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The military is its own culture with different norms of behavior, traditions, worldview, laws, language and dress. This complicates the mental health treatment of service members since not all mental health providers assessing and treating them are a part of this culture and may have little experience working within the military framework. However, understanding this culture and being able to work within it are essential skills needed by psychologists in order to provide effective treatment to military personnel. One of these core competencies is being able to communicate effectively with the military commands of service members, while adhering to federal law and the instructions and military laws which pertain to military personnel.
Per the Health Insurance Portability and Accountability Act (HIPAA), medical information may be disclosed to commands in a variety of circumstances necessary for safety, fitness for duty determinations and mission requirements. (Read more about the military command exception of HIPAA.) Because of the nature of military duties, the substantial safety issues that can arise with even small decrements in functioning, and the hazardous locations in which military members serve, mental health providers treating service personnel will find that they must interact frequently with commands. Consequently, understanding the military command exception to HIPAA is critical.
On the surface, giving mental health information to military commands sounds problematic, but the command has more resources and power than a psychologist does in a number of regards, and often a patient’s problems can be solved by the command or treatment can be significantly augmented by command involvement. It’s a Catch-22 though; you must protect confidentiality whenever possible, however, if the command doesn’t have necessary information, they can’t assist. As an example, a service member who hasn’t slept in a month because their roommate is on an opposite shift or is just generally an inconsiderate roommate can have this problem solved immediately by the command. Meeting in the psychologist's office to discuss sleep strategies will never help.
While that may be a simplistic example, the command can notably improve the lives of individual service members in mental health treatment. The command controls duty assignments, living arrangements, supervisory chain of command, deployment status, granting of leave and determines whether or not to support your recommendations.
So, how do you simultaneously interact with a command, protect confidentiality, and meet your military patient’s needs? Here are some tips to help:
1. Advocacy for your future patients begins with rapport building. If you are providing health services through a military clinic, it is vital to establish a working relationship with the local commands. If you can go to the command and meet the leadership, provide a required annual training, provide education for the leadership on changes in mental health policies, offer up your behavioral health technician to help with a training exercise, etc., you will be halfway to meeting future patients’ needs.
2. Know your laws and policies. Some things can’t be disclosed to a command, some things require patient permission and some things must be reported. Some examples of military instructions which address these issues are DoDI 6490.08 Command Notification Requirements to Dispel Stigma in Providing Mental Health Care to Service Members, DoDI 6490.04 Mental Health Evaluations of Members of the Military Services and DoDI 6495.02 Sexual Assault Prevention and Response (SAPR) Program Procedures.
3. Don’t give out any information that isn’t needed by the command. For example, developmental histories are pertinent for your assessment, but they are almost never needed by the command.
4. Make a plan. What do you need to accomplish by contacting the command? Are you calling just to provide a simple update e.g., an active-duty service member has been admitted to the hospital? Or, are you calling because you need information from the command, to advocate for your patient or to problem solve for the patient? Figure out what you want to accomplish.
5. Decide who to call. Most mental health providers default to calling the commander. While this is okay, the commander is often the least useful person to start with. Unless the command is very small, the commander may not know the service member in question, resulting in your input being conveyed down the chain to the designated action officer. Granted, the commander is the one you are generally permitted to call due to privacy laws and policies pertaining to confidentiality, so have a conversation with your patient, discuss the information that needs to be passed or discussed and let them tell you the person they are most comfortable with you contacting. Get written permission to call this individual. (Note that this person needs to be someone who has some decisional authority in either the enlisted or officer chain.)
6. When feasible, let the service member decide if he or she prefers a phone call or a meeting. When treatment planning is involved, particularly in an operational setting where this can get extremely complicated, a sit-down with the service member’s preferred contact from the chain of command may be more useful and garner more command support than a phone call.
7. Use straightforward language emphasizing outcome and leave the, at times, confusing psychological terms at home. Do not hedge on recommendations — be definitive or the command will be forced into making a medical decision. For example, either a service member is considered safe from a mental health perspective to have firearms or not — these types of decisions must be stated unequivocally.
8. Remember that the command holds most of the cards. The command will either implement what you suggest or not. Recommendations that drain command resources or interfere with a mission are unlikely to be supported. Recommendations that take these things into consideration and exhibit flexibility and creative problem solving are most likely to result in a positive outcome for your military patient.
9. Don’t forget your military etiquette or your communication may be over before it begins.
A version of this post appeared on the Psychological Health Center of Excellence website in 2017. Copyright Carrie Kennedy.
