669

Military Psychiatry Graduate Medical Education

Chapter 42

MILITARY PSYCHIATRY GRADUATE 

MEDICAL EDUCATION

CARROLL J. DIEBOLD, MD*; WENDI M. WAITS, MD†; MILLARD D. BROWN, MD‡; and DAVID M. 

BENEDEK, MD§

INTRODUCTION

HISTORY

PROGRAM LEADERSHIP 

Role of the Program Director 

Faculty Development

CURRICULUM

Core Competencies

Medical Students and Core Competencies 

Psychotherapy Competencies

General Psychiatry Residency Curriculum

Research and Scholarly Activity

Military Psychiatry Curriculum

Postresidency Fellowship Training 

RELEVANCE IN MISSION PERFORMANCE

Knowledge

Skills

Attitudes

FUTURE OF GRADUATE MEDICAL EDUCATION

SUMMARY

*Colonel, Medical Corps, US Army; Chief, Department of Psychiatry, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, Hawaii 96859-

5001

†

Lieutenant Colonel, Medical Corps, US Army; Chief, Inpatient Psychiatry Service, Department of Psychiatry, Tripler Army Medical Center, 1 Jarrett 

White Road, Honolulu, Hawaii 96859-5001; formerly, Child and Adolescent Psychiatry Fellow, Tripler Army Medical Center, Honolulu, Hawaii

‡

Major, Medical Corps, US Army; Psychiatry Residency Director, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, Hawaii 96859-5001 

§

Colonel, Medical Corps, US Army; Professor and Deputy Chair, Department of Psychiatry, Uniformed Services University of the Health Sciences, 4301 

Jones Bridge Road, Bethesda, Maryland 20814
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Combat and Operational Behavioral Health

INTRODUCTION

Graduate medical education (GME) is an essential aspect of military medicine. To maintain a 

healthy and productive operational force primed 

for success in varied environments and scenarios, 

medical personnel must possess adequate training 

and experience to provide appropriate and timely 

healthcare to service members. The unique skills 

required for a military healthcare provider to thrive 

in both operational and garrison environments 

necessitate comprehensive training and education. 

General lessons learned from past conflicts revealed 

that healthcare providers acquired knowledge and 

experience treating casualties on the battlefield rather 

than relying on training received from civilian medical institutions. From the advent of military GME in 

the early 20th century, the primary mission has been 

to prepare medical personnel to function in all types 

of operations. 

As military graduate medical education evolved, 

military-specific proficiencies were introduced early 

in the training process. Before beginning the first 

year of GME, most trainees complete the Basic Officer 

Leadership Course, in which rudimentary knowledge 

such as extending military courtesies, proper wear of 

the uniform, elementary leadership skills, and basic 

soldier proficiencies are taught.1

 Students who do not 

have the opportunity to complete the basic course prior 

to entering GME will complete this training shortly 

after graduation. Consistent with training given to all 

assigned soldiers, a military treatment facility (MTF) 

with a GME program may require trainees to participate in annual common task training to maintain 

proficiency in basic military skills such as nuclear, 

biological, chemical response; weapons familiarization and maintenance; and military communication 

procedures. 

Psychiatry is the medical specialty with the greatest number of military-unique tasks. Like a civilian 

psychiatrist practicing in a public institutional setting 

such as a prison or forensic healthcare facility, the 

military psychiatrist is consistently confronted with 

dual-agency issues, necessitating consideration of the 

needs of the organization versus those of the patient.2

However, unlike civilian behavioral healthcare providers, who can decide their degree of involvement in 

forensic and administrative psychiatric issues, military 

psychiatrists do not have a choice in participating 

in such cases, thereby requiring extensive training 

in military-unique behavioral health topics such as 

command-directed mental health evaluations, Rule 

for Courts-Martial 706 evaluations, security clearance 

assessments, and medical evaluation boards.3–6 Each 

of these military-unique administrative evaluations 

requires specific training and experience to perform 

competently. In addition to unique administrative 

tasks, the military psychiatrist must develop diverse 

skills such as consulting with commands, briefing 

nonmedical military leaders, providing psychoeducation to soldiers and leaders, and constructing realistic 

treatment plans while taking into account a service 

member’s duties.

This chapter will present the evolution of psychiatry GME in the military healthcare system from its 

origins in the early 20th century to the current process of training military psychiatrists. The US Army, 

Navy, and Air Force all participate in psychiatry GME, 

maintaining a pipeline of well-trained graduates who 

are frequently deployed to combat zones shortly after 

completion of training. Training programs vary in size 

and structure, including service-specific programs, 

programs sponsored by one service that accept trainees from other services, partnerships with civilian 

and Veterans Administration programs, and a joint 

service program in Washington, DC. All programs 

are accredited by the American Council of Graduate 

Medical Education (ACGME), fulfilling the same academic requirements observed by civilian programs, 

in addition to providing education in unique military 

psychiatric skills.7

 In addition to residency training in 

adult psychiatry, military psychiatry GME programs 

can offer subspecialty fellowship training in child 

and adolescent, forensic, addiction, and geriatric 

psychiatry. 

Areas addressed in the chapter will include leadership of a GME program, role of the program director, 

faculty development and recruitment, curriculum, 

contribution of undergraduate medical education to 

psychiatry GME, and research opportunities within 

training programs. The relevance of military psychiatric training will be presented, in addition to recommendations on how this unique specialty education 

can be enhanced in the future. 

History

Formal psychiatric GME in the US military is a 

relatively new entity, the development of which has 

mirrored civilian psychiatric training in the United 

States in many ways. In other ways, however, it has 

developed independently, establishing a unique 

legacy and creating for its alumni a broader clinical 

skill set than that acquired by most graduates of civilian training programs. Colonel (Retired) Michael 
671

Military Psychiatry Graduate Medical Education

G Wise authored an excellent summary of military 

GME through the mid 1980s, the highlights of which 

are summarized below.8

The first psychiatric “residents” in the Department of 

Defense (DoD) appear to have been four servicemen—

two from the Navy and two from the Army—assigned 

to work at Saint Elizabeths Hospital in Washington, 

DC, for a period of 2 years beginning in 19099 (the same 

year that Sigmund Freud first lectured at an American 

university, introducing the psychoanalytic movement 

to the United States and increasing American interest 

in psychiatry10). At the beginning of World War I, psychiatrists in the Army numbered only 50,11 an amount 

drastically insufficient to treat the 4 million US soldiers 

who would eventually serve in the war.12 In an effort 

to address this issue, the Army commissioned many 

psychiatrists from state hospitals, and nonpsychiatric 

Army physicians were enrolled in civilian neuropsychiatric training programs that lasted an average of 6 

weeks.11 By the time of the 1918 armistice, nearly 700 

psychiatrists were serving in the Army.11

Following World War I, psychiatrists gradually left 

the military, to such an extent that by 1940 uniformed 

psychiatrists on active duty numbered less than 

100.13,14 One year after the attack on Pearl Harbor, an 

improved and standardized neuropsychiatry course 

for nonpsychiatric military physicians was established 

and offered at a handful of civilian institutions.14

During the remainder of World War II, this 12-week 

course produced 1,300 graduates, referred to as “90-

day wonders.”15

In 1946, Congress passed the National Mental 

Health Act, which provided federal funds for a number of mental health initiatives, including training 

for mental health professionals.10 Over the course of 

the next decade, eight military psychiatry residency 

programs opened and received accreditation from 

ACGME (Table 42-1).8 The “90-day wonder” program 

remained active at Fort Sam Houston, Texas, from 

1946 to 1950, while physicians in the new psychiatric 

residencies completed their training.16

The field of psychiatry was also gaining a foothold 

in the civilian sector. During this same decade, the first 

Institute on Psychiatric Services meeting was held, the 

Psychiatric Services journal was established, the American Psychiatric Association authorized the creation 

of district branches, the first meeting of the American 

Psychiatric Association Assembly was held, the first 

Diagnostic and Statistical Manual of Mental Disorders was 

published, and psychoactive drugs were introduced 

in the United States.9

Perhaps as a result of psychotropic medications being introduced and the subsequent decreased number 

of psychiatric hospital admissions, three of the US military’s first psychiatric residencies closed shortly after 

opening: the Navy’s Great Lakes, Illinois, program in 

1948; the Navy’s San Diego, California, program in 

1954; and the Army’s Fitzsimons, Colorado, program 

in 1958.8

 However, the remainder of the programs 

stayed open for many years (Figure 42-1).

During the 1980s, as memories of the Vietnam 

War were fading and a Cold War conflict seemed 

increasingly less likely to materialize, pressure from 

the federal government to consolidate US military 

installations increased.17 After a preliminary round of 

DoD-initiated closures in 1988, Congress passed the US 

Department of Defense Base Realignment and Closure 

Act of 1990 (also known as the “BRAC law” or Public 

Law 101-510),18 which established a non-DoD committee and a schedule for the evaluation of military bases 

for closure. As a result of this legislation, additional 

BRAC rounds occurred in 1991, 1993, and 1995. 

Closure of military psychiatry residency programs 

took varied paths. The Presidio in San Francisco, 

California, home of Letterman Army Medical Center, 

table 42-1

american council of graduate medical education accreditation history

of US Military psychiatry residencies

Year Programs Accredited or Discontinued

1946 Bethesda (Md), Great Lakes (Ill), and Philadelphia 

(Penn) Navy programs accredited

1948 Walter Reed (Washington, DC) and Letterman 

(Calif) Army programs accredited; Great Lakes 

program discontinued

1950 Fitzsimons (Colo) Army program accredited

1951 San Diego (Calif) and Oakland (Calif) Navy programs accredited

1954 San Diego program discontinued

1958 Fitzsimons program discontinued

1965 Wilford Hall (Tex) Air Force program accredited

1976 Dwight D Eisenhower (Ga) Army program accredited; Philadelphia program moved to Portsmouth 

(Va) and accreditation continued

1977 Wright-Patterson (Ohio) Air Force program accredited

1978 Tripler (Hawaii) Army program accredited

1981 San Diego program reaccredited

1983 Oakland program discontinued

1993 Letterman program discontinued

1999 Dwight D Eisenhower program discontinued

Data source (through 1987): Wise MG. The past, present, and 

future of psychiatric training in the US armed services. Mil 

Med.1987;152:550–553.
672

Combat and Operational Behavioral Health

was identified for closure in 1988.19 Its final cohort 

of psychiatry residents graduated in 1993, and the 

hospital closed 1 year later.20 The training program at 

Eisenhower Army Medical Center in Augusta, Georgia, 

although not an official casualty of the BRAC, was 

closed preemptively by the Army in 1999 because of a 

dwindling pool of applicants.21 Similarly, although Oak 

Knoll Naval Hospital in Oakland, California, was not 

identified for closure until the 1993 BRAC, the Navy 

had already relocated the psychiatry training program 

from Oakland to San Diego in the mid-1980s.

In 1995, in an effort to fortify their programs against 

the threat of closure, the three DoD hospitals in the 

national capital area—Walter Reed Army Medical 

Center in Washington, DC; the National Naval Medical 

Center in Bethesda, Maryland; and Malcolm Grow Air 

Force Hospital in Prince George’s County, Maryland—

combined forces, creating the National Capital Area 

Consortium. Affiliated with the Uniformed Services 

University of the Health Sciences (USUHS), in Bethesda, Maryland, the consortium program is currently the 

largest active military psychiatry training program. 

A new BRAC initiative in 2005 has called for the 

= Navy

= Army

= Air Force

= Joint Svc

NCA Consortium

Tripler

Wright-Patterson

Portsmouth

Eisenhower

Wilford Hall

Oakland

San Diego II

San Diego I

Fitzsimons

Letterman

Walter Reed

Philadelphia

Great Lakes

Bethesda

1946 1956 1966 1976 1986 1996 2006

Figure 42-1. A graphic timeline of accredited US military psychiatry programs. The dotted lines represent when programs 

were either transferred to another location or merged.

NCA: National Capital Area; Svc: Service

closure of Walter Reed by 2011,22 but the consortium 

psychiatry residency program is expected to remain 

intact and headquartered at what is currently the National Naval Medical Center. The 2005 BRAC initiative 

also called for the consolidation of Wilford Hall Air 

Force Medical Center with Brooke Army Medical Center in San Antonio, Texas. By 2011, only a San Antonio 

Military Medical Center is expected to exist, with the 

north campus (Brooke) being primarily an inpatient 

facility and the south campus (Wilford Hall) having 

only outpatient services.23 As in Washington, DC, the 

Air Force psychiatry residency program in San Antonio 

is expected to remain intact.

The global war on terror (GWOT) has contributed 

to an increase in behavioral health problems among 

active duty personnel and their families, as well as 

among veterans and civilians in the United States. 

Interest in psychiatry as a career field also appears to 

be on the rise, perhaps as a direct result of this GWOTinfluenced increased demand.24 The future of military 

psychiatry GME will likely continue to parallel the 

need for services during times of war, as has been the 

case for the past century.

program Leadership

The military stresses competent leadership as an essential factor in successful completion of the mission. 

Much of an officer’s military education is composed 

of development and utilization of proper leadership 

techniques.25 Although the majority of military medical officers will never serve in command positions, 
673

Military Psychiatry Graduate Medical Education

many will become service, section, or department 

chiefs, directly responsible for delivering high-quality 

medical care in addition to promoting the professional 

development of subordinates. A fortunate few will 

be appointed to lead GME programs, taking on the 

responsibility of training future military clinicians to 

excel in varied environments.

The department chairperson performs diverse roles 

in a military psychiatry GME program. Besides the 

requirements established by ACGME, the chairperson 

must also meet the standards expected of a military 

leader.7 Essential attributes include articulating a clear 

vision, prioritizing the mission, managing personnel, and overseeing the budget, all while supporting 

the goals of the MTF commander. As the military 

healthcare system evolves into a managed care model 

emphasizing clinical productivity as a measurement 

of fiscal success, GME leaders are challenged with 

demonstrating financial success while maintaining a 

quality training program. GME-related activities such 

as clinical supervision, didactics, trainee performance 

assessments, medical education committees, psychiatric clinical report reviews, and research-related 

activities do not produce workload credit, resulting 

in a lower productivity standing compared with other 

MTFs that do not have GME programs.

Success of a military psychiatry program is predicated on the department leadership being able to 

incorporate GME into four essential tasks: (1) direct 

patient care delivery, (2) deployment cycle support, (3) 

operational readiness of personnel, and (4) research 

activities. Until the mid-1990s, military psychiatry 

GME programs were relatively insulated from external influences such as managed care and operational 

taskings. Programs readily focused on psychiatric 

education, utilizing direct patient care, clinical supervision, didactics, and research, augmented by a 

military psychiatry curriculum, to prepare trainees 

for success as clinicians in an MTF practice or as a 

garrison-based division psychiatrist. GME leaders 

were not pressured by the requirement to formulate 

intricate business plans to predict and subsequently 

demonstrate clinical productivity. Specific military 

psychiatric curriculum consisted of several didactic 

courses and focused on familiarization with basic 

military organization structure and function, dualagency issues, performing military-unique administrative mental health evaluations, interacting with 

operational leadership, and operational military 

mental health doctrine, much of which was from the 

Vietnam era and in the process of being updated. The 

operational experience for trainees was limited to a 

rotation during the final year of residency to a post 

with a large troop population, and in many instances 

such rotations lacked formal structure or stated goals 

and objectives. 

As the evolution of managed care within the military healthcare system of the late 1990s coincided with 

the changes in defense strategy after September 11, 

2001, conducting military GME became much more 

complex and challenging. Leaders of GME programs 

wer no longer able to dedicate resources exclusively 

to the training mission but were forced to balance 

multiple requirements while devising methods to 

maximize the learning experience of trainees. GME 

programs became directly affected by the GWOT 

through deployment of faculty and taskings to participate in deployment cycle support at locations serving 

as deployment platforms. Advantageously, trainees 

were given the opportunity to participate directly in 

many deployment cycle support activities, as well as 

to provide treatment for casualties evacuated from 

the theater of operations. A challenge for the GME 

leadership was to ensure that adequate supervision 

and training occurred during the provision of such 

services.26

With the extended GWOT-related campaigns of 

Operation Iraqi Freedom and Operation Enduring 

Freedom in the first decade of the 21st century, most 

graduates from Army psychiatry GME programs 

deployed to a combat zone within 2 years of completing training, requiring the programs to provide 

comprehensive instruction and practical experience in 

operational psychiatry. Faculty at the two Army GME 

programs became part of the psychiatry deployment 

pool and served in diverse assignments throughout 

both theaters of operations, directly enhancing the 

quality of the operational psychiatry curriculum. 

Prior deployment experience became a determining 

factor for prospective faculty, and by the end of 2006, 

over 75% of the active duty staff psychiatrists at the 

two Army psychiatry programs had deployed to a 

combat theater.27

Role of the Program Director 

A residency program’s existence and viability 

critically depends on a program director who is fully 

engaged and active in the program’s daily activities. 

In the field of psychiatry, such active participation is 

even more paramount in running a successful residency program. The field of psychiatry requires that 

residency graduates not only be skilled in diagnostic 

assessments and treatment modalities, but that they 

also be capable of engaging patients and systems to 

construct realistic individualized treatment plans. 

Such capabilities can be utilized effectively only if the 

psychiatrists are fully aware and in control of their own 

personal mental health. Therefore, a quality psychiatry 

residency program encourages trainees to develop an 
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Combat and Operational Behavioral Health

awareness of how their own histories can potentially 

affect their ability to engage patients in clinical service 

delivery and program faculty in their educational 

pursuits. The psychiatry residency program director 

must therefore possess skills as an effective parent, 

colleague, arbitrator, visionary, and leader when interacting with residents and faculty. 

When groups are formed in which some have power 

and control over other members, acting out behaviors 

will inevitably follow. In a residency program, the 

program director must anticipate these behaviors and 

develop methods of preventing them when possible, 

in addition to maintaining proper boundaries when 

challenged. The faculty and program director are 

expected to avoid leveraging their power differential 

while guiding the trainees through a process of personal growth and learning. The program director must 

learn to respond appropriately to acting out behaviors 

with the requisite amount of action, while redirecting 

residents with such behaviors toward more constructive use of their energies. 

Psychiatry residency training evolves along a developmental continuum. The beginning section usually 

involves encouraging residents to apply newly learned 

knowledge in patient care and to develop clinical instincts in evaluation and treatment procedures. During 

the middle phase, the program director helps residents 

consolidate basic skills and begin developing more 

advanced skills in therapeutics through treatment 

of challenging and treatment-resistant cases. Finally, 

during the end stage of training, the program director 

develops situations for the resident to become a leader 

of junior colleagues and begin taking on independent 

responsibilities as a credentialed provider. 

The visionary program director must be aware 

of the future of psychiatry as an evolving medical 

specialty while remaining cognizant of how the 

military plans to address its future behavioral health 

challenges. The latter requires the program director 

to maintain connections with military behavioral 

health leaders so the needs of the military system can 

quickly be built into the training of future military 

psychiatrists. These changing needs force the program 

director to continually refine the vision and mission 

of the program, articulating these refinements clearly 

and concisely to the faculty and residents. Program 

directors must also stay current with the latest developments and research in psychiatry, which is rapidly 

developing from a field of general syndromes to a 

complex specialty containing significant advances in 

neuroscience and therapeutics. 

Leaders of organizations are tasked with many responsibilities that can quickly become overwhelming 

and burdensome, and those whom they lead look to 

them for mentorship and guidance. Leaders’ behaviors 

set the tone for the entire organization and are naturally scrutinized by subordinates. Program directors 

must therefore be aware of the significance an action 

can have across the residency training program. The 

fundamental operating principles of a residency must 

be repeatedly articulated so that residents and faculty 

can understand the rationale and potential outcomes of 

certain decisions. Faculty and trainees may not agree 

with a decision, but they need to be made aware of how 

decisions are consistent with the stated principles of 

the program. With so many ongoing issues to incorporate into a residency program, the program director 

must balance being open to feedback at all levels with 

making decisive and timely decisions to keep the program current with psychiatry as a specialty and also 

with the needs of the military.

Faculty Development

In addition to capable GME leadership, recruitment 

and selection of appropriate faculty is a critical element 

to program success. Besides uniformed clinicians, the 

teaching staff is composed of civilian faculty employed 

by the federal government, clinicians on personal 

service contracts, and possibly faculty members from 

local civilian psychiatry GME programs. 

As with any enterprise, the recruitment and retention of bright, experienced, and energetic supervisors 

directly affects program success. A psychiatry GME 

faculty member should possess the inner drive for personal growth, passion to promote learning in trainees, 

and professional experience to provide capable supervision and guidance.7

 The composition of a military 

psychiatry GME faculty should be a mix of established 

clinicians with significant experience in academic settings and midcareer psychiatrists with an interest in 

further development of teaching and mentoring skills. 

In many instances, the more professionally mature 

members of the faculty are retired military clinicians 

who possess a wealth of practical military psychiatric 

experience. 

Retention of military physicians beyond completion 

of initial active duty service obligation has been a challenge since the conclusion of Operation Desert Storm. 

The potential of prolonged operational deployments 

combined with dwindling resources and the evolution of managed care within the military healthcare 

system has produced a less attractive environment for 

prolonged service. However, one extremely favorable 

aspect of military medicine is the wide scope of career 

tracks available.28 Within several tours of duty posttraining, active duty psychiatrists are in a position to 

mold their careers in a single area, such as a clinical, 
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Military Psychiatry Graduate Medical Education

operational, command, academic, or research-based 

concentration, with the flexibility to shift between 

these tracks. For the academically oriented military 

psychiatrist, the potential to become faculty at one of 

the military GME programs is a tremendous incentive 

to continue practicing medicine on active duty.

Potential faculty members are identified throughout 

the entire career path of the military psychiatrist. Occasionally, an outstanding trainee demonstrating a talent 

for academic psychiatry may be recruited to remain on 

staff as a junior faculty member while further refining 

teaching and mentoring skills under the guidance of 

senior faculty. More likely, promising graduates with 

an interest in teaching and academics will serve at least 

one tour as an MTF or operationally based psychiatrist 

to gain practical clinical and administrative experience 

as an independent healthcare provider. Another group 

consists of clinicians who initially were not recognized 

as future faculty members, but through a combination 

of experience, reassessment of career aspirations, and 

possibly attaining specialized skills such as forensic or 

addictions psychiatry training, may be deemed faculty 

material at midcareer or later. 

No codified requisite criteria exists for consideration 

for faculty appointment to a military psychiatry GME 

program, but the candidate should demonstrate superior clinical, leadership, management, scholarship, and 

military skills with an underlying passion to develop 

future military psychiatrists. A search committee composed of current faculty members should be formed 

to identify and interview candidates. One method to 

screen potential faculty is using ACGME competencies 

to predict a resident’s level of performance as an independent practitioner.7

 The potential faculty member 

should markedly exceed the baseline standard for each 

of the competency areas, with focus on the ability to 

provide mentorship and guidance (Exhibit 42-1). Additional data to be assessed are performance during 

GME training, scope of assignments post-GME, input 

from supervisors and colleagues, and unique skills to 

enhance the training program.

Recruitment of a dedicated and multitalented 

faculty is essential for the success of a military psychiatry training program. The increased frequency of 

exhibit 42-1

american council of graduate

medical education competencies

1. Patient care that is compassionate, appropriate, and effective for the treatment of health 

problems and the promotion of health.

2. Medical knowledge about established and 

evolving biomedical, clinical, and cognate 

sciences, as well as the application of this 

knowledge to patient care.

3. Practice-based learning and improvement 

that involves the investigation and evaluation of care for their patients, the appraisal 

and assimilation of scientific evidence, and 

improvements in patient care.

4. Interpersonal and communication skills that 

result in the effective exchange of information and collaboration with patients, their 

families, and other health professionals.

5. Professionalism, as manifested through a 

commitment to carrying out professional 

responsibilities, adherence to ethical principles, and sensitivity to patients of diverse 

backgrounds.

6. Systems-based practice, as manifested by 

actions that demonstrate an awareness of 

and responsiveness to the larger context and 

system of healthcare, as well as the ability 

to call effectively on other resources in the 

system to provide optimal healthcare. 

Data source: Accreditation Counsel for Graduate Medical 

Education. Psychiatry program requirements. ACGME 

Web site. Available at: http://www.acgme.org/acWebsite/

RRC_400/400_prIndex.asp. Accessed October 28, 2009.

 Curriculum

operational deployments since September 11, 2001, 

has necessitated frequent shifting and restructuring of 

faculty duties. To provide future military psychiatrists 

with the necessary skills to thrive in multiple complex 

environments, the GME faculty must be dedicated 

to the mission of being teachers, mentors, and role 

models. 

During the last 2 decades, the establishment of 

the core competencies and the psychotherapy competencies as the basic evaluation tools has brought 

significant changes to psychiatry GME. Training 

requirements are gradually shifting to an outpatientcentered treatment model as the inpatient rotation 

standard has been steadily reduced. Specific didactic 

requirements have also been expanded with the evolution of psychiatric subspecialties such as forensic, 

geriatric, and psychosomatic medicine, as well as 

with advancements in psychopharmacology. Training 

programs must also provide residents with adequate 

exposure to the challenges of managed care, because 

most psychiatrists-in-training will not have a practice 
676

Combat and Operational Behavioral Health

composed exclusively of direct-payment patients. In 

addition to the elements unique to psychiatry training, military programs have unique training requirements pertinent to the diverse role of the uniformed 

psychiatrist.

Core Competencies

The core competency movement within ACGME 

began with the “outcomes movement” by the US 

Department of Education in the 1980s and accelerated in Canada in 1996 through the publishing of the 

Canadian Medical Education Directions for Specialists 

(CanMEDS) 2000 Project report.29 This movement 

grew out of a recognition that the role of the physician has changed from a paternalistic medical expert 

model to a model in which the medical expert is part 

of a medical decision-making team that includes the 

patient. Also, the rapid pace of advancement of medical knowledge has repeatedly emphasized the need 

for physicians to be avid life-long learners and for 

residency training programs to teach new physicians 

how to develop life-long learning skills. In response 

to the change in the mechanism of healthcare delivery, 

ACGME and the American Board of Medical Specialties launched the core competencies program for all 

American residencies in 1999.30 In 2001, the psychiatry 

residency review committee (RRC) became the first 

RRC to change its official program requirements. 

The following year, site reviewers began assessing 

whether or not programs had begun to implement the 

core competencies. Similar to the overall emphasis in 

healthcare on the ability to assess quality in medicine 

by such certifying organizations as the Joint Commission, ACGME mandated outcome measures to assess 

competency in the core areas.31

The core competencies consist of six main elements: 

(1) medical knowledge, (2) patient care, (3) interpersonal and communication skills, (4) practice-based 

learning and improvement, (5) professionalism, and 

(6) systems-based practice.7 Medical knowledge and 

patient care emphasize the traditional elements of 

physician medical education over the past century. 

Medical school and clinical experiences in residency 

form the foundation of medical knowledge that 

physicians use to perform competent, safe patient 

care. The patient care competency focuses on interactions with patients, including the psychiatry-specific 

psychotherapy core competencies. Interpersonal and 

communication skills have become increasingly more 

important as fully informed consent and a focus on 

patient choice have steadily increased throughout 

the past 60 years, since the passage of the Nuremburg 

Code in 1947.32 Practice-based learning and improvement emphasizes the ability to understand and grow 

from clinical experiences in addition to keeping current on recent advances. The goal is to instill such abilities during training so that practitioners continue the 

process throughout their entire medical careers.

Professionalism is an essential aspect of any occupation, encompassing the requisite skills and sense 

of commitment needed to function in a competent 

and safe manner. No amount of medical expertise 

can overcome the requirement for strict standards of 

behavior that define professionalism and serve as the 

backbone for a strong physician-patient relationship. 

In addition to acting professionally with patients and 

healthcare colleagues, the military clinician has an additional obligation to maintain the high standards of a 

military officer.33 Finally, advances in medical practice 

have resulted in effective management and control of 

many chronic illnesses in the outpatient setting, which 

in turn has created a need for increasing collaboration 

with many different organizations to maximize the 

well-being of patients. The systems-based training 

competency emphasizes this ability to operate within 

systems of care, in coordination with many types of 

healthcare professionals, thereby maximizing quality 

of life for patients. By training within a systems-based 

environment, the military psychiatry resident gains an 

appreciation for the importance of utilizing primary, 

secondary, and tertiary prevention.34

Implied in the competency model is the idea that 

length of time in training alone is insufficient to establish competence. Rather, a consistent ability to use 

a specific set of knowledge, skills, and attitudes must 

be demonstrated by the trainee prior to clearance for 

graduation. Further development will produce a longitudinal assessment tool for competence as opposed 

to completion of a set of timed requirements. However, 

little evidence exists on what outcome measures can 

reliably assess the psychiatric core competencies. Currently, many programs use some form of standardized 

assessment tool in conjunction with subjective input 

from multiple sources such as supervisors, instructors, and mentors to assess overall competency of 

trainees.35

Medical Students and Core Competencies 

The core competencies of interpersonal and communication skills, professionalism, and systems-based 

practice in particular require trainees to demonstrate 

the ability to interact effectively with persons other 

than patients. Because they are so crucial to successful 

medical practice, development of these competencies 

begins very early in the medical education process. At 

the heart of these competencies is the theme of working 
677

Military Psychiatry Graduate Medical Education

cooperatively within multidisciplinary teams of other 

medical professionals in a manner that synergizes efforts to provide the best care for patients. With nurses, 

occupational therapists, medical technicians, and administrative staff, medical students are often members 

of these multidisciplinary teams. 

At USUHS, the only US federal medical school and 

the principle source of future military physicians, military medical students are introduced to the concepts 

of team learning, practice, and interpersonal communication through a variety of small-group laboratory 

exercises based on clinical vignettes. Students also 

participate in Introduction to Clinical Medicine smallgroup courses, where they learn and practice medical 

interviewing and physical examination skills with 

patients from the treatment facilities in the national 

capital area. 

Psychiatry residents from the National Capital 

Consortium’s psychiatry GME training program are 

actively recruited and encouraged to participate as coinstructors with full-time university faculty members 

in these exercises and courses. In this manner, residents 

are afforded opportunities to demonstrate their medical knowledge, to discuss principles of systems-based 

medicine, and to role model professional relationships 

with junior medical officer students and senior cofaculty. 

Third-year USUHS medical students currently 

participate in clinical clerkship rotations on psychiatry wards and clinics at the three medical centers 

within the National Capital Consortium; at Tripler 

Army Medical Center, Hawaii; and at Wilford Hall 

Air Force Medical Center (soon to be known as the 

San Antonio Military Medical Center–South). Additionally, 3rd- and 4th-year students from USUHS 

and other medical schools may also rotate at civilian 

treatment facilities and other military medical centers. 

At these sites, residents (under the appropriate guidance of military GME faculty) also hone their skills 

as mentors, teachers, supervisors, role models, and 

team leaders. 

GME program faculty members appointed by 

the USUHS Department of Psychiatry as clinical site 

directors at each of these sites assure that residents 

contribute to the core knowledge and competency 

requirements of the Liaison Committee on Medical 

Education for psychiatry clerkship students. Students are responsible for learning the fundamentals 

of psychiatric assessment, differential diagnosis and 

treatment, mental status examination, safety assessment, treatment planning, and case presentation to 

multidisciplinary teams during these rotations. In 

providing both didactic and “hands-on” training for 

medical students, GME residents also develop and 

demonstrate the RRC-required core competencies, as 

well as honing the professional and leadership skills 

necessary for the practice of psychiatry in military 

medical settings.

Psychotherapy Competencies

Psychiatry residency programs have had to restructure their training strategy to meet the competency 

requirements for various psychotherapies, including 

supportive therapy, psychodynamic therapy, brief 

therapies, cognitive-behavioral therapy, and combined medication and psychotherapy. The evolution 

of managed healthcare converging with marked 

advancement in psychopharmacology shifted the 

emphasis of psychiatry GME away from long-term 

psychotherapeutic treatment and toward a crisis intervention model. In response, many psychiatry residency programs experienced a shift in culture away 

from emphasis on psychotherapy skills toward a more 

neurobiology-based approach that led to increased 

reliance on safer, less burdensome medications for 

treating mental illnesses. By the end of the 1990s, numerous programs around the country were struggling 

to find the financial resources necessary for robust psychotherapy training.36 In contrast, military residency 

programs faced less financial pressure to demonstrate 

productivity and thus were able to maintain a strong 

emphasis on psychotherapy skills development. 

In 2001, the psychiatry RRC mandated not only 

that residencies must start implementing the six core 

competencies, but additionally that they must develop 

assessment tools to certify that their graduates are 

trained and competent in all five psychotherapies.37

No directives have been written on how to teach, 

develop, or assess each of these psychotherapies, and 

development of competencies was left to individual 

programs to design and implement.

General Psychiatry Residency Curriculum

An accredited psychiatry residency program must 

be 48 months in length, including the postgraduate 

year 1, also known as internship. Graduation from 

medical or osteopathic school is a prerequisite to enter 

such a program. The psychiatry internship usually 

consists of approximately 6 months of basic medical 

training in primary medicine areas, such as internal 

medicine, family medicine, or pediatrics, and about 

6 months of neurology and psychiatry training. Postgraduate year 2 typically involves mostly inpatient 

psychiatry rotations, as well as rotations in addictions, 

consultation-liaison, geriatric psychiatry, and other 

clinical experiences. The majority of outpatient psycho-
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Combat and Operational Behavioral Health

therapy and medication management training occurs 

during postgraduate year 3. Finally, postgraduate year 

4 involves consolidating medication management and 

psychotherapy skills, mentoring junior trainees, and 

learning administrative skills necessary for interacting 

in the larger system of medical care.7

Requirements for completion of GME training in 

psychiatry have evolved over time. During the past 

2 decades, focus has shifted from inpatient psychiatric experience to outpatient rotations, mirroring the 

medical industry’s evolution of an outpatient-based 

treatment model. For example, the required time for 

inpatient psychiatry rotations in 1984 was 12 months, 

compared to a minimum of 6 months in 2007.7,38

ACGME mandates specific time requirements for 

certain rotations, and others are left to the discretion 

of the training program (Exhibit 42-2). 

Three other aspects to psychiatry residency training 

are unique and increase the complexity and cost of executing a training program. First, much of psychiatric 

care occurs in one-on-one sessions with a patient. The 

duration of a typical appointment can be from 30 to 

90 minutes, with a low reimbursement rate compared 

exhibit 42-2

SUMMARY OF AMERICAN COUNCIL 

OF GRADUATE MEDICAL EDUCATION 

RESIDENCY REVIEW COMMITTEE 

REQUIREMENTS FOR PSYCHIATRY 

RESIDENTS, AS OF 2007

Timed Experiences

	 •	 Primary Care Medicine: 4 months in

internship year

	 •	 Inpatient Psychiatry: minimum of 6

months

	 •	 Outpatient Psychiatry: 12 consecutive

months

	 •	 Neurology: 2 months

	 •	 Consult-Liaison Psychiatry: 2 months

	 •	 Child and Adolescent Psychiatry: 2

months

	 •	 Addiction Psychiatry: 1 month

	 •	 Geriatric Psychiatry: 1 month

Untimed Experiences

	 •	 Forensic Psychiatry

	 •	 Community Psychiatry

	 •	 Family/Couples Therapy

	 •	 Group Therapy

	 •	 Electroconvulsive Treatment

	 •	 Psychological Testing

to other medical specialties. Because of the very sensitive nature of topics discussed and the structure of 

psychotherapy sessions, there are significant barriers to 

having a supervisor directly observe a trainee’s interactions with patients. Some programs in the military are 

beginning direct observations via video links to offices 

with consent by the patient as a means to observe but 

not intrude on the patient-physician interaction. 

Secondly, as mandated by ACGME, psychiatry 

trainees must meet with supervisors individually at 

designated times to review clinical encounters that 

have already occurred.7 Each trainee must have 2 

hours a week of individual time with faculty supervisors to discuss recent evaluations and therapy cases. 

Therefore, if a program has 25 residents, faculty must 

spend 50 hours a week of nonclinical time reviewing 

cases with the trainees, leading to a large amount of 

fiscally nonproductive time for both residents and 

supervisors. 

Third, much of psychiatry training involves trying 

to understand the enormously complex field of human behavior. Residents need to understand human 

development across the lifespan and how it manifests 

differently at various points in development. For example, a 5-year-old girl might be displaying normal 

developmental behavior when she states that she sees 

an invisible friend standing next to her, whereas such 

behavior would be abnormal for a 13-year-old child. In 

addition to learning through clinical experiences and 

case supervision, psychiatry GME training requires 

a greater amount of didactic learning than any other 

medical specialty. The total time spent participating 

in didactics does not include advanced preparation 

or individual reading and research pertinent to the 

resident’s cases. Learning how to distinguish normal 

behaviors from mental disorders, understanding 

various medication and therapy treatment modalities, 

and learning how to develop realistic treatment plans 

necessitate a large reading and didactic program.7 To 

satisfy all of the academic requirements, most psychiatry GME programs have developed didactics schedules 

of about 3 to 5 hours per week per year level, resulting in an overall didactic schedule of approximately 

13 to 15 hours per week for the entire program, all 

of which is nonbillable time for faculty and resident 

participants.

Research and Scholarly Activity 

Although not specifically mentioned as a GME core 

competency, the ACGME RRC requires that involvement in scholarly activity or research be incorporated 

into residency training.7

 All military psychiatry GME 

programs require participation in a research project or 

scholarly endeavor as a requirement for graduation. 
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Military Psychiatry Graduate Medical Education

Historically, such scholarly endeavors have included 

literature reviews presented at department-wide or 

hospital grand rounds. Increasingly, however, general 

psychiatry residents have been paired with research 

mentors—GME faculty members with specific skills 

and interest in research. As a result, many GME residents graduate with a sophisticated understanding of 

study design, institutional review board procedures, 

and research report writing skills. In addition to 

numerous book chapters, military residents have 

authored or coauthored publications accepted in the

American Journal of Psychiatry, Journal of the American 

Academy of Psychiatry and the Law, Jefferson Journal of 

Psychiatry, Psychosomatic Medicine, Military Medicine, 

and American Journal of Disaster Medicine, among others. These efforts have not only advanced the practice 

of psychiatry within the military, but have also expanded the knowledge and understanding of specific 

military psychiatric issues within the larger civilian 

community. 

Military Psychiatry Curriculum

In addition to satisfying all of the standard ACGME 

requirements for a psychiatry residency program, 

military GME programs must prepare trainees to function as capable leaders immediately upon completion 

of training. New graduates can be placed into various leadership positions, such as chief of a division 

mental health clinic or officer-in-charge of a brigade 

combat team mental health section.39 The staff of a 

mental health clinic or section may include other officers, several enlisted personnel, and possibly civilian 

employees. New graduates can also be assigned to 

combat stress control units or to other medical units 

in a deployment setting, where they will be expected 

to serve in leadership roles.

A well-executed military psychiatry curriculum 

spans the entire 4-year training cycle. Issues emphasized in the military psychiatry curriculum include 

dual-agency issues, utilizing the military structure to 

support soldiers in need, and ways to reduce stigma 

and perform primary prevention efforts. Dual-agency 

issues arise more often in military psychiatry because 

Army psychiatrists serve simultaneously as physicians and Army officers.40 Most of the time these two 

roles do not conflict, but in some situations duty to the 

mission may be of higher priority than the immediate 

best interest of the soldier. Especially during combat 

operations, the needs of the group and the mission 

may sometimes trump the needs of the individual, 

potentially creating a dilemma for physicians trained 

and sworn to act in the best interests of the patient.41

This dual-agency issue is addressed frequently in the 

training of military psychiatrists.

One benefit of the military structure is the ability to 

develop and execute a comprehensive biopsychosocial 

formulation and treatment plan for a service member. 

Military psychiatry GME programs provide trainees 

with practical experience in performing clinical psychiatry while addressing pertinent military issues. 

Applying an occupational health model by working 

closely with the service member’s chain of command, 

the military psychiatrist has influence in structuring 

a soldier’s work environment via the scope of work, 

physical setting of work, and even duty hours.6

 An indepth understanding of the challenges and constraints 

faced by military units is essential for the military 

psychiatrist when consulting with service members’ 

chains of command to develop realistic treatment 

plans. To promote familiarity with the practice of 

psychiatry in a military environment, trainees participate in rotations at posts and bases with large cohorts 

of operational units. Through such interactions, the 

psychiatrist-in-training gains practical experience in 

military group dynamics and learns to develop realistic treatment plans within the constraints posed by 

the unit’s mission.

Many military psychiatry GME graduates deploy to 

an operational environment shortly after completion 

of training, so familiarity with unit structure and dynamics is tremendously important to the psychiatrist 

aspiring to be of optimal service to both active duty 

patients and unit leaders. Learning about the critical 

role of mental health in the entire deployment cycle 

support process prior to completion of residency 

training will greatly aid the military psychiatrist in 

the initial assignment.42

Unlike most civilian occupations, military service 

does not impact solely upon the service member, but 

affects the entire family unit. The high percentage of 

married service members makes adequate knowledge 

and experience in managing family dynamics, particularly in the face of deployment, necessary for military 

psychiatry trainees. The mental health needs of military children have been recognized through research

and practical experience.43 Military psychiatry trainees 

should have experience with programs that address 

such needs outside of the traditional office setting, such 

as in school-based mental health programs.44

Over the last 5 to 10 years, increasing emphasis has 

been placed on early identification of mental health 

problems through education and primary prevention 

efforts. After the September 11, 2001, terrorist attacks, 

the Army instituted Operation Solace to offer assistance to Pentagon employees. Military psychiatry 

trainees played a prominent role as members of the 

assistance team.45 Boundaries of traditional methods 

of patient care had to be crossed to allow survivors 

easy access to mental healthcare providers while si-
680

Combat and Operational Behavioral Health

multaneously decreasing the stigma to seeking help. 

For example, mental health teams of various types of 

providers were assembled to bring outreach efforts 

directly to employees in work areas, creating the term 

“therapy by walking around.” Outcome data suggest 

that such efforts may have resulted in a smaller-thanexpected incidence of mental illness at the Pentagon 

following the attack.46

Combat operations since then have provided multiple opportunities for mental healthcare providers 

to further improve educational activities, to refine 

screening of service members during the entire deployment cycle, and to minimize the traumatic effects of 

the combat experience. Further advances in military 

psychiatry curricula will result in graduates being 

better prepared for the complex military mental health 

treatment mission. 

Postresidency Fellowship Training 

Postresidency psychiatric subspecialty education 

and training (fellowship programs) are currently 

offered at several military medical centers.47 These 

programs provide the Army and Navy Medical 

Corps with the majority of their military psychiatric 

subspecialists. Historically, the Air Force has opted to 

permit relatively few of their psychiatrists to complete 

fellowship training (and these primarily through 

civilian channels), but Air Force physicians have 

also participated in the training programs described 

below. The opportunity to apply for and, if selected, 

receive subspecialty training in child and adolescent 

psychiatry, forensic psychiatry, geriatric psychiatry, 

and addictions psychiatry serves as a retention incentive for physicians who might otherwise terminate 

their active duty service. Military psychiatrists with 

subspecialty training continue to primarily practice 

adult general psychiatry in most operational billets. 

However, those assigned to tertiary care facilities and 

teaching hospitals are often assigned duties specifically related to their subspecialty skills (eg, working 

several days a week at the child psychiatry service, 

or as a medical review officer for the base substance 

abuse program). Those assigned to smaller clinics or 

medical detachments are given duties that utilize their 

expertise. For example, although military regulations 

do not require a forensic psychiatrist for the evaluation 

of competency and criminal responsibility,4

 forensically 

trained psychiatrists are called upon to conduct these 

assessments by commanders or medical service chiefs 

whenever possible. Thus, the opportunity to practice 

specialized psychiatric skills also serves as a retention 

incentive for specialty-trained psychiatrists. 

Fellowship programs in child and adolescent psychiatry accredited by the ACGME RRC are presently 

offered at Tripler Army Medical Center and Walter 

Reed Army Medical Center (as part of the National 

Capital Consortium). Walter Reed also offers RRCaccredited fellowship training in forensic and geriatric 

psychiatry, and Tripler offers addictions psychiatry 

fellowship training. Army GME plans currently permit two Army psychiatrists to enter forensic training 

each year, five psychiatrists to enter child and adolescent training, and one to enter geriatric or addictions 

training in alternate years. The programs also offer 

training to Navy and Air Force psychiatrists on a spaceavailable basis, provided their parent service agrees 

to permit their matriculation. In this way, the training 

programs generate a pool of psychiatric subspecialists sufficient to fulfill forecasted needs and to justify 

continued program accreditation. 

The US Army, Navy, and Air Force have also 

recently established annual training billets for the 

National Capital Consortium’s Disaster Psychiatry 

Fellowship at USUHS. This military-unique training 

opportunity combines a competitive master’s in public 

health program with research and clinical mentorship 

in military operational response to disasters, war, and 

terrorism, as well as rotating internships at various 

federal agencies involved in disaster response. Disaster 

psychiatry subspecialty training, though not formally 

recognized by the ACGME through an accreditation 

process, has emerged to fill a need within the military 

for psychiatrists specifically trained in public health 

interventions, health surveillance, and principles of 

disaster mental health research and practice. Because 

the military is uniquely positioned and often tasked 

to provide medical and mental healthcare in natural 

and human-caused disasters, military psychiatrists 

with subspecialty training in this arena can augment 

the response of general psychiatrists and behavioral 

health specialists. 

The opportunity to apply subspecialty skill sets in 

military operational environments—whether addressing the mental health needs of child victims of the 

southeast Asian tsunami or the medico-legal issues 

surrounding the mental health of service members 

accused of war crimes—often encourages specialtytrained psychiatrists to remain on active duty beyond 

their contractual obligations. 

Relevance in Mission Performance

The delivery of mental health services in a military 

environment differs in multiple ways from civilian 

mental healthcare. Just as an attorney who relocates to 

a new state must learn the laws and culture of that state 
681

Military Psychiatry Graduate Medical Education

before establishing a practice, military mental health 

providers must thoroughly understand their service 

branch’s laws and culture to be effective caregivers. 

Military GME provides trainees with necessary exposure to the knowledge, skills, and attitudes required 

of military mental healthcare providers. Additionally, 

trainees in military programs receive guidance and 

supervision from experienced military supervisors 

while providing healthcare directly to service members and their dependents. Instruction and training in 

military-unique mental health issues is not available 

in civilian training, and being comfortable practicing 

in a military environment may be a major determinant of the length of time a military psychiatrist will 

ultimately remain in the service.8 As the Society of 

Medical Consultants to the Armed Forces emphasized 

in a 1987 white paper, “[Military] graduate medical 

education is the chief guarantor of quality medical 

care and an unmatched incentive for the recruitment 

and retention of active duty medical officers. It is the 

essential prop supporting the entire voluntary military 

medical structure.”48

The material presented in this section focuses on 

Army psychiatry GME training. Although the other 

mental health disciplines such as psychology, social 

work, psychiatric nursing, and occupational therapy 

may also offer graduate training programs in military 

healthcare facilities, psychiatry training is the longest 

and the most comprehensive. The authors of this 

chapter, all Army psychiatrists, are most familiar 

with Army standards and procedures. However, all 

branches of the US armed forces currently endorse 

a similar approach to evaluating, treating, and managing service members with psychiatric conditions. 

Additionally, each service recognizes the importance 

of addressing the issues of the entire military family 

when developing a mental healthcare delivery strategy. 

Each service also follows the same regulatory guidance, albeit with different nomenclature. Most of the 

information presented in this section is applicable to all 

mental health disciplines and all branches of the armed 

forces. Regardless of specialty or uniform, exposure 

to military systems as a trainee greatly contributes 

to the development of confidence and competence in 

caring for service members and their families during 

peacetime and war.

The military mental health field is unique, with 

many inherent challenges that are not addressed in civilian residency training programs. Besides simply offering cultural immersion, military residencies include 

both didactic and experiential training opportunities 

that appropriately prepare trainees for the jobs they 

will enter following graduation. These programs are 

a crucial component of military medicine and have 

been identified as the largest guarantor of provider 

longevity in the military. Additionally, appropriate 

implementation of the aforementioned knowledge, 

skills, and attitudes by well-trained military mental 

health providers will enhance overall unit readiness 

and improve mission performance by the units they 

support.

Military psychiatry is distinguishable from civilian adult psychiatry by two major constructs, both 

requiring years of experience to master. The first is the 

aforementioned dual-agency role, referring to the psychiatrist’s constant but necessary struggle to balance 

the best interest of the patient with the best interest of 

the patient’s unit, which includes overall unit health 

and successful completion of the military mission.45

The second construct is the extensive amount of technical, military-specific knowledge required to practice 

successfully within the military culture (Table 42-2). 

As mentioned above, all US military psychiatry 

programs are accredited by ACGME. Like psychiatrists 

trained in civilian programs, military psychiatrists are 

expected to demonstrate competence through successful development of specific knowledge, skills, and attitudes.7 Thriving as a military mental health provider 

requires the nurturing of career-specific knowledge, 

skills, and attitudes that can be gained only by repeated 

clinical encounters within military systems under the 

direction of an experienced supervisor. This section 

will introduce and explain these elements of competence as they relate to military psychiatry, accompanied 

by case examples pertinent to each. 

Knowledge

Knowledge begins with a basic understanding 

of the military culture, such as appropriate wear of 

the uniform, rank recognition, salutations, customs, 

and courtesies.49 It also involves an appreciation of 

the mindset of military leaders, who are responsible 

for the safety of hundreds of service members and 

millions of dollars worth of equipment, and whose 

success depends on their ability to motivate their 

troops to accomplish potentially life-threatening tasks 

under adverse conditions for minimal pay. Leaders 

often have neither the time nor the incentive to make 

special accommodations for service members who 

are not mentally fit for the mission at hand. Additionally, knowledge consists of understanding military 

occupations in terms of education, content, scope, 

typical duty environment, and inherent stressors. For 

example, the military psychiatrist should know that 

cooks and infantry soldiers require one of the lowest 

entrance examination scores,50 that recruiters have 

one of the most stressful jobs,51 and that aviation crew 

members are prohibited from taking certain types of 

medications.6
682

Combat and Operational Behavioral Health

table 42-2

OFFICIAL DOCUMENTS WITH WHICH US ARMY PSYCHIATRISTS SHOULD BE FAMILIAR

Number Title

Army Regulations and Pamphlets

AR 40-1 Composition, Mission, and Functions of the Army Medical Department

AR 40-66 Medical Record Administration and Documentation 

AR 40-400 Patient Administration 

AR 40-501 Standards of Medical Fitness 

AR 380-67 Personnel Security Program 

AR 600-8-4 Line of Duty Investigations 

AR 600-8-22 Military Awards

AR 600-8-24 Officer Transfers and Discharges

AR 600-85 Army Substance Abuse Program 

AR 608-18 The Army Family Advocacy Program 

AR 623-3 Evaluation Reporting System 

AR 635-40 Physical Evaluation for Retention, Retirement, or Separation 

AR 635-200 Active Duty Enlisted Administrative Separations

AR 670-1 Wear and Appearance of Army Uniforms and Insignia 

DA Pamphlet 600-24 Suicide Prevention and Psychological Autopsy 

Department of Defense Directives and Instructions

DoD Directive 1332.14 Enlisted Administrative Separations 

DoD Directive 1332.30 Separation of Regular and Reserve Commissioned Officers

DoD Directive 6490.1 Mental Health Evaluations of Members of the Armed Forces

DoD Instruction 6490.4 Requirements for Mental Health Evaluations of Members of the Armed Forces 

Army Field Manuals

FM 4-02.51 (formerly FM 8-51) Combat and Operational Stress Control 

FM 6-22.5 Combat Stress 

Other Documents

DoDSER Department of Defense Suicide Event Report 

Air Force Instruction 41-307 Aeromedical Evacuation Patient Considerations and Standards of Care

Furthermore, knowledge includes familiarity with 

community resources and programs available to assist 

troubled service members and their families. Each 

branch of the armed forces has its own service-specific 

support agencies, several of which psychiatrists are 

required by regulation to contact under specific circumstances, and others that are simply available for 

anyone who needs them. The first category includes 

substance abuse education and treatment programs,52

child and family welfare programs,53 patient administration offices,54 physical evaluation board liaison 

offices,55 other mental health treatment programs in the 

community, and law enforcement agencies. The second 

category includes organizations such as the command 

chaplain group, local community service agencies (eg, 

Army Community Service, Fleet and Family Services, 

Airman and Family Readiness Centers), the staff judge 

advocate (legal), the inspector general, Military OneSource, and the Veterans Administration.56,57

Another aspect of knowledge is the military 

psychiatrist’s ability to predict the effect of clinical 

decisions and administrative recommendations on 

service members, their command, and the military 

as a whole. For example, military psychiatrists must 

have an idea of realistic alternative duties available 

to a service member who is given a mental health 
683

Military Psychiatry Graduate Medical Education

profile or is prescribed sedating medications. They 

must proactively liaison with unit leaders to minimize 

stress on the service member, to help the unit accommodate the service member’s duty limitations, and to 

limit adverse effect upon the unit’s mission. Military 

psychiatrists must have an appreciation for how long it 

takes an individual to be administratively or medically 

separated from the service and how peers are likely 

to treat that individual during the separation process. 

An additional concern for commanders is that a recommendation for an administrative separation may 

trigger a flurry of requests for separation from other 

service members. This is especially concerning during 

times of high operational tempo, when a unit’s attrition 

rate is a critical factor that can degrade the unit’s ability 

to accomplish its mission. Additionally, the psychiatrist 

should know something about financial compensation 

and other benefits available to veterans upon leaving 

active duty service.

Finally, and perhaps most importantly, knowledge 

refers to being intimately familiar with a host of military regulations and instructional manuals.2 Because 

of their obligation to protect units as well as individual 

service members, military psychiatrists must know 

the medical conditions that disqualify recruits from 

entering military service, as well as those conditions 

that require a recommendation for medical discharge.6

They must be familiar with the regulation that addresses the medical disability program and know 

how to conduct a separation history and physical 

examination.55 In addition to knowing which mental 

health conditions warrant medical separation, military 

psychiatrists must be familiar with regulations pertaining to administrative (nonmedical) separations, 

which differ for officer and enlisted personnel, and 

some of which require an evaluation and recommendation for discharge by a doctoral-level mental health 

professional. During these separations, knowledge of 

the psychiatrist’s role as either a patient advocate or a 

neutral evaluator is essential.58,59

As part of a safeguard to prevent coerced mental 

health referral of service members, military psychiatrists must be very familiar with the tenets of 

the DoD policy on command-directed mental health 

evaluations, including service members’ rights in such 

proceedings, the limits of confidentiality, the psychiatrists’ obligations, the personnel involved, specific time 

limits, and required documentation.3 This policy was 

implemented in 1993 in response to congressional-level 

concern that service members were being inappropriately referred for mental evaluations after blowing 

the whistle on suspicious activities within their commands.60 Deviation from the prescribed process could 

result in significant administrative sanctions against 

the military psychiatrist. 

Additional administrative duties that do not have a 

correlate in civilian mental healthcare include security 

clearance evaluations,5

 participation in suicide investigations and appropriate documentation of suicide 

attempts,61–64 and transportation of patients via the 

military aeromedical evacuation system.65 Regulations 

pertaining to basic charting standards, maintenance 

of military medical and mental health records, and 

dispositioning of retired records are other duties required of a military psychiatrist.54,66 Since September 

11, 2001, having an understanding of service-specific 

medical and mental health units, their placement on 

the battlefield, and the behavioral health officer’s specific roles and obligations during wartime has become 

even more critical for the military psychiatrist.67–69 Such 

knowledge could conceivably be acquired through a 

concentrated training period shortly after entering 

active duty,8

 but the depth and scope of such training 

would not remotely approach the training and experience gained from a 4-year military training program. 

The following case studies, as well as the others in 

the chapter (all from the clinical experience of one of 

the authors [WW]), demonstrate the benefits of such 

a program.

Case Study 42-1: A deployed Army psychiatrist identifies 

a number of immature and maladaptive coping skills in many 

of the soldiers she evaluated. Concerned about their ability 

to successfully complete the deployment, she recommends 

most of them for personality disorder separations under 

Chapter 5-13, Army Regulation 635-200.59 Even though 

some of these soldiers are aggressive and unpredictable, 

the majority of them are not separated. The frequency with 

which the psychiatrist recommended separation reduced her 

credibility with the unit’s commander, who ultimately stops 

following through on any of the psychiatrist’s recommendations whatsoever.

Case Study 42-2: A 25-year-old deployed Army aviation 

soldier comes to the mental health clinic requesting treatment for insomnia. The soldier describes initial insomnia 

related to worries about upcoming missions that involved 

flying into hostile territory. In addition to clarifying the soldier’s 

psychiatric symptoms, the psychiatrist asks him about his 

job and work schedule. Knowing that aviation personnel are 

grounded while using psychotropic medications, as well as 

realizing that the soldier’s job could require him to wake up 

in the middle of the night and quickly perform an equipment 

check prior to flying, the psychiatrist does not feel comfortable prescribing a sleep medication for the soldier. Instead, 

she provides him with instructions in deep breathing and 

progressive muscle relaxation and schedules him to attend 

a sleep hygiene class offered by the clinic.

Case Study 42-3: A soldier walks into the mental health 

clinic with a memorandum stating that he needs a psychological evaluation to get his security clearance renewed. 

Having just graduated from a civilian residency program, the 
684

Combat and Operational Behavioral Health

psychiatrist is unaware that he should have received additional documents pertaining to the soldier’s background prior 

to the appointment and that the memorandum’s questions 

must be answered in a very specific fashion. He conducts a 

one-on-one assessment of the soldier and types up a letter 

stating that he thinks the soldier should be granted a security 

clearance. His letter is rejected by the requesting security 

agency because it does not address a key question raised 

during the background check and was not submitted in the 

proper format. 

Skills

Many of the skills required of military psychiatrists, 

including assessment, formulation, crisis management, 

consultation, and various psychotherapies, are taught 

in civilian training programs. Other skills, however, 

are required uniquely by military psychiatrists, and 

can only be learned by working within a military environment. Such skills are mastered through successful 

completion of a military psychiatry GME program 

followed by experience at the initial duty assignment. 

Military-related skills include the specific interpersonal 

skills required for interacting with individual patients 

as well as their patients’ commanders and military 

support personnel. Additionally, numerous technical and administrative skills related to both patient 

care and career management are required of military 

exhibit 42-3

UNIQUE SKILLS REQUIRED OF MILITARY 

PSYCHIATRISTS

Military psychiatrists must possess the ability to

	 •	 connect with service members who are

patients;

	 •	 connect with service members who are

not patients;

	 •	 connect with unit leaders;

	 •	 be a “salesperson” and an ambassador for

the field of mental health;

	 •	 provide appropriate interventions following traumatic events;

	 •	 interact within and among various military agencies;

	 •	 access pertinent regulations;

	 •	 format and write military memoranda;

	 •	 prepare official reports;

	 •	 provide quality care in austere environments;

	 •	 counsel subordinates; and

	 •	 prepare counseling statements, award recommendations, and performance reviews.

psychiatrists. Even unique clinical skills are required, 

particularly during times of overseas deployment 

(Exhibit 42-3).

Military psychiatry is not unique in requiring good 

interpersonal skills. However, the specific interpersonal skills required of a military psychiatrist are unique 

and vary depending upon the setting. For example, 

because some service members feel uncomfortable 

interacting with providers who do not maintain the 

decorum they expect of a military officer, the psychiatrist must maintain appropriate military bearing, yet 

not be so formal and rigid as to negatively influence 

the formation of a therapeutic alliance. Like patients 

in the civilian sector, service members will open up 

in a supportive, somewhat relaxed environment. A 

military psychiatrist who is too authoritative may 

have difficulty connecting with a service member 

who is having trouble with one or more supervisors, 

and thus may inadvertently create a barrier to care. 

Conversely, a style that is too casual may give service 

member patients permission to behave unprofessionally or spend excessive amounts of time at the mental 

health clinic—behaviors that will inevitably lead to or 

worsen preexisting occupational difficulties. 

Working with unit commanders requires an entirely different interpersonal skill set, consisting of a 

business-like attitude, a focus on data and regulations, 

emphasis on mission success, and a willingness to 

accept that the commander will not always seem appreciative of the psychiatrist’s efforts to help the unit 

or the soldier. Commanders often have preconceived 

negative opinions of mental health providers secondary to prior personal or family contacts with mental 

healthcare professionals, a perceived adversarial role, 

and a skewed opinion of the ability of mental health 

to enhance mission readiness.

As clinicians, psychiatrists are expected to maintain 

their clinical skills and to keep up with current medical literature. As military officers, they are expected 

to maintain their physical fitness and be familiar 

with current military tactics, procedures, and regulations. Often, the most challenging interpersonal skill 

required of a military psychiatrist is expert marketing 

to a population that may be resistant to receiving psychiatric assistance. Unlike their civilian counterparts, 

military mental health professionals must actively 

participate in primary prevention activities through 

education and outreach efforts for the units they support. By proactively getting to know their post’s units 

and commanders, they can reduce stigma associated 

with mental health interventions, an identified barrier to care.70 The ability of military psychiatrists to 

establish themselves as viable members of a unit’s 

healthcare team will enhance access to mental health-
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Military Psychiatry Graduate Medical Education

care for soldiers. Enhanced access to care is vital in 

an era of repeated combat operations when a large 

percentage of service members self-report operational 

mental health issues.71

Military psychiatry also requires a number of 

unique technical skills, many of which include researching and writing official correspondence and 

reports of various types (Exhibit 42-4).2 Failure to take 

the appropriate course of action or failure to document 

recommendations or actions in the correct manner 

could reduce the psychiatrist’s credibility, negatively 

impact the effectiveness of the unit, and potentially 

have lifelong consequences for uniformed patients. 

The military psychiatrist must be familiar with pertinent regulations, how to access the regulations, and 

how to apply them while providing high-quality 

mental healthcare for service members and commands. 

In the US Army, regulations dictate how a medical 

chart is prepared,54 what elements of the physical 

examination are required for a disability evaluation,55

how to schedule a command-directed mental health 

evaluation,3 what information must be provided to 

commanders after a command-directed evaluation,72

how to communicate recommended duty limitations 

to soldiers and their commanders,6 how to dispose 

exhibit 42-4

DOCUMENTS AND REPORTS PREPARED 

BY MILITARY PSYCHIATRISTS

	 •	 Clinical notes

	 •	 “Sick slips”

	 •	 Extended sick slips (eg, physical profile,

limited duty board)

	 •	 Safety precaution recommendations to

commanders 

	 •	 Security clearance evaluations

	 •	 Medical review officer findings

	 •	 Medical board narrative summaries

	 •	 Suicide line-of-duty statements

	 •	 Sanity boards

	 •	 Psychological autopsies*

	 •	 Military memoranda

	 •	 Standard operating procedures

	 •	 Counseling statements

	 •	 Officer evaluation report support forms

	 •	 Officer evaluation reports

	 •	 Award recommendations

	 •	 Line-of-duty investigations

*In the US Army, as of 2001, these are completed only by 

forensically trained psychiatrists.

of closed behavioral health charts,54 and even how to 

write in the “military style.”73 Significant failure to 

practice in accordance with these regulations could 

adversely affect a provider’s reputation, credentials, 

and medical license.

Technical skills required of military psychiatrists 

also include those relevant to their career progression 

and to that of their subordinates. If conducted appropriately, the military’s performance evaluation system 

ensures that service members are provided with timely 

feedback and ample opportunities to improve upon 

their deficits.74 Similarly, the military’s award system 

recognizes exceptional performance, providing incentives for exceeding the standard.75 Both mechanisms 

to recognize performance are complex and can be 

quite confusing, even to individuals with years of 

experience. Promotions and accompanying pay raises 

depend upon the ability to successfully navigate these 

two systems. All military leaders, including most 

military psychiatrists, are responsible for counseling 

and rating their subordinates, as well as for submitting 

award requests months before they will be presented. 

The psychiatrist must be familiar with subordinates’ 

accomplishments, know what level of award such accomplishments warrant, and what language to use to 

ensure the requested award is approved. Procedure 

and language is of equal, if not greater, importance 

when preparing performance reports, and information 

on these elements is not available in any official document. It is available primarily through mentoring and 

guidance by senior officers and supervisors. 

Military psychiatry GME programs provide 

trainees the opportunity to learn about the military 

performance rating system because trainees, like all 

military officers, require an annual evaluation report. 

Through formal instruction and individual guidance 

by a supervisor, trainees learn how to document personal goals and accomplishments.74 They also become 

familiar with the process of mentoring and evaluating subordinates, which they will most likely have 

to perform at their initial postresidency duty station. 

Trainees in civilian psychiatry GME programs do not 

have the same opportunity to experience the military 

rating system and thus are at a great disadvantage 

when evaluating other mental health professionals 

upon completion of residency training. 

Military psychiatry also requires unique clinical 

skills during deployment or other duty in austere 

environments. The practice of “combat psychiatry” 

requires the ability to conduct problem-focused 

interviews in suboptimal clinical settings with little 

privacy, loud ambient noise, extremes of temperature, 

and unreliable computer and telephonic support. 

Interventions must be brief (two to four sessions) and 
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Combat and Operational Behavioral Health

solution-focused. Long-term psychotherapy is not an 

option. The military psychiatrist must learn to trust 

the clinical capabilities of staff members, which often 

include enlisted mental health specialists with less 

than a year of training. Laboratory services are often 

very limited, commonly consisting of basic serology 

and urine screens only. The results of liver and thyroid 

function tests, drug levels, and advanced drug screens 

may take weeks to return, if they are available at all. 

Stocked medications are sometimes limited to one or 

two selective serotonin reuptake inhibitors (SSRIs), 

bupropion, one sleep agent, one benzodiazepine, and 

a first-generation antipsychotic such as haloperidol. 

Mood stabilizers, atypical antipsychotics, non-SSRI 

antidepressants, and stimulants may not be available at 

all. Subspecialty consultants are also difficult to access, 

and at times a military psychiatrist may be the only 

actual physician at the location. Such topics are integrated into the curriculum of military residencies to 

prepare trainees for successful practice in diverse and 

challenging environments. The following vignettes, 

as well as those elsewhere in the chapter, are illustrative of materials prepared for military physicians in 

training.

Vignette 42-1: A psychiatrist is treating a soldier who is 

extremely angry with his chain of command. He claims that 

his commander “plays favorites” and fails to take care of his 

subordinates’ basic needs. The soldier mentions several 

unsafe practices allegedly occurring in the unit and gives 

the psychiatrist permission to investigate. The psychiatrist 

discovers that an unusually high number of individuals within 

the soldier’s company are being seen at the mental health 

clinic, their charts all documenting similar complaints. He 

requests a meeting with the company commander to discuss 

the allegations. At the scheduled appointment time, the psychiatrist arrives in a pressed uniform, prepared with a briefing 

that includes specific data about recent behavioral trends in 

the unit, evidence-based information about how unsafe and 

unfair practices could contribute to reduced unit readiness, 

and very specific recommendations on how to improve the 

situation. The company commander states that he’s interested in trying to implement the recommendations.

Vignette 42-2: A new military psychiatrist was active in 

his residency’s psychotherapy interest group and authored 

several publications on dialectical behavioral therapy. One of 

his first patients as a division psychiatrist is a young woman 

with a very troubled past whom he diagnoses with borderline 

personality disorder. Intrigued by the case, the psychiatrist 

begins to see the patient for 50 minutes twice a week. 

Enlisted mental health specialists in the clinic complain to 

their noncommissioned officer in charge that the psychiatrist 

is always in session and is never able to staff cases. The 

patient herself seems to be getting worse and insists that 

she needs a sick slip excusing her from her upcoming field 

training exercise. At the end of the 4th week, the patient’s 

first sergeant accompanies her to the appointment and 

angrily asks the psychiatrist whether or not he understands 

the impact that her absence from the training exercise will 

have on the rest of the unit, and whom he expects to look 

after her while the unit is in the field.

Vignette 42-3: A deployed Army psychiatrist is working 

at a small base at a hostile location in Iraq. Late one night, 

he is sleeping in his cot at the back of his clinic tent when he 

is awakened by a weary-appearing soldier requesting help. 

The soldier is dirty, malodorous, and exhausted. Earlier in 

the day, he returned from a long convoy during which his platoon was attacked with small-arms fire and rocket-propelled 

grenades. He claims to be tense and worried about his wife, 

whom he has been unable to call in 2 weeks. He tearfully tells 

the psychiatrist that he is scheduled to go out again the next 

morning, but that he doesn’t feel like his “head is in the game,” 

and that he questions his ability to defend his comrades. The 

psychiatrist conducts a brief assessment and contacts the 

soldier’s commander to recommend he be removed from 

convoy duty for a couple of days and be allowed to participate 

in a “restoration” program offered by the clinic. 

Attitudes

The development of appropriate attitudes may 

seem less essential than the acquisition of sufficient 

knowledge and skills in the field of military psychiatry. However, psychiatrists who approach clinical and 

administrative tasks in the military with the wrong 

attitudes may inadvertently make their lives more 

stressful and find it difficult to achieve job satisfaction. 

They must adopt an attitude of selflessness and advocacy for patients while maintaining a skeptical eye for 

malingering. They may have to treat a patient while simultaneously providing support for the patient’s unit. 

They must adopt an attitude of flexibility and humility, 

including a willingness to take on challenging tasks for 

minimal recognition. Finally, they must excel in their 

role as a leader to ensure their subordinates receive the 

recognition and promotions they deserve.

The dual-agency role discussed earlier perfectly 

demonstrates the importance of having the right attitude for the job. Military psychiatrists must be willing 

to adopt a utilitarian viewpoint.76 They must regard the 

entire population of service members as their “patient” 

and endeavor to protect that “patient” from harm, even 

at the cost of violating the confidentiality of individual 

service members. Unforeseen violations of doctorpatient confidentiality are rare, but are necessary and 

appropriate if the identified patient is experiencing 

symptoms that could compromise the safety of the 

unit. Depending on the patient’s job, such symptoms 

might include poor concentration, sleep deprivation, 

errors in judgment, severe anxiety, profound depression, delusions, hallucinations, cognitive deficits, 

impaired impulse control, and of course, suicidal and 

homicidal fantasies.
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Military Psychiatry Graduate Medical Education

Military psychiatrists must be flexible and creative, 

satisfied with limited available resources and treatment capabilities, and moderately comfortable as the 

sole psychiatrist serving troop populations as large 

as 15,000.77,78 They must accept the inability to help 

everyone, a difficult concept to acknowledge for many 

psychiatrists, who presumably entered the field to help 

their patients live happier, more productive lives. Because of the high service-member-to-psychiatrist ratio, 

military psychiatrists must also believe in the power 

of primary prevention and commit themselves to the 

concept that psychiatric care begins in the foxhole, 

where troops help one another overcome adversity. 

Psychiatrists in the military should maintain an 

air of humility and understand that a caring friend, a 

chaplain, or a commander may be more effective and 

therapeutic than a mental health professional in certain 

situations. They must also accept that the title of “captain” or “major” is sometimes preferable to “doctor” in 

military units, because the former more clearly identifies them as a part of the military team. Additionally, 

they will come to realize that most of the troops they 

serve have no idea what the difference is between a 

psychiatrist, a psychologist, and a social worker. 

The military psychiatrist must be willing to work 

under and alongside other mental health professionals, such as psychiatric nurses, social workers, and 

occupational therapists. They must also be willing to 

place a great deal of trust in the clinical abilities of their 

enlisted mental health specialists, who are often the 

first providers to make contact with service members 

seeking treatment. These personnel serve a crucial 

role in triaging patients, performing and documenting 

initial assessments, conducting educational groups, 

providing supportive counseling, and managing acute 

crises, often with fewer than 12 months of mental 

health training.79 Mental health specialists in the Reserves and the National Guard may have completely 

unrelated civilian jobs, requiring an extensive amount 

of training prior to providing patient care. Military 

psychiatry training programs incorporate into the curriculum specific experience working with other mental 

health professionals and paraprofessionals. 

Operating in a military environment under close 

scrutiny also creates a number of unique challenges. 

Military psychiatrists must always remember they are 

representatives of the US armed forces. Many military 

bases are relatively small, and psychiatrists commonly 

encounter patients and their families at various locations on post and in the surrounding communities. 

Many military psychiatrists have had the experience 

of sharing a lunch table, a medical waiting room, and 

even a shower area with their patients. Such situations, 

while essentially unheard of in a civilian setting, are 

commonplace in today’s military environment, and 

uniformed psychiatrists must be capable of maintaining good military bearing and a professional demeanor 

at all times.

Case Study 42-4: A military psychiatrist is seeing an intelligence analyst who has had difficulty sleeping since she was 

switched to the night shift 4 weeks ago, and has had a limited 

response to sleep medications. Her energy and concentration 

have reached dangerously low levels and she has already 

made a couple of mistakes on the job. While recognizing the 

soldier’s right to seek treatment confidentially, the psychiatrist has valid concerns that his patient’s ability to accurately 

report important intelligence data may be compromised. He 

contacts the soldier’s commander to recommend that she 

be given a day shift job because of her compromised ability 

to perform her duties, knowing that her security clearance 

may be suspended as a result. 

Vignette 42-4: A military psychiatrist graduated with honors from an esteemed medical school on the East Coast and 

completed a civilian residency before joining the Army. She 

was used to wearing a white coat to work and having a large 

administrative staff to assist her. She was also accustomed 

to calling her staff by their first names and to joining them 

regularly at educational dinners sponsored by pharmaceutical companies. She has a very difficult time adjusting to the 

Army and feels disrespected by the other members of her 

department, whom she regards with an air of contempt. Her 

department chief, a psychologist, counsels her multiple times 

on the importance of being a team player and interacting 

regularly with the local commands. She ultimately deploys 

to Iraq, and as soon as possible following her miserable 15 

months in the desert, elects to resign from the Army. 

Vignette 42-5: A young soldier in Afghanistan walks into 

the combat stress control clinic in the middle of a chaotic 

afternoon. The psychiatrist, who is finishing up with one 

patient and has two more waiting to see him, just learned 

that a patrol from the base was attacked and that a unit is 

requesting a critical event debriefing. He missed lunch and 

has three phone calls to return, plus a tobacco cessation 

class to teach in 30 minutes. Noticing the new soldier standing in the entryway, he snarls at her and tells her she’ll have 

to come back unless it’s an emergency. The next morning 

the psychiatrist goes to the motor pool to catch a convoy to 

a neighboring base, and discovers that this soldier will be 

his driver. 

Future of Graduate Medical Education

Military psychiatry GME faces numerous pressures 

on different fronts. As emphasis on efficiency in the 

direct care side of the military healthcare system increases, a decision on whether GME should be financed 

within the system or contracted out to the civilian side 

may become necessary. Because the field of military 
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Combat and Operational Behavioral Health

psychiatry is distinctly different than its civilian counterpart, the training of psychiatrists outside the Army 

is less tenable than in other medical specialties. The 

large shift into the core competency movement will 

directly affect the structure and content of all training 

programs. The current conflicts in the Middle East 

and the GWOT will have direct effects on the future 

of GME in psychiatry as issues involving behavioral 

health gain even more national attention. 

The viability of GME within the military, because 

of its high costs, has always been debated. As medical services inside and outside the military strive for 

optimal efficiency, medical education is placed under 

increasing pressure because of the costly general 

apprenticeship model of medical education, which 

emphasizes personal experiences with teachers, mentors, and patients. Only through personal relationships 

with teachers and mentors and plentiful patient care 

experiences can a clinician develop sophisticated 

synthesizing capabilities. Traditionally, military GME 

was not affected as much as civilian training programs 

by the managed care model, but MTF commanders 

are now assessed by workload productivity via the 

relative value unit. GME-related tasks do not produce 

relative value units and therefore have no workload 

credit, a critical factor in whether the military decides 

to continue supporting GME with military and civil 

service faculty or contract the mission to nongovernment organizations. 

The competency movement carries some promise 

for transition from time-based experiences toward a 

competency standard independent of time. Although 

more applicable to procedure-dominant medical 

specialties, the development of treatment portfolios 

of medication and psychotherapy cases will benefit 

psychiatry, allowing more longitudinal, rather than 

cross-sectional, evaluations. The competency movement will also leverage psychiatry to develop more 

relevant clinical outcome measurements, enabling 

programs to start objectively measuring their trainees’ 

patient care skills.

The current conflicts in the Middle East and the ongoing GWOT will necessitate an elevated operational 

tempo for years to come and require that the mental 

wellness of all service members receive attention from 

the military. Added emphasis on treatment of posttraumatic stress disorder and traumatic brain injury 

must be incorporated into training programs. As proximity, immediacy, expectancy, and simplicity (PIES) 

principles and force sustainment and resetting efforts 

take on increasing importance in behavioral health 

force-shaping in all environments, further emphasis 

on military psychiatry doctrine in GME programs will 

become paramount. Because the overall number of 

matriculates from USUHS and the Health Professions 

Scholarship Program has decreased in recent years, increased recruitment efforts will be necessary to ensure 

adequate numbers of future psychiatrists. 

Summary

GME is an essential aspect of ensuring safe, highquality healthcare in the United States. Training 

programs for each medical specialty must abide 

by a specific set of requirements and guidelines 

and maintain available faculty to provide adequate 

physician-in-training supervision and mentoring. 

Psychiatry GME has very extensive didactic, clinical, and supervision requirements, resulting in the 

development of a comprehensive skill set over the 

course of the training period. Military psychiatry 

GME programs observe all of these requirements, in 

addition to providing education in military-specific 

behavioral health skills, which are essential for psychiatrists to function adequately in both garrison and 

operational environments. 

Lessons learned from military conflicts over the last 

40 years indicate that psychiatric trauma from war 

is a significant medical issue; this issue has become 

a prominent concern for American society. Service 

members returning from combat deployments can 

carry psychological scars that make reintegration 

into society challenging and stressful, affecting both 

veterans and their families. Military psychiatry GME 

programs have enhanced training in all aspects of the 

deployment cycle support process to ensure that military psychiatrists are prepared to address the varied 

needs of the military family during the deployment 

cycle. With behavioral health issues secondary to military service receiving extensive scrutiny in the media 

and by government agencies, military psychiatrists 

must be comfortable practicing in potentially highprofile environments, necessitating a comprehensive 

training experience.

With the anticipated long-term duration of the 

GWOT, military psychiatry GME will continue to be 

an essential aspect of military readiness. Ongoing 

refinement of behavioral health screening throughout 

the deployment cycle, treatment of psychiatric conditions related to combat stress, and deployment-related 

interventions for military families will require military 

psychiatry GME programs to be flexible in modifying military-specific training while complying with 

the standard requirements mandated by ACGME. 

Retention of qualified military GME program faculty 
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Military Psychiatry Graduate Medical Education

as mentors, role models, and subject matter experts 

will ensure the continued development of competent 

military psychiatrists prepared to support US service 

members and their families. 

References

1. US Department of the Army. Commissioned Officer Professional Development and Career Management. Washington, DC: 

DA; 2007. DA Pamphlet 600-3.

2. Diebold CJ. Military administrative psychiatry. In: Lande G, Armitage D, eds. Principles and Practice of Military Forensic 

Psychiatry. Springfield, Ill: Charles C Thomas; 1997. 

3. US Department of Defense. Mental Health Evaluations of the Members of the Armed Forces. Washington, DC: DoD; 1997.

DoD Directive 6490.1.

4. Joint Service Committee on Military Justice. Manual for Courts Martial United States. Washington, DC: US Government 

Printing Office; 2005. 

5. US Department of the Army. Personnel Security Program. Washington, DC: DA; 1988. Army Regulation 380-67.

6. US Department of the Army. Standards of Medical Fitness. Washington, DC: DA; 2007. Army Regulation 40-501.

7. Accreditation Counsel for Graduate Medical Education. Psychiatry program requirements. ACGME Web site. Available at: http://www.acgme.org/acWebsite/RRC_400/400_prIndex.asp. Accessed November 23, 2007.

8. Wise MG. The past, present, and future of psychiatric training in the US armed services. Mil Med.1987;152:550–553.

9. Heaton LD, Anderson RS, Glass AJ, Bernucci R, eds. Zone of Interior. Vol 1. In: Neuropsychiatry in World War II. Washington, DC: Department of the Army, Office of The Surgeon General; 1966.

10. Ozarin LO, McMillan G. The American Psychiatric Association: historical highlights. American Psychiatric Association Web site. Available at: http://www.psych.org/public_info/libr_publ/apahighlights.cfm. Accessed November 

23, 2007.

11. Bailey P, Williams FE, Komora PO. Neuropsychiatry. Vol X. In: The Medical Department of the United States Army in the 

World War. Washington, DC: US Government Printing Office; 1929.

12. US Army Center of Military History. Number of Army personnel who served during each major war, and the number 

of casualties incurred. US Army Center of Military History Web site. Available at: http://www.army.mil/cmh-pg/

faq/FAQ-C&C.htm. Accessed November 23, 2007.

13. Steyn RW. Retrospections: a sketch of nautical psychiatry through World War II. Mil Med. 1980:145:407–412.

14. Taylor RR, Mullins WS, Parks RJ. Medical Training in World War II. Washington, DC: Department of the Army, Office 

of The Surgeon General; 1974.

15. Menninger WC. Psychiatric experience in the war, 1941–1946. Am J Psychiatry. 1947:104:577–586.

16. Forrer GR, Grisell JL. US Army psychiatric training program. AMA Arch Neurol Psychiatry. 1957:77:218–277.

17. Department of the Army. Department of Defense Report to the Defense Base Closure and Realignment Commission. Vol 

III. Washington, DC: DA; 1995. Available at: http://www.defenselink.mil/brac/army.htm. Accessed November 23, 

2007.

18. Defense Base Closure and Realignment Act of 1990. Pub L No. 101-510 (1990).

19. The Defense Secretary’s Commission on Base Realignment and Closures. Report of the Defense Secretary’s Commission. Washington, DC: DoD; 1988. Available at: http://www.defenselink.mil/brac/army.htm. Accessed November 23, 2007.
690

Combat and Operational Behavioral Health

20. Pincus SH, Staff Psychiatrist, Madigan Army Medical Center, Fort Lewis, Washington. Personal communication, 

February 2007.

21. Orman DT, Director, PTSD-TBI/BH Integration Office, USAMEDCOM, Fort Sam Houston, Texas. Personal communication, April 2007. 

22. Defense Base Closure and Realignment Act of 1990 (as amended in 2004). Pub L No. 101-510 (2004).

23. Department of Defense, San Antonio Military Medical Center. San Antonio medical BRAC. SAMMC Web site. Available at: http://www.sambio.amedd.army.mil/About.htm. Accessed November 23, 2007.

24. Moran M. Medical school grads’ interest in psychiatry holds steady. Psychiatry News. 2007;42(8):1.

25. US Department of the Army. The leader, leadership, and human dimensions. In: Army Leadership Be, Know, Do. Washington, DC: DA; 1999. Army Field Manual 22-100. Part 1.

26. Accreditation Counsel for Graduate Medical Education. Duty hours language. ACGME Web site. Available at: http://

www.acgme.org/acWebsite/dutyHours/dh_Lang703.pdf. Accessed November 23, 2007.

27. Ritchie EC. Colonel, Medical Corps, US Army; Psychiatry Consultant to the Army Surgeon General. Personal communication, February 2007.

28. Barthel HJ. US Army Medical Corps Chief’s Briefing, presented at Tripler Army Medical Center, Hawaii, August 

2006. 

29. Canadian Medical Education Directions for Specialists (CanMEDS) 2000 Project. Skills of the New Millennium: Report 

of the Societal Needs Working Group. Ottawa, Ontario, Canada: Royal College of Physicians and Surgeons of Canada; 

1996. 

30. American Board of Medical Specialties Task Force on Competence. Proceedings From the 1999 Professional Competence 

and Board Certification Conference, Chicago, Illinois, 18–19 March, 1999. ABMS Web site. Available at: http://www.abms.

org/About_ABMS/ABMS_History/Extended_History/Competency_Movement.aspx. Accessed February 28, 2011.

31. Joint Commission on the Accreditation of Healthcare Organizations. Comprehensive Accreditation Manual for Hospitals. 

Oakbrook Terrace, Ill: Joint Commission; 2007.

32. National Cancer Institute. A guide to understanding informed consent. NCI Web site. Available at: http://www.cancer.

gov/clinicaltrials/conducting/informed-consent-guide/allpages. Accessed November 23, 2007

33. US Department of the Army. Oath of Office—Military Personnel. Washington, DC: DA; 1999. Department of the Army 

Form 71.

34. Sadock BJ, Sadock VA. Public and hospital psychiatry. In: Kaplan and Sadock’s Synopsis of Psychiatry. 9th ed. Philadelphia, 

Penn; Lippincott, Williams & Wilkins; 2003: 1376–1377.

35. My Evaluations Web site. Available at: https://www.myevaluations.com/Logon.asp. Accessed November 23, 2007.

36. Bender E. New residency requirements divide training directors. Psychiatric News. 2003;38(7):14.

37. Accreditation Counsel for Graduate Medical Education. ACGME Outcome Project. ACGME Web site. Available at: 

http://www.acgme.org/outcome. Accessed November 23, 2007.

38. Accreditation Council for Graduate Medical Education. Essentials of accredited residencies. In: Directory of Graduate 

Medical Education Programs. Chicago, Ill: American Medical Association; 1984: 81.

39. US Department of the Army. Heavy Brigade Combat Team Combined Arms Battalion. Washington, DC: DA; 2005. Field 

Manual 3-90.5.
691

Military Psychiatry Graduate Medical Education

40. Howe EC. Special problem for military psychiatrists. In: Simon RI, ed. Review of Clinical Psychiatry and the Law. Washington, DC: American Psychiatric Association Press; 1992: 305–307.

41. American Medical Association. Principles of medical ethics. AMA Web site. Available at: http://www.ama-assn.org/

ama/pub/category/2512.html. Accessed November 23, 2007.

42. US Department of the Army. Deployment Cycle Support (DCS) Directive. Washington, DC: DA; 2007. Army Directive 

2007-02. Appendix A-6.

43. 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.

44. Faran ME, Weist MD, Saito AY, Yoshikami L, Weiser JW, Kaer B. School-based mental health on a United States Army 

installation. In: Weist MD, Evans SW, Lever NA, eds. Handbook of School Mental Health: Advancing Practice and Research.

New York, NY: Kluwer Academic/Plenum Publishers; 2003: Chap 14.

45. Waits WM, Waldrep D. Application of Army combat stress control doctrine in work with Pentagon survivors. Mil 

Med. 2002;167(9 suppl):39–43.

46. Milliken CS, Leavitt WT, Murdock P, Orman DT, Ritchie EC, Hoge CW. Principles guiding implementation of the 

Operation Solace plan: “Pieces of PIES,” therapy by walking around, and care management. Mil Med. 2002;167(9 

suppl):48–57.

47. Accreditation Counsel for Graduate Medical Education. Reports—list of programs by specialty. ACGME Web site. 

Available at: http://www.acgme.org/adspublic/. Accessed November 25, 2007.

48. Society of Medical Consultants to the Armed Forces. Military Graduate Medical Education Under Stress: A White Paper. 

Fredericksburg, Va: SMCAF; 1987. Available at: http://www.smcaf.org/Military%20GME%20Under%20Stress%20

1987.pdf. Accessed November 25, 2007.

49. Bonn KE. Army Officers Guide. 50th ed. Mechanicsburg, Penn: Stackpole Press; 2005.

50. Powers R. Army enlisted job descriptions and qualification factors. About.com: US Military Web site. Available at: 

http://usmilitary.about.com/od/enlistedjobs/a/92g.htm. Accessed October 27, 2009.

51. Cave D. For Army recruiters, a hard toll from a hard sell. New York Times. March 27, 2005. Available at: http://www.

nytimes.com/2005/03/27/nyregion/27recruit.html. Accessed October 26, 2009.

52. US Department of the Army. Army Substance Abuse Program. Washington, DC: DA; 2006. Army Regulation 600-85.

53. US Department of the Army. The Army Family Advocacy Program. Washington, DC: DA; 2006. Army Regulation 608-

18.

54. US Department of the Army. Medical Record Administration and Health Care Documentation. Washington, DC: DA; 2006. 

Army Regulation 40-66.

55. US Department of the Army. Physical Evaluation for Retention, Retirement, or Separation. Washington, DC: DA; 2006. 

Army Regulation 635-40.

56. US Department of the Army. Army Community Service Center. Washington, DC: DA; 2006. Army Regulation 608-1.

57. Military OneSource Web site. 2007. Available at: http://www.militaryonesource.com/skins/MOS/home.aspx. Accessed November 25, 2007.

58. US Department of the Army. Officer Transfers and Discharges. Washington, DC: DA; 2006. Army Regulation 600-8-24.

59. US Department of the Army. Active Duty Administrative Separations. Washington, DC: DA; 2005. Army Regulation 

635-200.
692

Combat and Operational Behavioral Health

60. Military Whistleblower Protection Act of 1988, 10 USC § 1034 (1988).

61. US Department of the Army. Suicide Prevention and Psychological Autopsy. Washington, DC: DA; 1988. DA Pamphlet 

600-24.

62. US Department of the Army. Line of Duty Policy, Procedures, and Investigations. Washington, DC: DA; 2004. Army Regulation 600-8-4.

63. Department of Defense. Psychological autopsies. TRICARE Web site. Available at: http://mhs.osd.mil/pdfs/policies/2001/01-016.pdf. Accessed November 25, 2007.

64. US Army Suicide Risk Management and Surveillance Office. Army Suicide Event Report. ASER Web site. Available 

at: https://aser.amedd.army.mil/aser. Accessed November 25, 2007.

65. US Department of the Air Force. Aeromedical Evacuation Patient Considerations and Standards of Care. Washington, DC: 

US Government Printing Office; 2003. Air Force Instruction 41-307, Attachment 6.

66. US Department of the Army. Patient Administration. Washington, DC: DA; 2006. Army Regulation 40-40.

67. US Department of the Army. Composition, Mission, and Functions of the Army Medical Department. Washington, DC: DA; 

1983. Army Regulation 40-1.

68. US Department of the Army. Combat and Operational Stress Control. Washington, DC: DA; 2006. Field Manual 4-02.51 

(formerly Field Manual 8-51). 

69. US Department of the Army. Combat Stress. Washington, DC: DA; 2000. Field Manual 6-22.5.

70. Office of the Surgeon, Multinational Force–Iraq. Mental Health Assessment Team (MHAT-III) Operation Iraqi Freedom Report. Washington, DC: Department of the Army; 2006. Available at: http://www.behavioralhealth.army.mil/research/

index.html. Accessed November 25, 2007.

71. 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;351:13–22. 

72. US Department of Defense. Requirements for Mental Health Evaluations of the Members of the Armed Forces. Washington, 

DC: DoD; 1997. DoD Instruction 6490.4.

73. US Department of the Army. Preparing and Managing Correspondence. Washington, DC: DA; 2002. Army Regulation 

25-50.

74. US Department of the Army. Evaluation Reporting System. Washington, DC: DA; 2007. Army Regulation 623-3.

75. US Department of the Army. Military Awards. Washington, DC: DA; 2006. Army Regulation 600-8-22.

76. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 4th ed. New York, NY: Oxford University Press; 1994.

77. Ritchie EC, White R. Becoming a successful division psychiatrist: guidelines for preparation and duties of the assignment. Mil Med. 1993;158(10):644–648.

78. Hill JV, Lange C, Bacon B. Becoming a successful division psychiatrist: the sequel. Mil Med. 2007;172(4):364–369.

79. US Army Recruiting Command. Careers & jobs: mental health specialist (68X). GoArmy.com Web site. Available at: 

http://www.goarmy.com/JobDetail.do?id=160#training. Accessed November 25, 2007.