October – December 2014 

Perspective 1

MG Steve Jones 

Developing Effective Leadership Competencies in Military Social Workers 3

COL Jennifer L. Humphries; COL (Ret) Reginald W. Howard 

Evolution of the Combat and Operational Stress Control Detachment 8

MAJ Jason I. Dailey; CPT Victoria L. Ijames 

The Psychosocial Challenges of Conducting Counterinsurgency Operations 14

COL Derrick Arincorayan; Larry Applewhite, PhD; et al 

Sleep and the Use of Energy Products in a Combat Environment 22

LTC Wendi M. Waits; Michael B. Ganz, PhD; Theresa Schillreff, OTR/L; CPT Peter J. Dell 

Telebehavioral Health: Practical Application in Deployed and Garrison Settings 29

CPT Michelle M. Garcia; Kristin J. Lindstrom, PsyD 

Effectiveness of Telebehavioral Health Program Nurse Case Managers (NCM): 36

Data Collection Tools and the Process for NCM-Sensitive Outcome Measures 

Judy Carlson, EdD, APRN; Roslyn Cohen, MSN; Wynona Bice-Stephens, EdD, RN 

Military Service Member and Veteran Self Reports of Efficacy of Cranial Electrotherapy 46

Stimulation for Anxiety, Posttraumatic Stress Disorder, Insomnia, and Depression 

Daniel L. Kirsch, PhD; et al 

Raising the Clinical Standard of Care for Suicidal Soldiers: 55

An Army Process Improvement Initiative 

Debra Archuleta, PhD; David A. Jobes, PhD; Lynette Pujol, PhD; et al 

Mild Traumatic Brain Injury in the Military: Improving the Referral/Consultation Process 67

MAJ Charles Watson 

Directorate of Treatment Programs: Providing Behavioral Health Services 73

at the US Disciplinary Barracks 

LTC Nathan Keller; et al 

The Effects of Military Deployment on Early Child Development 81

Dana R. Nguyen, MD; Juliana Ee, PhD; Cristobal S. Berry-Caban, PhD; Kyle Hoedebecke, MD 

The Effect of Deployment, Distress, and Perceived Social Support on 87

Army Spouses’ Weight Status 

LTC Tammy L. Fish; Donna Harrington, PhD; Melissa H. Bellin, PhD; Terry V. Shaw, PhD 

Applying the Korem Profiling System to Domestic Violence 96

CPT Victor Johnson; Chandra Brown, LMSW 

Understanding the Student Veterans’ College Experience: An Exploratory Study 101

2LT Timothy Olsen; Karen Badger, PhD, MSW; Michael D. McCuddy, MSW 

Mental Health Outreach and Screening Among Returning Veterans: 109

Are We Asking the Right Questions? 

Karen Bloeser, MSW; Kelly K. McCarron, PsyD; et al 

Skilled and Resolute

A New Offering from the Borden Institute History Series 118

COL Betsy Vane, Army Nurse Corps Historian 

BEHAVIORAL HEALTH: INCREASING RESILIENCY AND ENDURANCE
October – December 2014 The Army Medical Department Center & School PB 8-14-10/11/12 

Online issues of the AMEDD Journal are available at http://www.cs.amedd.army.mil/amedd_journal.aspx 

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LTG Patricia D. Horoho 

The Surgeon General 

Commander, US Army Medical Command 

MG Steve Jones 

Commanding General 

US Army Medical Department Center & School 

Administrative Assistant to the 

Secretary of the Army 

GERALD B. O’KEEFE 

1421601 

By Order of the Secretary of the Army: 

Official: 

Raymond T. Odierno 

General, United States Army 

Chief of Staff

DISTRIBUTION: Special 
October – December 2014 1

Perspective

Commander’s Introduction

MG Steve Jones

Soldiering during the past 13 years of war has been 

tough, as tough as during any other time in our history. 

Soldiers endured deployments that were too frequent 

and too long, and their time at home was too short. 

While at home, the pace was often so fast that they 

looked forward to the next deployment as a break. As a 

result, Soldiers never fully mentally reset or reintegrated 

into their families.1

Whether Soldiers see combat or not, every day on a 

deployment is “Groundhog Day.” The monotony, long 

hours, and lack of time off take their toll. For some, boredom is interspersed with brief periods of high emotion 

and excitement.2 The loss of a buddy can be particularly 

traumatic because it strips away the Soldier’s feeling of 

invincibility. Continuous combat causes physical as well 

as psychological stress including sleep deprivation and 

both physical and mental fatigue. Many Soldiers live on 

energy drinks, some recover from operations by playing 

video games for hours into the night, others use alcohol 

and drugs.

Redeployment brings new challenges. The unremitting 

pace upon return coupled with reintegration issues cause 

additional stress. Soldiers return to a life that lacks the 

excitement and meaning they experienced in combat. 

They relinquish positions of authority—such as serving 

as mayor of a town—and in fact some of our Reserve 

Component Soldiers may find they have even lost their 

job. These issues occur in the face of normal post combat reactions which can lead to anger, violent behavior, 

and self-medication.

Genetic factors may increase the likelihood of developing PTSD in some individuals.3

 A shared genetic diathesis also leads to the association of PTSD and other 

behavioral health disorders. Genetic factors may also 

increase the exposure to trauma. Most of our Soldiers 

enlisted after September 11, 2001, and they joined our 

Army to fight. Some may have the high risk taking, high 

sensation seeking personality type known as the Type 

“T” personality.

Environmental factors also play a role in the development 

of high risk Soldiers.4 Adverse childhood experiences 

increase the risk for PTSD. A dysfunctional home and 

poor upbringing may produce a recruit without a strong 

value system and with poor life decision-making skills. 

They may produce a recruit with poor self-control, one 

prone to impulsive behavior who now faces high risk 

operational and personal environments. Deployments 

provide an environment where taking life threatening 

risks is an everyday occurrence. Every time Soldiers 

leave the wire, they face the threat of death from an IED 

or an ambush. Their risk taking is rewarded, a Soldier 

who attacks an enemy position across open terrain, or 

the combat medic who treats a casualty while under fire 

are recognized for their courage. With frequent exposure they adapt. Their sense of danger erodes and they 

no longer worry about the risk. They lose their natural 

inhibition towards engaging in high risk behaviors, and 

they acquire the ability to commit violence on themselves and others

One of the classic studies on human behavior in combat is The Anatomy of Courage. It was written by Lord 

Moran, Winston Churchill’s physician, based on his experience as medical officer of the First Battalion of the 

Royal Fusiliers in the First World War. He noted that 

courage is will power, it’s like money in the bank and no 

one has an unlimited supply. You can make deposits, but 

are always spending, and when your courage is used up, 

you’re finished.5

The most effective way to destroy psychological strength 

is through poor leadership. There is an unwritten moral 

contract between leaders and their Soldiers. Leaders are 

expected to take care of their Soldiers, treat them fairly, and share their hardships. In return, Soldiers follow 

orders—even though it may mean their death.6 When 

leaders break that contract and fail to care for their Soldiers, when they mistreat them or cause unnecessary 

casualties, then they will find it impossible to maintain 

morale, respect, or discipline.

Lt-Col Sir John Baynes, a British military historian, 

studied how the British infantry in the First World War 

was able to retain its morale in the face of the terrible 

slaughter. He noted the value of training, particularly 

that which instilled esprit de corps. He listed 5 factors 

The Human Dimension of Combat
2 http://www.cs.amedd.army.mil/amedd_journal.aspx

important in maintaining high morale: regimental loyalty, the pride in belonging to a good battalion, high 

quality leaders who are trusted by their Soldiers, strong 

discipline, the sense of duty, and sound administration 

(providing adequate rations and ammunition).7

These studies show that psychological strength can be 

built and sustained. Establishing a good command climate with firm, fair, and consistent enforcement of discipline is the foundation for developing morale. Training 

instills Army Values, the Warrior Ethos, discipline, and 

self-control. It builds emotional as well as physical fitness. Good health, rest, and nutrition, and a strong support network also help sustain a Soldiers’ strength.

The Army has implemented several primary prevention 

programs to build and maintain the resilience of Soldiers 

and Families as part of the Ready and Resilient Campaign. Comprehensive Soldier and Family Fitness develops an individual’s ability to face and cope with adversity, adapt to change, recover, learn, and grow from 

setbacks. The Performance Triad promotes healthy behaviors including adequate physical activity, nutrition, 

and sleep. The behaviors improve physical and cognitive 

performance, resilience, reduce injuries and illness, and 

speed recovery. The Center for the Army Profession and 

Ethic promotes the Army Profession, Army Ethic, and 

Character Development.

The Army Medical Department plays an important role 

in building fitness, resilience and strength, in advising 

commanders, and serving as a safety net for Soldiers 

and Families. However, the ultimate responsibility remains with the unit commander, as noted in Change 1 

to Medical Field Manual 8-10, Medical Service of Field 

Units, dated June 28, 1946: “Since the majority of the 

factors which determine mental health of troops fall 

within province of command, the main job of preventive 

neuropsychiatry must be done by commanding officers 

of the line.”8

REFERENCES

1. Army Health Promotion, Risk Reduction, and Suicide Prevention Report 2010. Washington, DC: US 

Dept of the Army; 2010. Available at: http://csf2.

army.mil/downloads/HP-RR-SPReport2010.pdf.

2. Holmes R. Acts of War: The Behavior of Men in 

Battle. New York, NY: The Free Press; 1985.

3. Beck JG, Sloan DM, eds. The Oxford Handbook of 

Traumatic Stress Disorders. New York, NY: Oxford University Press; 2012.

4. Felitti VJ, Anda RF, Nordenberg D, Williamson 

DF, Spitz AM, Edwards V, Koss MP, Marks JS. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in 

adults. The Adverse Childhood Experiences (ACE) 

Study. Am J Prev Med. 1998;14(4):245-258.

5. Lord Moran. The Anatomy of Courage. London, 

UK: Constable; 1945.

6. Shay J. Achilles in Vietnam: Combat Trauma and 

the Undoing of Character. New York, NY: MacMillan; 1994.

7. Baynes JCM. Morale: A Study of Men and Courage. London, UK: Cassell & Co Ltd; 1967.

8. Medical Field Manual 8-10: Medical Service of 

Field Units. Washington, DC: War Department; 

1942 (Chng 1 dtd 28 June 1946).[obsolete]

THE HUMAN DIMENSION OF COMBAT
October – December 2014 3

Developing Effective Leadership

 Competencies in Military Social Workers

COL Jennifer L. Humphries, MS, USA

COL (Ret) Reginald W. Howard, MS, USA

Abstract

Military social workers are facing transformative times in that demand for military social work has increased and become 

more complex, challenging, and diverse due to the last 13 years of combat experiences. Developing military social work 

leaders must be deliberate, continuous, and progressive in order to impact and improve organizational performance in 

the healthcare delivery system. The transformational leadership model has been proven to be effective in both the military and social service organizations. The strength of this leadership model coincides well with the values of the social 

work profession. Incorporating leadership development in a clinical Master of Social Work program has the potential to 

improve service provision and offer strategies for military social workers to effectively manage the ongoing challenges 

in the field of social work.

Over the last decade, military social work became more 

complex, challenging, and diverse due to ever-evolving 

changes in military operations, budget constraints due 

to sequestration, and anticipated reductions in force 

structure. Furthermore, the consolidation of behavioral 

healthcare teams combined with ongoing media coverage of the psychosocial effects of wartime deployments 

have further intensified expectations from stakeholders. Demand for behavioral health services has steadily risen from operational and combat support brigade 

leaders, active-duty service members, and their families, all of whom reasonably expect clinical providers to 

understand the deployment and home front challenges 

imposed on them by an extended period of continuous 

conflict. To further compound matters, rising healthcare costs have necessitated constant review, analysis, 

and revisions to healthcare business practices. Relatedly, 

there is a persistent need to synchronize and standardize Army behavioral healthcare services which has led 

to the creation of multidisciplinary behavioral health 

departments and the integration of behavioral healthcare in primary care settings. Therefore, military social 

workers can expect to be called upon to perform in a 

variety of positions including clinical, staff, command, 

education, and training assignments. For these reasons, 

rigorous clinical education augmented with training in 

leadership models applicable to the human domain is increasingly important for military social workers. While 

many effective leadership models coincide well with the 

social work profession, transformational leadership emphasizes ways to manage more complex environments, 

improve performance, and influence organizational culture in a manner consistent with core social work values.

The Army-Fayetteville State University (FSU) Master 

of Social Work (MSW) Program educates future military social workers for the Army, Navy, and the Army 

National Guard. The program uniquely incorporates 

coursework in leadership development into a clinicallyfocused social work curriculum. Blending leadership 

skills with graduate level clinical education and training 

has the potential to increase organizational performance 

while enhancing the quality of care delivered to our 

military members and families. This article describes 

the current transformative times in military behavioral 

healthcare delivery and the challenges social work officers confront as members of the behavioral healthcare team. An evidence-based leadership model, and 

its connection to social work values, is presented as a 

best-practice approach to leading the behavioral health 

transformation. Implications for preparing military social work graduate students to meet the challenges of a 

demanding future are addressed.

Today’s Behavioral Healthcare Environment

Today’s military behavioral healthcare environment is 

undergoing a transformation that began with the attacks 

on 9/11/2001 and accelerated with the lengthy operations 

in Iraq and Afghanistan. There have been unpredictable 

and intense levels of urban combat and multiple, extended tours of duty which have resulted in behavioral health 

consequences1-3 and increased utilization rates of behavioral healthcare.1,2 Furthermore, research has shown that 

deployment stressors and combat exposure have inflicted significant health problems,4,5 challenges in family 

and close relationships,6 and can potentially impact a 

family member’s ability to become a caregiver.7,8

Moreover, 13 years of combat deployments will most 

likely produce long-term consequences for those individuals who have served in the warzone. The National Vietnam Veterans Readjustment Study (NVVRS) 

demonstrated that combat exposure leads to problems 

in family functioning years after returning from the 
4 http://www.cs.amedd.army.mil/amedd_journal.aspx

combat zone.9 Additionally, veterans with higher levels 

of war-related trauma and posttraumatic symptomatology exhibited more difficulties in family functioning and 

greater domestic violence than those without trauma.9

Reanalysis of NVVRS data revealed that, in addition to 

PTSD, alcoholism, depression, and anxiety were prevalent maladies in both male and female Vietnam veterans.9

Further research indicates that veterans exposed to high 

levels of warzone activity are significantly more likely 

to develop problems in psychosocial functioning than 

those with low exposure.10 Further, those with PTSD are 

more likely to report marital, parental, and other family 

adjustment problems, including domestic violence.11 In 

addition to psychosocial challenges, other potential longterm complications include physical difficulties and an 

increased risk for externally-caused mortality.12-14 Evidence suggests that the association of wartime service 

with various physical and behavioral health problems 

portends that the demand for military behavioral health 

services will remain high for the foreseeable future.

As the military begins to transition from its combat mission in Afghanistan, the focus will shift to resetting the 

force while simultaneously experiencing troop reductions and resource constraints.15 Anticipating these challenges, the Army Medical Command prepared “Army 

Medicine Strategy–The Road Ahead” based on 3 strategic imperatives: create capacity, enhance diplomacy, 

and improve stamina.16 To this end, “Behavioral Health 

Service Line Policy, Consolidated Army Behavioral 

Health” was published to establish a seamless system of 

behavioral healthcare designed to address the residual 

effects of the war within a resource constrained environment.17 The policy mandates a complete transformation 

from a traditional stovepipe* model of care to a proactive, integrated, metrics-driven and patient-centered 

behavioral health system. This more efficient structure 

unites psychiatry, psychology, and social work into a 

consolidated department of behavioral health within the 

medical treatment facility. Individuals qualified to lead 

a diverse behavioral healthcare delivery system will 

necessarily possess superior clinical expertise and the 

ability to efficiently manage limited resources while executing complex programs.17 Leadership that maximizes 

performance improvement, manages precious resources 

and mitigates the stress experienced by the behavioral 

health team is perhaps the critical factor in successfully 

transforming the behavioral healthcare system.

Leading in a Transforming Environment

Successfully navigating through a transformative 

environment requires leadership that can influence 

organizations to successfully adapt to the new practice 

milieu. In this setting, effective leadership combines 

expert clinical knowledge, management abilities, and a 

positive attitude to coordinate the work of diverse, specialized professionals to produce patient-centered service delivery. Ideally, these skills inspire trust in leadership and excellence in practice. As defined by Northouse,18 leadership is a process of influencing a group 

of individuals to achieve a common goal that is guided 

by the leader’s core values. Without the ability to influence, leadership does not exist. Leadership is not a trait 

or list of characteristics that reside in the leader; it is a 

transactional event that occurs between the leader and 

their team.18 Leadership in the current operational environment requires one to motivate a multidisciplinary 

team to provide quality healthcare services.

Transformational leadership emphasizes the interactive, 

relational aspects between the leader and the organization by inspiring the team to look beyond self-interest 

and work collectively for a greater purpose. Leaders and 

their team are transformed through a commitment to a 

higher set of moral values and a common goal.19 The 

transformational leadership model has 4 components: 

idealized influence, inspirational motivation, individualized consideration, and intellectual stimulation.20

Idealized influence involves the leader modeling appropriate behavior. Inspirational motivation entails the 

leaders’ abilities to motivate not simply through rewards 

and punishment, but largely by effective performance.21

Transformational leaders motivate their teams by encouraging them to transcend self-interests by making 

them more aware of desired outcomes and how their 

efforts impact the organization’s goals. Individualized 

consideration demonstrates genuine need and concern for team members; relationships energize action 

and build cohesion. Intellectual stimulation manifests 

through challenging individuals to rise to higher levels 

of performance.20 Leaders encourage others to think 

critically to introduce innovation and new ideas for improving outdated and unproductive practices. Transformational leaders activate higher order needs of the team 

by inspiring them to work toward common goals and encouraging individuals to reach their full potential while 

working within a value-based framework.22-24

Transformational Leadership and

Military Social Work

Social Work Officers have played a leading role in delivering behavioral health services during the past 13 

years of war, and have the potential to be transformative figures in shaping the future of military behavioral 

DEVELOPING EFFECTIVE LEADERSHIP COMPETENCIES IN MILITARY SOCIAL WORKERS

*A stovepipe model refers to an organization that has a structure which largely or entirely restricts the flow of information within the organization 

to strictly up and down lines of control, inhibiting or preventing cross-organizational communication.
October – December 2014 5

THE ARMY MEDICAL DEPARTMENT JOURNAL

health. Much of their potential is rooted in the goodness-of-fit between transformation leadership and social 

work practice. Clearly, the social work profession’s values of service, integrity, importance of human relationships, and dignity and worth of a person closely align 

with transformational leadership thinking. Similar to a 

transformational leader using inspirational motivation 

through a shared vision and goals, social workers are 

attracted to the profession with a passion to improve the 

lives of others. When in leadership positions, military 

social workers can use this passion and commitment to 

others to formulate a vision and arouse others to achieve 

these shared objectives. Military social work leaders derive professional, as well as personal, fulfillment from 

serving the organization rather than self-interests. As 

the transformational leadership model appreciates the 

importance of relationships, so to do social work professionals. In social work, the primary mission is to enhance well-being and helping to meet the basic human 

needs of all people.25 As described by Pumphrey,26 social workers believe that every person should be regarded as having infinite worth, and positive change can be 

accelerated by purposeful assistance and active encouragement from others. Relationships are the vehicle for 

positive change and growth. These core principles become instrumental in developing an organizational vision and are fundamental motivators for social workers 

in practice. Conveying this principle through “leading 

by example” provides others with a motivation, or purpose, greater than themselves. Transformational leadership focuses on the leader-team relationship in forming 

a foundation to work toward the greater good; the underlying belief is that all leadership, at its core, is relational.

Others have described the merits of transformational leadership and have provided empirical evidence to support 

incorporating it into human service organizations. Fisher 

encouraged social workers to learn more about motivation and leadership and identified transformational leadership as a framework to consider adopting in practice.21

The values inherent in leading from a transformational 

perspective have made it a common theme among social 

work leaders with some supervisors intuitively applying 

its principles.27,28 Research has demonstrated that factors 

associated with transformational leadership are significantly correlated with social work leader outcomes of effectiveness, satisfaction, and extra effort.29,30 Qualitative 

data have shown that transformational leadership could 

be a contributing factor in understanding the potential 

impact that social workers may have in influencing positive change in the complex child welfare system.31 This 

leadership style satisfies the need to identify and define 

core attributes of effective leadership in a simple, clear, 

relevant, and consensually acceptable manner.32

Developing Leaders in the Army-FSU MSW Program

In the Army, leadership development is a deliberate, 

continuous, sequential, and progressive process that occurs within a value-based framework.33 In addition to 

providing direct clinical care, social work officers are 

expected to assume leadership roles with increasing levels of responsibility as they gain active-duty experience. 

Therefore, to develop military social workers prepared 

to succeed in today’s complex and dynamic healthcare 

environment, it is important to augment traditional professional military education with specialized leadership 

training early in their careers.

The Army-FSU MSW program, based at the Army 

Medical Department Center and School, was established in 2007 to help fill a critical shortage of behavioral health providers with active-duty social workers. 

The program’s curriculum was designed to produce 

clinical social workers with a concentration in mental 

health and substance use treatment. As the program 

evolved, it became clear that the clinical education and 

training should be supplemented with an additional 

emphasis on leadership. Therefore, leadership development strategies were infused throughout the curriculum 

and augmented with a distinct course on management 

and leadership. The course highlights unique aspects 

of managing behavioral health operations in a military 

environment that includes legal/ethical considerations, 

constructing a business case analysis, and exercising 

quality management with an emphasis on the credentialing process. Students learn principles of effective 

management styles that develop skills in team building, 

encourage participatory decision-making, and promote 

organizational productivity consistent with transformational leadership theory. As a way of establishing vertical integration between practice competencies, students 

are tasked to develop a comprehensive strategic plan to 

guide a community-based social service program they 

designed in a previous course. The assignment requires 

students to apply critical thinking to understand the 

importance of stating a clear vision, defining an organization’s mission, and creating quantifiable objectives 

from a leadership perspective. Particularly relevant to 

social work leadership, an emphasis is placed on the importance of developing positive relationships with both 

supervisors and subordinates through effective communication that empowers others to make good decisions. 

The course’s capstone assignment requires students to 

deliver a presentation that articulates their leadership 

philosophy and management style, and establishes clear 

expectations for team members.

In order to infuse leadership development throughout 

the curriculum, faculty members were purposely and 
6 http://www.cs.amedd.army.mil/amedd_journal.aspx

carefully selected. Currently, the 8 faculty members 

have over 160 years of clinical and leadership experience as active-duty social work officers. Their experience enables them to incorporate leadership principles 

and competencies in all foundation and concentration 

courses. Additionally, throughout the 14 months of education and training, senior military social workers are 

invited to lecture on proven leadership strategies that 

have been instrumental in improving organizational 

performance, policy development, and operational planning. To augment classroom leadership instruction during the Social Work Internship Program, students must 

complete 10 web-based modules from the Joint Medical 

Skills Institute which enhance their classroom instruction. Topics include labor relations, human resources, 

conflict management, coaching, counseling, and mentoring. Evidence thus far, based on the performance of 

the program’s 131 graduates, suggests that the approach 

used by the Army’s MSW program has been effective. 

As of March 2014, 96% have passed the Licensed Master of Social Work examination on their first attempt, 

surpassing the 82% national rate.34 Perhaps more importantly, of the 38 who have further completed their 

2-year Social Work Internship and have become independent providers, almost all have deployed with combat brigades to Afghanistan. Furthermore, they serve 

in vital positions in operational units located overseas 

as leaders of family advocacy teams within the medical 

treatment facilities and in command of a combat stress 

control detachment.

Observations and Conclusions

Leadership is an essential military skill. Therefore, 

skillful leadership can shape the well-being of military 

healthcare organizations and influence the quality of 

care provided. As the operating environment becomes 

increasingly challenging, positive leadership may be the 

decisive factor in determining future success. This is 

certainly true in today’s military behavioral health sector. The transforming operational context, declining 

resources, evolving business practices, and increased 

demand for services have underscored the need for effective leadership strategies. For military social work to 

contribute to accomplishing our shared mission, the following observations are offered:

3⁄4 Social Work Officers must develop evidence-based 

clinical competencies as well as leadership skills 

that are effective across a diverse range of operational and healthcare settings.

3⁄4 Military social workers operate in a distinctive environment with unique demands and challenges. 

Developing professionals who can flourish under 

these conditions is best accomplished by training 

them in a military-centric training program early in 

their careers.

3⁄4 Leadership skills can be learned through education 

and sharpened with experience. Integrating leadership training with social work core values in the 

Army’s MSW curriculum prepares future leaders 

to solve tomorrow’s problems.

3⁄4 As social work officers demonstrate abilities to succeed in positions with increasing levels of responsibility, they should be assigned to leadership positions commensurate with their rank.

Social work officers understand the military culture and 

are prepared to provide consultation to unit commanders, advocate for service members, and lead behavioral healthcare teams. The strengthening of leadership 

talents in military social workers early in their career 

development has the potential to enhance behavioral 

health outcomes. While further program evaluation is 

necessary to fully understand the impact of incorporating leadership education into a clinical MSW curriculum, we believe that to effectively prepare officers for 

military social work practice, graduate education must 

include specialized leadership training.

References

1. Hoge CW, Auchterlonie JS, Milliken CS. Mental 

health problems, use of mental health services, 

and attrition from military service after returning 

from deployment to Iraq or Afghanistan. JAMA. 

2006;295(9):1023-1032.

2. Smith TC, Ryan MA, Wingard DL, et al. New onset and persistent symptoms of posttraumatic stress 

disorder self-reported after deployment and combat 

exposures: prospective population based US military cohort study. BMJ. 2008;336(7640):366-371.

3. Jacobson IG, Ryan MAK, Hooper TI, et al. Alcohol use and alcohol-related problems before 

and after military combat deployment. JAMA. 

2008;300(6):663-675.

4. Tanielian T, Jaycox LH. InvisibleWounds of War: 

Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Santa 

Monica, CA: RAND Corporation; 2008.

5. Hoge CW, Castro CA, Messer, SC, McGurk D, 

Cotting DI, Koffman RL. Combat duty in Iraq and 

Afghanistan, mental health problems, and barriers 

to care. New Engl J Med. 2004;351:13-22.

6. Karney BR, Crown JS. Families Under Stress: An 

Assessment of Data, Theory, and Research on Marriage and Divorce in the Military. Santa Monica, 

CA: RAND Corporation; 2007.

7. Galovski T, Lyons JA. Psychological sequelae of 

combat violence: A review of the impact of PTSD 

on the veteran’s family and possible intervention. 

Aggress Violent Behav. 2004;9(5):477-501.

DEVELOPING EFFECTIVE LEADERSHIP COMPETENCIES IN MILITARY SOCIAL WORKERS
October – December 2014 7

THE ARMY MEDICAL DEPARTMENT JOURNAL

8. Figley CR. Coping with stressors on the home front. 

J Soc Issues. 1993:49(4):51-71.

9. Kulka RA, Schlenger WE, Fairbank JA, et al. Contractual Report of Findings from the National Vietnam Veterans Readjustment Study. Research Triangle Park, NC: Research Triangle Institute; 1988. 

Available at: http://www.ptsd.va.gov/professional/

research-bio/research/nvvrs-docs.asp. Accessed 

July 15, 2014.

10. Jordan BK, Schlenger WE, Hough R, et al. Lifetime and current prevalence of specific psychiatric 

disorders among Vietnam veterans and controls. 

Arch Gen Psychiatry. 1991;48:207-215.

11. Jordan BK, Marmar CR, Fairbank JA, et al. Problems in families of male Vietnam veterans with 

posttraumatic stress disorder. J Consult Clin Psychol. 1992; 60(6):916-926.

12. O’Toole BI, Catts SV, Outram S, Pierse KR, Cockburn J. The physical and mental health of Australian Vietnam veterans 3 decades after the war 

and its relation to military service, combat, and 

posttraumatic stress disorder. Am J Epidemiol. 

2009;170(3):318-330.

13. Yaffe K, Vittinghoff E, Lindquist K, et al. Posttraumatic stress disorder and risk of dementia among US 

veterans. Arch Gen Psychiatry. 2010;67(6):608-613.

14. Boscarino JA. Posttraumatic stress disorder 

and mortality among US Army veterans 30 

years after military service. Ann Epidemiol. 

2006;16(4):248-256.

15. Army 2020: Generating Health and Discipline 

in the Force Ahead of the Strategic Reset-Report 

2012. Washington, DC: US Dept of the Army; 2012. 

Available at: http://usarmy.vo.llnwd.net/e2/c/down

loads/235822.pdf. Accessed July 15, 2014.

16. Horoho PD, Brock DA. Army Medicine Strategy, 

The Road Ahead. Washington, DC: Office of the 

Army Surgeon General; 2012. Available at: http://

www.afgedefcon.org/sites/default/files/resources/

Army%20Medicine%20Strategy%202020.pdf. Accessed December 15, 2013.

17. US Army Medical Command. Memorandum: Behavioral Health Service Line Policy, Consolidated 

Army Behavioral Health (BH). October 29, 2013. 

OTSG/MEDCOM Policy Memo 13-059.

18. Northouse PG. Leadership: Theory and Practice. 

6th ed. Thousand Oaks, CA: SAGE Publications, 

Inc; 2013.

19. Burns JM. Leadership. New York, NY: Harper & 

Row; 1978.

20. Bass BM, Riggio RE. Transformational Leadership. New York, NY: Psychology Press; 2006.

21. Fisher E. Motivation and leadership in social work 

management: a review of theories and related studies. Adm Soc Work. 2009;33:347-367.

22. Yukl G. Leadership in Organizations. 6th ed. Upper Saddle River, NJ: Prentice Hall; 2006.

23. Bass BM. Bass & Stogdill’s Handbook of Leadership: Theory, Research & Managerial Applications. 

New York, NY: The Free Press; 1990.

24. Avolio BJ. Full Leadership Development: Building 

the Vital Forces in Organizations. Thousand Oaks, 

CA: SAGE Publications, Inc; 1999.

25. Code of Ethics of the National Association of Social Workers. Washington, DC: National Association of Social Workers; 2008. Available at: http://

www.socialworkers.org/pubs/code/default.asp. Accessed July 16, 2014.

26. Pumphrey MW. The Teaching of Values and Ethics 

in Social Work. New York, NY: Council on Social 

Work Education; 1959.

27. Bargal D, Schmid H. Recent themes in theory and 

research on leadership and their implications for 

management of the human services. Adm Soc Work. 

1989;13:37-54.

28. Arches JL. Connecting to communities: transformational leadership from Africentric and feminist 

perspectives. J Sociol Soc Welf. 1997;24:113-124.

29. Gellis ZD. Social work perceptions of transformational and transactional leadership in health care. 

Soc Work Res. 2001;25:17-25.

30. Mary N. Transformational leadership in human service organizations. Adm Soc Work. 2005;29:105-118.

31. McGuire LE, Howes P, Murphy-Nugen A, George 

K. Leadership as advocacy: the impact of a title 

IV-E supported MSW education on a public child 

welfare agency. J Public Child Welf. 2011;5:213-233.

32. Holosko MJ. Social work leadership: identifying core attributes. J Hum Beh Soc Env. 

2009;19:448-459.

33. Field Manual 6-22: Army Leadership: Confident, 

Competent, and Agile. Washington, DC: US Dept 

of the Army; October 12, 2006.

34. Association of Social Work Boards. Exam Candidates: Pass rates [2013]. Available at http://www.

aswb.org/exam-candidates/about-the-exams/passrates/. Accessed June 12, 2014.

Authors

COL Humphries is Program Director, Army-Fayetteville 

State University Master of Social Work Program, Army 

Medical Department Center and School, Joint Base San 

Antonio Fort Sam Houston, Texas.

COL (Ret) Howard is the Social Work Internship Program Coordinator, Army Medical Department Center 

and School, Joint Base San Antonio Fort Sam Houston, 

Texas.
8 http://www.cs.amedd.army.mil/amedd_journal.aspx

The structure of units providing combat stress control 

has continued to develop through lessons learned from 

various wars and conflicts since the Revolutionary War 

into the US Army’s current Combat and Operational 

Stress Control (COSC) detachments. The Army learned 

in World War I that treating Soldiers far forward under 

the principles of brevity, proximity, and immediacy improved a Soldier’s ability to return to duty while decreasing the likelihood of developing worsening psychiatric 

conditions.1 Army behavioral health was then further 

influenced by lessons learned from Russia, France, and 

England, who also practiced providing behavioral health 

interventions far forward on the battlefield and experienced similar positive results.2

 Therefore, by the onset 

of World War II, psychiatrists had been placed in most 

Army divisions, and the first trials of restoration care for 

Soldiers were implemented in “Training and Rehabilitation [T&R] Centers.” Soldiers sent to these T&R Centers 

practiced battle drills daily and maintained an exercise 

routine while at the site. Along with the value of restoration, World War II demonstrated that allowing Soldiers 

to remain a part of their unit positively affected unit cohesion and prevented further deterioration of psychiatric 

symptoms.2 As such, the first battlefield psychiatric care 

units, called “KOs,” were developed. These were teams 

of behavioral health providers who could deploy and 

maneuver far forward on the battlefield to provide consultive support. The first KO team deployed to Vietnam 

in 1965 was made up of 23 behavioral health personnel: 

a psychiatrist, a neurologist, a social worker, a psychologist, and a psychiatric nurse; and enlisted psychology, 

social work, and neuropsychiatric specialists.2 Following the Vietnam War, the KO teams were renamed OM 

teams in the new table of organization and equipment 

(TO&E), and differed by the OM’s increased ability to 

maneuver on the battlefield. The personnel required for 

the OM teams grew with the addition of the commander 

and executive officer, and could divide into 3 mobile 

consultation teams and one treatment section. This personnel structure is very similar to the personnel structure of the current COSC detachment.2

In 1989, the newly proposed TO&E renamed the OM to 

“Combat Stress Control” (CSC) units and detachments. 

The TO&E organized the new CSC’s 23 personnel into 

a Prevention Section and a Restoration Section. The 

Prevention Section was designed to support troops far 

forward and the Restoration Section was designed to 

provide 1 to 3 days of restoration while also having the 

capability of sending behavioral health teams far forward to support prevention teams if necessary. This new 

TO&E was approved by the Department of the Army, 

however, it was not supported with resources until after 

the Persian Gulf War (1991). Consequently, at the onset 

of the Persian Gulf War, the CSC units had not been 

fielded with personnel and equipment, thus requiring 

the rapid deployment of personnel from multiple installations who had not trained as a unit prior to the deployment.3 Lessons learned from the Persian Gulf War validated and supported the rapid fielding of personnel and 

equipment for the CSC detachments and units. On December 16, 1992, the 528th CSC was the first CSC unit 

activated.3 Since then, many lessons have been learned 

during support of operations in Somalia, Haiti, Guantanamo, Bosnia, Iraq, and Afghanistan. 

Today’s combat stress control services operate under 

the doctrine established in Field Manual (FM) 4-02.51,

4

which was published in July 2006. While FM 4-02.51

guides the COSC detachment doctrinally, the TO&E 

establishes the COSC personnel and equipment authorizations. The current COSC detachment TO&E was 

Evolution of the Combat and Operational

 Stress Control Detachment

MAJ Jason I. Dailey, MC, USA

CPT Victoria L. Ijames, MS, USA

Abstract

Medical units designed to provide combat and operational stress control services have evolved since World 

War II into the current Combat and Operational Stress Control (COSC) detachments. Yet the structure of 

these COSC detachments differ greatly between what is authorized in the table of organization and equipment 

(TO&E) and what is doctrinally described in the current field manual guiding combat and operational stress 

control operations. We therefore explore the evolution of the COSC detachment, compare the organizations 

found in current doctrine with that currently authorized on the TO&E, and conclude with a proposed structure 

of a modern COSC detachment that is functionally modular with more clear chains of command.
October – December 2014 9

approved in 2009 and has since undergone minor modifications. Interestingly, while the mission for the COSC 

detachment on the TO&E and FM 4-02.51 are similar, 

there are significant differences in the structure and 

manning of the detachment between the 2 documents. 

This article explores the differences between the “doctrinal” structure of the COSC detachment as found in 

FM 4-02.51 and the “TO&E” structure as found in the 

Fiscal Year 2015 (FY15) TO&E before presenting a proposed COSC structure that we believe better conforms 

to current operational needs.

Conflicting Structures of the COSC Detachment

Current doctrine as established in FM 4-02.514 splits 

the COSC detachment into 3 sections as shown in Table 1. The Headquarters Section consists of the primary 

command and control elements and limited support personnel. The Fitness Section is comprised of 2 teams of 

10 personnel each: a psychiatrist, an occupational therapist, 2 occupational therapy noncommissioned officers 

(NCOs), 2 behavioral health specialist NCOs, and 3 

junior behavioral health specialists. Finally, the Preventive Section is comprised of 4 teams of 4 personnel 

each: a psychologist, a social worker, a behavioral health 

specialist NCO, and a junior behavioral health specialist. The Fitness Section is designed with the capability 

of split-based advanced behavioral health treatment and 

restoration services primarily in an area support role, 

including operation of a psychiatric ward when necessary.4

 By contrast, the Preventive Section teams are designed to support brigade-sized units with more limited, 

though more mobile, behavioral health treatment and 

unit needs assessment services.

In contrast, the current FY15 TO&E* for the COSC detachment has a much different structure than that found 

in current doctrine. Table 2 presents the structures of 

the Main Support Element and the Forward Support 

*Restricted access document

Table 1. Current Combat and Operational Stress Control Detachment Organization and Structure as Established in

FM 4-02.51.

4

Headquarters Section Fitness Section Preventive Section

AOC

or

MOS

Position AOC

or

MOS

Position AOC

or

MOS

Position

05A Commander 60W Psychiatrist 73B Psychologist

70B Field Medical Assistant 65A Occupational Therapist 73A Social Worker

68X40 Detachment Sergeant 66R Psychiatric Nurse Practitioner 68X20 Behavioral Health NCO

92Y20 Supply Sergeant 68L20 Occupational Therapy NCO 68X10 Behavioral Health Specialist

42A10 Human Resource Specialist 68L20 Occupational Therapy NCO 73B Psychologist

91B10 Wheeled Vehicle Mechanic 68X20 Behavioral Health NCO 73A Social Worker

92G10 Cook 68X20 Behavioral Health NCO 68X20 Behavioral Health NCO

68X10 Behavioral Health Specialist 68X10 Behavioral Health Specialist

68X10 Behavioral Health Specialist 73B Psychologist

68X10 Behavioral Health Specialist 73A Social Worker

60W Psychiatrist 68X20 Behavioral Health NCO

65A Occupational Therapist 68X10 Behavioral Health Specialist

66R Psychiatric Nurse Practitioner 73B Psychologist

68L20 Occupational Therapy NCO 73A Social Worker

68L20 Occupational Therapy NCO 68X20 Behavioral Health NCO

68X20 Behavioral Health NCO 68X10 Behavioral Health Specialist

68X20 Behavioral Health NCO

68X10 Behavioral Health Specialist

68X10 Behavioral Health Specialist

68X10 Behavioral Health Specialist

AOC indicates area of concentration (officers).

MOS indicates military occupational specialty (enlisted).
10 http://www.cs.amedd.army.mil/amedd_journal.aspx

Element, each of which have a nearly identical structure 

of 6 teams of 3 personnel each: a provider, an NCO, and 

a junior specialist.5 Compared to the doctrinal structure 

in Table 1, the TO&E structure adds a chaplain, chaplain assistant, and a generator mechanic. Missing, however, are the human resource specialist and cook from 

the Headquarters Detachment. The TO&E structure 

therefore allows easier split-based operations between 

the 2 primary support elements, while maintaining simplicity by keeping nearly identical structures. In essence, 

each of these support elements acts as a “mini-COSC” 

detachment in that each is capable of both restoration 

and treatment missions in the split-based environment, 

compared to the doctrinal structure which functionally 

aligned restoration services into one section and treatment services into another. Moreover, the addition of a 

unit ministry team (chaplain and chaplain assistant) in 

the TO&E structure provides an additional resource for 

the COSC mission.

Proposed Structure of the COSC Detachment

In general, the authors’ experience in recent conflicts 

in Afghanistan and Iraq support a COSC structure that 

includes a single primary restoration center capable of 

split-based operations only in extreme circumstances in 

a particularly large area of operations, as well as several 

modular treatment teams consisting of 1 to 2 providers 

supported by an NCO and a junior enlisted behavioral 

health specialist. Recent history indicates that 2 restoration centers are rarely necessary at the expense of more 

forward treatment teams. In those situations where the 

area of operations is large enough to support 2 restoration centers, it is often more reasonable to deploy a second COSC detachment. This was most recently seen in 

Operation Enduring Freedom during which the reduction from 2 Army COSC detachments to one (supported 

by elements from the US Air Force) only occurred after 

the closing of restoration services at Kandahar Airfield 

in 2013 after which all restoration services were consolidated at Bagram Airfield.

Table 2. Current Combat and Operational Stress Control Detachment Organization and Structure as Published in

FY15 TO&E.

Headquarters Section Main Support Element Forward Support Element

AOC

or

MOS

Position AOC

or

MOS

Position AOC

or

MOS

Position

05A Commander 60W *Psychiatrist 60W *Psychiatrist

68X40 Detachment Sergeant 68L20 Occupational Therapy NCO 68X20 Team Chief

70B Executive Officer 68X10 Behavioral Health Specialist 68X10 Behavioral Health Specialist

92Y20 Supply NCO 73B *Psychologist 73B Psychologist

91B10 Vehicle Mechanic 68X20 Team Chief 68X30 Behavioral Health NCO

91D10 Generator Mechanic 68X10 Behavioral Health Specialist 68X10 Behavioral Health Specialist

56A Chaplain 73A *Social Worker 73A Social Worker

56M10 Chaplain Assistant 68L10 Occupational Therapy Specialist 68X20 Team Chief

68X10 Behavioral Health Specialist 68X10 Behavioral Health Specialist

67D *Behavioral Science Officer 67D *Behavioral Science Officer

68X20 Team Chief 68X10 Behavioral Health Specialist

68X10 Behavioral Health Specialist 68L10 Occupational Therapy Specialist

66R *Psychiatric Nurse Practitioner 66R *Psychiatric Nurse Practitioner

68X20 Team Chief 68L20 Occupational Therapy NCO

68X10 Behavioral Health Specialist 68X10 Behavioral Health Specialist

65A Occupational Therapist 65A Occupational Therapist

68X30 Behavioral Health NCO 68X20 Team Chief

68X10 Behavioral Health Specialist 68X10 Behavioral Health Specialist

*Position not staffed in garrison. Staffed with predesignated active duty health professionals by the AMEDD Professional Filler System for 

deployments.

AOC indicates area of concentration (officers).

MOS indicates military occupational specialty (enlisted).

EVOLUTION OF THE COMBAT AND OPERATIONAL STRESS CONTROL DETACHMENT
October – December 2014 11

THE ARMY MEDICAL DEPARTMENT JOURNAL

As such, the optimal structure of the COSC detachment 

would seem to be more akin to that listed within current 

doctrine with a functional organization consisting of a 

restoration-focused section and a separate treatmentfocused section, rather than splitting these functional areas into 2 identical combined sections as per the current 

TO&E. Nonetheless, the addition of a unit ministry team 

to the TO&E has proven beneficial, and the addition of 

a generator mechanic is of obvious use in an austere environment.5

 The loss of a human resources technician in 

the move from doctrine to the current TO&E has resulted in the loss of orderly room functionality within the 

headquarters section, and there is also no one specifically identified in either the doctrinal or TO&E structure 

to handle training room functions in garrison. Finally, 

while a cook is likely not an important requirement 

when comparing the personnel in Tables 1 and 2, the 

addition of a communications specialist (MOS* 25U10) 

would be immensely helpful given the large amount of 

communication equipment required for the detachments 

including radios, Blue Force Trackers, and computers.

While these issues pertain primarily to the US Army 

rather than joint units and doctrine, the Doctrine, Organization, Training, Materiel, Leadership and Education, 

Personnel, Facilities, and Policy (DOTmLPF-P) analysis 

process can nonetheless be used given that new materiel 

solution development is unnecessary, as delineated by 

the Joint Capabilities Integration and Development System (JCIDS) Manual.6

 To summarize the above discussion within the DOTmLPF-P context:

Current doctrine is decidedly out of date given subsequent changes to the TO&E, while this TO&E organization of the COSC detachment is ill-suited for the 

current and foreseeable missions described above.

Although training, materiel, and leadership and education issues are beyond the scope of this paper, it 

is evident that some personnel gaps do exist in the 

areas of communications and patient administration.

Finally, there are no facilities issues identified herein, 

nor would any policy issues predictably affect the 

other 7 areas to any significant degree.

The Figure presents a proposed structure of a modern 

COSC detachment which we believe better matches current operational needs while minimally changing current manning requirements as documented in the FY15 

TO&E. The Headquarters Platoon includes a communications specialist to operate and maintain the assigned 

communication equipment, as well as a patient administration specialist to track patients while deployed and 

to run the orderly room while in garrison. A behavioral 

health NCO is also moved to the Headquarters Platoon 

to maintain the training room activities. The Restoration Platoon in turn incorporates all the occupational 

therapy, treatment, and unit ministry personnel necessary to run a restoration center. Finally, the Treatment 

Platoon consolidates all other providers and behavioral 

health specialists into 4 treatment teams, each consisting of 1 to 2 providers, a behavioral health NCO, and a 

junior behavioral health specialist.

To better delineate a clear chain of command, an occupational therapist is identified as the Restoration Officerin-Charge (OIC) while the authorized social worker is 

identified as the Clinical Operations OIC, both acting 

as platoon leaders in their respective platoons. The E-6 

psychiatric technicians (68X30) are similarly identified as platoon sergeants in their respective platoons. 

Moreover, the proposed COSC structure in the Figure 

incorporates the functional modularity of the doctrinal 

structure compared to the TO&E structure, and can accordingly deploy sections of the detachment based on 

operational needs with ease. For example, the authors’ 

experience with the FY14/15 Defense CBRN† Response 

Force mission for defense support of civil authorities 

missions within Army Northern Command has shown 

that while a restoration center may not be necessary in 

the relatively short duration deployments required for 

this mission, individual teams from the Treatment Platoon could easily be deployed depending on the size of 

the mission, while maintaining established chains of 

command.

Conclusion

In a recent AMEDD Journal article, MG Steve Jones 

cited the need to “redesign medical units to make them 

more expeditionary and capable.... We will be flexible and responsive when supporting combatant commanders. They tell us the capabilities they need and we 

provide them quickly.” 7 To that end, we must continually examine the structure of medical units such as the 

COSC detachment to validate their conformation to 

these guiding principles. In the case of providing combat and operational stress control in a wide range of 

missions—from defense support to civil authorities, to 

expeditionary care in an unimproved battlefield, to support of stability operations as recently seen in Operation 

Enduring Freedom and Operation Iraqi Freedom—this 

“flexible and responsive” structure is likely best achieved 

through a return to doctrinal principles with the addition of a few added capabilities as described above and 

illustrated in the Figure. With this proposed functional 

*Military occupational specialty †Chemical, biological, radiological, nuclear
12 http://www.cs.amedd.army.mil/amedd_journal.aspx

modular organization featuring more clearly delineated 

chains of command, the COSC detachment is capable 

of responding quickly to a wide array of missions when 

called upon by combatant commanders, and training 

and manning can also be prioritized between platoons 

depending on the mission identified at that time. Finally, the above proposed structure represents minimal 

changes to the net number of personnel by MOS such 

that changes can be made quickly throughout the US 

Army and US Army Reserve without significant disruption to individual units. A separate analysis for the US 

Air Force and US Navy may be required given their different baseline structures and available personnel.

As a learning organization, the Army must continually 

revalidate processes and unit structures to maintain 

relevancy in the modern operational environment. We 

must not forget past lessons learned, however, and realize that sometimes a return to past doctrine is, ironically, 

the best way to move forward. The COSC detachment 

has certainly made significant strides since World War 

II Training and Rehabilitation Centers and Vietnam era 

KO Teams. With a few changes to the TO&E documents 

that guide manning and structure, the COSC detachment 

can continue to evolve into the flexible and responsive 

Headquarters

Platoon

Vehicle

Mechanic

(91B10)

Executive

Officer

(70B)

Training NCO

(68X20)

Patient Admin/

Orderly

(68G10)

Generator

Mechanic

(91D10)

Supply NCO

(92Y20)

Communication

(25U10)

Commander

(05A)

Detachment

Sergeant

(68X40)

*Behavioral

Science

Officer

(67D)

*Psychiatric

Nurse

Practitioner

(66R)

Officer-in-Charge

Clinical

Operations

(73A)

Treatment

Platoon

Platoon

Sergeant

(68X30)

Team Chief

(68X20)

Team Chief

(68X20)

Team Chief

(68X20)

Team Chief

(68X20)

*Psychiatrist

(60W)

*Psychologist

(73B)

*Social

Worker

(73A)

*Psychiatric

Nurse

Practitioner

(66R)

*Behavioral

Science

Officer

(67D)

Behavioral

Health

Specialist

(68X10)

Behavioral

Health

Specialist

(68X10)

Behavioral

Health

Specialist

(68X10)

Behavioral

Health

Specialist

(68X10)

Proposed structure for the Combat and Operational Stress Control Detachment. Designators in parentheses are either area of 

concentration (officers) or military occupational specialty (enlisted).

*Position not staffed in garrison. Staffed with predesignated active duty health professionals by the AMEDD Professional Filler System 

for deployments.

Chaplain

Assistant

(56M10)

Chaplain

(56A)

Occupational

Therapy

Specialist

(68L10)

Occupational

Therapy NCO

(68L20)

Restoration

Platoon

*Occupational

Therapist

(65A)

Platoon

Sergeant

(68X30)

Restoration

Officer-in-Charge

(65A)

Team Chief

(68X20)

Team Chief

(68X20)

*Psychiatrist

(60W)

*Psychologist

(73B)

Behavioral

Health

Specialist

(68X10)

Behavioral

Health

Specialist

(68X10)

Behavioral

Health

Specialist

(68X10)

Behavioral

Health

Specialist

(68X10)

Behavioral

Health

Specialist

(68X10)

Behavioral

Health

Specialist

(68X10)

Officer-in-Charge

Restoration

(65A)

EVOLUTION OF THE COMBAT AND OPERATIONAL STRESS CONTROL DETACHMENT
October – December 2014 13

THE ARMY MEDICAL DEPARTMENT JOURNAL

medical unit necessary for the wide variety of combat 

and operational stress control missions expected in the 

foreseeable future.

References

1. Jones FD. Psychiatric lessons of war. In: Davis LB, 

senior ed. War Psychiatry. Fort Sam Houston, TX: 

Borden Institute; 1995:1-34.

2. Cline WR, Fagan J, Franklin JD, Koshes RJ, Rock 

NL, Stokes JW. US Army combat psychiatry. In: 

Davis LB, senior ed. War Psychiatry. Fort Sam 

Houston, TX: Borden Institute; 1995:149-176.

3. Bacon BL, Staudenmeier JJ. A historical overview 

of combat stress control units of the US Army. Mil 

Med. 2003;168:689-693.

4. Field Manual 4-02-51. Combat and Operational 

Stress Control. Washington, DC: US Dept of the 

Army; July 6, 2006.

5. Mattila AM, Crandall BD, Goldman SB. US Army 

combat operational stress control throughout the 

deployment cycle: a case study. Work. 2011;38:13-18.

6. Manual for the Operation of the Joint Capabilities 

Integration and Development System. Washington, 

DC: Chairman, Joint Chiefs of Staff; January 19, 

2012. Available at: https://dap.dau.mil/policy/Docu

ments/2012/JCIDS%20Manual%2019%20Jan%20

2012.pdf. Accessed August 04, 2014.

7. Jones S. An Army and an AMEDD in transition. 

US Army Med Dep J. April-June 2014:1-2.

Authors

MAJ Dailey is the Commander, 212th Medical Detachment (COSC), Fort Campbell, Kentucky.

CPT Ijames is the Officer-in-Charge, Clinical Operations, 212th Medical Detachment (COSC), Fort Campbell, Kentucky.
14 http://www.cs.amedd.army.mil/amedd_journal.aspx

Over the past decade, much has been written about the 

psychosocial sequelae experienced by military personnel during an extended period of continuous conflict. 

Shortly after operations commenced, Hoge and colleagues provided a first look at Soldiers and Marines 

that had deployed to Iraq or Afghanistan and found that 

many met the screening criteria for major depression, 

generalized anxiety, or posttraumatic stress disorder 

(PTSD).1 Afterwards, others linked contemporary combat deployments to alcohol misuse,2,3 sleep disturbance,4

aggression,5 risk-taking behavior,6 mild traumatic brain 

injury (mTBI) and its related psychological and physical difficulties,7

 as well as supported the earlier findings of Hoge et al associating PTSD and depression 

with wartime deployments.8-12 In a descriptive study of 

behavioral healthcare use by Soldiers conducting counterinsurgency (COIN) operations the authors reported 

anxiety and adjustment disorders to be common reasons 

Soldiers sought behavioral health support.13 Deployment 

experiences such as combat exposure and multiple combat tours have been identified as contributing factors for 

exhibiting post-traumatic stress symptoms after returning home.14 Evidence suggests that some individuals 

may be more vulnerable to psychological distress due to 

the role they play on the battlefield. Healthcare providers and those serving in combat occupations have been 

found to be at a greater risk for being diagnosed with 

new-onset PTSD and depression after serving in a combat zone.15 Others believed to be susceptible to postdeployment difficulties, such as those who had expressed 

suicidal ideation, displayed behavioral disturbances, or 

experienced strained partner relationships while deployed, have reportedly benefited from early intervention to mitigate the risk of difficulties developing during 

the postdeployment period.16 Furthermore, those who 

engage in warzone experiences that violate deeply held 

moral and ethical beliefs are thought to be at-risk for 

adverse psychological outcomes.17

While a great deal has been learned about the personal 

struggles stemming from current wartime service, we 

have yet to fully explore contextual influences on the development of psychosocial disturbances. This is potentially an important distinction given the evolution of the 

military strategy, tactics, techniques, and procedures 

employed over the course of 2 lengthy overseas contingencies. The wars in Afghanistan and Iraq began as 

conventional operations. However, beginning with the 

surge in combat deployments to Operation Iraqi Freedom in 2007, COIN emerged as the nation’s prevailing 

strategic paradigm. Implementing a COIN strategy in 

Iraq, at the time considered somewhat controversial,18

is widely credited with establishing a more secure and 

stable environment prior to the 2011 withdrawal of US 

combat units. In 2010, in an attempt to leverage lessons 

learned from the successes gained in Iraq, COIN was 

formally adopted in Afghanistan, supported by a modest troop surge of its own. Historically, the fundamental 

objective of COIN is to sever the connection between 

insurgents and the populace by providing security and 

enhancing local living conditions.19 Adjusting tactics to 

fit the new strategy involved changing the operational 

The Psychosocial Challenges of Conducting

 Counterinsurgency Operations

COL Derrick Arincorayan, MS, USA

Larry Applewhite, PhD

MAJ Veronica Almeida, MS, USA

MAJ Erica DiJoseph, MS, USA

MAJ Charles Romero, MS, USA

Abstract

Counterinsurgency (COIN) operations have served as the fundamental component of the nation’s military 

strategy. Without the established boundaries of conventional operations, switching between diplomatic and 

combative roles can expose Soldiers to unique stressors when conducting COIN operations. An exploratory 

study of descriptive data obtained from a retrospective records review of 140 service members deployed to 

Operation Enduring Freedom identified and described problems in psychosocial functioning. Behavioral health 

records for the first 7 months of the deployment and throughout the first year of redeployment were reviewed. 

The most common problems reported by Soldiers were operational stress characterized by anxiety, fear, irritability, frustration, and isolation. Additionally, most of the Soldiers engaged services for psychosocial challenges within the first year of returning from deployment. Establishing reliable access to behavioral healthcare 

has emerged as an essential component of total force protection in COIN deployments.
October – December 2014 15

culture of coalition forces, reallocating resources, and 

overcoming bureaucratic challenges.20 In both theaters 

of operations, transitioning from conventional to irregular warfare created multiple challenges for the small unit 

leaders and Soldiers tasked with achieving COIN objectives. To succeed in a population-centric environment, 

military forces must understand local cultural dynamics and develop skills to operate in the human domain.21

Described as armed social work,22 COIN needs leaders 

that are not only tactically proficient, but who are also 

able to exercise keen social skills to meet the dual demands of being combat effective and culturally competent.23 From a tactical perspective, this means small 

unit leaders need the mental flexibility to interact with 

local sheiks and influential elders one day, and maneuver Soldiers to clear buildings of suspected insurgents 

the next.24 Furthermore, developing skills in “detective 

work” is useful for gathering evidence to build a case 

to justify detaining a suspected insurgent and, perhaps 

more importantly, to cultivate tactical sources, or confidential informants, who can be helpful in locating 

improvised explosive devices (IEDs) before they can 

be detonated.25,26 Moreover, executing the core tenets 

of COIN theory, to establish trust, improve life in the 

communities, and create a sense of security for the local 

populace, requires conducting dismounted patrols, targeted searches, and, when necessary, engaging the enemy within the constraints of strict rules of engagement 

to limit collateral damage.25 Achieving these seemingly 

contrasting tasks involves inherent risks as combining 

security patrols with engaging the local people necessitates putting “boots on the ground” and exposing 

Soldiers to enemy attack.26 Soldiers operating in such 

a fluid environment, which at times can seem counterintuitive, must be resilient and adaptable to the prolonged 

psychological and moral demands exerted by the COIN 

environment.27

Clearly, if COIN is to remain a central component of the 

nation’s military strategy, it is necessary that we further 

explore the threats to healthy psychosocial functioning 

encountered by service members. To that end, in this 

study we describe the psychosocial problems reported 

by service members both during and after their deployment to Afghanistan. Additionally, we address the challenges experienced by the Soldiers from the perspective 

of the complex nature of COIN missions. We conclude 

by offering observations to consider in supporting future COIN deployments.

Methodology

In this exploratory study we used a retrospective records 

review protocol to identify and describe the problems 

in psychosocial functioning reported by 140 service 

members during and after their deployment to Operation 

Enduring Freedom. We closely examined the electronic 

health records of 139 Soldiers and one airman who were 

assigned to, or supported, an active component brigade 

combat team (BCT) that operated from a forward operating base (FOB) located in the Logar Province of Eastern 

Afghanistan. The study includes all personnel who engaged the behavioral healthcare system during the first 7 

months of a deployment in theater from September 2011 

to July 2012. The individuals received behavioral health 

support from the BCT’s combat/operational stress control team comprised of a social work officer and 2 enlisted behavioral health specialists, augmented by a US Air 

Force combat stress team consisting of one active-duty 

social worker and an enlisted behavioral health technician. The deployment was split between 2 Army social 

work officers with the first one deploying for 7 months. 

The behavioral health providers supported a large geographical area that included the FOB and 12 combat 

outposts (COPs). Therefore, in addition to establishing 

a behavioral health clinic collocated with the FOB’s 

level II medical facility, the teams routinely conducted 

battlefield circulations, remaining at each COP for about 

48 hours to maintain contact with Soldiers assigned to 

the outlying areas. Using a client roster provided by the 

BCT’s initial social work officer (one of this study’s authors), 2 postgraduate social work interns assigned to 

Tripler Army Medical Center (TAMC) reviewed the 

clinical records and provider notes available through the 

Armed Forces Health Longitudinal Technology Application (AHLTA) system of those who received behavioral healthcare. Information pertinent only to behavioral healthcare received during the first 7 months of the 

deployment and throughout the first year after returning 

home was recorded on a review form developed specifically for this study. Data collected included demographics, referral information, presenting problem, primary 

diagnosis, exposure to combat, number of deployments, 

intervention provided, and postdeployment behavioral 

health follow-up. No personally identifying information 

was recorded to ensure anonymity. A consolidated database was created and sent to the author working at the 

Army Medical Department Center and School, Fort Sam 

Houston, Texas, for further review and coding. All 140 

records were included in the final analysis. Frequencies 

and means were tabulated using SAS version 9.2 (SAS 

Institute, Incorporated, Cary, North Carolina). The Institutional Review Board of TAMC granted approval for 

this study.

Results

Demographics

The clinical population consisted of 119 (85%) males 

and 21 (15%) females. The average age was 28 years 
16 http://www.cs.amedd.army.mil/amedd_journal.aspx

with a range of 19 to 49 years. The vast majority, 92 

(66%), were relatively young, aged between 19 and 

29, with only 13 (9%) individuals over 40 years of age. 

Most, 56 (40%), self-identified as Caucasian, followed 

by 17 (12%) African Americans, 6 (4%) Hispanics, 3 

(2%) Asian Americans, and 2 (1%) Native Americans. 

Twenty-four (17%) identified themselves as “other.” 

Race/ethnicity was unclear in 32 (23%) records, a considerable number. Almost half, 64 (46%), were married. 

Forty-two (30%) reported being single, never married 

whereas 13 (9%), were either separated or divorced. 

Marital status was missing in 21 (15%) records. Many, 

58 (41%), worked in support specialties such as military 

police, motor transport operator, wheeled vehicle mechanic, unit supply, or logistical specialist, with a significant number, 48 (34%), serving in the combat arms. 

Fourteen medical personnel, including combat medics 

who directly supported the COPs, comprised 10% of the 

clinical sample. Twenty (14%) records did not include 

military specialty. The overwhelming majority, 135 

(96%), were enlisted with 37 (26%) being in the junior 

grades (E1-E3). Most, 93 (66%), were junior noncommissioned officers (NCOs) (E4-E6) while 5 (4%), as E7s, 

were senior NCOs. Only 5 (4%) commissioned or warrant officers received behavioral health care. The majority, 91 (65%), were serving their first combat tour but 

many, 47 (34%), had previous deployment experience 

with 21 having deployed 3 or more times. Number of 

deployments could not be determined in 2 (1%) records.

Referral Information

Most, 88 (63%), who sought behavioral health support 

did so as self-referrals. Medical providers from battalion aid stations and the Level II troop medical clinic referred 25 (18%) Soldiers. Unit leadership accounted for 

23 (16%) referrals whereas Chaplains sent a relatively 

small number, 4 (3%), for behavioral health assistance. 

Nearly half, 67 (48%), of those seen by behavioral health 

had been involved in combat either through direct contact from IEDs, rocket propelled grenades, and small 

arms fire or indirect attacks by rocket or mortar rounds.

Presenting Problem

Operational stress, characterized by anxiety, fear, irritability, frustration and feeling isolated, was the most 

commonly reported problem affecting 39 (28%) Soldiers. Some of these individuals described themselves 

simply as “being stressed.” Twenty-three (16%) individuals sought behavioral healthcare for depression or 

anxiety. A modest number, 18 (13%), requested help for 

various sleep maladies. Direct involvement in, or witnessing a traumatic event, including several who saw 

combat casualties and one who witnessed an Afghan 

soldier shoot and kill an American contractor, produced 

an array of psychological reactions including anxiety, 

depression, nightmares, exhaustion, trouble concentrating, and intrusive images of the event that led 12 (9%) 

Soldiers to ask for help. Eighteen (13%) personnel reported marital problems that either developed or escalated during the deployment, creating multiple symptomatic responses including anger, sadness, decreased appetite, sleep difficulties, guilt, and a sense of hopelessness. 

Significantly, 14 (10%) Soldiers presented as a risk to 

themselves or others with all but one threatening suicide. 

Those expressing suicidal ideation variously reported 

being depressed, irritable, on edge, frustrated as well 

as experiencing shame and guilt. Freezing in combat, 

being under investigation, and negligently discharging 

a weapon were circumstances that contributed to some 

who contemplated suicide. It should be noted that one 

Soldier assigned to the BCT did commit suicide but had 

not engaged behavioral health services. Intense anger, 

primarily directed at perceived leadership deficiencies 

and inadequate working conditions, led 4 (34%) individuals to seek help. Three (2%) Soldiers needed support to 

cope with the grief of a fallen battle buddy. Substance 

abuse, in spite of strict prohibitions against alcohol and 

drug possession, resulted in 2 (1%) referrals for evaluation; one for alcohol intoxication, the other for inhalant abuse. The remaining 6 (4%) individuals engaged 

behavioral health services for various reasons; 2 were 

concerned about having an mTBI, 2 reported somatic 

complaints, and 2 had concerns regarding family problems back home. One (<1%) individual asked only to 

refill psychotropic medication for social phobia that had 

been prescribed prior to the deployment.

Primary Diagnoses

This deployment predated the release of the Diagnostic 

and Statistical Manual of Mental Disorders 5 (DSM); 

thus, these diagnoses reflect DSM IV-TR diagnostic 

criteria. Taking into consideration the demanding environmental and operational conditions, behavioral 

health providers were careful not to “over-pathologize” 

the chief complaints of those seeking help. Thus, Other 

Conditions That May be a Focus of Clinical Attention, 

commonly referred to as V Codes, such as Occupational, 

Life Circumstance, and Relational Problems, were used 

whenever possible. Those who reported various indicators of distress but whose symptoms did not constitute a 

formal DSM diagnosis were described as experiencing 

a combat/operational stress reaction. Some received no 

mental health diagnosis at all. Nevertheless, adjustment 

disorders and PTSD were the most commonly identified 

mental health conditions. A notable number of Soldiers 

met the diagnostic criteria for a Depressive Disorder, 

Not Otherwise Specified (NOS), with major depression 

and dysthymia used infrequently. Those who presented 

THE PSYCHOSOCIAL CHALLENGES OF CONDUCTING COUNTERINSURGENCY OPERATIONS
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THE ARMY MEDICAL DEPARTMENT JOURNAL

with significant anxiety were viewed as most likely 

manifesting an Anxiety Disorder, NOS. Although many 

Soldiers reported disturbed sleep, Primary Insomnia 

was diagnosed for those interested only in improving 

the quality of their sleep and reported no other concerns. 

Partner Relational Problems, another V Code, describes 

those who presented with symptoms related to failing 

relationships. One individual seemed to be exhibiting 

the hallmarks of an Intermittent Explosive Disorder. 

Another deployed with preexisting Social Phobia. The 

diagnostic assessment had yet to be completed for a Soldier who was initially seen but unfortunately was later 

killed in action. Two records did not have a recorded 

diagnosis. The distribution of primary diagnoses is presented in the Table.

Intervention and Disposition

Behavioral health intervention was predominantly accessed on the main FOB but was also offered at the 

various COPs during battlefield circulations. Although 

some individuals, 36 (26%), were seen only once, on 

average, Soldiers attended 4 sessions, including the initial intake. Most, 77 (55%), were seen between 2 and 6 

times for brief individual supportive therapy that used 

cognitive behavioral techniques. One Soldier needed 

more extensive support as evidenced by attending 25 sessions; 

however, the individual was able 

to remain in theater and contributed to the unit’s mission. Group 

treatment, specifically for anger 

control and stress management, 

was sporadically conducted depending upon provider availability. Psychotropic medication, prescribed by battalion surgeons and 

Level II medical officers, augmented the treatment of 58 (41%) 

behavioral health clients. The 

division psychiatrist was accessible via telebehavioral health for 

consultation on cases involving 

medication. Overall, the vast majority, 117 (84%), remained on, or 

were returned to full duty. Only 

3 (2%) had restrictions limiting 

them to duty on the FOB. Twelve 

(9%) Soldiers had to be medically 

evacuated for psychiatric reasons 

with 5 (3%) redeploying early for 

administrative purposes. Final 

disposition was unclear in 3 (2%) 

records.

Postdeployment Follow-up

Most of the Soldiers, 96 (69%), treated during the deployment engaged services for psychosocial challenges 

within the first year of returning home. Almost half, 

69 (49%), were seen at behavioral health clinics for a 

wide range of problems including adjustment disorders, 

PTSD, depression, anxiety, sleep disturbance, and occupational stress. Four (3%) received follow-up at the 

Family Advocacy Program (FAP), 3 for spouse abuse 

and one for child abuse. Two (1%) individuals were 

evaluated at the TBI clinic. The Army Substance Abuse 

Program (ASAP) provided treatment to one (<1%) Soldier. Several needed support from multiple sources as 

11 (8%) were seen by both behavioral health and ASAP, 

6 (4%) by behavioral health and FAP, and 2 (1%) were 

followed by behavioral health and the TBI clinic. One 

(<1%) individual was treated at ASAP for alcohol abuse, 

behavioral health for depression and was evaluated at 

FAP for domestic violence. There was no documentation indicating that the remaining 44 (31%) Soldiers received postdeployment behavioral healthcare.

Comment

As expected, behavioral health clients treated in theater 

were typically young, male, enlisted Soldiers on their 

first deployment. They tended to 

pursue services at their own volition for an array of psychosocial 

problems that ranged from combat-related psychological trauma 

to family concerns back home. 

Consistent with previous reports,6,13,16 officers were distinctly 

underrepresented in the clinical 

population. This observation suggests that officers either possess 

protective factors that minimize 

the impact of psychological distress during combat deployments, 

or social barriers-to-care continue to exist that inhibit them from 

seeking needed behavioral health 

support. Fully exploring the reasons officers, and perhaps senior 

NCOs, rarely engage the behavioral healthcare system while deployed warrants further study.

The increasing number of military suicides over the past several years is widely recognized; 

therefore, it is not surprising that 

suicidal ideation complicated the 

Distribution of Diagnoses.

Primary Diagnosis* No.

Diagnosed

(N=140)

%N

Occupational Problems 25 18%

Adjustment Disorder

with Depressed Mood 8 6%

with Anxiety 3 2%

with Anxiety and

Depressed Mood

4 3%

Unspecified 9 6%

PTSD 18 13%

Partner Relational Problems 15 11%

Depressive Disorder, NOS 10 7%

Major Depressive Disorder 1 <1%

Dysthymic Disorder 1 <1%

No Diagnosis 11 8%

Combat/Operational Stress† 9 6%

Anxiety Disorder, NOS 9 6%

Primary Insomnia 8 6%

Relational Problems 2 1%

Life Circumstances Problems 2 1%

Intermittent Explosive 

Disorder

1 <1%

Social Phobia 1 <1%

Missing Data 3 2%

*Criteria: Diagnostic and Statistical Manual of Mental 

Disorders IV-TR (DSM-IV-TR)

†Not listed in DSM-IV-TR.
18 http://www.cs.amedd.army.mil/amedd_journal.aspx

clinical management of several Soldiers. Behavioral 

health providers, coordinating closely with unit leadership, initiated safety plans and provided treatment 

to mitigate risk so that those thinking of suicide could 

safely remain in country to hopefully achieve a sense of 

mastery over their distress and build resiliency by contributing to their unit’s success for the remainder of the 

deployment. However, individuals assessed as being at 

high risk or who were unresponsive to treatment had to 

be evacuated to higher levels of psychiatric care. Nevertheless, the unfortunate suicide of a Soldier assigned to 

the BCT indicates that perhaps more can be done.

The combination of numerous deployment stressors 

such as a harsh climate, austere living conditions, and 

duty at isolated outposts, compounded by family separation, created conditions ripe for operational stress reactions. Additionally, while not unique to COIN deployments, physical separation from significant others can 

strain healthy relationships and may hinder the healing 

of those troubled prior to deployment. Experiencing 

the deterioration of an intimate relationship from afar 

seems to lead to a sense of helplessness and depression 

as Soldiers struggle with the inability to return home to 

save distressed relationships. Treating those who abused 

substances, albeit small in number, may be particularly 

challenging given the risks they took to use prohibited 

substances. The absence of specialized ASAP treatment 

programs in the combat zone places the onus on the behavioral health team to deliver services to this population and can jeopardize the continuity of care for those 

enrolled in the program prior to deployment.

Perhaps the most surprising feature of the deployment 

was the apparent frequency and intensity of combat 

engagements. Doctrinally, COIN missions focus on 7 

lines of effort that emphasize stability tasks aimed at 

supporting local civil operations.28 The extent to which 

Soldiers reported experiencing enemy contact indicates 

that the BCT may have operated in a more kinetic environment that required offensive and defensive measures 

to secure the local populace. The well-established link 

between combat and PTSD1,29-31 suggests that enemy 

action most likely contributed to the development of 

psychological trauma and stress-related disorders. Additionally, any worries about insurgent attacks may have 

been exacerbated by a perceived insider threat spurred 

by the “green on blue” assault of an American contractor. As reflected in the Mental Health Advisory Team 9 

report, as COIN operations evolve into an “advise and 

assist” role and exposure to combat declines, behavioral 

health problems should decrease accordingly.32

Nevertheless, there may be other intrinsic aspects of a 

COIN deployment that uniquely contribute to adverse 

psychological reactions. Leaders at the small unit level, 

perhaps represented by the NCOs in this study, must 

cope with the demands of performing the dual role of 

warrior-diplomat. This complex role entails seemingly 

divergent responsibilities. Leaders must conduct combat 

maneuvers to secure the local populace, enforce strict 

rules of engagement, exercise cultural competency 

when engaging local leaders, and work diplomatically 

with members of the host nation’s security forces during 

joint operations. While today’s military leaders are certainly capable of multitasking, demanding and at times 

conflicting role expectations can create stress leading to 

feeling tense, frustrated, and anxious.33,34 Furthermore, 

The work of Nash et al17 on moral injury adds another 

interesting dimension for considering possible threats to 

psychological health during COIN deployments. Changes in behavior and distress, or “inner conflict,” can occur 

when an individual conducts acts contrary to, or fails to 

prevent others from violating, deeply held values and 

beliefs.17 During this long period of armed conflict, the 

Army has cultivated a fighting spirit within its Soldiers, 

in part, by instilling a warrior ethos that becomes the 

foundation for the warrior identity. Principles inherent 

within the code include a dedication to one’s mission, 

defeating the enemy, perseverance, and an obligation to 

take care of fellow Soldiers, particularly those who have 

fallen. Additionally, in COIN operations it is necessary 

to establish rules of engagement to constrain overly 

aggressive tactics that run the risk of creating new insurgents.28 There may be circumstances when Soldiers 

are confronted with the dilemma of having to quickly 

choose to either fulfill deeply held beliefs about what 

it means to them to be a warrior, while being tactically 

sound, or adhere to the strategically imperative rules 

of engagement. Regardless of the potentially ethically 

ambiguous choice they make, an individual may experience frustration, guilt, and the anxiety of facing possible legal ramifications.

Establishing access to behavioral healthcare for Soldiers dispersed throughout a large geographical area 

is a daunting task. Working jointly with an Air Force 

combat stress team enabled the BCT providers to institute outreach to the outlying COPs while maintaining 

a behavioral health presence at the main FOB. Brief 

therapeutic interventions using cognitive behavioral 

concepts appeared effective in enhancing coping skills 

and strengthening resiliency as the vast majority of clients either remained on, or were returned to, full duty. 

Options for group therapeutic approaches were limited 

THE PSYCHOSOCIAL CHALLENGES OF CONDUCTING COUNTERINSURGENCY OPERATIONS
October – December 2014 19

THE ARMY MEDICAL DEPARTMENT JOURNAL

only by the need to divide behavioral health coverage 

between supporting the main clinic and conducting outreach throughout the battle space. Psychopharmacologic treatment, incorporated as an adjunct to the combat 

stress program, was readily available through coordination with unit medical providers. Telebehavioral health 

proved to be an effective tool for engaging psychiatric 

consultation for the most complicated clinical cases. For 

many, it appears that the psychosocial challenges they 

experienced while deployed may have followed them 

home. It is heartening to learn that most continued to 

receive help after returning.

An exploratory study using descriptive data derived from 

a retrospective review of healthcare records certainly 

has limitations. This clinical sample cannot be construed 

as being representative of the entire BCT and therefore 

our ability to generalize beyond the study group is limited. Additionally, the sample only included individuals who received behavioral healthcare during the first 

7 months of the deployment. Those who engaged care 

afterwards may have differed appreciably both demographically and clinically. Although care was taken to 

minimize mistakes, information extracted from health 

records are subject to recording and coding errors. Also, 

health records available in AHLTA only included those 

who received treatment within the military’s behavioral 

healthcare system after returning home; others may have 

used civilian resources and were unavailable for review.

Observations

While recognizing that more rigorous analysis is needed 

before definitive actions can be recommended, we offer 

the following observations for further consideration:

` Accounting for behavioral health support should 

be a priority in planning a COIN deployment due 

to the uniquely complex and stressful operational 

characteristics, including combat exposure, that 

threaten psychosocial health.

` Establishing adequate behavioral health support 

will, in many instances, require working jointly 

with providers from others services, therefore, opportunities for joint training should be pursued.

` Effectively supporting COIN operations requires 

behavioral health providers who have clinical experience in military settings and are capable of 

adapting their practice to fluid environmental and 

operational demands. Proficiency in treating psychological trauma and conducting traumatic event 

management is essential.

` Innovative practices, such as telebehavioral health 

and circuit riding, need to be further developed and 

evaluated for effectiveness.

` Further development of a seamless system of behavioral healthcare is critical for ensuring early intervention and continuity of care for Soldiers determined to be at-risk for postdeployment challenges.

Conclusions

A military capable of conducting COIN to support 

emerging democracies is an essential strategic component of our nation’s security. However, helping to build 

a democratic society may be more complex and difficult 

than simply defeating an enemy. Operationally, fighting 

an insurgency entails exposing Soldiers to a dynamic, 

multifaceted, and potentially dangerous environment 

that can mentally and emotionally strain those responsible for executing COIN tactics. Driven by a confluence 

of factors that threaten psychological health, behavioral 

health support has emerged as an essential component 

of total force protection. Thus, sufficiently supporting 

a COIN deployment requires establishing access to behavioral healthcare that can respond to a wide-spectrum 

of psychosocial problems. Given the complex features 

intrinsic to COIN missions, the behavioral health team 

should consist of experienced personnel who can respond flexibly and incorporate innovative procedures to 

support units dispersed across a vast area of operations. 

Further, it is important that those individuals believed 

to be at-risk for psychosocial challenges after the deployment are linked to services that can help facilitate a 

much-deserved healthy homecoming.

References

1. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems and barriers to 

care. New Engl J Med. 2004;351:13-22.

2. Jacobson IG, Ryan MA, Hooper TI, et al. Alcohol use and alcohol-related problems before 

and after military combat deployment. JAMA. 

2008;300:663-675.

3. Allison-Aipa TS, Ritter C, Sikes P, Ball S. The impact of deployment on the psychological health status, level of alcohol consumption, and use of psychological resources of postdeployment U.S. Army 

Reserve Soldiers. Mil Med. 2010;175:630-637.

4. Gellis LA, Gehrman PR, Mavandadi S, Oslin DW. 

Predictors of sleep disturbances in Operation Iraqi 

Freedom/Operation Enduring Freedom veterans 

reporting a trauma. Mil Med. 2010;175:567-573.

5. Angkaw AC, Ross BS, Pittman JO, Kelada AY, 

Valencerina MA, Baker DG. Post-traumatic stress 

disorder, depression, and aggression in OEF/OIF 

veterans. Mil Med. 2013;178:1044-1050.
20 http://www.cs.amedd.army.mil/amedd_journal.aspx

6. Thomsen CJ, Stander VA, McWhorter SK, Rabenhorst MM, Milner JS. Effects of combat deployment on risky and self-destructive behavior among 

active duty military personnel. J Psychiatr Res. 

2011;45(10):1321-1331.

7. Hoge CW, McGurk D, Thomas JL, Cox AL, Engel CC, Castro CA. Mild traumatic brain injury in 

U.S. Soldiers returning from Iraq. New Engl J Med. 

2008;358(5):453-463.

8. Grieger TA, Cozza SJ, Ursano RJ, Hoge C, Martinez PE, Engel CC, Wain HJ. Postraumatic stress 

disorder and depression in battle-injured soldiers. 

Am J Psychiatry. 2006;163(10):1777-1783.

9. Tanielian T, Jaycox LH. Stop loss: a nation weighs 

the tangible consequences of invisible combat 

wounds. Rand Review. 2008;32(2):7-15. Available 

at: http://www.rand.org/publications/randreview/

issues/summer2008/wounds1.html. Accessed July 

29, 2014.

10. Shen YC, Arkes J, Pilgrim J. The effects of deployment intensity on post-traumatic stress disorder: 

2002-2006. Mil Med. 2009;174:217-223.

11. Vasterling JJ, Proctor SP, Friedman MJ, Hoge 

CW, Heeren T, King LA, King DW. PTSD symptom increases in Iraq-deployed soldiers: comparison with nondeployed soldiers and associations 

with baseline symptoms, deployment experiences, and postdeployment stress. J Trauma Stress. 

2010;23(1):41-51.

12. Thomas JL, Wilk JE, Riviere LA, McGurk D, Castro CA, Hoge CW. Prevalence of mental health 

problems and functional impairment among active 

component and National Guard Soldiers 3 and 12 

months following combat in Iraq. Arch Gen Psychiatry. 2010;67:614-623.

13. Applewhite L, Keller N, Borah A. Mental health 

care use by Soldiers conducting counterinsurgency 

operations. Mil Med. 2012;177:501-506.

14. Phillips CJ, LeardMann CA, Gumbs GR, Smith 

B. Risk factors for posttraumatic stress disorder 

among deployed US male Marines. BMC Psych. 

2010;10:6-11.

15. Mayo JA, MacGregor AJ, Dougherty AL, Galarneau MR. Role of occupation on new-onset 

post-traumatic stress disorder and depression 

among deployed military personnel. Mil Med. 

2013;178:945-950.

16. Arincorayan D, Applewhite L, DiJoseph E, Ahlvers 

A, Mangindin A. Army social work: helping at-risk 

Soldiers come home. J Hum Behav Soc Environ. 

2013;23:692-698.

17. Nash WP, Marino Carper TL, Mills MA, Au 

T, Goldsmith A, Litz BT. Psychometric evaluation of the moral injury events scale. Mil Med. 

2013;178:646-652.

18. Tovy T. Learning from the past for present counterinsurgency conflicts: the Chieu Hoi program as 

a case study. Armed Forces Soc. 2012;38:142-163.

19. Ricks TE. The Gamble: General David Petraeus 

and the American Military Adventure in Iraq. New 

York, NY: The Penguin Group; 2009.

20. Chandrasekaran R. Little America: The War Within 

the War for Afghanistan. New York, NY: Alfred A. 

Knopf; 2012.

21. Cleveland CT, Farris SL. Toward strategic landpower. Army Mag. July 2013:20-23. Available 

at: http://www.ausa.org/publications/armymaga

zine/archive/2013/07/Documents/Cleveland_Ju

ly2013ARMY.pdf. Accessed July 30, 2014.

22. Kilcullen D. Twenty-eight articles: fundamentals 

of company-level counterinsurgency. Io Sphere. 

Summer 2006:29-35. Available at: http://home.io

sphere.org/?page_id=234. Accessed July 30, 2014.

23. Laurence JH. Military leadership and the complexity of combat and culture. Mil Psychol. 

2011;23:489-501.

24. Baird R. COIN: on-the-job learning for the new platoon leader. Infantry. January-February 2009:25-32.

25. Luttrell J. Infantry battalion COIN operations. Infantry. July-August 2008:6-10.

26. Coppock C. COIN cliff notes: techniques for the 

conventional rifle platoon in layman’s terms. Infantry. July-August 2008:11-14.

27. Vane MA. New norms for the 21st century Soldier. 

Mil Rev. July-August 2011:16-24.

28. Field Manual 3-24.2: Tactics in Counterinsurgency. 

Washington, DC: US Dept of the Army; April 2009.

29. Foy DW, Sipprelle RC, Rueger DB, Carroll EM. 

Etiology of posttraumatic stress disorder in Vietnam veterans: Analysis of premilitary, military, 

and combat exposure influences. J Consult Clin 

Psychol. 1984; 52(1): 79-87.

30. Kang HK, Natelson BH, Mahan CM, Lee KY, 

Murphy FM. Post-traumatic stress disorder and 

chronic fatigue syndrome-like illness among Gulf 

War veterans: a population-based survey of 30,000 

veterans. Am J Epidemiol. 2003;157(2):141-148.

31. LeardMann CA, Smith TC, Smith B, Wells TS, 

Ryan MA, and the Millennium Cohort Study Team. 

Baseline self-reported functional health and vulnerability to post-traumatic stress disorder after 

combat deployment: prospective US military cohort study. BMJ. 2009;338:b1273.

32. Mental Health Advisory Team (MHAT) 9: Operation Enduring Freedom (OEF) 2013. Washington, 

DC: Office of The Surgeon General, et al; October 

10, 2013:26. Available at: http://armymedicine.mil/

Documents/MHAT_9_OEF_Report.pdf. Accessed 

July 30, 2014.

THE PSYCHOSOCIAL CHALLENGES OF CONDUCTING COUNTERINSURGENCY OPERATIONS
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THE ARMY MEDICAL DEPARTMENT JOURNAL

Authors

COL Arincorayan is Chief, Department of Social Work, Tripler Army Medical Center, Honolulu, Hawaii.

Dr Applewhite is a Professor, US Army/Fayetteville State University MSW Program, Army Medical Department Center and School, Joint Base San Antonio Fort Sam Houston, Texas.

MAJ Almeida is a Social Work Officer, Department of Social Work, Carl R. Darnall Army Medical Center, 

Fort Hood, Texas.

MAJ DiJoseph and MAJ Romero are Social Work Interns, Department of Social Work, Tripler Army Medical 

Center, Honolulu, Hawaii.
22 http://www.cs.amedd.army.mil/amedd_journal.aspx

Over the past decade, the use of energy products and 

metabolism-inducing dietary supplements, which often 

contain a cocktail of caffeine, taurine, riboflavin, pyridoxine, nicotinamide, B vitamins, and herbal derivatives,1

 has reapidly escalated worldwide. Energy drinks 

have led this trend, comprising a $4.8 billion industry in 

the United States in 2008, and was predicted to grow to 

$19.7 billion by 2013.2 Alternative energy products, such 

as shots, gels, powder packets, pills, and gum, are also 

on the rise. Nearly 35% of teenagers, more than 50% of 

college students, and 45% of deployed service members 

are estimated to regularly consume energy drinks.3-6

The military demographic is the prime target for energy drink advertising campaigns,7

 but as of this writing 

there are only 2 published studies addressing the use of 

energy products by deployed personnel.5,6

Troops have used energy products such as caffeine and 

nicotine for ages in an effort to combat the fatigue and 

sleep deprivation that is inevitable in a combat environment. Thirty-one percent of Army Soldiers in one recent 

study reported taking dietary supplements “to increase 

energy”7 and the presence of sleep disturbances in deployed populations is well-established.8-11 Investigators 

have demonstrated that individuals who have been 

awake for 23 hours have psychomotor impairments 

equivalent to people who are legally intoxicated.12 Even 

continued partial sleep deprivation, ie, sleeping only 4 

to 5 hours a night on a continual basis, can have demonstrable results on cognitive performance.13 Since 2009, 

US Army doctrine has recommended the prescribed 

use of over-the-counter stimulants to promote wakefulness during sustained operations, defined as 2-3 days.14

However, modern warfare often requires troops to remain highly alert for much longer periods of time, likely 

contributing to the growing popularity and expanding 

diversity of energy products on today’s battlefield.

Commercially available energy products are infused 

with various amounts of caffeine.15 Caffeine is characterized by the Food and Drug Administration as a 

“flavor enhancer,” and therefore is not required to be 

quantified on food labels. It has been deemed by the US 

government to be safe in amounts below 72 mg per 12 fl 

oz.16 However, while most caffeinated sodas fall below 

this threshold, many energy products clearly exceed it. 

In fact, only 3 of the 28 most popular non-soda energy 

drinks in America contain less than 71 mg of caffeine 

Sleep and the Use of Energy Products

 in a Combat Environment

LTC Wendi M. Waits, MC, USA

Michael B. Ganz, PhD

Theresa Schillreff, OTR/L

CPT Peter J. Dell, MS, USA

Abstract

Background: The use of energy products appears to be widespread among deployed personnel, presumably to 

combat fatigue and sleep deprivation. However, these products have been associated with unpleasant side effects and adverse events, including insomnia, mood swings, fatigue, cardiac arrest, and even death.

Objective: To quantify the sleep habits and energy products used among deployed service members in Afghanistan from 2010-2011.

Methods: Participants completed an anonymous survey querying their demographic information, sleep habits, 

combat exposure, and energy product use.

Results: Respondent data: 83% experienced some degree of insomnia; 28% were using a prescription or overthe-counter sleep aid; 81% reported using at least one energy product daily. The most frequently consumed 

energy products were caffeinated coffee and soda. Only 4 energy products were used more frequently during 

deployment than prior to deployment: Rip-It, Tiger, Hydroxycut, and energy drink powders. On average, respondents who increased their use consumed only 2 more servings per week during deployment than they had 

prior to deployment. Only degree of combat exposure, not quantity of energy products consumed, predicted 

degree of insomnia.

Conclusion: Energy product consumption by service members during deployment was not dramatically different than predeployment and was not associated with insomnia.
October – December 2014 23

per 12 oz.16 Caffeine has a number of unpleasant side 

effects when taken in excess,17,18 and energy products 

have been increasingly associated with serious adverse 

effects, including tachycardia, hypertension, seizures, 

bowel ischemia, mania, psychosis, cardiac arrest, and 

sudden death.19-27 It has even been suggested that caffeine 

may contribute to the development of combat stress reactions such as posttraumatic stress disorder (PTSD).28

Physiological risks seem especially high when energy 

products (including dietary supplements) are taken prior 

to vigorous exercise or combined with other psychoactive substances.29 Since deployed troops often ingest energy products containing a cocktail of psychoactive substances, and since they are frequently physically active 

during deployment, it is imperative that their consumption of these substances be more closely investigated.

The authors endeavored to quantify the overall use of 

energy products among deployed personnel, as well 

as to see if environmental factors such as sleep habits, 

combat exposure, and sleep deprivation placed certain 

populations at risk for heavier use.

Methods

Research Design

This study involved the administration of an anonymous 

survey to evaluate energy product use and sleep behaviors among deployed International Security Assistance 

Force personnel. Although deployed personnel may have 

different reasons for consuming wake-promoting energy products and metabolism-inducing energy products, 

we chose to inquire about both types because they can 

both affect sleep and they share a similar adverse effect 

risk profile. The goal was to distribute as many surveys 

as possible in nonclinical settings (ie, in supported units’ 

operational areas, at briefings, and in public areas such 

as gyms, MWR facilities) at forward operating bases 

visited by the investigators throughout Afghanistan.

Participants

Inclusion criteria included English-speaking military 

and civilian personnel deployed or working in Afghanistan in support of Operation Enduring Freedom. Local 

nationals, non-English speakers, and individuals aged 

less than 18 years were excluded from participation. Investigators emphasized that participation was entirely 

voluntary and that surveys were anonymous. Participants were recruited with flyers and verbally during 

walk-about missions (staging areas, motor pools, office areas, tactical operation centers, etc) and in areas 

encountered during daily activities (military quarters, 

dining facilities, recreation facilities, laundry facilities, 

flight terminals, etc). Anonymous survey boxes were 

also used at some locations.

Instruments

The survey administered was created by 2 of the authors 

(W. M. W. and M. B. G.) and included questions about 

demographics, occupation, frequency of shift changes, 

number of roommates, use of sleep aides, combat exposures, sleep habits, and energy product use. The survey 

incorporated the Combat Exposure Scale30 and the Pittsburgh Sleep Symptom Questionnaire–Insomnia (PSSQI), also known as the Insomnia Symptom Questionnaire.31 Study variables came directly from the survey.

Data Collection

Once recruited, participants were given the choice of 

returning their survey to the survey box or to the investigator. Completed surveys were secured by the investigators in their respective clinical areas. Data collection 

ceased once the target number of surveys was reached.

Results

Participants (N=183) in this study were mostly male 

with a median age of 27 years and an age range of 18-58. 

Junior enlisted service members were the most frequent 

respondents followed by noncommissioned officers, 

warrant and company-grade officers, and field grade officers. All participants were in Afghanistan at the time 

they completed the survey, but their length of time in 

country varied, with an average of 6.6 months. Other 

relevant demographic data is highlighted in the Table.

The majority of participants (66%) indicated that they 

were required to change their occupational hours at least 

once. Respondents reported the following rates of shift 

change: never=44%, less than once per month=25%, 

every 1 to 14 days=23%, and every 15 to 30 days=9%. 

Most participants had multiple roommates: 45.4% of the 

sample reported having 4 to 9 roommates, 19.7% stated 

they had 2 or 3 roommates, 13.1% stated they had only 

one roommate, 12.0% had 10 or more roommates, and 

9.3% lived alone.

Figure 1 depicts the raw data of sample-wide number 

of consumers by product type reported by participants 

both 30 days prior to and during their deployment. There 

were raw-value increases in number of total consumers 

from the predeployment period to the deployed period 

for only 6 of the 15 assessed energy products (Figure 

2). However, the total number of consumers across 

all energy products was statistically unchanged from 

the predeployment and deployment periods (t=0.402, 

P=.694). Nevertheless, energy products were consumed 

at a faster rate during deployment compared to predeployment: That is, 24.0 servings per week on average 

during deployment compared to 16.6 servings per week 

prior (t=-3.34, P=.001). The energy products that were 
24 http://www.cs.amedd.army.mil/amedd_journal.aspx

consumed most often by the entire 

sample, both during deployment and 

at home, were caffeinated coffee and 

soda. However, during deployment, 

there were significant increases in 

rates of consumption in the preworkout supplement Hydroxycut and the 

free and widely available energy 

drink Rip-It (t=-2.051, P=.042 and 

t=-3.434, P=.001, respectively).

Surprisingly, we found no statistical difference in energy product 

use among respondents of different 

rank, gender, or military occupational specialty. Additionally, energy 

product users were no more likely 

than nonusers to have frequent shift 

changes or use sleep aids. However, 

consumption of energy products was 

positively correlated with the total 

number of sleep-inhibiting bedtime 

habits (r=0.204, P=.006). Additionally, respondents with no roommates (P=.047) and those with 10 or 

more roommates (P=.047) were less 

likely to use energy products than 

those with one roommate, although 

the significance of this finding is 

unclear. Finally, despite the lack of 

statistical difference among different occupations, several groups were 

found to be particularly frequent 

(food service, transportation, signal/

communications, and aviation) and 

infrequent (supply/logistics, military 

police/security, maintenance, detainee operations, and ground combat) consumers of energy products.

Participants were asked about their 

engagement in activities believed 

to either promote or inhibit sleep 

within one hour of bedtime (Figure 

3). Two was the median number of 

sleep-inhibiting behaviors in which 

participants engaged at bedtime across the entire sample. 

Only 15 respondents denied having any negative bedtime habits. They were more likely to be female, older in 

age, and from the following occupations: ground troops, 

transportation, and medical.

Insomnia symptoms were assessed with the PSSQ-I. 

Based on established cut-offs, 24% of the sample met 

criteria for an insomnia diagnosis 

worthy of clinical attention. Proportions of the sample that reported 

moderate to extreme levels of insomnia symptoms are represented in 

Figure 4. Figure 5 details the distribution of moderate to extreme types 

of psychosocial impairment that respondents reported were caused by 

their insomnia. The most commonly 

reported impairments were feeling fatigued during the day, feeling 

sleepy during the day, finding the 

insomnia bothersome, feeling their 

concentration was affected, and feeling their occupational functioning 

was affected.

As many as 83% of the sample reported that at least one area of their 

life was negatively affected by their 

insomnia symptoms at moderate to 

extreme levels, and 63% indicated 

that at least one area of impairment 

was extreme. Eighty-three percent 

of the sample also indicated that at 

least one of their insomnia symptoms was at a clinically significant 

level, and 20% of the sample reported that the frequency of their 

symptoms was “Always” (5-7 nights 

per week). However, only 28% of the 

sample used either a prescription or 

over-the-counter sleep aid.

As expected, insomnia symptoms 

and severity were positively correlated with the use of a sleep aide 

(r=0.322, P=.005). However, no significant relationship existed between 

insomnia and any other pertinent 

variable, including frequency of shift 

changes (r=0.126, P=.295), number of roommates (r=0.18, P=.879), 

level of combat exposure (r=-0.041, 

P=.734), number of sleep-inhibiting 

bedtime habits (r=-0.150, P=.213), and quantity of energy products consumed (r=-0.145, P=.229).

Comment

To our knowledge, this is the first published comprehensive analysis of energy product use by military personnel 

in a deployed environment. It is a preliminary study conducted with a relatively small population, but nonetheless 

Distribution of Demographic Data for 

Study Participants

Variable

(N=183)

n %N

Gender

Male 148 81%

Female 22 12%

Not indicated 13 7%

Age (years)

18-25 76 42%

26-35 71 39%

35-45 27 15%

46+ (maximum is 58) 8 4%

Omitted 1 0

Rank

E1-E4 84 46%

E5-E9 76 42%

WO1-WO3 16 9%

O4 and above 2 1%

Military/Civilian

Military 179 98%

Civilian 1 0

Not indicated 3 1%

Average time in theater 6.6 months

Job in theater

Ground combat 

operations 20 11%

Aviation 12 7%

Military police/

security 10 5%

Detainee operations 6 3%

EOD/mine clearing 

operations 0 0

Civil affairs 0 0

Maintenance 16 9%

Construction 1 0

Supply/logistics 27 15%

Personnel/

administration 5 3%

Military intelligence 3 2%

Food service 2 1%

Signal/

communications 6 3%

Transportation 10 5%

Medical 40 22%

Other 25 14%

SLEEP AND THE USE OF ENERGY PRODUCTS IN A COMBAT ENVIRONMENT
October – December 2014 25

THE ARMY MEDICAL DEPARTMENT JOURNAL

yielded some noteworthy findings that have implications for future deployments and research.

The redistribution of energy product consumption 

toward a select “high-use” population was interesting but reasons for this finding were unclear. Product availability is believed to play some role, since 

2 of the 4 products consumed more frequently and 

by more people during deployment (RipIt and Tiger) are widely available in Afghanistan but are 

very difficult to find within the United States. The 

other 2 products (Hydroxycut and energy powders) 

may have been popular among respondents due to 

their ease of use and storage compared to some 

other products listed on the survey. However, product availability is unlikely to be the only contributing factor to increased use since coffee and tea did 

not see significant increases and are easily found in 

even the most austere dining environments.

There was no statistical difference between the 

use of energy products and the presence of insomnia. This was somewhat reassuring given the high 

reported rates of insomnia and the potential health 

consequences of energy products. However, the 

high percentage of respondents reporting that their 

insomnia caused “extreme” levels of impairment is 

definitely concerning and warrants additional study, 

particularly given the complexity and hazardous nature 

of work-related tasks on the modern battlefield.

In addition to its effects on cognitive function and reaction time, sleep deprivation has recently been associated with hostility, violence, sexual dysfunction, and 

increased pain sensitivity.32-34 These are problems frequently attributed to PTSD in combat veterans, but this 

data raises the question as to whether or not such problems may actually be due to sleep deprivation rather 

than trauma exposure. Clearly more research in this 

area is required.

We were surprised by the lack of correlation between 

insomnia and traditional sleep-inhibiting variables, including shift changes, roommates, combat exposure, 

bedtime habits, and quantity of energy products consumed. We were also surprised by the lack of positive 

correlation between insomnia and energy product consumption. We had predicted that respondents with insomnia would be high consumers of energy products 

because of their wake-promoting (and sleep inhibiting) 

properties, but such was not the case.

Although there was a positive correlation between insomnia and the use of sleep aids, 83% of respondents 

reported clinically significant insomnia while fewer 

than 30% reported regularly using a sleep aid, suggesting that more than half of the respondents were suffering the effects of chronic, unmitigated sleep deprivation. 

We considered the possibility that the relatively low use 

of sleep aids was because respondents did not want to 

impair their ability to function if awakened emergently 

from sleep. However, the use of sleep aids was actually 

highest in 2 populations most likely to be awakened 

emergently: ground combat troops (45%) and medical personnel (35%). Thus, reasons for this finding are 

unclear.

The facts that respondents engaged in an average of 2 

sleep-inhibiting activities before bedtime and that nearly one-third of respondents changed shifts at least once 

a month were somewhat concerning. Perhaps similarly 

concerning was the fact that higher-ranking respondents 

consumed energy products at the same frequency as 

lower-ranking respondents. Enhanced education about 

healthy sleep habits, the consequences of insomnia, and 

the potential dangers of energy products may be warranted for both leaders and junior enlisted personnel.

Limitations of this study include its relatively small 

sample size, retrospective survey design, potentially 

Figure 1. Total number of consumers of energy products by product 

type or brand name.

0 20 40 60 80 100

Deployment

Predeployment

Other Drink

TigerTM

Gum

Tea

Red Bull®

NO-Xplode®

Rockstar

Pill

Coffee

Rip-it®

Hydroxycut®

Shot

Powder

Soda

MonsterTM
26 http://www.cs.amedd.army.mil/amedd_journal.aspx

biased sampling (22% had a medical occupation), and 

reliance on self-report rather than laboratory measurement and direct observation. Future research is needed 

to improve upon these design elements and to further assess the relationship between insomnia, deployment environments, and energy products. Future investigations 

should assess the reason for individuals’ use of energy products (ie, wake promotion vs weight loss 

vs workout enhancement), and whether or not there 

is any correlation between these reasons and outcomes such as sleep quality and duration. It would 

also be informative to track energy product use 

prospectively over time, including predeployment, 

during-deployment, and postdeployment consumption. Subsequent investigations should also include 

inquiries about respondents’ desired amount of 

sleep, availability of sleep time, and satisfaction 

with sleep patterns. Finally, future research should 

endeavor to answer the question of whether or not 

prescription, wake-promoting medications have a 

role in modern combat operations.

Conclusion

Insomnia among our deployed population is ubiquitous and multifactorial. Surprisingly, we found 

the use of energy products during deployment to 

be neither extreme nor clearly associated with insomnia, though it could still be argued that these 

products have the potential for unexpected health 

consequences and may warrant better regulation. 

Sleep, whether during deployment or after one returns home, is imperative for the restoration and renewal of our physical and mental abilities. It is our 

hope that this article will contribute to the ongoing 

collection of information and research in this field 

and will be used as a basis for continued research in the 

future.

References

1. Aranda M, Morlock G. Simultaneous determination of riboflavin, pyridoxine, nicotinamide, caffeine and taurine in energy drinks by planar chromatography-multiple detection with confirmation 

by electrospray ionization mass spectrometry. J 

Chromatogr A. 2006;1131:253-260.

2. Heckman MA, Sherry K, Gonzalez de Mejia 

E. Energy drinks: an assessment of their market 

size, consumer demographics, ingredient profile, 

functionality, and regulations in the United States. 

Compr Rev Food Sci Food Saf. 2009;9:303-317.

3. Seifert SM, Schaechter JL, Hershorin ER, 

Lipshultz, SE. Health effects of energy drinks on 

children, adolescents, and young adults. Pediatrics. 

2011;127(3):511-528.

4. Malinauskas BM, Aeby VG, Overton RF, Carpenter-Aeby T, Barber-Heidal K. A survey of energy 

drink consumption patterns among college students. Nutr J. 2007;6:35.

Figure 3. Percentages of study sample-endorsed sleepinhibiting habits at bedtime, by type. 

0% 10% 20% 30% 40% 50% 60% 70% 80%

72%

63%

26%

30%

5%

TV/Movie

Video

Games

Computer

Exercise

Fast

Music

Energy 

Product

25%

Figure 2. Mean number of servings of energy products by product 

type or brand name consumed per week.

Notes: A indicates Sig P≤.05. B indicates Sig P≤.001.

A

0 2 4 6 8 10 12 14 16 18 20

A

B

Deployment

Predeployment Other Drink

TigerTM

Gum

Tea

Red Bull®

NO-Xplode®

Rockstar

Pill

Coffee

Rip-it®

Hydroxycut®

Shot

Powder

Soda

MonsterTM

SLEEP AND THE USE OF ENERGY PRODUCTS IN A COMBAT ENVIRONMENT
October – December 2014 27

THE ARMY MEDICAL DEPARTMENT JOURNAL

5. Toblin RL, Clarke-Walper K, Kok BC, Sipos 

ML, Thomas JL. Energy drink consumption and 

its association with sleep problems among U.S. 

service members on a combat deployment–Afghanistan, 2010. MMWR Morb Mortal Wkly Rep. 

2012;61(44):895-898.

6. Jacobson IG, Horton JL, Smith B, eta al, for the 

Millennium Cohort Study Team. Bodybuilding, 

energy, and weight-loss supplements are associated 

with deployment and physical activity in U.S. military personnel. Ann Epidemiol. 2012;22(5):318-330.

7. Lieberman HR, Stavinoha TB, McGraw SM, 

White A, Hadden LS, Marriott BP. Use of dietary 

supplements among active-duty US Army soldiers. 

Am J Clin Nutr. 2010;92:985-995.

8. Lieberman HR, Tharion WJ. Effects of caffeine, 

sleep loss, and stress on cognitive performance 

and mood during U.S. Navy SEAL training. Psychopharmacol. 2002;164:250-261.

9. Kryger MH, Pouliot Z, Peters M, Neufeld H, Delaive K. Sleep disorders in a military population. 

Mil Med. 2003;168(1):7-10.

10. Peterson AL, Goodie JL, Satterfield WA, Brim 

WL. Sleep disturbance during military deployment. 

Mil Med. 2008;173:230-235.

11. Seelig AD, Jacobson IG, Smith B, et al. Sleep patterns before, during, and after deployment to Iraq 

and Afghanistan. Sleep. 2010;33(12):1615-1622.

12. Dawson D, Reid K. Fatigue, alcohol and performance impairment. Nature. 1997;388(6639):235.

13. Dinges DF, Pack F, Williams K, et al. Cumulative 

sleepiness, mood disturbance and psychomotor 

vigilance performance decrements during a week 

of sleep restricted to 4-5 hours per night. Sleep. 

1997;20:267-277.

14. Field Manual 6-22.5: Combat and Operational 

Stress Control Manual for Leaders and Soldiers. 

Washington, DC: US Dept of the Army; March 18, 

2009.

15. Reissig CJ, Strain EC, Griffiths RR. Caffeinated 

energy drinks–a growing problem. Drug Alcohol 

Depend. 2009;99(1-3):1-10.

16. Caffeine, 21 CFR 182.1180 (2011). Available at: 

http://www.gpo.gov/fdsys/granule/CFR-2011-title21-vol3/CFR-2011-title21-vol3-sec182-1180/content-detail.html. Accessed August 3, 2014.

17. Curatolo PW, Robertson D. The health consequences of caffeine. Ann Intern Med. 1983;98:641-653.

18. Karacan I, Thornby JI, Anch M, Booth GH, Williams RL, Salis PJ. Dose-related sleep disturbances 

induced by coffee and caffeine. Clin Pharmacol 

Ther. 1976;20(6):682-689.

19. Steinke L, Lanfear DE, Dhanapal V, Kalus JS. 

Effect of “energy drink” consumption on hemodynamic and electrocardiographic parameters in healthy young adults. Ann Pharmacother. 

2009;43(4):596-602.

20. Iyadurai SJ, Chung SS. New-onset seizures 

in adults: possible association with consumption of popular energy drinks. Epilepsy Behav. 

2007;10(3):504-508.

21. Magee CD, Moawad FJ, Moses F. NO-Xplode: A 

case of supplement-associated ischemic colitis. Mil 

Med. 2010;175:202-205.

22. Hedges DW, Woon FL, Hoopes SP. Caffeine-induced psychosis. CNS Spectr. 2009; 14(3):127-129.

23. Cerimele JM, Stern AP, Jutras-Aswad D. Psychosis following excessive ingestion of energy drinks 

in a patient with schizophrenia. Am J Psychiatry. 

2010;167(3):353.

Figure 4. Percentages of study sample who endorsed insomnia symptoms at moderate to severe levels, by type. 

Not

Sound

Awakenings

Unrefreshing

Falling

Asleep

Staying

Asleep

82%

75%

76%

65%

75%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Figure 5. Percentages of study sample who endorsed insomnia sequelae at moderate to extreme levels, by type. 

Social

Fatigue

Irritable

Sleepy

Occupational

Concentration

Bothers

You

Other Parts

of Life

0% 10% 20% 30% 40% 50% 60%

49%

49%

48%

38%

32%

32%

39%

54%
28 http://www.cs.amedd.army.mil/amedd_journal.aspx

24. Machado-Vieira R, Viale CI, Kapczinski F. Mania 

associated with an energy drink: the possible role 

of caffeine, taurine, and inositol. Can J Psychiatry. 

2001;46:454-455.

25. Berger AJ, Alford K. Cardiac arrest in a young 

man following excess consumption of caffeinated 

“energy drinks.” Med J Aust. 2009;190(1):41-43.

26. Chelben J, Piccone-Sapir A, Ianco I, Shoenfeld 

N, Kotler M, Strous RD. Effects of amino acid 

energy drinks leading to hospitalization in individuals with mental illness. Gen Hosp Psychiatry. 

2008;30(2):187-189.

27. Dhar R, Stout CW, Link MS, Homoud MK, Weinstock J, Estes NA 3rd. Cardiovascular toxicities 

of performance-enhancing substances in sports. 

Mayo Clin Proc. 2005; 80(10):1307-15.

28. 28 Iancu I, Dolberg OT, Zohar J. Is caffeine involved in the pathogenesis of combat-stress reaction? Mil Med. 1996; 161(4):230-32.

29. Dhar R, Stout CW, Link MS, Homoud MK, Weinstock J, Estes NA III. Cardiovascular toxicities 

of performance-enhancing substances in sports. 

Mayo Clin Proc. 2005;80(10):1307-1315.

30. Keane T, Fairbank J, Caddell J, Zimering R, Taylor 

K, Mora C. Clinical evaluation of a measure to assess combat exposure. Psychol Assess. 1989;1:53-55.

31. Okun ML, Kravitz HM, Sowers MF, Moul DE, 

Buysse DJ, Hall M. Psychometric evaluation of the 

Insomnia Symptom Questionnaire: a self-report 

measure to identify chronic insomnia. J Clin Sleep 

Med. 2009;5(1):41-51.

32. Kamphuis J, Meerlo P, Koolhaas JM, Lancel M. 

Poor sleep as a potential causal factor in aggression 

and violence. Sleep Med. 2012;13(4):327-334.

33. Andersen ML, Alvarenga TF, Mazaro-Costa R, 

Hachul HC, Tufik S. The association of testosterone, sleep, and sexual function in men and women. 

Brain Res. 2011;1416:80-104.

34. Okifuji A, Hare BD. Do sleep disorders contribute to pain sensitivity?. Curr Rehumatol Rep. 

2011;13(6):528-534.

Authors

LTC Waits is with the Directorate of Behavioral Health, 

Fort Belvoir Community Hospital, Fort Belvoir, Virginia.

Dr Ganz is with the Department of Behavioral Health, 

US Army Health Center, Vicenza, Italy.

Ms Schillreff is a registered Occupational Therapist in 

Tuckahoe, New Jersey.

CPT Dell is with Behavioral Health Services, BG Crawford F. Sams US Army Health Clinic, Camp Zama, Japan.

SLEEP AND THE USE OF ENERGY PRODUCTS IN A COMBAT ENVIRONMENT
October – December 2014 29

We were introduced to telebehavioral health (TBH) by 

the outgoing Brigade Behavioral Health Officer upon 

our arrival in Kandahar, Afghanistan, in March 2012 

for a 9-month deployment. She informed us that we 

would use the TBH system to support remote outposts 

throughout the deployment. We had been educated on 

telemedicine as a way to deliver care through technology in our respective social work and psychology programs. However, we both realized that we were reluctant 

to use telemedicine because of our prejudice that the use 

of technology is impersonal and could diminish skills 

we deemed necessary during the interview process between patient and provider. We quickly learned to set 

aside our preconceived notions and embrace telemedicine, specifically TBH, in order to deliver care to the 

Soldiers across our battle space. This article describes 

our experiences using TBH in both deployed and garrison clinical settings, the benefits, the challenges, and 

how we adapted our practice to incorporate its use.

Definitions

Telemedicine has been referred to as telehealth and 

telerehabilitation. Maheu et al1 defined telemedicine 

as “clinical or supportive medical practices delivered 

across distances via telecommunication technology, 

performed by licensed or otherwise legally authorized 

individuals.”1(p6) Telemedicine systems were established 

to deliver care for radiology, ophthalmology, dermatology, and psychiatry from a combat support hospital in 

Afghanistan to the Landstuhl Regional Medical Center 

in Germany as early as November 2002.2 Gillert 3 pointed out that “most DoD medical centers operate telemedicine clinics...” and that roughly 25% of telemedicine 

consultation at the National Naval Medical Center was 

related to behavioral health services. With advances in 

technology over the past few decades combined with the 

identified need to provide medical consultation and treatment over distance in military settings, telemedicine allows delivery of behavioral health care to military forces 

deployed to various locations throughout the world.4

Although not an exhaustive list, behavioral health 

services delivered through telemedicine has been referred to as telepsychiatry, telemental health, virtual 

behavioral health, and psychotechnologies. According 

to Myers and Turvey,5 behavioral health services is one 

of the most commonly used aspects of telemedicine, 

starting as early as 1957. Behavioral health care can be 

readily used through videoconferencing because other 

medical instrumentation such as x-rays or CAT scans is 

not required.1 As applied in this article, TBH is the use 

of interactive videoconferencing software with a camera loaded on a desktop or laptop computer linked to a 

network transmitted over the internet to deliver care to 

a different physical/geographic location. The TBH system allowed us to communicate with patients in need 

of care similar to the way people communicate using 

internet applications such as Skype or Facetime. Behavioral health care services delivered over the TBH system included assessment, psychoeducation, monitoring, 

mental status exams, counseling interventions, and consultation for a wide variety of presenting problems and 

behavioral health diagnoses.

Advantages of TBH

There are many advantages described in the literature 

detailing reasons telemedicine should be adopted in 

mainstream clinical care. The 3 most frequently discussed benefits include expanding care to underserved 

populations or geographically remote areas, reducing 

overall cost, and improving access to care by bridging the gap between no services and services offered 

by specialty providers or disciplines. Besides Soldiers 

in combat environments, underserved populations or 

geographically remote areas that may be appropriate 

for telemedicine can include children, elderly in nursing 

homes, prisoners, survivors of natural disasters, people 

in rural areas, and veterans.1,4-6 Cost reduction is demonstrated by a decrease in hospitalizations, emergency 

room visits, length of hospital stays, as well as less 

travel costs for both patients and providers. Specifically, 

costs within the military health system are reduced by 

avoiding unnecessary medical evacuation from theater 

and eliminating duplication of services across service 

branches.1,4,6-9 With increasing shortages of specialty 

providers, telemedicine can help meet the demands of 

care and improve access with little to no disruption to 

the provider’s clinical practice and workflow.1,4-6,8-10

Telebehavioral Health: Practical Application in

 Deployed and Garrison Settings

CPT Michelle M. Garcia, MS, USA

Kristin J. Lindstrom, PsyD
30 http://www.cs.amedd.army.mil/amedd_journal.aspx

Other benefits to TBH include its comparability to inperson encounters,5,6 its demonstrated effectiveness in 

diagnosing and treating mental illness,5 and its wide 

acceptance by patients and providers with high rates of 

satisfaction.6,8,9 Telebehavioral health can be used across 

the care continuum from inpatient to outpatient clinics11,12 to support a multidisciplinary approach extending beyond patient and provider, including consultation 

between providers1,4,10 resulting in improved continuity 

of care.1,4,10,11 Telebehavioral health can be implemented 

to protect patient privacy5,13 and mitigate risk related to 

patient safety in emergent situations.5,6 It also provides 

behavioral health support to help meet temporary surges 

in demand for services such as redeployment of large 

numbers of Soldiers.4 Hoge et al14 identified stigma as 

one of the barriers to providing behavioral health care 

to service members who met the screening criteria of 

a mental disorder before or after deployment. Reducing 

stigma through telemedicine is another benefit.1,6 Soldiers perceive less stigma given the anonymity and ability to access care through primary care clinics rather than 

a designated behavioral health clinic at a distant location.

In order to maximize the benefits of TBH, one should 

consider the setting, technology/bandwidth, data protection, patient privacy, informed consent, and implementation of policies and guidelines related to the use 

of TBH including emergency protocols, staff training, 

and exclusion criteria for seeing a patient via TBH. According to Myers and Turvey,5

 telemental health should 

be conducted in a comfortable and private setting. They 

also recommend that a dedicated network with high 

bandwidth be used in order to optimize the quality of 

care and help to ensure patient privacy.5 In their literature review of video teleconferencing (VTC) with 

patients with psychosis, Sharp et al6 found that higher 

bandwidths were associated with better outcomes, specifically with acceptance and satisfaction for both the 

patient and provider. Encryption software and the use of 

a secure network should be considered to support data 

protection and patient privacy.5,13 Patients should be 

aware of their rights to privacy and the limitations in the 

use of telemedicine through informed consent.5,13 Gusarova13 discussed that the patient has the right to refuse or 

consent to telemedicine services and recommended obtaining both written and verbal informed consent from 

the patient. If the patient refuses telemedicine treatment, 

other treatment options should be offered.5 Although no 

patient safety issues associated with using VTC were 

reported, Sharp et al6 recommend instituting emergency 

protocols. In order to address safety, emergency considerations should include clarifying procedures, roles, and 

responsibilities in psychiatric emergencies; addressing 

legal issues regarding care provided by local staff; and 

considering diminished control by the provider at another location compared to the interactions with local 

staff and the patient on site.5,6 Myers and Turvey5 discussed the importance of outlining inclusion and exclusion criteria, as well as when and where to refer patients 

if they are deemed inappropriate for TBH, such as those 

at higher risk for crisis, dysfunction, or noncompliance. 

If such considerations are not addressed, they easily become challenges identified in implementing TBH.

Challenges of TBH

The literature identifies several challenges of TBH. 

Some of those challenges involve legal and ethical considerations, such as patient privacy, appropriate private 

settings for treatment, data protection, informed consent, and problems within organizations with regard to 

policies and protocols.5 Other obstacles to implementation include certification of providers or consultants,3,10

lack of a streamlined process for licensure,12 acceptance 

by the patient as it relates to comfort and familiarity,4

and concerns regarding rapport, though little evidence 

was cited.6 Resistance to or the lack of acceptance of 

the use of telemedicine by providers was another challenge cited due to the perceived threat of depersonalization, fear of diminishing the quality of the patient-client 

relationship, and overall resistance to change current 

practices.1,5,6,10 Problems unique to the technology or 

network used such as unreliable equipment, distorted 

images, pauses in audio, and speech clarity were identified as significant issues with providing treatment and 

ultimately decreased rates of acceptance by patient and 

provider.1,6 Other identified challenges include training 

and maintaining staff to use the equipment appropriately and seek consultation when necessary,1,4,5 providing 

assistance or support to staff with expanded roles, including other medical or behavioral health staff at other 

sites,4,5 and systemic problems of establishing TBH care 

that extend to multiple sites rather than one location or 

one special interest.10

With regard to certification and licensure, Brannon et 

al12 pointed out that although telemedicine offers treatment to a mobile population, mobility does not reach 

beyond state licensures for providers offering the treatments. They highlight the lack of uniformity across 

state licensure requirements and delays and expense 

involved in obtaining a license, and they question who 

should be designated to streamline the process to facilitate interstate practice.12 Though the Department of 

Defense allows federal employees with one valid state 

license to practice in any of their military treatment facilities (MTFs) worldwide,8

 it is still a lengthy process to 

transfer credentials to every MTF in which the provider 

practices. This is especially true of those who will work 

TELEBEHAVIORAL HEALTH: PRACTICAL APPLICATION IN DEPLOYED AND GARRISON SETTINGS
October – December 2014 31

THE ARMY MEDICAL DEPARTMENT JOURNAL

using TBH, as they will necessarily have to undergo 

separate credentialing processes at multiple locations 

simultaneously.

Another challenge identified with the adoption of telemedicine into mainstream clinical care is the lack of research or the unreliability of research in early studies.1

With more sophisticated and growing evidence-based 

research demonstrating the effectiveness of TBH, Myers and Turvey5

 predict that this along with other conditions will be more supportive to the adoption of TBH 

in mainstream clinical care. Trondsen et al 9 proposed 

to enhance research on the use of VTC in psychiatric 

emergencies through an on-call system with local access to a specialist assessment. This was the situation 

in Afghanistan with on-call services offered to Soldiers 

through TBH in our area of operations.

Applications During Deployment

Initially, 4 TBH sites were established within our area 

of operations, including the TBH system in the behavioral health offices located in the Kandahar aid station 

that served as our base of operations. By the end of our 

deployment in November 2012, the number of TBH systems had expanded to 10 as part of the effort to establish 

TBH at each aid station at every outpost. These numbers 

do not include the TBH systems established at the combat stress control (CSC) facility or the military hospital at 

Kandahar. The expansion in our area of operations was 

supported by the division psychiatrist and was successfully executed by our CSC team who supplied the necessary equipment and expert personnel to set up the TBH 

systems at distant sites where no systems were previously 

available. The TBH system was configured on a Medical 

Communication Combat Casualty Care laptop computer 

with Logitech camera and software. The 2-way video 

communication was transmitted over a secure, dedicated 

network, assuring that the patients’ data were protected.

During the 9-month deployment, about a third of our 

patients were seen via TBH. There were various combinations in the provision of treatment among these patients. There were some cases in which the intake was 

conducted face-to-face and follow-up sessions via TBH. 

In other cases, care was initiated on TBH and the patient 

was then seen face-to-face when providers were at the 

patient’s remote location during battlefield circulation.* 

In some cases, the patient was seen exclusively via TBH. 

The majority of our TBH patients seemed satisfied with 

the service. Only one patient refused treatment via TBH 

and a very small number openly complained about it 

when faced with connectivity challenges. Fortunately, 

there was a CSC provider at the location of the one individual who refused treatment via TBH, therefore, his 

care was easily transferred. In some instances, TBH was 

the only treatment modality readily available due to lack 

of behavioral health providers nearby, so another option may not have been possible for some other patients 

within our battle space. Despite some initial concern 

that care delivered via TBH would be substandard, we 

discovered that, in general, we did not notice substantial 

differences in our TBH experiences or patient care. Our 

ability to return TBH patients to duty, meaning the case 

did not result in evacuation from theater to a higher level 

of care, was not noticeably different from our face-toface patient therapy. We also noted that patients generally conveyed positive therapy experiences and established treatment goals were met, including reduction of 

reported symptoms, regardless of whether patients were 

seen face-to-face or via TBH. From our perspective, the 

majority of patients who engaged in care via TBH were 

comfortable with the technology.

Despite our initial hesitation and discomfort with the 

unfamiliar mode of treatment, we soon discovered that 

while TBH care presented with challenges, there were 

many benefits as well. It improved access to care and 

minimized the need for patients and providers to make 

travel arrangements that ultimately would result in delay 

of care. It also allowed our small, 4-member behavioral 

health team (2 providers and 2 behavioral health specialists) to support a much larger area of operations, helped 

to provide care to a larger patient caseload in a more 

timely fashion, and protected against provider burnout 

through peer consultation, supervision, and reduced 

traveling requirements.

Through appropriate setup and interactions with medical personnel at remote aid stations, TBH could be used 

as a means for patients to engage in regular ongoing 

supportive counseling, brief check in, or follow-up appointments as needed. It could even be used for crisis 

evaluation if deemed appropriate by the behavioral 

health provider exercising clinical judgment after the 

case was staffed with the medics and provider at the remote aid station. If the case was deemed inappropriate 

for TBH, which most often occurred if the patient was 

acutely suicidal or homicidal, had intent to act on his or 

her ideations, and would not agree to a safety plan, the 

TBH provider recommended to the unit command that 

the patient be transported with unit escort via ground 

or air to a higher level of care within the theater of operations. A lateral move to the nearest behavioral health 

*Battlefield circulation is the term for the movement of behavioral health personnel among smaller, remote locations such as 

forward operating bases and combat outposts to provide individual face-to-face contact with service members for therapy, 

education, and awareness, as well as allowing direct command 

consultation.
32 http://www.cs.amedd.army.mil/amedd_journal.aspx

provider, such as the closest CSC unit, was not used 

in these cases as the higher level of care was typically 

necessary to address the crisis directly. Typically, crisis 

cases were related to safety concerns for individual patients, such as risk of harm to self or others. However, 

crisis events could also refer to critical incidents that 

took place as a result of combat, such as the loss of a 

Soldier. We did not use TBH to handle critical incident 

debriefings, often due to the functionality of the space 

where the TBH equipment was located. Most of the locations had the TBH equipment set up in small rooms 

that would not have been conducive to a group debriefing. When a critical incident occurred, we would use 

battlefield circulation to address the loss directly at the 

location, or locations, of the Soldiers and leaders most 

affected by the event. We would communicate face-toface and coordinate directly with leadership on site to 

assess the needs of that population and appropriately 

manage these sensitive incidents.

Whether in crisis interventions or cases with no elevated 

risk, TBH helped to enhance the coordination between 

medical and behavioral health providers in providing 

patients with the best care and supported referrals for 

medication or other resources as indicated. If during the 

TBH assessment a referral for medication evaluation 

was indicated or if safety precautions should be implemented, we could communicate that directly to that aid 

station medical provider via TBH, who would then prescribe the medication or work directly with the chain 

of command at his or her location. We could also staff 

cases with other behavioral health providers and refer 

patients to psychiatric care that was conducted via TBH 

from the MTF on Kandahar. The use of other technology such as e-mail and secure voice over internet protocol also helped enhance communication among providers and our unit command teams.

Perhaps the most significant challenges we faced in delivering care via TBH technology were related to connectivity and network issues. There were many occasions in which the system was unavailable or the call 

was disrupted during an appointment. At times the video would freeze or the audio would malfunction. As a 

result, appointments sometimes had to be rescheduled, 

and, in a few rare cases, a crisis evaluation was postponed. This resulted in a higher burden on the on site 

care provider and chain of command. The patient had to 

be maintained within the on site aid station or company 

headquarters on one-to-one watch, using valuable unit 

resources, until TBH capability was restored and the patient could be properly assessed and triaged. In some 

cases in which the TBH system was not functioning, the 

decision was made by the aid station medical provider, 

the behavioral health provider, and/or the unit command 

to evacuate the patient to a higher level of care, especially in crisis care situations. In our experience, however, 

most of these issues could be adequately addressed via 

good communication and prior planning with the providers managing the TBH system at the on site location.

Other challenges using TBH in the deployment setting 

included determining the location of the TBH system at 

each site, determining priority of TBH when considering 

other operational variables, inability to use screening instruments unless coordinated through the on site medical 

team, and provider and patient comfort with the system.

The selection of the TBH system location had the potential to affect both the challenges and the benefits TBH 

offered at the site. The majority of the TBH sites in our 

area of operations were set up in aid stations. This allowed seamless transition of care between the behavioral health provider and medical provider at the patient’s 

location, especially for medication referrals or safety 

concerns. The aid station was the optimal location to 

use TBH with patients expressing safety concerns due 

to the availability of medical staff and unit representatives on hand. The primary challenge of a TBH system 

in the aid station in a deployed setting is the lack of private rooms that can lead to a breach in confidentiality 

or mass casualties interrupting the care. On the other 

hand, using a location separate from the aid station had 

challenges with privacy as well, and detracted from the 

coordination between providers during the session. One 

site decided that due to the small size of their aid station 

and interruption of other medical care during TBH encounters, the TBH system was more effective in another 

building in a room with a curtain for a door. Another 

site designated a private room in their command operations building as their TBH setup; the patient obtained 

the key from the aid station, walked roughly 5 minutes 

to the building, and returned the key after the TBH session was complete. It is important to note that these 

same considerations concerning location to maximize 

privacy and care coordination during patient care also 

existed with face-to-face encounters during site visits 

on battlefield circulation.

Another challenge our unit encountered with TBH involved the number of dedicated, secure lines available at 

each location. For example, there were only 3 dedicated 

lines at one of the locations, and operations and intelligence had higher priority than TBH. The command 

team and medical assets on location initially tried connecting the TBH system to the network at their convenience, but since TBH required a dedicated line, the system was taken completely off the network. This resulted 

TELEBEHAVIORAL HEALTH: PRACTICAL APPLICATION IN DEPLOYED AND GARRISON SETTINGS
October – December 2014 33

THE ARMY MEDICAL DEPARTMENT JOURNAL

in unavailability of TBH capability for 2 to 3 months 

which significantly affected access to care for patients 

at that location. Eventually, more dedicated lines were 

installed and TBH capability was restored.

Lastly, TBH slightly changed the delivery of care in the 

provision of screening instruments, handouts, and a portrayal of the therapeutic principles or models in session. 

For example, conducting the Beck Depression Inventory 

verbally was extremely difficult due to the amount of 

time required to conduct the screening instrument. We 

resolved this challenge by sending the screening inventories electronically to the provider on site to print and 

give to the patient. However, there were occasions when 

the aid station did not have printing capability or did 

not have time to return the completed screening inventory. These same challenges applied to patient handouts. 

Anecdotally we did not find that the assessment and 

interventions were greatly affected by the absence of 

screening instruments or handouts. When portraying a 

therapeutic model on paper, we realized that the image 

was mirrored, therefore, our hand gestures had to be the 

opposite of what we expected in face-to-face sessions. 

Additionally, the TBH communication was confined to 

viewing the shoulder and face of the other person which 

necessitated adjustment when using gestures, modeling 

behavior, or demonstrating therapeutic tools on paper. 

These challenges were overcome and diminished over 

time with increased provider experience.

Overall, the benefits and gains achieved using TBH 

technology, as well as the improved access to care for 

our Soldiers, outweighed the challenges we experienced 

in the process of becoming familiar and proficient with 

TBH capabilities.

Applications in Garrison

Upon redeployment, the Embedded Behavioral Health 

(EBH) model was implemented on Joint Base LewisMcChord (JBLM), Washington. An EBH team is a clinic of mostly civilian behavioral health providers located 

within the footprint of a designated unit. The EBH team 

serves only Soldiers within their designated unit and operates under a model in which one provider is assigned 

to each battalion, providing care to any patients that 

come from that particular battalion. This allows providers to develop rapport with their unit leadership and is 

intended to help decrease stigma in the use of behavioral 

health services. The EBH model was implemented to 

improve access to care, to track trends in order to tailor 

support based on unit needs, and to foster relationships 

between behavioral health providers and command 

teams for the combined interest of the patient and unit 

readiness. Our EBH providers had an opportunity to 

use TBH at the Yakima Training Center for 4-6 weeks 

in the fall of 2013. The unit’s behavioral health officers 

could not attend the training and TBH implementation 

became increasingly more valuable.

Implementing TBH in the training environment had 

some unique challenges and benefits. First, we needed 

to work with the Department of Behavioral Health at 

the Madigan Army Medical Center and our EBH lead 

to assign a dedicated laptop computer for TBH use. At 

the time we had only one behavioral health specialist assigned. She received a computer with the Tandberg Movi 

teleconferencing system and a camera. She then loaded 

the software necessary to conduct message and video 

exchange across the internet in real time and established 

an account. We coordinated with the signal support officer to determine if any network or bandwidth limitations could possibly affect use of TBH. We also learned 

that TBH conducted on an unsecured network required 

different informed consent forms.

There were limited network connections in Yakima for 

each unit, so we were not allocated a dedicated line for 

TBH use. To address this problem, we borrowed our 

medical command team’s line for previously coordinated TBH encounters which did not interfere with company operations. We could only secure one computer with 

TBH capability at one location at Yakima to communicate with the EBH providers at JBLM. The location itself was inside a field tent that was collocated with other 

ancillary medical services (eg, preventative medicine 

and x-ray). The other medical services were asked to vacate the tent during a behavioral health or TBH encounter. The EBH team providing behavioral health care 

while the unit was training worked a set schedule from 

7:30 am to 4:30 pm. Therefore, any emergent behavioral 

health concerns outside of those hours were taken to the 

nearest emergency room or were managed by the unit 

which provided one-to-one watch until a TBH assessment could be conducted the next day. The behavioral 

health specialist conducted intakes or triaged the patient, 

then staffed the case with a licensed behavioral health 

provider via TBH in order to make appropriate recommendations for care. Despite the challenges, the benefits 

of offering some behavioral health care versus none 

outweighed the difficulties and supported the intended 

goals of the EBH model.

Another training opportunity presented itself when our 

brigade conducted a training exercise at the National 

Training Center, Fort Irwin, California. We considered using TBH to continue EBH support to the unit by 
34 http://www.cs.amedd.army.mil/amedd_journal.aspx

providing continuity of care, continuing coordination 

between command teams and their respective EBH representative, and to assist our behavioral health team in 

supporting over 3,000 Soldiers. However, we were unable to use TBH in this situation. The main challenge 

was again the network. We learned that it would be 

necessary to configure our JBLM/Madigan laptop on 

the Fort Irwin network. This required prior authorization which had not been obtained, so TBH could not be 

used. Therefore, only one provider and one specialist 

were available to provide support for the unit. During 

the first week at Fort Irwin, there was an unexpectedly 

large number of patient encounters in a short amount of 

time, several of which resulted in referral for hospitalization, and many of which required coordination with 

command and other medical providers. If the demand 

for behavioral health care had continued at that rate for 

an extended time, it could have easily led to provider 

burnout. Fortunately, the demand for behavioral health 

patient care did not remain at this pace for the duration 

of the training. Also, the Fort Irwin behavioral health 

team and command surgeon were very supportive in 

meeting the needs of our unit.

Outside of our unit’s garrison application of TBH, efforts are underway to establish TBH capabilities on 

JBLM to improve access to care in the Western Regional Medical Command. Certain duty stations within the 

Region have less access to care due to smaller staffing 

and more austere environments, such as some locations 

in Alaska, for example. Consequently, a number of patients, both Soldiers and their family members, have 

been unable to receive timely behavioral health care at 

their assigned MTFs. They experienced increased wait 

times and were referred to the TRICARE network. Currently, a new clinic at JBLM is providing services for active duty military members and their families via TBH. 

Providers working in the TBH clinic are credentialed to 

provide care at 10 different facilities within the Western 

Region. The credentialing process is complex and can 

be lengthy, but multiple state credentials are essential 

to provide an increase in access to care and a decrease 

in wait times for military members and their spouses 

in locations where they would otherwise be referred to 

outside providers.

While the benefits and advantages of TBH technology 

contribute to TBH care in this capacity, there are also 

continued challenges. Despite being in garrison where 

a vast improvement in connectivity in comparison to a 

deployed setting is expected, network issues continue to 

present the biggest challenge. Calls still disconnect and 

video images freeze with surprising frequency.

Conclusion

Based on the research and our personal experiences, 

our opinion is that there are consistently more advantages than disadvantages in the use of TBH technology, 

regardless of environment or setting. Telebehavioral 

health capability is a valuable tool for the delivery of 

care to our patients, and both patients and providers will 

benefit from its continued development. Time, money, 

and energy invested in the improvement of software, 

hardware, and network capabilities of TBH technology 

will be resources well spent. Actively implementing solutions to expand TBH capacity and address challenges 

will result in expanded behavioral health care availability not only for Soldiers in deployed and garrison settings, but also to beneficiary populations in underserved 

areas and remote locations.

References

1. Maheu MM, Pulier ML, Wilhelm FH, McMenamin JP, Brown-Connolly NE. The Mental Health 

Professional and the New Technologies: A Handbook for Practice Today. Mahwah, New Jersey: 

Lawrence Erlbaum Associates, Inc; 2005.

2. Sinha V. Telemedicine gains ground on the battlefield. Government Computer News [serial online]. 

February 21, 2003. Available at: http://gcn.com/ar

ticles/2003/02/21/telemedicine-gains-ground-onthe-battlefield.aspx. Accessed April 11, 2014.

3. Gillert D. Telemental health of growing interest to 

DoD medics. Department of Defense News [serial 

online]. February 26, 1998. Available at: http://www.

defense.gov/news/newsarticle.aspx?id=41239. Accessed April 11, 2014.

4. Girard P. Military and VA telemedicine systems 

for patients with traumatic brain injury. J Rehabil 

Res Dev. 2007;44(7):1017-1026. Available at: http://

www.rehab.research.va.gov/jour/07/44/7/Girard.

html. Accessed April 11, 2014.

5. Myers K, Turvey CL, eds. Telemental Health: Clinical, Technical, and Administrative Foundations 

for Evidence-Based Practice. Waltham, Massachusetts: Elsevier; 2013.

6. Sharp IR, Kobak KA, Osman DA. The use of 

videoconferencing with patients with psychosis: 

A review of the literature. Ann Gen Psychiatry. 

2011;10(1):14. doi: 10.1186/1744-859x-10-14.

7. Pellerin C. Changes aim to strengthen military 

health system. Department of Defense News [serial 

online]. March 2, 2012. Available at: http://www.

defense.gov/news/newsarticle.aspx?id=67406. Ac- cessed April 11, 2014.

8. Reed C. Telehealth offers hopes for better access to 

specialists, lower costs. Stars and Stripes. March 

21, 2013. Available at: http://www.stripes.com/

news/telehealth-offers-hopes-for-better-access-tospecialists-lowers-costs-1.212850#. Accessed April 

11, 2014.

TELEBEHAVIORAL HEALTH: PRACTICAL APPLICATION IN DEPLOYED AND GARRISON SETTINGS
October – December 2014 35

THE ARMY MEDICAL DEPARTMENT JOURNAL

9. Trondsen MV, Bolle SR, Stensland GO, Tjora A. 

VIDEOCARE: decentralised psychiatric emergency care through videoconferencing. BMC Health 

Serv Res. 2012;12:470. 

10. Joseph S. Telemedicine in the military health 

services system. Defense Issues [serial online]. 

1996;11(62). Available at: http://www.defense.gov/

Speeches/Speech.aspx?SpeechID=978. Accessed 

April 11, 2014. 

11. Castelnuovo G, Manzoni GM, Cuzziol P, et al. 

TECNOB: study design of a randomized controlled 

trial of a multidisciplinary telecare intervention for 

obese patients with type-2 diabetes. BMC Public 

Health. 2010;10:204.

12. Brannon JA, Cohn ER, Cason J. Making the case 

for uniformity in professional state licensure requirements. Int J Telerehabil. 2012;4(1):41-46. 

13. Gusarova A. Data protection in telemedicine. 

SHS Web of Conferences. 2012;2(00013). Available at: http://www.shs-conferences.org/articles/

shsconf/pdf/2012/02/shsconf_shw2010_00013.pdf. 

Accessed August 18, 2014.

14. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to 

care. New Engl J Med. 2004;351(1):13-22.

Authors

CPT Garcia is the Behavioral Health Officer, 2nd Brigade Combat Team, 1st Armored Division, Fort Bliss, 

Texas. She was previously deployed to Afghanistan as a 

Brigade Behavioral Health Officer, 3-2 Stryker Brigade 

Combat Team, 7th Infantry Division, Joint Base LewisMcChord, Washington.

Dr Lindstrom is a Clinical Psychologist in the Arches Telebehavioral Health Clinic, Madigan Army Medical Center, Tacoma, Washington. She was previously deployed 

to Afghanistan as a Brigade Behavioral Health Officer, 

3-2 Stryker Brigade Combat Team, 7th Infantry Division, 

Joint Base Lewis-McChord, Washington.
36 http://www.cs.amedd.army.mil/amedd_journal.aspx

As a part of our nation’s pursuit of improvements in patient care outcomes, continuity of care, and cost containment, the case manager has become a vital member of 

interdisciplinary teams and in health care agencies. The 

case manager acts as the patient’s key stakeholder in 

coordinating, collaborating, and communicating health 

care needs.1 The Pacific Regional Medical Command/

Tripler Army Medical Center integrated the nurse case 

manager (NCM) into the telebehavioral health (TBH) 

program. Where services may not otherwise be available, the TBH program links patients in need of behavioral health treatment to behavioral health providers 

using computers and video teleconferencing (VTC) 

technology over a secure network. There was a desire 

to measure patient care outcomes resulting from TBH, 

but processes to collect outcomes had not been fully developed, especially for the nurse case manager who was 

integrated into the multidisciplinary team.

This article is a report of the development of the processes and surveys that captured the outcomes of the nurse 

case manager’s care in a telebehavioral health program. 

The project began with a systematic search of the literature by the authors, including general and military data 

bases on telebehavioral health, telehealth, nurse case 

management, nursing, social work, health promotion, 

and population health. Over 50 articles, chapters, reports, and policies were reviewed and consolidated by 

the project leaders for the survey development. The 

search provided substantial evidence for NCM outcome 

determination and identified critical core NCM functions, in addition to relationship-based care, self-efficacy, and patient empowerment concepts that are embedded in NCM care.

Four outcome surveys were developed, based on concepts that were synthesized by the project leaders from 

the literature, and using rigorous survey development 

methodology:

Patient Impact Survey (Figure 1)

Family Impact Survey (Figure 2)

NCM as Care Partner Impact Survey (Figure 3)

NCM as Consultant Impact Survey (Figure 4)

Also, an NCM Action Log (Figure 5) was developed. It 

became evident from the literature and initial planning 

that the challenge with collecting outcome information 

from telehealth programs revolved around the logistics 

of making the surveys available to patients, providers, 

and collaborators at multiple sites and centralizing the 

data for analysis.

Effectiveness of Telebehavioral Health

 Program Nurse Case Managers (NCM):

 Data Collection Tools and the Process for

 NCM-Sensitive Outcome Measures

Judy Carlson, EdD, APRN

Roslyn Cohen, MSN

Wynona Bice-Stephens, EdD, RN

Abstract

As a part of our nation’s pursuit of improvements in patient care outcomes, continuity of care, and cost containment, the case manager has become a vital member on interdisciplinary teams and in health care agencies. 

Telebehavioral health programs, as a relatively new method of delivering behavioral health care, have recently 

begun to incorporate case management into their multidisciplinary teams. To determine the efficacy and efficiency of healthcare programs, program managers are charged with the determination of the outcomes of 

the care rendered to patient populations. However, programs that use telehealth methods to deliver care have 

unique structures in place that impact ability to collect outcome data. A military medical center that serves 

the Pacific region developed surveys and processes to distribute, administer, and collect information about a 

telehealth environment to obtain outcome data for the nurse case manager. This report describes the survey 

development and the processes created to capture nurse case manager outcomes. Additionally, the surveys and 

processes developed in this project for measuring outcomes may be useful in other settings and disciplines.
October – December 2014 37

The purposes of this project were to develop nurse case 

manager impact surveys and determine the processes 

needed to capture the effect of the TBH NCM, as well 

as determine the feasibility of those processes to gather the necessary data to measure NCM effectiveness. 

In this project, the data sources were literature, other 

stakeholders consisting of providers, command (leadership from a service member’s unit of assignment), and 

other care team members who partnered in care or consulted with the NCM. The data obtained were intended 

to develop valid and reliable NCM impact surveys and 

feasible processes to distribute, administer, and collect 

the surveys and analyze the data that could be obtained 

from the NCM impact surveys. Underlying the development of the processes was the requirement to maintain anonymity of the participants to mitigate any possible influence stemming from interaction of the NCM 

with the participants or staff involved in the conduct of 

the project. Before actual data collection occurred, the 

evidence-based practice (EBP) team submitted the EBP 

quality improvement application to conduct the project 

in accordance with the EBP approval procedures of the 

institution. The application was approved as an EBP 

project by the medical center’s deputy chief of clinical 

services. This project maintained all HIPAA requirements relative to patients. Collecting patient satisfaction 

and outcome of care data is considered an acceptable 

and leadership encouraged practice at the Pacific Regional Medical Command. Survey participants were not 

asked for identifiers on any of the surveys.

Methods

The project began when leadership and staff members 

recognized the need to measure NCM effect on patient 

care. Direction came from telehealth/telebehavioral 

health (TH/TBH) leadership to measure outcomes. The 

TBH NCM responded by inviting others to join a project 

team, which included the senior nurse scientist and the 

regional telehealth clinical advisor. The 3 team members committed to leading the project, with their supervisors’ support.

After the literature review, it was clear to the project leaders there was sufficient evidence to develop standardized 

processes and outcome surveys for telehealth at multiple 

sites. From this information, an action plan and timeline 

were formulated. To obtain a comprehensive view of the 

NCM’s impact, it was determined that 4 different impact 

surveys were needed for patients, family members, care 

partners, and those who consulted with the NCM. The 

NCM as care partner was distinguished from the NCM 

as consultant, depending on whether the NCM was actively case managing and directly intervening with the 

patient or consulting without direct patient interaction. 

Patient

Telebehavioral Health Nurse Case Manager Impact Survey

 Please Circle Your Answer

1. The Nurse Case Manager helps me get the services I need. Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

2. The Nurse Case Manager understands my concerns. Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

3. The Nurse Case Manager suggests additional resources, 

educational programs, information, and/or services to 

me as needed.

Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

4. I know how to contact the Nurse Case Manager when I 

need to. 

Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

5. I am better able to get the services I need because of the 

Nurse Case Manager’s help.

Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

6. I believe the Nurse Case Manager makes a positive impact 

on my well-being.

Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

7. I trust the Nurse Case Manager’s suggestions. Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

8. I feel like the Nurse Case Manager cares about me. Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

9. I am satisfied with the Nurse Case Manager’s assistance. Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

Instructions: Please circle the answer that best reflects your agreement with the statement indicated. This survey is 

confidential and will be collected by the administrative assistant for data collection purposes only. The Nurse Case Manager 

will have no access to your survey. Thank you for helping us serve you better!

Figure 1. Patient impact survey.
38 http://www.cs.amedd.army.mil/amedd_journal.aspx

It was also determined that an action log was needed to 

record the number and type of NCM activities. 

Survey Development Methodology

Following a rigorous survey development methodology, 

4 telebehavioral health NCM impact surveys were constructed using processes outlined by Waltz et al.1

 The 

survey development process included:

 Literature review and critique of prevailing critical 

core functional elements

 Expert review of critical elements

 Delphi process for consensus of content

 Content validity indexing

 Beta testing with representative populations

 Review

 Revision

The 4 impact surveys underwent 9 rounds of review to 

establish content validity. There was a 100% consensus 

that established a content validity index as 1.00. The 

individual items on each NCM impact survey were 

developed based on published research, meta-analysis; 

theory, standards of nursing, social work, case management literature, and expert opinion and critique. Multiple standards of practice related to nursing and case 

management served to identify customary critical core 

NCM functions for care coordination, collaboration, facilitation, and advocacy items.2-5 Items inquiring about 

relationship-based care, the therapeutic relationship, 

and the caring aspects of the nurse-patient relationship 

were well documented in nursing and behavioral health 

literature.6-9 Finally, items measuring patient education, 

patient empowerment, and self-efficacy stemmed from 

social change, health promotion, and population health 

models.10-14 The impact surveys were beta tested with patients and providers and recommendations incorporated.

The NCM’s action log (Figure 5) depicted the customary 

care elements that are provided by the NCM. Categories 

included were:

• Roles conducted by the NCM such as case manager, 

care coordination, and consultations.

Family

Telebehavioral Health Nurse Case Manager Impact Survey

Impact on my Family Member

Please Circle Your Answer

1. The Nurse Case Manager helps my family member get the 

services he/she needs.

Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

2. My family member is better able to help himself/herself get 

needed services because of the Nurse Case Manager’s 

help. 

Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

3. I believe the Nurse Case Manager makes a positive impact 

on my family member’s well-being.

Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

Impact on Me

Please Circle Your Answer

4. The Nurse Case Manager understands my concerns as a 

family member. 

Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

5. The Nurse Case Manager suggests additional resources, 

educational programs, information, and/or services to me 

as needed to help my family member.

Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

6. I know how to contact the Nurse Case Manager when I 

need to.

Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

7. I trust the Nurse Case Manager’s suggestions. Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

8. I feel like the Nurse Case Manager cares about me. Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

9. I am satisfied with the Nurse Case Manager’s assistance. Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

Instructions: Please circle the answer that best reflects your agreement with the statement indicated. This survey is 

confidential and will be collected by the administrative assistant for data collection purposes only. The Nurse Case Manager 

will have no access to your survey. Thank you for helping us serve you better!

Figure 2. Family impact survey.

EFFECTIVENESS OF TELEBEHAVIORAL HEALTH PROGRAM NURSE CASE MANAGERS (NCM):

DATA COLLECTION TOOLS AND THE PROCESS FOR NCM-SENSITIVE OUTCOME MEASURES
October – December 2014 39

THE ARMY MEDICAL DEPARTMENT JOURNAL

• Modalities used by the NCM to carry out interactions such as video teleconferencing, telephone, emails, or face-to-face.

• Critical dispositions of patients such as discharge 

planning, level of care changes, and diverting from 

emergency services.

• Critical safety interventions such as crisis intervention and emergency actions.

• Medication related discussions such as those related to adverse drug effects, medication adherence, 

medication education, medication reconciliation, 

pharmacy collaboration, and medication refills.

• Stakeholders contacted or with whom the NCM 

collaborated for/about patient care such as psychologists, psychiatrists, non-telebehavioral health 

NCMs, command, primary care managers, and 

family members.

The action log was beta tested by the NCM for one week 

to determine completeness and relevance to practice.

Process Development Methodology

The project leaders met with small group stakeholder 

teams to determine the processes needed. This phase 

involved determining the specific processes that were 

needed for each of the surveys used in the collection 

of outcome data. The following is a description of the 

involved staff and logistical processes developed unique 

to each survey.

1. Patient Impact Surveys would be e-mailed to the 

telepresenters (staff members at remote patient sites 

who facilitate the VTC connections between patients 

and providers). The telepresenters were to invite 

patients to complete the NCM impact survey after 

each NCM encounter. A script was prepared for the 

Nurse Case Manager as Care Partner

Telebehavioral Health Nurse Case Manager Impact Survey

 Please Circle Your Answer

1. The Nurse Case Manager understands the treatment plan 

I have in place for the patient.

Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

2. The Nurse Case Manager suggests additional resources, 

educational programs or information, and/or services for 

the patient as needed. 

Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

3. I know how to contact the Nurse Case Manager when I 

need to. 

Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

4. The Nurse Case Manager is skillful in supporting, 

educating, and assisting the patient.

Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

5. The Nurse Case Manager effectively coordinates the 

patient’s care with me and other team members (eg, 

chaplain, family members, other providers).

Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

6. The Nurse Case Manager effectively collaborates with me 

and other team members (eg, chaplain, family members, 

other providers) about the patient’s care.

Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

7. I am better able to get services for the patient because of 

the Nurse Case Manager’s assistance.

Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

8. The Nurse Case Manager adds value to the patient’s care 

by providing logistical, social, and/ or emotional support.

Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

9. The Nurse Case Manager serves as an advocate for 

getting the resources needed for the patient.

Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

10. I trust the Nurse Case Manager’s suggestions. Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

11. The Nurse Case Manager makes a positive impact on the 

patient’s wellbeing.

Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

12. I am satisfied with the Nurse Case Manager’s assistance. Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

Instructions: Please circle the answer that best reflects your agreement with the statement indicated. This survey is 

confidential and will be collected by the administrative assistant for data collection purposes only. The Nurse Case Manager 

will have no access to your survey. Thank you for helping us serve you better!

Figure 3. Nurse Case Manager as Care Partner impact survey.
40 http://www.cs.amedd.army.mil/amedd_journal.aspx

telepresenters to ensure standardized, noncoercive 

language which stressed voluntary and anonymous 

participation. The patient was instructed to return 

the survey to a designated location after completion.

2. Family Impact Surveys would be offered to family 

members who were distinct recipients of NCM services such as family education, resources, or support. 

At completion of interaction, the NCM would inquire 

if the family would be willing to provide feedback 

via e-mail. If so, the NCM would relay the name and 

e-mail address of the participant to an administrative assistant. The administrative assistant, using a 

specially created account with limited access, would 

send an e-mail with the survey as an attachment. 

The surveys include standard language about the 

voluntary, anonymous participation, as well as instructions for completion and return. Recipients’ 

names would be shielded from identity by use of 

the e-mail BCC (blind-carbon-copy) function. Any 

recipient who desired to participate would save the 

PDF fillable survey and return it to the outcome 

e-mail account. The administrative assistant would 

then save the survey, delete the e-mail, and enter the 

data into a Microsoft Excel spreadsheet. Each survey would be assigned a sequential generic number 

upon receipt. If the recipient did not return the survey 

within one week, the administrative assistant would 

send a reminder e-mail. After that, no further contact 

would be made and the name deleted.

3. Either a NCM as Care Partner or a NCM as Consultant Impact Survey would be offered based on the 

NCM’s role in care. The process internal to the TBH 

clinic itself would begin with a clinic briefing and 

provider agreement to receive, complete, and return 

the NCM as Care Partner or NCM as Consultant Survey appropriate to the type of NCM assistance. External care team members (providers not part of TBH 

clinic, command, and others), with whom the NCM 

partnered in care or provided consultation, would receive an e-mail detailing the purpose and the voluntary nature of the outcome survey after completion of 

the consultation or episode of care partnership with 

the NCM. 

Nurse Case Manager as Consultant

Telebehavioral Health Nurse Case Manager Impact Survey

 Please Circle Your Answer

1. The Nurse Case Manager understands my treatment 

goals.

Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

2. The Nurse Case Manager helps me understand the services available for Behavioral Health patients. 

Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

3. The Nurse Case Manager suggests helpful resources, educational programs, information, and/or services. 

Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

4. The Nurse Case Manager suggests ideas for effective 

collaboration with other members of the patient’s team 

(eg, healthcare providers, social services, and/or family 

members).

Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

5. The Nurse Case Manager responds to my calls and 

e-mails.

Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

6. I am better able to get the services my patient needs 

because of theNurse Case Manager’s assistance.

Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

7. I am better able to get services for the patient because of 

the Nurse Case Manager’s assistance.

Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

8. I believe the Nurse Case Manager’s consultation makes a 

positive impact on my patient’s well-being.

Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

9. I trust the Nurse Case Manager’s suggestions. Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

10. I am satisfied with the Nurse Case Manager’s assistance. Strongly 

Agree Agree Unsure Strongly Disagree Disagree Not Applicable

Instructions: Please circle the answer that best reflects your agreement with the statement indicated. This survey is 

confidential and will be collected by the administrative assistant for data collection purposes only. The Nurse Case Manager 

will have no access to your survey. Thank you for helping us serve you better!

Figure 4. Nurse Case Manager as Consultant impact survey.

EFFECTIVENESS OF TELEBEHAVIORAL HEALTH PROGRAM NURSE CASE MANAGERS (NCM):

DATA COLLECTION TOOLS AND THE PROCESS FOR NCM-SENSITIVE OUTCOME MEASURES
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THE ARMY MEDICAL DEPARTMENT JOURNAL

The process to identify potential recipients of the 

survey, deliver the survey, receive and enter returned 

data would be the same for those care team members 

internal and external to the TBH clinic. The NCM 

would create a list of the names and e-mail addresses, 

and identify the appropriate survey (NCM as Care 

Partner or NCM as Consultant) to be sent to each, 

and then e-mail the list to the administrative assistant on a weekly basis. The administrative assistant 

would follow the same process described in the Family Member Survey section. 

4. The NCM Action Log would be completed each day 

by the TBH NCM to identify numbers and types of 

NCM functions. After each discreet encounter with 

the patient, family member, or care partner relating 

to patient care or consultation, the NCM would place 

tally (tick) marks on the Action Log in the appropriate categories to track activities. At the end of each 

week, the Action Log would be submitted to the 

administrative assistant who tallied and entered the 

data into an Excel spreadsheet. As a new, uncategorized item was listed under the “other” column, an 

additional category was created to allow for tracking 

multiple related instances.

Evaluation of Outcome Surveys and Processes 

Methodology

The evaluation of the surveys and processes were conducted after the completion of the project to obtain TBH 

NCM outcome data. Because of the extensiveness of the 

outcome data received, the actual NCM outcomes will 

be presented in a future article. 

After the EBP project completion, final debriefing meetings were convened with the TBH providers, telepresenters, administrative assistant, and NCM to obtain 

qualitative data regarding the processes and surveys. 

After both qualitative and quantitative data were analyzed, the results were compiled and findings presented 

to leadership and other stakeholders.

Nurse Case Manager Action Log

Part A: Roles, Modality, Continuity of Care

Active Case Management Care Coordination Consultation

Active Case Management: Perform all NCM functions, assessment, planning, facilitation, care coordination, evaluation, and advocacy. 

Care Coordination: Perform continuity of care and facilitation activities (phone calls, e-mails etc.); limited patient engagement.

Consultation: Provide information, resources, advice, guidance, and/or directions to healthcare providers; no direct patient engagement.

Modality

VTC:

TC:

EM:

F2F

O:

VTC - video teleconference EM - e-mail O - other

TC - telephone call F2F - face to face

Disposition Safety

DCP: LOC: CR: Inpt:

DIV: O: ER: DTS/DTO:

DCP - discharge planning LOC: Level of Care change

DIV - diverted from ER O: Other

CR - Crisis Intervention Inpt - Arranged Inpt Admit

ER - Sent to ER DTS/DTO - Danger to Self/Others

Comments

Figure 5. Nurse Case Manager Action Log, Part A
42 http://www.cs.amedd.army.mil/amedd_journal.aspx

Results

The surveys and processes developed were implemented. The following subsections discuss findings regarding the feasibility of the processes.

Survey Distribution and Completion

Patient Impact Survey

The surveys were distributed without incident. The 

Patient Impact Survey completion and submission 

had challenges relating to logistics which included the 

physical location of the telepresenter in relation to the 

patient’s exit from the telehealth room, complex patient 

exit requirements (with multiple check points or procedures), or VTC rooms used as multipurpose facilities 

with no secure place for patients to leave surveys. All 

telepresenters indicated the need to provide additional 

written and verbal information to patients about the outcome survey’s purpose and process. Additionally, the 

consensus was that information emphasizing the survey 

purpose and focus to evaluate the NCM services rather 

than the identity of the NCM should be in bold font on 

the information sheet. All telepresenters indicated there 

Nurse Case Manager Action Log

Part B: Medication Related Functions, Contacts/Collaborations

ADE: 

ADH:

ME: 

MR:

Pharm:

RF:

Includes evaluating therapeutic/adverse effects, monitoring medication adherence, providing med education, reconciling medications, 

consulting with Pharmacy, and facilitating medication refills. 

ADE - Adverse Drug Effects ME - Medication Education Pharm - Pharmacy collaboration

ADH - Medication Adherence MR - Medication Reconciliation MR - Medication Refills 

ACS:

CHAP:

CMD:

DX: (labs, imaging studies)

FAP: 

Fam:

IPMC:

Legal:

NCM:

Patient: 

PCM:

PEBLO/MEB:

PSY:

PSY MD:

Rehab: (PT/OT)

SPEC:

SW:

TBI:

WTU:

ACS - Army Community Services CHAP - Chaplain CMD - Command

DX - Labs/Imaging FAP - Family Assistance Program Fam - Family Member

IPMC - Integrated Pain Mgmt Clinic Legal - JAG/Ombudsman NCM - Another NCM

Patient - Patient PCM - Primary Care Manager PEBLO - MEB Functions

Psy - Psychologist PSY MD - Psychiatrist Rehab - PT/OT/ST

SPEC - Specialty Care TBI - Traumatic Brain Injury WTU - Warrior Transition Unit 

Figure 5 (continued). Nurse Case Manager Action Log, Part B.

EFFECTIVENESS OF TELEBEHAVIORAL HEALTH PROGRAM NURSE CASE MANAGERS (NCM):

DATA COLLECTION TOOLS AND THE PROCESS FOR NCM-SENSITIVE OUTCOME MEASURES
October – December 2014 43

THE ARMY MEDICAL DEPARTMENT JOURNAL

was little to negligible burden on them and believed it 

was important to continue collecting outcome data.

Family Impact Survey

Two family members who were seen by the NCM during 

the 3-month time frame were e-mailed a survey without 

response. There was no further solicitation to provide 

feedback regarding completion of the surveys. 

NCM as Care Partner Survey

Qualitative data gained from an after action focus group 

session with 8 providers indicated the survey was clear 

and easy to use/submit, comprehensive in capturing the 

elements of the NCM role, and not perceived as a burden 

to distribute or complete. There was concern that without 

patient identifying information, the providers could not 

always determine which patient or patient situation they 

were to consider in the completion of the NCM impact 

surveys. Also, the providers indicated that assessing isolated points in ongoing care was sometimes challenging. 

NCM as Consultant Survey

No issues were identified relating to survey distribution 

or completion.

Action Log Completion

The Action Log was completed by the TBH NCM on a 

daily basis over the 3-month data collection period. In 

an after action debrief with the NCM, the mental focus 

needed and time required to complete the action log were 

identified as challenges. In addition, the newness of the 

process and usability of the Action Log were thought to 

affect completion since, according to the NCM, the survey required some editing and clarification. The NCM 

also noted that it was difficult to complete the Action 

Log each day, especially on very hectic days, and to capture the information immediately after the intervention. 

Five of the surveys were completed on the day following 

receipt, which may have affected accuracy. The NCM 

suggested inclusion of action log elements into the documentation system (electronic health record) as a possible solution to reduce the burden of capturing care on 

a separate paper form.

Surveys Data Collection and Entry

Patient Impact

The telepresenters and administrative assistant reported 

that sending the completed surveys to the administrative assistant as a group of attachments in an encrypted 

e-mail at the end of the week worked well. All indicated 

that receiving a receipt of the scanned and e-mailed 

surveys was beneficial. The telepresenters destroyed 

originals once the administrative assistant downloaded, 

generically coded, entered the data into an Excel spreadsheet, and sent a receipt to the originating telepresenter. 

Family Impact Survey

No issues could be identified since neither of the Family 

Impact Surveys was returned.

NCM as Care Partner Survey

In a debriefing session, the administrative assistant identified that data collection and entry became burdensome 

when the assistant’s duties and assigned geographic location changed. The tasks related to this project then 

became additional duties. In addition, delays in distribution and survey return resulted when the provider list 

was not submitted in a timely fashion by the NCM. With 

regard to the one week reminder process to complete the 

Care Partner Survey, 2 recipients of the 21 reminder emails completed and returned surveys.

NCM as Consultant Survey

As with the Care Partner Impact Survey, the administrative assistant identified the administrative burden relating to collection of surveys and data entry when the lists 

of consultants were delayed. This affected the timing of 

distribution and potential return of surveys. 

NCM Action Log

The Action Logs were given directly to the dedicated 

administrative assistant weekly when he/she was collocated with the NCM, and later by e-mail after the administrative assistant was relocated. The requirement to scan 

and e-mail the Action Log was a challenge for the NCM. 

Comment

This project was able to collect Telebehavioral Health 

NCM impact data with the processes and surveys developed. The after action debriefing sessions with care 

partners, telepresenters, the NCM, and the administrative assistant yielded vital data to help identify the 

strengths and limitations of the project and provide future recommendations. Overall the feedback received 

indicated that the processes put into place worked well.

Recommendations

The authors’ overall recommendation was to continue 

the NCM outcome survey distribution and collection, 

with the following process changes:

Patient Impact Survey Process

` Enhance buy-in from patients by providing a short 

orientation at the beginning of treatment, clarifying 

that they may be asked to provide feedback on their 

encounters to give them a voice in their health care, 

and provide data for program sustainability.
44 http://www.cs.amedd.army.mil/amedd_journal.aspx

` Standardize procedures and language across all 

telepresenters for the collection and distribution of 

surveys. For example, each telepresenter would distribute a reminder slip to the patient to check out 

with the telepresenter.

` For future enhancements, rather than paper survey 

copy, develop a software application for phone, iPad, 

Facebook, or other medium for immediate survey 

distribution to the patient and return to TBH. This 

would necessitate a consent form for nonsecure, unencrypted forms of telecommunications unless a 

secure encrypted process was available.

Care Partner Survey Process

• Develop a secure, anonymous method to correlate 

the patient with each survey distributed to care 

partners so it would be clearly known for which 

patient-NCM interaction they were providing feedback. The use of generic IDs placed on the survey, 

sent with an encrypted master list with IDs sent to 

the individual providers, was suggested as a solution. Logistics of this process was found to be a 

challenge at this time.

• Implementation of a periodic summative survey 

process was suggested as an alternative to an individual patient-NCM interaction feedback survey 

from the care partners. Doing summative evaluations would require minor changes to the survey to 

reflect more general feedback of several patients for 

specific time periods, perhaps giving the instruction, “In general, provide feedback on the NCM 

care of your patients over the past 3 months on the 

following items.” 

Action Log Process

 Since completing the Action Log was seen as an 

important but arduous additional documentation 

task, reduce or streamline the NCM workload by 

developing an embedded template in the electronic 

medical record to capture stakeholder’s interactions 

and NCM actions. 

 Use drop down boxes in the embedded template 

collocated with mandatory documentation to allow 

input of actions in an efficient manner. Drop down 

boxes would also enable easy outcome data extraction of the number and type of actions taken for the 

patient’s case management. 

General Processes

3⁄4 A dedicated assistant is required for outcome determination, outcome survey distribution, and data entry. Time must be allotted for these responsibilities. 

To enable standardized outcome processes, a standard operating procedure should be developed for 

remote sites for staff members who are not organic 

to the TBH program functioning as telepresenters 

and points-of-contact.

Conclusion

Timely, relevant, and robust outcome data related to 

NCM services delivered and received via telehealth can 

be obtained by following standardized processes and using standardized surveys. This article offers processes 

to capture NCM impact developed by a teleBehavioral 

program located at a military medical facility. 

Implications for Practice

Although outcome measurement of NCM practice is 

clearly called for in case management standards, until 

now there have been no published standardized outcome 

processes or measurement surveys, and very little published outcome data. This EBP Project developed surveys using standardized survey development processes 

with items based on NCM scope of practice and standards, social change and health promotion theories, and 

relationship-based care. This project presents surveys 

and processes which may be of value in other healthcare 

settings as well.

References

1. Waltz C, Strickland OL, Lenz E. Measurement in 

Nursing and Health Research. 4th ed. Philadelphia, 

PA: FA Davis & Company; 2010.

2. Case Management Society of America. Standards 

of Practice for Case Management. Little Rock, 

AR: Case Management Society of America; 2010. 

Available at: http://www.cmsa.org/Individual/

MemberToolkit/StandardsofPractice/tabid/69/Default.aspx. Accessed August 4, 2014.

3. Tricare Management Activity. Medical Management Guide. Washington DC: US Dept of Defense. 

Available at: http://www.tricare.mil/tma/ocmo/

download/MMG_v3_2009.pdf. Accessed August 

4, 2014.

4. Institute of Medicine. Returning Home From Iraq 

and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, 

and Their Families. Washington, DC: The National Academies Press; March 31, 2010. Available 

at: http://www.iom.edu/Reports/2010/ReturningHome-from-Iraq-and-Afghanistan-PreliminaryAssessment.aspx. Accessed July 31, 2014.

5. American Academy of Family Physicians. Definition of Continuity of Care. AAFP Website. Available at: http://www.aafp.org/online/en/home/poli

cy/policies/c/continuityofcaredefinition.html. 2013.

6. Koloroutis M, Manthey M, Felgen J, Person D, 

Kinnaird L, Wright D, Dingman S. Relationshipbased Care: A Model for Transforming Practice. 

Minneapolis, MN: Creative Healthcare Management, Inc; 2004. 

EFFECTIVENESS OF TELEBEHAVIORAL HEALTH PROGRAM NURSE CASE MANAGERS (NCM):

DATA COLLECTION TOOLS AND THE PROCESS FOR NCM-SENSITIVE OUTCOME MEASURES
October – December 2014 45

THE ARMY MEDICAL DEPARTMENT JOURNAL

7. Quinn JF, Smith M, Ritenbaugh C, Swanson K, 

Watson MJ. Research guidelines for assessing the 

impact of the healing relationships in clinical nursing. Alt Ther Health Med. 2003; 9(suppl 3):A65-A79.

8. Yamashita M, Forchuk C, Mound B. Nurse case 

management: negotiating care together within a 

developing relationship. Perspect Psychiatr Care. 

2005;41(2):62-70.

9. Kondrat DC, Early TJ. An exploration of the working alliance in mental health case management. Social Work Res. 2010;34(4):201-211.

10. Bastable SB. Nurse as Educator: Principles of 

Teaching and Learning for Nursing Practice. 3rd 

ed. Burlington, MA: Jones and Bartlett Publishers; 

2008.

11. Glanz K, Rimer BK, Lewis FM. Health Behavior and Health Education: Theory, Research, and 

Practice. 2nd ed. Palo Alto, CA: John Wiley & 

Sons, Inc; 2002.

12. Pender NJ, Murdaugh CL, Parsons MA. Health 

Promotion in Nursing Practice. 4th ed. Upper Saddle River, NJ: Prentice Hall; 2002. 

13. Coyle MK, Duffy JR, Martin EM. Teaching/learning health promoting behaviors through telehealth. 

Nurs Educ Perspect. 2007;28(1),18-23.

14. Suter P, Suter WN, Johnston, D. Theory-based 

telehealth and patient empowerment. Popul Health 

Manag. 2011;14(2):87-92.

Authors

Dr Carlson is a VA Nursing Academy Nurse 

Scientist, VA Pacific Islands Health Care System, Spark 

M. Matsunaga Medical Center, Honolulu, HI.

Ms Cohen is a Nurse Case Manager, TeleBehavioral 

Health and Surge Support Clinic, Tripler Army Medical 

Center, Honolulu, HI.

Dr Bice-Stephens, a retired Army Nurse, is Telehealth 

Clinical Advisor, Pacific Regional Medical Command, 

Tripler Army Medical Center, Honolulu, Hawaii.

The Tripler Army Medical Center is located in Honolulu, Hawaii. It is the only federal tertiary 

care hospital in the Pacific Basin. It also is the home of the Pacific Regional Medical Command.
46 http://www.cs.amedd.army.mil/amedd_journal.aspx

Cranial electrotherapy stimulation (CES) is a noninvasive, prescriptive medical treatment approved by the 

Food and Drug Administration for anxiety, insomnia, and depression. About the size of a smart phone, 

a CES device uses electrodes typically placed on both 

ear lobes to send a low level (less than 1 mA), pulsed 

electrical current transcranially through the brain.1 An 

EEG analysis of 30 subjects who received one 20 minute CES treatment showed significant increases in alpha 

activity (increased relaxation) and decreases in delta activity (increased alertness) and theta activity (increased 

ability to focus attention).2 These changes induce a calm, 

relaxed, yet alert state. A recent functional magnetic 

resonance imaging (fMRI) study provides irrefutable 

proof that CES causes cortical brain deactivation in the 

midline frontal and parietal regions of the brain after 

one 20 minute treatment.3 Many psychiatric and sleep 

problems are thought to be caused by cortical activation 

from anxiety or attention disorders.4,5 Thus, the fMRI 

study provides additional insight into the mechanism for 

the effectiveness of CES.

Since the early 2000s, Department of Defense (DoD) 

and Department of Veterans Affairs (VA) practitioners 

have prescribed CES for the treatment of anxiety, Posttraumatic stress disorder (PTSD), insomnia, depression, 

pain, and headaches.6,7 CES is classed as a tier II modality for pain by The Army Surgeon General’s Pain Management Task Force.8

 When CES is used primarily for 

centralized pain, it also can decrease anxiety, insomnia, 

and depression, common comorbidities of pain. Tan and 

colleagues9 compared service members’ and veterans’ 

preferences for 5 different therapeutic modalities for decreasing stress, anxiety, insomnia, and pain at a veterans’ 

outpatient pain management clinic. Participants could 

choose which device they wanted to use and could use a 

different device if they chose at future clinic visits. Cranial electrotherapy stimulation was selected 73% of the 

time (n=144), while the other 4 stress reducing modalities were selected from 4% to 11% of the time (n=53).

The purpose of this nonprobability, purposive sampling 

survey was to examine service members’ and veterans’ 

perceptions of the effectiveness and safety of CES for 

the treatment of anxiety, PTSD, insomnia, and depression. It was part of a postmarketing surveillance report 

for the Food and Drug Administration.

Safety

Cranial electrotherapy stimulation has an excellent safety profile. Electromedical Products International, Inc 

(EPI) (Mineral Wells, TX) reported, based on a survey 

Military Service Member and Veteran Self

 Reports of Efficacy of Cranial Electrotherapy

 Stimulation for Anxiety, Posttraumatic Stress

 Disorder, Insomnia, and Depression

Daniel L. Kirsch, PhD Jeffrey A. Marksberry, MD

Larry R. Price, PhD Katherine T. Platoni, PsyD

Francine Nichols, PhD, RN

Abstract

Cranial electrotherapy stimulation (CES) is being prescribed for service members and veterans for the treatment of anxiety, posttraumatic stress disorder (PTSD), insomnia and depression. The purpose of this study was to examine service 

members’ and veterans’ perceptions of the effectiveness and safety of CES treatment. Service members and veterans 

(N=1,514) who had obtained a CES device through the Department of Defense or Veterans Affairs Medical Center from 

2006-2011 were invited to participate in the web based survey via email. One hundred fifty-two participants returned 

questionnaires. Data were analyzed using descriptive statistics. Participants reported clinical improvement of 25% or 

more from using CES for anxiety (66.7%), PTSD (62.5%), insomnia (65.3%) and depression (53.9%). The majority of 

these participants reported clinical improvement of 50% or more. Respondents also perceived CES to be safe (99.0%). 

Those individuals who were not taking any prescription medication rated CES more effective than the combined CES and 

prescription medication group. CES provides service members and veterans with a safe, noninvasive, nondrug, easy to 

use treatment for anxiety, PTSD, insomnia, and depression that can be used in the clinical setting or self-directed at home.

Financial Disclosure

Dr Kirsch is a major shareholder and officer of Electromedical Products International, Inc.

Dr Marksberry is an employee of Electromedical Products International, Inc.
October – December 2014 47

of Alpha-Stim CES users, that during 2007-2011 there 

was a total of 8,248,920 Alpha-Stim CES treatments

(1,982,520 individual users treatments plus 6,266,400 

in-office treatments by practitioners). Any side effects 

that occurred were mild and self-limiting. Reported side 

effects from all sources (EPI survey and the scientific 

literature) are 1% or less. These include dizziness, skin 

irritation at electrode sites, and headaches. Headaches 

and dizziness are usually associated with a current setting too high for the individual. The symptoms normally 

resolve when the current is decreased. Irritation at the 

electrode site can be decreased by using alternate sites 

for placement of electrodes. There have been no serious adverse effects reported from using CES during 31 

years on the market in the United States.10

Efficacy

The first scientific investigations of the effect of CES were 

performed by Russian scientists in the 1950s and 1960s. 

These studies focused on the effect of CES on inducing 

sleep. After the 1966 International Symposia for Electrotherapeutic Sleep and Electroanesthesia in Graz, Austria, 

American scientists began investigating the effectiveness 

of CES for treating anxiety, insomnia, depression, and 

substance abuse. Numerous publications on these topics 

appeared during the 1970s. These early studies were typically small and had methodological limitations reflecting the research designs used in the time period during 

which they were conducted. However, the findings from 

the studies were consistently positive, showing CES decreased anxiety, insomnia, and depression.1

Table 1. Alpha-Stim CES studies on anxiety.

Principal

Investigator

Total

(n)

Subjects Study

Type

Findings

H. J. Kim

(2008)

11

60 Preoperative 

patients

RCT, IB CES group had significantly lower scores from baseline on the Likert Anxiety Scale than 

control group at end of study (P<.01, d=-0.88).

R. C. Cork

(2004)

12

74 Fibromyalgia 

patients

RCT, DB,

OL

CES group had significantly lower scores from baseline on the Profile of Mood States 

Scale (POMS), indicating less anxiety, than sham group at end of study (P<.01). Open 

label CES group had significantly lower scores on POMS at posttest from baseline 

scores (P<.001).

A. S. Lichtbroun

(2001)

13

60 Fibromyalgia 

patients

RCT, DB,

OL

CES group had significantly lower scores on the Profile of Mood States Anxiety Subscale (POMS-A), indicating less anxiety, from baseline than sham group at end of 

study (P=.02, d=-0.60). There was no significant difference in Open Label crossover 

group from pretest to posttest on POMS-A (P>. 05).

R. L. Winick

(1999)

14

33 Dental 

patients

RCT, DB CES group had significantly lower scores from baseline, indicating less anxiety, on the 

Visual Analog Scale (P<.01, d=-0.61) and higher scores on Likert Anxiety Scale, indicating less anxiety (P<.01) than sham group at end of study.

A. Bystritsky

(2008)

15

12 General

anxiety 

disorder 

patients

OL Anxiety scores decreased significantly on the Hamilton Anxiety Rating Scale from baseline to end of study (P=.01, d=-1.52). Anxiety scores were significantly lower on the 

Four-Dimensional Anxiety and Depression Scale at end of study from baseline (P<.01, 

d=-0.75).

S. J. Overcash

(1999)

16

197 Anxiety 

disorder 

patients

OL Subjects rating of anxiety was significantly less on Numerical Anxiety Rating Scale, 

0-100, from baseline to posttest (P<.05).Subjects’ physiological measures of anxiety–

EMG, EDR and Temp–changed significantly from baseline to posttest indicating less 

anxiety (P<.05).

RCT indicates randomized control trial; IB, investigator blind; DB, double blind; and OL, open label clinical study.

Table 2. Alpha-Stim CES studies on insomnia and depression.

Principal

Investigator

Total

(n)

Subjects Study

Type

Findings

Insomnia CES Studies

A. G. Taylor 

(2013)

17

46 Fibromyalgia 

patients

RCT, DB CES group had significantly lower scores on General Sleep Disturbance Scale (indicating less sleep disturbance) than sham from baseline at end of study (P<.001, d=-

0.30) and completed the study with scores below the range of insomnia.

A. S. Lichtbroun 

(2001)

13

60 Fibromyalgia 

patients

RCT, DB, 

OL

CES group had significantly higher scores on Numerical Sleep Quality Rating Scale, 

0-10, than sham group at end of study (P<.02, d=-0.54).

Depression CES Studies 

R. R. Mellon 

(2009)

18

21 Jail security 

and patrol 

officers

RCT, DB CES group had significantly less depression from baseline than sham group at end 

of study on Beck Depression Inventory (P<.01) and on Brief Symptom Inventory 

Depression scale (P<.05).

A. Bystritsky 

(2008)

15

12 General

anxiety 

disorder 

patients

OL Depression scores were significantly less on Hamilton Depression Rating Scale at 

end of study from baseline (P=.01, d=-0.41).

RCT indicates randomized control trial; IB, investigator blind; DB, double blind; and OL, open label clinical study.
48 http://www.cs.amedd.army.mil/amedd_journal.aspx

Over the past 15 years or so, the sophistication of the 

research designs and the quality of CES research improved substantially. Four randomized clinical trials 

(RCTs) investigated the efficacy of CES in treating state 

anxiety (Table 1).

Three of the RCTs, used a double-blind sham controlled 

design, while one RCT used an investigator-blind design. In these RCTs, the active CES group had significantly lower scores on state anxiety outcome measures 

than the sham or control group. Three RCTS on anxiety included Cohen’s d effect sizes that ranged from 

d=-0.60 (moderate) to d=-0.88 (high). Two open clinical studies found a significant difference from baseline to the endpoint of the study, with subjects having 

lower state anxiety scores at the endpoint of the study. 

Bystritsky and colleagues reported Cohen’s d effects 

sizes for 2 anxiety outcome measures: d=-1.53 on the 

Hamilton Anxiety Rating Scale (very high) and d=-0.75 

(moderate) on the Four-Dimensional Anxiety and Depression Rating Scale. Cranial electrotherapy stimulation was also shown to significantly decrease insomnia 

and depression (Table 2). All studies that investigated 

the effect of CES used reliable and valid scales for the 

measurement of outcomes.

Methods

The CES Device

The Alpha-Stim CES device with ear clips electrodes 

(0.5 Hz, 100–600 μA, 50% duty cycle, biphasic asymmetrical rectangular waves) was used in this study. Two 

electrodes that clip onto the ear lobes are used to send 

a mild electrical current through the brain. Treatment 

duration is a minimum of 20 minutes, but may be an 

hour at least one time daily. PTSD patients sometimes 

do a one hour CES treatment several times a day. During acute PTSD episodes, patients may use CES for extended periods of time (several hours) until symptoms 

decrease. While CES treatments should last a minimum 

of 20 minutes to achieve the desired effect, extended use 

of CES has no adverse side effects and is well tolerated.

The Questionnaire

One thousand five hundred fourteen (N=1,514) active 

duty service members and veterans who obtained an 

Alpha-Stim CES device through the DoD or VA medical 

centers from 2006 to 2011 were invited to participate in 

the web-based survey via email. Email addresses were 

obtained from prescription information for CES devices 

that was on file at EPI, the manufacturer of the device. 

All of the potential participants had been taught, using a 

standardized DoD or VA CES protocol, how to use selfdirected CES at home. Participants either voluntarily 

chose to respond or not to respond to the questionnaire. 

Survey Monkey is the professional website (http://www.

surveymonkey.com) for survey research that was used 

for this study. Respondents completed the questionnaire 

on-line from September 1, 2011, to October 1, 2011. Of 

the 1,514 persons who were invited to participate in the 

survey, 152 (N) responses to the questionnaire were received, yielding a response rate of 10%. Although response rates vary by the population sampled, a response 

rate somewhere between 15% and 40% is common for 

web-based surveys.19,20

The questionnaire contained 27 questions that covered 

demographic information, prescription medication use, 

and current exercise activity, as well as questions asking 

respondents to rate the effectiveness of CES technology 

for treating anxiety, PTSD, insomnia, and depression. A 

single item, 7-point Likert scale, which has established 

validity in the literature,21 was used to measure respondents’ perceived effectiveness of CES for anxiety, PTSD, 

insomnia, and depression. A sample question follows:

If you are using CES for your PTSD, since starting 

CES, rate your improvement as:

a. Worse (negative change)

b. No change (0%)

c. Slight improvement (1% to 24%)

d. Fair improvement (25% to 49%)

e. Moderate improvement (50% to 74%) 

f. Marked improvement (75% to 99%)

g. Complete recovery (100%)

Results

Data were analyzed using descriptive statistics. The 

characteristics of respondents, their use of CES technology, conditions for which they used CES, how often they 

used CES, and the length of time they had used CES are 

shown in Table 3. In addition to analysis of improvement-related questions on anxiety, PTSD, insomnia, and 

depression, questions were also interpreted in consideration of respondents’ use of prescription medication 

while using CES. There were 152 responses to the questionnaire. Seven questionnaires did not include any effectiveness and safety data. Thus, the valid sample size 

was N=145 for the analysis of these questions.

Safety and Overall Perceived Efficacy

Of the 145 persons responding to “Do you consider CES 

safe and effective?”, 99% reported that they view CES as 

safe and effective. Of the 1% of respondents (n=2) reporting CES as unsafe or ineffective, the reasons given were 

(1) that they were never shown how to use CES properly, 

and (2) CES was ineffective for their medical condition.

MILITARY SERVICE MEMBER AND VETERAN SELF REPORTS OF EFFICACY OF CRANIAL ELECTROTHERAPY 

STIMULATION FOR ANXIETY, POSTTRAUMATIC STRESS DISORDER, INSOMNIA, AND DEPRESSION
October – December 2014 49

THE ARMY MEDICAL DEPARTMENT JOURNAL

Anxiety

Thirty-one subjects (21.3%) reported 

that they were not currently using 

CES for anxiety. One hundred fourteen subjects (combined sample taking and not taking prescription medications regularly) using CES for anxiety responded to, “If you are using 

CES for anxiety, since starting CES, 

rate your improvement as ....” Figure 

1 shows the results for the total group 

(N=114), the CES only no medication group (n=26), and the CES and 

medication group (n=88).

Posttraumatic Stress Disorder

Fifty-six of the subjects (38.6%) 

reported not using CES for PTSD. 

Although PTSD is an anxiety disorder, it was included as a separate 

variable because of its importance 

in the treatment of service members 

and veterans.22 Eighty-eight subjects 

(combined sample taking and not 

taking prescription medication regularly) using CES for PTSD responded 

to “If you are using CES for PTSD, since starting CES, 

rate your improvement as....” The findings of the total 

group (N=88), CES only no medication group (n=18), 

and CES and medication group (n=70) are shown in Figure 2.

Insomnia

Forty-six subjects (31.7%) reported that they did not 

use CES for insomnia. Ninety-eight subjects (combined 

sample taking and not taking prescription medication 

regularly) who used CES for insomnia responded to , “If 

you are using CES for insomnia, since starting CES, rate 

your improvement as....” The findings of the total group 

(N=98), CES only no medication group (n=21), and CES 

medication group (n=77) are shown in Figure 3.

Depression

Fifty-six subjects (38.6%) reported that they were not 

using CES for depression. Eighty-nine subjects (subjects combined sample taking and not taking prescription medication regularly) using CES for depression responded to “If you are using CES for depression, since 

starting CES, rate your improvement as....” The findings of the total group (N=89), CES only no medication 

group (n=13), and CES medication group (n=76) are 

shown in Figure 4.

Determining Important Clinical Improvement

Dworkin and colleagues23 defined the criteria for important clinical improvement as follows:

Improvement of moderate clinical importance is 30% 

to 49%, and improvement of substantial clinical importance, the highest category, is 50% or more.

While the criteria were developed to evaluate clinical trial outcomes on chronic pain, it provides a useful 

framework for the assessment of clinical improvement 

in anxiety, PTSD, insomnia, and depression as well. For 

this study, improvement of moderate clinical importance was defined as 25% to 49% because the Likert 

scale which has been validated for use in measuring CES 

outcomes used 25% increments for categories. Using a 

conservative approach, the “Slight Improvement” (1% 

to 24%) category on the 2011 Alpha-Stim CES service 

members and Veterans survey was excluded, leaving the 

top 4 categories of “Fair Improvement” (25% to 49%), 

“Moderate Improvement” (50% to 74%), “Marked Improvement” (75% to 99%) and “Complete Improvement” 

(100%). Participants reported clinical improvement of 

25% or more from using CES for anxiety (66.7%), PTSD 

(62.5%), insomnia (65.3%), and depression (53.9%). The 

majority of service members and veterans who reported improvement of 25% or more had improvement in 

Table 3. Respondent characteristics and use of CES.

Characteristics n (%N) Characteristics n (%N)

Military status (N=152) Conditions for which respondents 

Active duty service members 109 (72%) used CES technology* (N=145)

Veterans 43 (28%) Anxiety 114 (78%)

Age (N=152) Depression 89 (61%)

Range: 19 to 67 years 

(mean=38, SD=10)

Insomnia 98 (67%)

PTSD 88 (60%)

Gender (N=152) How often respondents used CES 

Male 114 (75%) (N=145)

Female 33 (22%) Once a day 72 (50%)

No response 5 (3%) Twice a day 35 (24%)

Currently using CES? (N=152) 2 to 3 times a day 6 (4%)

Yes 125 (82%) 3 or more times a day 4 (3%)

No 23 (15%) No response 28 (19%) 

No response 4 (2%) Length of time using CES (N=145)

Currently taking at least one 

prescription drug? (N=152)

90 days 19 (13%)

4 months 9 (6%)

Yes 112 (73%) 5 months 5 (3%)

No 40 (27%) 6 months 17 (12%)

Currently exercise regularly? 

(N=152)

9 months 5 (3%)

1 year 31 (21%)

Yes 116 (76%) 2 years 20 (14%)

No 31 (20%) 3 years 7 (5%)

No response 5 (3%) No response 32 (22%)

*Use of CES for the following conditions was reported as 4% or less: attention deficit disorder, 

spasticity, antibiotic, anti-inflammatory, acid reflux, narcolepsy, Parkinson’ disease, erectile 

dysfunction.
50 http://www.cs.amedd.army.mil/amedd_journal.aspx

the highest category, “substantial clinical importance,” 

(50% or more) on all variables: anxiety, PTSD, insomnia, 

and depression, as shown in Figure 5.

Prescription Medication Use

Of the 112 respondents who reported they took at least 

one prescription medication, 98 provided the name of the 

drug or condition for which it was taken. The number 

of prescription medications taken ranged from one to 

11, with a mean of 2.6 and a median of 2.0. The types 

of medications taken are shown in Table 4. Medications that are used clinically for anxiety and depression 

were placed in the anxiety category.24 Medications used 

primarily for depression were placed in the depression 

Figure 1. Perceived Improvement in anxiety with use of CES by group.

Anxiety (N=114): Categories of Improvement

Percentage Improvement

No Change

(0%)

Slight

(1%-24%)

Fair

(25%-49%)

Moderate

(50%-74%)

Marked

(75%-99%)

9.7%

7.7%

32.5%

14.0%

15.4%

19.2%

26.9%

21.6%

10.2%

20.2%

25.0%

23.7%

30.8%

34.1%

9.1%

Total Group CES with Medications CES Only

35

30

25

20

15

10

5

0

40

Figure 2. Perceived Improvement in PTSD with use of CES by group.

PTSD (N=88): Categories of Improvement

17.1% 16.7%

14.8%

22.7% 22.9% 22.2% 22.2%

24.3% 23.9%

31.8% 31.4%

33.3%

5.6%

6.8%

4.3%

Total Group CES with Medications CES Only

No Change

(0%)

Slight

(1%-24%)

Fair

(25%-49%)

Moderate

(50%-74%)

Marked

(75%-99%)

35

30

25

20

15

10

5

0

Percentage Improvement

MILITARY SERVICE MEMBER AND VETERAN SELF REPORTS OF EFFICACY OF CRANIAL ELECTROTHERAPY 

STIMULATION FOR ANXIETY, POSTTRAUMATIC STRESS DISORDER, INSOMNIA, AND DEPRESSION
October – December 2014 51

THE ARMY MEDICAL DEPARTMENT JOURNAL

category. Only those medications categorized as sedative hypnotics were placed in 

the insomnia category. Only those drugs 

specifically approved for migraine headaches were included in the migraine headache category, while all narcotic and other 

pain medications were included in the pain 

category, the subject of a separate paper.

Comparison of CES with Drug Therapy

Several of the most common drugs used 

to treat anxiety, PTSD, insomnia, depression, pain and 

headaches were compared to the findings of the AlphaStim service member and civilian surveys as shown in 

Figure 6. CES data from October 2011 Military Service 

Member and Veterans study (N=152) and the CES Civilian User Survey (N=1,745) August 2011 were used. 

Pharmaceutical Survey Data were obtained from on-line 

WebMD user surveys (http://www.WebMD.com/drugs).

The Alpha-Stim CES civilian survey was conducted in 

August 2011 from data collected between July 2006 and 

July 2011 (http://www.alpha-stim.com). The final sample size from the civilian survey was 1,745 responders 

from a mail survey of 4,590 (38% useable responses). 

The WebMD drug survey asked civilians the question: 

“This medication has worked for me?” Respondents 

could choose to answer in one of 5 categories, with “1” 

being the lowest to “5” being the most effective. The 

sample size for the drugs selected ranged from N=62 to 

N=2,238. The CES survey questionnaire 

asked respondents to rate their improvement for a specific condition based on using CES. Subjects could choose one of 7 

categories: worse (negative change), no 

improvement (0%), slight improvement 

(1% to 24%), fair improvement (25% to 

49%), moderate improvement (50% to 

74%), marked improvement (75% to 99%), 

and complete recovery (100%). While the 

questions in the WebMD and CES surveys were slightly different, all surveys asked questions 

about effectiveness. The WebMD data were changed to 

percentages and ranged from 1% to 100%. Two categories were excluded from the CES survey as they were 

not included in the WebMD survey: worse (negative 

change) and no change (0%). The categories of “worse 

(negative change)” or “no change” reflected less than 1% 

of the responses in all instances (ie, on all questions). 

The upper 5 categories which ranged from 1% to 100% 

were used for comparison. The scale was the same, 1% 

to 100% for the data from all surveys. The comparison 

of the data from the 2 surveys is both appropriate and 

justifiable based on the item content (ie, content/construct validity) and the format of item response.19

Comment

It is not surprising that the response rate to the survey 

was not higher. The majority of persons asked to participate in the survey were active duty service members. 

Table 4. Prescription Medications Use by Condition.

Anxiety 45.9%

Depression 44.8%

Pain 38.7%

Insomnia 27.5%

Hypertension 16.3%

Seizure Control 11.2%

Migraine Headache 9.0%

Schizophrenia/Bipolar 9.0%

Figure 3. Perceived Improvement in insomnia with use of CES by group.

Insomnia (N=98): Categories of Improvement

Percentage Improvement

19.5%

1.3%

9.5%

4.8% 4.8%

15.6%

14.3%

21.4%

18.1%

16.3%

18.4%

20.4%

22.0%

23.8% 23.4%

21.4%

42.9%

2.0%

Total Group CES with Medications CES Only

No Change

(0%)

Complete

(100%)

Slight

(1%-24%)

Fair

(25%-49%)

Moderate

(50%-74%)

Marked

(75%-99%)

35

30

25

20

15

10

5

0

40

45

50
52 http://www.cs.amedd.army.mil/amedd_journal.aspx

Many email addresses may not have been valid because 

the survey covered a 6-year period and some may have 

moved, were discharged, or may have elected not to respond to the email if they were no longer 

using CES. This study supports the efficacy and safety of CES technology for 

the treatment of anxiety, PTSD, insomnia, 

and depression in service members and 

veterans. The findings are consistent with 

findings of previous research studies on 

CES. The effectiveness of CES in a military population was comparable to the 

effectiveness of drugs commonly used in 

the treatment of the same conditions in 

the civilian population.

Ninety-nine percent of subjects in this 

survey considered CES technology to be 

safe. An important safety benefit of CES 

is that it leaves the user alert and relaxed 

after treatment, in contrast to drugs that 

can have adverse side effects and affect 

service members’ ability to function on 

missions that require intense focus and 

attention.25 This is particularly true in the 

combat theater of operations.

The information on prescription medication use provides a general view of drugs 

used by respondents for their specific condition(s). The 

findings that a high percentage of respondents took prescription medications for anxiety (45.9%), depression 

Figure 4. Perceived Improvement in depression with use of CES by group.

Depression (N=89): Categories of Improvement

Percentage Improvement

7.7%

13.5%

10.5%

30.1%

25.0%

23.0% 22.5%

17.1%

18.0%

15.4%

26.3%

24.7%

21.4% 21.0%

23.1%

35

30

25

20

15

10

5

0

No Change

(0%)

Slight

(1%-24%)

Fair

(25%-49%)

Moderate

(25%-49%)

Marked

(75%-99%)

Total Group CES with Medications CES Only

20.2% 46.5%

21.6% 43.2%

15.4% 57.7%

66.7%, N=76

64.8%, n=57

73.1%, n=19

60.0%, n=42

72.2%, n=13

62.5%, N=55

59.8%, n=46

85.8%, n=18

65.2%, N=64

52.6%, n=40

60.8%, n=8

54.0%, N=48

23.9% 38.6%

24.3% 35.7%

22.2% 50.0%

20.4% 44.8%

19.5%

23.8%

18.0%

17.1%

36.0%

35.5%

37.8%

40.3%

23.0%

62.0%

Total Group

CES

CES & Med

Total Group

CES

CES & Med

Total Group

CES

CES & Med

Depression

N=89

Insomnia

N=98

PTSD

N=88

Anxiety

N=114

CES

CES & Med

Total Group

Improved 25% to 49% Improved 50% or more

Figure 5. Service members and veterans who had improvment of moderate (25% to 49%) and substantial (50% or more) clinical importance.

Note: CES & Med indicates CES and medication. CES indicates CES alone.

MILITARY SERVICE MEMBER AND VETERAN SELF REPORTS OF EFFICACY OF CRANIAL ELECTROTHERAPY 

STIMULATION FOR ANXIETY, POSTTRAUMATIC STRESS DISORDER, INSOMNIA, AND DEPRESSION
October – December 2014 53

THE ARMY MEDICAL DEPARTMENT JOURNAL

(44.8%), pain (38.7%), and insomnia 

(27.5%) is consistent with the literature.6,7

The importance of controlling for medication type and dosage in future CES 

studies is a valuable outcome of this survey. It would also be helpful to classify 

the severity of illness of the subjects in 

future studies. While it appears that medication may influence the effectiveness of 

CES technology, it is possible that respondents taking prescription medication had 

far more serious symptoms and medical 

and psychological conditions than the no 

medication group. The group sizes were 

unequal. The “CES only, no medication” 

group was considerably smaller, ranging 

from 13 to 26 subjects, in comparison to 

the CES medication groups that ranged 

from 53 to 88 subjects. This may account 

for the differences in scores between the 

groups. However, the effect of medication 

appears to be an important confounding 

variable when investigating the efficacy 

of CES.

Conclusions

The results of this survey are compelling 

and provide the foundation for a rigorous 

placebo controlled RCT that investigates 

the effectiveness of CES for treating anxiety, PTSD, insomnia, and depression in service members and veterans. In addition, this study also examines 

the influence of medication on CES efficacy outcomes. 

This study provides evidence that service members and 

veterans perceived CES as an effective treatment for 

anxiety, PTSD, insomnia, and depression. CES can be 

used either as an adjunct to pharmaceutical therapy or 

as a standalone therapy, providing service members and 

veterans with a safe, noninvasive, nonpharmacologic 

treatment for anxiety, PTSD, insomnia, and depression 

that can be used in the clinic setting, including the wartime theater clinics, or self-directed at home.

References

1. Kirsch D. The Science Behind Cranial Electrotherapy Stimulation. Edmonton, Alberta, Canada: 

Medical Scope Publishing; 2002.

2. Kennerly R. QEEG analysis of cranial electrotherapy: a pilot study [abstract]. J Neurother. 

2004;8(2):112-113. Available at: http://www.stress.

org/wp-content/uploads/CES_Research/kennerlyqeeg.pdf. Accessed July 11, 2014.

3. Feusner JD, Madsen S, Moody TD, Bohon C, Hembacher E, Bookheimer SY, Bystritsky A. Effects of 

cranial electrotherapy stimulation on resting state 

brain activity. Brain Behav. 2012;2(3):211-220.

4. Yassa MA, Hazlett RL, Stark CE, Hoehn-Saric R. 

Functional MRI of the amygdala and bed nucleus 

of the stria terminalis during conditions of uncertainty in generalized anxiety disorder. J Psychiatr 

Res, 2012;46(8):1045-1052.

5. Bonnet MH, Arand DL. Hyperarousal and insomnia: state of the science. Sleep Med Rev. 

2010;14(1):9-15.

6. Bracciano AG, Chang WP, Kokesh S, Martinez A, 

Moore K. Cranial electrotherapy stimulation in the 

treatment of posttraumatic stress disorder. a pilot study 

of two military veterans. J Neurother. 2012;16(1):60-69.

7. Tan G, Rintala D, Jensen MP, et al. Efficacy of 

cranial electrotherapy stimulation for neuropathic pain following spinal cord injury. a multisite randomized controlled trial with a secondary 

6-month open-label phase. J Spinal Cord Med. 

2011;34(3):285-296.

8. Pain Management Task Force: Final Report. Washington, DC: US Dept of the Army, Office of the 

Surgeon General; May 2010.

Figure 6. Comparison of service members’ (SM) and civilians’ (C) perceived 

responses to Alpha-Stim CES and drug therapy. CES data from Alpha-Stim 

Military Service Member Survey (N=152) and Alpha-Stim Patient Survey 

(N=1,745), October 2011. Pharmaceutical survey data from WebMD (http://

www.WebMD.com/) accessed October 28, 2011.

Percentage Perceived Improvement

70%

67%

83%

56%

78%

84%

68%

81%

84%

80%

85%

90%

0 10 20 30 40 50 60 70 80 90 100

Ativan (n=838) 

Xanax (n=2238) 

CES- C (n=358)

CES-SM (n=114)

Sonata (n=62) 

Lunesta (n=462) 

CES- C (n=163)

CES-SM (n=98)

Wellbutrin (n=1198) 

Zoloft (n=2028) 

CES- C (n=311)

CES-SM (n=89)

Depression Insomnia Anxiety

Service Members Civilians WebMD Survey
54 http://www.cs.amedd.army.mil/amedd_journal.aspx

9. Tan G, Dao TK, Smith DL, Robinson A, Jensen 

MP. Incorporating complementary and alternative medicine (CAM) therapies to expand psychological services to veterans suffering from chronic 

pain. Psychol Serv. 2010;7(3):148-161

10. Petitioner Presentation to Neurological Devices 

Panel for Reclassification of Alpha-Stim CES Devices From Class III to Class II. Mineral Wells, TX: 

Electromedical Products International, Inc; February 10, 2012. Available at: http://www.alpha-stim.

com/wp-content/uploads/EPIs-fda-presentation.

pdf. Accessed July 11, 2014.

11. Kim HJ, Kim WY, Lee YS, Chang M, Kim JH, Park 

YC. The effect of cranial electrotherapy stimulation on preoperative anxiety and hemodynamic responses. Korean J Anesthesiol. 2008;55(6):657-661.

12. Cork RC, Wood PM, Norbert C, Shepherd JE, Price 

L. The effect of cranial electrotherapy stimulation 

(CES) on pain associated with fibromyalgia. Internet J Anesthesiol [serial online]. 2004;8(2). Available at: http://ispub.com/IJA/8/2/12659. Accessed 

July 11, 2014.

13. Lichtbroun AS, Raicer MC, Smith RB. The treatment of fibromyalgia with cranial electrotherapy 

stimulation. J Clin Rheumatol. 2001;7(2):72-78.

14. Winick RL. Cranial electrotherapy stimulation 

(CES): a safe and effective low cost means of 

anxiety control in a dental practice. Gen Dent. 

1999;47(1):50-55.

15. Bystritsky A, Kerwin L, Feusner J. A pilot study 

of cranial electrotherapy stimulation for generalized anxiety disorder. J Clin Psychiatry. 

2008;69:412-417.

16. Overcash SJ. Cranial electrotherapy stimulation 

in patients suffering from acute anxiety disorders. 

Am J Electromedicine. 1999;16(1):49-51.

17. Taylor AG, Anderson JG, Riedel SR, Lewis JE, 

Kinser PA, Bourguignon C. Cranial electrical stimulation improves symptoms and functional status 

in individuals with fibromyalgia. Pain Manag Nurs. 

2013;14(4):327-335.

18. Mellon RR, Mackey W: Reducing sheriff’s officers’ 

symptoms of depression using cranial electrotherapy stimulation (CES): a control experimental study. 

Correct Psychologist. 2009;41(1):9-15.

19. Dillman D. Mail and Internet Surveys. 2nd ed. 

Hoboken, NJ: John Wiley & Sons; 2007.

20. Czaja R, Blair J. Designing Surveys: A Guide to 

Decisions and Procedures. 2nd ed. Thousand Oaks, 

CA: Pine Forge Press; 2005.

21. Davey HM, Barratt AL, Butow PN, Deeks JJ. A 

one-item question with a Likert or visual analog 

scale adequately measured current anxiety. J Clin 

Epidemiol. 2007;60(4):356-360. 

22. US Department of Veterans Affairs, National Center for PTSD. Available at: http://www.ptsd.va.gov/. 

Accessed May 10, 2012.

23. Dworkin RH, Turk DC, Wyrwich KW, et al. Interpreting the clinical importance of treatment outcomes in chronic pain clinical trials: IMMPACT 

recommendations. J Pain. 2008;9(2):105-121.

24. Mental Health Indications: What medications are 

used to treat anxiety disorders?. National Institute of Mental Health Website; 2008. Available 

at: http://www.nimh.nih.gov/health/publications/

mental-health-medications/index.shtml. Accessed 

July 11, 2014.

25. Tilghman A, McGarry B. Medicating the military: 

use of psychiatric drugs has spiked; concerns surface 

about suicide, other dangers. Army Times. March 17, 

2010. Available at: http://www.armytimes.com/ar

ticle/20100317/NEWS/3170315/Medi

cating-military. Accessed July 11, 2014.

Authors

Dr Kirsch is President, American Institute of Stress, Fort 

Worth, Texas.

Dr Price is Director of Faculty Research and Professor of 

Psychometrics and Statistics, College of Education and 

Department of Mathematics, Texas State University, San 

Marcos, Texas.

Dr Nichols is a research consultant and retired Professor, 

Georgetown University, Washington, DC.

Dr Marksberry is Director, Science and Education, Electromedical Products International, Inc, Minerals Wells, 

Texas.

When this article was written, COL Platoni was Army 

Reserve Psychology Consultant to the Chief, US Army 

Medical Services Corp. Now retired from the Army 

Reserve, Dr Platoni is in private practice in Centerville, 

Ohio.

MILITARY SERVICE MEMBER AND VETERAN SELF REPORTS OF EFFICACY OF CRANIAL ELECTROTHERAPY 

STIMULATION FOR ANXIETY, POSTTRAUMATIC STRESS DISORDER, INSOMNIA, AND DEPRESSION
October – December 2014 55

It has been estimated that in recent years up to 15% of 

casualties in the wars in Afghanistan and Iraq were the 

result of suicidal behavior and completed suicide.1 According to the 2010 Department of Defense Sentinel 

Event Report (DoDSER),2 22.42% of Soldiers who died 

by suicide (n=63) and 44.15% of those who attempted 

suicide (n=381) had received outpatient behavioral 

health treatment during the prior month. The former US 

Army Vice Chief of Staff cited a document produced 

by the National Institute of Mental Health entitled “Opportunities to Improve Interventions to Reduce Suicidality: Civilian ‘Best Practices’ for Army Consideration”3

 to illustrate the current lack of suicide-focused, 

empirically validated clinical treatments. In response, a 

number of suicide prevention initiatives have been enacted throughout the Army. Suicide prevention efforts 

within the Army aim in part to reduce suicidal behaviors through education, encouragement of help-seeking 

behaviors, and destigmatization.4,5 This is evident in the 

materials and publications developed by the US Army 

Center for Health Promotion and Preventive Medicine 

(now the Army Public Health Command) in conjunction with the American Association of Suicidology, and 

in multimedia publications from the Defense Centers 

of Excellence. These initiatives largely focus upon the 

identification of early warning signs in order to implement early intervention, namely, a referral to behavioral health. In spite of the development of these suicide 

prevention initiatives, Army service member suicide 

continues to rise. In 2012, a total of 349 US military 

suicide deaths were recorded across the branches; the 

largest portion of these deaths, 182 potential suicides, 

comprised of members of active duty Army.6,7 These 

findings, coupled with the lack of suicide-focused clinical treatments for the military, prompted a flourish of 

research to understand suicidal behaviors within the 

military.

Suicide risk may concentrate more in Army Behavioral Health (BH) patient populations for several of the 

reasons that make military experience unique when 

compared to civilian life. When suicidality among military members accompanies behavioral health conditions associated with sleep disturbances, concentration 

problems, and physical symptoms that impact on daily 

functioning, this can lead to reduced occupational performance, physical conditioning, and combat readiness. 

Soldiers who are suicidal may also experience somatic 

concerns and related problems that result in a higher frequency of medical or sick call visits. This may then contribute to increased work stress and increased conflict 

with coworkers and family members, affecting morale 

and well-being. Special populations within the military 

community, such as Wounded Warriors, have their own 

unique set of risks including chronic pain, decreased 

level of functioning due to injury or other health problems, and potential prescription drug abuse. Psychological and physical pains are both likely contributors to 

suicide. Previous factor analytic research with suicidal 

inpatients has shown the important psychometric role of 

Raising the Clinical Standard of Care for

 Suicidal Soldiers: An Army Process

 Improvement Initiative

Debra Archuleta, PhD René M. Lento, MA

David A. Jobes, PhD Katherine Brazaitis, MA

Lynette Pujol, PhD Bret A. Moore, PsyD

Keith Jennings, MA Bruce Crow, PsyD

Jennifer Crumlish, PhD

Abstract

From 2004 to 2008, the suicide rate among US Army Soldiers increased 80%, reaching a record high in 2008 

and surpassing the civilian rate for the first time in recorded history. In recent years, the rate of Army suicides 

rose again; the year 2012 reflects the highest rate of military suicides on record. There is a need to assess current behavioral health practices to identify both effective and ineffective practices, and to adapt services to 

meet the needs of the Army behavioral health patient population. This paper discusses a process improvement 

initiative developed in an effort to improve clinical processes for suicide risk mitigation in an Army behavioral 

health clinic located in the catchment area of the US Army Southern Regional Medical Command.
56 http://www.cs.amedd.army.mil/amedd_journal.aspx

psychological pain in acute suicidal states.8 In addition, 

in an analysis of risk factors for suicide in the Army, 

Retired COL Elspeth Ritchie notes the role of physical 

pain and disability as a precipitant for suicide, especially 

among older Service Members with higher rank.9

Soldiers who experience suicidal behaviors or who complete suicide have a disproportional effect on military 

communities. Units are primarily affected by a suicidal 

Soldier or by the loss of an integral team member which 

can have significant effects on surviving Soldiers and 

may lead them to experience a range of emotional reactions such as grief, guilt, and anger. This reduces work 

performance and contributes to increased vulnerability 

for a range of health-related problems including suicidal 

behaviors (ie, “contagion” effects).10 The contagion effect occurs when one suicide leads to a subsequent suicide.10 Factors that may support to the contagion effect 

have been researched and include documented clusters 

of suicides in close temporal or geographic proximity, 

exposure to media coverage of suicides and exposure 

to suicidal peers.10 Research has been focused on adolescents and young adults due their tendency to learn 

behavior by observing and modeling the behavior of 

others.10 This is of particular concern for military leadership due to the large number of military service members who are young adults under the age of 25.11 There 

were indications of possible suicide clusters in the military among Army recruiters in 2008 and in 2009 within 

a National Guard unit, though these incidents have not 

been formally studied.11 Additionally, the death of a Soldier by suicide often brings increased media and congressional attention leading to an increase in scrutiny of 

the chain of command. Finally, the military population 

is a highly transient population which translates into the 

high mobility of Soldier suicide risk. This often leads 

to disjointed treatment services that create challenges 

in the coordination of care for a Soldier between duty 

stations, as well as between clinics in a military medical 

treatment facility (MTF). Early and efficient treatment 

and intervention of suicidality can therefore improve 

occupational performance and mission effectiveness, 

while also having a positive effect on the health and wellbeing of a wide spectrum of the military community.

This paper discusses a process improvement (PI) initiative developed to meet the above noted needs and contribute to Army suicide prevention, as well as raise the 

clinical standard of care through improved clinical processes for suicide risk mitigation in an Army BH clinic 

located in the catchment area of the US Army Southern 

Regional Medical Command. What follows is our stepby-step approach systematically to endeavor to raise the 

clinical standard of care in an outpatient Army BH clinic.

A Process Improvement Initiative

Development of a Needs Assessment Report

The initial phase of the PI initiative included a thorough 

and systematic evaluation of existing clinical practices 

related to suicidal Soldiers and their care. The evaluation was conducted to understand the unique needs of a 

military outpatient BH clinic and current clinical practices, both effective and ineffective, in order to tailor 

services to the needs of the Soldiers at risk for suicide.

Similar to many Army BH clinics, this was a busy outpatient clinic setting with a high volume of complex 

cases, including Soldiers who were actively suicidal. At 

the time of the needs assessment, no aggregate data and 

few formal policies and procedures that were specific to 

tracking number of Soldier attempts at suicide, methods 

of suicide, or completed suicides existed, in part, due to 

the low incidence of the events. Anecdotal reports indicated that there may have been “3 or 4” Soldiers seen 

at the clinic who completed suicide over the past “2 or 

3 years.” The clinic leadership acknowledged that this 

information was included in the root cause analysis and 

the DoDSER which was completed following the death 

of a Soldier seen in any BH clinic, but not tracked locally

It was determined that the procedure in place to track 

suicidality at this clinic was a minimal paper and pencil 

self-report screening completed at the intake evaluation, 

during which the patient was asked only a single question 

about suicide. When suicidal ideation was endorsed, the 

clinic’s standard operating procedures (SOPs) required 

an assessment of suicidal risk using a local form derived 

from the Suicide Status Form-II that was then scanned 

into the electronic medical record. Routinely, no level of 

risk was assigned to the Soldier. The primary intention 

of the risk assessment was to assist in assessing safety 

and need for hospitalization. Although some suicidal patients were entered into a database developed by a psychologist within the BH department called the high interest patient database and monitored by a treatment team, 

not all individuals with suicidal ideation were included. 

Thus, there was no existing system for the tracking of 

ongoing suicide risk among suicidal patients, and there 

was no systematic methodology for recording when and 

if suicide risk had resolved in a patient. Extensive review 

of the clinic’s available procedures found guidelines for 

the hospitalization of a patient in the military hospital 

and in the community, as well as line of sight procedures 

for the emergency room for military personnel. There 

was no specific information available to the providers on 

instructions for weapons access or to aid in risk mitigation. Each provider passed along information informally 

to each on how to manage these situations or consulted 

RAISING THE CLINICAL STANDARD OF CARE FOR SUICIDAL SOLDIERS:

AN ARMY PROCESS IMPROVEMENT INITIATIVE
October – December 2014 57

THE ARMY MEDICAL DEPARTMENT JOURNAL

with the clinic chief for guidance. Some providers did 

periodic checks on the patients by phone, but there was 

no standardized procedure for this action. As a result of 

these findings, the team determined a great need for the 

development of SOPs with specific information available to all providers.

Treatment for suicidal ideation and behaviors generally 

followed the provider’s theoretical orientation and most 

often focused on treatment of depression or coping with 

situational or relational concerns which may have minimized the risk posed by other factors such as pain and 

anxiety. Patients experiencing anxiety or posttraumatic 

stress-related symptoms were often placed in group 

treatment due to the limited number of providers available for individual treatment because of high workloads. 

Patients with pain problems were typically referred outside the clinic to a specialty care pain clinic at the hospital. Suicidal Soldiers were routinely hospitalized for 

brief inpatient stays at an MTF managed by active-duty 

personnel. A memorandum of understanding (MOU) 

was also negotiated with a private psychiatric facility 

where clinic patients may be hospitalized, seen in a day 

treatment program, or receive other outpatient services. 

There was no established or routine use of “postvention” 

(a systematic supportive intervention that follows a patient’s death by suicide) to assist clinic staff who were 

affected by a loss.

Overall, the clinic’s processes for working with suicidal 

Soldiers at the time of the needs assessment were relatively typical when compared to other Army MTFs and 

reflected the standard of care for similar civilian settings (ie, what reasonably prudent practitioners do with 

comparable patients in comparable settings). However, 

it seemed existing practices did not reflect optimal clinical care that could be provided in such a setting. In order to provide a more thorough consideration of what 

might constitute optimal care, a series of sensing sessions were conducted with clinic staff and Soldiers with 

current suicidal ideation or a history of ideation or attempts. The results of those sessions are described in the 

following sections.

Staff

Clinical staff indicated that their caseloads were full and 

challenging. Treatment providers, including psychology 

technicians (military occupational specialty 68X), described an average of 14 years of practice with an average of 1.6 years at this specific treatment facility. They 

estimated the rate of Soldiers with suicidal ideation or 

behaviors in their current practice as 21%, with a range 

of 0 to 85%. The lifetime rate of patient completed suicides ranged from zero to two, with an average number 

of lifetime patient attempts per provider at slightly over 

three. Providers estimated that they completed an average of 9 hours of continuing medical education on suicide over the course of their careers.

Problems described by clinical staff mostly centered on 

the volume of complex, high-risk cases and the overall 

sense of being “spread too thin.” New civilian clinical 

staff with little military background experienced challenges connected to acclimating to the military culture, 

including rules, regulations, and military acronyms. 

Providers noted various challenges in dealing with unit 

commanders and observed that commanders, for a variety of reasons, can implicitly or directly undermine BH 

treatment. Clinical staff struggled with threats of suicide that Soldiers used for secondary gain or as a means 

of avoiding further deployments. Some clinicians perceived a culture of blame vs being supported or understood after an adverse event. Clinical consultation was 

usually done informally with peers and senior clinicians. 

However, many clinicians expressed a desire for more 

support and for regularly scheduled formal consultation opportunities with subject matter experts. The perceived delay in medication consultation was also noted 

as a major challenge to the delivery of effective care.

Leadership

Clinic leadership recognized the high operational tempo 

of the clinic environment, the need for more staff support, and the development and use of postvention strategies following a suicide event in the clinic. There also 

was a sense that unit commanders would benefit from 

better education about BH in order to support—not undermine—BH care.

Service Members

Soldiers were interviewed individually by the external consulting team in the presence of their clinic BH 

provider. Between October 2009 and August 2010, the 

overall number of outpatient BH encounters was 4,951. 

Soldiers were primarily male (69%). Thirty-seven percent of patients ranged from ages 26-35 years, 29% were 

in the 36-45 year age group and 22% were in the 18-25 

year age group. Due to limitations of the records system, there was no method for accurately tracking demographics on race, ethnicity, and marital status. Ranks 

most often seen by outpatient BH providers were E4 to 

E7 for enlisted and O3 to O5 for officers. The top 4 diagnoses for patients were: (1) adjustment reaction, (2) 

episodic mood disorders, (3) depressive disorder, and 

(4) anxiety. The modal number of visits fell in the 1 to 

5 range, far exceeding the next category of 6 to 10 visits. There were issues with relatively high no-show rates 

(leadership estimated up to 33%) among clinic patients.
58 http://www.cs.amedd.army.mil/amedd_journal.aspx

Point of service for entry into the clinic for Soldiers occurred through walk-ins, referrals by commanders, or 

transfers from other medical treatment providers. Many 

Soldiers were in a state of personal and/or professional 

crisis and were having considerable problems at work 

and with their command. There were vocation-specific 

issues implicated in their suicidality, including the effect 

of multiple deployments, posttraumatic stress disorder 

(PTSD), and traumatic brain injury, as well as problems 

at home (ie, marital, parenting, and financial stressors). 

A major barrier to care for suicidal Soldiers was the 

perceived lack of support or even the undermining effect of their command. A number of the Soldiers interviewed readily acknowledged that their clinic treatment 

had been very helpful while others seemed somewhat 

critical of the larger military’s response to their mental 

health situation.

Perceived strengths of the clinic were the quality of the 

staff and the excellent care the Soldiers received. The 

dedication and advocacy of clinical staff on the Soldiers’ 

behalf was noted as a particularly helpful aspect of their 

treatment. Various evidence-based treatments used in 

the clinic (eg, prolonged exposure for PTSD) were found 

to be helpful. The perceived major weaknesses of the 

clinic were described as the staff being over-extended, 

very long wait times for medication consultation, and 

delays in referrals to specific treatments.

Outside Providers

Mixed reviews were provided about outsourced care. 

The MTF inpatient stays were relatively brief and oriented to short-term stabilization The MTF inpatient staff reported that there were no treatment or therapies offered. 

There were very positive reviews of the care provided in 

the private setting that had established a military-specific treatment unit that catered to the culture and needs of 

active duty Soldiers. The MOU with the private center 

and the collaborative consultations had created a userfriendly treatment environment about which Soldiers 

and providers felt quite positive due to the availability of 

inpatient services and programming. Another private facility that did not have an MOU arrangement seemed to 

provide much less satisfactory care that largely reflected 

standard contemporary psychiatric care (ie, not tailored 

to the unique needs of active duty Soldiers).

Recommendations for the Process Improvement

Based on the initial evaluation of clinic practices and 

focus groups, a number of recommendations were developed by the consultation team for consideration to 

enhance BH-related care of suicidal Soldiers. These 

included recommendations to establish written suicidespecific policies and procedures, increase the use of 

screening tools to identify initial suicidal risk, and track 

ongoing risk across the course of care and to apply an 

electronic health record version of the Suicide Status 

Form (SSF) for the Collaborative Assessment and Management of Suicidality (CAMS), which is an evidencebased assessment of suicide risk. Additional suggestions 

included the use of CAMS-based therapeutic tools to 

stabilize outpatient care, problem-focused interventions 

and treatment of suicidal drivers, tracking of clinical outcomes, and overall improvement of clinical documentation. In addition, creation of a procedure for postvention 

for adverse events was proposed to support clinical staff 

and garner lessons learned. Lastly, effectively engaging 

commanders, family members, and supportive peers in 

support of clinical care of suicidal Soldiers (which may 

require separate educational efforts and the cultivation 

of collaborative working relationships with a Soldier’s 

support structure) was considered as essential to successful remediation of the suicidal risk.

Another critical recommendation for a successful suicide-specific PI effort was to provide an opportunity for 

all clinical providers to attend a weekly telephonic clinical consultation meeting with the external consultation 

team members who are expert in the treatment. The external consultants would eventually withdraw from this 

consultation meeting once the meeting is clearly established and the use of the intervention has become routine. 

Such a meeting should be primarily case-focused, input 

on clinical strategies and related risk management issues should be encouraged to facilitate adoption of a new 

evidence-based clinical practice across the clinical staff. 

We observed that even the most reluctant clinical staff 

members eventually engaged in the use of the evidencebased approach when they heard about improvements in 

other providers’ suicidal patients and saw growth in confidence among their peers cases with this new approach, 

even in the face of some very challenging circumstances.

A recommendation was also made for the implementation phase of the PI initiative, including a series of follow-up CAMS training sessions for the clinical staff by 

Dr Jobes and members of the Catholic University Suicide Prevention Laboratory. These training sessions emphasized the “nuts and bolts” of using CAMS and used a 

practical, hands-on approach featuring role-plays, video 

illustrations, and case examples. The primary learning 

objectives for training were: use of the SSF for risk assessment; development of Crisis Response Plans and 

problem-focused interventions targeting “suicidogenic” issues; use of the SSF to track suicide risk over the 

course of care; update crisis response plans and treatment plans as needed; and use of CAMS and the SSF to 

achieve optimal clinical outcomes.

RAISING THE CLINICAL STANDARD OF CARE FOR SUICIDAL SOLDIERS:

AN ARMY PROCESS IMPROVEMENT INITIATIVE
October – December 2014 59

THE ARMY MEDICAL DEPARTMENT JOURNAL

Development of a Clinic Advisory Team

A well-intended PI effort to raise the clinical standard 

of care related to suicide risk can be potentially doomed 

by taking a purely top-down approach. In other words, 

if the chief of the clinic or the commander of the military treatment facility directs or orders clinical staff to 

embrace wholesale changes in their clinical practices, 

resistance in the form of subtle or even overt push-back 

is likely unavoidable. However, some of the anticipated 

resistance to changing clinical practices may be moderated somewhat by abject fears of losing patients to suicide. In addition, such resistance may be even more constrained by the prospect of malpractice litigation and/or 

a root cause analysis that attributes a suicide to failures 

in clinical care. But, even in the face of suicide risk, there 

are often challenges encountered when changing from 

familiar clinical practices to a new approach to treatment. Preparatory actions for the formation of a clinic 

advisory team can be taken to increase the likelihood 

of successful implementation. A successful PI initiative 

may be rooted in the ability of the consulting team to 

successfully engage key clinic providers as members of 

an internal advisory team within the overall PI effort. 

This can not be merely a symbolic gesture. It should 

be a genuine effort to engage a small group of invested 

staff members to help shape and tailor the PI efforts to 

the culture of the clinic. This allows the generation of 

a “bottom-up” effort as the advisory team is a key part 

of meaningfully shaping and influencing the changes 

that come with efforts to improve clinical practices. To 

avoid undesirable inefficiency and redundancy, the advisory team should not be too large, perhaps 3 to 5 members depending upon the size of the clinic. Beyond the 

formation of this internal team, we have also seen the 

critical need of an identified individual clinician “champion” who leads the internal team and serves as a point 

of contact to the external consulting team. Ideally, this 

champion is someone who has the respect of clinic staff 

and also has the requisite energy and ability to lead the 

effort and the work of the advisory team.

It is critical that the facility is prepared to make an ongoing commitment to successfully raising the standard of 

care through the PI initiative. The clinic advisory team 

must have strong leadership support and the necessary 

authority to make systemic changes and exact minimum 

requirements for success from clinic staff. As previous 

literature indicates, success or failure in the use of evidence-based practices begins and ends with sufficient 

behavioral reinforcements for providers to risk changing 

what they ordinarily do.12 One of the biggest implications 

in this regard is that many evidence-based practices are 

labor intensive and require more front-end engagement, 

sometimes including longer session durations.

An almost certain way to undermine a PI effort is to 

require busy clinicians to do more on top of more; such 

an approach will only breed resentment and resistance, 

dooming the potential success of the PI. Systemic 

changes and potential modifications of policies and procedures, such as modified schedules including longer 

sessions initially, must be pursued so as to “reward” clinicians for engaging in an evidence-based form of care. 

While these providers may see fewer patients—which is 

an obvious problem in many over-run systems—there 

are ways to offset the effect by triage, risk stratification, 

and matching patients to different kinds of treatments 

(group vs individual) of different intensities and “doses” 

of care in direct relation to the risk that they present. 

There should not be a “one-size fits all” approach to effectively treating the range of suicidal risk. In 2012, the 

National Action Alliance for Suicide Prevention published clear guidance about specific systemic changes 

to better accommodate and facilitate the treatment of 

suicidal risk across treatment settings.13

Selecting an Evidence-Based Approach

As discussed in previous reviews,3,14 there have been 

surprisingly few empirically-supported treatments 

for suicide risk published in the professional literature. 

Among the limited options, dialectical behavior therapy and a suicide-specific form of cognitive-behavioral 

therapy (CBT) are the leading approaches with the best 

empirical support. Specific to suicide risk among military personnel, a newly adapted brief CBT approach 

is now being studied in randomized clinical trials for 

suicidal service members in outpatient15 and inpatient16 

clinical settings. As noted in the review by Schoenbaum 

and colleagues,3 other approaches such as Stanley and 

Brown’s safety planning intervention17 and CAMS developed by Jobes18,19 are being studied in Department 

of Defense (DoD) and Veterans Affairs (VA) settings 

within rigorous randomized clinical trials.

The PI effort described in this article featured the use of 

CAMS because, as described by Jobes and colleagues,20

this is a flexible clinical intervention that focuses on an 

effort to keep suicidal service members out of the hospital through the effective development an outpatient stabilization plan (eg, a crisis response plan or a safety plan) 

as well as the successful targeting and treatment of key 

suicidal “drivers”—those patient-identified issues that 

directly and indirectly compel the patient to take their 

life. It was deemed to have an inherent adaptability that 

is unique among existing evidence-based approaches. 

Moreover, this is currently the only published approach 

that has been used successfully with suicidal active duty 

service members.21 In their nonrandomized clinical trial 

of CAMS vs treatment as usual (TAU) with 55 active 
60 http://www.cs.amedd.army.mil/amedd_journal.aspx

duty suicidal Air Force personnel, these investigators 

observed a strong relationship between CAMS care and 

rapid and significant reductions in suicidality with cooccurring significant decreases in nonmental healthcare 

use related to emergency department and primary care 

visits. As described by Jobes in a recent review paper 

on CAMS,19 an additional 5 correlational studies have 

provided uniformly strong support for the effectiveness 

of CAMS across a variety of settings and populations. A 

recent, small randomized clinical trial (RCT) provided 

convincing causal data about the effectiveness of CAMS 

in relation to significant decreases in suicidal ideation 

and overall symptom distress at 12-month follow-up 

compared to TAU. In addition, CAMS caused significant increases in hope, patient satisfaction, and retention when compared to TAU.22 Currently, a well-powered RCT is underway with suicidal Soldiers in Georgia, 

and another large RCT is being conducted in Denmark 

comparing CAMS to dialectical behavior therapy with 

suicidal outpatients.19 Given our successful experiences 

in various PI efforts featuring CAMS, we anticipate the 

prospective use of CAMS being practiced both widely 

and effectively with suicidal military members across 

all service branches.23

Clinician Training

The training process used in the course of this PI initiative was largely successful but not without challenges. 

One of the inherent training issues that plague DoD and 

VA evidence-based professional training is the lack of 

actual subsequent use of the newly-trained intervention 

after the training. To address this concern, we sought a 

3-phase training approach within the process improvement effort:

1. Phase I. One full day of didactic CAMS orientation-training to BH clinical staff across 

professional disciplines (including psychology 

technicians).

2. Phase II. Follow-up CAMS role-play training for 

all clinical providers over a day and half.

3. Phase III. Follow-on consultation calls between 

key PI members and clinical staff.

The following sections detail each phase of training and discuss the highlights and challenges that we 

encountered.

Phase I: CAMS Orientation Training

A 6-hour PowerPoint-based didactic training session 

was given to all PI participants from the participating 

clinic. This orientation training was video-recorded for 

future use by new providers arriving in the clinic. The 

goal of this training was to broadly orient the clinicians 

to the field of clinical suicidology and, more specifically, 

to help them learn about CAMS, including the theoretical foundation and existing empirical support for the 

approach. This training provided an orientation to the 

problem of suicide, including the rising rate of suicide 

in the US Army, difficulties of accurately predicting suicidal behaviors, and the latest research in suicidology. 

In the course of this training, the providers learned that 

CAMS is a therapeutic framework, not a new psychotherapy, that emphasizes a certain philosophy of clinical 

care as well as the clinical use of the suicide status form, 

a multipurpose assessment, treatment planning, tracking, and outcome tool.

Phase II: CAMS Role-play Training

This phase consisted of 2 days of training for providers approximately one month after Orientation Training. 

Focus was an introduction to the CAMS suicide status 

forms which are collaboratively used in all sessions with 

service members with suicidal behaviors. Role-plays of 

a hypothetical course of typical CAMS care of 10 to 12 

sessions were interspersed with practice in dyads for 

intakes, safety planning, follow-up sessions, and suicide resolution sessions using CAMS. Use of the new 

electronic version of the suicide status form (eSSF) was 

taught during the second day. Additionally, the SOPs 

developed by the PI Clinic Advisory Team for integration into the clinic and measures for evaluation of the 

PI were covered. Two separate training sessions were 

conducted one week apart to accommodate the number 

of people who required training.

Participants of the phase II training were 12 psychologists, 7 psychiatrists, 6 social workers, a licensed professional counselor, 5 psychology interns, 2 psychology 

residents, an advanced practical nurse, a pharmacist, 4 

psychology technicians, and a secretary. Prior to the 

training, participants rated their anxiety working with 

suicidal patients and their confidence in their ability to assess and treat suicidal patients on a 1-5 scale (1=strongly 

disagree, 2=disagree, 3=neutral, 4=agree, 5=strongly 

agree). Most participants indicated confidence in their 

ability to form a strong therapeutic alliance with a patient with suicidal concerns (3.9/5), and to successfully 

assess (3.7/5) and treat (3.6/5) suicidal behaviors.

The role-play training sessions were conducted by the 

external consulting team that included 2 licensed psychologists and 3 senior doctoral students in clinical 

psychology. The format for this training experience 

involved 2 members of the training team performing 

demonstrations of segments of CAMS over a “typical” 

course of CAMS care. One member played a suicidal 

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Soldier; the other showed the CAMS-use of the SSF for 

each segment of care (eg, session 1, a subsequent “tracking” session, and a final “resolution” outcome session). 

After each demonstration role-play, the clinicians in the 

training sessions were placed in dyads and then asked 

to role-play the demonstration that was just modeled. 

Within each training dyad, one partner was designated 

to role-play a suicidal Soldier-patient that he or she had 

previously seen, which gave their training partner an 

experiential chance to learn about using CAMS with a 

realistic case. With the successful completion of each 

segment of CAMS, the partners would then switch roles 

so that each had the chance to experience the clinician 

role for each training segment. During the role-playing, members of the external consultation team moved 

among the dyads to answer questions and make suggestions if the role-players became “stuck” or were unclear 

about certain aspects of the intervention. This role-play 

training gave providers an initial, first-hand experience 

of using CAMS.

During the training phase, participants completed a 

6-question pre- and postknowledge test to measure 

their knowledge of CAMS principles and practices. 

Participants’ correct scores increased by 1.6 (27%) at 

posttest. Satisfaction with the implementation training 

experience was also measured. Most participants were 

satisfied with training, with 72.5% of participants stating they were “very satisfied,” and 25% indicating they 

were “satisfied.” The remaining 2.5% answered “neutral.” Satisfaction ratings with training averaged greater 

than 4 (agree) on a 5-point scale for the content and 

presentation of material, willingness to learn more, and 

an expectation that CAMS would benefit practice. Participants on average said they were confident they would 

use the material learned in training (4.4/5) and indicated 

they would recommend other providers participate in 

CAMS training (4.5/5).

Ultimately, the goal for the PI training effort was for all 

providers to have the orientation and role-play training 

prior to clinic-wide implementation of CAMS, which occurred within weeks of the final role-play training. With 

clinic providers fully oriented and trained in CAMS, the 

implementation phase would be supported by phase III.

Phase III: Follow-on Consultation Calls

As noted earlier, the follow-on consultation calls for clinicians was seen as a critical element to implementation 

success. The calls between the clinical providers and 

members of the consultation team began on schedule 

within weeks of the implementation of CAMS across 

the clinic. Despite all efforts to thoughtfully orient, 

train, and prepare providers through the phasic training 

process, early uptake and use of this intervention was 

slow and inconsistent among all providers. In our experience, there was initial reluctance of many staff 

members to use the evidence-based treatment for which 

they had been trained because many reported that they 

were “too busy” to introduce a new and “complicated” 

approach into their practice. In spite of this feedback, 

one provider was able to present a new case almost every week and the patients markedly improved. Hearing 

about this success over time inspired clinicians to give 

the approach a try.

There were various problems that we encountered in 

the course of the training. Although CAMS was implemented in military and VA settings prior to this PI initiative, it had not been integrated into an Army BH clinic. 

Therefore, the trainers’ approach to the PI was to keep 

the process as flexible as possible to meet the needs of 

providers in a busy military clinic. The initial format of 

training was based on the extensive training experience 

of one of the authors (D. A. J.) who developed CAMS. 

This flexible approach was helpful in designing the ultimate form of training, but also may have introduced 

some ambiguity for providers.

The biggest problem that plagued each phase of training 

was related to technology. The training team decided to 

develop the digital eSSF, with the hope of potential ease 

of use in administration and the collection of long-term 

outcome data. However, the beta version of the eSSF 

that debuted during the first orientation training proved 

to be more cumbersome for providers than expected. It 

required a multistepped procedure for converting SSF 

data into a PDF that could then be cut and pasted into 

the electronic medical record. Providers in the initial 

training experienced frustration with the system and 

the transfer of the document, which produced a negative perception of the eSSF. Providers’ comments were 

used to refine the system and it was later presented in 

the Phase III training. The results of the CAMS roleplay training were somewhat mixed. Much of the roleplay training slowed due to the technology complication 

which became a major distraction. Ultimately, within 

the PI effort, the decision was made to scan hard copy 

versions of the SSF into the electronic medical record 

due to the many complications associated with the eSSF.

The acceptance and routine use of CAMS in the targeted 

clinic was quite slow from the start and was also somewhat discouraging. There was both subtle and overt resistance to using CAMS consistently across clinic providers. Providers were encouraged to use the approach, 

gently noting it was clinic policy to be using the intervention. However, there were transitions in leadership 
62 http://www.cs.amedd.army.mil/amedd_journal.aspx

as well as internal systems issues that perhaps contributed to the modest start. For example, personnel changes 

due to deployment and staff turnover were challenging 

during the 3-year implementation of the PI. The clinic 

leadership changed 5 times, causing at least a temporary setback each time. Also, participation in the PI 

was initially mandatory for all providers. However, as 

leaders changed and reprioritized the PI, a reduction in 

staff adoption was experienced and implementation was 

voluntary by the end of the PI. In addition, significant 

momentum was lost during the training and implementation process due to unexpected challenges related to 

funding the contract, which resulted in the PI being interrupted for 6 months, thereby delaying the second orientation training. Reenergizing the PI proved to be challenging for the team. Nevertheless, we did eventually 

see the critical effect of 2 dedicated successive “champions” who led the clinic advisory team and sustained 

a focus on the use of the intervention. In addition, both 

department and internal clinic leadership maintained 

steady support for the use of the intervention.

Tracking PI Outcomes

An evaluation plan to assess both the process and outcomes of the PI initiative was constructed prior to its 

implementation. The process evaluation focused on 

documenting various portions of the PI initiative, including the clinic advisory team and Warrior Resiliency 

Program team meetings, the Southern Regional Medical 

Command organization supporting the PI, and consultation calls. These documents served as due diligence 

for the processes associated with the PI and reminded 

individuals of tasks due to the various groups involved. 

Additionally, the process evaluation was helpful in documenting the real-life difficulties in the implementation 

of the PI initiative.

An outcome evaluation plan was constructed which included a logic model that depicted the flow of resources, 

services, and measurable outcomes expected from the 

PI initiative as shown in the Figure. Components that 

were to be assessed were CAMS training, the eSSF, 

consultative support, and the postvention process. The 

use of CAMS was to be assessed by an increase in the 

frequency and quality of documentation of suicide risks 

and treatment course in the electronic medical record. 

Individual patient outcomes were to be documented by 2 

standardized instruments. The Scale for Suicide Ideation 

(SSI) and the Outcome Questionnaire 45 (OQ-45), were 

given by the providers at both the beginning and end of 

treatment to assess CAMS effectiveness. The clinic advisory team assisted in determining how the instruments 

would be administered based on measures used in past 

research studies using CAMS,20,22 as well as the time to 

administer and the training required for administration. 

While other outcome measurements were initially introduced, they proved to be too complex to complete given 

multiple personnel changes at the clinic and the organization facilitating the PI and the operational tempo of 

the clinic. The possibility of the active duty psychology 

technicians administering the measures was explored, 

however, due to their changing roles/responsibilities 

and obligations outside the clinic, they were ruled out 

as an option to relieve some of the time constraints of 

the providers. Another option explored for administration of these measures was to use them during patient 

triage, but providers reported that they would prefer to 

administer the measures in order to build rapport and 

obtain important data related to the service member’s 

suicidality. In spite of great care in vetting the SSI and 

OQ-45 with the Clinic Advisory Team, providers did not 

feel they had adequate time to provide services and collect outcome data. The providers seemed to see a benefit 

to the administration of the measures beyond collection 

of data for the PI, and many reported that they would 

use them if allotted more time for their intake sessions 

with the service member. Unfortunately, due to the high 

workload, this was not feasible. Therefore, due to realitybased constraints, both instruments were dropped from 

the evaluation plan and a plan for qualitative evaluation 

through focus groups was developed.

At the end of the PI initiative, focus groups were held 

by a person not involved in its implementation. A total 

of 11 individuals attended 2 focus groups. Two of the 

individuals had recently been hired and were trained by 

a designee in the clinic. Focus group participants were 

asked about the training, their use of CAMS, the SSF 

and what they thought were most and least beneficial.

During these focus groups, the majority of individuals (63%) indicated relatively consistent use of the SSF, 

while 27% used it “here and there, but not consistently.” 

When asked about their overall use of CAMS, few individuals reported using CAMS regularly according to the 

original protocol. Participants indicated that the SSF did 

not work well in triage with high risk patients because of 

the time needed to perform an intake. A familiar, shorter 

screening was preferred during triage as the first choice 

for individuals who were likely to be hospitalized.

Mixed opinions regarding training were expressed in reviews. Some individuals who attended the focus group 

indicated the training was long and too basic for senior 

clinicians. Most participants indicated the eSSF training 

time was wasted because it was never implemented. Other participants were pleased with training, indicating it 

was “clear and precise and people understood everything 

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that was being taught.” Participants’ feedback on the SSF 

was largely positive. Participants indicated that using the 

form was good for “not getting lost in drama or stories,” 

but helped focus quickly on the drivers of suicidal ideation. They also commented that collaboration with the 

patients increased because they signed and dated the 

form, “validating the information and showing them exactly why they are in treatment.” One person said the 

form was useful beyond the suicidality to “speed up 

treatment.” Individuals also gave largely positive feedback on the consultation calls, primarily for meeting an 

area of unmet need at the clinic. Some appreciated the 

consultant’s acknowledgement of the difficulty of the 

cases and found suggestions he gave helpful. Others indicated that it was most valuable to discuss cases with 

their colleagues since “we don’t get to do that very often 

anymore with the amount of work load given.”

Sustainment of PI Initiative

A plan for sustainment of the new process for the use of 

the CAMS framework was made at the beginning of the 

PI initiative. Clinic protocols and SOPs were developed 

for each area of use for CAMS in the clinic including 

triage, intake session, follow-up visits, termination sessions, and hospitalization. These SOPs defined roles for 

the leadership, providers, and other clinic staff, including the front desk staff, in supporting the use of CAMS 

within the clinic. The SOPs were intended to provide 

guidance to current staff as well as new staff, and be 

flexible enough for the Clinic Advisory Team to review 

and to adapt as needed over time. A model for ongoing 

training of new staff and refresher training was envisioned to be completely managed within the clinic by 

two volunteers or selected clinic staff members. However, because of staff changes and the waxing and waning 

Process Outcomes

Activities Participants

What we invest: What we do: Whom we reach:

Providers and staff at the Behavioral 

Health Clinic

Dr Jobes and Catholic University of 

America team

Facilitating organization staff

Facilitating organization funding

CAMS book

Needs assessment

Sensing sessions

CAMS training

Risk assessment

Treatment

Documentation

Create electronic version of the SSF

Documentation

Support

Consultative support

Postvention process

Behavioral health providers

Soldiers (all components)

Program stakeholders (eg, family 

members)

Effects

Short-term Medium-term Long-term

What are the expected short-term effects and measures?What are the medium-term effects and 

measures expected one to 2 years out?

What are the long-term effects and 

measures expected 2 to 5 years out?

Changes in practice

Improved accuracy of risk 

assessment

Increased clarity in treatment 

planning

Resolution of suicidal crisis

Decrease no-show rate

Increased documentation of risks and 

treatment course

Increased sense of provider support

Use and satisfaction with consultation 

service

Decrease in provider anxiety

Increased confidence in how leaders 

handle deaths by suicide

Increased competence in assessment 

and treatment of suicidal behaviors

Decreased hospitalization

Increased tracking of disposition

Increased clinical outcome tracking

Decreased perceived organizational 

barriers

Increased perceived provider support

Increase quality of care

Decreased cost of care

Improved professional quality of life

The outcome evaluation plan logic model depicting the flow of resources, services, and measurable outcomes 

expected from the collaborative assessment and management of suicidality (CAMS) PI initiative.

Mission: Pilot test and develop a military-specific, evidence-based, best-practice framework for suicide risk 

assessment, treatment, and documentation
64 http://www.cs.amedd.army.mil/amedd_journal.aspx

support for the PI initiative, the training plan originally 

developed as a train-the-trainer model, did not materialize. Instead, a clinic staff member involved in implementation in the clinic used the videotaped orientation 

training to informally instruct new employees.

Lessons Learned for a PI Initiative in a Military

Behavioral Health Clinic

With strong leadership and sustained focus over time, 

providers eventually began using CAMS with their suicidal Soldiers and realizing clinical success. Within 6 

months of formal implementation, a robust clinical consultation meeting evolved where the majority of providers were using CAMS, presenting cases, and benefitting 

from the constructive and collegial phone meeting with 

members of the external consultation team. Critically, 

the explicit and implicit “blessing” of key, respected 

staff members seemed to markedly turn the tide from 

resistance to acceptance for the majority of providers 

in the clinic to use CAMS or at least be supportive of 

its use.

With regard to tracking patients with suicide risk, ideations, and/or attempts, clinic leadership instituted the 

required use of the high-interest patient database for 

all Soldiers seen within the clinic experiencing suicidal 

ideation, suicide attempts, or hospitalization. The policy 

also specified that Soldiers receiving CAMS would be 

included and tracked in the database. The high-interest 

patient database, along with the CAMS documentation 

placed directly in the electronic medical record, provided the clinic with a method to track and monitor Soldiers 

who have any inclinations or concerns related to suicide.

The program evaluation was designed to generate simple and flexible lessons learned. A PI initiative is not a 

randomized controlled trial, therefore, evaluation methods must be as fluid as the process of the initiative itself. 

Although more systematic evaluation methods were 

preferred, given the circumstances it was necessary to 

adapt. The feedback resulted in the creation of an updated version of CAMS training for the Army which is currently being implemented in another Army BH clinic. 

As a result of provider feedback, 2-day training consisting of orientation of CAMS and role-playing training 

was confirmed as sufficient for most providers to obtain 

basic competence in delivering CAMS.

In terms of its actual clinic use, there were internal adaptations in the use of CAMS that occurred naturally 

as the clinic staff and culture became more interested 

in using the approach. For example, there were cases 

where clinical social workers (who are assigned to handle walk-ins) would initially engage a suicidal Soldier 

in CAMS for a few sessions while waiting for psychotherapy (provided by psychologists) openings in the 

schedule. When a walk-in who was initially engaged by 

a CAMS-using clinical social worker began psychotherapy sessions, the transition to ongoing CAMS care with 

the new provider was readily facilitated because both 

the social worker and psychologist were familiar with 

treatment. In one case, the Soldier proudly “presented” 

the CAMS-guided SSF work that he done with his walkin social worker to his new psychologist psychotherapist, 

who was of course quite interested and receptive. The 

process under which all clinic providers worked from 

the same “sheet of music” proved to be highly effective 

for a number of cases within this clinic’s system of care.

Finally, it is interesting to note the success was achieved 

in a separate Army BH clinic that was added near the 

end of the CAMS familiarization training . Even though 

members of this clinic staff received only the one-day 

orientation training (ie, they did not receive the role-play 

training and were not a part of the follow-on consultation calls), they had virtually adopted the use of CAMS 

by every provider within 6 months following the training. This particular clinic had received much less formal 

focus within the larger PI effort and limited consultation 

from the Warrior Resiliency Program team, but nevertheless enthusiastically adopted the CAMS strategy. 

This apparent success was attributed to strong internal 

leadership and an internal clinic culture that readily embraced evidence-based practices and worked with sensitivity to being “second guessed” in a root cause analysis 

should a suicide occur.

Army suicide prevention emphasizes the identification 

of Soldiers at risk and connecting them with helping 

resources, primarily Army BH. Although Army Medicine functions as a single healthcare system, there are 

few policies that standardize processes for BH providers with regard to the clinical management of suicidal 

behaviors among beneficiaries, of whom Soldiers are 

the primary patients. As a result, there is a need for 

knowledge regarding the application of an evidencebased treatment for suicide within individual Army BH 

clinics. The Process Improvement Initiative discussed 

in this article provided a unique insight into creating 

systematic change in a military behavioral health clinic 

and provided knowledge regarding perspectives of Soldiers and BH providers as well as areas of need. The 

PI initiative also showed the potential to enhance the 

clinical standard of care through improved clinical processes for suicide risk mitigation with the intervention 

of a suicide-focused clinical treatment tailored for the 

Army population. The use of CAMS offers providers a 

framework for managing a patient’s symptoms related 

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to the patient’s suicidal ideations or attempts, a process 

for documenting the risk , and the development of an 

infrastructure for support with the clinic. Due to the intricacies encountered during the implementation of this 

PI initiative, the lessons learned from this project were 

key in the development of the design for the randomized 

clinical controlled trial using CAMS implemented at Ft 

Stewart, Georgia. Future possibilities for the development of PI projects for implementation at other installations such as Darnell Army Community hospital at Ft 

Hood and Walter Reed Army Medical Center have been 

under consideration as well.

Areas of future research include examining the use of 

the PI to determine if it reduces suicide scores or reduces the need for “curbside consultations” with a military 

population. Real-life constraints limited this PI project 

from collecting data within these areas. Working with 

the Air Force, Jobes et al 21 found reductions in emergency departments and primary care visits were related 

to using CAMS. Their findings support an examination 

of the clinic staff to investigate if the adoption of CAMS 

bolsters the moral of the clinic and/or increases effective 

and efficient provision of service as an important area 

for future research.

References

1. Luxton DD, Osenbach JE, Reger MA, et al. Department of Defense Suicide Event Report (DoDSER) 

Calendar Year 2011 Annual Report. Tacoma, WA. 

National Center for Telehealth and Technology; 

2012. Available at: http://t2health.dcoe.mil/sites/de

fault/files/dodser/DoDSER_2011_Annual_Report.

pdf. Accessed October 17, 2014.

2. Kinn JT, Luxton DD, Reger MA, Gahm GA, Skopp 

NA, Bush NE. Department of Defense Suicide 

Event Report (DoDSER) Calendar Year 2010 Annual Report. Tacoma, WA. National Center for 

Telehealth and Technology; 2011. 

3. Shoenbaum M, Heissen R, Pearson J. Opportunities to Improve Interventions to Reduce Suicidality: Civilian ‘‘Best Practices’’ for Army Consideration. Washington DC: US Dept of Health and 

Human Services; 2009.

4. Army Health Promotion, Risk Reduction, and Suicide Prevention Report 2010. Washington, DC: US 

Dept of the Army; 2010. Available at: http://csf2.

army.mil/downloads/HP-RR-SPReport2010.pdf. 

Accessed August 3, 2013.

5. US Department of Defense. Defense Centers of 

Excellence for Psychological Health & Traumatic 

Brain Injury Website. Available at: http://www.

dcoe.health.mil/Families/Suicide_Prevention_

Warriors.aspx. Accessed August 2, 2013.

6. Army Releases December 2012 and Calendar Year 

2012 Suicide Information [news release]. Washington, DC: US Department of Defense; February 1, 

2013. Available at: http://www.defense.gov/releas

es/release.aspx?releaseid=15797. Accessed August 

12, 2013. 

7. Chappell W. US military’s suicide rate surpassed 

combat deaths in 2012. National Public Radio 

[serial online]; January 14, 2013. Available at: 

http://www.npr.org/blogs/thetwo-way/2013/01/

14/169364733/u-s-militarys-suicide-rate-surpassed-combat-deaths-in-2012. Accessed August 

12, 2013.

8. Conrad, AK, Jacoby AM, Jobes DA, et al. A psychometric investigation of the suicide status form 

II with a psychiatric inpatient sample. Suicide Life 

Threat Behav. 2009;39:307-320. 

9. Ritchie EC. Suicide and the United States Army: 

perspectives from the former psychiatry consultant 

to the Army Surgeon General. Cerebrum. January 

2012. Available at: http://dana.org/news/cerebrum/

detail.aspx?id=35150. Accessed August 25, 2014.

10. Insel BJ, Gould MS. Impact of modeling on adolescent suicidal behavior. Psychiatr Clin North Am. 

2008;31:293-316.

11. Ramchand R, Acosta J, Burns RM, Jaycox LH, 

Pernin CG. The War Within: Preventing Suicide on 

the US Military. Santa Monica, CA: RAND Corporation: 2011. Available at: http://www.rand.org/

pubs/monographs/MG953.html. Accessed October 

1, 2014.

12. Jobes DA, Bryan CJ, Neal-Walden TA. Conducting 

suicide research in naturalistic clinical settings. J 

Clin Psychol. 2009;65:382-395. 

13. Covington D, Hogan M, and the Clinical Care & 

Intervention Task Force. Suicide Care in Systems 

Framework. Washington, DC: National Action Alliance for Suicide Prevention: 2011. Available at: 

http://actionallianceforsuicideprevention.org/sites/

actionallianceforsuicideprevention.org/files/task

forces/ClinicalCareInterventionReport.pdf. Accessed August 7, 2013.

14. Jobes DA. Reflections on suicide among soldiers. 

Psychiatry. 2013;76(2):126-131.

15. Rudd MD. Brief cognitive behavioral therapy 

(BCBT) for suicidality in military populations. Mil 

Psychol. 2012;24:592-603.

16. Ghahramanlou-Holloway M, Cox DW, Greene 

FN. Post-admission cognitive therapy: a brief 

intervention for psychiatric inpatients admitted after a suicide attempt. Cogn Behav Pract. 

2012;19(2):233-244.
66 http://www.cs.amedd.army.mil/amedd_journal.aspx

17. Knox KL, Stanley B, Currier GW, Brenner L, 

Ghahramanlou-Holloway M, Brown G. An emergency department-based brief intervention for veterans at risk for suicide (SAFE VET). Am J Public 

Health. 2012;102(suppl 1):S33-S37.

18. Jobes DA. Managing Suicidal Risk: A Collaborative Approach. New York, NY: The Guilford Press; 

2006.

19. Jobes DA. The collaborative assessment and management of suicidality (CAMS): an evolving evidence-based clinical approach to suicidal risk. Suicide Life Threat Behav. 2012; 42:640-653.

20. Jobes DA, Comtois K, Brenner L, Gutierrez P. 

Clinical trial feasibility studies of the collaborative assessment and management of suicidality 

(CAMS). In: O’Connor RC, Platt S, Gordon J, eds. 

International Handbook of Suicide Prevention: 

Research, Policy, & Practice. West Sussex, UK: 

Wiley-Blackwell; 2011:383-400.

21. Jobes DA, Wong SA, Conrad A, Drozd JF, NealWalden T. The collaborative assessment and management of suicidality vs treatment as usual: a retrospective study with suicidal outpatients. Suicide 

Life Threat Behav. 2005;35:483-497. 

22. Comtois KA, Jobes DA, O’Connor SS, et al. Collaborative assessment and management of suicidality (CAMS): feasibility trial for next day appointment services. Depress Anxiety. 2011;28:963-972.

23. Jobes DA, Lento R, Brazaitis K. An evidencebased clinical approach to suicide prevention in the 

Department of Defense: the collaborative assessment and management of suicidality (CAMS). Mil 

Psychol. 2012;24:604-623.

Authors

Dr Archuleta is with the University of Texas Health Science Center at San Antonio, Texas.

Dr Jobes, Mr Jennings, Dr Crumlish, Ms Lento, and Ms 

Brazaitis are with The Catholic University of America, 

Washington, DC.

Dr Pujol is with the Brooke Army Medical Center, San 

Antonio Military Medical Campus, San Antonio, Texas.

Dr Moore and Dr Crow are with the Warrior Resiliency 

Program of the Southern Regional Medical Command, 

Fort Sam Houston, Texas.

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Traumatic brain injury (TBI) is an increasing health 

problem with approximately 1.4 million people affected 

annually.1 Of those affected, nearly 75% are considered 

to have a mild TBI.2 Also known as a concussion, mild 

TBI can develop into significant life-long impairment.3

The Centers for Disease Control and Prevention (CDC) 

estimated the national cost at nearly $17 billion (109) 

each year, with 10% to 15% of patients diagnosed with 

mild TBI suffering from persistent disabilities. The US 

Public Health Service estimated 14% to 20% of military service members have sustained TBI since the beginning of the Iraqi and Afghanistan wars.4

 Of those 

military service members sustaining TBI from combat, 

mild TBI is estimated to encompass about 11% of these 

injuries or about 75% of all head injuries. These percentages are comparable with nationally reported TBI 

prevalence data for civilians. Based on these statistics, 

mild TBI has become the signature injury of the 21st 

century Middle East wars.4

In the military, patients are generally identified for TBI 

and referred by their primary care provider to a specialist. Communication, collaborative teamwork, and 

patient-centered approaches are critical to patient safety 

and effective treatment for TBI.5 Novak and Fairchild6

reported almost two-thirds of adverse events in hospitals 

are related to communication deficiencies. In a meeting 

with A. Bowles, MD (February 27, 2013), lack of communication was identified in one of the military’s largest 

medical treatment facilities between primary care providers and specialists when patients with suspected mild 

TBI were referred for further evaluation and treatment. 

Dr Bowles cited poor communication with behavioral 

health, a difference in the understanding of concussion, 

and lack of agreement in fundamental philosophies for 

care as common communication deficiencies in the military healthcare system.

In general, Meester et al7 cited The Joint Commission 

(TJC) as also reporting effective communication among 

healthcare providers as being poor; moreover, TJC encouraged improvement in communication between providers to reduce potential errors and improve patient 

outcomes. The use of a situation, background, assessment, and recommendation (SBAR) tool may be useful 

in organizing information and providing cues for communicating what is important between medical providers.8

 The SBAR is a communication tool that can be 

applied to many situations between healthcare professionals to facilitate an exchange of needed information.9

The SBAR generally provides information as to what 

is happening, pertinent background information about 

the situation, and a relevant health assessment, and offers potential solutions for consideration.9

 Furthermore, 

Mitchell et al10 developed an assessment tool based on 

the SBAR format that was validated to identify and improve the overall quality and educational value. This 

tool contained 3 successful iterations with internal 

Mild Traumatic Brain Injury in the Military:

 Improving the Referral/Consultation Process

MAJ Charles Watson, AN, USA

Abstract

Background: Clinical practice inconsistencies in the identification and referral of patients suspected of mild 

traumatic brain injury have been identified within primary care clinics in a major military medical center.

Objective: To determine if the use of an overprinted communication tool would improve the referral/consultation 

process between identified clinics in one Army medical center.

Design: The consultation/referral process was evaluated following an educational presentation regarding the 

use of a situation, background, assessment, and recommendation (SBAR) communication form. Data were 

collected from consultation charts before and after two months of use of the SBAR communication form.

Results: The communication tool improved capture of dates of injury, prior treatment, history of testing, patient 

education, and request for therapy.

Conclusion: Findings from this project demonstrated that a communication tool such as the TBI-SBAR would 

be beneficial for use in primary care clinics.

This article is the text of a Residency Project presented by MAJ Watson to the Graduate Faculty of the University of Missouri 

in candidacy for the degree of Doctor of Nursing Practice at the School of Nursing, University of Missouri, Columbia, Missouri, April 24, 2014.
68 http://www.cs.amedd.army.mil/amedd_journal.aspx

consistency and interassessor reliability improving with 

each iteration.10 The communication deficiencies within 

the military medical facility, particularly when a referral is made by the primary care provider to a specialist, may benefit from the use of a simple communication tool such as an SBAR. The University of Missouri 

and Brooke Army Medical Center Institutional Review 

Boards both viewed this as a Quality Improvement project and exempted it from human subjects review. The 

purpose of this quality improvement project was to 

determine if using the SBAR tool would improve communication during the referral process for mild TBI between primary care and specialty clinics in one Army 

medical center.

Background

Traumatic brain injury occurs when an external force 

or rapid acceleration/deceleration force causes damage 

to the brain. This can be the result of an indirect force 

such as a blast exposure or from a direct force such as 

a blow to the head.3 Traumatic brain injuries are acute 

processes with pathophysiological cascades that can be 

initiated within minutes. Therefore, the efficacy of many 

neuroprotective agents administered before or within 15 

minutes after an injury makes it time-sensitive for implementing treatments.11 The effect of resultant neurometabolic changes can cause a disturbance in the brain’s 

function manifested as impairment in cognitive function and/or physical function.12 Bryan and Hernandez13

reported a significantly slower reaction time from those 

suffering from a mild TBI and a slower reaction time 

from those who also suffer from headaches and psychological symptoms as compared to those without any 

head trauma or illness. In general, mild TBI symptoms 

usually occur immediately or within days of the event 

but resolve within 3 months postinjury.14 These mild 

symptoms, or the immediate lack thereof, may make it 

difficult for primary care doctors to initially recognize 

and begin treatment. Additional diagnostic testing may 

enable primary care doctors to make more informed decisions when deciding care for patients suffering from 

any head trauma. For patients undergoing acute neuroimaging as part of their initial evaluation, the computed 

axial tomography scan findings on the day of injury may 

provide important baseline information.15

Boake et al16 reported that the frequency of postconcussive symptoms (PCS) in patients without obvious brain 

injury supported the theory that symptoms of PCS may 

not be sufficient to make the diagnosis of mild TBI. In 

another study, a change or lack of symptoms in individuals with PCS and PCS-like symptoms was found 

not to have a correlation with mild TBI.17 Posttraumatic 

headaches (PTHA) have also been studied. Bryan and 

Hernandez13 reported a longer loss of consciousness 

(LOC) was associated with increased PTHA severity, 

whereas, in former studies, longer LOC was associated 

with a greater severity of brain injury. This suggests that 

a greater LOC may be more associated with a more severe TBI versus a mild TBI.

The CDC3 reported better outcomes when a mild TBI 

was diagnosed early, making it imperative that communication between primary care and specialty providers for TBI be rapid and efficient. Although much has 

been done to standardize the process for communication, healthcare providers continue to have difficulty in 

communicating effectively and efficiently.18 There are 

various ways of communicating between nurses, providers, and ancillary staff, including verbally, written, 

and electronically. The SBAR was developed by the 

military, adapted by the airlines, and used initially in 

the Kaiser Permanente healthcare system. Evidence 

shows that SBAR may be applied to communication 

between providers in almost any healthcare setting.9

The tool acknowledges and defines the current situation, 

provides important background information, enhances 

a focused assessment, and offers recommendations for 

consideration.9 Renz et al8 found the implementation 

of the SBAR coupled with targeted training on its use 

improves satisfaction with the communication by standardizing important required information and providing 

structure for the communication of this information.

The SBAR provides a timely and pertinent communication narrative blending nursing and physician communication documentation techniques.19 An SBAR communication tool may enhance communication of pertinent 

information from a primary care provider for referral 

to a specialist. For example, MacGregor et al20 reported 

personnel with symptoms of mild TBI were much more 

likely to report headaches, memory problems, tinnitus, 

and dizziness compared to those personnel without 

head injuries. It is important for that information to be 

identified by the primary care provider to mental health 

specialists, neurologists, and neuropsychologists as part 

of a referral.

Nurses, physicians, and ancillary healthcare providers 

are frequently in situations requiring accurate and timely communication.19 As the SBAR has been primarily 

used by nurses, lack of education about SBAR among 

physicians has resulted in inconsistencies in its implementation and sustainability.21 Fay-Hillier et al5

 developed an instructional guide that included the purpose, 

objectives, goals, and directions for a simulation experience involving the use of an SBAR. Simulation exercises and structured opportunities offered useful feedback 

MILD TRAUMATIC BRAIN INJURY IN THE MILITARY:

IMPROVING THE REFERRAL/CONSULTATION PROCESS
October – December 2014 69

THE ARMY MEDICAL DEPARTMENT JOURNAL

in improving the performance, confidence, and experience of those who performed recommended exercises.22

In healthcare settings, Kotter and Cohen23 recommended beginning with the formation of a healthcare team to 

assess and discuss the significance of the communication problem between departments. Interventions and 

outcomes can be developed from identification of specific problem areas.24 Next, the goal of the intervention 

or outcomes should be established and communicated, 

the intervention implemented, performance feedback 

provided, the new process or intervention monitored for 

improvement, and, finally, integration of the intervention into standard practice with ongoing monitoring.23

In summary, it is notable that there are a host of issues 

at work in TBI, such as postconcussive syndrome, posttraumatic headaches, and ineffective communication 

between primary care providers and specialists. Since 

patients with mild TBI do better when diagnosed early, 

any action that leads to quick, effective communication 

is welcomed.3 Evidence shows that implementation of 

the SBAR paired with targeted training on its use improves communication (rate and effectiveness) by providing structure and standardization of the information 

being communicated.8

Assessment of the Problem

The plan-do-study-act cycle recommended by the Institute for Healthcare Improvement was used for this quality improvement project.25 Thirty-five consultation charts 

to the TBI clinic were initially reviewed to determine 

what information that may be important for the referral 

consultation was provided consistently or not provided. 

The pre-SBAR charts were reviewed between October 

1, 2013, and November 30, 2013. A meeting was held 

with the Chief Medical Officer for the TBI clinic and the 

provider staff to review this information and determine 

what information would be most helpful for optimum 

communication from the primary care provider to the 

TBI specialist.

Strategies for Quality Improvement

An SBAR tool, presented in the Figure, was created 

based on peer review from the above mentioned meeting and published evidence. Use of the TBI-SBAR tool 

by primary care clinics for referrals made to the TBI 

clinic was directed.

An initial education session was held in December 2013 

to familiarize physicians, nurse practitioners, and physician assistants with the use of the TBI-SBAR and the 

rationale for its use. The TBI-SBAR tool was implemented between January 1, 2014, and March 2, 2014. 

During that time, a biweekly site visit was conducted to 

answer questions or concerns that providers had regarding implementation of the tool. A retrospective chart review regarding use of the tool and appropriateness of the 

referral was completed after the implementation period.

Post Improvement Implementation Results

Information was collected about the documentation of 

communication between providers before the SBAR 

education intervention (pre-SBAR) and after the SBAR 

classes (post-SBAR). Information included the diagnosis 

developed by the primary care provider, the reason for 

the referral, the date of injury, any prior treatment, any 

history of prior testing, any patient education provided 

by the primary care clinic, and if a request for therapy 

by the referring providers (physicians, physician assistants, and nurse practitioners) was recorded. A referring 

diagnosis was noted. No referring diagnosis was noted 

as such. In regards to reasons for referrals, it was noted 

whether or not there was an actual reason for the referral, 

and exactly what that reason was. Additionally, any dates 

of injury, prior treatment, complication with treatment, 

history of testing, patient education provided by the primary care clinic, or request for therapy by the referring 

provider were all noted only as being present or absent. 

No detailed mention of these data was needed, only the 

presence or absence of each element was recorded.

The χ2 test for independence was used to compare the 

documentation of communication of important information in charts before and after TBI-SBAR implementation. Statistical significance was set at. As shown in 

the Table, 35 charts were reviewed pre-SBAR implementation and 27 reviewed post-SBAR implementation. 

The Table details the means and standard deviations 

between pre-SBAR and post-SBAR implementation. 

Patient education provided by the primary care clinic 

was the only statistically significant factor at the P=.05 

level (χ2=14.18, dƒ=1). Communication of any patient 

Results for Pre-SBAR and Post-SBAR Implementation 

Chart Reviews (N=62) Including Means and Standard 

Deviations for Each Category

Category Pre

n

Post

n

Pre

mean (SD)

Post

mean (SD)

Diagnosis present 33 25 0.94 (0.24) 0.89 (0.31)

Reason for referral 35 28 1 (0) 1 (0)

Date of injury 19 21 0.54 (0.51) 0.75 (0.44)

Prior treatment 10 13 0.29 (0.46) 0.89 (0.31)

History of testing 7 7 0.2 (0.41) 0.25 (0.44)

Patient education* 0 3 0 (0.11) 0.11 (0.31)

Request for therapy 34 28 0.97 (0.17) 1 (0)

*Statistically significant. Patient education provided by the primary care clinic was more likely to be communicated to the 

TBI clinic and was statistically significant at the P=.05 level 

(χ2=14.18, dƒ=1).
70 http://www.cs.amedd.army.mil/amedd_journal.aspx

education given by the primary care provider depends 

on the use of an SBAR. Despite evidence of improved 

communication with the other variables, they were not 

found to be statistically significant.

Comment

This project demonstrated improved documentation and 

communication between pre-SBAR and post-SBAR 

implementation for 5 of the 7 items of important information: the date of injury, any prior treatment, any 

history of testing, any patient education provided by 

primary care clinics, and a request for therapy by the 

referring providers (physicians, nurse practitioners, and 

physician assistants). Based on feedback from the TBI 

specialists, documentation of patient education given in 

the primary care clinics was thought to be an important 

MILD TRAUMATIC BRAIN INJURY IN THE MILITARY:

IMPROVING THE REFERRAL/CONSULTATION PROCESS

SBAR Patient Transfer Communication Tool: Mild Traumatic Brain Injury Services

Report given by: _______________________ Time: ____________ Phone: _________________

Report received by: _______________________ Phone: _________________

S

Situation:

[ Patient name

[ Age/race/gender

[ Chief complaint

[ Provisional diagnosis

[ Reason for referral

[ Referring agency

B

Background:

[ Date of injury

[ Type of injury

[ Previous testing (psychiatric testing, labs, 

radiology, etc)

[ Treatment history (medications, therapy, 

hospitalization, etc)

[ Patient education

[ Complications with treatment

A

Assessment:

Mild TBI Symptoms

Early

[ Headache

[ Dizziness or vertigo

[ Lack of awareness

[ Nausea with/without memory dysfunction

[ Vomiting

Late

[ Persistent low grade headache

[ Lightheadedness

[ Poor attention/concentration

[ Excessive fatigue

[ Bright light intolerance

[ Loud noise intolerance

[ Tinnitus

[ Anxiety

[ Depression

[ Irritability/low frustration tolerance

PTSD Symptoms

Avoidance

[ Emotionally numb

[ Avoidance of enjoyable activities

[ Hopelessness

[ Memory problems

[ Concentration problems

[ Relationship problems

Anxiety and Increased Emotional Arousal

[ Irritability

[ Overwhelming guilt or shame

[ Self destructive behavior

[ Sleeping difficulties

[

[

Easily startled or frightened

Hallucinations

R

Recommendation

If provider has assessed using all of the above 

mentioned tools and patient meets criteria for mild 

TBI, then refer patient to TBI clinic and request 

specific treatment or additional diagnostics (ie, 

request for speech therapy or request for additional 

diagnostic testing to R/O mTBI).

If provider has assessed using all of the above 

mentioned tools and patient does not meet 

criteria for mild TBI, then return patient to PCP for 

additional diagnostic workup or refer patient to 

appropriate specialty clinic for further definitive 

care based on diagnostic criteria met.
October – December 2014 71

THE ARMY MEDICAL DEPARTMENT JOURNAL

element of information for the TBI clinic. Prior to SBAR 

implementation, documentation of this information was 

nonexistent. The implementation of an SBAR demonstrated a statistically significant improvement in communication of this information.

According to the data, 54% of charts pre-SBAR captured 

dates of injuries, whereas 75% captured these dates 

post-SBAR. Prior treatment was documented 28% of 

the time in pre-SBAR charts, whereas they were seen in 

46% of the post-SBAR charts. A history of testing was 

only visible in 20% of the pre-SBAR charts, while 25% 

of the post-SBAR charts had this information. Lastly, a 

request for therapy was made in 97% of the pre-SBAR 

charts, and all 100% of the post-SBAR charts contained 

these requests. It is evident that the use of the SBAR, 

while not always statistically significant, did provide a 

positive improvement over the previous charts’ histories. 

The SBAR may have served as a guide to improving 

documentation as well as increasing provider awareness 

on what is critical for TBI clinic specialist to know.

Lessons Learned

Lessons learned from this project include building 

in time to collect more information from more charts. 

Since a validated clinical tool for screening of mild TBI 

was not used, referrals from the primary care provider 

to the TBI specialist was subjective and may have been 

dependent on provider training when initiating the referral. Current clinical tools used to detect mild TBI are 

held to subjective reports of symptoms and short cognitive exercises but offer little objective evidence for clinical decisions.26 The diagnosis of mild TBI is challenging 

due to a variety of symptoms including cognitive, physical, and/or behavioral, and may be confused with other 

medical issues.27 The presence of comorbid conditions 

such as posttraumatic stress disorder (PTSD) may have 

been a confounding factor. Given the existing low detection rate and undertreatment of people with PTSD, implementation of PTSD screening tools in general mental 

health treatment settings are recommended28 but were 

not the focus of this study. Finally, Adams and OsborneMcKenzie18 noted difficulty with consensus in SBAR 

categories for communicating important information, 

furthering the notion that tailoring SBARs to various 

situations may be difficult. Tailoring the SBAR to this 

specific area of specialization presented challenges 

based on a lack of consensus between departments and 

providers as to what should be included.

Implications and Recommendations for Practice

This quality improvement project used existing evidence 

that there are communication problems between primary and specialty providers in referring potential TBI 

patients, selected the SBAR communication format, implemented it, and measured whether it improved documentation of key elements that should be communicated 

in TBI referrals. The SBAR intervention seemed to improve the referral/consultation process by identifying key 

elements of information in the TBI referral. An SBAR 

tool is recommended for use when communicating between the primary care provider and a specialty provider.

The TBI-SBAR tool demonstrated improved communication between the primary care clinic and the TBI 

clinic. Improving communication may have enhanced 

the primary care provider’s knowledge of important information needed by the TBI specialist and allowed for 

more efficient use of the TBI specialist’s time during the 

consultation. This was achieved by the reduction in time 

spent by the TBI specialist contacting the referring provider for clarification of referring needs. Consultation 

with the Performance Improvement Research Assessment Program team enhanced implementation of the 

process. Involvement of quality improvement experts is 

recommended when implementing process change between departments.

Conclusion

Findings from this project demonstrated that use of a 

communication tool such as the TBI-SBAR increased 

the frequency that key elements were documented between 3 primary care clinics and the TBI clinic located 

within a large Army medical center. Other healthcare 

settings may benefit from improved communication, 

particularly between primary care and other specialty 

services. Enhanced communication may reduce errors 

and improve patient outcomes.

References

1. Moore E, Terryberry-Spohr L, Hope D. Mild traumatic brain injury and anxiety sequelae: a review 

of the literature. Brain Inj. 2006;20(2):117-132.

2. Rao V, Bertrand M, Rosenberg P, Makley M, 

Schretlen DJ, Brandt, J. Predictors of new-onset 

depression after mild traumatic brain injury. J Neuropsychiatry Clin Neurosci. 2010;22(1),100-104.

3. Traumatic Brain Injury page. Centers for Disease 

Control and Prevention web site [2014]. Available 

at: http://www.cdc.gov/TraumaticBrainInjury/. Accessed July 25, 2014.

4. Helmick K, Parkinson G, Chandler L, Warden D. 

Mild traumatic brain injury in wartime. Fed Pract. 

2007;108:58-65.

5. Fay-Hillier T, Regan R, Gordon M. Communication and patient safety in simulation for mental 

health nursing education. Issues Ment Health Nurs. 

2012;33(11):718-726.
72 http://www.cs.amedd.army.mil/amedd_journal.aspx

6. Novak K, Gordon M. Bedside reporting and SBAR: 

improving patient communication and satisfaction. 

J Pediatr Nurs. 2012;27(6):760-762.

7. Meester K, Verspuy M, Monsieurs KG, Van Bogaert P. SBAR improves nurse-physician communication and reduces unexpected death: a 

pre and post intervention study. Resuscitation. 

2013;84(9):1192-1196.

8. Renz SM, Boltz MP, Wagner LM, Capezuti EA, 

Lawrence TE. Examining the feasibility and utility of an SBAR protocol in long-term care. Geriatr 

Nurs. 2013;34(4):295-301.

9. Thomas C, Bertram E, Johnson D. The 

SBAR communication technique. Nurse Educ. 

2009;34(4):176-180.

10. Mitchell EL, Lee DY, Arora S, et al. SBAR M&M: 

a feasible, reliable, and valid tool to assess the quality of surgical morbidity and mortality conference 

presentations. AM J Surg. 2012;203(1):26-31.

11. Kompanje E, Maas A, Hillhorst M, Slieker F, Teasdale G. Ethical considerations on consent procedures for emergency research in severe and moderate traumatic brain injury. Acta Neurochir (Wien). 

2005;147(6):633-639. Available at: http://link.

springer.com/article/10.1007/s00701-005-0525-3. 

Accessed July 25, 2014.

12. Arciniegas D, Anderson C, Topkoff J, McAllister 

T. Mild traumatic brain injury: a neuropsychiatric 

approach to diagnosis, evaluation, and treatment. 

Neuropsychiatr Dis Treat. 2005;1(4):311-327.

13. Bryan C, Hernandez A. Predictors of post-traumatic head severity among deployed military personnel. Headache. 2011;51:945-953.

14. Bergman K, Bay E. Mild traumatic brain injury/

concussion: a review for ED nurses. J Emerg Nurs. 

2010;36(3):221-230.

15. Bigler E. Neuroimaging in mild traumatic brain injury. Psychol Inj Law. 2010;3(1):36-49.

16. Boake C, McCauley S, Levin H, et al. Diagnostic 

criteria for postconcussional syndrome after mild 

to moderate traumatic brain injury. J Neuropsychiatry Clin Neurosci. 2005;17(3):350-356.

17. Meares S, Shores EA, Taylor AJ, et al. The prospective course of postconcussion syndrome: the 

role of mild traumatic brain injury. Neuropsychology. 2011;25(4):454-465.

18. Adams J, Osborne-McKenzie T. Advancing the evidence base for a standardized provider handover 

structure: using staff nurse descriptions of information needed to deliver competent care. J Contin 

Educ Nurs. 2012;43(6):261-266.

19. Woodhall LJ, Vertacnik L, McLaughlin M. Implementation of the SBAR communication technique in 

a tertiary center. J Emerg Nurs, 2008;34(4),314-317.

20. MacGregor A, Dougherty A, Tang J, Galarneau 

M. Postconcussive symptom reporting among US 

combat veterans with mild traumatic brain injury 

from operation Iraqi freedom. J Head Trauma Rehabil. 2013;28(1):59-67.

21. Compton J, Copeland K, Flanders S, Cassity C, 

Spetman M, Xiao Y, Kennerly D. Implementing 

SBAR across a large multistate hospital health 

system [abstract]. Jt Comm J Qual Patient Saf. 

2012;38(6):261-268.

22. Johnson M, Hamilton M, Delaney B, Pennington 

N. Development of team skills in novice nurses 

through an athletic coaching model. Teach Learn 

Nurs. 2011;6(4):185-189.

23. Kotter J, Cohen D. The Heart of Change. Real-Life 

Stories of How People Change Their Organizations. Boston, MA: Harvard Business School Press. 

2002.

24. Rosswurm MA, Larrabee JH. A model for change 

to evidence-based practice. Image J Nurs Sch. 

1999;31(4),317-322.

25. Institute for Healthcare Improvement. Improving Health and Health Care Worldwide: Plan-DoStudy-Act (PDSA) Worksheet [internet]. 2014. 

Available at: http://www.ihi.org/resources/pages/

tools/plandostudyactworksheet.aspx. Accessed 

July 25, 2014.

26. Prichep L, Jacquin A, Filipenko J, Dastidar S, Zabele S, Vodencarevic A, Rotham N. Classification 

of traumatic brain injury severity using informed 

data reduction in a series of binary classifier algorithms. IEEE Trans Neural Syst Rehabil Eng. 

2012;20(6):806-822.

27. Kan E, Ling E, Lu J. Microenvironment changes 

in mild traumatic brain injury. Brain Res Bull.

2012;87(4-5):359-372.

28. Tiet Q, Schutte K, Leyva Y. Diagnostic accuracy 

of brief PTSD screening instruments in military 

veterans. J Subst Abuse Treat. 2013;45(1):134-142.

Author

MAJ Watson is a board certified Psychiatric/Mental 

Health Nurse Practitioner at the San Antonio Military 

Medical Center and is on the faculty of the Behavioral 

Health Technician Program at the Medical Education 

and Training Campus, Joint Base San Antonio Fort Sam 

Houston, Texas.

MILD TRAUMATIC BRAIN INJURY IN THE MILITARY:

IMPROVING THE REFERRAL/CONSULTATION PROCESS
October – December 2014 73

The number of inmates with mental health disorders 

incarcerated in the US prison system has grown into a 

national public health crisis. The literature reports that 

15% to 24% of US inmates have a severe mental illness,1-5 and according to the Bureau of Justice Statistics, 

over 1 million inmates are diagnosed with at least one 

mental health condition.3 Several studies identified multiple factors that have contributed to the growth of this 

epidemic.2-4

The availability of new antipsychotic medications starting in the 1960s made it feasible to manage many psychiatric disorders on an outpatient basis, leading to the 

argument formulated by prominent members of the 

psychiatric community that discharging patients from 

inpatient hospitals and providing community-based outpatient care represented a humane alternative to overcrowded and understaffed institutions.1,2,4,6 As a result, 

a national movement arose that resulted in the mass 

closing of public mental health hospitals.1,2,4,6 However, 

the new psychiatric paradigm of closing state hospitals 

and managing psychiatric patients via outpatient clinics 

and halfway houses was, in most cases, not supported 

by the necessary resources to provide adequate care 

for the number of patients released from inpatient facilities.1,2,4,6 Additionally, the health maintenance organization (HMO) model evolved into the primary health 

delivery model in the United States, requiring patients 

to use network providers covered by health insurance to 

receive medical care. However, HMO health insurance 

policies provide more restrictive coverage for individuals with mental health disorders and limit the enrollment 

of psychotic patients in private hospitals.1,2,4,6 Finally, 

civil commitment laws became more restrictive, making it difficult to involuntarily medicate or hospitalize 

individuals with severe mental illness.1,2,4,6 The aforementioned factors have culminated in a revolving-door 

phenomenon resulting in many individuals with mental 

health disorders moving continuously between homelessness and the criminal justice system.1,2,4,6,7

The large numbers of incarcerated individuals with 

mental health disorders leads to the logical assumption 

that prison systems should incorporate quality mental 

health assessment and treatment as a primary component of the inmate’s rehabilitation process. Hills et al8

describes the optimal correctional mental health system 

as a continuum of services which include inpatient and 

outpatient services, crisis intervention programs, and 

24-hour on-call access to mental health services. Mental 

Health treatment modalities should include individual 

and group treatment and access to psychotropic medications.8

 However, an abundance of literature reports 

a large disparity in the quality of correctional mental 

health services provided in US prisons.

In most correctional facilities, significant shortcomings 

in both the diagnosis and treatment of inmates with 

mental illness have been identified.1,2,4,6-8 For example, 

Hornung et al 9 surveyed 41 prison systems assessing 

mental health services offered to prisoners. They found 

15 systems had treatment protocols or guidelines for 

the management of inmates with mental illness, 12 had 

no protocols, and the remainder did not respond to the 

question. Additionally, the National Commission on 

Correctional Health Care conducted an analysis of mental health care in the US Federal Prison System in 2002. 

The study concluded that most prisons ‘‘fail to conform 

to nationally accepted health care guidelines for mental 

health screening and treatment.’’5 As a result, inmates 

with mental health disorders are not receiving adequate 

mental health services during incarceration, resulting in 

a disproportionate burden of adverse clinical outcomes, 

social isolation, and ultimately criminal recidivism 

among this already disadvantaged population.1,2,4-9

This article discusses the comprehensive mental health 

services offered to inmates incarcerated at the United 

States Disciplinary Barracks (USDB) Fort Leavenworth, 

Kansas and how those services are a critical component to the overall success of the USDB mission. The 

Directorate of Treatment Programs:

 Providing Behavioral Health Services

 at the US Disciplinary Barracks

LTC Nathan Keller, MS, USA Laura Whaley, LCSW

CPT Ashley Franklin, MS, USA John Lesniak, LCSW

Ellen Galloway, PsyD
74 http://www.cs.amedd.army.mil/amedd_journal.aspx

discussion includes the types of mental health disorders 

experienced by inmates at the USDB and how those disorders contribute to the risk the inmate poses both inside the facility and to the community at large. We detail 

the role of the Directorate of Treatment Programs which 

initiates processes to classify an inmate’s risk, identify 

their specific behavioral health needs and provides rehabilitative programs and mental health interventions to 

mitigate those risks, and increase the likelihood that an 

inmate will successfully integrate back into the community upon release.

Background

The USDB at Fort Leavenworth is the center of correctional excellence for the US Army. Established in 1874 

by Federal law, the USDB is the oldest penal institution 

in continuous operation in the Federal system and is the 

only maximum security correctional facility in the Department of Defense.10 In 2002, a new state-of-the-art, 

515 bed facility became operational with the capability of 

incarcerating US military prisoners from the Army, Marine Corps, Navy, Air Force, and Coast Guard sentenced 

to long terms of confinement.10 Since January 2013, inmates confined at the USDB must have a sentence length 

to confinement of more than 10 years. The type of crimes 

committed by inmates housed at the USDB range from 

murder, kidnapping, robbery, assault, sexual offenses, 

and property offenses to drug offenses. Currently, 95% 

of the inmates incarcerated at the USDB are serving a 

sentence for a violent or sexual offense.* The USDB mission is to conduct correctional and treatment programs 

that are intended to maintain good order and discipline 

in the facility and reduce recidivism upon release. The 

USDB prioritizes educational, vocational, and behavioral health programs that prepare inmates to become selfreliant, trustworthy, and productive members of society. 

The Directorate of Treatment Programs (DTP) at the 

USDB is essential in accomplishing this mission.

The DTP at the USDB is comprised of a multidisciplinary 

team which includes one psychiatrist, 3 psychologists, 

8 social workers and 15 behavioral health specialists 

(military occupational specialty 68X) assigned to 3 divisions: Assessment, Rehabilitation, and Mental Health. 

Collectively, DTP offers a rehabilitation system which 

accurately defines the risk imposed by an inmate on the 

institution and society, and provides treatment programs 

which mitigate that risk. The DTP presents all USDB 

inmates with the opportunity to participate in a variety 

of behavioral health programs that will enable them to 

successfully adjust to a correctional environment and reduce the likelihood that they will reoffend upon release. 

Historically, inmates have presented with depressive disorders as the predominant diagnosis at the USDB. However, over the last 7 years, a transformation of inmate 

psychopathology within the institution has occurred, as 

illustrated in the Figure. The increase in the proportion 

of inmates diagnosed with posttraumatic stress disorder 

(PTSD) can be attributed to an increase in the number 

of inmates with combat experience, currently 53%. Otherwise, the USDB population mirrors the population of 

the United States in a shift from mood disorders to anxiety disorders being the predominant behavioral health 

concern.11

The DTP is responsible for assisting all inmates with 

the adaptation to confinement, often a challenging transition. Inmates adapting to prison can experience dysfunctional patterns of thinking and acting that make 

postconfinement adjustment difficult and increase the 

likelihood they will reoffend.12 Service members who 

enter prison often present with preexisting behavioral 

health concerns, including, at a minimum, impaired 

insight, deficient judgment, and poor problem solving. 

Inmates must then adapt to confinement. While most 

inmates are able to effectively adapt to the correctional 

environment, there are some inmates who are more vulnerable to the stressors of confinement and thus more 

likely to act out in self-injurious, violent, or disruptive 

ways. The majority of USDB inmates respond positively 

to the standard behavioral health treatment regimen. 

However, 30% of the USDB inmate population present 

with significant psychopathology that require an abundance of resources to manage and treat as shown in the 

Figure. The psychopathology of these inmates increases 

the difficulty of mitigating their risk through an effective rehabilitation process. Thus, it is critical to rapidly 

DIRECTORATE OF TREATMENT PROGRAMS: PROVIDING BEHAVIORAL HEALTH SERVICES

AT THE US DISCIPLINARY BARRACKS

Psychotic Depression PTSD Anxiety Other

2007

10%

15%

20%

47%

8%

72 of 423 (17%) inmates 

were prescribed psychotropic medications.

2014

54% 22%

9%

7% 8%

132 of 464 (28%) inmates 

are prescribed psychotropic medications.

Comparison of Psychopathology Diagnoses in the USDB 

Population, 2007 and 2014.

Source: USDB Inmate Database, June 2007 and June 2014.

*Source: USDB Inmate Database, June 2014
October – December 2014 75

THE ARMY MEDICAL DEPARTMENT JOURNAL

identify which inmates may have difficulties adapting 

to confinement. The DTP Assessment Division is tasked 

with the important and complex process of identifying 

inmate risk and recommending individual rehabilitation 

treatment plans.

DTP Assessment Division

Classifying inmates in accordance to potential risk is 

twofold. The first step is to identify internal risk, the 

risk an inmate poses to himself, other inmates, and 

the USDB staff. Accurately identifying internal risk is 

crucial to maintaining the safety and security of the facility. The second step is to identify external risk, the 

risk an inmate poses to the greater community. Accurately identifying external risk supports recommendations on parole, clemency, and conditions of release and 

improves the safety of the community. The assessment 

process as a whole fosters appropriate adaptation to the 

correctional environment and will ultimately increase 

the potential for inmates to experience a successful transition back into society.

Assessing a new inmate’s internal and external risk typically begins within 2 hours of the inmate’s arrival at the 

USDB. The DTP Assessment Division conducts an initial behavioral health triage to ensure the new inmate is 

not experiencing current suicidal or homicidal ideations, 

or psychotic symptoms, as well as determining whether 

he is at above average risk to be a victim or perpetrator of sexual assault within the facility. Additionally, 

the triage identifies whether the inmate has a history 

of mental illness and/or a current psychiatric diagnosis and whether he is currently prescribed psychotropic 

medications. If any of the above conditions are reported, 

the Assessment Division immediately implements an 

appropriate crisis management plan until the reported 

issues are resolved.

Upon completion of the initial triage, new inmates undergo a 3-week reception process allowing the DTP Assessment Division to conduct an in-depth evaluation of 

the inmate’s risk factors and behavioral health needs. A 

full psychosocial interview is conducted to explore the 

inmate’s perception of the circumstances resulting in incarceration and identify significant psychological events 

across the inmate’s developmental lifecycle from childhood to the present.

In conjunction with the psychosocial interview, psychological testing is used to assess the inmate criminologically. The DTP Assessment Division administers Robert Hare’s Psychopathy Checklist-Revised (PCL-R).13

The PCL-R is a diagnostic tool used to rate a person’s 

psychopathic or antisocial tendencies. Psychopaths use 

charm, deceit, violence, or other methods to ruthlessly 

prey on others to get what they want, making them extremely dangerous in a correctional environment. The 

PCL-R consists of a 20-item symptom rating scale that 

allows qualified examiners to compare a subject’s degree of psychopathy with that of a prototypical psychopath. Each item is scored 0, 1, or 2 with the overall score 

ranging from 0 to 40. Any score of 25 or higher meets 

the criteria for dangerousness. A score of 30 or higher 

indicates that the individual is a psychopath. Additionally, the USDB has found a correlation exists between 

inmates with a PCL-R score of 20 or higher and acts 

of misconduct and disruptive behavior within the institution. Thus, inmates that have a high enough level of 

psychopathy are assessed as having higher internal risk.

In addition to the PCL-R, the DTP Mental Health Division administers a battery of psychological tests during 

the reception process to assess the inmate’s internal and 

external risk. Psychological testing includes the Shipley-2, a screening measure for intelligence,14 and the 

Aggression Questionnaire, which measures the many 

facets of aggression such as verbal, physical and indirect aggressive behavior as well as anger and hostility.15

Also, the Substance Abuse Subtle Screening Inventory16

and the CAGE substance use questionnaire17 are administered to determine the likelihood that an inmate 

suffers from a substance use disorder and are used to 

make recommendations as to whether the inmate needs 

substance abuse treatment. This is particularly important when substance use played a role in the inmate’s 

confining offenses as ongoing substance use problems 

can affect risk for reoffense upon release from confinement. Because 53% of the inmates have been deployed 

to a combat zone,* the PTSD Checklist is administered 

to identify treatment needs associated with PTSD.18 Finally, the Personality Assessment Inventory (PAI) is 

administered to get a broad-brush picture of traits and 

symptoms associated with a variety of psychological 

disorders, such as psychotic symptoms, personality pathology, mania, anxiety, depression, somatic complaints, 

physical aggression, suicidal ideations, as well as general stress and perceived social support. Additionally, 

the PAI has several validity scales that inform the interpreter whether the inmate is attempting to present himself in an overly positive or negative light.19 The validity 

scales assist DTP in determining the likely veracity of 

the inmate’s self-report of his problems.

The data collected through the interviews and psychological testing is further used by the DTP Assessment 

Division to determine the inmate’s appropriate custody 

*Source: USDB Inmate Database, June 2014
76 http://www.cs.amedd.army.mil/amedd_journal.aspx

grade and classification. The USDB manages inmate 

custody and classification through an objective, pointsbased classification system. The system is based upon 

risk factors that have been codified into a mathematical formula. The risk factors are calculated into custody 

points that determine the custody grade of each inmate. 

Custody grades within the USDB consist of Maximum 

Custody (MAX), Medium Custody (MED), Minimum 

– Inside Only, Minimum Custody, and Trusty Custody. 

Most inmates entering the facility are classified as MED 

which gives them the opportunity to integrate into the 

facility, learn about the inmate subculture, and adjust 

to long-term confinement. Custody elevation is earned 

through reduction in custody points (decay of disciplinary points, time served, and completion of treatment).

By the end of the reception process the DTP Assessment Division has created a formal risk assessment, an 

initial treatment plan, and a Risk Assessment Management Plan (RAMP). The risk assessment identifies the 

inmate’s internal and external risks. The initial treatment plan identifies his correctional, behavioral health, 

and rehabilitation needs and recommends interventions 

to meet those needs. Additionally, the RAMP outlines 

possible custody elevation dates, initial and future job 

assignments, and tentative dates to start the formal rehabilitation groups. Before leaving reception, the inmates 

meet with their temporary case manager to review their 

RAMP. The inmates will also be assigned a permanent 

case manager from DTP rehabilitation division who will 

assist them in successfully navigating the rehabilitation 

process.

DTP Rehabilitation Division

Upon completion of the reception process, inmates assigned to a custody level other than MAX are elevated 

to the general population housing unit. At this time, 

inmates meet with their assigned DTP Rehabilitation 

Division case manager to begin their long-term rehabilitation process. Inmates are assigned case managers 

based on their behavioral health needs. If an inmate has 

significant psychopathology or presents with complex 

problems, he will be assigned to a credentialed provider 

for treatment; all other inmates will be managed by a behavioral health specialist. The role of the case manager 

is to coordinate treatment plans, provide counseling for 

maladaptive behaviors, and prepare confinement summaries for various armed services parole and clemency 

boards. Although behavioral health treatment is a critical part of the rehabilitation process, all individual and 

group treatment remains voluntary and inmates have 

the option to stop treatment at any time or decline participation altogether. 

The theoretical underpinnings for the majority of behavioral health interventions provided at the USDB are 

derived from Cognitive Behavior Therapy (CBT) and 

administered in a group setting. Inmates participate 

in a variety of evidence-based CBT treatment groups 

facilitated by behavioral health specialists and credentialed providers. Treatment groups are delineated on 

the RAMP and purposefully sequenced starting with a 

general cognitive skills group followed by anger management. These 2 groups are designed to improve the 

inmate’s adaptation to confinement. Additionally, they 

develop CBT and emotions management skills which 

then form a foundation for the treatment groups that follow. After these 2 groups, if necessary, the inmate will 

be offered formal substance abuse treatment. Finally, 

after the general groups are completed, the inmate is 

offered the opportunity to participate in offense-specific 

treatment. This treatment sequence allows the inmates 

to participate in treatment over the duration of their sentence and sets up a process where the later groups build 

on the skills developed in the earlier groups. 

The first group is Reasoning and Rehabilitation (R&R),20

a cognitive skill-building group that is the foundation 

for all other treatment within DTP. The goals of R&R 

include (1) improvement in thinking skills, particularly 

problem-solving and decision-making, (2) developing 

pro-social behavior that is not dependent on external 

controls, and (3) improving interpersonal skills in problem-solving, and viewing frustration as a problem-solving task rather than a personal threat. The next group is 

Anger Management.21 This CBT-based group enhances 

the inmate’s ability to recognize underlying motivations 

for anger, develop their ability to examine their own behavior in response to anger, recognize cognitive errors 

that contribute to anger, and cultivate thinking and behaviors designed to handle anger appropriately.

Inmates who have an identified or self-reported history 

of substance abuse problems have the Chemical Abuse 

and Addictions Program (CAAP) (The Change Companies, Carson City, NV) on their RAMP. The level of 

substance abuse treatment provided is dependent upon 

the severity of the inmate’s substance abuse problem. 

The CAAP-Didactic is a structured program designed 

to meet the needs of those inmates who do not have an 

extensive history of substance abuse. CAAP-Intensive 

consists of a year-long treatment program facilitated by 

credentialed providers for inmates with a substantial 

history of substance abuse. CAAP-Intensive is based on 

the philosophy that recovery is a life-long process requiring full commitment, practice, and life-style changes. In addition to CAAP, a 12-step based, voluntary 

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THE ARMY MEDICAL DEPARTMENT JOURNAL

self-help group is offered twice a month to any inmate 

with substance abuse issues. The content of the selfhelp program is developed by the inmates, supervised 

by behavioral health staff, and supported by community 

volunteers who bring the message of recovery to those 

incarcerated.

Once an inmate has successfully completed all previous 

treatment groups on his RAMP, he is eligible to participate in crime specific groups that address the thinking 

and behaviors that contributed to his confining offenses. 

Inmates are screened for these groups by credentialed 

providers to determine the appropriateness of the inmate 

for the group. Group enrollment requires that the inmate 

accept some responsibility for having committed the offenses for which he was convicted. Furthermore, the 

inmate must demonstrate a desire and commitment to 

address the ideas and behaviors that led to his confining 

offenses and be willing to make the changes necessary 

to reduce the likelihood of reoffending upon release. 

The crime specific treatment groups currently offered at 

the USDB are Assaultive Offenders Group (AO) and Sex 

Offenders Treatment Group. 

The AO20 is designed for inmates incarcerated for violent and assaultive behaviors. The AO group enables inmates to identify the values, thoughts, behaviors, and 

attitudes that contributed to their assaultive behavior. 

It encourages a change to a violence-free lifestyle and 

helps the inmate develop skills to effectively problemsolve, appropriately manage emotions, and successfully 

engage in healthy conflict resolution. 

The Sex Offender Treatment Group (SOT) is the most 

comprehensive treatment group offered at the USDB. 

Currently, 75% of the inmates incarcerated at the USDB 

are confined for a sexual offense.* Over the course of 

the past 25 years, sex offender treatment provided at the 

USDB has evolved, incorporating research and treatment protocols from the broader sex offender treatment 

literature. The USDB sex offender treatment program 

currently uses the Self-Regulation/Good Lives Model22

as the primary method of sex offender treatment. The 

Self-Regulation/Good Lives Model assumes that sex 

offenders use sex offending in order to meet important 

needs. The purpose of treatment under this model, then, 

is to assist each inmate in identifying (1) what needs 

are most important to him, (2) which needs he was 

attempting to meet through his sexually offensive behavior, and (3) how he can meet those needs through 

healthier and more socially-appropriate behavior. The 

Self-Regulation/Good Lives Model is a dramatic shift in 

sex offender treatment in that it is the first model to emphasize important “approach goals” rather than focusing 

solely on what the inmate must avoid. This focus on approach goals is far more motivating to inmates and gives 

them hope for a full and offense-free lifestyle. Group 

treatment educates inmates on recognizing how their 

thoughts, behaviors, and emotions led to their offenses. 

It then teaches inmates how to develop and implement 

healthy skills and coping mechanisms to manage their 

risk factors, identify and improve their life skills deficits, 

and attain their personal life goals.

Effectively treating sex offenders requires an accurate 

assessment process to identify all of the factors that contribute to the inmate’s urges to offend, as well as intense 

therapy to enable the inmate to identify realistic strategies to reduce those urges. Inmates undergo a comprehensive assessment process prior to enrollment in SOT. 

The assessment tools utilized include the STATIC-99R, 

STABLE 2007, penile plethysmograph (PPG), and sexual history polygraph. These assessments combined present a picture of risk for reoffense as well as identified 

treatment targets for change through the group process.

The STATIC-99R23 is an actuarial measure that uses demographic and historical factors (such as age and past 

convictions) identified in the literature to be related to 

risk of recidivism. By definition, these are risk factors 

that cannot be changed or affected by treatment. The 

outcome of the measure is a numerical value that places 

the inmate into a “risk category” (low, moderate-low, 

moderate-high, or high) that has been shown in the literature to provide an overall moderate degree of predictive accuracy. The STABLE-200724 is a structured 

interview that measures 13 dynamic factors shown in 

the literature to be related to risk of recidivism. The outcome of this measure provides a numerical value that 

also places the inmate into a risk category (low, moderate, or high). These factors are important to measure as 

they can be changed with treatment over time. Thus, the 

STABLE-2007 provides group facilitators with valuable treatment targets that, if appropriately addressed, 

can reduce the inmate’s risk of recidivism. Once both 

assessments are completed, the results are combined to 

provide one final risk category which will determine 

whether the inmate is directed into the low-moderate 

risk or moderate-high/high risk SOT group. This overall risk category also provides a research-based percentage risk of sexual or violent recidivism over 1, 3, or 5 

year periods postrelease. Additionally, the PPG is administered to measure the inmate’s arousal to auditory 

and visual stimuli depicting normal sexual encounters 

as well as deviant (coercive or age-inappropriate) sexual encounters, through the measurement of change in *Source: USDB Inmate Database, June 2014
78 http://www.cs.amedd.army.mil/amedd_journal.aspx

penile tumescence. The empirically-based outcome of 

the instrument is a numerical “deviance differential” 

that provides a risk category (low, moderate, or high), 

indicating whether the inmate has a greater, equal, or 

lower level of sexual arousal to children versus adults. 

This is a critical risk indicator because sexual deviance 

has routinely been shown in the literature to be among 

the most potent indicators of recidivism risk.25-27 The 

PPG results are used to determine whether an inmate 

should complete the Deviant Arousal Reduction module 

of treatment, which uses covert sensitization and masturbatory satiation to help manage and reduce arousal to 

deviant stimuli.

Finally, all inmates are required to take a sexual history 

polygraph, administered by a contracted certified polygrapher, in order to be eligible for the SOT group. The 

polygraph interview covers the inmate’s sexual history 

across his entire lifespan. The purpose of the polygraph 

is to obtain information that is pertinent to the inmate’s 

treatment. For instance, often inmates who are incarcerated for the sexual abuse of one child will acknowledge 

other sexually deviant behavior (excessive pornography 

use, bestiality, etc) or additional victims that demonstrate 

a pattern of sexual behavior problems that must be addressed in treatment. Furthermore, while not foolproof, 

the polygraph provides the facilitator with an indication 

of the inmate’s veracity surrounding his sexual behavior. 

This alone can provide the facilitator with insight into areas that need further inquiry over the course of treatment.

Inmates assessed as moderate-low/low risk (based on the 

combined STATIC-99R/STABLE-2007 score) will participate in a group in which factors such as relationship 

skills, cognitive restructuring, management of emotions, 

and development of risk management plans are the primary focus of treatment. Inmates who are assessed as 

moderate-high/high risk for re-offending participate in 

a more intensive group treatment program due to the 

increased number of needs, beliefs, and attitudes the inmates have that contribute to their offending. Treatment 

comprises both psychoeducational components (emotions management, cognitive restructuring, relationship 

skills, and deviant arousal reduction) and an intensive 

dynamic therapy group which addresses entrenched 

schemas and belief systems that support sexual offending, development of offense chains, motivation for treatment, and the development of a good life/comprehensive 

risk management plan for their release. 

Upon completion of the inmate’s required treatment, the 

inmate will be placed in a sex offender maintenance 

group that meets based upon their risk level to reoffend. 

The maintenance group helps to keep the inmates focused 

on achieving their life goals without offending, as well as 

preparing further for release into the community.

DTP Mental Health Division

In addition to rehabilitation, some inmates need indepth treatment to address mental illness or personality 

disorders. The credentialed professionals from the DTP 

Mental Health Division are responsible for in-depth psychological assessment of inmates who pose diagnostic 

challenges and management problems within the facility. Referral questions often require additional testing to 

aid in differential diagnoses and recommendations for 

treatment planning. 

The DTP Mental Health Division credentialed providers maintain an individual caseload of up to 12 inmates, 

focusing on the most severely mentally ill or personality disordered, as these inmates historically require the 

most resources in terms of time and systemic management. To facilitate successful management of these 

inmates, the DTP Mental Health Division insures the 

development of Inmate Management Plans for the most 

seriously mentally ill/behaviorally disordered inmates, 

and provides consultation for the other professionals and 

behavioral health specialists when they are treating an 

inmate with particularly challenging mental illness or 

severe personality disorder. 

Because 53% of the USDB inmates have a history of 

combat deployments,* there are a high number with 

PTSD. The DTP Mental Health Division has implemented a Cognitive Processing Therapy (CPT) group,28 an 

evidence-based PTSD treatment program that focuses 

on helping inmates identify stuck points in their thinking and distorted beliefs that stem from their traumatic 

experiences. The inmates then go through a number of 

sequenced exercises designed to challenge and shift 

those distorted beliefs to more reality-based and healthy 

beliefs.

The DTP Mental Health Division is also responsible for 

the case management of inmates in the Special Housing 

Unit (SHU). Sixty-four percent of the inmates housed 

in the SHU have been diagnosed and are receiving 

pharmacological treatment for an anxiety disorder, as 

opposed to 11% of the inmates housed in the general 

population. Additionally, 92% of the inmates housed 

in the SHU, as opposed to 21% of the inmates in general population, have been diagnosed and are receiving 

pharmacological treatment for a behavioral health disorder.* Most inmates housed in the SHU are there due to 

an inability to adapt to confinement and conform their 

DIRECTORATE OF TREATMENT PROGRAMS: PROVIDING BEHAVIORAL HEALTH SERVICES

AT THE US DISCIPLINARY BARRACKS

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October – December 2014 79

THE ARMY MEDICAL DEPARTMENT JOURNAL

behavior to the requirements of the facility. It appears 

that there is a relationship between sustaining a major 

mental illness and an increased likelihood of committing disciplinary infractions. As a result, the inmates in 

the SHU require specialized behavioral health interventions that target both behavioral health issues and adaptation to confinement.

Because many of the inmates who end up in the SHU 

have common problems, such as anger and emotion 

management issues, impulsivity, social skills deficits, 

and anxiety and personality disorder traits, an SHU 

group was implemented to allow treatment to be provided to a larger target group as well as for inmates to 

reap the benefits of interpersonal feedback from their 

peers. Group topics are focused on stress management, 

anger and emotion management, problem-solving, and 

communication skills. Relevant movies are occasionally 

shown after the discussion of a topic to permit a less 

personal, thus less threatening, exploration of the topic. 

A more personal exploration of the topic is addressed in 

follow-on sessions. This sequence encourages participation and allows a less defensive response to the material. 

While not formally investigated as of this writing, the 

SHU group appears to reduce the number of problems 

between staff and inmates in the SHU.

The DTP Mental Health Division facilitates all aspects of 

inmate psychiatric care. On average, 30% of the USDB 

inmate population require psychopharmacological intervention.* The DTP Mental Health Division provides 

organizational and administrative support to the on-site 

psychiatrist and to the psychiatrist providing telepsychiatry services. It also works closely with the pharmacy 

and medication nurses to insure seamless access to and 

accurate administration of all psychotropic medication.

Conclusion

The USDB mission is to conduct correctional and treatment programs to foster maintenance of good order and 

discipline in the facility and reduce recidivism upon 

release. The DTP staff faces a myriad of challenges in 

working within the correctional environment. First, in 

addition to situational and personal factors that drive 

inmates to commit the offenses for which they are confined, many also present with complex, significant, or 

comorbid behavioral health problems. These additional 

problems pose unique challenges to treatment and risk 

remediation that must be addressed. Furthermore, the 

factors inherent in the USDB correctional environment 

such as separation from support systems, lack of control over daily routines, lack of privacy, and insecurity 

about postincarceration employment and relationships 

can elicit behavioral problems within confinement. The 

DTP’s CBT focus and logical sequencing of treatment 

has enabled it to develop programs that provide a consistent therapeutic language and address both behavioral 

health and rehabilitation needs.

The DTP staff also takes a systemic approach in addressing safety and risk within the institution, providing 

crisis intervention and de-escalation services to serve 

the inmates and support the correctional staff. They 

also work towards reducing the stigma and misunderstanding of inmates with behavioral health disorders 

through education, thus improving how cadre interact 

with behaviorally challenged inmates. Additionally, the 

DTP provides command consultation to USDB staff at 

all levels, advising on the appropriate management of 

inmates with behavioral health difficulties. As a result, 

the USDB has implemented policies and procedures that 

promote effective management of inmates with behavioral health conditions which has increased the safety 

and security of the facility.

Although there is research on a variety of cognitive 

behavior-based treatments, including many of the programs DTP uses, future research could focus on examining the effectiveness of these treatments specifically 

at the USDB. It would also be beneficial to engage in 

treatment outcome research for the cognitive behavior 

groups developed at the USDB which are not researched, 

manual-guided treatment programs. Finally, a relationship between serious mental illness and disciplinary reports has been noted. However, no direction of a causal 

relationship or whether there is another substantial variable in that relationship has been identified. Research 

examining the relationship between mental illness and 

disciplinary infractions may permit us to more effectively treat inmates with a mental illness while simultaneously increasing the safety and security of the facility. 

The USDB’s motto is “Our Mission–Your Future.” The 

USDB is not content to simply confine and release inmates; it is invested in ensuring that each inmate has 

been given an opportunity to develop the skills necessary to reduce the likelihood that they will reoffend 

upon release. The DTP’s extensive portfolio of services 

makes it an integral part of that mission.

References

1. Baillargeon J, Penn JV, Knight K, Harzke AJ, Baillargeon G, Becker EA. Risk of reincarceration 

among prisoners with co-occurring severe mental 

illness and substance use disorders. Adm Policy *Source: USDB Inmate Database, June 2014 Men Health. 2010;37(4);367-374.
80 http://www.cs.amedd.army.mil/amedd_journal.aspx

2. Baillargeon J, Binswanger I, Penn J, Williams B, 

Murra, O. Psychiatric disorders and repeat incarcerations: the revolving prison door. Am J Psychiatry. 2009;166(1):103-109.

3. James DJ, Glaze LE. Mental Health Problems of 

Prison and Jail Inmates. Washington, DC: US Dept 

of Justice, Office of Justice Programs, Bureau of 

Justice Statistics; 2006.

4. Kinsler PJ, Saxman A. Traumatized offenders: don’t 

look now, but your jail’s also your mental health 

center. J Trauma Dissociation. 2007;8(2):81-95.

5. The Health Status Of Soon-To-Be-Released Inmates: A Report To Congress. Chicago, IL: National Commission on Correctional Health Care; 2002.

6. Lamb HR, Bachrach LL. Some perspectives on deinstitutionalization. Psychiatr Serv. 

2001;52(8):1039-1045.

7. Hoge SK. Providing transition and outpatient 

services to the mentally ill released from correctional institutions. In: Greifinger R, ed. Public Health Behind Bars. New York, NY: Springer 

Science+Business Media; 2007:461-477.

8. Hills H, Siegfried C, Ickowitz A. Effective Prison 

Mental Health Services: Guidelines to Expand and 

Improve Treatment. Washington, DC: National Institute of Corrections, US Dept of Justice; 2004. 

Available at: https://s3.amazonaws.com/static.nicic.

gov/Library/018604.pdf. Accessed August 11, 2014.

9. Hornung CA, Anno BJ, Greifinger RB, Gadre S. 

Health care for soon-to-be-released inmates: a survey of state prison systems. In: The Health Status 

Of Soon-To-Be-Released Inmates: A Report To 

Congress, Volume 2. Chicago, IL: National Commission on Correctional Health Care; 2002:1-11.

10. Grande P. United States Disciplinary Barracks. 

Charleston, SC: Arcadia Publishing; 2009.

11. Kessler RC, Chiu WT, Demler O, Walters EE. 

Prevalence, severity and comorbidity of 12-month 

DSM-IV disorders in the National Comorbidity 

Survey Replication (NCS-R). Arch Gen Psychiatry. 

2005;62(6):617-627.

12. Haney C. The psychological impact of incarceration: Implications for post-prison adjustment. In: 

Travis T, Waul M, eds. Prisoners Once Removed: 

The Impact of Incarceration and Reentry on Children, Families, and Communities. Washington, 

DC: The Urban Institute Press; 2003:33-66.

13. Hare RD, Neumann CS. Psychopathy. New York, 

NY: Oxford University Press; 2009.

14. Shipley WC, Gruber CP, Martin TA, Klein AM. 

Shipley-2. Torrance, CA: WPS Publishing; 2009.

15. Buss AH, Warren WL. Aggression Questionnaire 

Manual. Torrance, CA: WPS Publishing; 2000.

16. Miller FG, Roberts J, Brooks MK, Lazowski LE. 

Adult SASSI-3 User’s Guide. Springville, IN: The 

SASSI Institute; 2003.

17. Ewing JA. Detecting Alcoholism: the CAGE questionnaire. JAMA. 1984;252(14):1905-1907.

18. Weathers FW, Blake DD, Schnurr PP, Kaloupek 

DG, Marx BP, Keane TM. Clinician-administered 

PTSD scale for DSM-5 (CAP-5). US Dept of Veterans Affairs Website; 2014. Available at: http://www.

ptsd.va.gov/professional/assessment/adult-int/caps.

asp. Accessed August 12, 2014.

19. Hopwood CJ, Morey LC, Rogers R, Sewell K. Malingering on the Personality Assessment inventory: 

identification of specific feigned disorders. J Pers 

Assess. 2007;88(1):43-48.

20. Porporino FJ, Fabiano EA. Theory Manual for 

Reasoning and Rehabilitation (Revised). Ottawa, 

Canada: T3 Associates; 2000.

21. Reilly PM, Shopshire MS. Anger Management for 

Substance Abuse and Mental Health Clients: A 

Cognitive Behavioral Therapy Manual. Washington, DC: Center for Substance Abuse Treatment, 

US Dept of Health and Human Services; 2002.

22. Yates PM, Prescott DF. Building a Better Life: A 

Good Lives and Self-Regulation Workbook. Brandon, VT: Safer Society Press; 2011.

23. Phenix A, Helmus L, Hanson RK. STATIC-99R 

Evaluators’ Workbook. Static 99 Clearinghouse 

[internet]; 2009. Available at: http://www.static99.

org. Accessed August 11, 2014.

24. Hanson RK, Harris AJ, Scott T, Helmus L. Assessing the Risk of Sexual Offenders on Community Supervision: The Dynamic Supervision Project 2007-

05. Ottawa, Canada: Public Safety Canada; 2007.

25. Hanson RK, Morton-Bourgon K. The Accuracy of 

Recidivism Risk Assessments for Sexual Offenders: 

A Meta-Analysis. Ottawa, Canada: Public Safety 

and Emergency Preparedness Canada; 2007.

26. Beech AR, Fisher DD, Thornton D. Risk assessment of sex offenders. Prof Psychol Res Pr. 

2003;34(4):339-352.

27. Olver ME, Wong SC. Psychopathy, sexual deviance, and recidivism among sex offenders. Sex 

Abuse. 2006;18(1):65-82.

28. Resick PA, Monson CM, Chard K. Cognitive Processing Therapy. Washington, DC: US Dept of Veterans Affairs; 2007.

Authors

LTC Keller is the Director of Treatment Programs, 

USDB, Fort Leavenworth, Kansas.

CPT Franklin is a Clinical Psychologist, Directorate of 

Treatment Programs, Fort Leavenworth, Kansas.

Dr Galloway is Chief, Mental Health Division, Directorate of Treatment Programs, Fort Leavenworth, Kansas.

Ms Whaley is Chief, Rehabilitation Division, Directorate of Treatment Programs, Fort Leavenworth, Kansas.

Mr Lesniak is Chief, Assessment Division, Directorate 

of Treatment Programs, Fort Leavenworth, Kansas.

DIRECTORATE OF TREATMENT PROGRAMS: PROVIDING BEHAVIORAL HEALTH SERVICES

AT THE US DISCIPLINARY BARRACKS
October – December 2014 81

To date, over 2.5 million service members have deployed 

in support of Operation Enduring Freedom (OEF) and 

Operation Iraqi Freedom (OIF). Of these, approximately 

1.9 million are parents, with 48% having served at least 

2 tours in Iraq and/or Afghanistan, affecting over 2 million children.1,2 Additionally, despite increases since the 

1970s in the percentage of women who serve, the military is still overwhelmingly male (84%), that is, the majority of military parents are fathers.

The adverse effects of combat deployments on families 

have been supported by research.3,4 Several studies report higher rates of depression, anxiety, overall stress, 

and decreased family cohesion when the parent is deployed in a combat zone.3,5 Service members also report 

higher rates of family stress and lower rates of partner 

cohesion. In one study, up to 20% of deployed service 

members indicated that they planned separating or divorcing their spouse upon return from deployment.6

 Soldiers with posttraumatic stress disorder have even higher rates of post-deployment adjustment problems with 

their partner.7

Limited literature suggests adverse effects of parental 

military deployment on children and adolescents. As 

more research emerges from the current Overseas Contingency Operations (formerly Global War on Terror), 

studies show higher rates of behavior problems and 

decreased social and emotional functioning in children 

of all ages.8-11 In one study of military families with a 

deployed parent, Lester et al found that 33% of schoolaged children were at “high risk” for psychosocial morbidity.10 Similarly, adolescents reported higher rates 

of school, family, and peer difficulties.13 Additionally, 

these children were also at risk for higher rates of physical abuse following periods of deployment.14,15 Recent 

literature suggests that drug and alcohol use are higher 

among children of deployed military personnel.16

Several studies suggest that military children have increased rates of internalizing and externalizing behaviors when their parent deploy.4,17 Furthermore, children 

have reported higher rates of sadness during the parent’s deployment.18,19 Lastly, children with preexisting 

psychopathology or coming from poorly-functioning 

The Effects of Military Deployment

 on Early Child Development

Dana R. Nguyen, MD

Juliana Ee, PhD

Cristóbal S. Berry-Cabán, PhD

Kyle Hoedebecke, MD

Abstract

Purpose: The purpose of this observational, point prevalence study is to determine if parental deployment affects the cognitive, social and emotional development of preschool age children in the military family.

Methods: Demographic information was collected and an age-appropriate Ages and Stages Questionnaire 

(ASQ-3) and Ages and Stages Social-Emotional Inventory (ASQ:SE) were administered. The primary outcome 

measure was the failure rates on the developmental instruments.

Results: We identified 151 parents of eligible children; 95 children had a parent that deployed during their 

lifetime. We found a significant difference in ASQ-3 failure rates for children in the deployed group compared 

to those in the nondeployed group. Children of deployed parents were at least twice as often to fail the ASQ-3 

or ASQ:SE developmental screen compared to children whose parents did not deploy. 30.5% of children in the 

deployed group failed the ASQ-3 screen while 12.5% of children who did not have a deployed parent failed 

(P=.009). On the ASQ:SE developmental screen, 16.8% of children who had a parent deploy failed versus 5.4% 

of children who did not have a parent deploy (P=.031).

Conclusions: This study suggests that parental deployment is related to adverse risk for developmental delays 

in children in military families. The psychological burden on military children could be life-long or require 

significant resources to address. These adverse outcomes could be possibly mitigated by early detection of developmental delay and firm attention to aggressive screening techniques in military communities.
82 http://www.cs.amedd.army.mil/amedd_journal.aspx

predeployment families may also be more vulnerable to 

the effects of deployment.20,21

The effect of deployment on children under the age of 

5 years has been little studied. Several studies suggest 

that young children’s reactions to parental deployment 

differ by a number of individual (temperament, age, and 

developmental stage) and family factors (the length of 

deployment, family composition, total time of service 

member being absent, financial conditions, the neighborhood in which the family lives, relocation, and other 

family stressors).22 In general, children’s reactions and 

adjustment to parental deployment are largely based 

on their age and developmental stage.23-25 Simultaneously, children’s reactions to parental deployment show 

a strong linkage with family functioning during deployment, that is, the nondeployed parent’s responses in 

particular.19

Literature on military deployment-related family separation indicates that younger children, compared with 

older children, are more vulnerable to the effects of the 

separation.18,19 A study of Army families found that children ages 0 to 5, compared to older children, coped least 

well with deployment-related parental absence.26 Unable 

to express their feelings and experiences easily in words, 

children under the age of 5 tend to express their feelings 

about parental deployment in externalizing behaviors 

(eg, aggression, hyperactivity, and problematic behaviors), rather than internalizing behaviors (eg, depressive 

symptoms, withdrawal, and anxiety).17,18 Young children 

also exhibit changes in moods, attention seeking, sadness, reduced appetite, and sleep problems.17,27 Recent 

studies support these findings. One study of 169 Marine Corps families with children enrolled in an on-post 

daycare center showed that children aged 3 to 5 with 

a deployed parent exhibited higher rates of behavioral 

symptoms compared to children without a deployed parent.28 Controlling for socioeconomic variables, Barker 

and Berry’s study showed that young children with a 

deployed parent experienced behavioral problems.22

While some studies have shown increased behavioral 

symptoms in children with deployed parents, the data 

have limitations. Risk assessment for preschool age 

children is crucial since important psychological formation and development are forged during these preschool 

years. Because 40% of military children fall into this 

age category, failure to assess the consequences of military parent deployment on young children could prove 

disastrous. The purpose of this study is to determine if 

parental deployment affects the cognitive, social, and 

emotional development of preschool age children in the 

family.

Methods

The sample consisted of 151 children of active duty service members’ households between the ages of 6 and 65 

months stationed on Fort Bragg. A convenience sample 

of parents was selected among children presenting for 

routine appointments in a family medicine clinic. Only 

one preschool age child per family was surveyed. If 

more than one child in the family met the inclusion criteria, a random number generator was used to pick the 

child evaluated. All parents signed a written consent 

prior to data collection.

Three data collection instruments were used: a demographic data collection sheet; the age-appropriate Ages 

and Stages Questionnaire (ASQ-3); and the age-appropriate Ages and Stages Social-Emotional Inventory 

(ASQ:SE).29,30 Along with basic family demographic 

information, the study survey assessed several military 

service-specific variables: rank of the military parent, 

the length of deployments, and whether a parent was currently or recently deployed. If a parent deployed to a combat military operation during the subject child’s lifetime, 

the subject was categorized in the “Deployed Parent.” If 

neither parent had deployed to a combat operation during 

the child subject’s lifetime, the subject was placed in the 

“Nondeployed Parent” data group. The demographic survey also asked which parent deployed (mother, father, or 

both parents). Finally, parents were asked to self-report if 

they currently have depression or anxiety.

The ASQ-3 and the ASQ:SE are widely used parentalreported assessment tools with established psychometric properties.29,30 The ASQ-3 consists of a 10-minute 

questionnaire completed by parents. Answers to screening questions are assigned points that are then summed 

in 5 different areas: communication, gross motor, fine 

motor, problem solving, and personal-social. Scores beneath the cutoff points indicate a need for further assessment; scores near the cutoff points call for discussion 

and monitoring; and scores above the cutoff suggest the 

child is developmentally appropriate.

Each ASQ-3 developmental area is associated with a 

number score. The absolute score for each category can 

be up to 60, but the “cutoff” for values of concern varies for each age surveyed. The absolute score was recorded as a data point, and the qualitative rating was 

recorded in order to compare all children as a whole. 

For the ASQ-3, the qualitative rating is “pass,” “at-risk,” 

or “fail,” based on the subject’s score compared to the 

cutoff value. This qualitative value was converted into 

“pass” or “fail” (combining “at-risk” and “fail” into one 

category for this study).

THE EFFECTS OF MILITARY DEPLOYMENT ON EARLY CHILD DEVELOPMENT
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THE ARMY MEDICAL DEPARTMENT JOURNAL

The ASQ:SE is also completed by the parent. The outcome variables measured by the ASQ:SE include selfregulation, compliance, communication, adaptive behaviors, autonomy, affect, and interaction with people. 

One number score is determined for the ASQ:SE. In 

addition to the number score, a qualitative rating is also 

given. There is no “at-risk” category for the ASQ:SE. 

Therefore, the rating of this study was recorded as either 

“pass” or “fail.”

Statistical analyses were conducted using PASW Statistics 18 (IBM Corporation, Armonk, NY). All values 

were statistically analyzed using frequency distributions 

with calculations of means and standard deviations (SD). 

Continuous variables were assessed for normality of distribution and compared using 2-tailed t tests. Categorical 

variables were compared using the Fisher’s Exact Test. 

Statistical significance was established at a P value less 

than or equal to 0.05. In order to detect the difference in 

failed developmental screens as a result of deployment 

(Cohen’s Kappa=0.6), that is, to have 80% power to reject the null hypothesis with type I error of 5%, a sample 

of 50 participants was required for each group if 80% of 

children passed both tests. Therefore, our sample 

size of 151 is sufficient for this analysis.

This research protocol was approved by the Womack Army Medical Center Institutional Review 

Board and the Clinical Investigation Regulatory 

Office, Office of Research Protections, of the US 

Army Medical Research and Materiel Command.

Results

One hundred fifty-one parents of eligible children 

consented for the study and completed all parts of 

the questionnaire packet. Basic demographic data 

are presented in Table 1. Parent and child characteristics are comparable between deployment groups. 

Parents are distributed evenly among officer and 

enlisted ranks. More parents in the deployed group 

reported having depression or anxiety currently 

when compared to the nondeployed group; however, this was not statistically significant (27.4% vs. 

17.9%, P=.24). Average length of parental deployment 

was 10.4 months (range=1-36 months). The groups also 

had a comparable distribution for children’s gender and 

race. A slight variance existed between the mean age of 

children (32.7 months for the deployed group and 21.6 

months for the nondeployed group).

There is a significant difference in ASQ-3 failure rates 

for children in the deployed group compared to those 

in the nondeployed group (Table 2). Children who had 

a parent deploy during their lifetime failed the ASQ-3 

twice as often when compared to the nondeployed group; 

30.3% of children who had a deployed parent failed the 

ASQ-3, while 12.5% of children who did not have a deployed parent failed (P=.009).

Failure rates for the 5 different subcomponents of the 

ASQ-3 are also shown in Table 2. Statistically significant differences were found between groups for the 

areas of gross motor skills (P=.008). Scores for the 

personal-social skills (P=.061) approached significance. 

The subcategories of communication, fine motor skills, 

and problem solving had similar trends for each group.

On the ASQ:SE developmental screen: 16.8% of children who had a parent deploy failed versus 5.4% of children who did not have a parent deploy (P=.031).

The effect of the length of total months of parent deployment during a child’s lifetime is presented in the 

Figure. In our study, the 95 children in the deployed 

parent group were placed into one of 3 categories: 1 to 

11 total months, 12 to 23 total months, and 24 to 36 total months. While there appears to be a trend for higher 

Table 1. Child and Parent Characteristics by Deployment Status.

Child

Characteristics

Deployed Parent

(N=95)

Nondeployed Parent

(N=56)

Age, mean months

(SD, range) 32.7 (16.1, 7-65) 21.6 (14.3, 6-60)

Male 45 (47.4%) 29 (51.8%)

Race/Ethnicity

White 59 (62.1%) 38 (67.9%)

Black 13 (13.7%) 10 (17.9%)

Hispanic 13 (13.7%) 5 (8.9%)

Asian 4 (4.2%) 1 (1.8%)

Native American 3 (3.2%) 2 (3.6%)

Unknown 3 (3.2%) 0 (0.0%)

Parent

Characteristics

P

value

Length of deployment 

mean months (SD) 10.4 (6.81) n/a

Enlisted rank 73 (76.8%) 35 (62.5%) .23

Anxious/depressed 26 (27.4%) 10 (17.9%) .12

Table 2. Analysis of Screening Outcomes by Parent 

Deployment Status.

Outcome Deployed

(N=95)

Nondeployed

(N=56)

P

value

ASQ-3 Fail Overall 29 (30.5%) 7 (12.5%) .009

Communication 6 (6.3%) 3 (5.4%) .557

Gross Motor 10 (10.5%) 0 (0.0%) .008

Fine Motor 17 (17.9%) 5 (8.9%) .100

Problem Solving 7 (7.4%) 1 (1.8%) .133

Personal-Social 9 (9.5%) 1 (1.8%) .061

ASQ:SE Fail 16 (16.8%) 3 (5.4%) .031
84 http://www.cs.amedd.army.mil/amedd_journal.aspx

rates of failed developmental screens with longer time 

away from the child, these results were not statistically 

significant (P>.05).

Other variables were recorded on the demographic sheet, 

however, the number of subjects present in these subcategories was not robust enough for data analysis. These 

variables included current deployment status of a parent, recent return of a parent from a deployment, and 

whether the mother or father had deployed.

Comment

There are few studies that suggest that parental wartime 

deployment has adverse effects on preschool age children. Our study suggests that preschool age children 

with a deployed parent during their lifetime more often have higher rates of adverse developmental screens 

compared to those military children who did not have 

a parent deploy. Our data show that a larger number of 

these children failed the ASQ-3 developmental screen. 

Our data also show that children of deployed parents fail 

the ASQ:SE 3 times as often.

Our trends in failure rates are above the expected failure 

rates for these screening tools. An anticipated failure 

rate for the ASQ-3 in the general population is between 

10% and 15%. A 12.5% failure rate in the nondeployed 

group is similar to the expected rate of the general population. In contrast, the deployed group 

has a 30.5% failure rate for the ASQ3. Higher failure rates are also found 

in the deployed group for the ASQ:SE. 

Given the fact that children in both 

groups live in a military household, 

one could possibly deduce from these 

findings that the temporary absence 

of a parent does have an impact on the 

emotional and overall developmental 

status of young military children.

The absence of a parent during a 

child’s important developmental 

years is most likely to have adverse 

effects on the child’s interpersonal 

behaviors. This hypothesis is supported by the ASQ:SE fail rates that were 

higher among children with deployed 

parents. Additionally, these children had higher failure rates on the 

personal-social subcomponent of the 

ASQ-3. The fact that the gross motor 

subcomponent scores were statistically different between both groups 

of children is not readily explained. 

Previous studies have shown that children were at risk 

for higher rates of physical abuse following periods of 

deployment.15,16 One could hypothesize that a link exists between the increased risk of child maltreatment or 

neglect in a household with a deployed parent and the 

delayed gross motor development on the screening tools 

in our study. Further assessment is needed to delineate 

this possible relationship.

One previous study demonstrated a pattern between 

the length of parent deployment and increased mental 

health diagnoses.31 In our study, a trend appears to exist 

between length of parent deployment and frequency of 

failing a developmental screen. As shown in the Figure, 

the overall failure rate of children for both the ASQ-3 

and the ASQ:SE increases with each deployment length 

of time. However, the differences in failure rates between groups were not statistically significant. Further 

research in this area is warranted.

Our study has several limitations. First, we acknowledge that the ASQ-3 and the ASQ:SE are screening 

tools and do not confer a diagnosis of developmental delay. However, rates of abnormal developmental screens 

should represent or reflect underlying rates of developmental delays in these children. Other more comprehensive screening instruments exist, but they are costly and 

lengthier to administer in the primary care setting.

THE EFFECTS OF MILITARY DEPLOYMENT ON EARLY CHILD DEVELOPMENT

ASQ:SE P=.24

ASQ-3 P=.23

Percentage of Failed ASQ Screens

Total Months of Parent Deployment

Analysis of ASQ screening outcomes relative to length of parent deployment.
October – December 2014 85

THE ARMY MEDICAL DEPARTMENT JOURNAL

We also recognize that even though our subjects are all 

under 65 months old, multiple developmental stages exist within the age range studied (6 to 65 months). Infants 

and toddlers experience deployment differently than 

preschool age children. Thus, conclusions regarding 

age range among children with different developmental 

stages may not take into consideration possible intervening variables.

Lastly, we did not control for self-reported parental 

depression or anxiety. Our demographic data suggest 

a trend of higher frequency of anxiety or depression 

in families that have had a deployed service member. 

However, this difference was not statistically significant. 

While we expect that increasing sample size would not 

affect the overall results of our study, enrolling more 

subjects may allow us to better control for parental anxiety or depression.

Operational deployments affect all military families. 

The lasting effects on family members remain largely 

unknown. This study suggests that parent deployment 

is related to adverse risk for developmental delays in 

children. These adverse outcomes could be mitigated 

by early detection of developmental delay and aggressive screening techniques. Additionally, the psychological burden on children could have lasting effects that 

require significant resources. Increasing the number of 

behavioral health professionals to work with military 

families could be beneficial. Finally, this study contributes to the growing body of evidence of the enormous 

toll paid by military families.

Acknowledgments

The authors acknowledge Dr Javier Vazquez-Ortiz for 

his assistance in administering the survey. The authors 

also acknowledge University of North Carolina Chapel 

Hill Faculty Development Fellowship faculty for their 

support and guidance for the conceptualization of this 

project.

References

1. Baiocchi D. Measuring Army deployments to Iraq 

and Afghanistan. Santa Monica, CA: RAND Corporation; 2013. Available at: http://www.rand.org/

pubs/research_reports/RR145.html. Accessed July 

8, 2014.

2. Report on the Impact of Deployment of Members 

of the Armed Forces on Their Dependent Children. 

Washington, DC: US Dept of Defense; 2010. Available at: http://www.militaryonesource.mil/12038/

MOS/Reports/Report_to_Congress_on_Impact_

of_Deployment_on_Military_Children.pdf. Accessed July 8, 2014.

3. Blount BW, Curry A, Lubin GI. Family separations 

in the military. Mil Med. 1992;157:76-80.

4. Kelley ML. The effects of military-induced separation on family factors and child behavior. Am J 

Orthopsychiat. 1994;64(1):103-111.

5. Haas DM, Pazdernik LA. Partner deployment 

and stress in pregnant women. J Reprod Med. 

2007;52(10):901-906.

6. Mental Health Advisory Team (MHAT) VI: Operation Iraqi Freedom 07-09. Washington, DC: 

Office of The Surgeon General, US Dept of the 

Army; May 2009. Available at: http://www.ntis.

gov/search/product.aspx?ABBR=PB2010104249. 

Accessed July 8, 2014.

7. Gewirtz AH, Polusny MA, DeGarmo DS, Khaylis 

A, Erbes CR. Posttraumatic stress symptoms among 

National Guard soldiers deployed to Iraq: associations with parenting behaviors and couple adjustment. J Consult Clin Psychol. 2010;78(5):599-610.

8. Barker LH, Berry KD. Developmental issues impacting military families with young children 

during single and multiple deployments. Mil Med. 

2009;174:1033-1040.

9. Chandra A, Martin LT, Hawkins SA, Richardson 

A. The impact of parental deployment on child 

social and emotional functioning: perspectives of 

school staff. J Adolesc Health. 2010;46(3):218-223.

10. Lester P, Peterson K, Reeves J, et al. The long 

war and parental combat deployment: effects on 

military children and at-home spouses. J Am Acad 

Child Adolesc Psychiatry. 2010;49(4):310-320.

11. Aranda MC, Middleton LS, Flake E, Davis BE. 

Psychosocial screening in children with wartimedeployed parents. Mil Med. 2011;176:402-407.

12. Flake EM, Davis BE, Johnson PL, Middleton LS. 

The psychosocial effects of deployment on military 

children. J Dev Behav Pediatr. 2009;30:271-278.

13. Chandra A, Lara-Cinisomo S, Jaycox LH, et 

al. Children on the homefront: The experience 

of children from military families. Pediatrics. 

2010;125(1):16-25.

14. Gibbs DA, Martin SL, Kupper LL, Johnson RE. 

Child maltreatment in enlisted soldiers’ families during combat-related deployments. JAMA. 

2007;298:528-535.

15. Rentz ED, Marshall SW, Loomis D, Casteel C, 

Martin SL, Gibbs DA. Effect of deployment on 

the occurrence of child maltreatment in military and nonmilitary families. Am J Epidemiol. 

2007;165:1199-1206.

16. Acion L, Ramirez MR, Jorge RE, Arndt S. Increased risk of alcohol and drug use among children from deployed military families. Addiction. 

2013;108:1418-1425.
86 http://www.cs.amedd.army.mil/amedd_journal.aspx

17. Kelley ML, Hock E, Smith KM, Jarvis MS, Bonney JF, Gaffney MA. Internalizing and externalizing behavior of children with enlisted Navy mothers experiencing military-induced separation. J Am 

Acad Child Adolesc Psychiatry. 2001;40:464-471.

18. Jensen PS, Martin D, Watanabe H. Children’s response to parental separation during Operation 

Desert Storm. J Am Acad Child Adolesc Psychiatry. 

1996;35:433-441.

19. Watanabe HK, Jensen PS. Young children’s adaptation to a military lifestyle. In: Martin JA, Rosen LN, 

Sparacino LR, eds. The Military Family: A Practice Guide for Human Service Providers. Westport, 

CT: Praeger Publishers; 2000:209-223.

20. Lincoln A, Swift E, Shorteno-Fraser M. Psychological adjustment and treatment of children and 

families with parents deployed in military combat. 

J Clin Psychol. 2008;64:984-992.

21. Cozza SJ, Guimond JM, McKibben JB, et al. Combat-injured service members and their families: the 

relationship of child distress and spouse-perceived 

family distress and disruption. J Trauma Stress. 

2010;23(1):112-115.

22. Barker LH, Berry KD. Developmental issues impacting military families with young children 

during single and multiple deployments. Mil Med. 

2009;174:1033-1040.

23. Amen DG, Jellen L, Merves E, Lee RE. Minimizing the impact of deployment separation on 

military children: stages, current preventive efforts, and system recommendations. Mil Med. 

1988;153(9):441-446.

24. Lester P, Peterson K, Reeves J, et al. The long 

war and parental combat deployment: effects on 

military children and at-home spouses. J Am Acad 

Child Adolesc Psychiatry. 2010;49:310-320.

25. Murray L. Helping children cope with separation 

during war. J Spec Pediatr Nurs. 2002;7:127-130.

26. Orthner DK, Rose R. Adjustment Among Army 

Children to Deployment Separations. Washington, DC: Army Research Institute for the Behavioral and Social Sciences; 2005. Available at: http://

www.army.mil/fmwrc/docs/saf5childreportoct05.

pdf. Accessed July 8, 2014.

27. Roberts D, McGulre B, Engell D. Children’s reactions to the Desert Storm deployment: initial findings from a survey of Army families. Mil Med. 

1993;158:465.

28. Chartrand MM, Frank DA, White LF, Shope TR. 

Effect of parents’ wartime deployment on the behavior of young children in military families. Arch 

Pediatr Adolesc Med. 2008;162:1009-1014.

29. Squires J, Bricker D. Ages & Stages Questionnaires: A Parent-Completed Child Monitoring System. Baltimore, MD: Paul H. Brookes Publishing 

Co; 2009.

30. Squires J, Potter L, Bricker D. The ASQ User’s 

Guide for the Ages & Stages Questionnaires: A 

Parent-Completed Child Monitoring System. Baltimore, MD: Paul H Brookes Publishing Co; 1999.

Authors

Dr Nguyen, Dr Ee, and Dr Hoedebecke are with the Department of Family Medicine, Womack Army Medical 

Center, Fort Bragg, North Carolina.

Dr Berry-Caban is with the Clinical Investigation Service, Womack Army Medical Center, Fort Bragg, North 

Carolina.

THE EFFECTS OF MILITARY DEPLOYMENT ON EARLY CHILD DEVELOPMENT
October – December 2014 87

Being overweight or obese is one of the leading causes of 

preventable deaths in the United States. Approximately 

400,000 people die per year of diseases related to being 

overweight or obese.1 Specifically being overweight is 

associated with hypertension; type 2 diabetes; stroke; 

gallbladder disease; osteoarthritis; endometrial, breast, 

prostate, or colon cancer; and respiratory problems.2,3

Given the enormity of the issue, there is pressure to use 

funds efficiently with empirically informed practices. 

The Army Surgeon General stated:

In a fiscally constrained environment, we will have to 

mobilize the political will to invest in the long-term 

health and readiness of our beneficiaries, while being 

good stewards of the resources that we are given.4

Being overweight or obese can translate into costly medical care. The military spends $1.1 billion (109) a year to 

treat overweight or obese health-related problems of service members, retirees, and their families.5

 Measures can 

be taken to prevent being overweight or obese. Therefore, strategies must be developed to assist the Army 

spouse population in learning the skills necessary to 

make more informed choices and increasing awareness 

of the resources that are available to assist them. Being 

overweight or obese is a financial burden, just as military 

spouses are emotionally burdened with deployments.

The duration of the current war in Afghanistan and recent war in Iraq has taken its toll on US Army spouses.6

The high operational tempo of repeated combat deployments, unexpected extended deployments, short dwell 

times, and a dangerously unpredictable war zone that 

includes the potential for combat-related casualties are 

all sources of uncertainty and stress for Army spouses.7

The stressors of the war became apparent with elevated 

rates of psychological distress (eg, posttraumatic stress 

disorder, depressive symptomology) in returning Soldiers.8

 Consequently, priorities were established by the 

US Army Medical Department to assess, identify, and 

treat the needs of Soldiers and their families.8

A key concept in the Army Medicine 2020 Campaign 

Plan is The Performance Triad that addresses the sleep, 

activity, and nutrition of Army personnel and their 

families. The strategy begins with identication of the 

variables that may impact an individual’s ability to sleep, 

engage in activity, and consume proper nutrition, followed by teaching awareness and methods of changing 

behaviors that result in choosing healthy options.9 The 

Performance Triad may be an effective method to contribute to the transformation of Army medicine from a 

reactive to proactive preventative public health focus. 

The philosophy extends beyond the active duty Soldier 

The Effect of Deployment, Distress,

 and Perceived Social Support on

 Army Spouses’ Weight Status

LTC Tammy L. Fish, MS, USA Melissa H. Bellin, PhD

Donna Harrington, PhD Terry V. Shaw, PhD

Abstract

This study examined the relationship between deployment status, psychological distress, perceived social support, age, 

rank, and gender with Army spouses’ (N=1863) weight status. We posited that spouses of deployed Soldiers have a higher 

body mass index (BMI) than spouses of nondeployed Soldiers; spouses with higher psychological distress scores have 

a higher BMI than those with lower distress scores; and spouses with low social support scores have higher BMIs than 

those with higher social support scores.

Method: Secondary analysis of data from the 2008 Active Duty Spouse Survey was used to examine the relationship 

between weight status (health versus overweight or obese) and Army spouses’ deployment status, demographic characteristics, psychological distress, and perceived social support.

Results: Deployment status and weight status were not related (P=.097). Male spouses were significantly more likely than 

female spouses to be overweight or obese. Psychological distress increased in direct correlation with increased age, and 

as perceived social support decreased, the incidents of being overweight or obese increased.

Conclusions: Findings suggest several risk factors are associated with being overweight or obese: male spouse, noncommissioned officers in the ranks of E5 through E9, older age, higher psychological distress scores, and lower perceived 

social support scores. The risk factors support the use of the Army Surgeon General’s Performance Triad of sleep, activity, and nutrition as a tool to assist Army personnel and Department of the Army civilians in teaching spouses awareness 

and methods of changing behaviors that may result in choosing healthy options.
88 http://www.cs.amedd.army.mil/amedd_journal.aspx

to also emphasize the well-being of military spouses. 

A primary example of this commitment is The Army 

Family Covenant, the Army’s pledge to take care of the 

Soldiers’ families signed by the Army’s Public Health 

Command and the Chief of Staff of the Army.10,11 However, research on the physical health and psychological 

well-being of military spouses is limited in scope.

The relationship between stress and weight among military spouses was first studied during the Vietnam War 

and Operation Desert Storm (1991-1995) with Navy 

spouses. One of many shared physical symptoms among 

military spouses with deployed spouses was eating disorders.12 Navy spouses also reported weight loss when 

their husbands were at sea for long periods of time.13,14

However, another study revealed that Navy wives’ 

weight loss and gain were equivalent regardless of the 

Sailors’ deployment status.15 Although these studies offered important initial insights into the relationship between service-related stress and weight, they occurred 

prior to the obesity epidemic in the US, which has markedly increased since 1980 across all demographics and 

among the military population as well.10,16

Recent epidemiology data indicate 1 in 5 Army active 

duty spouses are overweight, and one-third are obese 

compared to one-third overweight and one-third obese 

in the civilian sector.10 These descriptive findings suggest that although Army spouses may have fewer incidents than the general population for unhealthy weight 

status, more than half are at risk for weight related health 

problems. Several demographic factors are related to increased risk of being overweight or obese. Research suggests that as adults grow older, their BMI increases.17 Further, as men increase in age, their BMI scores increase at 

a rate higher than women’s BMI scores increase for the 

same age.18 In the civilian sector, obesity rates increased 

for all socioeconomic status groups and education levels 

from the middle of the 1990s until 2007.19

It is well established that spouses of deployed Soldiers 

experience stress, but it is not known whether stress 

elevates the incidents among Army spouses for being 

overweight or obese.20,21 Analysis of the civilian sector 

yielded inconsistent results for the relationship between 

stress and body weight. Women experiencing major life 

events, such as long-term illness of themselves or children, death of loved ones, major financial setbacks, or 

problematic adult children are at greater risk of gaining weight and obesity.22 However, research has failed to 

support a relationship between everyday hassles, defined 

as that which “causes problems or makes life more difficult,” and obesity among women.23 A systematic review 

of the literature concerning Army spouses concluded 

that spouses with poor coping skills are predisposed 

to physical health problems and recommended further 

study of the effect of stress associated with separation 

on military spouses’ health and well-being.24 Associations among psychological symptoms (eg, depression, 

anxiety) and weight status are similarly inconsistent. 

There is a significant positive relationship between obesity and depression among women.25 A systematic review revealed that US studies consistently showed a relationship between obesity and depression with women, 

meaning that there are higher odds that an obese woman 

may become depressed.26 Conducted simultaneously, a 

systematic review and meta-analysis revealed a moderate level of evidence for a positive association between 

obesity and anxiety disorders for women specifically.27

Although social support theory suggests that individuals with a social support system are healthier, no studies 

were identified that examine the relationship between 

Army spouses’ perceived social support and being 

overweight or obese.28 In the civilian population, it was 

found that perceived social support protects against obesity among men but not for women, suggesting the need 

to examine this relationship further.29

Army Spouses

Being obese or overweight is a significant public health 

concern in the general public. Attention to correlates of 

weight status among Army spouses is particularly important because the spouses have the unique stressors of 

permanent change of station relocations, adjusting to the 

military, adapting in foreign countries, decreased social 

support from the family of origin, and family separations 

due to combat and noncombat related tours.30 The unique 

challenges that military spouses face as a result of their 

Soldier deploying to a combat zone include constant fear 

for the safety of the Soldier, managing the household and 

children solo, and coping with loneliness.31

Army spouses whose Soldiers are deployed to a combat 

zone are at risk of negative mental and physical health 

outcomes. For example, one-fifth of spouses reported 

moderate to severe emotional problems that negatively 

affected other areas in their life.20 Almost one-fifth of 

the Army spouses surveyed met the DSM-IV* criteria 

for generalized anxiety. More than one-tenth of Army 

spouses whose Soldiers were deployed at the time of the 

survey had depressive symptoms, which is double the rate 

of the civilian community in the US adult population.20,32

When spouses lack social support, they report increased 

loneliness. Spouses faced with extended deployments 

and unexpected extensions may struggle with mental 

THE EFFECT OF DEPLOYMENT, DISTRESS, AND PERCEIVED SOCIAL SUPPORT

ON ARMY SPOUSES WEIGHT STATUS

*Diagnostic and Statistical Manual of Mental Disorders, 4th ed.
October – December 2014 89

THE ARMY MEDICAL DEPARTMENT JOURNAL

health problems and loneliness compared to spouses 

whose Soldier’s deployment is not extended.20,33-35

Researchers hypothesized that poor coping is associated 

with physical health problems, which may be related to 

being overweight or obese.3,12 Additional researchers 

supported the hypothesis and found an association between an Army spouse’s ability to cope and health problems.12,36,37 Spouses with effective coping skills such as 

the ability to solve problems were less likely to have 

physical health problems.

In summary, we do not know if there is an association 

between Soldiers’ deployment status and Army spouses’ 

weight status, but in the earlier studies,13,14 spouses of 

Sailors either lost or maintained their weight when the 

Sailor was at sea. Spouses of deployed Soldiers experience stress and are more likely to be diagnosed with depression than spouses of nondeployed Soldiers.20,21 In the 

civilian population, depression and anxiety are related 

to increases in weight, and weight increases in concert 

with increasing age.17,25-27 It is unclear whether there is 

an association between social support and weight status.

The purpose of this study is to examine Army spouses’ 

weight status (eg, BMI, healthy weight, overweight, or 

obese) in relation to their Soldiers’ deployment status 

along with the variables of rank and education, psychological distress, and perceived social support. It is hypothesized that Army spouses’ chronic stress of deployment may be related to being overweight or obese. Having an understanding of the variables associated with an 

Army spouse’s overweight or obese status may assist in 

program planning and treatment of problematic weight 

and behavioral health issues.

Method

Data Source

Permission was granted by the Department of Defense 

(DoD) to use the 2008 Active Duty Spouses Survey 

(ADSS) for the secondary data analyses used in this 

study. The data for this study are from the 2008 ADSS 

development by the Human Resources Strategic Assessment Program and Defense Manpower Data Center’s 

Program Evaluation Branch in support of the Under 

Secretary of Defense for Personnel and Readiness. The 

purpose of the survey was described to its participants 

as an opportunity to voice their concerns on issues that 

affect them and their families with the goal of improving “personnel policies, programs, and practices.”38 The 

2008 ADSS has 95 questions across 9 sections:

1. Background information

2. Permanent change of station moves

3. Spouse’s deployment status

4. Effect of deployments on children

5. Education and employment status of the spouse

6. Financial well-being of the family

7. Health and well-being of the spouse

8. Feelings about military life

9. The spouse’s use of Military One-Source

A sample of 49,368 spouses was collected from active 

duty databases (Army, Air Force, Marine Corps, Navy, 

and Coast Guard), and 13,423 spouses responded (a 28% 

response rate from the DoD military spouses). Spouses 

no longer married to the service member, widowed, or 

whose spouse was no longer active duty were excluded 

from the survey. The final sample (N=1863) consists 

solely of Army spouses. Because all identities were removed from the data, the University of Maryland, Baltimore, Institutional Review Board reviewed and approved 

this study as Not Human Subjects Research.

Study Sample

The target population for this study (N=1863) consists 

of male and female legally married spouses of US Army 

active duty Soldiers below the rank of general who have 

been in the military for at least 6 months. The majority of the sample was female (90%); the average age of 

the spouses was 26 (SD=5.73). Race was distributed 

into 2 categories: non-Hispanic white (67%) and minority (33%). Almost one-third of the sample was from the 

rank structure of E-5 through E-9. More than half of 

active duty Army Soldiers are married, which is almost 

the same as the marriage percentage (56%) for the services combined (Air Force, Army, Marine Corps, and 

Navy). In this sample, the average age of married enlisted Soldiers (30.3 years) is lower than the average age of 

married officers (36.8 years). The percentage of married 

officers (70.5%) is higher than married enlisted Soldiers 

(65.6%). Spouses who were underweight (<1%) were 

not included in this study.

Study Measures

The survey measures demographic characteristics 

through self-response categories of gender, race, age, 

rank, education, and deployment status (not deployed, 

deployed but not to a combat zone, and deployed to a 

combat zone) with deployment defined as being away 

from home for more than 30 days.

Psychological Distress. The Kessler Scale (K6) was used 

in the survey. It is designed to assess whether a mental illness is present and its severity. The questions are 

similar to those used to assess symptoms of anxiety and 
90 http://www.cs.amedd.army.mil/amedd_journal.aspx

depression.39 Six questions inquire of the participants’ 

feelings over the last 4 weeks: (a) so sad that nothing 

could cheer you up, (b) nervous, (c) restless or fidgety, (d) 

hopelessness, (e) that everything was an effort, and (f) 

worthless. The 6 items are individually answered using 

a 5-point Likert scale ranging from 0 to 4 (none of the 

time, little of the time, some of the time, most of the time, 

all of the time). The scoring for the K6 is the total of the 

6 items with scores ranging from 0 to 24. Scores of 0 to 

7 indicate no diagnoses, 8 to 12 moderate mental illness, 

and scores above 12 indicate a severe mental illness.38,40

The K6 has a strong Cronbach’s α (.89) in the current 

study and in Kessler’s psychological distress scale.32

Social Support. A 10-item perceived social support scale 

was used in the 2008 ADSS. The scale “indicates the 

degree to which spouses have a network of friends and 

family, other than their spouse, who can provide companionship, assistance, and other types of support. A 

higher score on the scale indicates greater perceived support.”38 The questions ask how likely is it that a friend, 

neighbor, or relative other than their spouse would: (a) 

listen to you if you needed to talk, 

(b) help with your daily chores if 

you were sick, (c) lend you tools 

or equipment if you needed them, 

(d) help you with physically demanding chores, (e) look after 

your belongings (house, pets, 

etc.) when you travel, (f) loan 

you $25 or more, (g) give you a 

ride if you need it, and (h) tell 

you about community resources. 

The answer to the 10 questions 

are averaged so each respondent 

has a total score on the perceived 

social support scale with a higher 

average score meaning more perceived support and lower meaning less perceived support. Cronbach’s α for the 10 perceived social support items was .94 in this 

study.

Weight Status. The survey asks 

the respondents their height without shoes and their weight. The respondent’s BMI was calculated as 

(weight in pounds×703)/(height 

in inches squared). In addition 

to the continuous BMI measure, 

BMI was also categorized as3:

3⁄4 Healthy: 18.5 kg/m2 to 24.9 kg/m2

3⁄4 Overweight: 25.0 kg/m2 to 29.9 kg/m2

3⁄4 Obese: 30 kg/m2 or higher

Data Analysis

The primary study hypothesis is that spouses of US Army 

Soldiers who are deployed (whether to a combat zone 

or other environment) have higher BMIs than spouses 

of Soldiers who are not deployed. One-way analyses of 

variance (ANOVAs) were conducted to examine the difference in the average BMIs for the 3 groups of interest: (1) Soldiers not deployed, (2) deployed but not to 

a combat zone, and (3) deployed to a combat zone. For 

all significant ANOVAs, Tukey post hoc tests were conducted to examine which groups are significantly different. A χ2

 analysis was used to examine whether there is 

a significant difference of the spouses in the 3 groups 

of interest when compared to the categories of having a 

healthy weight and being overweight or obese.

Results

Table 1 shows the basic demographics of the Army spouses 

from this survey (N=1863). The 

majority of the sample are women (90%) with non-Hispanic 

white (67%) representing the 

highest percentage in the race 

category. The ages of the spouses 

were equally dispersed among 

the 5 age categories. The highest percentage of the spouses has 

Soldiers in the ranks E5 through 

E9 (29%) and the lowest percentage in the ranks W1 through W5 

(10%). Forty-two percent of the 

Army spouses have some college 

and the smallest percentage represents no college (13%). Only 

8% of the Army spouses report 

that their Soldier has been deployed away from home but not 

to a combat zone. Forty-six percent report that their Soldier has 

never deployed.

Comparison of Healthy and 

Overweight or Obese Army 

Spouses

There were several differences 

between Army spouses with 

THE EFFECT OF DEPLOYMENT, DISTRESS, AND PERCEIVED SOCIAL SUPPORT

ON ARMY SPOUSES WEIGHT STATUS

Table 1. Demographics of the Army Spouses*

Characteristic n (%N)

Gender (N=1861)

Male 183 (9.8) 

Female 1678 (90.1)

Race (N=1851)

Non-Hispanic white 1248 (67.0)

Total minority 603 (32.4)

Age (N=1858)

<26 368 (19.8)

26-30 394 (21.1)

31-35 385 (20.7)

36-40 344 (18.5)

>40 367 (19.7)

Rank (N=1862)

E1-E4 465 (25.0)

E5-E9 549 (29.5)

W1-W5 199 (10.7)

O1-O3 312 (16.7)

O4- O6 337 (18.1)

Education (N=1853)

No college 252 (13.5)

Some college 789 (42.4)

4 year degree 534 (28.7)

Professional degree 278 (14.9)

Deployment Status (N=1842)

No deployment 865 (46.4)

Deployed but not to a combat zone 153 (8.2)

Deployed to a combat zone 824 (44.2)

*NOTE: N of each subgroup does not equal total study 

sample population of 1863 due to missing data.
October – December 2014 91

THE ARMY MEDICAL DEPARTMENT JOURNAL

healthy weights and those who were overweight or obese (see Tables 2 and 3). Male 

spouses were significantly more likely than 

female spouses to be overweight or obese 

(75% versus 47%) (P<.005). More than half 

of the minority spouses are in the overweight 

or obese category compared to less than half 

of the non-Hispanic white spouses (P<.005). 

Spouses with Soldiers in the enlisted ranks 

of E1 through E9 are more likely to be in the 

overweight or obese category compared to 

the spouses in the officer ranks O1 through 

O6 (P<.001). Spouses with no or some college were more likely to be in the overweight 

or obese category compared to spouses with a 

4-year or professional degree (P<.005). Compared to those with weights in the healthy 

range, spouses who were overweight or obese 

were older, had higher psychological distress 

scores, and reported less perceived social 

support. Of the variables examined, only deployment status was not significantly related 

to weight status.

One-way ANOVAs were conducted to compare the BMIs, age, education, K6, and perceived social support of Army spouses in the 

3 deployment groups (Table 4). Age, education, and K6 scores were all significantly related to deployment status. Spouses in the no 

deployment group were significantly older 

(approximately 2 years older) than spouses 

in either deployment group; spouses in the 2 

deployment groups were not significantly different in age. Table 5 presents the Tukey post 

hoc comparisons. Spouses in the no deployment group on average had higher levels of 

education than spouses in either deployment 

group; spouses in the 2 deployment groups were not significantly different in education levels. Spouses in the 

no deployment group had significantly lower K6 scores 

than spouses in either deployment group; spouses in the 

2 deployment groups did not have significantly different K6 scores. BMI scores and perceived social support 

were not significantly different across the 3 groups.

A χ2 analysis was used to examine whether the spouses 

in the 3 deployment statuses have different rates of being in the healthy or overweight or obese category and 

the results were not significant (Table 6).

Comment

The purpose of this study was to examine Army spouses’ weight status (eg, BMI, healthy weight, overweight, 

or obese) in relation to their Soldiers’ deployment status 

along with the variables of rank, education, psychological distress, and perceived social support. Results fail to 

Table 2. Descriptive Variables Comparing Healthy to Overweight/Obese

Categorical

Variable

Weight

Healthy

n (%N)

Overweight/

Obese

n (%N)

χ2 P

Gender 49.74 <.005

Male (N=183) 46 (25.1) 137 (74.9)

Female (N=1678) 864 (52.6) 778 (47.4)

Race 14.29 <.005

Non-Hispanic white (N=1226) 646 (52.7) 580 (47.3)

Total minority (N=590) 255 (43.2) 335 (56.8)

Age 14.60 .006

<26 (N=354) 198 (55.9) 156 (44.1)

26-30 (N=389) 206 (53.0) 183 (47.0)

31-35 (N=376) 184 (48.9) 192 (51.1)

36-40 (N=338) 163 (48.2) 175 (51.8)

>40 (N=365) 156 (42.7) 209 (57.3)

Rank 29.99 <.005

E1-E4 (N=451) 209 (46.3) 242 (53.7)

E5-E9 (N=544) 234 (43.0) 310 (57.0)

W1-W5 (N=194) 97 (50.0) 97 (50.0)

O1-O3 (N=306) 171 (55.9) 135 (44.1)

O4- O6 (N=331) 198 (59.8) 133 (40.2)

Education 36.41 <.005

No college (N=245) 117 (47.8) 128 (52.5)

Some college (N=774) 329 (42.5) 445 (57.5)

4 yr degree (N=526) 309 (58.7) 217 (41.3)

Professional degree (N=272) 149 (54.8) 123 (45.2)

Deployment Status 4.67 .097

No deployment (N=849) 406 (47.8) 443 (52.2)

Deploy, no combat zone (N=149) 68 (45.6) 81 (54.4)

Deploy to combat zone (N=808) 424 (52.5) 384 (47.5)

K6 Scale 18.83 <.005

No mental illness (N=1221) 651 (53.3) 570 (46.7)

Moderate mental illness (N=358) 158 (44.1) 200 (55.9)

Severe mental illness (N=197) 78 (39.6) 119 (60.4)

K6 Scale indicates Psychological Distress Subscale: 1-5=no mental illness; 6-12=moderate 

mental illness; >13=severe mental illness

Table 3. Continuous Variables Comparing Healthy to Overweight/Obese (N=1863)

Continuous

Variables

Weight

Healthy

Mean (SD)

Overweight/Obese

Mean (SD)

t P

Age 32.7 (8.2) 34.3 (8.4) -4.07 <.0005

K6 Scale 5.4 (5.0) 6.4 (5.3) -4.01 <.0005

Social 

Support

3.9 (1.1) 3.7 (1.2) 4.40 <.0005

K6 Scale indicates Psychological Distress Subscale: 1-5=no mental 

illness; 6-12=moderate mental illness; >13=severe mental illness

Social Support indicates subscale for perception of likelihood of support: 

very unlikely=1; unlikely=2; neither likely nor unlikely=3; likely=4; very 

likely=5
92 http://www.cs.amedd.army.mil/amedd_journal.aspx

support a statistically significant relationship between 

deployment status and spouse weight status. However, 

spouses’ weight status was related to gender, rank, psychological distress, and perceived social support. Specifically, male spouses, spouses of those at lower ranks, 

increased psychological distress, and lower perceived 

social support were related to increased incidence of being overweight or obese.

The percentage (60%) of Army spouses who are overweight or obese is lower than what has been reported 

for the civilian population in which 68% of adults over 

20 are overweight or obese.41 However, an unexpected 

finding in this study is that male spouses are more likely 

to be overweight or obese compared to females. This 

finding is consistent with the literature where 

men in the United States are more likely to be 

overweight or obese in comparison to women.17 Further, in the civilian sector in the last 

10 years, male BMI scores have significantly 

increased compared to that of women.18 However, the weight differences between men and 

women in the Army are notably higher (25%) 

than the civilian sector’s difference of 10%.17

Spouses of Soldiers in the enlisted ranks (E1 

through E9) are more likely to be overweight 

or obese compared to spouses of Soldiers in 

the higher ranks (O1 through O6). Because 

rank is directly associated with income, it is 

possible that spouses of Soldiers in enlisted 

ranks experience greater financial barriers to 

accessing high quality foods such as whole grain, lean 

meats, and fresh fruits and vegetables. They may also 

rely on fast food options that are often perceived as more 

economical and convenient. Previous research has tied 

socioeconomic status to diet quality, with lower socioeconomic status associated with greater consumption of 

foods characterized by refined grains and added fats.42-44

Psychological stress was also associated with weight 

status, with spouses who endorsed greater distress also 

reporting higher BMI. The physiological pathway in 

which stress may predispose an individual to obesity 

is well documented. Individuals experiencing acute or 

chronic stress have been found to have elevated glucocorticoids related to hypothalamic-pituitary-adrenal 

axis simulation that may increase eating behaviors, and, 

in turn, elevate BMI.45,46 Consistent with other studies, 

our research also identified that psychological distress 

can increase when the Soldier is deployed.34,47

Relatedly, study findings indicate an inverse relationship 

between perceived social support and BMI; participants 

who had higher social support scores were less likely to 

be overweight or obese. Social support is especially important for military populations who are new, adjusting 

to the military way of life, and are often separated from 

their Soldier.48,49 The protective effect of social support 

may work directly on weight status by providing opportunities for shared physical activity and may also offer a 

buffer for psychological distress.50 Spouses’ perceptions 

of social support affects Soldiers’ decisions to continue 

serving their country, and Airmen who perceive that 

their spouses benefit from social support report their 

spouses cope effectively with the military lifestyle.47,51

Men differ from women in their use of social support 

and the support’s effectiveness in decreasing stress.52

THE EFFECT OF DEPLOYMENT, DISTRESS, AND PERCEIVED SOCIAL SUPPORT

ON ARMY SPOUSES WEIGHT STATUS

Table 4. Comparing Deployment and Weight Status of Army Spouses

Continuous

Variable

Deployment Status Past 12 Months

No Deployment

Mean (SD)

Deployment to Combat Zone?

No

Mean (SD)

Yes

Mean (SD)

F P

BMI 26.17 (5.47) 26.12 (6.08) 26.11 (5.94) 0.02 .977

Age 34.8 (8.46) 32.7 (8.62) 32 (7.84) 23.2 <.005

Education 2.52 (0.91) 2.33 (0.88) 2.40 (0.89) 5.01 .007

K6 Scale 5.16 (4.70) 6.43 (5.47) 6.49 (5.49) 14.68 <.005

Social 

Support

3.75 (1.15) 3.82 (1.09) 3.80 (1.13) 0.62 .537

BMI indicates body mass index.

Assigned Education values: no college=1; some college=2; 4-year degree=3; 

graduate degree=4

K6 Scale indicates Psychological Distress Subscale: 1-5=no mental illness; 

6-12=moderate mental illness; >13=severe mental illness

Social Support indicates subscale for perception of likelihood of support: very 

unlikely=1; unlikely=2; neither likely nor unlikely=3; likely=4; very likely=5

Table 5. Tukey Post Hoc Test on Deployment Status

Categorical 

Variable

Deployment Status P

Age

not deployed deployed not combat .012

deployed combat <.005

deployed not combat not deployed .012

deployed combat .666

deployed combat not deployed <.005

deployed not combat .666

Spouse 

Education

not deployed deployed not combat .042

deployed combat .024

deployed not combat not deployed .042

deployed combat .607

deployed combat not deployed .024

deployed not combat .607

K6 Scale

not deployed deployed not combat .016

deployed combat <.005

deployed not combat not deployed .016

deployed combat .989

deployed combat not deployed <.005

deployed not combat .989
October – December 2014 93

THE ARMY MEDICAL DEPARTMENT JOURNAL

Implications

Future Research. The results of this study provide a direction for building programs that maximize protective 

factors and address risk factors associated with spouse 

weight status. Because this study only included data 

through 2008, it is important to conduct follow-up research to fully capture the long-term effects of deployments, especially in light of the ongoing operations related to Operation Enduring Freedom. Operations Iraqi 

Freedom and Enduring Freedom are unprecedented insofar as the US military population has never served as 

long or had as many repeated deployments to combat 

zones. The literature shows that Soldiers with multiple 

deployments (noncombat) are at higher risk of adjustment problems compared to those with only one deployment.8,53 Soldiers with at least 2 deployments have higher 

incidents of posttraumatic stress disorder, major depressive disorder, or traumatic brain injury than those with 

less than 2 deployments.8,53 The experience of multiple 

deployments over 13 years may also have substantial 

negative effects on spouses. Examining 13 years of war 

instead of 7 years may offer a more comprehensive picture of the interrelationships among deployment, stress, 

social support, and weight status.

Policy and Practice. We have enhanced understanding 

of how psychological distress and perceived social support are associated with being overweight or obese and 

the higher incidents of overweight among male spouses. 

The associations and incidents identified are consistent with The Surgeon Generals drive for beneficiaries’ 

health through the Performance Triad; they may also 

improve the ability of primary care providers and Army 

units to enhance the treatment and programs provided 

for spouses. For example, Army units could tailor a social support program to have physical activities, such as 

basketball leagues, that may attract the male spouses. 

Morale, Welfare, and Recreation support services could 

make a concerted effort that focuses on engaging male 

spouses to participate in their sponsored activities such 

as fitness classes and running events. Army units and 

providers could also channel educational 

material about the relationships of stress, 

social support, and healthy lifestyle choices to spouses of Soldiers who are preparing to deploy.

The findings of this study may also inform 

programs such as the Army Wellness Centers (AWC) and Comprehensive Soldier 

Fitness (CSF) program. For example, the 

fact that three-quarters of male spouses 

are overweight or obese may also be critical information for the AWC as they could 

design programs geared towards reaching out to male 

spouses. As another example, the AWC could provide 

networking opportunities to increase perceived social 

support for families living outside the United States 

where they may be removed from their families of origin. The CSF could use these findings to inform how 

they structure their programs that address their 5 dimensions of strength: physical, emotional, family, social, 

and spiritual.

Conclusion

The results of this study fail to support a relationship 

between deployment and weight status among Army 

spouses during the period 2001 through 2008. However, 

findings address a gap in research with Army spouses 

by identifying several key risks (older age, lower rank, 

male gender, psychological distress) and protective 

mechanisms such as social support associated with 

spouse weight status. Moreover, this study contributes to 

The Army Surgeon General’s Performance Triad strategy of recognizing and intervening on factors that create challenges with sleep, activity, and nutrition. It also 

offers suggestions to shape policy and clinical practice 

to enhance care for Army spouses. Additionally, study 

results may help shape clinical practice in primary care 

settings by encouraging providers to routinely screen 

spouses of deployed Soldiers for the identified factors 

associated with being overweight or obese, and help link 

at-risk groups to programs and resources. Collectively, 

these steps could help advance The Army Surgeon General’s Performance Triad initiative.

References

1. Robbins AS, Chao SY, Baumgartner N, Runyan 

CN, Oordt MS, Fonseca VP. A low-intensity intervention to prevent weight gain in active duty Air 

Force members. Mil Med. 2006;171(6):556-561. 

2. Gantt CJ, Neely JA, Villafana IA, Chun CS, Gharabaghli SM. Analysis of weight and associated health 

consequences of the active duty staff at a major Naval medical center. Mil Med. 2008;173(5):434-440.

Table 6. Comparing Deployment Status of Spouse with Being Overweight/

Obese

Categorical

Variable

Deployment Status*

No Yes

Not

Combat Zone

Combat Zone

n (%N) n (%N) n (%N) χ2 P

Healthy weight (N=898) 406 (47.8) 68 (45.6) 424 (52.3) 4.34 .114

Unhealthy weight 5.03 .081

Overweight (N=528) 269 (60.7) 51 (63.0) 208 (53.7)

Obese (N=383) 174 (39.3) 30 (37.0) 179 (46.3)

*Deployment status during the last year.
94 http://www.cs.amedd.army.mil/amedd_journal.aspx

3. Karasu SR, Karasu TB. The Gravity of Weight: A 

Clinical Guide to Weight Loss and Maintenance. 

Arlington, VA: American Psychiatric Publications; 

2010.

4. Horoho PD, Brock DA. Army medicine strategy: 

the road ahead. Paper presented at: 2012 Performance Triad Nutrition Action Plan Workshop; September 2012; US Army Public Health Command; 

Aberdeen Proving Ground, MD.

5. Dall TM, Zhang Y, Chen YJ, et al. Cost associated with being overweight and with obesity, high 

alcohol consumption, and tobacco use within the 

military health system’s TRICARE prime-enrolled population. Am J Health Promot. 2007;22 

(2):120-139.

6. Verdeli H, Baily C, Vousoura E, Belser A, Singla D, 

Manos G. The case for treating depression in military spouses. J Fam Psychol. 2011;25(4):488-496.

7. Sheppard SC, Malatras JW, Israel AC. The impact 

of deployment on U.S. military families. Am Psychol. 2010;66(1):65-72.

8. Tanielian TL, Jaycox LH, eds. Invisible Wounds of 

War: Psychological and Cognitive Injuries, Their 

Consequences, and Services to Assist Recovery. 

Santa Monica, CA: Rand Corporation; 2008. Available at: http://www.rand.org/pubs/monographs/

MG720.html. Accessed August 4, 2014.

9. Kukral L. Performance triad to change focus of 

Army medicine. US Army Website. September 

27, 2012. Available at: http://www.army.mil/ar

ticle/88044/. Accessed May 1, 2013.

10. Kennan JO. Nutrition Plan. Presentation at 2012 

Performance Triad Nutrition Action Plan Workshop. September 2012; US Army Public Health 

Command; Aberdeen Proving Ground, MD.

11. McLeroy C. Army family covenant: keeping promises. Soldiers. 2008;63(6):22.

12. Blount BW, Curry A, Lubin GI. Family separations 

in the military. Mil Med. 1992;157(2):76-80.

13. Snyder AI. Periodic marital separation and physical 

illness. Am J Orthopsychiatry. 1978;48(4):637-643.

14. Van Vranken EW, Jellen LM, Knudson KHM, Marlowe DH, Segal MW. The Impact of Deployment 

Separation on Army Families. Washington, DC: 

Walter Reed Army Institute of Research; August 

1984. Report WRAIR NP-84-6. Available at: http://

www.dtic.mil/dtic/tr/fulltext/u2/a146595.pdf. Accessed August 5, 2014.

15. Nice DS. The course of depressive affect in 

Navy wives during family separation. Mil Med. 

1983;148(4):341-343.

16. Ogden CL, Yanovski SZ, Carroll MD, Flegal 

KM. The epidemiology of obesity. Gastroenterol. 

2007;132:2087-2102.

17. Wang Y, Beydoun MA. The obesity epidemic in the 

United States–gender, age, socioeconomic, racial/

ethnic, and geographic characteristics: A systematic review and meta-regression analysis. Epidemiol 

Rev. 2007; 29: 6-28.

18. Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of 

body mass index among US adults, 1999-2010. 

JAMA. 2012;307(5):491-497.

19. Ogden C, Lamb M, Carroll M, Flegal K. Obesity 

and socioeconomic status in adults: United States, 

2005-2008. NCHS Data Brief. 2010;50:1-8.

20. Eaton KM, Hoge CW, Messer SC, et al. Prevalence of mental health problems, treatment need, 

and barriers to care among primary care-seeking 

spouses of military service members involved 

in Iraq and Afghanistan deployments. Mil Med. 

2008;173(11):1051-1056.

21. Gottman JM, Gottman JS, Atkins CL. The comprehensive soldier fitness program: the family component. Am Psychol. 2011;66(1):52-57.

22. Iversen LB, Strandberg-Larsen K, Prescott E, Schnohr P, Rod NH. Psychosocial risk factors in weight 

changes and risk of obesity: The Copenhagen City 

Heart Study. Eur J Epidemiol. 2012;27(2):119-130.

23. Rohrer JE, Young R. Self-esteem, stress and selfrated health in family planning clinic patients. 

BMC Fam Prac. 2004;5(11):1-8.

24. Blakely G, Hennessy C, Chung MC, Skirton H. A 

systematic review of the impact of foreign postings 

on accompanying spouses of military personnel. 

Nurs Health Sci. 2012;14:121-132.

25. De Wit L, Luppino F, van Straten A, Penninx B, 

Zitman F, Cuijpers P. Depression and obesity: a 

meta-analysis of community-based studies. Psychiatry Res. 2009;17:230-235,26.

26. 26 Atlantis E, Baker M. Obesity effects on depression: Systematic review of epidemiological studies. 

Int J Obes. 2008;32:881-889.

27. Gariepy G, Nitka, D, Schmitz N. The association 

between obesity and anxiety disorders in the population: A systematic review and meta-analysis. Int 

J Obes. 201;34:407-419.

28. House JS, Landis KR, Umberson D. Social relationships and health. Science. 1988;241(4865):540-545.

29. Wiczinski E, Doring A, John J, von Lengerke T. 

Obesity and health-related quality of life: Does social support moderate existing associations? Br J 

Health Psychiatry. 2009;14:717-734.

30. Burrell LM, Adams AA, Durand DB, Castro CA. 

The impact military lifestyle demands on wellbeing, Army, and family outcomes. Armed Forces 

Soc. 2006;33(1):43-58.

31. Warner CH, Appenzeller GN, Warner CM, Grieger 

T. Psychological effects of deployments on military 

families. Psychiatr Ann. 2009;39(2):56-63.

THE EFFECT OF DEPLOYMENT, DISTRESS, AND PERCEIVED SOCIAL SUPPORT

ON ARMY SPOUSES WEIGHT STATUS
October – December 2014 95

THE ARMY MEDICAL DEPARTMENT JOURNAL

32. 32.Kessler RC, Barker PR, Colpe LJ, et al. Screening for serious mental illness in the general population. Arch Gen Psychiatry. 2003;60(2):184-189.

33. Hill R. Families Under Stress: Adjustment to the 

Crises of War Separation and Reunion. New York, 

NY: Harper & Brothers; 1949.

34. Mansfield AJ, Kaufman J S, Marshall S W, Gaynes 

BN, Morrissey J P, Engel CC. Deployment and the 

use of mental health services among U.S. Army 

wives. N Engl J Med. 2010; 362(2): 101-109.

35. SteelFisher GK, Zaslavsky AM, Blendon RJ. 

Health-related impact of deployment extensions 

on spouses of active duty army personnel. Mil Med. 

2008;173(3):221-229.

36. Dimiceli EE, Steinhardt MA, Smith SE. Stressful experiences, coping strategies, and predictors 

of health-related outcomes among wives of deployed military servicemen. Armed Forces Soc. 

2010;36(2):351-373. 

37. Padden DL, Connors RA, Agazio JG. Stress, 

coping, and well-being in military spouses during deployment separation. West J Nurs Res. 

2011;33(2):247-267.

38. Defense Manpower Data Center. 2008 Survey 

of active duty spouses: Tabulations of Responses. Washington, DC: US Dept of Defense; 2008. 

DMDC Report No. 2008-041. Available at: http://

prhome.defense.gov/Portals/52/Documents/RFM/

MCFP/docs/2008%20Military%20Spouse%20

Survey.pdf. Accessed August 5, 2014.

39. Green JG, Gruber MJ, Sampson NA, Zaslavsky 

AM, Kessler RC. Improving the K6 short scale 

to predict serious emotional disturbance in adolescents in the USA. Int J Methods Psychiatr Res. 

2010;19(suppl 1):23-35.

40. Kessler RC, Andrews G, Colpe LJ, et al. Short 

screening scales to monitor population prevalences 

and trends in non-specific psychological distress. 

Psychol Med. 2002;32(6):959-976.

41. Ogden CL. Disparities in obesity prevalence in the 

United States: black women at risk. Am J Clin Nutr. 

2009;89(4):1001-1002.

42. Darmon N, Drewnowski A. Does social class predict 

diet quality? Am J Clin Nutr. 2008;87(5):1107-1117.

43. Lallukka T, Laaksonen M, Rahkonen O, Roos 

E, Lahelma E. Multiple socio-economic circumstances and healthy food habits. Eur J Clin Nutr. 

2007;61:701-710.

44. Turrell G, Hewitt B, Patterson C, Oldenburg B. 

Measuring socio-economic position in dietary research: is choice of social-economic indicator important? Public Health Nutr. 2003;6(2):191-200.

45. Adam TC, Epel ES. Stress, eating and the reward 

system. Physiol Behav. 2007;91(4):449-458.

46. Warne JP. Shaping the stress response: interplay 

of palatable food choices, glucocorticoids, insulin and abdominal obesity. Mol Cell Endocrinol. 

2009;300(1-2):137-146.

47. Faulk KE, Gloria CT, Cance JD, Steinhardt MA. 

Depressive symptoms among US military spouses 

during deployment: the protective effect of positive 

emotions. Armed Forces Soc. 2012;38(3):373-390.

48. Bowen GL, Mancini JA, Martin JA, Ware WB, 

Nelson JP. Promoting the adaptation of military 

families: an empirical test of a community practice 

model. Fam Relat. 2003;52(1):33-44.

49. Pittman JF, Kerpelman JL, McFadyen JM. Internal 

and external adaptation in Army families: lessons 

from Operations Desert Shield and Desert Storm. 

Fam Relat. 2004;53(3):249-260.

50. Watt RG, Heilmann A, Sabbah W, et al. Social 

relationships and health related behaviors among 

older US adults. BMC Public Health [serial online]. 

2014;14(533). Available at: http://www.biomedcen

tral.com/content/pdf/1471-2458-14-533.pdf. Accessed August 5, 2014.

51. Pittman JF. Work/family fit as a mediator of 

work factors on marital tension: evidence from 

the interface of greedy institutions. Hum Relat. 

1994;47(2):183-209.

52. Bellman S, Forster N, Still L, Cooper CL. Gender differences in the use of social support as a 

moderator of occupational stress. Stress Health 

2003;19(1):45-58.

53. Adler A, Huffman AH, Bliese PD, Castro CA. The 

impact of deployment length and experiences on 

the well-being of male and female soldiers. J Occup Health Psychol. 2005;10(2):121-137.

Authors

LTC Fish is Clinical Assistant Professor, Army-Fayetteville State University Master of Social Work Program, 

Army Medical Department Center and School, Joint 

Base San Antonio Fort Sam Houston, Texas.

Dr Harrington is Professor and Associate Dean for Doctoral and Post-Doctoral Education, University of Maryland School of Social Work, Baltimore, Maryland.

Dr Bellin is an Associate Professor, University of Maryland School of Social Work, Baltimore, Maryland.

Dr Shaw is an Associate Professor, University of Maryland School of Social Work, Baltimore, Maryland.
96 http://www.cs.amedd.army.mil/amedd_journal.aspx

Until relatively recently, many cultures viewed “wife 

beating” as an acceptable part of marriage.1 Even 

though violence in relationships is not condoned in the 

United States, one in 4 women will experience a form of 

domestic abuse in their lifetime.2 While men comprise 

85% of the domestic violence arrests, women also perpetrate violence towards their partners.3

 Three million 

children witness domestic violence every year.2 Most 

healthcare professionals agree that domestic violence 

is far-reaching and has effects on families, communities, and society as a whole. Researchers have identified 

and defined 3 types of intimate partner violence which 

including situational couple violence (SCV), intimate 

partner terrorism, and violent resistance.4

The most common form of violence between couples is 

SCV.4 This type of violence is commonly called battering, which involves a partner physically attacking another. It can either be an isolated incident or reoccurring, potentially a particularly dangerous situation since 

physical attacks often increase in severity. Intimate 

partner terrorism involves an individual who terrorizes 

by using coercion to control the partner through a combination of violence and other tactics including threats, 

intimidation, or psychological abuse. This form of abuse 

is believed to be less frequent than SCV but still affects 

2 million women in the United States. Violent resistance 

occurs when the victim of intimate partner terrorism 

fights back.4 Resistance can be especially dangerous if 

the female obtains a weapon and attacks the male out of 

fear. All 3 types of violence can be dangerous, in some 

cases life threatening, thus requiring timely and effective intervention.

The Department of Defense created the Family Advocacy Program (FAP) to treat victims and offenders of family violence. A significant majority of FAP cases seem 

to involve SCV. Service members are under a great deal 

of public scrutiny since many individuals believe that 

the stress of military life can lead to family abuse.5 The 

Army has been involved in an almost 13-year period 

of continuous conflict, resulting in war-weary service 

members and their families. The many stressors associated with military service may impede healthy family 

functioning.6 Nearly 18% of married Soldiers report interpersonal conflicts as they return home from deployments.7

 Operation Iraqi Freedom deployments are often 

correlated to decreased marital satisfaction, increased 

divorce intentions, and an increase in self-reported 

spousal abuse.8 Mansfield and colleagues found that 

military deployments also increase marital dissatisfaction, divorce rates, and decrease the emotional health of 

partners.9

Assessing a FAP referral, which in many cases is a complex endeavor, begins with an intake interview that includes a biopsychosocial assessment and determining 

the details of the allegedly abusive incident. Establishing 

safety is of paramount importance. The standard protocol involves completing the Spouse Abuse Risk Assessment, Spouse Abuse Manual Assessment Worksheet, 

and Safety Plan to address the presenting circumstances. 

However, FAP social workers would benefit from an additional assessment tool that can quickly assess the level 

of danger in a SVC situation and identify individuals 

that may be vulnerable to future incidents. The Korem 

Profiling System (KPS)10 may be useful as an adjunct to 

current FAP assessment procedures.

The Korem Profiling System

The KPS examines the method in which an individual 

communicates and the process they use to make decisions.10 Properly application of the system requires a 

clinician to determine the degree of assertiveness delivered in an individual’s communication and the emotion expressed in their messages. Examining a person’s 

Applying the Korem Profiling System to

 Domestic Violence

CPT Victor Johnson, MS, USA

Chandra Brown, LMSW

Abstract

Soldiers involved in domestic violence are a focus of concern for the US Army. The Family Advocacy Program 

is designed to prevent and intervene to mitigate future violence. Some of the Family Advocacy Program assessment tools are limited in their ability to identify contributing factors of situational couple violence. This article 

proposes incorporating the Korem Profiling System, a rapid assessment tool, to help identify underlying causes 

of situational couple violence and provide appropriate interventions to prevent future incidents.
October – December 2014 97

decision making process, seen as a performance trait, 

involves identifying how confident an individual is in 

the decisions they make and whether their thought processes tend to be conventional. Assessing these characteristics is helpful to understanding a person’s typical 

style in communicating and performing. When combined, these 2 basic traits form a broad picture of the 

characteristic manner in which a person relates to others 

and responds to environmental demands.

Communication Traits

A social worker can use the KPS to explore the breakdown in the communication. First, the social worker 

should evaluate if the client is assertive when they talk. 

The social worker should evaluate if the individual is 

mostly assertive or mostly nonassertive and place a point 

on a graph as illustrated in Figure 1. Next, the social 

worker evaluates if an individual uses a lot of emotion or 

controls their emotions when communicating. A point 

is placed on the graph as shown on Figure 1. Plotting 2 

different traits forms what is called a “type” which is 

represented by each quadrant.10 Individuals who are in 

different quadrants may have difficulty communicating.

Each quadrant has a specific communication trait that is 

typical with their respective professions. The 2 personalities that control their emotions are the “Accountant” 

and “Sergeant.” For instance, the Accountant is nonassertive and controls emotions. This type of individual 

maintains emotional composure and nonassertively 

makes inquires like an investigator or detailer. While 

the Accountant can be easy-going, analytical, and efficient, this trait has a dark side of being suspicious, pessimistic, and critical of others. The Sergeant, a designation coined by Korem which can also be called a leader 

or commander, is more typical in the military and gives 

orders while controlling emotion. While a Sergeant is 

strong, takes charge, has confidence, and is action oriented, this trait has the dark side of being overbearing, 

egotistical, impatient, and unsympathetic.10

The 2 types that express emotion are the “Artist” and 

“Salesman.” The Artist has traits typical of a counselor 

or sensor in the sense of a person who communicates 

nonassertively while using emotion. An Artist is typically agreeable, creative, compassionate, and loyal, 

however, this trait has the dark side of being critical, 

moody, unsure, and naive. The last personality type is 

the Salesman who can also be seen as a communicator 

or presenter since they convey emotion and enthusiasm, 

selling their product while using assertion. This trait has 

the upside of being optimistic, passionate, friendly, and 

confident, but has a downside of being impulsive, overselling, unfocused, and short-fused.10

Interactions among Traits

Each quadrant in Figure 1 has a position that is often 

associated with individuals that have a specific type of 

communication trait. Sergeants are more likely to control their emotions and be assertive in their communication. In complete contrast is an Artist who expresses 

emotion while lacking assertiveness in communication. 

Individuals that have communication patterns that are 

complete opposites, which would be represented by a 

diagonal plot, are more likely to have conflict with 

their communication.10 A social worker armed with this 

knowledge can quickly assess the dysfunctional communication pattern and explain it to the couple suffering 

from SCV.

Korem’s assertion that the method of communication 

can cause conflict if 2 individuals operate on different 

profiles is supported by Chapman,11 who posited that individuals who are communicating in different love languages are bound to have more conflict than those who 

are similar. The KPS argues that individuals who control 

emotions and are nonassertive, such as the Accountant, 

are more likely to have conflicts with the Salesman who 

expresses emotions and is assertive. The same opinion 

applies for the Sergeant and Artist.10

Armed with a fast communication assessment tool, a social worker can quickly provide important information 

and recommendations to a couple suffering from SCV. 

Individuals with certain communication traits require 

unique methods for effectively engaging in conversation. For example, one should be more directive when 

addressing a nonassertive person to control miscommunication. Further, be slightly less assertive when asking 

a nonassertive person a question or making a statement 

to make the message less threatening. When addressing an assertive or control individual, who is typically 

blunt, use direct communication.10 Control and expressive individuals often require someone to show emotion 

in messages that are subjective in order to place them in 

Figure 1. Communication Axis. (Courtesy of Dan Korem.)

Nonassertive Assertive

Control

Express

Accountant

Salesman

Sergeant

Artist

Plot 1

Plot 2
98 http://www.cs.amedd.army.mil/amedd_journal.aspx

the emotional thought process. To maintain an objective 

tone, a provider or significant other should use communication that is without emotion when obtaining factual 

information from expressive individuals.10

Decision Making

Social workers devise safety plans in every assessment to ensure the welfare of their clients. Tools such 

as the Spouse Abuse Manual Assessment Worksheet 

and Spouse Abuse Risk Assessment have limitations in 

their ability to protect an individual in the long run. The 

KPS addresses this problem by analyzing the method by 

which an individual makes decisions. Figure 2 is used 

to evaluate an individual’s emotional approach and predictability in decision making. A social worker should 

first examine whether an individual uses confidence or 

fear when making decisions. It should be determined if 

the individual is slightly fearful, cautious, or has a high 

degree of fear. The social worker would then make a 

horizontal plot as illustrated in Figure 2. Next, the social 

worker can examine whether the individual makes conventional or unconventional decisions. A conventional 

person makes predictable decisions and often thinks 

“inside of the box.” In contrast, an unconventional person is often unpredictable and thinks “outside of the 

box.” A plot reflecting that determination is placed on 

the vertical axis of the graph as shown in Figure 2.10

Understanding the Performance Quadrants

The 2 conventional types are the “Loyalist” and “Manager.” The Loyalist is typically obedient and a team 

player, and can be also viewed as a supporter or sustainer. While Loyalists are manageable, reliable, and precise, 

they have the downside of being uncreative, indecisive, 

and unwilling to take responsibility for their actions. 

The Manager type are typically leaders who tend to follow the rules and follow orders. While Managers are 

organized, goal oriented, logical, and self-assured, they 

have a dark side of being bureaucratic, entrenched, fault-finding, 

and micromanaging. A Manager 

also relies on experience versus 

creativity to solve problems. In 

contrast with these conventional 

traits are unconventional types of 

individuals.10

The 3 unconventional types are 

the “Random Actor,” “Cautious 

Innovator,” and “Innovator.” Individuals of the Random Actor type 

are usually troubled and operate 

out of paranoia or fear. While 

Random Actors are imaginative 

and creative, they can be dangerous, deceptive, moody, 

and lack empathy. These individuals also seek protection through control, which is a red flag in FAP. The 

Cautious Innovators are creative types of individuals 

similar to designers or software developers, but do not 

take risks. Individuals with these traits are loyal, freethinking, and creative, however they can be aimless, irresponsible, insecure, and unwilling to take responsibility for their actions. The last unconventional type that 

makes decisions out of confidence is the Innovator. This 

type of individual is willing to take risks and challenge 

a system. While this trait has the strength of being selfassured, creative, decisive, and adapts to change, it can 

have the downside of being forgetful, reckless, unreliable, and irresponsible.10

Interactions Among Types

The 2 different methods of assessing the decision-making traits of an individual forms quadrants that reveal 

certain personality types. The Manager is both a predictable and confident individual. The Innovator is similarly confident, however, he/she thinks outside of the box. 

The complete opposite type is the Loyalist who makes 

decisions out of fear, but is predictable. Naturally the 

Manager can get along with the Loyalist who will follow 

suit. A slightly fearful individual who is unconventional 

is the Cautious Innovator. This individual has some fear 

in his/her decisions, but is not overly fearful, similar to 

an air traffic controller who has to ensure aircraft take 

appropriate flight paths.10 Last is the Random Actor who 

is both fearful and unconventional. Random Actors 

and Innovators initially get along well in relationships. 

Eventually Innovators become annoyed and weary of 

the Random Actor’s paranoia. This personality type 

can be the most dangerous since Random Actors make 

choices based on paranoia. These types of individuals 

often engage in random acts of violence and harm innocents. Examples of Random Actors include John Muhammad, the Beltway Sniper, and 

Mark Kools who killed members 

of his chain of command with a 

hand grenade in Kuwait.12 These 

individuals have the traits of the 

Intimate Terrorist that Leone et al 

describe as an individual who operates on fear.13 Not all Random 

Actors are dangerous as explained 

below. An individual who lacks 

violent traits should not warrant 

as much concern.12

A social worker armed with this 

knowledge can quickly assess 

how dangerous a partner may be 

Loyalist

Random Actor

Manager

Innovator

Conventional

Unconventional

Fear Confident Plot 1 Cautious

Innovator

Plot 2

Figure 2. Performance Axis. (Courtesy of Dan 

Korem.)

APPLYING THE KOREM PROFILING SYSTEM TO DOMESTIC VIOLENCE
October – December 2014 99

THE ARMY MEDICAL DEPARTMENT JOURNAL

in a relationship. The Random Actor profile has 2 separate traits. One is the “hammer,” which is the Random 

Actor who uses unconventional traits for creative and 

constructive projects.12 This type of individual is typically not violent. In contrast is the “gun,” the Random 

Actor who is waiting to explode. There are usually 2 criteria for the gun type of Random Actor to explode. First, 

the gun needs bullets, which can be a bad relationship or 

a history of being bullied. The second criteria is the trigger, the event that pushed the individual over the edge 

such as a partner ending a relationship.12 This type of 

individual can cause a great deal of harm to a partner. 

The social worker conducting the assessment should 

look for a history of violence throughout the interview 

to determine if the individual is a hammer or a gun. A 

social worker should examine a more thorough safety 

plan with a Random Actor demonstrating the gun trait.

Application to Family Advocacy

Physically aggressive couples tend to lack appropriate 

communication skills.14 There are a number of factors 

that contribute to communication difficulties between 

couples. Researchers have found that wives who tend 

to be physically aggressive can be easily provoked by 

their spouse’s offensive or defensive statements.15 A social worker who understands how each communication 

profile communicates can bring those traits to the client’s attention in order to select an appropriate intervention. More importantly, the social worker can teach and 

coach their clients to communicate more smoothly with 

other communication types which allows them to prevent frustration during conversations that can ultimately 

lead to violence.

Limitations

The KPS is not without its weaknesses. Inexperienced 

individuals using the system may take a “snapshot” at 

a point in time and misread a person. Individuals that 

are presenting to FAP are often attempting to conceal 

their actual communication traits from the social worker 

to protect their careers. Korem argued that watching an 

individual in a stressful situation or the use of confrontation can cause the person to present their true traits.12

Korem argues to use a quick safety check to verify a 

read by evaluating the final result and see if the individual actually fits the profile. He also argues an individual using his system should look at the total person 

and not a particular incident when an individual may act 

out of character.10 Couples experiencing SCV are prime 

examples of individuals who may not necessarily be 

violent individuals. A situation in which the couple simply cannot figure out how to communicate a point can 

result in physical conflict. Another potential weakness 

of applying the system is mistaking communication for 

action. Korem stressed the importance of separating the 

two. Adolph Hitler is an example of an individual who 

presented unwavering confidence while actually making decisions based on fear and paranoia.12

Conclusion

Using the KPS as a screening tool along with other 

mandated techniques allows providers to quickly assess 

potential communication issues with an individual. The 

KPS is in no way designed to replace assessment tools 

approved by the Army Medical Command which are 

critical in safety planning and determining therapeutic 

interventions. The KPS also allows providers to go beyond an individual’s personal communication presentation and find behavior patterns that may become more 

problematic in the future. In the case of working with 

FAP, it allows a social worker to find a long-term fearful trait in clients that may require an intervention that 

a conventional biopsychosocial assessment may miss. 

While Korem posits law enforcement and businesses 

have empirically concluded that his profiling system 

works,10 the behavioral health community should evaluate the applicability of the system to the clinical field of 

work. The KPS is a promising system for incorporation 

into the FAP. A pilot study should be conducted to measure its true effectiveness for addressing situations of 

domestic violence.

Acknowledgement

The authors thank Dan Korem for his mentorship, advice, 

and permission to use the Korem Profiling System. Additionally, the authors thank Sandy Korem for her guidance and assistance in preparing this article.

References

1. Salber PR, Taliaferro E. The Physician’s Guide to 

Domestic Violence: How to Ask the Right Questions and Recognize Abuse....Another Way to Save 

a Life. Volcano, CA: Volcano Press; 1995.

2. Safe Horizon. Domestic Violence: Statistics & 

Facts. Available at: http://www.safehorizon.org/

index/what-we-do-2/domestic-violence--abuse-53/

domestic-violence-statistics--facts-195.html?gclid

=CMGS9ZnQl70CFenm7AodAU0AHw. Accessed 

March 15, 2014.

3. Rennison CM. Intimate Partner Violence, 1993-

2001 [internet]. Washington DC: US Dept of Justice; 2003. Available at: http://www.bjs.gov/con

tent/pub/pdf/ipv01.pdf. Accessed July 17, 2014.

4. Ooms T. A Sociologist’s Perspective on Domestic Violence: A Conversation with Michael 

Johnson, Ph.D. Interview conducted at Center 

for Law and Social Policy and National Conference of States Legislatures conference: Building 
100 http://www.cs.amedd.army.mil/amedd_journal.aspx

Bridges: Marriage, Fatherhood, and Domestic Violence; May 1-3, 2006; Racine, WI. Available at: 

http://www.clasp.org/resources-and-publications/

states/0314.pdf. Accessed July 17, 2014.

5. Thompson M. The living room war. Time. 

1994;143:48-51. Cited by: Robichaux JR, McCarroll, 

JE. Family maltreatment and military deployment. 

In: Lenhart MK, ed-in-chief; Ritchie EC, senior ed. 

Combat and Operational Behavioral Health. Fort 

Sam Houston, TX: Borden Institute; 2011:535-542.

6. Martin SL, Gibbs DA, Johnson RE, et al. Male soldier family violence offender: spouse and child offender compared to child offenders. Violence Vict. 

2009;24(4):458-468.

7. Gibbs D, Clinton-Sherrod M, Johnson R. Interpersonal conflict and referrals to counseling among 

married soldiers following return from deployment. 

Mil Med. 2012:177(10):1178-1183.

8. Hoge CW, Auchterlonie JL, Milliken CS. Mental 

health problems, use of mental health services, 

and attrition from military service after returning 

from deployment to Iraq or Afghanistan. JAMA. 

2006:295(9),1023-1032.

9. Mansfield A, Kaufman J, Marshall S, Gaynes 

B, Morrissey J, Engel C. Deployment and the 

use of mental health services among U.S. Army 

wives. New Engl J Med. 2010;362(2):101-109. Cited by: Lewis M, Lamson A, Leseuer B. Health 

dynamics of military and veteran couples: a biopsychorelational overview. Contemp Fam Ther. 

2012:34:259-276.

10. Korem D. The Art of Profiling - Reading People 

Right the First Time - Expanded Second Edition.

Richardson, TX: International Focus Press; 2012.

11. Chapman G. The 5 Love Languages. Chicago, IL: 

Northfield Publishing; 2010.

12. Korem D. Rage of the Random Actor. Richardson, 

TX: International Focus Press; 2005.

13. Leone J, Johnson M, Cohan C. Victim help 

seeking: differences between intimate terrorism and situational couple violence. Fam Relat. 

2007;56(5):427-439.

14. Burman B, Margolin G, John R. America’s angriest 

home videos: behavioral contingencies observed 

in home reenactments of marital conflict. J Consult Clin Psychol. 1993;61:28-39. Cited by: Ronan 

G, Dreer L, Dollard K, Ronan D. Violent couples: 

coping and communication skills. J Fam Violence. 

2004;19(2):131-137.

15. Ronan G, Dreer L, Dollard K, Ronan D. Violent 

couples: coping and communication skills. J Fam 

Violence. 2004;19(2):131-137.

Authors

CPT Johnson is a Social Work Intern at the Carl R. Darnall Army Medical Center, Fort Hood, Texas.

Ms Brown is with the Family Advocacy Program, Carl R. 

Darnall Army Medical Center, Fort Hood, Texas.

Articles published in the Army Medical Department Journal are indexed in 

MEDLINE, the National Library of Medicine’s (NLM’s) bibliographic database 

of life sciences and biomedical information. Inclusion in the MEDLINE 

database ensures that citations to AMEDD Journal content will be identified 

to researchers during searches for relevant information using any of several 

bibliographic search tools, including the NLM’s PubMed service.

APPLYING THE KOREM PROFILING SYSTEM TO DOMESTIC VIOLENCE
October – December 2014 101

Students with active-duty military experience represent a unique population on the college campus. Over 

945,000 students in the United States use education benefits from the Department of Veterans Affairs (VA).1

 In 

addition, the Department of Defense’s voluntary education program reports that over 400,000 current service 

members are using aid such as the Tuition Assistance 

Program and are enrolled in higher education programs.2

 The Post 9-11 Veterans Education Assistance 

Act of 2008 (38 USC ch 33 (2008)), commonly known 

as the Post 9-11 GI Bill, has made higher education an 

attractive and financially feasible option for many veterans. Use of education benefits to pursue a college degree 

may be an especially attractive option in coming years; 

deployments to combat zones may decrease and the 

military may potentially enter a period of downsizing.3

This nontraditional student population has had different 

life experiences and circumstances compared to more 

traditional students, which can both enrich the veteran 

student’s college experience and give rise to challenges 

during transition and retention. This suggests the need 

to better understand how student veterans perceive their 

transition to and experience in higher education.

This mixed-methods study of 10 student veterans explored their perceptions of personal strengths that support academic success, the challenges they experienced 

in the academic setting, factors impacting veteran participation in college resource programs, and suggestions for 

ideal resources aimed at supporting the student veteran.

The Student Veteran and the College Experience

Much of the earlier research regarding students with 

military experience was conducted following World 

War II and the Vietnam War. These studies focused 

primarily on topics such as the impact of service on 

veterans’ academic achievement pre- and postcombat,4

academic planning, federal assistance programs,5 and 

student veteran academic success compared to their 

nonveteran counterparts6 rather than on their transition 

to the college environment and subsequent experience. 

However, several recent studies have explored the transition experience in higher education of the veteran population. One such study investigated experiences of 25 

combat veterans who transitioned to college as full-time 

students,7 and 2 studies explored the transitional experiences of college students who returned to college to 

resume the student role following combat zone deployments or other active military service.8,9 The findings 

of these studies yielded several themes that described 

veterans’ transitions, including feeling ambivalent about 

leaving the camaraderie of military life7 and a reluctance to acknowledge veteran status on campus.8

 DiRamio and colleagues7

 found that relational concerns were 

prevalent among the veteran participants in their study, 

who described the challenge of simultaneously dealing 

with strained existing relationships and the difficulty of 

relating to newfound student peers. Consistent across 

these studies were descriptions of how military experience seemed to have equipped student veterans with a 

different type of maturity than that generally observed 

in more traditional college students which resulted in 

difficulties connecting with other students and, at times, 

diminishing class participation.7-9 Mental and physical 

health concerns were also noted as contributing to the 

challenge of renegotiating new identities as students.7,9

While several possible ways to aid student veterans 

in the future were discussed, DiRamio et al noted an 

Understanding the Student Veterans’

 College Experience: An Exploratory Study

2LT Timothy Olsen, MS, ARNG

Karen Badger, PhD, MSW

Michael D. McCuddy, MSW Abstract

Objective: Students with active duty military experience are a unique and growing population on college campuses in the United States. This study explores student veterans’ perceptions of their transition to and experience in higher education.

Method: This mixed methods study used a sample of 10 active military and reserve component student veterans to explore their perceptions of their personal strengths, challenges, factors impacting participation in 

university resource programs, and suggestions for ideal resources to support their academic success.

Results: Content analysis yielded primary themes such as the strength of self-discipline, the challenge of social 

interactions, and the desire for programs that connect student-veterans and assist with social integration.

Conclusion: Implications for education, retention, and transition from active duty are discussed.
102 http://www.cs.amedd.army.mil/amedd_journal.aspx

overarching theme: the wish of the study participants 

that “faculty members would acknowledge their veteran 

status and attempt to understand them.”7(p89)

Citing the paucity body of existing literature on the transitions and well-being of student veterans and noting 

specifically the lack of quantitative research, Whiteman 

et al10 conducted a study examining the effects of support received from nonveteran student peers in a sample 

of student veterans (n=199) compared to their civilian 

counterparts (n=181) and found that student veterans 

perceived receiving less emotional support from other 

students compared to that reported by civilian students. 

Additionally, while peer support correlated with better 

emotional and mental health for both student veterans 

and civilian students, this correlation was weaker in student veterans.

Student veterans represent a unique group of nontraditional students. Like most nontraditional students, they 

are often older than their student peers, may support 

families at home, may have significant work commitments outside of school, may be less involved in campus 

activities and feel less a part of the university community than traditional college students.11 While retention 

rates specifically for student veterans have not yet been 

thoroughly examined,12 surveys have shown that nontraditional students, a group to which most student veterans belong, are at a higher risk for dropping out of 

college,13 and that being a student veteran is negatively 

correlated to grade point average (GPA).14

Durdella and Kim14 explored differences between civilian and veteran student groups in relation to academic 

outcomes and sense of belonging in the college community. They found that the student veteran participants on 

average had a lower cumulative GPA than the civilian 

students, an outcome for which veteran status was found 

to be a significant predictor. However, freshmen status 

was a positive predictor of higher GPAs, a characteristic that fits only a small number of the student veteran 

respondents. The student veterans also reported feeling 

less a part of the college campus than civilian student respondents, however, veteran status itself was not found 

to be a significant predictor of this difference. Another 

student characteristic, family annual income, was supported as a significant predictor of the variance in respondents’ reported sense of belonging; the student veterans on average reported lower levels of family income 

than their civilian counterparts. These findings suggest 

the necessity to understand with greater specificity the 

differences between veteran and civilian student groups 

in order to better support student veteran’s success.

These previous study findings support the need to better 

understand the experiences of student veterans and what 

relevant support provided by college campuses would be 

beneficial for transitioning veterans. This study furthers 

the examination of student veteran transitions and challenges, and specifically asked participants to provide suggestions on the types of support they desired and would 

use to improve their college experience and retention.

Study Methodology

This mixed-methods exploratory study used a purposive 

sample of university students with active duty military 

experience. The sampling frame consisted of members 

of a university military student email list that had approximately 500 subscribers. Although it was not possible to determine how many of these subscribers met 

this study’s inclusion criteria, the decision was made to 

use this email list as it was the most far-reaching mechanism available on campus to reach this specific population. To participate in the study, respondents had to be 

at least 18 years of age and full-time university students 

who had served in any military branch on an active duty 

status for at least one year.

After approval by the university’s institutional review 

board, an introductory email was sent via the university’s Military Veterans of America email list to introduce 

the study. Invitations to participate were sent within one 

week and again in 2 weeks. Interested students replied 

directly to study personnel and provided contact information so that an individual interview could be scheduled. Twelve students responded to the study invitation 

and asked to be contacted. However, only 10 of these 

potential participants successfully scheduled and completed interviews, which was assessed to be adequate 

for this exploratory study; Kvale15 suggests a range of 5 

to 25 participants as satisfactory for qualitative research.

Data collection took place in October and November 

2011. Qualitative data were gathered using semistructured individual interviews15 exploring these areas: (1) 

student veterans’ perceptions of the assets and strengths 

they developed as a result of their military experience, 

(2) specific challenges the veterans faced as they transition to the student role and throughout their college experience, (3) their perception of why student veterans may 

choose not to participate in social and academic support 

programs directed toward them, and (4) ideas about what 

programs or resources might benefit future student veterans to transition successfully and succeed in college.

Participants received an instructional letter at the beginning of each interview which was conducted by one of 

UNDERSTANDING THE STUDENT VETERANS’ COLLEGE EXPERIENCE: AN EXPLORATORY STUDY
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THE ARMY MEDICAL DEPARTMENT JOURNAL

the 2 veteran investigators and lasted an average of 45 

minutes. In addition to demographic information, quantitative data were gathered prior to and during the interviews that assessed participants’ perceptions of their 

own and other veterans’ comfort with seeking social and 

academic support, gauge their awareness of resources 

for veterans, and assess their comfort in being affiliated 

with programs created for student veterans.

All interviews were conducted in person in a private 

study room on campus with one exception, one respondent completed the interview by phone. Investigators recorded field notes during each interview (omitting personal identifiers) and periodically restated the responses 

to ensure that participants’ statements were fully understood. Verbatim statements were repeated to be sure 

they were recorded correctly. At the completion of the 

interview, participants were each given a $3.00 gift card 

as an incentive.

Data Analysis

The field notes were compiled by the 2 investigative 

interviewers and read repeatedly and independently by 

all 3 researchers. Open coding and constant comparative analysis was used during these readings.16 Once the 

researchers discerned the patterns and themes found in 

the data from each of their perspectives, they discussed 

and determined major themes together. The resulting 

categorized emerging themes well exceeded the minimum of 2 confirmations suggested by Miles and Huberman.17 Quantitative data gathered in this study were 

entered into a database using no personal identifiers and 

were analyzed using SPSS (IBM Corp, Armonk, NY).

Trustworthiness of the data was ensured through a verification process created by an initial independent assessment of the data for major themes by each investigator,18

which resulted in agreement on prominent themes. All 3 

researchers independently noted saturation with the data 

as themes were repeated consistently throughout data 

collection, and new cases resulted in little variance.19 In 

addition, the 2 investigators who interviewed participants have extensive military experience, including combat deployment, and have been immersed in the military 

milieu and enrolled as student veterans. Quantitative 

data were employed as a method to further triangulate 

the data and affirm the accuracy of qualitative analysis.

Results

Demographics

Of the 10 respondents, 70% were male. Eighty percent 

of the participants were undergraduate students and 20% 

were enrolled in graduate programs. They had a mean 

age of 30 (SD=7.23) and ranged in age from 23 to 47 

years. Forty percent had served in the Army or Army 

Reserve components, 20% in the Marine Corps or Marine Corps Reserve component, 20% in the Navy, and 

20% in the Air Force. The average time served in the 

military was 5.15 years (SD=3.26). Seventy percent of 

the participants were deployed to a combat zone while on 

active duty. Eighty percent of the participants left active 

duty at junior enlisted ranks (E5 and below) and 20% 

were junior officers (O3 and below) at the time that they 

left active service. On average, participants were separated from the military before beginning school for 43.5 

months (SD=37.81) and had completed 3.7 college semesters at the time of the interviews (SD=2.26). Though 

specific GPAs for each participant were not recorded, 

each participant reported that they were in good academic standing at the time of the interview. All 10 participants lived off campus. Fifty percent of the participants 

were employed and one was serving in a military reserve 

component. Half also stated they were in committed relationships and only one reported having children.

Data gathered about gender, branch of service, and deployment status in this study sample were comparable to 

that of the active duty component of military service.20,21

Similar to the study sample, the majority of active duty 

service personnel were male (86%). About 40% of personnel in the active military were in the Army, 22% in 

the Air Force, and 22% in the Navy. Sixty-seven percent 

of the Army personnel had deployed compared to 70% 

of the total study sample.

Qualitative Findings

Qualitative findings are presented according to themes 

associated with the undergraduate and graduate student 

veterans’ (1) perceived strengths helpful in the college 

environment, (2) perceived challenges experienced in 

their college experience, (3) ideal support resources, and 

(4) perceptions regarding low participation of student 

veterans in established support programs.

Perceived Strengths

Participants were asked to identify strengths they thought 

they had gained from their time in the military that they 

considered assets in a college environment. The unanimous and prominent themes that emerged from the data 

were (1) self-discipline (2) leadership and teamwork abilities, and (3) possessing new perspectives and different/

valuable experiences as a result of their military service.

Self-Discipline

Study participants described how the work ethic and 

time management skills that were a part of military life 

were strong assets in an academic setting. They shared 

how these qualities and skills related to behaviors such 
104 http://www.cs.amedd.army.mil/amedd_journal.aspx

as attending each class on time, meeting deadlines for 

assignments and papers, preparing adequately for upcoming exams, and coordinating plans with peers for 

group assignments. When describing how strengths developed in the military transferred to academic activities, 

one participant stated:

The biggest (strength I have) is a sense of discipline...

In the military...you finish tasks that are assigned to you 

and that helps with doing homework. I feel like I have to 

get homework done the same way.

Leadership and Teamwork

Participants attributed the refinement of their leadership and teamwork abilities to the communication skills 

required of them within the different professional roles 

they assumed in the military. Interviewees described 

how their military duties often involved being responsible for teams, communicating effectively with seniors 

and subordinates, managing group conflict, and giving 

briefings to other service members. One veteran discussed the perceived strength of leadership by saying:

I learned how to interact with people. [I] know how 

to work with people...how to be on a team and lead a 

team...I have self-confidence.

The participants found that these experiences aided 

them in confidently participating in team and groupwork activities in an academic environment.

New Perspectives and Different/Valuable Experiences

Student veterans repeatedly mentioned their ability to 

bring a different perspective into the classroom as a result of unique experiences in the military as strengths. 

Interviewees described how having such a variety of 

responsibilities and experiences in their pasts allowed 

them to have insights and perspectives about material 

covered in class that were different from students without military experience. These experiences also provided motivation for excelling in school. For example, 

one student shared his personal reasons for pursuing a 

degree:

Losing my brother [in combat] helped put things into 

perspective for me and motivated me to make something 

of myself and reach my full potential. So many people 

want to be [in college], to have the opportunity to do 

this...I want to make the most of these opportunities for 

that reason.

Other veterans discussed how their time in the service 

helped prepare them to manage stress. Participants 

described how the stress they endured in the military 

made the stress faced in college much easier to handle. 

Speaking of the confidence gained from enduring challenges in the military, one interviewee said:

There’s nothing here I can’t do after my accomplishments in the military.

Perceived Challenges

Three predominant perceived challenges were prevalent 

in the data: (1) social interactions with other students, 

(2) financial stress, and (3) experiencing culture and/or 

role differences. These themes are described below.

Social Interactions

Student veterans unanimously expressed frustration 

over social interactions with other students. One participant said:

Socially connecting with other [undergraduate] students 

is difficult...it’s hard to find common ground with other 

students.

Participants described how, in military environments, 

unit members often share a close bond as they spend 

large amounts of time together in high-stress situations. 

Adjusting to the absence of that bond was described as 

difficult by some of the participants. One student veteran expressed these sentiments by saying:

You’re used to a tight knit community, but here it’s like 

you’re an island...I miss that camaraderie.

In addition to a lack of common ground, student veterans mentioned that the maturity and attitudes of their 

college peers were significant barriers to social connection. Elaborating on these differences, one student said:

I have experienced frustration with the attitudes of other 

students. They complain a lot about the reading and work 

they have to do.

Another participant talked about how the complaints of 

some students seemed “trivial” after enduring the discomforts that he had in the military. Others mentioned 

that being older than most students, in addition to having different experiences and backgrounds, made connecting socially challenging.

Financial Stress

Several of those interviewed explained that financial 

stress added an additional burden to being a student 

veteran. Although financial stress is most likely experienced by student civilians, this concern is tied to a transition for student veterans. While on active duty, their 

basic housing, medical, and food expenses were met by 

the military. As a student, however, the veterans were 

independently responsible for their finances. Transitioning between these financial situations was described as 

difficult for some of the interviewees. “Money is the 

biggest problem I face,” said one student, “the military 

was stable and you always had a paycheck.”

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THE ARMY MEDICAL DEPARTMENT JOURNAL

Culture/Role Adjustments

A final challenge that emerged as a theme was the veteran’s need to adjust to a new culture and role as she/he 

left active duty to become a college student. Some of the 

participants described their difficulties in leaving leadership or management roles in the military to assume 

the role of a new student. Others described how the 

nuances and cultural norms of military environments 

were different from those in a college setting and that 

they had to be intentional about interacting with others 

appropriately. For instance, multiple study participants 

described how in military circles it may be appropriate 

to speak very directly and assertively to others, whereas 

that type of interaction could be perceived as rude or aggressive in college. One participant said:

The biggest [challenge] is learning how to become a 

civilian after living in the military. The culture is a lot 

different. You’re no longer in charge of anyone and you 

have to act more cordial toward others.

Ideal Support

The predominant themes that emerged when describing 

ideal support resources for student veterans were that an 

ideal program to assist them would be socially focused 

and offer services to help connect them with the VA or 

other financial resources. One veteran stated:

Social support would be the biggest purpose of the [ideal] program, to help [veterans] feel connected again to 

something.

Another explained:

The thing I would appreciate the most is...if someone 

were to contact me and provide social help, especially 

opportunities to learn about financial help.

Another participant again emphasized the need for social support and stated:

I would love to talk to people sometime, people who understand what I’ve been through. So many people feel 

isolated and alone.

Reasons for Low Participation in Existing Programs

Three themes emerged as possible explanations for low 

participation in support programs: (1) not wanting to be 

identified as veterans on campus, (2) having a lack of 

free time, and (3) living off campus.

“Some people get out and want nothing to do with the 

military,” explained a male veteran. Another suggested, 

“Veterans don’t respond possibly because they have a 

lot going on, like family and jobs. Students don’t have 

time to participate.” Participants also mentioned that, 

like nontraditional students in general, most student 

veterans live off campus and may not have the time or 

means to return to campus for evening meetings (all 10 

participants in this study lived off campus). Participants 

repeatedly stated that future programs should be highly 

visible and actively promoted to encourage participation.

Quantitative Responses

Participants were asked to complete survey questions 

using a Likert scale of 1 (minimal comfort) to 10 (maximum comfort) and share their own perceptions and 

their thoughts about other student veterans’ attitudes 

regarding topics that corresponded with the qualitative 

interview questions (eg, perceived comfort with seeking social and academic support, awareness of resources 

for veterans, and comfort with being affiliated with programs created for student veterans). Veteran students 

on average rated their own level of comfort in seeking social support as a 6.5 (SD=2.84) and rated other 

student veterans at a 4.9 (SD=4.8). Students rated their 

own level of comfort with being affiliated with groups 

created for student veterans at an average score of 7.4 

(SD=2.84) and other students’ comfort in doing so lower 

(mean=6.55, SD=1.83).

When asked about their own awareness of resources 

available to student veterans, they rated themselves as 

moderately aware (mean=6.9, SD=2.28). They assessed 

other student veterans’ level of awareness of resources 

as lower (mean=5.02, SD=1.93). Quantitative responses 

were consistent with the themes generated in qualitative 

analysis. Details of these perceptions among student 

veterans are presented in the Table.

Comment

The study’s themes were consistently found across 

participants’ responses. This was especially evident 

regarding the themes of discipline, work ethic, and 

time management, which were generated when exploring for perceived strengths of the veteran students and 

mentioned in some way by each participant. Likewise, 

the challenge of having difficulties or frustrations with 

social connections and interactions with other students 

was also brought up in each interview, a challenge further reinforced by the participants’ recommendation 

that support programs for veterans be primarily socially 

focused and be actively promoted in order to improve 

participation levels. Data gathered to better understand 

the potential challenges veteran students may face could 

inform the development of campus support resources 

specific to their needs. Both qualitative and quantitative 

findings suggested that veterans might not be comfortable seeking out social support on the college campus. 

The discomfort or reluctance to seek support found in 

this study sample is consistent with findings in previous 
106 http://www.cs.amedd.army.mil/amedd_journal.aspx

research by Livingston et al 8 who discussed how student 

veterans’ pride and humility can result in self-reliance 

and curtailed their pursuit of support.

Study findings also suggest that student veterans’ 

awareness of available support programs could be improved and utilization may be increased as a result of 

intentional marketing efforts. Participants consistently 

rated themselves higher on all quantitative items in this 

study compared to their perception of the level of comfort of other student veterans who did not participate 

in the study. This difference might be explained by the 

participants’ self-selection to participate in this research 

and/or a greater degree of confidence in speaking for 

themselves rather than for others which yielded more 

conservative responses.

The predominant qualitative themes described by this 

sample of active military student veterans were found 

to be compatible with those discussed in previous studies involving veterans attending college.7,9,10,14 Previous 

study findings yielded themes including veterans’ relational difficulties with other students, ambivalence 

about not having the camaraderie of military life, and 

financial stressors, all of which were notably consistent 

with primary themes found in this study. While common misconceptions of student veterans are often focused on them being a disadvantaged population with 

prevalent mental health issues,22 the cumulative findings 

of this and previous studies suggest that student veterans are a population with significant strengths who may 

benefit from social support provided by others who understand their experiences. Support services also appear 

to positively influence the academic achievement of student veterans. Theoretical models such as that proposed 

by Tinto purport that engagement and integration in the 

campus community positively influence student retention23 as does feeling a sense of belongingness on campus.14 Gilardi and Gugielmetti13 found a strong positive 

correlation between the retention of nontraditional students, their perceived social integration (relationships in 

and out of class with other students and faculty), and 

their use of university support services. Indeed, a recent study showed that veteran students outperformed 

their civilian counterparts when provided appropriate 

support.24 The results of these other studies underscore 

the importance of promoting the engagement of student 

veterans with other students and faculty on campus and 

establishing relevant support services.

Both the qualitative and quantitative findings of this 

study support these actions to encourage engagement 

and offer opportunities for support to student veterans. 

The respondents spoke of social frustrations and their 

need for improved social support. The potential for supporting student veterans (and students who continue 

to serve) exists in both military and academic settings. 

Several veterans interviewed mentioned the lack of 

preparation they felt they received as they transitioned 

out of the military and suggested that improvements 

could be made to existing transition programs bridging 

these 2 environments. One veteran in this study, who 

was still serving as a Reservist, suggested that transition programs could focus on making connections with 

VA and campus resources, reviewing study habits, and 

helping service members understand some of the social and financial challenges of leaving military culture. 

Commanders, noncommissioned officers, and medical/

behavioral health providers working with service members preparing to leave active duty (or Reserve component service members preparing to leave a deployment 

or active duty status) could also have a great effect in 

providing counseling and guidance during this transition. Wilson et al 25 applied Tinto’s integration theory to 

the nontraditional experience using a systems perspective and suggested that the community into which these 

students are assimilating should be broadly defined and 

account for the various elements of their worlds. For 

example, the “community” for military students should 

encompass both the university campus and their military context when facilitating integration. Indeed, Wilson and colleagues found that the Soldier participants in 

UNDERSTANDING THE STUDENT VETERANS’ COLLEGE EXPERIENCE: AN EXPLORATORY STUDY

Veteran Students’ Perceptions of Comfort in Seeking Support 

and Resource Awareness.*

Item Response

mean (SD)

(N=10)

To what extent are you comfortable seeking social 

support?

6.5 (2.8)

To what extent do you think other students with 

military experience are comfortable seeking social 

support?

4.9 (0.9)

To what extent are you comfortable with seeking 

academic support?

7.4 (2.2)

To what extent do you think other students with military experience are comfortable seeking academic 

support?

5.9 (1.3)

To what extent do you think that you are aware of the 

resources and programs available to students with 

military experience?

6.9 (2.3)

To what extent do you think other students with 

military experience are aware of the resources and 

programs available to them?

5.2 (1.9)

To what extent are you comfortable being affiliated with groups created specifically for student 

veterans?

7.4 (2.8)

To what extent do you think other students with 

military experience are comfortable being affiliated with groups created specifically for student 

veterans?

6.5 (1.8)

*Data generated from Likert scale responses:

1 (minimal comfort/awareness) to 10 (maximum comfort/awareness)
October – December 2014 107

THE ARMY MEDICAL DEPARTMENT JOURNAL

their study reported that support of their endeavors from 

their unit command was important to them when pursuing their education.

Data from this study and others suggest the need to better understand established and existing resources that 

specifically serve student veterans. An example of such 

support in an academic setting is a Veterans Resource 

Center, such as the one established at the University of 

Kentucky (https://www.uky.edu/Veterans/benefits.

htm), which houses a full time student veteran liaison 

and a student-led veterans’ organization. The student liaison can assist with applications for veterans’ benefits, 

and promote and advocate for veterans’ support programs. The veteran-focused organization provides a setting for veterans to connect with other veterans. These 

centers can also provide information and referrals for 

campus and VA mental health resources, efforts mentioned as important in this study. Additionally, faculty 

can be encouraged to make intentional efforts to engage 

nontraditional students, including student veterans, in 

and out of class to develop professional relationships 

that serve as a “protective factor” against student attrition.13 Targeted efforts to educate faculty and civilian 

students of the experiences and needs of students with 

military experience, such as that of the VET Net Ally 

program,26 may also serve to improve the campus community’s understanding of the needs and experiences of 

students with military experience.

In sum, the strengths participants perceived they brought 

to their education to help them excel in their academic 

endeavors as a result of their military service included 

self-discipline, leadership abilities, unique perspectives 

on classroom material, and the ability to manage stress. 

Employing a strengths-based perspective27 when interacting with student veterans may assist faculty, advisors, 

and other support staff to recognize and emphasize the 

strengths student veterans bring to academic environments. Veteran and military students and faculty can 

also assume leadership roles in advocating for student 

veterans by helping other personnel on college campuses understand this population’s unique strengths and 

challenges.

Limitations and Future Directions

While the participants in this study provided valuable 

insights and consistent themes emerged in their interviews, the number of participants in this qualitative 

study represented a very small number of the approximately 500 student veterans at the University of Kentucky in 2011 (T. Dotson, oral communication, March 

22, 2011). Further research with larger samples that 

capture the diversity of this population would be useful 

to build a more comprehensive understanding of their 

strengths, challenges, and characteristics of potentially 

beneficial services. Given the low response rates and 

discretion that can be characteristic of this population, a 

factor addressed in this study and in that of Livingston 

et al,8 increased time, personnel, and financial support 

may be required to reach out to and increase response 

rates in future studies. Additionally, this study does not 

include a number of variables that could help to more 

fully describe the study sample. It is recommended that 

future research efforts include additional demographic 

variables such as respondents’ academic performance, 

choice of majors, and military experience beyond what 

is presented in this study to better understand the demographics and characteristics of veteran students’ experiences and assess the generalizability of study findings.

Student veterans represent a diverse population consisting of subsets that merit their own individual examination in research efforts, such as students who are attending school while also serving as members of the active 

duty or reserve component military. This population’s 

academic success directly affects the military as service members develop professional expertise and pursue career advancement through their college endeavors. 

Gaining an understanding of student veterans through 

additional research efforts may provide guidance for 

implementation of support and transition programs that 

promote successful entry of service members into the 

campus community and their retention. With their diverse skill sets and experiences and effective support, 

student veterans can excel in academic environments, 

just as they did in their military service.

References

1. Veterans Benefits Administration. Annual Benefits 

Report Fiscal Year 2012. Washington DC: US Department of Veterans Affairs; 2013. Available at: 

http://www.benefits.va.gov/reports/abr/2012_abr.

pdf. Accessed June 9, 2014.

2. Ford D, Northrup P, Lusharon W. Connections, 

partnerships, opportunities, and programs to enhance success for military students. New Dir Student Serv. 2009;126:61-69.

3. Vacchi DT. Considering student veterans on the 

twenty-first-century college campus. About Campus. 2012;17(2):15-21.

4. Love LL, Hutchinson CA. Academic progress of 

veterans. Educ Res Bull. 1946;25:223-226.

5. Carpenter CR, Glick CE. Educational plans of soldiers. J High Educ. 1946;17:469-473,498.

6. Teachman J. Military service in the Vietnam 

era and educational attainment. Sociol Educ. 

2005;78(1):50-68.
108 http://www.cs.amedd.army.mil/amedd_journal.aspx

7. DiRamio D, Ackerman R, Mitchell RL. From combat to campus: voices of student-veterans. NASPA 

J. 2008;45(1):73-102. Available at: http://wellness.

missouri.edu/Suicide/docs/NASPA%20From%20

Combat%20to%20Campus.pdf. Accessed July 23, 

2014.

8. Livingston WG, Havice PA, Cawthon TW, Fleming DS. Coming home: student veterans’ articulation of college reenrollment. J Stud Aff Res Pract. 

2011;48(3):315-331.

9. Rumann CB, Hamrick FA. Student veterans in 

transition: re-enrolling after war-zone deployments. J High Educ. 2010;81(4):431-458.

10. Whiteman SD, Barry AE, Mroczek DK, Wadsworth SM. The development and implications of 

peer emotional support for student service members/veterans and civilian college students. J Couns 

Psychol. 2013;60(2):265-278.

11. Forbus P, Newbold JJ, Mehta SS. A study of 

nontraditional and traditional students in terms 

of their time management behaviors, stress factors, and coping strategies. Acad Educ Leader J.

2011;15(1):109-125.

12. Fain P. Do veterans graduate? Inside Higher Ed

[serial online]. January 8, 2013. Available at: http://

www.insidehighered.com/news/2013/01/08/neweffort-collect-student-veterans-graduation-rates. 

Accessed June 9, 2014.

13. Gilardi S, Gugielmenti G. University life of nontraditional students: engagement styles and impact on 

attrition. J High Educ. 2011;82(1):33-53.

14. Durdella N, KimYK. Understanding patterns of 

college outcomes among student veterans. J Stud 

Educ. 2012;2(2):109-129.

15. Kvale S. InterViews: An Introduction to Qualitative 

Research Interviewing. Thousand Oaks, CA: Sage 

Publications; 1996.

16. Royse D. Research Methods in Social Work. Belmont, CA: Thomson Brooks/Cole; 2010. 

17. Miles MB, Huberman AM. Qualitative Data Analysis. Thousand Oaks, CA: Sage Publications; 1994.

18. Constas MA. Qualitative analysis as a public event: 

The documentation of category development procedures. Am Educ Res J. 1992; 29(2): 253-266.

19. Yeh CJ, Inman AG. Qualitative data analysis and interpretation in counseling psychology: strategies for 

best practice. Couns Psychol. 2007;35(3):369-403.

20. Bonds TM, Baoicchi D, McDonald LL. Army Deployments to OIF and OEF. Santa Monica, CA: 

RAND Corp; 2010. Doc No. DB-587-A. Available 

at: http://www.rand.org/content/dam/rand/pubs/

documented_briefings/2010/RAND_DB587.pdf. 

Accessed July 22, 2014.

21. US Department of Defense. Demographics 2010: 

Profile of the Military Community. Washington, 

DC: Office of the Deputy Under Secretary of Defense (Military Community and Family Policy). 

2010. Available at: http://www.militaryonesource.

mil/12038/MOS/Reports/2010_Demographics_

Report.pdf. Accessed July 22, 2014.

22. Hassan AM, Jackson R, Lindsay DR, McCabe DG, 

Sanders JE. Bottom line: the veteran student in 

2010. About Campus. 2010;15(2):30-32.

23. Jensen U. Factors Influencing Student Retention 

in Higher Education. Summary of: Influential Factors in Degree Attainment and Persistence to Career or Further Education for At-risk/high Educational Need Students. Honolulu, HI: Pacific Policy 

Research Center, Kamehameha Schools-Research 

& Evaluation Division; 2011. Available at: http://

www.ksbe.edu/spi/pdfs/retention_brief.pdf. Accessed July 22, 2014.

24. Murphy E. Operation graduation. Inside Higher 

Ed [serial online]. November 11, 2011. Available at: 

http://www.insidehighered.com/news/2011/11/11/

student-veterans-do-better-peers-when-given-sup

port-services. Accessed June 9, 2014.

25. Wilson KB, Smith NL, Lee AL, Stevenson 

MA. When the Army post is the campus: understanding the social and academic integration 

of soldiers attending college. J Coll Stud Dev. 

2013;54(6):628-642.

26. Thomas MW. A Safe Zone for Veterans: Developing the VET NET Ally Program to Increase Faculty 

and Staff Awareness and Sensitivity to the Needs 

of Military Veterans in Higher Education [dissertation]. Long Beach, CA: California State University, 

Long Beach; 2010. Abstract available at: http://eric.

ed.gov/?id=ED519743. Accessed July 22, 2014.

27. Robbins SP, Chatterjee P, Edward RC. Contemporary Human Behavior Theory. Boston, MA: Pearson Education, Inc; 2006.

Authors

2LT Olsen is a Behavioral Health Officer on active duty 

with the Kentucky Army National Guard.

Dr Badger is Director of Undergraduate Studies, Associate Dean of Academic and Student Affairs, and Associate Professor, College of Social Work, University of 

Kentucky.

Mr McCuddy is a Social Worker with the Department of 

Veterans Affairs, Lexington, Kentucky.

UNDERSTANDING THE STUDENT VETERANS’ COLLEGE EXPERIENCE: AN EXPLORATORY STUDY
October – December 2014 109

The US military and Veterans Health Administration 

(VHA) regularly conduct outreach with the hope of 

engaging those who need it in effective treatment. The 

need for active mental health outreach is apparent. Estimates place the prevalence of posttraumatic stress disorder (PTSD) among returning Veterans between 10% 

and 20%.1,2 Despite these high rates, treatment utilization rates among returning Veterans remain low with 

only half of those who indicate mental health problems 

seeking help from the military or VHA.3 According 

to the most recent VHA health care utilization report, 

roughly 55% of all separated Veterans of Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), 

and Operation New Dawn (OND) Veterans used VHA 

health care. Of those, 53.3% carried a mental health 

diagnosis.4

The response to this unmet need for mental health treatment includes regular screening both in the VHA and 

Department of Defense (DoD), both of which provide 

active screening to detect the presence of potential mental health symptoms and guide referral to appropriate 

services.5,6 Screening gathers important information 

for providers and researchers alike. Identifying Veterans who may be experiencing difficulties and responding with appropriate treatments can prevent long-term 

disability and chronic difficulties.7 These screening 

tools also provide important data for epidemiological 

studies of treatment utilization and need.8

The VHA currently uses the 4-item Primary Care PTSD 

Screen (PC-PTSD) to identify Veterans who may have 

PTSD.9,10 Primary care providers then use this information to guide referrals for mental health treatment. When 

compared with the Clinician Administered PTSD Scale 

(CAPS), the screen has the ability to correctly identify 

78% of PTSD cases.9

While research demonstrates that the PC-PTSD screen 

can accurately predict a PTSD diagnosis, research has 

not demonstrated whether the screen is useful for predicting treatment use. Within the VHA, regular screening provides a means of referring Veterans for treatment. 

In one study, 38% of Veterans who screened positive 

on the PC-PTSD screen (by answering “yes” to any 2 

of the 4 questions) completed a mental health followup visit within 90 days.11 Screening instruments in nonVA or civilian primary care settings are more likely to 

capture those with more severe diagnoses of PTSD,12

which means screens may not aid in identifying individuals who may benefit from intervention before their 

symptoms become worse. Research has also shown that 

Mental Health Outreach and Screening

 Among Returning Veterans: Are We

 Asking the Right Questions?

Katharine Bloeser, MSW

Kelly K. McCarron, PsyD

Benjamin Batorsky, MPH

Matthew J. Reinhard, PsyD

Stacey J. Pollack, PhD

Richard Amdur, PhD

Abstract

This study looked at predictors of mental health treatment utilization in a unique cohort of recently separated 

Veterans coming to the Department of Veterans Affairs (VA) (N=152). This convenience sample voluntarily 

completed questionnaires, which included mental health screening tools, during an outreach event at a large 

urban VA Medical Center. Researchers reviewed computerized medical records of these consenting participants to record VA treatment utilization. There is a statistically significant association between posttraumatic 

stress disorder screening results, functional impairment, and treatment-seeking. Certain functional impairments increase the odds of participation in VA mental health care. These include problems with school and/or 

work (odds ratio (OR)=2.8), physical fights (OR=2.8), physical health problems (OR=3.0), financial difficulties 

(OR=3.0), irritability/anger (OR=3.4), isolation (OR=3.8), drug use (OR=5.7), and problems with social support (OR=7.0). This study concluded that asking about symptoms alone may not capture the breadth and nature 

of Veterans’ postdeployment difficulties.
110 http://www.cs.amedd.army.mil/amedd_journal.aspx

age plays a factor in the effectiveness of the PC-PTSD 

screen in referring Veterans for treatment. One study 

showed that Veterans aged 30 to 44 years are 57% less 

likely than Veterans aged 18 to 29 years to attend any 

mental health visits after screening positive on the PCPTSD screen. Older veterans, over the age of 75, are the 

least likely to attend a follow up appointment.13

One reason for concern about VHA screening measures 

predicting treatment use might be that screening focuses on symptoms rather than on functioning in daily 

life. The concern is that screening procedures may underestimate the impact of subthreshold symptoms, thus 

deterring seeking help before problems get worse.14

Returning combat Veterans report difficulties in their 

general functioning and adjustment to civilian life, independent of diagnosis,15 and it is often these functional 

impairments that are foremost among their concerns.16

Researchers at the VHA Puget Sound17 found that OEF/

OIF Veterans with PTSD were no more likely than Veterans with subthreshold PTSD (as measured by the Posttraumatic Stress Disorder Checklist–Military Version) 

to endorse difficulty with aggression. There is a broad 

body of literature that also points to examination of distress that does not necessarily meet diagnostic thresholds yet still merit intervention.18,19 Functional difficulties, or problems related to everyday life, may provide a 

glimpse into these subthreshold conditions.

This study sought to uncover the relationship between 

screening for functional impairments and mental health 

care engagement among a cohort of new VHA enrollees. This study was designed to answer 3 main research 

questions:

1. What types of functional impairments do service members and Veterans report?

2. What associations exist between problem presentation and eventual VHA treatment-seeking?

3. Can screening for functional impairment better 

predict VHA mental health treatment-seeking 

than screening for PTSD symptoms alone?

Methods

Following approval from a Veterans Administration 

Medical Center Committee on Human Subjects and the 

Research and Development Committee, questionnaires 

were distributed to Veterans during a “Welcome Home” 

event. This event was held by the VHA at a sports stadium in a suburb of a major US city in the summer of 

2010 for Veterans who recently returned from deployment. This event offered Veterans the opportunity to 

learn more about and enroll in the VHA. It targeted a 

group of Veterans who may or may not decide to seek 

VHA care. The authors often work in a clinical capacity 

at these events, offering screening and support. The usefulness of such events, beyond enrollment numbers, had 

not yet been examined in a research capacity.

Researchers provided a full description of the study both 

verbally and in writing. Participants provided written 

informed consent and completed questionnaires that included clinical screening tools and questions about military history, perceived stigma, and attitudes toward the 

VHA. At this time, Veterans also provided consent for a 

review of their medical records. Demographic questions 

like age, gender, and housing status were also included.

In December 2011, researchers reviewed computerized 

medical records of consenting participants to record 

treatment utilization data. This information was coded 

according to standard criteria and entered into the dataset. Of note, the race/ethnicity variable was taken from 

chart reviews of VHA records.

Questionnaire

The questionnaire included the PC-PTSD Screen5; the 

yes/no version of the 2-item Patient Health Questionnaire (PHQ-2)20 to assess for possible depression; the 

Cut down, Annoyed, Guilty, and Eye-opener (CAGE)21

and the Alcohol Use Disorders Identification Test-C 

(AUDIT-C)22 to assess for alcohol abuse; and the VHA’s 

traumatic brain injury (TBI) screening tool.23 The TBI 

screening tool consists of items that ask about mechanism of head injury as well as immediate and long term 

postconcussive symptoms.

Two other assessments were created. While not validated measures, these questions were adapted from the 

literature and clinical observation to asses for perceived 

barriers to care24 and functional difficulties.25 The functional impairment questions asked Veterans on a 4-point 

Likert scale (None=1, Severe=4) to rank their level of 

difficulty with road rage or driving, school/education or 

work, relationships, finances, irritability or anger, isolation, physical fights, drug use, social support, physical 

health, sleep, and home life.

Electronic Health Records

In addition to data collected by questionnaire, a brief 

chart review for each subject was conducted with available records to determine VHA health care use. Data 

collected in these chart reviews included percentage of 

service connected disability benefits (including service 

connection due to mental health diagnoses), race and 

ethnicity, and VHA health care use. These included data 

points for all VHA medical encounters (eg, specialist 

MENTAL HEALTH OUTREACH AND SCREENING AMONG RETURNING VETERANS:

ARE WE ASKING THE RIGHT QUESTIONS?
October – December 2014 111

THE ARMY MEDICAL DEPARTMENT JOURNAL

referrals, primary care appointments), receipt of VHA 

mental health treatment, and mental health diagnoses 

(ie, depression, PTSD, Bipolar, Anxiety and/or other). 

Mental health treatment was defined as care provided 

in a mental health clinic by a psychiatrist, psychologist, 

social worker, registered nurse, or nurse practitioner.

Statistical Analyses

Associations between categorical variables were examined using χ 2 tests for association. Logistic regression 

was used to examine prediction models with utilization 

as the dependent variable. Data were analyzed using SAS 

Version 9.2 (SAS Institute Inc, Cary, NC) with P≤.05 

considered significant. Corrections were not made for 

multiple comparisons as this is considered a pilot study 

with initial results presenting important questions to 

guide future research. Full P values are provided to assist with interpretation. The study is powered to detect 

a medium effect size (Cohen’s d=0.5) for bivariate associations and for multiple regression.

Sample

The sample included consenting service members and 

Veterans who attended the event. For some, the event 

was their only contact with the VHA system of care. 

Others had used VHA health care services. Inclusion 

criteria stipulated that participants had to be an OEF/

OIF active duty service member or an OEF/OIF veteran.

At the event, 152 questionnaires were completed. Research assistants then conducted chart reviews using 

VHA computerized records on the 88 participants with 

available records. The process flow in shown in the 

Figure. Questionnaires that were partially completed 

or did not have the Veteran’s name or other identifying 

information were included in the dataset. Chart reviews 

were not performed for questionnaires that either did 

not have needed identifiers (n=45) or in which identifiers were provided but the participant was locatable in 

the VHA electronic medical record system (n=19). The 

final sample was split into 2 groups for initial analyses 

as shown in Table 1. This consisted of participants who 

had a chart review completed (n=88) and those who did 

not (n=64). No clinical data on treatment use could be 

provided for those Veterans who did not have a chart 

review completed.

Results

Subjects

Bivariate analyses showed few significant differences between Veterans with and without chart reviews. 

There were more women in the group without a chart 

review (χ 2=9.3, P≤.001). Forty percent of participants 

who did not have chart reviews responded that they had 

children compared with 20% of those with chart review 

data (χ 2=8.0, P=.02).

Results of Screening, Report of Functional Impairment, 

and VHA Treatment-Seeking

Of the total sample (N=152), 28.9% of Veterans 

screened positive for PTSD (endorsed 2 or more PTSD 

symptoms), 34.0% screened positive for depression, and 

35.4% screened positive on the CAGE. A large number of Veterans chose not to respond to the AUDIT-C 

(n=56). Of the 96 who did respond, 35.4% screened positive. Many Veterans also left the TBI screen blank, of 

the 72 who did respond, 36.1% screened positive. Veterans reported problems with numerous functional difficulties. These included moderate to severe problems 

with drug use (2.0%), social support (6.7%), physical 

fights (7.9%), physical health (8.5%), home life (8.5%), 

isolation (16.8%), finances (18.4%), school/education/

work (19.8%), relationships (21.7%), road rage or driving 

(27.0%), irritability/anger (34.3%), and sleep (34.9%).

Bivariate analyses were used to determine associations 

between problem presentation and eventual VHA treatment-seeking. A χ 2 test for association was used to determine the relationship between conditions reported and 

receipt of any VHA treatment (ie, mental health and/or 

medical treatment) (Table 2). The population described 

in Table 2 consists only of those Veterans who had a chart 

review completed (n=88). Results indicate that one-half 

of those Veterans (n=44) eventually sought VHA health 

care after the event. Analyses showed that stable housing, PC-PTSD screen responses, AUDIT-C responses, 

TBI screen responses, the CAGE, and PHQ-2 were not 

significantly associated with VHA treatment. However, 

2 functional impairments appeared to be significantly 

associated with VHA treatment-seeking. Twenty percent of participants who sought VHA medical and/or 

Processing of participants’ questionnaires and 

chart reviews.

Questionnaires completed

at event

N=152

Name and last

4 digits of SSN 

illegible

n=45

Name and last

4 digits of SSN

legible

n=107

Unable to locate

in system

n=19

Chart review

conducted

n=88
112 http://www.cs.amedd.army.mil/amedd_journal.aspx

mental health treatment reported moderate or severe difficulty with isolation 

(a functional impairment that is not 

assessed in diagnostic screening tools). 

This is in comparison to 9% among 

those who did not seek VHA treatment (χ2=11.1920, P=.0107). Similarly, the majority of those who did 

not receive VHA treatment (90.9%) 

did not self-report any problems with 

social supports. Those who sought 

VHA treatment were more likely to 

report problems related to social support (χ2=11.3002, P=.0035). No other 

functional impairments were statistically significantly associated with any 

VHA treatment.

Results of Screening, Report of 

Functional Impairment, and VHA 

Mental Health Treatment-Seeking

A total of 23 Veterans sought mental 

health treatment following the Welcome Home event. Bivariate analyses 

using a second χ2 test were conducted 

to determine factors associated with 

VHA mental health treatment. Certain 

functional impairments increase the 

odds of participation in VHA mental 

health care (Table 3). These include 

problems with irritability/anger (odds 

ratio (OR)=2.5, P=.0333), school and/

or work (OR=3.5, P=.0174), difficulty with sleep (OR = 4.8, P=.0283), 

physical health problems (OR=10.9, 

P=.0010), and difficulties with social 

support (OR=11.3, P=.0008). Veterans who reported 3 or more functional 

impairments were 3 times more likely 

to engage in mental health treatment 

(OR=3.1, P=.0254). There was no association between screening positive 

on the PC-PTSD or PHQ-2 screens and participation in 

mental health treatment.

Statistically significant functional impairments were 

selected for inclusion in a series of logistic regressions. 

These regressions were used to calculate odds ratios and 

95% confidence intervals for the associations between 

functional impairment and mental health treatment after 

controlling for a positive PC-PTSD screen and a positive 

PHQ-2 screen (Table 4). After controlling for a positive 

PC-PTSD screen, Veterans who reported difficulty with 

school or work (OR=3.5, P=.0239), irritability or anger 

(OR=3.2, P=.0339), social support (OR=11.8, P=.0049), 

physical health (OR=12.9, P=.0050), or sleep (OR=3.1, 

P=.0333) were more likely to seek mental health treatment. After controlling for a positive PHQ-2 screen, 

Veterans who reported difficulty with school or work 

(OR=3.3, P=.0425), social support (OR=10.9, P=.0059), 

or physical health (OR=10.4, P=.0087) were more likely 

to seek mental health treatment.

Comment

Once enrolled in the VHA, seeking treatment for a mental health condition, as defined by a visit to a mental 

MENTAL HEALTH OUTREACH AND SCREENING AMONG RETURNING VETERANS:

ARE WE ASKING THE RIGHT QUESTIONS?

Table 1. Demographic Characteristics of Sample: VA Chart Review Versus No VA 

Chart Review

Chart Review 

Completed

(n=88)

Number (%n)

Chart Review not 

Completed

(n=64)

Number (%n)

χ2 P

value

Age, 

years

<=25

26-30

31-35

36+

Missing

8 (42.1%)

7(36.8%)

1 (5.3%)

3 (15.8%)

0

45 (51.1%)

31 (35.2%)

7 (8.0%)

5 (5.7%)

45

2.5554 .4654

Gender Female

Male

Missing

1 (1.1%)

87 (98.9%)

0 

3 (15.8%)

16 (84.2%)

45 

9.324 .0023

Race White

Unanswered/Unknown

African American

Other (Multiple or Asian)

54 (61.4%)

23 (26.1%)

7 (8.0%)

4 (4.5%)

Not available 

(chart reviewed 

for race 

variable)

Ethnicity Hispanic/Latino

Not Hispanic/Latino

Unanswered/Unknown

8 (9.1%)

56 (63.6%)

24 (27.4%)

Not available 

(chart reviewed 

for ethnicity 

variable)

Marital 

Status

Married

Remarried

Divorced

Separated

Never Married

Missing

35 (39.8%)

0 (0%)

3 (3.4%)

3 (3.4%)

47 (53.4%)

0

27 (42.2%)

1 (1.6%)

3 (4.7%)

1 (1.6%)

31 (48.4%)

1 

2.2365 .6923

Children Yes

Missing

18 (20.5%)

0

25 (39.7%)

1 

6.6646 .0098

Service 

Status

Enlisted

Officer

Missing

74 (86.1%)

12 (14.0%)

2 

56 (93.3%)

4 (6.7%)

4 

1.9232 .1655

Branch Army

Marine Corps

Navy

Missing

1 (1.1%)

87 (98.9%)

0 (0%)

0

3 (4.7%)

58 (90.6%)

2 (3.1%)

1 

4.792 .091

Rank E-3

E-4

E-5

E-6

E-7+

Missing

13 (17.3%)

31 (41.3%)

26 (34.7%)

3 (4.0%)

2 (2.7%)

13 

6 (11.3%)

17 (32.1%)

23 (43.4%)

5 (9.4%)

2 (3.8%)

11 

3.673 .452

Deployments

0

1

2

3

4

5

Missing

2 (2.6%)

25 (32.5%)

40 (52.0%)

9 (11.7%)

1 (1.3%)

0 (0%)

11

0 (0%)

21 (39.6%)

27 (50.9%)

4 (7.6%)

0 (0%)

1 (1.9%)

11 

4.5165 .4777
October – December 2014 113

THE ARMY MEDICAL DEPARTMENT JOURNAL

Table 2. Functional Impairment, Diagnosis and Prediction of Any VHA Treatment

Total 

Sample

(N=152)

Number 

(%N)

VHA Treatment*

Number Who Received

Any VHA Treatment

(n=44)

Number (%n)

Number Who Did Not 

Receive Any

VHA Treatment

(n=44)

Number (%n)

χ2 P value

PTSD Screen Positive

Negative

43 (28.9%)

106 (71.1%)

15 (34.1%)

29 (65.9%)

10 (76.7%)

33 (76.7%)

1.2467 .2642

PTSD Screen 

Responses

Nightmares

Avoidance

Hypervigilance

Numbing

39 (25.7%)

37 (24.7%)

46 (30.5%)

44 (29.1%)

13 (29.6%)

11 (25.0%)

16 (36.4%)

14 (31.8%)

9 (20.9%)

8 (18.6%)

13 (30.2%)

11 (25.6%)

0.8544

0.5211

0.3679

0.4131

.3553

.4704

.5442

.5204

AUDIT-C Positive

Negative

62 (64.6%)

34 (35.4%)

31 (73.8%)

11 (26.2%)

22 (61.1%)

14 (38.9%)

1.4356 .2309

TBI Positive

Negative

26 (36.1%)

46 (63.9%)

7 (38.9%)

11(61.1%)

8 (47.1%)

9 (52.9%)

0.2383 .6254

CAGE Positive

Negative

51 (35.4%)

93 (64.6%)

17 (40.5%)

25 (59.5%)

15 (37.5%)

25 (62.5%)

0.0763 .7824

Depression Positive

Negative

51 (34.0%)

99 (66.0%)

17 (38.6%)

27 (61.4%)

13 (30.2%)

30 (69.8%)

0.6798 .4096

Functional Difficulties

Road rage/driving None

Mild

Moderate

Severe

70 (46.1%)

41 (27.0%)

32 (21.1%)

9 (5.9%)

17 (38.6%)

13 (29.5%)

12 (27.3%)

2 (4.5%)

20 (45.5%)

14 (31.8%)

9 (20.5%)

1 (2.3%)

1.042 .7910

School/education/

work

None

Mild

Moderate

Severe

89 (58.6%)

32 (21.2%)

25 (16.5%)

5 (3.3%)

26 (59.1%)

8 (18.2%)

8 (18.2%)

2 (4.5%)

25 (56.8%)

10 (22.7%)

8 (18.2%)

1 (2.3%)

0.5752 .9021

Relationships None

Mild

Moderate

Severe

76 (50.0%)

43 (28.3%)

26 (17.1%)

7 (4.6%)

20 (45.5%)

10 (22.7%)

11 (25.0%)

3 (6.8%)

25 (56.8%)

13 (29.5%)

5 (11.4%)

1 (2.3%)

4.1969 .2410

Finances None

Mild

Moderate

Severe

86 (56.7%)

37 (24.3%)

23 (15.1%)

5 (3.3%)

23 (52.3%)

13 (29.5%)

6 (13.6%)

2 (4.5%)

25 (56.8%)

12 (27.3%)

5 (11.4%)

2 (4.5%)

0.2142 .9753

Irritability/anger None

Mild

Moderate

Severe

57 (37.5%)

43 (28.3%)

32 (21.1%)

20 (13.2%)

13 (29.5%)

13 (29.5%)

10 (22.7%)

8 (18.2%)

18 (40.9%)

14 (31.8%)

10 (22.7%)

2 (4.5%)

4.4435 .2174

Isolation None

Mild

Moderate

Severe

81 (54.4%)

43 (28.9%)

19 (12.8%)

6 (4.0%)

16 (36.4%)

19 (43.2%)

7 (15.9%)

2 (4.5%)

31 (70.5%)

8 (18.2%)

3 (6.8%)

1 (2.3%)

11.1920 .0107

Physical fights None

Mild

Moderate

Severe

112 (76.7%)

28 (18.4%)

12 (7.9%)

0

27 (61.4%)

13 (29.5%)

4 (9.1%)

0

34 (77.3%)

8 (18.2%)

2 (4.5%)

0

2.6604 .2644

Drug use None

Mild

Moderate

Severe

140 (92.1%)

9 (5.9%)

2 (1.3%)

1 (0.7%)

38 (86.4%)

5 (11.4%)

1 (2.3%)

0

42 (95.5%)

1 (2.3%)

1 (2.3%)

0

2.8667 .2385

Social support None

Mild

Moderate

Severe

119 (79.9%)

20 (13.4%)

10 (6.7%)

0

27 (64.3%)

7 (16.7%)

8 (19.0%)

0

40 (90.9%)

4 (9.1%)

0

0

11.3002 .0035

Physical health None

Mild

Moderate

Severe

96 (63.2%)

43 (28.3%)

9 (5.9%)

4 (2.6%)

23 (52.3%)

14 (31.8%)

5 (11.4%)

2 (4.5%)

29 (65.9%)

14 (31.8%)

0

1 (2.3%)

6.0256 .1104

Table 2 continued on the next page.

*Includes mental health treatment.
114 http://www.cs.amedd.army.mil/amedd_journal.aspx

health professional, is associated with difficulties with 

school/education or work, irritability or anger, social supports, physical health, and sleep. Surprisingly, 

screening positive for PTSD, alcohol abuse, TBI, or depression are not associated with seeking treatment for 

mental health care. After controlling for screening positive for PTSD or depression, functional impairments 

predicted engagement in mental health treatment. In our 

study, those Veterans with children were less likely to 

have a chart review completed, indicating that this sample may be biased towards Veterans without children.

This study joins a body of literature that points to the 

importance of social support in the treatment and identification of PTSD. Functional social supports are an important factor in recovery from and prevention of symptoms of PTSD for Vietnam Veterans.26 Specifically, emotional as well as concrete support mediates the effects 

of war zone stressors on development of PTSD.27 Other 

studies of OEF/OIF Veterans indicate that readjustment 

stressors, including those related to marriage and children are integral to examination of treatment-seeking 

behaviors among older returning National Guard Veterans.28 In a path analysis examining PTSD symptoms as 

the outcome, the effects of postdeployment social support were equal to those of combat exposure.29 While 

this study presents similar findings, they are within a 

younger, recently separated sample.

Implications for Behavioral Health

These results suggest that at outreach events like Welcome Home and within the VHA in general, screening 

might be improved by assessing functional impairments 

in addition to psychiatric symptoms. Clinicians should 

pay particular attention to difficulties with social support when screening for mental health needs among 

returning service members. Awareness of PTSD symptoms as well as other mental conditions has improved 

in military settings. Veterans may believe that these 

symptoms are a normal part of the homecoming process. However, functional difficulties can point to areas 

where this normal response to abnormal circumstances 

may result in impairment. Early detection of difficulty with social support, physical health conditions, and 

school or work may also indicate that while a PTSD or 

depression screen is negative, Veterans may still benefit from brief interventions at the primary care level or 

through referral.

Like any health care system, the VHA has a goal of enrolling new users. In the case of the VHA, this means enrolling veterans at the end of their active duty status (ie, 

like the current sample). These results could help inform 

VHA policymakers how to better approach and advertise potential VHA users who are not currently enrolled 

in VHA care. For instance, a campaign conceptualizing 

VHA as an avenue for additional social support, which 

in our experience it tends to be (similar to a family, circle 

of friends, or caring individuals) might be considered.

The importance of functional outcomes, highlighted in 

these findings, has implications for referral for care and 

treatment approach. Due to noted difficulties with functional impairment, mental health treatments that target 

both symptom reduction and functional status may be 

most effective. This could include multidisciplinary care 

that combines traditional psychotherapy with tangible 

resources like case management and systems focused 

MENTAL HEALTH OUTREACH AND SCREENING AMONG RETURNING VETERANS:

ARE WE ASKING THE RIGHT QUESTIONS?

Table 2 (continued). Functional Impairment, Diagnosis and Prediction of Any VHA Treatment

Total 

Sample

(N=152)

Number 

(%N)

VHA Treatment*

Number Who Received

Any VHA Treatment

(n=44)

Number (%n)

Number Who Did Not 

Receive Any

VHA Treatment

(n=44)

Number (%n)

χ2 P value

Sleep None

Mild

Moderate

Severe

63 (41.5%)

36 (23.7%)

33 (21.7%)

20 (13.2%)

15 (34.1%)

10 (22.7%)

13 (29.5%)

6 (13.6%)

19 (43.2%)

11 (25.0%)

8 (18.2%)

6 (13.6%)

1.7087 .6350

Home life None

Mild

Moderate

Severe

97 (63.8%)

42 (27.6%)

11 (7.2%)

2 (1.3%)

25 (56.8%)

13 (29.5%)

6 (13.6%)

0

29 (65.9%)

13 (29.5%)

1 (2.3%)

1 (2.3%)

4.8677 .1817

Stable housing Yes

No

137 (92.6%)

11 (7.4%)

39 (88.6%)

5 (11.4%)

38 (90.5%)

4 (9.5%)

0.0776 .7805

Three or more 

functional 

difficulties†

Yes

No

26 (29.6%)

62 (70.5%)

17 (38.6%)

27 (61.4%)

9 (20.5%)

35 (79.5%)

3.4938 .0616

*Includes mental health treatment.

†Determined by answering “moderate or severe” to 3 or more functional difficulties.
October – December 2014 115

THE ARMY MEDICAL DEPARTMENT JOURNAL

care, such as family therapy. This study also confirms 

research examining social functioning specifically as a 

focus of treatment.30,31 These findings inform a patientcentered care approach; meeting the Veteran where they 

are is important when screening for mental health problems. Veterans may first present with problems related 

to everyday life rather than distinct PTSD symptoms. 

This should be an indication of need for treatment just as 

much as a positive response to the Primary Care PTSD 

screen. Veterans may not pursue care because they do 

not meet criteria for specific programs (eg, the PTSD 

Clinical Team) and therefore do not necessitate the evidenced-based practices these programs offer. The treatment indicated in these cases may be a referral to family 

therapy, recreational therapy, or to community support. 

These referrals, when applied appropriately, may prevent Veterans from developing more complex diagnoses 

later in life.

Table 3. Functional Impairment, Diagnosis, and Prediction of VHA Mental Health Treatment

VHA Mental Health Treatment*

Number WhoReceived VHA 

Mental Health 

Treatment

(n=23)

Number (%n)

Number Who 

Did Not Receive 

VHA Mental 

Health Treatment

(n=65)

Number (%n)

Total

(N=88)

Number (%N)

χ2 Odds 

Ratio

P value

PTSD Screen

(2 or more)

Positive

Negative

7 (30.4%)

16 (69.6%)

18 (28.1%)

46 (71.9%)

25 (28.7%)

62 (71.3%)

0.0441 1.1 .8337

PTSD Screen

(3 or more)

Positive

Negative

5 (21.7%)

18 (78.3%)

13 (20.3%)

51 (79.7%)

18 (20.7%)

69 (80.3%)

0.0210 1.1 .8848

AUDIT-C Positive

Negative

18 (81.8%)

4 (18.2%)

35 (62.5%)

21 (37.5%)

3(67.9%)

25 (32.1%)

2.7066 2.7 .0999

TBI Positive

Negative

6 (60.0%)

4 (40.0%)

9 (36.0%)

16 (64.0%)

15 (42.9%)

20 (57.1%)

1.6800 2.7 .1949

CAGE Positive

Negative

8 (9.8%)

14 (63.6%)

24 (40.0%)

36 (60.0%)

32 (39.0%)

50 (60.9%)

0.0895 0.52 .7649

Depression Positive

Negative

10 (43.5%)

13 (56.5%)

20 (31.3%)

44 (68.8%)

30 (34.5%)

57 (65.5%)

1.1199 1.7 .2900

Functional Difficulties

Road rage/driving None/Mild

Moderate/Severe

15 (65.2%)

8 (34.8%)

49 (75.4%)

16 (24.6%)

64 (72.7%)

24 (27.3%)

0.8854 1.6 .3467

School/education/

work

None/Mild

Moderate/Severe

14 (60.9%)

9 (39.1%)

55 (84.6%)

10 (15.4%)

69 (78.4%)

19 (21.6%)

5.6584 3.5 .0174

Relationships None/Mild

Moderate/Severe

15 (65.2%)

8 (34.8%)

53 (81.5%)

12(18.5%)

68 (77.3%)

20 (22.7%)

2.5768 2.4 .1084

Finances None/Mild

Moderate/Severe

18 (78.3%)

5 (21.7%)

55 (84.6%)

10 (15.4%)

73 (83.0%)

15 (17.1%)

0.4851 1.5 .4861

Irritability/anger None/Mild

Moderate/Severe

11(47.8%)

12 (52.2%)

41 (72.3%)

18 (27.7%)

58 (65.9%)

30 (34.1%)

4.5316 2.5 .0333

Isolation None/Mild

Moderate/Severe

17 (73.9%)

6 (26.1%)

57 (89.1%)

7 (10.9%)

74 (85.1%)

13 (14.9%)

3.0552 0.8 .0805

Physical fights None/Mild

Moderate/Severe

21 (91.3%)

2 (8.7%)

61 (93.9%)

4 (6.2%)

82 (93.2%)

6 (6.8%)

0.1728 1.5 .6777

Drug use None/Mild

Moderate/Severe

22 (95.7%)

1 (4.4%)

64 (98.5%)

1 (4.4%)

86 (97.7%)

2 (2.3%)

0.6037 2.9 .4372

Social support None/Mild

Moderate/Severe

16 (72.7%)

6 (27.3%)

62 (96.9%)

2 (3.1%)

78 (90.7%)

8 (9.3%)

11.3154 11.6 .0008

Physical health None/Mild

Moderate/Severe

17 (73.9%)

6 (26.1%)

63 (96.9%)

2 (3.1%)

80 (90.9%)

8 (9.1%)

10.8837 11.1 .0010

Sleep None/Mild

Moderate/Severe

10 (43.4%)

13 (56.5%)

45 (69.2%)

20 (30.8%)

55 (62.5%)

33 (37.5%)

4.8071 2.9 .0283

Stable housing Yes

No

20 (87.0%)

3 (13.0%)

57 (90.5%)

6 (9.5%)

77 (89.5%)

9 (10.5%)

0.2228 0.70 .6369

Three or more

functional 

difficulties†

Yes

No

11(47.8%)

12 (52.2%)

15 (23.1%)

50 (76.9%)

26 (29.5%)

62 (70.5%)

4.9990 3.1 .0254

*Only treatment in a VA medical center, including medication management.

†Determined by answering “moderate or severe” to 3 or more functional difficulties.
116 http://www.cs.amedd.army.mil/amedd_journal.aspx

Limitations

The research team identified numerous limitations 

within this study. First, the questionnaire relied upon 

self-report data using very short yet validated scales as 

well as scales developed from the literature and clinical 

experience. Researchers have questioned the diagnostic 

validity of self-report scales that do not have the input 

of clinicians.32 Secondly, this population, which consists 

of mostly white, male Marines, is not indicative of the 

entire population of Veterans returning from OEF/OIF/

Operation New Dawn. Finally, not all Veterans surveyed 

had a chart review completed, creating a small sample 

for these analyses.

Acknowledgement

The authors sincerely thank the Veterans who participated in this research study for their time and their service. 

This study was approved by the Washington, DC VHA 

Medical Center Institutional Review Board.

This study was conducted at the VHA Medical Center, 

50 Irving Street NW, Washington, DC.

References

1. Thomas JL, Wilk JE, Riviere LA, Castro CA, 

Hoge CW. Prevalence of mental health problems 

and functional impairment among active component and National Guard soldiers 3 and 12 months 

following combat in Iraq. Arch Gen Psychiatry. 

2010;67(6):614-623.

2. Milliken CS, Auchterlonie JL, Hoge CW. Longitudinal assessment of mental health problems among 

active and reserve component soldiers returning 

from the Iraq war. JAMA. 2007;298(18):2141-2148.

3. Tanielian T, Jaycox LH, eds. Invisible Wounds of War, 

Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Santa 

Monica, CA, RAND Corporation; 2008. Available at: http://www.rand.org/pubs/monographs/

MG720.html. Accessed October 8, 2014.

4. Department of Veterans Affairs. Analysis of VHA 

Health Care Utilization among Operation Enduring Freedom (OEF), Operation Iraqi Freedom 

(OIF), and Operation New Dawn (OND) Veterans: 

Cumulative from 1st Qtr. FY2002 through 3rd Qtr. 

FY2012 (October 1, 2001-June 30, 2012). Washington, DC: Epidemiology Program, Postdeployment 

Health Group, Office of Public Health; 2012. Available at: http://www.publichealth.va.gov/docs/epide

miology/healthcare-utilization-report-fy2012-qtr3.

pdf. Accessed November 15, 2012.

5. Prins A, Ouimette P, Kimerling R, Cameron RP, 

Hugelshofer DS, Shaw-Hegwer J, Thrailkill A, 

Gusman FD, Sheikh JI. The primary care PTSD 

screen (PC-PTSD), development and operating 

characteristics. Prim Care Psychiatry. 2003;9(1):9-

14. Available at: http://www.ptsd.va.gov/profes

sional/articles/article-pdf/id26676.pdf. Accessed 

October 7, 2014.

6. Wright KM, Huffman AH, Adler AB, Castro CA. 

Psychological screening program overview. Mil 

Med. 2002;167:853-861.

7. Friedman MJ. Posttraumatic stress disorder among 

military returnees from Afghanistan and Iraq. Am 

J Psychiatry. 2006;163(4):586-593.

8. Jha AK, Perlin JB, Kizer KW, Dudley RA. Effect 

of the transformation of the Veterans Affairs health 

care system on the quality of care. N Engl J Med. 

2003;348:2218-2227.

9. Prins A, Ouimette P, Kimerling R, Cameron RP, 

Hugelshofer DS, Shaw-Hegwer J, Thrailkill A, 

Gusman FD, Sheikh JI. The primary care PTSD 

screen (PC-PTSD), Corrigendum. Prim Care 

Psychiatry. 2003;9(1):151. Available at: http://

www.ptsd.va.gov/professional/articles/article-pdf/

id26676.pdf. Accessed October 7, 2014.

10. VA/DoD Clinical Practice Guideline for the Management of Post-Traumatic Stress. Washington, 

DC: US Dept of Veterans Affairs, US Dept of Defense; 2010. Available at: http://www.healthquality.

va.gov/PTSD-FULL-2010c.pdf. Accessed November 14, 2012.

11. Seal KH, Berthenhal D, Maguen S, Gima K, Chu 

A, Marmar CR. Getting beyond “don’t ask; don’t 

tell”, an evaluation of US Veterans Administration 

postdeployment mental health screening of veterans returning from Iraq and Afghanistan. Am J 

Public Health. 2008;98(4):714-720.

12. Borowsky SJ, Rubenstein LV, Meredith LS, Camp 

P, Jackson-Triche M, Wells KB. Who is at risk of 

nondetection of mental health problems in primary 

care?. J Gen Intern Med. 2000;15:381-388.

13. Lu MW, Carlson KF, Duckart JP, Dobscha SK. The 

effects of age on initiation of mental health treatment after positive PTSD screens among Veterans 

Affairs primary care patients. Gen Hosp Psychiatry. 2012;34(6):654-659.

MENTAL HEALTH OUTREACH AND SCREENING AMONG RETURNING VETERANS:

ARE WE ASKING THE RIGHT QUESTIONS?

Table 4. Odds Ratio Predicting VA Mental Health Treatment 

Adjusting for Positive PTSD Screen and Positive Depression 

Screen

PTSD Screen

Positive*

Depression

Functional

Difficulty

Odds Ratio

(95% OR)

P

value

Odds Ratio

(95% OR)

P

value

School or work 3.5 (1.2-10.5) .0239 3.3 (1.0-10.2) .0425

Irritability or anger 3.2 (1.1-9.6) .0339 2.6 (0.9-7.4) .0721

Social support 11.8 (2.1-65.9) .0049 10.9 (2.0-59.8) .0059

Physical health 12.9 (2.2-76.5) .0050 10.4 (1.8-60.1) .0087

Sleep 3.1 (1.1-8.6) .0333 2.7 (0.9-7.8) .0642

*Two or more questions in screen answered affirmatively.
October – December 2014 117

THE ARMY MEDICAL DEPARTMENT JOURNAL

14. Pietrzak RH, Goldstein MB, Malley JC, Johnson 

DC, Southwick SM. Subsyndromal posttraumatic 

stress disorder is associated with health and psychosocial difficulties in veterans of Operations Enduring Freedom and Iraqi Freedom. Depress Anxiety. 2009;26:739-744.

15. Institute of Medicine of the National Academies. 

Returning Home from Iraq and Afghanistan. Preliminary Assessment of Readjustment needs of Veterans, Service Members, and Their Families. Washington, DC: The National Academies Press; 2010.

16. Sayer NA, Noorbaloochi S, Frazier P, Carlson K, 

Gravely A, Murdoch M. Reintegration problems 

and treatment interests among Iraq and Afghanistan combat veterans receiving VHA medical care. 

Psychiatr Services. 2010;61(6):589-597.

17. Jakupcak M, Conybeare D, Phelps L, Hunt 

S, Holmes HA, Felker B, Klevens M, McFall 

ME. Anger, hostility, and aggression among 

Iraq and Afghanistan war veterans reporting 

PTSD and subthreshold PTSD. J Trauma Stress. 

2007;20(6):945-954.

18. Naylor JC, Dolber TR, Strauss JL, Kilts JD, Strauman TJ, Bradford DW, Szabo ST, Youssef NA, 

Connor KM, Davidson JRT, Marx CE. A pilot 

randomized control trial with paroxetine for subthreshold PTSD in Operation Enduring Freedom/

Operation Iraqi Freedom era veterans. Psychiatry 

Res. 2013;206(2-3):318-320.

19. Marshall RD, Olfson M, Hellman F, Blanco C, 

Guardino M, Struening EL. Comorbidity, impairment, and suicidality in subthreshold PTSD. Am J 

Psychiatry. 2001;158(9):1467-1473.

20. Whooley MA, Avins AL, Miranda J, Browner WS. 

Case-finding instruments for depression. J Gen Intern Med. 1997;12(7):439-445.

21. Mayfield D, McLeod G, Hall P. The CAGE questionnaire, validation of a new alcoholism screening instrument. Am J Psychiatry. 1974;131(10):1121-1123.

22. Bush K, Kivlahan DR, McDonell MB, Fihn SD, 

Bradley KA. The AUDIT alcohol consumption 

questions (AUDIT-C), an effective brief screening test for problem drinking. Arch Intern Med. 

1998;158(3):1789-1795.

23. TBI Screening-National VHA Clinical Reminder. 

Washington, DC: Veterans Healthcare Administration; 2007. Appendix 4: VHA Directive 2007-013. 

Available at: http://www.rehab.research.va.gov/

jour/07/44/7/pdf/page1027append4.pdf. Accessed 

October 23, 2012.

24. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to 

care. N Engl J Med. 2004;351(1):13-22.

25. Batten SV, Pollack SJ. Integrative outpatient treatment for returning service members. J Clin Psychol. 2008;64(8):928-939.

26. Boscarino JA. Posttraumatic stress and associated disorders among Vietnam veterans: the significance of combat exposure and social support. J 

Trauma Stress. 1995;8(2):317-336.

27. King DW, King LA, Fairbank JA, Keane TM, Adams G. Resilience-recovery factors in posttraumatic stress disorder among female and male Vietnam 

Veterans: hardiness, postwar social support, and 

additional stressful life events. J Pers Soc Psychol. 

1998;74,420-434.

28. Pietrzak RH, Johnson DC, Goldstein, MB, Malley, 

JC, Rivers AJ, Morgan CA, Southwick SM. Psychosocial buffers of traumatic stress, depressive symptoms, and psychosocial difficulties in veterans Operations Enduring Freedom and Iraqi Freedom: the 

role of resilience, unit support, and postdeployment 

social support. J Affect Disord. 2010;120:188-192.

29. Interian A, Kline A, Callahan L, Losonczy M. Readjustment stressors and early mental health treatment-seeking by returning National Guard Soldiers 

with PTSD. Psychiatr Services. 2012;63(9):855-861.

30. Fontana A, Rosenheck R. War zone Veterans 

returning to treatment: effects of social functioning and psychopathology. J Nerv Ment Dis. 

2010;198:699-707.

31. Monson CM, Taft CT, Fredman SJ. Military-related PTSD and intimate relationships, From description to theory-driven research and intervention development. Clin Psychol Rev. 2009;29:707-714.

32. Shalev AY, Freedman S, Peri T, Brandes D, Sahar 

T, Orr SC, Pitman RK. Predicting PTSD in trauma 

survivors: prospective evaluation of self-report and 

clinician administered instruments. Br J Psychiatry. 1997;170:558-564.

Authors

Ms Bloeser is with the War Related and Injury Study 

Center, Department of Veterans Affairs, Office of Public 

Health.

Dr McCarron is with the Polytrauma System of Care, 

VHA Medical Center, Washington, DC.

Mr Batorsky is with the RAND Corporation.

Dr Reinhard is with the War Related and Injury Study 

Department of Veterans Affairs, Office of Public Health.

Dr Pollack is with Mental Health Services, Department 

of Veterans Affairs.

Dr Amdur is Chief of Biostatistics at the VHA Medical 

Center, Washington, DC.
118 http://www.cs.amedd.army.mil/amedd_journal.aspx

Skilled and Resolute chronicles the history of the 12th 

Evacuation Hospital which then became the 212th Mobile Army Surgical Hospital (MASH), covering the 

years from 1917 to 2006. Each chapter provides a comprehensive summary from researched resources and begins with the role of the hospital for that time period. 

The chapters are supplemented with excellent maps, diagrams, photos, abbreviations and acronyms, and a list of 

all oral histories.

Dr Marble outlines the chapters in a clear narrative style 

while he explains the strategic and technological importance of a mobile hospital. Additionally, he ties in the 

sociopolitical and environmental contextual elements 

with the type of trauma care available at each time period, and has blended his research analysis with many 

oral history accounts to help readers better understand 

the progress made by the Army Medical Department’s 

(AMEDD) oldest mobile/deployable hospital unit.

Skilled and Resolute is the culmination of a 7-year quest 

to capture the story of this mobile hospital unit with 

their challenges, sacrifices, and beliefs. The book encompasses 90 years of “who we are” and “what we do” 

as health care professionals on the battlefield, as well as 

during humanitarian and peacekeeping missions.

It is the author’s goal to give credit to where references 

and resources were found. Relying on official interviews, 

books, files, and oral histories, Dr Marble paints a colorful picture of capabilities and missions. He has made the 

information available to the reader with valuable depictions of results, observations, ideas, and perspectives of 

military medicine.

Perhaps the books’ strongest feature is the detailed descriptions of mobile medical care that transformed with 

each conflict. Much change occurred in 90 years with 

regard to military force structure and doctrine, along 

with advances in medical military technology and its 

applications. Over the years, the capabilities of military 

medicine have dramatically expanded, a fact directly reflected in the ever-improving, significant survival rates 

of those injured on the battlefield. Understanding that 

context while seeing the details of life and medical care 

throughout those times provides a fascinating picture of 

military innovation, leadership, and caring. Dr Marble 

expertly weaves numerous eyewitness accounts into the 

chapters, providing welcomed additions and a virtual 

account of the challenges and successes of providing 

medical care in this mobile environment. This book addresses numerous areas of interest, including how education, training and experience can help staff actions 

remain within the commander’s intent and in support 

of the overall objectives, yet remain flexible and responsive for quality patient care solutions. 

It should be noted that this book is not intended to be 

a comprehensive reference for how the AMEDD delivers care at every level. It examines Level III hospitals, 

not the forward battlefield care or the care in rear-area 

hospitals.

Skilled and Resolute is chronologically organized, encompassing service in World War I, World War II, the 

Vietnam War, Operation Desert Shield/Desert Storm, 

the Balkans, and Operation Iraqi Freedom. Below are 

snippets of interesting facts to entice readers to read the 

book in its entirety: 

World War I: Evacuation hospital experiences in WWI 

called for not only a surgical focus, but the addition of 

dentists, administrative officers, clerks, a chaplain, mechanics, 2 buglers (there was no public address system), 

A New Offering from the

Borden Institute History Series

Skilled and Resolute

Sanders Marble, PhD

Office of Medical History

US Army Medical Department

Center of History and Heritage

COL Betsy Vane, AN, USA
October – December 2014 119

cooks, pharmacists, and x-ray operators. These mobile 

hospitals now had 750 beds, but only 5 trucks with 

which to be mobile.

World War II: Evacuation hospitals were not as important as in WWI, but they could handle major surgical 

and medical procedures for casualties. These hospitals had a neurosurgical team, a thoracic surgeon, and 

a plastic-maxillofacial team. There were also 3 general surgical teams and splint and shock teams. During 

the 12th Evacuation Hospital’s stay in England in 1943, 

they treated about 8,000 patients, and another 26,000 

in France, Luxembourg, and Germany. They had many 

risks such as German shells, buzz bombs, debarking 

from landing ships at Normandy beaches, and a glider 

insert—yet only 2 staff died, both were nurses.

The Vietnam War: In May 1966 the 12th Evacuation 

Hospital was sent to an “undisclosed location” in the 

Pacific. It ended up at Cu Chi for 4 years and treated 

over 37,000 patients. Over 36,000 survived because of 

treatment received there. The 12th Evacuation Hospital 

was awarded 3 Meritorious Unit Commendations, the 

Vietnamese Cross of Gallantry with Palm (twice), and 

Civil Action Honor Medal. In 1970, the 12th Evacuation 

Hospital (semimobile) was deactivated for the third time.

Operation Desert Storm/Desert Shield: The 12th Evacuation Hospital was in Saudi Arabia from December 

1990 until April 1991. It was augmented with 3 medical 

teams: orthopedic surgery, neurosurgery, and anesthesia. The 12th Evacuation Hospital treated injured from 

traffic accidents and other accidents; their own staff; 

older active duty personnel with seizures, diabetes, high 

blood pressure, and asthma; POWs; friendly fire casualties; civilians; and Coalition troops. In 101 days of hospital operations, they saw 10,309 outpatients and 1,299 

inpatients. Upon redeployment to Germany, the hospital 

was converted to the 212th MASH.

The Balkans: The 212th MASH deployed for an international operation and was under foreign command, something that had not happened since 1918, and had to have 

vehicles and equipment painted white with light blue 

United Nations markings. The 212th treated patients 

from 34 countries across 5 continents, which obviously 

produced some language problems. Landmines caused 

9 wounds, and there were 2 gunshot wounds. Supplies 

came from 3 sources: the United Nations, the United 

States, and some local procurement. The 212th cared 

for 4,454 outpatients, and admitted 333 inpatients in 6 

months’ time.

By 1999, the 212th Contingency Medical Facility in 

Kosovo had seen 788 patients and 32 surgical patients. 

In 6 months during 2000, the 212th handled 339 major 

surgical and medical cases before returning to Germany.

Operation Iraqi Freedom: The 212th saw 701 patients 

and admitted 394. This portion of the book includes 

first-hand accounts from the Soldier caregivers.

In October 2006, the 212th MASH became the 212th 

Combat Support Hospital (CSH). As of that redesignation, this unit’s history already included service in 5 

wars, over 18 campaigns, and many humanitarian and 

peacekeeping missions.

“Skilled and Resolute” remains the motto of the US 

Army’s oldest deployable hospital and illustrates how 

it gave the best care for its time and remains effective 

today, no matter the mission or the locations. The symbolism of the distinctive unit insignia of the 212th CSH 

includes the maroon and white colors associated with 

medical units. The 12-sided device reflects the heritage 

of the parent organization. The stars and fleurs-de-lis 

commemorate campaign credits earned in WWI and 

WWII. The red and gold stripes signify service in Vietnam. The scarlet motto scroll and ribbon symbolize the 

2 Meritorious Unit Commendations (European theater 

during WWII and Vietnam 1966-1967), and the circle 

suggests mobility and speed. The cross is symbolic of 

medical care.

This book is highly recommended for those studying the 

best way to provide quality medical and surgical care to 

Warriors and other designated patients as soon as it is 

needed whether in combat, peacekeeping, or humanitarian environments. In approximately 250 pages of Skilled 

and Resolute, we walk alongside these caregivers and 

reflect on their lives, times, challenges, and successes. 

Dr Marble reminds us that much of this practical information can help healthcare providers of today, not only 

in appreciating AMEDD history and heritage, but in 

planning and responding to current situations.

COL Vane is the Army Nurse Corps Historian at 

the AMEDD Center of History and Heritage, Joint 

Base San Antionio Fort Sam Houston, Texas.
120 http://www.cs.amedd.army.mil/amedd_journal.aspx

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