitudes toward mothers in the workforce overall were controlled, type of college did not add to the prediction of acceptance of women in various military roles. In general, nonmilitary affiliated respondents, women, and those identifying as Democrat offered higher approval scores. Our findings suggest more aggressive programs, designed to educate and socialize these future leaders about women’s roles in the military, may require development.     

Spouse and Family Functioning Before and After a Marine’s Suicide: Comparisons to Deaths by Accident and in Combat

The impact of service member suicides on families is not well understood. Civilian studies have demonstrated that family survivors of suicide deaths experience complicated grief, feel guilt and shame, and often do not receive sufficient social support. In this exploratory study, spouse survivors of Marines who died by suicide (N = 17), accident (N = 19), and in combat (N = 34) retrospectively reported on their immediate pre- and postmortem and current personal and family functioning. Nonparametric analyses revealed that several between-group differences existed. Observation of the means suggested that the spouses and families of Marines who died by suicide exhibited significantly poorer pre- and postmortem functioning compared with those whose spouses died in combat. Specific challenges included low family cohesion, high family conflict, perceived stigma, and shame. There were no differences in current spouse or family functioning, and there was weak evidence for posttraumatic growth among surviving spouses of those dying by suicide. These results should be considered preliminary and interpreted with caution given several methodological challenges.     

Associations Between Participant Ratings of PREP for Strong Bonds and Marital Outcomes 1 Year Postintervention

After completing a relationship education program, collecting participant evaluations of the program is common practice. These are generally used as an index of “consumer satisfaction” with the program, with implications for feasibility and quality. Rarely have these ratings been used as predictors of changes in marital quality, although such feedback may be the only data providers collect or have immediate access to when considering the success of their efforts. To better understand the utility of such ratings to predict outcomes, we evaluated links between participant ratings and changes in self-reported marital satisfaction and communication scores 1 year later for a sample of 191 Army couples who had participated in a relationship education program delivered by Army chaplains (PREP for Strong Bonds). Overall ratings of general satisfaction with the program and the leader did not predict changes in marital outcomes 1 year later, whereas higher ratings of how much was learned, program helpfulness, increased similarity in outlook regarding Army life, and helpfulness of communication skills training predicted greater change in communication skills 1 year later. Higher ratings of items reflecting intent to invest more time in the relationship, and increased confidence in constructive communication and working as a team with the spouse predicted greater increases in both marital satisfaction and communication skills 1 year later. The constructs of intention and confidence (akin to perceived behavioral control) suggest that the Theory of Planned Behavior may be particularly useful when considering which Army couples will show ongoing benefit after relationship education.