89

The Division Psychiatrist and Brigade Behavioral Health Officers

Chapter 6

THE DIVISION PSYCHIATRIST AND 

BRIGADE BEHAVIORAL HEALTH 

OFFICERS

CHRISTOPHER H. WARNER, MD*; GEORGE N. APPENZELLER, MD†; TODD YOSICK, LISW‡; MATTHEW J. 

BARRY, DO§; ANTHONY J. MORTON, MD¥; JILL E. BREITBACH, PsyD¶; GABRIELLE BRYEN, MSW, LCSW**; 

ANGELA MOBBS, PsyD††; AMANDA ROBBINS, PsyD‡‡; JESSICA PARKER, PsyD§§; and THOMAS GRIEGER, MD¥¥

INTRODUCTION

DOCTRINE

PERSPECTIVES ON THE POSITION

DUTIES AND RESPONSIBILITIES

CHALLENGES OF THE POSITION

FUTURE DIRECTIONS

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

†

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; Deputy Director, Resilience and Prevention Directorate, Office of the Assistant Secretary of Defense for Health 

Affairs, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, 1335 East-West Highway, Silver Spring, Maryland 20910; 

formerly, Chief, Battlemind Training Office/Chief, Combat and Operational Stress Control, AMEDD Center and School, Fort Sam Houston, Texas

§

Major, Medical Corps, US Army Reserve; Staff Psychiatrist, Rochester Veterans Affairs Outpatient Clinic, 465 Westfall Road, Rochester, New York 

14620; formerly, Major, Medical Corps, US Army; Chief of Psychiatric Service USA MEDDAC and 10th Mountain Division Psychiatrist, Fort Drum, 

New York

¥

Major, Medical Corps, US Army; Medical Director, Department of Behavioral Health, Moncrief Army Community Hospital, 4500 Stuart Street, Fort 

Jackson, South Carolina 29207-5720; formerly, Division Psychiatrist, 1st Armored Division, Wiesbaden, Germany

¶

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

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

**Major, Medical Service Corps, US Army; Deputy Chief, Department of Social Work, Womack Army Medical Center, Stop A, Fort Bragg, North Carolina 

28310; formerly, Brigade Behavioral Health Officer, 3rd Brigade Combat Team, 4th Infantry Division, Fort Carson, Colorado 80913

††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

‡‡Captain, Medical Service Corps, US Army; Brigade Combat Team Behavioral Health Officer, 4th Brigade Combat Team, 10th Mountain Division, Fort 

Polk, Louisiana 71459

§§Captain, Medical Service Corps, US Army; Chief, Warrior Restoration Center, Department of Behavioral Medicine, Winn Army Community Hospital, 

541 East 9th Street, Building 359, Fort Stewart, Georgia 31314-5674; formerly, Psychology Resident, Traumatic Brain Injury, Brooke Army Medical 

Center, San Antonio, Texas

¥¥Captain (Retired), US Navy; Associate Professor, Department of Psychiatry, Uniformed Services University of the Health Sciences, 4301 Jones Bridge 

Road, Bethesda, Maryland 20814

A portion of this chapter has been published as: Warner CH, Breitbach JE, Appenzeller GN, Barry MJ, Morton A, Grieger T. The evolving 

role of the division psychiatrist. Mil Med. 2007;172:918–924.
90

Combat and Operational Behavioral Health

INTRODUCTION

The psychological effects of warfare have been well 

documented throughout history, with names such as 

nostalgia, soldier’s heart, shell shock, battle fatigue, 

and most recently, combat operational stress. In the late 

19th and early 20th centuries, military leaders began to 

recognize the impact of treating and addressing these 

reactions. This led to an increased presence of mental 

health providers on the battlefield. Since World War 

I, the United States Army has been deploying mental 

health assets to the front line for treatment of combat 

operational stress and to advise unit commanders 

on mental health issues and the effect of war on soldiers.1–3 

The first battlefield psychiatrist for the US Army 

was Dr Thomas Salmon. During World War I, he 

noted the value of maintaining a psychiatrist on the 

division staff who works directly with the surgeon 

to provide consultation, as well as the importance of 

the role as a staff officer for the command.2 Salmon 

created a successful battlefield management system 

incorporating treatment, prevention, and consultation. 

Unfortunately, many of those lessons learned were 

lost or were deemed unnecessary after the end of the 

war. It was not until World War II that General Omar 

Bradley again realized the value of organic mental 

health assets during the North African campaign of 

1943 and reestablished the division psychiatrist position.3

 Since the Korean War, the division psychiatrist 

has led the division mental health activity (DMHA), 

both in garrison and during deployment.1,3 The roles 

and responsibilities for a division psychiatrist and the 

DMHA were first outlined in Army Regulation 40-216, 

Neuropsychiatry and Mental Health, in 1957.4

The division psychiatrist serves as the leader of 

the division mental health team whose mission is to 

assist command in controlling combat operational 

stress through training, consultation, and restoration.5

Until recently, the DMHA consisted of three providers 

(a psychiatrist, a psychologist, and a social worker), 

complimented by six mental health technicians (Figure 

6-1). However, in the midst of the global war on terror, 

the Army began its largest restructuring since World 

War II, changing the emphasis from the division to the 

brigade combat team (BCT).6 This restructuring effort 

was designed to make the Army a more modular force, 

increase efficiency and combat power, and increase the 

number of BCTs within the force.6

In conjunction with the restructuring, there has been 

a reorganization and an increase in the behavioral 

health assets assigned to each division. The new force 

structure eliminated a formal centralized mental health 

section and created a modular DMHA. The new modular DMHA structure, outlined in Figure 6-2, includes 

a division psychiatrist and senior noncommissioned 

officer located with the division surgeon at the division 

headquarters unit, and a brigade behavioral health 

officer (BCT BHO; psychologist or social worker) and 

an enlisted mental health specialist assigned to each 

BCT. Multiple BCTs are under the control of the division, such that five to six mental health providers (psychiatrists, psychologists, and social workers) can be 

assigned to a DMHA. This new, modular design yields 

more providers and allows for projection of resources 

to commanders at lower levels (ie, battalion and company). With this rapid expansion and evolution of the 

DMHA, the role of the military mental health provider 

Mental Health

Specialist 

(91X)

Division

Psychiatrist

Division

Psychologist

Division

Social Worker

Mental Health

Specialist 

(91X)

Mental Health

Specialist 

(91X)

Mental Health

Specialist 

(91X)

Mental Health

Specialist 

(91X)

Mental Health

Specialist 

(91X)

Figure 6-1. Prior structure of division mental health activity.
91

The Division Psychiatrist and Brigade Behavioral Health Officers

Aviation Brigade

(No Assests)

Mental Health

Specialist 

(68X10)

Division

Psychiatrist

Mental Health

Specialist 

(68X10)

Mental Health

Specialist 

(68X10)

Mental Health

Specialist 

(68X10)

1st BCT

BHO

3rd BCT

BHO

2nd BCT

BHO

4th BCT

BHO

DMH

NCOIC 

(68X30)

Figure 6-2. Current structure of division mental health activity in the modular Army. 

BCT: brigade combat team

BHO: behavioral health officer (psychologist or social worker)

DMH: division mental health

NCOIC: noncommissioned officer in charge

has become more diverse and multifaceted. 

The complex effects of combat on soldiers in modern 

warfare demonstrate the importance of combat and 

operational stress control during deployment and 

the need to monitor mental health issues following 

deployment.7–11 This has led to recent updates in US 

Army doctrine, though, unfortunately, little guidance 

on the specific roles of division mental health has been 

provided.12 The purpose of this chapter is to outline 

the role and utilization of the division psychiatrist and 

the BCT BHO in both the division and in the DMHA as 

defined by current military doctrine and based on the 

more than 10 combined years of deployment experience of the authors. 

DOCTRINE 

Although much has been published on the psychological consequences of combat and deployment, little 

has been published on the specific roles of the division psychiatrists, DMHA, or BCT BHOs in garrison 

or during deployment.13–20 Army Regulation 40-216, 

Neuropsychiatry and Mental Health, the primary regulation associated with mental healthcare, has not been 

updated since 1984 and cites only that the division 

psychiatrist will lead the DMHA, serve as a consultant 

on neuropsychiatric issues, and in conjunction with the 

DMHA, provide care to soldiers with neuropsychiatric 

conditions.4 Field Manual 8-51, Combat Stress Control 

in a Theater of Operations: Tactics, Techniques, and Procedures, was released in 1994 and updated in 1998.5

 It 

provided an outline of the overall mission and role of 

the DMHA and gave some additional insight into the 

roles and responsibilities of the division psychiatrist 

as a supervisor. This guidance was recently updated to 

outline combat and operational stress control (COSC) 

in Field Manual 4-02.51, Combat and Operational Stress 

Control, but provides little guidance on the operation 

of a DMHA or on the roles and responsibilities of a 

division psychiatrist and the BCT BHO.12 

 Lieutenant Colonel Albert Glass defined in his 

chapter “Lessons Learned” from Neuropsychiatry in 

World War II the need to maintain a strong regiment 

of active duty psychiatrists, both in war and in peacetime, to manage the operational needs of the armed 

services. He argued that civilian psychiatric agencies were unable to meet the ongoing demands and 

maintain the operational preparedness that military 

psychiatry requires. He also reviewed the complexity of psychiatric diagnosis and screening/selection 

in wartime, as it effects conservation of the fighting 

force.1

 In Combat Psychiatry, Lieutenant Colonel Glass 

specifically discussed the role of “Psychiatry at the 

Division Level.” This in-depth review outlined the 

specific principles for the evaluation, treatment, and 
92

Combat and Operational Behavioral Health

disposition of soldiers in a combat environment. Additionally this chapter provided historical data analysis 

from World War II.21

Rock and colleagues discussed the historical development of US Army mental health resources in 

War Psychiatry, in a chapter titled “US Army Combat 

Psychiatry.” This chapter provides insight into changes 

that were made in doctrine and in the development 

of division mental health units from World War I 

through Vietnam. However, as Army mental healthcare evolved into the 1980s, it moved away from 

the roles of the divisional units and focused on the 

development of nonembedded combat stress control 

units.3 Although both chapters are an excellent source 

of information on the historical development of military mental health systems and the treatment role of 

division-level behavioral health officers, they provide 

little guidance on other duties and responsibilities of 

these positions.

In 1993, two relevant articles were published in 

Military Medicine. In the first of these, Engel and Campbell addressed the challenges facing a division mental 

health unit. They discussed the minimal attention focused on their role while not deployed and noted the 

importance of ongoing preventive missions based on 

their lessons learned from deployment to Operation 

Desert Storm.14 In the second of these, Ritchie and 

White outlined the guidelines for becoming a successful division psychiatrist, providing practical guidance 

for preparing psychiatrists who were relatively new 

to the military on effective means of interacting and 

engaging with infantry commanders. Additionally, the 

latter article outlined the various duties and responsibilities of the position including (in their listed order 

of importance): behavioral health provider, supervisor of other behavioral health providers, educator of 

division medical providers, administrative psychiatry, 

consultation to command, planning and oversight of 

the division mental health section, and serving as an 

officer in the division.15 This guidance was recently 

revised by Hill, Lange, and Bacon. Their focus was 

on what psychiatry residents should do to prepare 

for assuming the role.16 Although these two articles 

did not deal with the role of the division psychologist 

or the division social worker, they did outline some 

of the duties and responsibilities expected of a unit 

behavioral health leader. 

During Operation Iraqi Freedom, Warner, Appenzeller, and colleagues published a group of articles in 

Military Medicine on the roles and responsibilities of 

division mental health units in the new brigade combat team structure. These articles provided a roadmap 

of prevention, early identification, and intervention 

methods for other DMHAs. Additionally, the authors 

cited several advantages to the new structure, including the increased ability to provide mental health services closer to the front line and the ability to interact 

and regularly serve as consultants to lower levels of 

command. Additionally, they noted several limitations 

of the new structure, including dispersed command 

and control, increased independence of each provider 

with decreased supervision, and an increased risk for 

provider burnout due to the smaller teams. Although 

there was some discussion about garrison actions required prior to the deployment and the role of the division psychiatrist while in garrison, these articles were 

predominantly focused on the deployed role.20,22,23

Expanding beyond the role of the division psychiatrist to include other mental health providers, 

Military Psychiatry: Preparing for Peace in War addresses 

the evolving interface between the behavioral health 

leader and command. Chapter 9 highlights the heightened value by command of services mental health 

officers offer via command consultation, including 

cross service consultation needs.24 Also discussed, in 

Chapter 10, is the need for mental health providers in 

recognizing the stressors of those in leadership positions and offering support to build resilience of those in 

command.25 Chapters 11 and 12 approach the training 

needs of mental health workers, emphasizing the value 

of field training exercises,26 and proposes a two-part 

training model to assist medical personnel and command in recognizing combat stress concerns and how 

to effectively triage combat stress casualties.27

PERSPECTIVES ON THE POSITION

According to one division commander, the division psychiatrist and the DMHA are responsible for 

“maintaining a ‘finger on the pulse’ of the unit.”28 This 

guidance provides a global commander’s intent to the 

DMHA, but interpretation and execution of that intent 

is subject to individual variability. 

There are multiple perspectives to consider, as illustrated in Figure 6-3. Division psychiatrists rely on their 

own perspectives, but must be cognizant of the requirements and expectations of the division surgeon and 

division commander. Similarly, the BCT BHO must 

consider the expectations of the division psychiatrist, 

brigade surgeon, and brigade commander. Additionally, behavioral health providers’ different training 

backgrounds may influence which areas they are both 

competent and confident to address. For instance, a 

BCT BHO who is a psychologist has different skill capabilities than a social worker. Despite these training 

differences, all providers bring their own experiences 

to the position, which also influences their scope and 
93

The Division Psychiatrist and Brigade Behavioral Health Officers

Division 

Psychiatrist

BCT

Behavioral

Health 

Teams

Division 

Commander

Division 

Surgeon

Soldiers

Special Staff Officer

Consultant

Supervisor/Educator

Clinician

Figure 6-3. Perspectives on the position of the division 

psychiatrist.

BCT: brigade combat team

breadth of practice. 

The division psychiatrist position tends to be assigned to junior officers following completion of their 

psychiatric residency or fellowship. Many enter the 

position as a company-grade officer (captain) and are 

promoted to field grade (major) while in the position. 

For many incoming division psychiatrists, this is their 

first opportunity to practice independently. Furthermore, few of the incoming division psychiatrists are 

familiar with the operation and function of a division 

staff and most have not attended their branch-specific 

career course.

Like the psychiatrist, the BCT BHO position tends 

to be assigned to a junior to mid-level officer. Many 

enter the position as a company-grade officer and some 

will be promoted to field grade while in the position. 

In the past, the psychologists would likely have just 

completed their internship training and have not done 

any other operational tour. However, that has changed 

recently with requirements for licensure for deployability. Currently, most psychologists have completed 

a 1- or 2-year postinternship tour prior to arriving to 

the BCT. For social workers, most have completed 

one tour, generally at a medical center working with a 

senior social work officer, and then are assigned to an 

operational billet. For many incoming BCT BHOs, this 

is their first opportunity to practice without a senior 

supervisor in their discipline. Like psychiatrists, few of 

the incoming BCT BHOs are familiar with the operation and function of a brigade staff, and most have not 

attended their branch-specific career course. 

In keeping with their recent training program experience, both incoming division psychiatrists and BCT 

BHOs tend to focus on their roles as clinicians, and 

quite possibly, as educators for their enlisted mental 

health technicians and BCT primary care physicians. 

They may not rapidly embrace their roles as staff 

officers, advisors, and consultants to the division or 

brigade leadership or comprehend how these roles 

affect care for soldiers. In some instances, division 

psychiatrists have relinquished their leadership and 

administrative responsibilities to a brigade BHO to 

increase time available for their own clinical work. 

Similarly, for many BHOs, this is their first experience integrating with a line combat unit. The BHO 

must quickly adjust to training and operation tempo 

requirements that are expected in these units.

In contrast, division and brigade surgeons expect 

BHOs to act as advisors and consultants. They envision 

the psychiatrist or BCT BHO providing assistance in 

planning for the behavioral health aspects of the entire 

spectrum of operations and coordinating behavioral 

health support resources for garrison and deployed 

activities. They expect their behavioral health consultant to be able to identify the behavioral health 

threats to the units and make recommendations on 

preventive mechanisms for the division or brigade. 

They further expect the BHO to be familiar with the 

Army Medical Department (AMEDD) principles of 

treatment, evacuation, and restoration in theater. This 

includes arranging transportation, coordinating care 

for evacuated soldiers, and patient tracking. 

Additionally, the division psychiatrist expects the 

BCT BHO to serve as both an advisor and a clinician. 

In many cases, BCTs are not collocated with their 

divisions, and division psychiatrists rely on the BCT 

BHOs to advise them on behavioral health issues that 

occur within the brigade. Furthermore, they expect the 

BCT BHO to be the primary provider of behavioral 

healthcare within the units and to be responsible for 

evaluating soldiers’ behavioral health fitness for duty. 

Further requirements include training and developing 

the enlisted mental health technicians and consulting 

with BCT medical and command personnel. 

Both division and brigade commanders expect their 

staff officers to be able to provide expert advice and 

alternative courses of action to enable them to make 

educated decisions in the best interest of the unit. 

Many commanders see BHOs as an important part of 

the division or BCT medical team and expect them to 

be experienced in analyzing behavioral health trends 

and their potential impacts on unit readiness. 

In general, commanders have become very attuned to the behavioral health effects of combat and 
94

Combat and Operational Behavioral Health

deployment on their soldiers and look to the unit 

BHO to provide expert consultation on what they, as 

commanders, can do to mitigate the inherent stress 

of deployment, ensure proper surveillance of mental 

health issues upon redeployment, reduce the stigma 

of seeking care, and help their soldiers. 

Case Study 6-1: During one recent deployment, a division commander told his division psychiatrist that he was 

“concerned about the mental health of my unit and I want my 

commanders to know that we as a unit have the resources, 

ability, and concern to do something to help them.” He frequently had the division psychiatrist travel with him throughout the theater of operations to ensure that the behavioral 

health team was aware of the various conditions soldiers 

were encountering but also for the subordinate commanders 

to see the importance that he placed on soldier behavioral 

health. The division psychiatrist was able to get a “finger on 

the pulse” of the units that they were visiting, identify the 

potential risks for combat and operational stress within the 

unit, and provide the commanders with recommendations 

on how to mitigate those risks. 

These various duties, responsibilities, expectations, 

and external pressures on unit behavioral health 

officers pose a formidable challenge for relatively 

junior officers to properly prioritize their duties. In 

this setting, optimal performance will be achieved 

through proper professional development and updated doctrine.

DUTIES AND RESPONSIBILITIES

There are several areas of responsibility of particular 

importance to these junior officers. These will be discussed in this chapter; a comprehensive listing of the 

multiple duties and responsibilities of the unit BHO 

can be found in Exhibit 6-1.

Planning and Oversight for Behavioral Healthcare

The division psychiatrist or BCT BHO is the unit’s 

subject matter expert on the behavioral health effects 

of combat and other deployments. Therefore, it is 

imperative that the division psychiatrist or BCT BHO 

serve as a staff officer within the division or brigade 

leadership to provide recommendations on the positioning and utilization of behavioral health resources, 

both in garrison and during deployment.

Prior to deployment the division psychiatrist is responsible for developing and implementing training 

programs for primary care providers, nonmedical officers, and noncommissioned officers. Training should 

focus on prevention and management of operational 

stress and other mental health problems that may be 

encountered during deployment. 

During deployment, it is the responsibility of the 

division psychiatrist and the BCT BHO to assess 

the behavioral health threat of the environment and 

work closely with the command surgeon to review 

how behavioral health assets are being deployed and 

utilized within the operational environment. Sources 

of information include historical data from prior conflicts both in the unit and for that area, rates of combat 

stress in other units deployed to the conflict, rates of 

behavioral health issues in the unit in garrison, and 

effects of psychological profiles related to combat 

on the fighting strength. The division psychiatrists 

or BCT BHOs can make recommendations to their 

respective commands on where to position and how 

to implement the behavioral resources within the 

unit. Furthermore, the division psychiatrist should 

develop standard operating procedures for division 

mental healthcare, create traumatic event management 

plans, and provide guidance on the utilization of the 

Unit Behavioral Health Needs Assessment or other 

unit evaluation tools. Additionally, it is imperative to 

coordinate with external assets such as combat stress 

control units when they are positioned within the area 

of operations. 

Key concepts to be considered when planning the 

distribution of resources are safety, security, and a 

close proximity to the units at greatest risk for combat 

operational stress reactions. This not only involves the 

division psychiatrist, but also the BCT BHO who must 

develop plans for allowing outreach from a primary 

clinic location to extend throughout the unit area of 

operations that requires logistical support. 

Also of significance is the monitoring of, and guidance on, the use of psychotropic medications within 

the division and brigade, an area that has come under 

recent public scrutiny. The division psychiatrist needs 

to work with the medical logistic assets to determine 

which medications should be used in the area of operations and should help set guidelines for indications, 

use, and monitoring of psychotropics within the division. In general, use of antidepressants and mild sleep 

aids is common practice. Use of other psychotropics 

such as benzodiazepines, stimulants, and antipsychotics should be considered on a case-by-case basis and 

warrant increased vigilance. This topic is covered in 

great depth in Chapter 10, Psychiatric Medications in 

Military Operations, in this volume.

 Although BCT BHOs are not credentialed to prescribe medication, they need to be aware of the utilization of psychotropics and their effects on the soldiers 

within the unit. The BCT BHO needs to work closely 
95

The Division Psychiatrist and Brigade Behavioral Health Officers

EXHIBIT 6-1 

DUTIES AND RESPONSIBILITIES OF THE UNIT BEHAVIORAL HEALTH OFFICER

Planning/Oversight for Division Mental Healthcare

	 •	 Plans and coordinates pre- and postdeployment mental health screening

	 •	 Provides recommendations on positioning of division mental health assets in garrison and deployment

	 •	 Develops division traumatic event management plan

	 •	 Consults with combat stress detachment (CSC) commander on placement of resources within division area

during deployment

	 •	 Monitors and provides guidance on use of psychotropic medications

 ° Determines which medications medical logistical personnel need to have on hand during deployments

 ° Knows that use of antidepressants and mild sleep aids is common practice; use of other psychotropic 

medications such as benzodiazepines, stimulants, and antipsychotics should be considered on a case-bycase basis and based on current guidance from higher levels

	 •	 Liaisons with other support resources in garrison and during deployment

 ° Consults with garrison medical treatment facility, Army Substance Abuse Program, chaplains, Army 

Community Services, Military OneSource, and local civilian mental health providers and hospitals

 ° Works with deployment chaplains, combat stress detachments, and medical providers

Consultant to Commanders and Division Surgeon on Behavioral Health Trends/Issues

	 •	 Coordinates behavioral health prevention efforts

 ° Provides routine consultative updates on behavioral health threats through monitoring of utilization rates 

of the division mental health clinic, behavioral health hospitalization rates, child/spouse abuse cases, DUI 

reports, positive drug test results, and pre- and postdeployment health assessment results

 ° Oversees standardized Army Battlemind training for development of mental resiliency of soldiers, spouses, 

and their families

	 •	 Prepares for potentially traumatic events

 ° Works with commanders, chaplains, and other medical personnel to develop a unit traumatic event 

management plan for addressing potentially traumatic events

	 •	 Monitors issues of public attention

 ° Educates the commander about current ongoing issues of mental health significance and advises commander about potential mental health impacts of varying policy/strategic changes

 ° Provides commander with information updates and potential questions/answers for media encounters 

about mental health prevention and ongoing issues within the unit

Supervisor of BCT Behavioral Health Officers and Enlisted Mental Health Specialists

	 •	 Serves as the officer in charge of division mental health

	 •	 Establishes the standard of care for practice within the division mental health activity (should be published

in some format and reviewed on a regular basis)

	 •	 Supervises all BCT behavioral health officers

 ° Conducts frequent supervision and chart reviews

 ° Ensures that BCT behavioral health officers are adequately supervising their enlisted mental health technicians

	 •	 Manages continuing education

 ° Develops a continuing education plan for each provider including local training (morning reports, routine 

training) and other opportunities (combat operational stress course, behavioral health short course)

 ° Ensures that all providers are obtaining necessary continuing education requirements and completing 

necessary tasks for licensure, etc

	 •	 Officer and noncommissioned officer development

 ° Ensures that all personnel are working towards advancement and achieving necessary requirement to 

include schooling (captain’s career course, NCO Academy) and civilian schooling

 ° Serves as a rater for all of the behavioral health officers

Educator of Division Medical Providers

	 •	 Ensures that all medical providers are educated about most recent practices in recognition and management of:

 ° Posttraumatic stress disorder

(Exhibit 6-1 continues)
96

Combat and Operational Behavioral Health

 ° Sleep disorders

 ° Depression and anxiety

 ° Psychiatric emergencies

 ° Traumatic event management

 ° Use of psychotropic medications during deployment

Clinician

	 •	 Serves as a direct provider both in garrison and during deployment

	 •	 Understands that care is generally limited to medication management because of limited resources

Administrative Psychiatry

	 •	 Performs command-directed evaluations

 ° Knows that guidance is provided in Department of Defense Directive 6490.1 and Department of Defense 

Instruction 6490.4; (can be ordered by the commander or required by Army regulation)

	 •	 Performs security clearance evaluations

	 •	 Performs forensic exams (sanity boards)

	 •	 Writes medical evaluation boards (MEBs)

	 •	 Writes Army suicide evaluation reports (ASERs)

Officer and Leader in the Division

	 •	 Maintains personal readiness

	 •	 Serves as a leader and example for junior officers and enlisted soldiers

ASER: Army suicide evaluation report

BCT: brigade combat team

DUI: driving under the influence

MEB: medical evaluation board

NCO: noncommissioned officer

Exhibit 6-1 continued

with the division psychiatrist, BCT providers, and the 

medical logistic assets as they determine which medications should be used in the area of operations, and 

know the guidelines for indications, use, and monitoring of psychotropics within the division. 

Additionally, the unit behavioral health officer must 

consider other potential operational activities that 

might require behavioral health participation, such as 

detainee operations and preventive training, as well as 

the soldier resiliency programs. A comprehensive, division level, planning and oversight program, spanning 

the entire deployment lifecycle, will identify unforeseen obstacles while ensuring that access to care is not 

impeded by faulty screening programs, unprepared 

clinical services, or inadequate personnel staffing. At 

the brigade level it is imperative that a comprehensive 

planning and oversight program, including brigade 

behavioral health standard operating procedures 

(SOPs), be developed within the guidelines of the 

divisional mental health SOPs.

Attention has been focused on pre- and postdeployment screening by the media and Government Accountability Office for several reasons. These include 

reports of soldiers being identified during screening 

but not receiving their consultations or treatment, 

as well as multiple studies of returning soldiers indicating that rates of reported deployment-related 

symptoms can increase with time after returning from 

deployment.7,9,10,29,30 The responsibility for overseeing 

an effective screening program (that commanders 

fully endorse) falls to the division psychiatrist and 

the DMHA. These plans must focus on education, 

early identification, and prompt treatment. Additionally, education and coordination must be made with 

commanders to ameliorate the stigma associated with 

behavioral healthcare. 

Lastly, both during deployment and in garrison, the 

division psychiatrist must coordinate between, and 

communicate with, ancillary resources available both 

within the unit, such as the chaplains and medical providers, and external to the unit. These latter resources 

include the department of behavioral medicine at the 

local medical treatment facility and representatives 

from Military OneSource, Army Community Service, 

the Army Substance Abuse Program, social work services, garrison chaplain services, and civilian community agencies. Coordination and discussion with these 

assets arms the psychiatrist with an array of resources 
97

The Division Psychiatrist and Brigade Behavioral Health Officers

available for individual soldiers, families, units, and 

commanders. In general, for BCTs that are collocated 

with their division headquarters, the responsibility of 

coordinating with external resources should fall on 

the division psychiatrist. However, for BCTs that are 

in isolated locations, it is the responsibility of the BCT 

BHO to perform this coordination. 

Provide Consultation to Commanders and Command Surgeons on Behavioral Health Trends and 

Issues

One of the vital roles of unit behavioral health 

officers is the consultation that they provide to commanders and medical staff. There are many areas on 

which the psychiatrist or BCT BHO can provide expert 

advice. Three major areas of concern are prevention, 

responding to critical events, and dealing with current 

public affairs issues. 

Preventive advice involves prioritizing the threats 

that have been identified and making recommendations to the medical staff and command on measures to 

be taken and areas requiring command emphasis. This 

includes monitoring ongoing trends such as utilization 

rates of the DMHA, behavioral health hospitalization 

rates, child and spouse abuse cases, driving under 

the influence reports, positive drug test results, Army 

Substance Abuse Program utilization, and pre- and 

postdeployment health assessment results. Additionally, longitudinal analysis should be made over a 

significant time frame to visualize current trends and 

examine behavioral health indicators from current 

and previous deployments. The outcome of crucial, 

predictive information could help direct placement 

and utilization of the limited resources available. Monitoring of these trends should be a regular action and 

the command should be updated on a monthly basis, 

in consultation with the command surgeon. 

Additionally, a mental health service utilization 

tracking system that includes the unit, diagnosis, and 

primary stressor to identify smaller organizational 

trends, such as at the battalion level, can provide commanders at all levels with valuable information and 

facilitate targeted interventions. 

Case Study 6-2: During a recent deployment, one DMHA 

was monitoring unit behavioral health trends and noted a 

significant spike in combat operational stress in a particular 

battalion. This trend was reported to both the battalion and 

brigade commander shortly after it developed. The commander then was able to relate that information with safety 

officer reports of a recent increase in accidents, coupled with 

a noted decrease in combat effectiveness. This led to the 

commander switching areas of operation to “give the unit a 

break” and resulted in both a rapid improvement in combat 

effectiveness for both units and maintenance of the ongoing 

combat mission.

In addition to prevention, unit behavioral health 

officers can have a significant effect in response to 

potential traumatic events. Working with the unit 

chaplains, medical resources, and commanders, the 

division psychiatrist can advise and determine how 

to respond to deaths, nonbattle injuries, casualties, 

and other significant events within units. The unit 

behavioral health officer should develop a traumatic 

event management plan for advising commanders and 

responding to soldiers’ needs after these occurrences. 

Being successful in this realm involves good communication, a knowledge and understanding of current 

medical literature, and good relationships with unit 

commanders and support resources. 

Case Study 6-3: During a recent deployment, one DMHA 

established a formalized traumatic event management policy. 

This policy provided clear guidance to the unit commanders 

and support personnel on how to respond after a potential 

traumatic event, including contacting the unit mental health 

and ministry teams to conduct a unit assessment and perform a debriefing if necessary. Additionally, if required, the 

debriefing would be a joint venture by the behavioral health 

providers and the chaplains. Whereas during a prior deployment, many of the commanders or chaplains often wanted 

to conduct sessions immediately upon the return of the unit 

or conduct full critical incident stress debriefings (which may 

be harmful), this plan provided clear guidance on how to 

respond to potentially traumatic events and helped to reduce 

confusion within the unit.31 In this case, it was imperative for 

the BHO to educate command on the importance of the timing and the type of debriefings to reduce potential negative 

outcomes for the soldiers. 

Educating and advising commanders on current 

ongoing issues of public attention is of critical importance. For example, recent media reports have been 

critical of the military on such topics as the ability to 

identify and treat posttraumatic stress disorder and the 

use of psychotropic medications in combat settings.30–33

Both the division psychiatrist and BCT BHOs must 

be aware of these ongoing issues through their own 

reading and attention. They should be able to advise 

the commander of any potential questions from media 

encounters. Identification of these potential topics is 

accomplished through various sources of information 

including the unit public affairs officer and review of 

critical incident reports and serious incident reports. 

Information can also be gathered from local and 

national newspaper reports about behavioral health 

issues in the military and via ongoing communication 

with the various behavioral health consultants, fellow 

division psychiatrists, and BCT BHOs about such re-
98

Combat and Operational Behavioral Health

quests. Responses to media queries should always be 

coordinated through the unit public affairs officer.

Education of command and support staff can be 

conducted through various methods: e-mail updates, 

power-point educational briefings, or prepared commander talking points. The method is at the discretion 

of the commander and is dependent upon how he 

or she best processes information. A recommended 

method is to prepare written talking points in a question-and-answer type format with bulleted responses. 

It will provide commanders with the information in a 

succinct format while also preparing them for potential 

questions from the media. 

Supervise the Brigade Combat Team Behavioral 

Health Officers and Enlisted Mental Health 

Technicians

The division psychiatrist establishes the standards 

of care and practices for all the behavioral health providers in the division. The BCT BHO further refines 

and applies those procedures to the brigade. This task 

requires the setting of the standards and monitoring 

practices through ongoing supervision and routine 

feedback for all BCT BHOs. This is generally done first 

through a written SOP. Certain taskings or reporting 

requirements might require a fragmentary order. Areas 

that require SOPs include operation of the division 

mental health clinic, record keeping procedures, and 

management of high-risk personnel. Additionally, the 

division psychiatrist should establish a supervision 

policy for chart review and routine feedback, generally 

conducted on a monthly basis, to all brigade behavioral 

health officers. For BCTs that are not collocated with 

the DMHA, it is important for the BCT BHO to obtain 

the division SOPs and augment them to fit the working 

environment of the BCT.

Enlisted mental health technicians require ongoing supervision by a licensed provider. Mental health 

technicians must be supervised at the time of every 

new soldier encounter and as needed during followup evaluations. The supervising provider should 

use the context of the soldier encounter to teach the 

enlisted mental health technician about such topics 

as interviewing techniques, the epidemiology of 

behavioral disorders, and common adverse medication effects. 

Providing this supervision can be challenging 

with some divisions because not all of the personnel 

are located at the same installation. Additionally, it is 

imperative that this feedback and supervision continue throughout deployments, keeping in mind that 

with the new BCT structure it is likely that BCTs and 

behavioral health staff from outside the division will 

be joining the unit during deployment. 

An additional responsibility for division psychiatrists is the provision of accruing continuing education 

for themselves, the BCT BHOs, and the mental health 

technicians. The BCT BHOs share this responsibility 

and should be closely involved in the training and 

education of their assigned technicians. This includes 

ensuring that there are ongoing training opportunities 

for educational advancement and access to teaching on 

the latest information and practices in combat operational stress management. How that is implemented 

is the responsibility of each division psychiatrist, 

but consideration can be given to morning reports, 

monthly training sessions, use of “sergeant’s time” 

training, utilization of local medical treatment facility 

training, or sending personnel to training conferences 

or schools. 

All behavioral health officers should be encouraged 

to attend the annual Army Behavioral Health Short 

Course. This opportunity ensures that behavioral 

health officers earn sufficient continuing education 

credits to maintain licensure and promotes professional development, while providing an opportunity for 

collegiality among officers who are dispersed around 

the globe. Additionally, all soldiers in the DMHA 

should attend the combat operational stress course 

prior to deployment because it provides the most 

current training on theater policies, lessons learned, 

and ongoing practices. It also provides an opportunity 

for teambuilding, predeployment planning, and SOP 

guidance for those deploying units that are not collocated in garrison. 

Lastly, there is the responsibility, as a supervisor, to 

provide opportunities and advice for career development for BHOs and mental health technicians. This includes counseling soldiers on their duty performance 

and affording them opportunities to participate in 

required training, such as the AMEDD career course. 

Additionally, both the division psychiatrist and the 

BCT BHOs need to ensure that they develop the writing skills necessary for contributing to, or initiating, 

developmental counseling forms, officer evaluation 

reports, noncommissioned officer evaluation reports, 

and awards. 

Educate Division Medical Providers

Because there is only one psychiatrist for a unit 

of approximately 20,000 soldiers who are, at times, 

spread over several locations, teaching the unit’s 

primary care providers about key behavioral health 

issues is imperative, as well as a force multiplier. This 

can be done through a variety of teaching modalities; 

creativity is encouraged. Key topics to cover include 
99

The Division Psychiatrist and Brigade Behavioral Health Officers

postdeployment stress, psychiatric emergencies, sleep 

management, posttraumatic stress disorder, traumatic 

event management, and depression. This education 

should include information on recognition, diagnostic evaluation, and pharmacologic management. 

Pharmacologically, providers should understand the 

indications for use, common side effects, drug interactions, monitoring requirements, and deployment 

considerations of each somatic intervention.

The BCT BHO should take responsibility for developing and incorporating this curriculum with the BCT 

surgeon for providers within the unit. This becomes 

most important in the deployed environment where the 

division psychiatrist may not be located close to the brigade. It is incumbent on both the division psychiatrist 

and the BCT BHO to plan for the continuing curriculum 

during all portions of the deployment cycle.

Provide Direct Care of Patients

As previously mentioned, the division psychiatrist 

functions as the senior behavioral health provider for 

the entire division. Due to other demands, direct clinical opportunities for the division psychiatrist will be 

limited, and will most often involve brief interventions 

and medication management. However, to retain skills 

and credibility, it is important that the psychiatrist 

continue to maintain practice both during deployment 

and in garrison. 

In garrison the division psychiatrist will be a 

provider at the consolidated division mental health 

clinic. Where the division psychiatrist should be located during deployment has been an area of ongoing 

debate since World War I.3

 With enhanced battlefield 

communication capabilities offering accessibility to 

other widely dispersed mental health providers, placing division psychiatrists within the division surgeon 

section allows them to perform as staff officers and 

consultants to the command while also providing 

consultative advice on care, medication management, and other guidance throughout the division via 

telephonic, e-mail, and, when required, face-to-face 

evaluations. However, the division psychiatrist should 

frequently travel to remote sites to provide on-site 

care, supervision, consultation, guidance, and teaching. This practice not only ensures that the division 

psychiatrist has a clear understanding of conditions 

and potential problems throughout the division, but 

it also enhances visibility from all elements of the 

forward line units.

The BCT BHO functions as the primary behavioral 

health provider for the entire BCT. In garrison, BHOs 

should work in a combined DMHA clinic when possible to help share the workload. When not possible, 

they are encouraged to collocate with their BCT troop 

medical clinic because it allows them to maintain close 

contact with the commanders, medical providers, and 

soldiers in their units. During deployment, BCT BHOs 

will routinely locate with their brigade troop medical 

clinic, but are encouraged to develop close relationships with the combat stress control units supporting 

their units, which may include collocating clinics. 

In both settings, BCT BHOs will be challenged to 

adapt their schedules and modalities of care, based on 

the demands of the unit. In general, opportunities for 

long-term therapy will be very rare. Most interventions 

will utilize psychoeducation and brief supportive, 

cognitive, or group therapy modalities.

Fulfill Administrative Psychiatry Requirements

Both the division psychiatrist and the BCT BHO 

have a large number of administrative responsibilities. Command-directed mental health evaluations 

are defined in Department of Defense Instructions 

6490.434 and Directive 6490.1,35 which outline rules 

for both command-directed discretionary and nondiscretionary referrals. Nondiscretionary evaluations are 

those required by regulation, including drill sergeant, 

recruiter, and sniper evaluations. Additionally, all 

soldiers undergoing certain administrative (“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 

assessment and feedback. In turn, the qualified unit 

behavioral health officer provides commanders with 

feedback and recommendations about their soldiers. 

When performing a command-directed evaluation, the evaluator should provide the commander 

with a formal report of mental status (Department 

of the Army Form 3822-R, Medical Command Form 

699-R) outlining feedback and recommendations. At 

a minimum, the report should address whether or 

not a diagnosis exists, a prognosis for the soldier’s 

condition, any duty limitations, 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, BCT BHOs must be familiar with 

the restrictions that their level of professional degree 

places on their ability to perform and sign commanddirected evaluations. In general, non-PhD social 

workers are able to perform and sign nondiscretionary evaluations. Discretionary evaluations and those 

recommending a Chapter 5-13 (personality disorder) 

or a Chapter 5-17 (failure to adapt) discharge require 
100

Combat and Operational Behavioral Health

a PhD-level social worker, or a psychologist, or a psychiatrist. Psychologists who are BCT BHOs are able 

to perform and sign all forms required for commanddirected evaluations. 

BCT BHOs who are non-PhD–level social workers should develop contingency plans with their 

colleagues for performing discretionary commanddirected evaluations either in garrison or during 

deployment. During deployment, this may require 

coordination with combat stress detachment assets in 

the area of operations. Additionally, if no psychologists or psychiatrists are available, then a physician 

(preferably the brigade surgeon) may serve as the 

signing authority. 

At times, military mental health providers may 

perceive pressure to recommend use of these chapter 

separations as opposed to a fitness for duty and disability evaluation. This pressure often comes from 

the patient, the unit, or both who are primarily trying 

to expedite a rapid exit from the military for varying 

reasons. These chapter separations are often more expedient, requiring less paperwork and fewer levels of 

review. However, soldiers who are chapter separated 

are not afforded medical disability benefits and may 

reenter military service as early as 6 months after discharge. It is imperative that the military mental health 

provider conduct a thorough evaluation and ensure 

appropriate disposition as defined by the current 

military regulations. It is also important for the service 

member to understand the meaning and consequences 

of the evaluation and rationale for separation. This will 

ensure the best care for the patient, the military, and 

the society that the soldier may be returning to upon 

discharge from the military.

In addition, there are a number of other administrative requirements. These include security evaluations 

for unit soldiers applying for clearance, sanity boards 

and other forensic psychiatry evaluations when ordered by the courts, and medical evaluation boards 

when indicated for disposition through medical channels. These assessments all require that the evaluator 

be either a psychiatrist or psychologist. Lastly, unit 

behavioral health officers may be asked to perform 

line-of-duty investigations for those involved in events 

with unfortunate outcomes, and the Department of 

Defense suicide event reports when soldiers either 

make a suicidal gesture or attempt, or complete a 

suicide. These evaluations can be time consuming, 

but must be performed expeditiously because they 

provide commanders and the Army with important 

information.

Be an Officer and Leader in the Division

Lastly, all BHOs must remember that they are officers in the unit. The Army combat uniform does not 

display branch insignia; hence, it is imperative that as 

officers, the division psychiatrists or the BCT BHOs 

set the standard. They must ensure that they maintain personal readiness and weapons qualification, 

actively participate in physical training, and attend 

all functions. It can also be expected that they assume 

additional taskings; it is their responsibility to perform 

those duties to the utmost of their ability. 

CHALLENGES OF THE POSITION

Balancing the duties and responsibilities of being 

a division psychiatrist or BCT BHO can be very challenging. There are several other factors that confront 

those in this position. First, division psychiatrists tend 

to be junior in rank to other division staff officers. 

With the recent Modified Table of Organization and 

Equipment (MTOE) adjustments, the division psychiatrist serves on the staff of the division surgeon (a 

lieutenant colonel) and works directly with several of 

the division surgeon’s deputies (majors). Additionally, 

the majority of the officers who directly advise the 

commanding general are at field-grade level, while 

the division psychiatrist position has traditionally 

been filled by individuals shortly after residency who 

are still at the company-grade (captain) level. This 

makes it difficult for the individual to gain the trust 

of the key leaders and advisors. Furthermore, recent 

changes in assignments have introduced BHOs working for the BCTs who are senior in rank to the division 

psychiatrist, thus potentially placing psychiatrists in 

the position of supervising those who are senior to 

themselves.

The BCT BHO, in turn, serves as a direct advisor 

to the BCT commander and the BCT surgeon, but is 

not located within the same unit allocation as those 

individuals. With the recent MTOE adjustments, the 

BCT BHO is assigned to the medical company in the 

brigade support battalion, while the BCT surgeon is 

assigned to the BCT headquarters unit. This can be 

very difficult because company and battalion commanders may feel that the BCT BHO “works for them.” 

They may attempt to restrict BHO and enlisted mental 

health technicians’ access to the DMHA and the BCT 

commander without clearing information through 

them first. It is the responsibility of the BCT BHOs 

to work out agreements with their company and battalion commanders about places of duty, interaction 

with command staff, and required unit activities. BCT 
101

The Division Psychiatrist and Brigade Behavioral Health Officers

BHOs are reminded to maintain appropriate bearing 

throughout these interactions and seek the assistance 

of their division psychiatrists and their BCT surgeons 

if they are having difficulty. 

Access to the enlisted mental health technicians, 

both in a deployed and garrison environment, can be 

problematic. This may need to be addressed by the 

brigade surgeon, the support planning officer, or the 

division psychiatrist if the BCT BHO is having trouble 

gaining full use of the mental health technician.

Another challenge is that the BCT BHO works with 

the BCT surgeon to directly advise the BCT commander about behavioral health issues, but tends to be more 

junior than other BCT staff officers. In general, both 

the BCT surgeon and the BCT BHO are junior to midlevel captains or junior majors, while most of the BCT 

commander’s deputies are mid-level to senior majors 

or other field-grade officers. Being more junior in experience, especially in the operational arena, makes it 

difficult for the individual to gain the trust of the key 

leaders and advisors. This requires the BCT BHOs 

to demonstrate respect, learn about the mission, and 

develop an understanding of unit capabilities. They 

must also rapidly adapt to the needs and demands of 

the BCT commander’s staff for updates and information dispersal. 

Additionally, both the division psychiatrist and the 

BCT BHO have to coordinate with other behavioral 

health resources within the area. While in garrison, the 

division psychiatrist needs to coordinate resources and 

the flow of information with the Medical Department 

activity, medical center, or the local civilian hospitals. 

This can be difficult at times because many in the 

hospital positions will not understand the full scope 

of the division-level BHO’s duties and responsibilities. 

It is possible that they might request that a division 

psychiatrist, BCT BHO, or enlisted mental health 

technician work at the local facility and share duty 

responsibilities. There are no guidelines or specifics on 

this. Therefore, all such requests should be coordinated 

locally with the supervising command surgeon.

During deployment, similar coordination will be 

required. There is potential that a BCT can be spread 

over a large area through many small forward operating bases, making it difficult for the BCTs limited assets 

to respond to all of the behavioral health needs. It may 

be difficult to coordinate with corps-level behavioral 

health assets for coverage, which will depend on their 

commanders’ opinions on the optimal emplacement 

of behavioral health resources. In these situations it 

is vital to have a theater behavioral health consultant 

who can address these issues. 

Another consideration is that, currently, several of 

the divisions are spread over multiple sites while in 

garrison. In such situations, it is difficult to both gauge 

the climate and establish a channel of communication 

between the BCT BHO and the division psychiatrist. 

This can create a gap in information flow within the 

DMHA and can leave a BCT BHO feeling unsupported 

by the rest of the DMHA. Such a deficiency can persist, 

and even flourish, during deployment because communications can be unreliable in theater and BCTs 

may deploy under a different division command than 

they are assigned to in garrison. It is vital for both the 

division psychiatrist and the BCT BHO to maintain 

open communication lines for continued visibility 

and comprehension of the trends and activities in the 

units. This provides for continuity of ongoing unit 

initiatives.

In the theater of operations, assuming unanticipated 

roles, such as mental health consultant for detainee operations, may present another challenge. In most cases, 

detainee operations have designated mental health 

attachments; however, should this service require support of the division psychiatrist, review of local policy, 

current Army regulations, and Department of Defense 

guidelines is critical. Comprehensive reference documents would include Army Regulation 190-8, Enemy 

Prisoners of War, Retained Personnel, Civilian Internees, 

and Other Detainees, and Annex F of the Mental Health 

Advisory Team (MHAT) II Report.

36,37 These, along with 

current guidance from the US Army surgeon general, 

can assist the division psychiatrist in ensuring ethical 

mental healthcare of detainees.

Other stressors in the garrison environment are 

finances and personnel. The DMHA clinic may be 

“owned” by the division, where there is little emphasis 

on workload capture or compensation. Or, as is the 

case at Fort Drum, New York, DMHA may fold into a 

larger behavioral health department. Regardless of the 

specific arrangement, clear boundaries and working 

agreements must be established between the various 

organizations to address budgetary, logistical, maintenance, operational, and personnel issues. 

There are several possible personnel issues that 

should be considered. First, in garrison the division 

resources are limited, as only the maneuver brigades 

are equipped with BHOs. Units such as the sustainment brigade and combat aviation brigade require 

support from both division and nondivision resources. 

Furthermore, it has not been uncommon for BCTs to be 

missing their full complement of personnel in garrison. 

This may result in BCT BHOs providing care coverage 

for soldiers from other brigades at the DMHA clinic 

or a BCT BHO arriving to the unit shortly before a 

deployment. During deployment, the division is likely 

to add BCTs, bringing additional providers who have 

been working under a different DMHA. It falls upon 
102

Combat and Operational Behavioral Health

the division psychiatrist to ensure that all behavioral 

health providers within the division are properly supervised and educated, and function under the same 

policies and standards of care.

Lastly, all BCT BHOs should expect to receive supervision, feedback, and information from their division 

psychiatrist, including those who are not collocated 

with their divisions. However, under certain circumstances, the BCT BHOs might need to seek supervision 

from their local Medical Department activity, such as 

when the division headquarters is deployed while the 

brigade remains in garrison. 

FUTURE DIRECTIONS

With increased public awareness of the behavioral 

health effects of deployment and the shifting of the 

Army to a more modular force, the DMHA has many 

challenging roles. These roles involve a variety of 

duties and responsibilities that demand a clinically 

competent provider fluent in the art of multitasking and executive decision making. With the recent 

Army changes and the increase in size of the division 

mental health activity, it is imperative that capable, 

well-prepared psychiatrists, psychologists, and social 

workers are placed in these positions. With that in 

mind, several areas of discussion are provided for 

future consideration. 

In the last two decades the US Army has shifted 

focus away from assets internal to the combat units 

toward placing emphasis on area support resources 

(combat support hospitals and combat operational 

stress control units), which provide coverage based on 

region rather than units.3

 Furthermore, the combat operational stress control units have larger, more diverse 

teams normally containing several psychiatrists, psychologists, social workers, and mental health specialists as well as occupational therapists and psychiatric 

nurses.11 These units are then spread over a large area 

providing both preventive and restorative care, often 

with a centralized restoration center that can provide 

up to 2 weeks of care.11

Many of these units are called to active duty from 

the Army Reserve or from other branches of service. 

Few, if any, of these units have had any contact with 

the units in garrison and thus have not established 

consultative relationships with the commanders prior 

to the deployment. Therefore, they do not have the 

preestablished credibility necessary to provide effective education and consultation to commanders. The 

essence of this credibility is established in prior demonstration, to command, of the consultant’s availability, 

utility of clinical skills and services, and perception 

that the consultant is not “investigating or blaming 

the unit for its problems.”34

In addition, Department of Defense Directive 6490.5 

states that each unit should have training, curricula, 

and guidance on combat operational stress control 

with a focus on primary, secondary, and tertiary 

prevention in garrison.38 Combat operational stress 

control units are generally not available in garrison for 

teaching. Likewise, many medical treatment facilities 

are not currently capable of providing the primary and 

secondary prevention and training because of ongoing 

demands for treatment of soldiers and their family 

members. This role is, therefore, ideal for the division 

mental health team and allows for development of 

strong bonds with units and a sense of ownership 

among the behavioral teams in their units. 

SUMMARY

Now, more than ever, the DMHA is critical. The 

new modular BCT structure projects mental health 

resources to lower levels and further toward the front 

lines. It also allows for development of long-term consultative and treatment relationships at the battalion 

and company level. This structure can also help to 

strengthen and emphasize pre- and postdeployment 

mental resiliency and medical provider training. 

Maintaining both division and combat stress control 

mental health resources in a collaborative working 

environment—where patient-specific issues and policy 

decisions are jointly determined—allows for continuity of training, education, consultation, and treatment 

during nondeployed times, with additional mental 

health resources available during a deployment. Similar lessons are being seen within the US Marine Corps 

and have led to the development of their Operational 

Stress Control and Readiness (OSCAR) program. Their 

program, like that of the US Army, increases the behavioral health resources within the units. That system is 

placing two psychiatrists within divisions, with one 

focusing toward the consultative and administrative 

aspects while the other is leading a multidisciplinary 

treatment team. 

The position of division psychiatrist and BCT BHO 

presents many challenges, especially in the aspect of 

balancing responsibilities. The US Marine Corps is 

the only other US military service that embeds mental 

health assets with their soldiers and has recognized 

these same challenges. Because of the complexities 
103

The Division Psychiatrist and Brigade Behavioral Health Officers

of staff, consultant, leadership, teaching, and clinical 

roles, future assignments to these positions should be 

based on knowledge, skills, and experience. Preferably, 

such individuals should be field-grade officers who 

have served at least one utilization tour after residency 

to gain experience as a practicing psychiatrist, and are 

graduates of the AMEDD career course. Additionally, as noted in the 5th iteration of the Mental Health 

Assessment Team’s report, consideration should be 

given to expanding mental health resources within 

the divisions, including the addition of an enlisted 

mental health technician in each battalion and an 

aeromedically trained psychologist in each combat 

aviation brigade.

REFERENCES

1. Glass AJ. Lessons learned. In: Anderson RS, Glass AJ, Bernucci RJ, eds. Neuropsychiatry in World War II. Vol I. Zone of 

the Interior. Washington, DC: Government Printing Office; 1966: 735–759. 

2. Bailey P, Williams FE, Komora PA, Salmon TW, Fenton N. Neuropsychiatry. In: The Medical Department of the United States 

Army in the World War. Washington, DC: Department of the Army, Office of The Surgeon General; 1929: 303–310.

3. Rock NL, Stokes JW, Koshes RJ, Fagan J, Cline WR, Jones FD. US Army combat psychiatry. In: Jones FD, Sparacino LR, 

Wilcox VL, Rothberg JM, Stokes JW, eds. War Psychiatry. In: Zajtchuk R, Bellamy RF, eds. Textbooks of Military Medicine. 

Washington, DC: Department of the Army, Office of The Surgeon General, Borden Institute; 1995: 149–175.

4. US Department of the Army. Neuropsychiatry and Mental Health. Washington, DC: DA; June 18, 1959. Army Regulation 

40-216.

5. US Department of the Army. Combat Stress Control in a Theater of Operations: Tactics, Techniques, and Procedures. Washington, DC: HQDA; 1998. Field Manual 8-51, Change 1.

6. US Department of the Army. 2004 Army Transformation Roadmap. Washington, DC: DA; July 2004. 

7. 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 Eng J Med. 2004;351:13–22.

8. Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from 

military service after returning from deployment to Iraq or Afghanistan. JAMA. 2006;295:1023–1032.

9. Southwick SM, Morgan CA 3rd, Darnell A, et al. Trauma-related symptoms in veterans of Operation Desert Storm: a 

2-year follow-up. Am J Psychiatry. 1995;152:1150–1155.

10. Grieger TA, Cozza SJ, Ursano RJ, et al. Posttraumatic stress disorder and depression in battle-injured soldiers. Am J 

Psychiatry. 2006;163:1777–1783.

11. Appenzeller, GN, Warner CH, Grieger T. Postdeployment health reassessment: a sustainable method for brigade 

combat teams. Mil Med. 2007;172:1017–1023. 

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

13. Jones E, Palmer IP. Army psychiatry in the Korean War: the experience of 1 Commonwealth Division. Mil Med.

2000;165:256–260.

14. Engel CC, Campbell SJ. Revitalizing division mental health in garrison: a post-Desert Storm perspective. Mil Med.

1993;158:533–537. 

15. Ritchie C, White R. Becoming a successful division psychiatrist: guidelines for preparation and duties of the assignment. Mil Med. 1993;158:644–648.

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

17. Leamon MH, Sutton LK, Lee RE. Graduate medical educators and infantry commanders: working together to train 

Army psychiatry residents. Mil Med. 1990;155:430–432. 
104

Combat and Operational Behavioral Health

18. Deeken MG, Newhouse PA, Belenky GL, Eshelman SD, Parker MT, Jones FD. Division psychiatrists in peacetime. Mil 

Med. 1985;150:455–457. 

19. Noy S. Division-based psychiatry in intensive war situations: suggestions for improvement. J R Army Med Corps.

1982;128:105–116. 

20. Warner CH, Appenzeller GN, Barry MJ, Morton A, Grieger T. The evolving role of the division psychiatrist. Mil Med.

2007;172:918–924.

21. Glass AJ. Psychiatry at the division level. In: Anderson RS, ed. Combat Psychiatry: Experiences in the North African and 

Mediterranean Theaters of Operation, American Ground Forces, World War II. Washington, DC: Government Printing Office; 1949: 45–73.

22. Warner CH, Breitbach JB, Appenzeller GN, Yates V, Grieger T, Webster WG. Division mental health in the new brigade 

combat team structure. Part I. Predeployment and deployment. Mil Med. 2007;172:907–911.

23. Warner CH, Breitbach JB, Appenzeller GN, Yates V, Grieger T, Webster WG. Division mental health in the new brigade 

combat team structure. Part II. Redeployment and postdeployment. Mil Med. 2007;172:912–917.

24. McCarroll JE, Jaccard JJ, Radke AQ. Psychiatric consultation to command. In: Jones FD, Sparacino LR, Wilcox VL, Rothberg JM, eds. Military Psychiatry: Preparing for Peace for War. In: Zajtchuk R, Bellamy RF, eds. Textbook of Military Medicine. 

Washington, DC: Department of the Army, Office of The Surgeon General, Borden Institute; 1994: 151–170.

25. Kirkland FR, Jackson MA. Psychiatric support for commanders. In: Jones FD, Sparacino LR, Wilcox VL, Rothberg 

JM, eds. Military Psychiatry: Preparing for Peace for War. In: Zajtchuk R, Bellamy RF, eds. Textbook of Military Medicine. 

Washington, DC: Department of the Army, Office of The Surgeon General, Borden Institute; 1994: 171–192.

26. Koshes RJ, Plewes JM, McCaughey BG, Stokes J. Educating mental health workers. In: Jones FD, Sparacino LR, Wilcox VL, Rothberg JM, eds. Military Psychiatry: Preparing for Peace for War. In: Zajtchuk R, Bellamy RF, eds. Textbook of 

Military Medicine. Washington, DC: Department of the Army, Office of The Surgeon General, Borden Institute; 1994: 

193–213.

27. Lande RG. A model combat psychiatry training program for division personnel. In: Jones FD, Sparacino LR, Wilcox VL, 

Rothberg JM, eds. Military Psychiatry: Preparing for Peace for War. In: Zajtchuk R, Bellamy RF, eds. Textbook of Military 

Medicine. Washington, DC: Department of the Army, Office of The Surgeon General, Borden Institute; 1994: 215–226.

28. Major General WG Webster. Commander, Task Force Baghdad. Personal communication, September 17, 2005.

29. Government Accountability Office. Post Traumatic Stress Disorder: DoD Needs to Identify the Factors Its Providers Use to 

Make Mental Health Evaluation Referrals for Servicemembers. Washington, DC: GAO; May 2006: 1–34. Report No. GAO06-397.

30. Milliken CS, Auchterlonie JL, Hoge CW. Longitudinal assessment of mental health problems among active and reserve 

component soldiers returning from the Iraq War. JAMA. 2007;298:2141–2148.

31. Jacobs J, Horne-Moyer HL, Jones R. The effectiveness of critical incident stress debriefing with primary and secondary 

trauma victims. Int J Emerg Ment Health. 2004;6:5–14.

32. Chedekel L, Kauffman M. Mentally Unfit, Forced to Fight. Hartford Courant. 2006, May 14, 2006. Available at: www.

courant.com/news/nationworld/hc-unfit0515.artmay14,0,7374793.story. Accessed April 24, 2009.

33. Thompson M. America’s medicated army. Time. June 5, 2008. Available at: www.time.com/time/nation/article/0,8599,1811858,00.html. Accessed April 24, 2009.

34. Department of Defense. Requirements for Mental Health Evaluations of Members of the Armed Forces. Washington, DC: 

DoD; August 28, 1998. DoD Instruction 6490.4.

35. Department of Defense. Mental Health Evaluations of Members of the Armed Forces. Washington, DC: DoD; October 1, 

1997. DoD Directive 6490.1.
105

The Division Psychiatrist and Brigade Behavioral Health Officers

36. US Department of the Army. Enemy Prisoners of War, Retained Personnel, Civilian Internees, and Other Detainees. Washington, DC: DA; October 1, 1997. Army Regulation 190-8.

37. Mental Health Advisory Team (MHAT-II). Operation Iraqi Freedom (OIF-II). Annex F: Internment Detainee Facility Assessment of Mental Health Advisory Team (MHAT) II. Report. The US Army Surgeon General. January 30, 2005. Available 

at: www.armymedicine.army.mil/reports/mhat.html. Accessed September 4, 2008.

38. Department of Defense. Combat Stress Control (CSC) Programs. Washington, DC: Department of Defense; February 

23,1999. DoD Directive 6490.5.
106

Combat and Operational Behavioral Health