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Psychiatric Consultation to Command

Chapter 12

PSYCHIATRIC CONSULTATION TO 

COMMAND

CHRISTOPHER H. WARNER, MD*; GEORGE N. APPENZELLER, MD†; JILL E. BREITBACH, PsyD‡; JENNIFER T. LANGE, MD§

; ANGELA MOBBS, PsyD¥; and ELSPETH CAMERON RITCHIE, MD, MPH¶

INTRODUCTION

ORIGIN AND HISTORY OF PSYCHIATRIC COMMAND CONSULTATION

FACTORS ASSOCIATED WITH COMMAND CONSULTATION

PERFORMING THE CONSULTation

DETERMINING FITNESS FOR DUTY AND DEPLYOMENT CLEARANCE

COMMAND-DIRECTED EVALUATIONS

RISKS TO THE CONSULTANT AND ETHICAL ISSUES IN CONSULTATION

NOTABLE CONSULTATIVE POSITIONS IN THE ARMY

SUMMARY

*Major, Medical Corps, US Army; Chief, Department of Behavioral Medicine, Winn Army Community Hospital, Building 9242, Room 20, 1083 Worcester 

Drive, Fort Stewart, Georgia 31324; formerly, Division Psychiatrist, 3rd Infantry Division, Fort Stewart, Georgia

†

Lieutenant Colonel, Medical Corps, US Army; Commander, US Army Medical Activity, Alaska, 1060 Gaffney Road #7400, Fort Wainwright, Alaska 

99703-7400; formerly, Deputy Commander for Clinical Services, Command Group, Winn Army Community Hospital, Fort Stewart, Georgia 31314 

‡

Major, Medical Service Corps, US Army; Neuropsychologist, Department of Psychology, Evans Army Community Hospital, USAMEDDAC, 1650 

Cochrane Circle, Fort Carson, Colorado 80913; formerly, Group Psychologist, 1st Special Warfare Training Group, Fort Bragg, North Carolina 

§

Lieutenant Colonel, Medical Corps, US Army; Medical Director, Behavioral Health Clinic, Department of Psychiatry, Walter Reed Army Medical Center, 

6900 Georgia Avenue NW, Washington, DC 20307-5001

¥

Captain, Medical Service Corps, US Army; Special Forces Assignment and Selection Psychologist, Special Warfare Center and School, Rowe Training 

Facility, Building T-5167, 1500 Camp Mackall Place, Marston, North Carolina 28363; formerly, Brigade Psychologist, 3rd Brigade Combat Team, 3rd 

Infantry Division, Fort Benning, Georgia 

¶

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

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

NE, 4th Floor, Washington, DC 20002
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Combat and Operational Behavioral Health

INTRODUCTION

The psychological effects of warfare have been well 

documented throughout history. Since World War I, the 

US Army has been deploying behavioral health assets to 

the front line for treatment of combat operational stress 

and to advise unit commanders about combat stress 

and its effects on soldiers. Currently, commanders of 

combat units are being encouraged to attend to the overall health of their soldiers, including consulting with 

behavioral health professionals about the psychiatric 

well-being of their soldiers. One of the many challenges 

that behavioral health professionals are confronted with 

is the need to educate commanders about the role of 

psychiatric command consultation. This chapter outlines the many responsibilities of this role. 

ORIGIN AND HISTORY OF PSYCHIATRIC COMMAND CONSULTATION

Whereas mental health evaluations are typically 

thought of in terms of an encounter between a provider and a patient, a psychiatric command consultation occurs when a military commander desires to 

know mental health information or factors about an 

individual, unit, or command, and how to improve 

overall behavioral health. Historically, psychiatric 

command consultation has occurred in two different 

capacities: (1) attempts to screen for vulnerability 

and determine fitness for duty, and (2) preventive 

psychiatry. Previous overviews have described the 

history related to these components in depth. It is 

important to know how these roles have developed 

when outlining the future of psychiatric command 

consultation.1

 Additionally, although “psychiatric 

consultation” will often be performed by psychiatrists, other behavioral health professionals will also 

perform these consultations, thus, the term “behavioral health professionals” is used in discussion of 

consultations. For guidance regarding the specific 

roles of psychiatrists, psychologists, social workers, 

and technicians, the reader is encouraged to explore 

their individual discipline regulations. 

Screening for Vulnerability and Determining 

Fitness for Duty

For individuals desiring to enter the military, their 

first encounter with medical personnel will generally 

be at the Military Entrance Processing Station. Here 

new recruits complete a thorough medical evaluation 

that includes answering questions regarding mental 

health. Certain individuals may be barred from entry to 

service or require further evaluation prior to entering 

the military. This process, a reflection of the recognized 

need to screen military personnel for psychiatric vulnerabilities, dates back to the mid-18th century. 

“Nostalgia,” which was the recognized ailment 

defined by Aurenbrugger in 1761, was the term used 

to describe the “disease” where soldiers lost hope, 

became sad, isolative, inattentive, and apathetic—what 

today is commonly termed “combat stress.”2

 French 

physicians of the Napoleonic era recognized factors 

associated with producing and preventing nostalgia, 

and began screening soldiers accordingly.2

The US military began psychological screening 

in the early 20th century. During World War I, the 

famous Army Alpha and Beta testing and psychiatric 

interviews were applied to screen the massive influx of 

military recruits needed to fight the war.3 At that time, 

the personality and estimated intellectual functioning 

of each individual was assessed, and recommendations regarding suitability for military service and 

service specialties were made. The decisions made 

concerning suitability largely reflected the belief that 

psychiatric symptoms and illnesses reflected a “weak 

personality”; individuals with psychoneurotic illness 

were not normal, and thus not capable of marshalling 

defenses needed to serve during war.3 This method 

of screening military soldiers for service is largely 

viewed by historians as a failure.4 However, as a consequence of the efforts, the perception of psychology 

as a valuable science capable of producing results of 

immediate and practical significance to command was 

substantially bolstered.5

In 1941, Harry Stack Sullivan was appointed as a 

psychiatric consultant to the Selective Service Program 

and helped develop a more comprehensive system that 

incorporated screening interviews.6 However, over the 

course of World War II, attitudes changed about the 

effectiveness of these screening methods and many began to view them as excessive, ineffective in accurately 

predicting the resilience of individuals to withstand the 

risks of war, and resulting in a substantial and excessive loss of potential soldiers.6–8 After World War II, 

psychiatric screening methods were modified to focus 

on identifying and disqualifying only gross psychiatric 

disorders. This process has remained in place since 

then, with varying modifications over time. 

Although the screening purpose has remained 

relatively unchanged, the debate continues over the 

role that preexisting medical and psychiatric conditions have in making individuals more vulnerable to 

negative outcomes in times of stress. Conflicting data 
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Psychiatric Consultation to Command

continue to exist as to whether preexisting psychological conditions are a contributing factor to psychiatric 

attrition in a combat zone.9–18 This debate is especially 

salient given the estimated rates of depression, anxiety, 

and posttraumatic stress disorder in returning Operation Iraqi Freedom and Operation Enduring Freedom 

veterans.19

What remains unclear is what number of service 

personnel experiencing psychiatric problems upon 

return from combat had preexisting mental health 

conditions before deployment and, more specifically, 

what number had conditions that existed prior to 

entry into the service. The psychiatric conditions that 

should perhaps preclude service because of vulnerability under stress, which may only have minimal 

effects on the well-being of soldiers in combat, are not 

yet understood. 

Since the establishment of the Office of Strategic 

Services in World War II, screening processes have 

also been conducted in soldiers seeking special duties. Through the years, the role of behavioral health 

professionals has evolved with expansion of special 

operations and special missions. Not only do psychologists screen applicants for suitability for special 

operations, they also monitor progress throughout 

special operations training.20 After training has been 

completed, psychologists screen soldiers for special 

missions, which requires these behavioral health 

professionals to carefully assess the “biopsychosocial 

fit” of individuals to their specified mission tasks. 

Mental health providers must become familiar with 

the demands that will be placed on the soldier (ie, 

isolation from others, exposure to extreme conditions), and work intimately with command regarding the establishment of desired competency for the 

mission. This aspect of command consultation is 

unique in that the commander of the mission will 

often dictate aspects of required competencies. It 

is the job of the mental health professional to apply these principles in a psychiatric framework for 

screening. Assessments are presently performed for a 

variety of special missions (special operations service 

members) or specialty job requirements (security 

clearance evaluations, intelligence positions, nuclear 

weapons specialists). 

Preventive Psychiatry

Military psychiatrists were the first to focus on the 

total social environment of the individual in establishing programs not only for the treatment, but also the 

prevention, of mental illness.11 This shift in focus came 

in 1944, when the Army began using psychiatrists in 

a preventive fashion, morphing the role of psychiatry 

from overseeing straight disposition of personnel into 

recommending how to use marginal personnel and 

implementing mental hygiene training programs.21

Furthermore, the Vietnam War provided a unique 

opportunity to understand combat, from which significant understanding of the individual’s response 

to extreme conditions was gained.11 Thus, the role 

of psychiatry in providing primary, secondary, and 

tertiary prevention training based on understanding 

the biopsychosocial influences on behavior was established. The effectiveness of preventive psychiatry 

was later shown by the Group for the Advancement 

of Psychiatry when it reported that preventive psychiatry could reduce combat ineffectiveness through 

early recognition and prompt outpatient treatment of 

emotional difficulties during combat and noncombat 

situations.22

Much of what is understood about prevention of 

psychiatric casualties comes from the work of William 

C Menninger, who identified the failure to meet basic 

needs (such as food, water, sleep, social interaction, 

and recreation) as a significant contributor to the incidence of psychiatric casualties in combat.7

 Likewise, 

unit cohesion and morale have repeatedly been found 

important in supporting individual coping behavior 

and unit performance, both in wartime and in peacetime.23,24 Although morale remains difficult to operationally define, it may be considered to represent the 

general sense of unit cohesion, confidence in ability, 

and overall well-being of a unit. Failure to experience 

positive morale in a group (because of a lack of order 

and security, a lack of fusion with the group, having 

insufficient leadership, or lack of absorption into the 

unit’s work) has been associated with increased psychiatric referral, at least upon initial deployment.23

Morale and unit cohesion are often synonymous; one 

of the greatest defenses against breakdown in combat 

is the development and reinforcement of group cohesiveness.25

Additionally, it has been well documented throughout history that the time spent exposed to combat correlates with the number of psychiatric casualties.21–26

This was perhaps most salient in the Vietnam War, 

where soldiers knew that if they could survive for 12 

months, their removal from combat was assured. The 

rest-and-recreation policy, which sought to reduce continued exposure, was also widely implemented. The 

effect of time on psychiatric visits has also been seen 

in recent conflicts, where multiple studies have noted 

an increase in combat operational stress reactions after 6 months of deployment.26,27 Understanding these 

factors, as well as their historical context, provides a 

framework for application of current principles and 

avoidance of prior pitfalls.
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FACTORS ASSOCIATED WITH COMMAND CONSULTATION

As the consultant prepares to perform an evaluation, there are several factors that must be considered. 

These include the environment, the nature of the request, and the proximity of the consultant to the unit 

or individual being evaluated.

Deployed Versus Garrison

Consultations can vary significantly depending 

on the environment. In a garrison environment, commanders are generally looking for risk reduction 

methods and to determine if a soldier is fit for duty 

or deployment. During deployment, commanders 

are more focused on interventions for maintaining 

their combat power and assessing the levels of unit 

cohesion and soldier quality of life to maintain soldier 

readiness. 

Level of Preventive Consultation

Preventive consultative advising involves using the 

threats identified during the planning and oversight 

phases of operations and making recommendations 

to the medical staff and command on measures to be 

taken and areas requiring command emphasis. Three 

categories of prevention can generally occur both in 

the garrison and deployed environment: (1) primary 

prevention, (2) secondary prevention, and (3) tertiary 

prevention. These prevention activities are especially 

critical in the deployed environment given that resources may be limited.

Primary Prevention

Primary prevention generally comes in the form 

of education. Most units regularly employ periodic 

training on topics such as prevention of sexual assault, 

suicide, and substance abuse. These training sessions 

allow behavioral health professionals an opportunity 

to gain visibility with command and soldiers alike. 

Furthermore, behavioral health professionals can play 

key advisory roles in preparation for deployment, as 

well as during deployment, in such areas as training 

(including training schedules), personnel issues, discipline, crosscultural issues, and, most importantly, the 

morale of the unit. All preventive services provided in 

garrison and during deployment establish credibility 

with the command. 

Recently, in response to evolving technology and 

the recognition that soldiers and commanders are 

presented with differing stressors throughout the 

deployment cycle, the Army Medical Department 

designed an educational series called “Battlemind” 

training.28 These modules were designed for specific 

portions of the deployment cycle, to build upon a 

soldier’s strength, help soldiers develop resiliency in 

stressful situations, and to teach soldiers how to utilize 

their strengths during times of transition. Modules 

for both soldiers and their families were designed for 

predeployment, reintegration (immediate return from 

a deployment), and reconstitution (90–180 days after 

return from deployment).28 Initial research on the effectiveness of “Battlemind” training appears promising; 

this effectiveness will continue to be explored.26,29

Secondary Prevention

Secondary prevention involves identifying as early 

as possible those soldiers who are at risk to develop 

mental health problems and intervening to prevent 

the development or worsening of symptoms after exposure. These types of procedures are accomplished 

both through individual and unit-level screening and 

also through traumatic event management.

Postdeployment psychological screening has been 

growing in importance since Operation Desert Storm 

in 1991 and became mandatory in 1997.30,31 Shortly 

thereafter, the Department of Defense introduced the 

Post-Deployment Health Assessment, which screened 

soldiers for physical and mental health problems 

upon return from deployment. It was a method for 

early identification of problems and for decreasing 

the stigma associated with behavioral healthcare. 

However, few studies have looked at validating the 

postdeployment screening instrument against other 

measures or functional outcomes.32,33 Furthermore, 

experiences from other samples of returning soldiers 

indicate that rates of reported deployment-related 

symptoms increased with time after returning from 

deployment.19,34,35 This led to an extension of the PostDeployment Health Assessment program to include 

a reevaluation (the Post-Deployment Health Reassessment) at 3 to 6 months after return from a combat 

zone.36 These programs allow for early identification; 

however, there has been notable criticism that effective 

follow-up of the concerns identified has not occurred.37

It is important that consultants be engaged throughout 

these screening processes and that commanders be 

very involved. Both occurrences will increase soldier 

participation and help decrease the potential for soldiers to “fall through the cracks.”38

Other assessment methods allow for broad unitwide assessments rather than individual screenings. 

An example of this type of method is the Unit Behav-
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ioral Health Needs Assessment. This tool allows the 

consultant to take a sampling of a unit, employing a 

standardized survey that assesses areas such as morale, 

cohesion, ongoing stressors, and soldier concerns, as 

well as current levels of need and barriers to care. 

This allows the consultant to provide the commander 

with clear objective findings and provide customized 

recommendations specific to the unit. Additionally, the 

Unit Behavioral Health Needs Assessment has comparison data that have been collected from multiple 

units at varying stages throughout Operation Iraqi 

Freedom to serve as a gauge.39

Another area of secondary preventive psychiatric 

consultation is that of traumatic event management 

(TEM). TEM involves intervening after a potentially 

traumatic event has occurred, with the purpose of 

seeking to decrease the effect of the event and prevent 

long-term negative consequences. Considerable debate 

continues between both military and civilian behavioral health providers about the utility and efficacy of 

debriefings (which are traditionally part of an overall 

TEM strategy) as preventative interventions. Traditionally, the TEM process is conducted at the request of a 

unit supervisor to begin the process of integrating a 

traumatic experience into the individual and group 

experience. Debriefings involve a structured meeting 

of all parties directly involved with a traumatic event. 

Members of the group tell their individual stories 

about what happened in the presence of trained behavioral health providers or chaplains, followed by 

processing of the cognitive and emotional components 

of the event. 

Currently there are many different models for 

debriefings. Most evolved out of Marshall’s work in 

World War II when he attempted to record accounts of 

unit operations for historical purposes.40 Interestingly, 

these initial sessions were not for the expressed purpose of psychological benefits to the involved parties. 

Marshall noted, however, that during the process of 

debriefing many misperceptions were corrected by 

other individuals involved in the traumatic event, 

and the debriefing appeared to render social support 

and decrease the development of combat stress reactions.40

Although debriefings have been used throughout 

military conflicts, their effectiveness has not been 

well documented in research studies and they have 

not been proven to prevent posttraumatic stress disorder.41–44 Part of the problem in examining the utility 

of debriefings is the evolution of what TEM actually 

entails. In fact, “debriefings” are now thought to take 

many forms commonly used by all military personnel, to include after-action reviews, which are now a 

standard operating procedure for all US Army teams 

and small units following any training exercise.40

Other forms of debriefings include defusing, critical 

event debriefing, critical incident stress debriefing, 

psychiatric debriefing, historical debriefing, and intelligence debriefing. Thus, one of the inherent problems 

in determining the effectiveness of TEM is the lack of 

consistent standardized protocols across providers and 

across organizations. Furthermore, what constitutes a 

debriefing, or what form of a debriefing to use for a 

particular circumstance, often varies. 

Despite all of the inherent problems in TEM definition, standardization, and demonstrable utility, TEM 

nonetheless remains a common consultation task that 

is expected of behavioral health providers, and thus it 

is imperative that behavioral health providers be proficient in TEM. US Army Field Manual 4-02.51, Combat 

and Operational Stress Control,

45 provides a standardized 

outline and structure for current TEM operations. The 

Army has recently introduced Battlemind psychological debriefings.46 These debriefings take into account 

military rank and structure and incorporate resiliency 

based educational principles that help to build upon 

the soldier’s strengths during the process. As with 

other debriefing methods, the effectiveness of this 

process is not known at this time.

Tertiary Prevention

Disease nonbattle injuries—specifically combat operational stress and psychiatric casualties—have long 

accounted for vast numbers of non–mission-capable 

soldiers. Indeed, one of the defining principles of history’s victorious commanders has been to “break the 

enemy’s will to fight,” and thus produce combat stress 

and psychiatric casualties in the opposing force. History has revealed consistent themes in soldiers who 

persevere in combat compared with those who break 

down in combat, with the difference in outcome often 

being reduced to adaptability and cohesion.23,24 Tertiary 

prevention involves the treatment of those who have 

ongoing issues, with the goal to return soldiers to duty 

and to advise commanders on who should be removed 

from the combat operations. 

Internal (Division Mental Health) Versus External 

(Combat Stress Detachment) Resources

The primary resources responsible for preventive 

psychiatry missions and the control of combat operational stress during both garrison and deployment are 

the combat stress control (CSC) and division mental 

health (DMH) units. These units establish a diplomatic 

relationship with command to earn credibility in the 

consultative role. Preventive missions of both of these 
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Combat and Operational Behavioral Health

units are defined by US Army doctrine as the following: consultation-liaison services; reorganization and 

reconstitution support; proximate neuropsychiatry 

triage; and stabilization, restoration, and reconditioning and retraining.23

Although the mission is the same, the two units 

have notable differences that present varying challenges. DMH units are organic to the organization and have 

been deploying in that structure since World War II.47,48

Recently, the transformation of the US Army from a 

division-centric focus to one in which the brigade combat team is the primary unit of action has resulted in the 

expansion of the DMH organization and mission. (In 

this volume, Chapter 6, The Division Psychiatrist and 

Brigade Behavioral Health Officers, discusses DMH 

and the positions within it at much greater length.) 

DMH units are with the larger organization both in 

garrison and during deployment and thus have the 

ability to establish long-term relationships with commanders and implement long-term prevention plans. 

These units, however, tend to be smaller and more 

limited in capability than CSC units. 

Like DMH units, CSC detachments have been 

evolving for quite some time in the US Army. They 

first appeared during the Korean War when Colonel 

Albert Glass established these teams to augment 

existing DMH assets.47 Glass, drawing on his own 

experiences from World War II, organized what were 

called “KO” teams (the “KO” designation refers to 

one in a series of hospital augmentation detachments). 

They provided mobile consultation throughout the 

corps and US Army areas.47 The first KO teams were 

deployed to Korea; CSCs have augmented organic 

mental health assets in every major conflict since that 

time. They officially became known as CSCs in the 

mid-1980s. Presently, the CSC model remains largely 

unchanged from that originally established by Colonel 

Glass; however, the mission has expanded to include 

additional preventive psychiatric care and restoration 

capabilities. Today, CSC detachments and companies 

traditionally provide US Army Echelon II or III care 

during deployed operations and are external to the 

brigade, division, or other unit.45

Local Versus Remote Behavioral Health Resource

The type of consultation may dictate the use of a 

local versus a remote behavioral health resource. For 

issues that will require ongoing follow-up and will 

require a relationship with a commander, it is best to 

use local resources. These individuals are more apt to 

have some familiarity with the systems, personnel, and 

processes involved and can develop ongoing relationships with the commanders and provide follow-up. 

An excellent example of this process is the use by a 

brigade behavioral health officer of a unit behavioral 

health needs assessment within a battalion. The officer 

may have only a limited relationship with that commander but has some familiarity with the brigade. The 

officer performs the assessment and informs the command of the key findings and recommendations. As 

a local resource, the brigade behavioral health officer 

is then able to follow up with the unit and continue 

to both monitor and reassess the situation to provide 

continued feedback to the leadership. These processes 

allow for identification of such items as barriers to care, 

stigma about using mental healthcare, and leadership 

issues.

In contrast, remote consultations will generally require mobilization of a team to conduct an evaluation, 

make recommendations, and then return to its home 

station, likely not to follow up again or with limited 

follow-up. These types of consultations tend to occur 

in units that have minimal mental health contacts 

or desire an independent assessment from someone 

who has minimal to no knowledge of the unit or its 

experiences. 

Examples of these types of consultation can be seen 

in the site assistance visit or with the epidemiologic 

consultation team evaluations of suicide behaviors that 

have occurred at several sites throughout the Army in 

the past several years. In these cases, the team arrives, 

does a thorough analysis of potential factors, interviews individuals from the unit, and then provides a 

report of its findings and recommendations. It is left 

to the unit and local personnel to enact and follow up 

those recommendations. 

PERFORMING THE CONSULTation

Forming a Consultative Team

A consultation can be completed by either an 

individual clinician or by a team. If forming a team, 

the lead consultant should seek individuals who 

either have areas of expertise that will be needed to 

answer the consultation question, or with similarities 

in experience or background to the group requesting the consult. When assembling a team, it is also 

important to ensure it can work cohesively. The lead 

consultant must make clear the roles and duties of 

each team member. This can be especially difficult if 

the members have not worked together before and 

are coming together solely for the purpose of a consultation. It is often immediately evident if a team is 

or is not working together. Team cohesion will often 
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Psychiatric Consultation to Command

determine success of the consultation process and 

whether the consultation is performed adequately, 

effectively, and efficiently.

Formulating the Consultation Question

Prior to performing the consultation, the clinician 

should ensure that the question being asked has been 

clarified. For instance, the consultative question can 

concern clinical care requirements or the deployability of a particular soldier, or it may include a broader 

question of unit policy, behaviors, or actions. The consultative team needs to ensure that it focuses its efforts 

to meet the needs of the requesting commander. The 

team should only give additional information about individuals on a need-to-know basis. Once the nature of 

the request is determined, specific goals of the consultation must be established. Often command and other 

military personnel are unclear of their desired “goals,” 

and are best able to describe a “desired end state.” 

Setting specific goals at the onset of the consultation 

will ensure that expectations are met. It will also help 

prevent any misperceptions of what the consultative 

team is doing or its capabilities. In addition to setting 

goals, it is also important to explain the limitations of 

the consultative team. One specific difficulty can arise 

if the requesting commander believes that a consultation also provides treatment. An illustration of this 

misperception is discussed below. 

Case Study 12-1: A company commander came to the 

brigade behavioral health office during a deployment in Iraq. 

He stated that one of his route clearance platoons was recently having behavioral problems. It was also failing to find 

as many improvised explosive devices as it had on previous 

missions. After the brigade behavioral health officer went on a 

route clearance mission with the platoon members, it became 

evident they were fatigued—arguing with each other instead 

of focusing on the mission—and frustrated about not having 

had a day off in weeks. When this information was shared 

with the company commander, the command expressed 

confusion with regards to the outcome of the consultation. 

Specifically, the command in this instance had expected the 

brigade behavioral health officer would “fix” the soldiers by 

just spending time with them. Instead, the behavioral health 

officer had taken the consultative question and developed 

recommended changes in the soldiers’ schedules. This 

example highlights the need for the consulting provider to 

clarify the request, set clear goals, and explain the limitations 

of the consultation services. Attention to these processes 

can ensure both parties are clear about the goals of the 

consultation and satisfied with its outcome. 

Gaining Entry to the Unit

A consultation generally occurs at the request of the 

unit’s commander. First and foremost, an appropriate 

member of the chain of command must request the 

consultation. During deployments, this can be difficult, 

because many individuals, especially those in combat 

stress detachments, want to assist the unit. However, 

if their participation is not invited, the “consultation” 

may develop into a confrontational relationship with 

the commander. 

Additionally, the consultation team must establish 

rapport with the soldiers being evaluated. It should be 

clear that the team is there to help the unit, not to blame 

or hold certain members responsible for any problems 

that the unit may have. Demonstrating that the team 

cares and wants to make improvements will increase 

the willingness of the unit to disclose factual as well 

as emotional material, thus providing information that 

may assist in answering the consultation question. 

It is important that the unit views the consultant 

as someone who is genuine; available not only in the 

moment, but for future involvement; supportive of 

their needs; and perceived as someone recognized in 

the field in which the consultant is asked to evaluate. 

Additionally, being someone who has provided assistance previously or spent time with members of the 

unit helps to establish an early rapport. By ensuring the 

behavioral health consultant possesses these qualities, 

there is an increased likelihood of being asked into the 

unit, as well as ensuring the consultant will be used 

again in the future. 

In Case Study 12-1, concerning the evaluation of the 

route clearance platoon, the consultant had previously 

gone on a few route clearance missions with the soldiers for no other reason than to understand what their 

mission was and experience what it was like. Not only 

did this permit the consultant to earn the respect of the 

soldiers, it also solidified the consultant’s credibility 

with command and led to numerous consultations in 

which the consultant was able to assist the unit.

Explaining the Purpose of the Consultation

Before gathering information from soldiers, it is 

necessary to explain the purpose of the consultation, 

including who requested it, what information is being 

gathered, and what will be done with that information. 

It is imperative for all parties in the evaluation to be 

clear about all the issues involved, including legal and 

ethical ones, and potential consequences. Knowing the 

basic legal rights of the individuals undergoing the 

process, as well as to whom to refer service members 

if issues arise, is also important. Furthermore, walking 

the involved parties through a step-by-step overview 

of the process and then performing a “back brief” will 

also ensure that command understands the consulta-
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Combat and Operational Behavioral Health

tion process. Finally, clarifying the scope of the consultation process as it is occurring is essential. 

Cross-Service Consultations

In some cases, individuals may be required to perform consultations for another US military service. The 

consultative team should review the doctrine, regulations, and mission-specific goals for sister services and 

their units because there may be significant differences 

in how information is gathered, what documents are 

used, and how information is shared. Additionally, 

consultants should take time to learn about the differences in a particular service’s systems, as well as 

the differences in unit functions. Consultants can 

demonstrate interest by explaining what information 

they have already learned, then asking questions that 

may assist in better understanding the sister branch. 

This process will likely guide the consultation while 

building rapport. 

Uniform

One of the greatest challenges for a consultative 

team is to establish trust and mutual respect with the 

leadership requesting the consultation. To further this 

end, team members should determine the current uniform status of the unit to which they are consulting and 

dress accordingly. For example, if the consultative team 

was meeting with a number of line commanders in a 

field environment, the Army Class B uniform would 

not be appropriate. 

Additionally, members of the consultative team 

need to ensure that they display the proper wear, fit, 

and appearance of the uniform. Commanders may 

see it as a sign of disrespect and lack of concern about 

their military mission if consultative team members 

do not pay attention to what is the proper uniform; 

this can have a negative effect on the relationship 

developed between the team and the command. In a 

deployment setting, knowing what the proper uniform is and wearing it appropriately may also be a 

safety concern because some locations are at high-risk 

for attacks, therefore requiring more extensive gear 

and protective wear. Moreover, it can provide yet 

another segue in building rapport with the unit by 

showing interest in how it operates, while decreasing 

the psychological distance between the consultant 

and unit members. 

Language 

The consultative team members should identify the 

common terminology, slang, and descriptive terms that 

are frequently used by the organization requesting the 

consult and adapt their own language to those with 

whom they are speaking. Not only does this require 

adapting to the language of the command, but also to 

that of the members of the unit. Speaking in simple 

language, minimizing medical jargon, and not using 

“psychobabble” are recommended. However, when 

trying to adapt one’s own communication style to that 

of the group, do not use obscene or coarse language 

that may jeopardize professional credibility. 

Understanding Unit Structures and Functions 

Prior to providing a unit with recommendations 

for intervention and ideally prior to beginning the 

consultation, consulting clinicians should educate 

themselves about the unit or organization requesting 

the consultation. Understanding the unit and its mission will guide how the consultant engages with the 

participating soldiers and the interventions that might 

be recommended. It is helpful to know the formal and 

informal structure of the unit and how it directly and 

indirectly affects the unit. Relying solely on an organizational chart of the unit would be remiss. Many 

subgroups and personalities frequently play a significant role in how the unit runs and operates. Gaining 

knowledge on how communication is relayed and who 

has the power in the unit is also of utmost significance. 

Making assumptions due to rank (enlisted or officer) 

and branch could lead to false or inappropriate conclusions. Additionally, the consultant must be cognizant 

of the limitations that these functions place on their 

recommendations; otherwise, it may set the unit up 

for failure or not have the intended result. 

Case Study 12-2: A company commander at a patrol base 

in Iraq stated that morale was down and he wasn’t exactly 

sure why. He asked the brigade behavioral health officer if 

she could assess the situation and give him some feedback 

and recommendations. After surveying the unit and talking 

to the soldiers at length, the consultant determined that the 

soldiers were frustrated with their leadership because they 

felt they were not receiving information on missions and they 

were doing missions that were not necessary, thus putting 

them in harm’s way. This information was back briefed to the 

commander. When the situation was reassessed a week 

later, nothing had changed; the soldiers continued to be 

frustrated and unmotivated. During the reassessment, the 

behavioral health officer determined that the first sergeant 

was failing to provide information to the soldiers, leading 

to a breakdown in information flow within the unit. Until the 

first sergeant was briefed directly, none of the feedback 

from the consultation had been discussed or implemented 

at his level. Once he fully understood the recommendations, 

he began making changes on the patrol base and morale 

began improving. 
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Engaging With Soldiers 

Consultants need to be cautious about how they 

begin a visit. Many times the participating soldiers 

will decide within the first 5 minutes whether they 

feel the effort of talking with a consultant is relevant 

to them and if they will participate. It is the job of 

the consultant to get service members to “buy in” to 

the consultation process. Many times it is effective 

to begin by opening with a question and seeking the 

participants’ responses and input rather than talking to 

them at length. Zeroing in on key leaders and getting 

them engaged in the process will lower the barriers and 

intimidation of other soldiers who may be reluctant to 

get involved. Consultants should inform the unit of 

how they want to help the unit and the soldiers, while 

telling the soldiers that they are the true experts and 

allowing them to inform the consultant. Taking the 

time to sit back and listen to them in their element (ie, 

motor pool, guard towers, etc) will assist in making 

soldiers feel comfortable and further reinforce how 

the consultant values their opinions and knowledge. 

Soldiers are trained and conditioned to listen and take 

orders, so when somebody sits back and genuinely 

listens, a lot of valuable information and insight can 

quickly and easily be gathered. 

Interventions 

The consultant must consider realistic interventions 

that are not only applicable to the current conditions, 

mission, operational tempo, and resources available, 

but also with realistic implementation strategies. As 

one division commander in combat expressed to a 

visiting consultation team, “Don’t tell me it’s hard 

here or that conditions suck, we all know that. Don’t 

give me platitudes, give me clear and specific guidance that my commanders can actually use to help 

my soldiers.”

To meet these goals, the consultant must consider 

realistic interventions that will address function as 

opposed to pathology. These include educating the 

unit as well as the command on how the intention 

of the intervention is to keep soldiers ready to fight 

and make them more productive for the mission; 

briefing the commander with simple, objective, and 

clear-cut ways that the situation can be improved 

using clearly defined recommendations that can 

be easily implemented; and reinforcing in a stepby-step method how the recommendations will be 

executed and how they will ultimately improve the 

unit’s ability to accomplish its mission. Once the 

interventions have been made, it is imperative that 

the consultant remains available to clarify any ambiguities or address any questions that arise during 

the implementation process. 

Terminating the Consultation 

The type of consultation determines the number of 

sessions required. Some consultations will be over after 

one visit, others might last several months. As part of 

terminating the consultation, a final report should be 

provided to the requestor, the participants should be 

thanked, and those who may have developed relationships during the consultation experience should have 

an opportunity to say goodbye. Consultants must 

ensure all of their questions have been addressed, and 

make certain they have provided information for future contacts while imparting other resources that may 

be of assistance. It is preferable that the consultants 

talk to all parties involved in the consultation process 

to close all the loops of communication. Consultants 

use valuable unit resources such as time, energy, and 

information. Therefore, it is important to include the 

contributing parties in the termination process. 

A good consultation can be ruined by a poor 

termination. If consultants leave the group feeling 

“used” or “no longer important” then they will lose 

credibility. It is probable that the long-term benefit of 

their interventions will fail because they are likely to 

lack unit acceptance. Additionally, it can make it more 

difficult to gain access to future groups for establishing 

consultative relationships. 

Reporting the Consultation 

As part of the termination process, a report should 

be given to the requestor. This may not initially be in 

written form, but should at least be via a back brief 

and then followed at a later date by a written brief 

with recommendations. A formal out brief should 

always be offered to the commander who has allowed 

access into the unit. This not only shows respect and 

understanding of the command relationship, it also 

provides access to the person who can implement the 

recommendations and programs suggested. Furthermore, it is an opportunity to gain insight into areas 

that may have been missed or may require further 

study. This should be followed by sending a written 

brief subsequent to the back brief, which guarantees 

that consultants have had time to reflect and consider 

all aspects of the group; think things through more 

carefully; and consult with a trusted colleague if any 

reservations have arisen.49 It will also provide the consultant with an opportunity to ensure that the consultation question has been answered clearly and concisely 

while ensuring the commander’s objectives were met. 
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Additionally, if the consultant intends to use the information from this report for any other endeavor, such as publication or report to any outside agencies, then 

permission should be gained from the unit.

DETERMINING FITNESS FOR DUTY AND DEPLOYMENT CLEARANCE 

At times, consultants are requested by commanders 

to determine if a soldier is fit for continued military 

service or deployment. There are several aspects associated with determining fitness for duty and deployment clearance. 

Disqualifying Conditions 

The first step is to have a thorough and detailed 

understanding of Army Regulation 40-501, Standards 

of Medical Fitness, particularly Chapters 3 and 7.50

Chapter 3 outlines the standards for medical fitness 

and separation. Chapter 7 provides guidance on profiling.50 Current Army regulations require soldiers 

with disorders with psychotic features not caused by 

organic pathology or toxic substances to undergo a 

medical board to determine fitness for continued service in the military. This includes bipolar disorder and 

schizophrenia or any other mental disorder that causes 

gross impairment in reality testing. There is further 

guidance regarding other diagnoses and the criteria 

for referral to a medical board. In general, mood, 

anxiety, somatoform, and dissociative disorders are 

disqualifying if they necessitate recurrent hospitalization, persistently limit duty, or interfere with effective 

military performance.50

Personality, substance-related, and adjustment 

disorders are generally not disqualifying through 

the physical disability system, but may be cause for 

administrative separation. Before recommending administrative separation for these conditions, a detailed 

exploration for potential posttraumatic stress should 

be performed, particularly in previously deployed 

soldiers with changes in behavior patterns, because 

the outcome of the evaluation may significantly affect postseparation benefits and access to ongoing 

medical care.

Medical Profiling 

Army Regulation 40-501, Chapter 7, details physical 

profiling and is an area of ongoing confusion and contention among soldiers, providers, and commanders.50

A thorough knowledge of the regulations will enable 

providers to clearly articulate both the limitations of 

the profile and the regulatory responsibilities of command, and ensure expectation management on the part 

of the profiled soldier.

The profile serial system (P-U-L-H-E-S, which 

stands for Physical capacity or stamina; Upper extremities; Lower extremities; Hearing and ears; Eyes; 

and pSychiatric) is used to define the effects of a 

soldier’s medical condition in relation to the performance of duties. Psychiatric disorders are denoted 

in the “S” section and rated from 1 to 4. This rating 

is to provide an assessment of overall functioning 

and is not based on the diagnosis itself. When determining the rating, the provider must consider the 

type, severity, and duration of symptoms, amount of 

external stressors, predisposition, intelligence, prior 

psychiatric history, and current duty performance. 

Additionally, the regulation provides some specific 

guidance for conditions that require a particular rating to be given, including when (a) no psychiatric 

pathology is evident; (b) there is a history of recovery of an acute psychotic reaction from external but 

non–substance-abuse-related cause; (c) there has been 

remission of a mental health disorder that is not otherwise disqualifying, but requires either limitations of 

assignments or duties; and (d) a rating of “3” cannot 

be met.50 Assignment of a permanent S3 or S4 rating 

requires a medical board to be performed.

The specific limitations recommended on the profile 

are as important as the profile designator. According 

to Army Regulation 40-501, the condition itself should 

not be the sole consideration when recommending 

limitations. The profiling officer must also consider 

the prognosis, the possibility of aggravation, and the 

effects the profile will have on the soldier’s ability to 

perform required duties.50 The regulation states specifically that profiles “must be realistic.”50(p73) Profiles are 

required to be specific and written in lay terms.50

It should be clearly articulated to a soldier being 

profiled that determination of duties, assignments, and 

deployment are command matters. Given this, profiles 

such as no deployment, no field duty, or no overseas 

duty are “not proper medical recommendations”50(p73)

to be written on a profile. It is incumbent upon the 

profiling officer to provide adequate and clear recommendations so the commander can make an informed 

decision based on medical limitations and capacities, 

duty requirements, assignment limitations, mission 

requirements, and duties of the soldier among other 

command and mission-related issues.

If the commander does not feel the soldier can 

perform within the profile, reconsideration can be 

requested. If requested, reconsideration must be accomplished and will either amend the profile or re-
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validate it. This can be requested for both temporary 

and permanent profiles. 

Deployment Clearance 

In the fall of 2006, the Assistant Secretary of Defense 

for Health Affairs and The Surgeon General, US Army, 

provided guidance on the minimum mental health 

standards for deployment.51 This policy was outlined 

in a memorandum, “Policy Guidance for Deployment 

Limiting Psychiatric Conditions and Medications.” This 

guidance came in response to a congressional directive52 after several media reports stated that mentally 

ill soldiers were being deployed who were unstable or 

taking medications without follow-on care. Additionally, some media reports cited soldiers being started on 

medications shortly before deployment and receiving a 

year supply of medication without monitoring. 

Key factors in the policy related to mental health 

conditions and medications included: (a) soldiers currently being treated for psychosis or bipolar disorder 

were not deployable; (b) soldiers who were taking 

medications that require laboratory monitoring, such 

as lithium or valproic acid, were not deployable; (c) 

soldiers who are taking antipsychotic medications to 

control psychotic, bipolar, or chronic insomnia conditions were not deployable; (d) the continued use of 

psychotropic medications that are clinically and operationally problematic during deployments, including 

short half-life benzodiazepines and stimulants, should 

be balanced between the necessity for successful functioning in the theater of operations and the ability to 

obtain the medication, the potential for withdrawal, 

and the potential for abuse; (e) soldiers with significant 

mental health conditions require 3 months of stability 

prior to deployment; and (f) if a soldier is placed on a 

psychotropic medication within 3 months of deployment, then that soldier must be improving, stable, 

and tolerating the medication without significant side 

effects to deploy.51 Although not articulated in the 

policy, consideration should be given to monitoring, 

for at least 1 month prior to deployment, any soldier 

on medication for anxiety, depression, or insomnia.

Screening for conditions that preclude deployment 

as part of the predeployment health process enables 

identification of soldiers not meeting minimum criteria 

for deployment. The screening process in one deploying unit prior to Operation Iraqi Freedom in 2007 

consisted of an initial survey that was filled out concurrently with the predeployment health assessment. 

This process identified any soldier who was currently 

on any psychiatric medication, under psychiatric care, 

or experiencing significant stressors. Soldiers who 

screened positive were referred to mental health services for an evaluation for deployability based on the 

outlined minimum standards for deployment. Those 

who met standards were cleared. Those who did not 

were either referred to a medical board or the provider 

met with command to discuss limitations. Soldiers 

were then either left on rear detachment (delayed in 

deployment until stable on medications [typically 1–2 

months]) or a waiver was granted through the combatant command surgeon. In general, the number of 

soldiers requiring clearance was minimal (less than 

20/3,500 soldiers) because the majority who were unable to deploy were identified prior to beginning the 

predeployment screening process. However, this is 

an important safety mechanism that is recommended 

to all deploying units, and it is likely that a standardized procedure and survey will be implemented in 

the near future.53

Separation From the Military 

At times soldiers may have mental health conditions 

that make them unfit for duty, although they do not 

require a medical board per se. These conditions are 

defined in Army Regulation 635-200, Enlisted Separations.

54 Although these separations are primarily a 

command function, an evaluation and diagnosis by 

an appropriately credentialed provider is required. 

Functional knowledge of these chapters and the 

separation process will enable consultants to counsel 

commanders—who may be junior or facing other more 

pressing issues—regarding the appropriate and judicious use of these actions, thus avoiding unnecessary 

delays, misdiagnoses, inappropriate separations, and 

potential procedural errors.

Mental health providers will predominantly be 

involved with Chapter 5-13 (personality disorders) 

and Chapter 5-17 (other mental or physical disorders).54 Both of these chapters require that the soldier 

not have a condition that amounts to disability, and 

both require that the soldier be formally counseled 

and afforded “ample opportunity to overcome those 

deficiencies.”54(p56) These mechanisms should not be 

used in lieu of judicial actions or other administrative 

separations.

Chapter 5-13 states that a soldier can be separated 

for personality disorder if the condition severely impairs the soldier’s ability to function in the military environment. It further states it must be a long-standing 

and deeply ingrained condition.54 This is particularly 

important when dealing with the postdeployment 

soldier who may have confounding posttraumatic 

stress issues, mild traumatic brain injury, or acute 

situational issues. 

Chapter 5-17 deals with physical or mental is-
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sues that “potentially interfere with assignment to 

or performance of duty”54(p57) and are not covered 

under other areas of the separation regulations. 

This includes conditions such as claustrophobia; 

disturbances of perception, emotional control, or 

behavior; dyslexia; sleepwalking; or other disorders 

that may significantly impair the performance of 

military duties.

COMMAND-DIRECTED EVALUATIONS

Command-directed mental health evaluations 

are defined in DoD Instruction 6490.4,55 DoD Directive 6490.1,56 and US Army Medical Command 

Regulation 40-38,57 which outline rules for both discretionary and nondiscretionary command-directed 

referrals. Nondiscretionary evaluations are those 

required by regulation to include the positions of 

drill sergeant, recruiter, and sniper. Additionally, 

all soldiers undergoing certain chapter separations 

require mental status evaluations. However, when 

commanders request evaluations for soldiers who 

do not require assessment by regulation, they use 

their discretionary authority to request evaluation 

and feedback. 

When performing a command-directed evaluation, 

commanders should be provided a formal “Report of 

Mental Status” outlining feedback and recommendations. At a minimum, the report should address if a 

diagnosis exists, a prognosis for the soldier’s condition, any limitations, a review of soldier safety and any 

safety interventions required, and the soldier’s fitness 

for duty. Regulations require that the commander receive that report no later than 24 hours after completion 

of the evaluation. 

Additionally, evaluating providers must be familiar 

with the restrictions that their level of professional 

degree places on their ability to perform and sign command-directed evaluations. In general, non–doctorallevel social workers are able to perform and sign nondiscretionary evaluations. Discretionary evaluations 

and those recommending a Chapter 5-13 (personality 

disorder) or Chapter 5-17 (failure to adapt) discharges 

require a doctoral-level social worker, a psychologist, 

or a psychiatrist. If there is a condition in which the 

only available mental health provider does not have 

signing authority, such as during a deployment or in 

a remote location, then a physician may serve as the 

signing authority. 

RISKS TO THE CONSULTANT AND ETHICAL ISSUES IN CONSULTATION

As previously mentioned, serving in the role of a 

command consultant is very different from a typical 

doctor–patient encounter. The role of the consultant 

can at times present ethical challenges and difficult 

situations. 

Double Agency 

In command consultation, the military mental health 

provider is frequently called upon to simultaneously 

address the needs of both the unit and the soldierpatient. This dual responsibility is termed “double 

agency.” Sometimes in command consultation, the 

only “patient” is the unit, and there is not an identified 

soldier of concern. In other cases, a soldier is identified 

as the patient, and the provider has a responsibility to 

provide treatment and, at the same time, to advise the 

commander regarding the military’s most favorable 

course of action. The two are synchronous a majority of the time: that is, what is good for the soldier is 

also good for the military. For example, a soldier with 

permanent cognitive impairment from a brain injury 

should not remain in the military, because it would 

not be safe for that soldier to function in combat. Thus, 

the soldier is recommended for a medical evaluation 

board to determine the level of disability and ensure 

that this individual receives the appropriate long-term 

medical and financial benefits. Additionally, the unit’s 

needs are met because having an impaired soldier in 

combat poses greater risk for fellow soldiers, and by 

medically boarding such a soldier, the unit is able to 

receive a healthy replacement. 

However, a mutually beneficial course of action 

does not always exist. Such is the case when a dysfunctional soldier will suffer financial hardship, or the 

family will lose needed medical benefits due to separation from the military. When making recommendations concerning treatment, limitations, or separation/

evacuation, the behavioral health officer must keep in 

mind the soldier’s ability to perform assigned tasks in 

a combat environment. This becomes more difficult in 

the case of soldiers who are struggling with the psychological effects of combat. The provider may find 

it very difficult to determine when is the proper time 

to remove a soldier from continued combat exposure 

while also keeping in mind the unit’s mission and 

current needs.

These situations must be carefully examined and, as 

with many ethical issues, there is no single correct answer. Discussion with colleagues or senior behavioral 
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health providers, including the theater mental health 

consultant, can be helpful in processing these issues 

and is recommended.

Confidentiality 

The commander has a right to know a soldier’s 

diagnosis, prognosis, treatment plan, and duty limitations. Beyond these concise details, the behavioral 

health providers must be very careful concerning what 

information is provided to the commander. However, 

the commander is under no such restriction and can 

provide a great deal of information to the behavioral 

health provider, including reports about the soldier’s 

ability to function at work, relationships with peers 

and supervisors, past occupational counseling, and 

the “other side” of the story. If viewed as partners 

on a team, rather than as adversaries, the consulting 

relationship between behavioral health providers and 

commanders can be mutually beneficial to each party, 

as well as to soldiers. Frequently, both the commander 

and the behavioral health provider can work together 

to help a soldier function better.

Thus, even though a commander has a right to 

know a soldier’s diagnosis, prognosis, treatment plan, 

and duty limitations, behavioral health providers 

certainly do not contact every patient’s commander 

with that information. If soldiers have mild symptoms 

that neither impair their functioning at work nor 

require duty limitations, there is no need to contact 

the commander. However, if there is risk to the unit, 

mission, or soldier, it is incumbent upon the provider 

to be certain that command is aware to ensure the 

ongoing safety and treatment of the patient, as well 

as that of the unit.

Objectivity Versus Intimacy 

When the mental health provider is closely integrated into the unit, ongoing relationships are established with commanders that significantly improve 

the effectiveness of the consultative process. However, 

because of this intimacy, some objectivity may be lost. 

The behavioral health provider needs to continually 

ask the question, “What is my role in this situation?” 

to ensure that appropriate impartiality is being maintained. As a result of the intimacy, the provider is also 

vulnerable to the same stressors and tragedies as the 

unit. Closely aligned behavioral health providers can 

still be able to help the unit during times of crisis, 

but also need to be aware of their own stressors and 

limitations. In some circumstances, behavioral health 

providers may need their own treatment or intervention as a part of the unit.

Short Versus Long Consultations and the Development of Relationships 

Some consultation relationships exist over an extended period of time, such as that of DMH officers 

with the commanders in their division. Others by 

nature are of a limited or one-time duration, such as 

a soldier who is seen for a command-directed mental 

health evaluation. Although a behavioral health provider may only plan to see a particular soldier for a 

single evaluation, frequently the provider ultimately 

has further contact with the command regarding 

other soldiers. This fosters the long-term consultative 

relationship. 

Every interaction with a commander has the potential to help a particular soldier, but also to “take the 

pulse” of the unit’s climate, to cultivate future cooperative relations, and to educate commanders about 

leader actions for decreasing combat operational stress 

within their units. The behavioral health provider’s 

conscious grooming of this relationship allows commanders to begin to feel more comfortable accepting 

behavioral health interventions for their soldiers, as 

well as for themselves.

Investigation Verus Consultation 

It can be easy for commanders to feel that they 

or their practices are being investigated during the 

information-gathering portion of a consult. This can 

feel intrusive and cause anxiety. For example, a commander in Iraq referred a soldier who had allegedly 

assaulted the unit’s first sergeant. The soldier reported 

having assaulted the first sergeant only after the first 

sergeant had pushed him against the wall in a chokehold. This situation required a careful consultative approach to balance advocating for the soldier, defusing 

tension at the unit, and promoting future consultation. 

Generally, approaching the situation from a shared 

problem-solving stance, rather than seeking to find 

blame, is more productive. 

Impact of HIPAA on Command Consultation 

Aspects of the Health Insurance Portability and 

Accountability Act (HIPAA) address safeguarding 

the security and privacy of protected health information, including names, Social Security numbers, dates 

of birth, and other patient identifying data. Soldiers 

are commonly designated on military records by 

this information. Military hospitals and clinics are 

required to comply with HIPAA, and generally have 

the required safeguards in place. Providers need to 

ensure that any protected health information sent 
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electronically to commanders is either sent over a 

closed network, or that some form of encryption 

is used. Routine measures for HIPAA compliance 

ensuring patient privacy include placing computer 

workstations out of the public view and locking them 

when not in use, securing charts behind locked doors, 

and protecting identifying information on charts from 

being seen by others during an office visit.

NOTABLE CONSULTATIVE POSITIONS IN THE ARMY

Most military behavioral health providers will be 

placed in a command consultative role at some time 

in their careers, whether it is simply to evaluate one 

soldier or to provide an overview of a large unit. Three 

particular consultative roles merit further discussion: 

(1) Consultant to The Surgeon General of the Army; (2) 

member of a Mental Health Advisory Team (MHAT); 

and (3) division psychiatrist/brigade behavioral health 

officer. 

Consultant to The Surgeon General, US Army 

This assignment is generally a 4-year tasking, which 

the consultant undertakes in addition to usual assigned 

duties. In behavioral health, these consultant positions 

include research and clinical psychology, social work, 

psychiatric nursing, and occupational therapy. There 

are four consultant positions in psychiatry: general, 

child, forensics, and addiction. There is also a consultant for the Exceptional Family Member Program, 

which usually is either a pediatrician or a psychiatrist. 

Functionally, the consultant positions in general and 

child psychiatry, research and clinical psychology, 

social work, and psychiatric nursing contribute to 

assignment determinations for personnel in these 

specialties. 

For the last 20 years, these behavioral health consultants have been located throughout the United 

States, although principally at the US Army Medical 

Command Headquarters in San Antonio, Texas. After the attacks on September 11, 2001, the respective 

behavioral health consultants spent numerous weeks 

and months at the Office of The Surgeon General in 

Washington, DC. In 2007, a new Proponency for Behavioral Health was established, solidifying a requirement 

for a behavioral health consultant at the Office of The 

Surgeon General.

Key functions of the behavioral health Consultants 

to The Surgeon General of the Army include assignments, taskings for deployment, review of records, and 

strategic communications. 

Assignments 

The most important function of a Consultant to 

The Surgeon General is the task of assignments. The 

consultant recommends assignments to the specialty 

branch manager who makes the assignment decision. 

In general, the recommendations of the consultant are 

followed. The assignment process, however, involves 

several matrices. The current psychiatry consultant, for 

instance, asks graduating residents and staff who are 

eligible to move for a list of ten desired assignments as 

well as any family considerations. The consultant then 

generates a list of potential assignments. Additional 

related issues, such as whether candidates are medically deployable, are also considered. (It is essential 

to put deployable psychiatrists and other behavioral 

health assets in divisions and CSC units.) Following 

the Graduate Medical Education Selection Board and 

the Officer Distribution Plan conference (where Board 

decisions are made and announced), the draft assignments can be distributed. Request for orders and the 

actual orders subsequently follow. These orders may 

be modified in the event of unanticipated personnel 

changes or in the event of new, emergent missions.

The priorities for assignment are: first the needs of 

the Army and second the needs of the soldier. Army 

needs include the two graduate medical education 

programs (National Capital Area and Tripler Army 

Medical Center) and power projection platforms, 

such as Fort Hood, Texas; Fort Benning, Georgia; Fort 

Riley, Kansas; Fort Stewart, Georgia; and Fort Bragg, 

North Carolina.

Many assignment choices are dominated by family 

needs. Those couples with small children usually want 

to live as close as possible to their extended families. 

Spouses who are employed usually want to be able to 

find good career-related jobs. Some have aged parents 

or ill siblings to tend for. The consultant works to take 

all these needs into account, but the needs of the Army 

are still paramount.

Tasking for Deployment 

For “Tier I specialties,” including psychiatry, 

psychology, and social work, the consultant is now 

intimately involved in deciding who will be tasked 

to deploy. The “cardinal rule” for the Medical Command is that no one should go twice until all have gone 

once. The deployment decisions are now made at the 

Professional Officer Filler Information System support 

conference, with the input of the regional medical consultants. However, it is not infrequent that last-minute 
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taskings will arise due to unforeseen illness, injury, or 

other factors that make a projected officer unable to 

deploy, requiring the consultant to review the entire 

provider inventory and adjust priorities of need.

Review of Records 

Another function of the psychiatry consultant is 

to review mental health records. These are received 

for a multitude of purposes, including: (a) waivers 

for accessions to both the officer and enlisted ranks; 

(b) determinations on line-of-duty investigations, 

especially following suicides; (c) review of completed 

investigations; and (d) review of cases where there is a 

question as to whether someone should have received 

a medical board or chapter. 

Strategic Communications 

The consultant functions in numerous roles to 

include reviewing scientific papers, answering media inquiries, advising on the suitability of others 

to participate in media interviews, and advising the 

public affairs officer. The position presents numerous challenges. A major one is that of recruiting and 

retaining medical personnel with the Army’s current 

operation tempo. 

Mental Health Advisory Team Member 

Since 2003, the Army Surgeon General has annually 

deployed an MHAT at the request of the US Central 

Command commanding general to evaluate the behavioral health needs of soldiers during deployment. 

The initial team performed their evaluation during 

Operation Iraqi Freedom 1 after there were reports of 

elevated suicide rates in theater. More recently, MHAT 

teams have focused on the quality of care provided and 

the behavioral healthcare system of delivery within the 

theater of operations. 

The MHATs have varied in their composition, at 

times consisting of large multidisciplinary mental 

health teams while more recent MHATs have only 

had a few research psychologists. The MHAT teams 

utilize methods of paper surveys and focus groups, 

and each year issue a report of findings with recommendations. Key recommendations have included 

the establishment of a theater suicide prevention 

program, implementation of “Battlemind” training, 

institution of unit behavioral health needs assessments, 

and battlefield ethics training. The MHAT teams and 

their recommendations are discussed in greater detail 

in Chapter 5, Walter Reed Army Institute of Research 

Contributions During Operations Iraqi Freedom and 

Enduring Freedom: From Research to Public Health 

Policy, in this volume.

Division Psychiatrist/Brigade Behavioral Health 

Officer 

Chapter 6, The Division Psychiatrist and Brigade 

Behavioral Health Officers, in this volume details the 

role of these mental health specialists. However, this 

unique position places a behavioral health officer 

within a combat unit working directly as an ongoing 

consultant to a combat commander rather than working for the medical command. This position entails 

continuing responsibilities to the command as a consultant on issues such as how and where to deploy behavioral health resources, methods and techniques for 

controlling combat operational stress, and determining 

plans for prevention of behavioral casualties.

SUMMARY

Military mental health professionals provide critical 

consultation to command when psychiatric casualties 

are seen in garrison or during deployment. The challenge to the mental health consultant is to balance the 

need of the unit with what is in the best interest of 

the soldier’s short-term and long-term mental health. 

Commanders have the utmost concern for their soldiers; it is therefore imperative that they trust the 

judgment of their consulting behavioral health officer 

in the decisions that they are making on the treatment 

of their soldiers. In addition, these same challenges exist in garrison because the consultant has to determine 

if a soldier is no longer fit to continue in service and 

requires a medical evaluation board or if this soldier 

might have a more favorable prognosis for recovery 

and continued military service. 

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