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Combat and Operational Behavioral Health: Final Thoughts and Next Steps

Chapter 47

COMBAT AND OPERATIONAL 

BEHAVIORAL HEALTH: FINAL 

THOUGHTS AND NEXT STEPS

ELSPETH CAMERON RITCHIE, MD, MPH,* and MICHAEL DOYLE, MD†

INTRODUCTION

RECENT BEHAVIORAL HEALTH INITIATIVES

Behavioral Health Proponency

Defense Centers of Excellence

Comprehensive Soldier Fitness

Behavioral and Social Outcomes Health Program

Behavioral Health Providers

Other Initiatives

SUMMARY

*Colonel, US Army (Retired); formerly, Psychiatry Consultant to the Army Surgeon General, and Director, Behavioral Health Proponency, Office of The 

Surgeon General, Falls Church, Virginia; currently, Chief Clinical Officer, District of Columbia Department of Mental Health, 64 New York Avenue 

NE, 4th Floor, Washington, DC 20002

†

Colonel, Medical Corps, US Army; Deputy Chief of Clinical Services, US Army Medical Activity, US Military Academy, 900 Washington Road, West 

Point, New York 10996; formerly, Commander, US Army Health Clinic, Wiesbaden, Germany
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Combat and Operational Behavioral Health

INTRODUCTION

While this book has been in production, Department of Defense (DoD) behavioral healthcare delivery 

has improved dramatically. From the beginning of the 

conflicts in Afghanistan and Iraq, a robust combat stress 

control presence has been operating in theater. Much 

of the initial improvement was in the management of 

patients in theater and as they redeploy (return home) to 

the United States. Many chapters, such as those focused 

on patient care at Landstuhl Regional Medical Center 

in Germany and Walter Reed Army Medical Center in 

Washington, DC, have highlighted these improvements. 

Back in the United States, improving the reintegration 

of soldiers and their families is a continuous priority for 

leaders at all levels and for the nation.

RECENT BEHAVIORAL HEALTH INITIATIVES

Multiple new organizations and initiatives emerged 

in the last few years, such as: (a) the Behavioral Health 

Proponency; (b) the Defense Center of Excellence; (c) 

the Comprehensive Soldier Fitness Program; and (d) 

the Behavioral and Social Health Outcomes Program 

at the former Center for Health Promotion and Preventive Medicine (CHPPM), now the Public Health 

Command (Provisional). The Army Campaign Plan 

for Health Promotion, Risk Reduction, and Suicide 

Prevention was formed in the spring of 2009. In 2010, 

the Army’s Comprehensive Behavioral Health System 

of Care was implemented. The November 5, 2009, 

shootings at Fort Hood, Texas, spurred numerous 

recommendations for both the DoD and the military 

services. Finally, there is a new DoD–Department of 

Veterans Affairs Integrated Mental Health Strategy. All 

of these new programs and organizations have sought 

improved approaches to the emerging challenges facing military behavioral health. 

Behavioral Health Proponency

The Army Medical Department (AMEDD) Behavioral Health Proponency, the first of these new initiatives, was established in 2007 to coordinate all the 

different behavioral health functions in the AMEDD. 

Modeled after AMEDD’s Proponency of Preventive 

Medicine, this organization is a multidisciplinary 

group, with its director located at the Office of The 

Surgeon General (this volume’s senior editor was the 

first director of the Behavioral Health Proponency). 

A Suicide Prevention Program Office was also established in 2007 to help centralize the diverse AMEDD 

elements that assist with education, training, and 

tracking of suicide prevention efforts. However, this 

latter office became redundant with the Behavioral 

Health and Social Outcomes Program and the Army 

Campaign Plan for Health Promotion, Risk Reduction, 

and Suicide Prevention and is not currently active. 

Defense Centers of Excellence 

The congressionally mandated Defense Centers of 

Excellence (DCoE) also started in 2007 and grew with 

congressional support due to a recommendation from 

the DoD Mental Health Task Force. The Department 

of Veterans Affairs and all of the military services are 

represented at DCoE, including the Public Health 

Service. The mission statement of the DCoE (available 

at: http://www.dcoe.health.mil/) is: 

Mission: The DCoE assesses, validates, oversees and 

facilitates prevention, resilience, identification, treatment, outreach, rehabilitation, and reintegration programs for psychological health (PH) and traumatic 

brain injury (TBI) to ensure the Department of Defense meets the needs of the nation’s military communities, warriors and families.

Comprehensive Soldier Fitness

The Army’s chief of staff, General George W Casey, 

Jr, requested the establishment of the Comprehensive 

Soldier Fitness (CSF) program, which was begun in 

2008. Under the umbrella of the G-3 (ie, the training 

directorate), the Army developed a comprehensive 

behavioral health strategy—“whole-life fitness”—that 

includes multiple categories of wellness (physical, 

emotional, social, family, and spiritual). This strategy 

recognizes the need to incorporate enhancement of 

current health (of the soldier and family), prevention of 

future problems, and treatment when problems arise. 

The strategy also emphasizes the use of standardized 

metrics to determine success, standardized screening 

and treatment modalities, and the use of evidencebased clinical guidelines. Ultimately the strategy 

recognizes that the Army team is successful when 

leadership and behavioral health professionals partner 

to remove any stigma associated with identifying the 

need for help and receiving behavioral health intervention. This strategy encompasses a holistic approach to 

behavioral health issues.

The “Army Strong” campaign has been a success. 

But mental, emotional, and spiritual strength, like 

physical strength, do not just “happen”—these attributes can and must be taught, practiced, and perfected. 

As with physical capability, everyone enters the Army 
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Combat and Operational Behavioral Health: Final Thoughts and Next Steps

with a variable amount of strength in each of these 

domains, everyone has the potential to improve, and 

both the rate of improvement and ultimate achievement will be different for every soldier and family. At 9 

years into the global war on terror, with its unrelenting 

operational tempo, a focus on comprehensive fitness 

has become an operational mandate. 

The vision and mission statements of whole-life 

fitness (available online at: http://www.army.mil/

csf/about.html) are:

Vision: An Army of balanced, healthy, self-confident 

Soldiers, families and Army civilians whose resilience 

and total fitness enables them to thrive in an era of 

high operational tempo and persistent conflict.

Mission: Develop and institute a holistic fitness program for Soldiers, families, and Army civilians in order to enhance performance and build resilience. 

The CSF program ensures that all soldiers undergo 

appropriate assessment of their total fitness, encompassing all the “Army Strong” components. The 

results of the assessment will direct further training, 

intervention, or treatment as needed. This begins at 

accession and, like physical fitness, includes reassessment at appropriate intervals. Furthermore, the CSF 

office makes certain that all training, interventions, and 

treatments utilized have demonstrated effectiveness, 

applying accepted methodology and scientific rigor. 

They are also chartered to ensure timely reassessment, 

to demonstrate value added to both the soldier and 

the leadership. 

The CSF office also ensures that the training programs, services, and interventions offered complement 

one another, are not duplicative, are resourced based 

on objective outcomes, and are standardized across the 

Army, including the Reserve components. Lastly, CSF 

is dedicated to making sure that all stakeholders, both 

internal (soldiers, families, leaders, and Army commands) and external (members of Congress and staff, 

media, and veterans’ groups) understand the absolute 

necessity of a comprehensive, coordinated effort to 

enhance the fitness and resiliency of the Army, which 

is particularly important during this era of persistent 

conflict and for the foreseeable future. 

Behavioral and Social Health Outcomes Program

A new focus on surveillance of behavioral health 

emerged at the former CHPPM, now the Public Health 

Command (Provisional). Great demand exists for such 

capacity, as evidenced by increasing requests from 

Army leadership for actionable data from population 

health indicators in this area. Recent Mental Health 

Advisory Team surveys and epidemiological consultation investigations have clearly demonstrated that 

no single data source is sufficient for acquiring the 

information necessary to perform analysis of individual, community, or military health system factors 

that are associated with suicides and related adverse 

behavioral outcomes. Timely and effective intervention 

requires data to be collected and reviewed in a way 

that allows a comprehensive understanding of both 

individual suicide cases and the broader community 

context (psychological and physical health, installation 

and unit factors, social ties, and other applicable factors). The former CHPPM received funding from the 

US Army Medical Command for the establishment 

of this capability, as well as funding from the Army 

G-1 to establish a separate “strategic analysis cell” 

to collect and follow data for the specific purpose of 

generating actionable data in the effort to mitigate 

suicides in the Army. 

CHPPM’s Behavioral and Social Health Outcomes 

Program (BSHOP) is a comprehensive behavioral 

health epidemiology and surveillance program formed 

to evaluate the full spectrum of psychological health 

and social wellness in Army communities. BSHOP’s 

mission is to establish and operate a central behavioral 

health and social health outcomes epidemiologic resource for the Army and to bolster ongoing behavioral 

health program development and evaluation capability at CHPPM. The program is structured to analyze, 

interpret, and disseminate information on the status, 

trends, and determinants of the behavioral health 

and fitness of America’s Army. The end objective is to 

provide a ready means to identify and evaluate impediments to medical readiness and establish a basis 

for preventive action. 

In the spring of 2009, the Army’s vice chief of staff 

established the Army Suicide Prevention Task Force 

(ASPTF) in response to the Army’s increasing suicide 

rate. The ASPTF’s effort has resulted in roughly 250 

initiatives throughout the Army that are currently 

being executed, in addition to the development of 

the Army Campaign Plan for Health Promotion, Risk 

Reduction, and Suicide Prevention.

Efforts to mitigate the psychological effects of war 

continue. The shootings at Fort Hood led to both DoD 

and service-specific recommendations. The recommendations relevant to behavioral health, published in 

“Protecting the Force” (available at: http://www.army.

mil/-news/2010/01/15/33006-protecting-the-forcelessons-learned-from-fort-hood/), emphasized caring 

for medical personnel and screening for violence. It is 

unclear at this point how well these recommendations 

will be implemented. 

The Army’s Comprehensive Behavioral Health 

System of Care, begun in 2010, seeks to implement 

best practices in optimal integration across the Army. 
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Combat and Operational Behavioral Health

Begun in the Western and Pacific regions, under the 

leadership of Brigadier General Patricia Horoho and 

Brigadier General Steve Jones, it seeks to improve the 

reintegration process using lessons learned throughout 

the Army. The new DoD–Veterans Affairs Integrated 

Mental Health Strategy incorporates 28 strategic actions aimed at aligning the two healthcare systems. 

Although many of the recommendations are similar 

to others already made, the new program focuses on 

transitions from military to civilian life. 

The shootings at Fort Hood have led to three major 

health-related efforts for the Army and DoD: (1) to 

seek to uncover violent tendencies in individuals; 

(2) to build upon the comprehensive behavioral response to the shooting; and (3) to expand provider 

resiliency training. There have also been concerted 

efforts to improve access to care by increasing the 

number and availability of providers and decreasing stigma. In the Army, the number of behavioral 

healthcare providers has increased almost 70% between 2007 and 2010.

When this chapter was written, the Army had 2,579 

behavioral health providers available, with a conservative need estimate of 3,072 military, civilian, and 

contract behavioral healthcare providers. This represented an 84% fill, or a shortage of 493 providers. The 

Army is currently attempting to hire or contract the 

additional providers (87 psychiatrists, 146 psychologists, 222 social workers, and 38 psychiatric nurses). 

However, these numbers continually change, as providers are hired or leave and as new requirements are 

developed. 

Provider hiring difficulties are not due to lack of 

funding; rather, the difficulties stem from a lack of 

civilian providers willing to practice in remote locations, compensation limitations inherent to government employment, and a national shortage of qualified 

providers. To address these limitations, the Army has 

employed selected behavioral health recruitment and 

retention incentives. These include

• implementing a critical skills retention bonus 

for master’s level clinical psychologists;

• including social work officers (captains) in 

the critical skills retention bonus program 

instituted by the Army;

• establishing incentive special pay for psychiatric nurse practitioners;

• providing increases in multiyear special pay 

for psychiatrists

• utilizing the active duty health professions 

loan repayment program for both accession 

and retention of behavioral healthcare providers;

• making health professions scholarship program allocations available as a tool for the 

US Army Recruiting Command to recruit 

psychiatric nurse practitioners; and

• increasing the number of health professions 

scholarship allocations dedicated to clinical 

psychology and increased the seats available in 

the clinical psychology internship program.

SUMMARY

This volume began with a brief look at the history of 

behavioral healthcare in the US military, especially the 

genesis of the two volumes on military psychiatry in 

the Textbooks of Military Medicine series that were published over 15 years ago. Many of the “lessons learned” 

described in those two volumes were based on military 

experiences during Vietnam. Both the military and civilian society have dramatically changed since Vietnam, 

but one point that remains constant is that the human 

ability to adapt to the horrors of combat is finite. It is 

through the evolution of both proactive measures to 

help soldiers “steel” themselves against their experiences and therapeutic interventions by the behavioral 

healthcare system that the best possible outcomes can be 

achieved for military personnel. This project has summarized the experiences of more than 150 behavioral 

healthcare providers, in all fields and specialties, who 

have given their time and words to capture these latest 

battlefield conditions and lessons learned. 

The system of behavioral healthcare in the US 

military is always in flux, with numerous individuals and organizations attempting to improve it via 

various innovative programs. One constant theme, as 

demonstrated in the discussion in this chapter, is that 

the many attempts at both quick and comprehensive 

solutions only demonstrate the complexity and difficulties of the mission. Clearly the effects of the conflicts 

in Operation Enduring Freedom and Operation Iraqi 

Freedom, as well as tsunamis and other natural and 

manmade disasters, will continue to take their toll 

on US military members, their families, and the nation. It is thus a national duty to continue providing 

our service members the best behavioral healthcare 

available.