Spotlight on Research
Welcome to the Spotlight on Research column. This column showcases research activities and projects underway in many of the research laboratories within the Department of Defense (DoD), partnering organizations and the academic and practitioner community in military psychology. Research featured in the column includes a wide variety of studies and programs, ranging from preliminary findings on single studies to more substantive summaries of programmatic efforts on targeted research topics. Research described in the column is inclusive of all disciplines relevant to military psychology—spanning the entire spectrum of psychology including clinical and experimental, as well as basic and applied. If you would like your work to be showcased in this column, please contact Colleen Varga.
This edition of the newsletter spotlights an area of psychology that is ripe for study. In the past few years, the demand for embedded psychological resources among special operations units has skyrocketed. This demand has stemmed from multiple factors, not least of which is an attempt to increase the likelihood that military members in high-risk and high ops tempo careers are getting care that they need when they need it and where they need it. This model embodies the therapeutic tenet of “meeting the client where they are at,” both literally and figuratively. The present article discusses the potential roles an embedded psychologist can fill, the characteristics that enable psychologists to be successful in this role, and the challenges associated with working in an embedded context.
Embedded Psychological Resources: A Model for Enhancing Individual and Organizational Resiliency
Bringing the critical psychological support to the fight – resiliency at the tip of the spear
By James A. Young, Chad E. Morrow, Mark A. Taylor, Jeffery J. Peterson, and Tatiana M. Soria
The military has a long history of utilizing psychologists and psychological principles to bolster the resiliency of troops and strengthen the organizations to which they belong (Laurence & Mathews, 2012; Mathews, 2014). In fact, active duty military members have grown to expect easy access to psychological care both in garrison and in the deployed environment. Military members can easily find a clinic or hospital with a full array of mental health specialties such as psychiatry, psychology and social work on most military installations. With such easy access, why do they often choose not to utilize these resources? Rather, they frequently elect to struggle in silence with a variety of psychological issues.
As long as there have been available resources to help with psychological issues, there has been a corresponding stigma associated with utilizing this support (Hoge, 2010; Hoge et al., 2004). Having identified stigma as a significant barrier to receiving adequate care, the military has aggressively sought creative alternatives to decrease this stigma, with the ultimate goal of connecting all military personnel with the help they may need.
One such approach has been to embed psychological resources in primary care clinics, as it is the location where much of the behavioral health care takes place. Some estimates suggest that about half of all mental health care will be accomplished by primary care providers (Robinson & Reiter, 2007). Another tactic has been to make resources readily available in the community near the military installation, for example, through programs such as Military One Source. This option for off-base care is appealing for some military members as their concerns about career impact are too weighty for them to feel comfortable seeking care on the installation where they work. Another attempt to increase access is to place Military Family Life Counselors (MFLCs) on military installations, but external to clinics or hospitals. While MFLCs, most typically Masters-level clinicians, retain the requirement to report certain issues such as suicidality, homicidality and domestic violence, they are allowed to offer “non-medical counseling” without a requirement to document the session. This absence of documentation puts many military members at ease with regard to career limiting implications (e.g., flying status, security clearances, etc.) because concerns about confidentiality are mitigated (Hoyt, 2013).
Utilizing an approach farther removed from the traditional mental health model, the military has increasingly embedded psychological resources directly into the units where the military men and women work, such as special operations units; remotely piloted aircraft organizations; basic military training; survival, evasion, resistance and escape training units; and intelligence, surveillance and reconnaissance units. Within this model, rather than going to another location on the military installation or somewhere in town, the military member receives support at the location where he or she works. Similar embedded models, albeit nonpsychological, have been utilized extensively in the military (e.g., chaplains, flight surgeons, independent duty medical technicians, etc.). There are many potential advantages and disadvantages of this model. Some of the advantages include easy access to psychological resources, greater potential for rapport because of familiarity, and the psychologist’s increased awareness of the work conditions associated with that person’s career field. Embedding these resources directly into the units will increase the frequency of nonthreatening contact and decrease stigma, thereby increasing the probability military personnel will feel comfortable asking for help before issues become unmanageable. Potential disadvantages might include loss of objectivity in dealing with unit members’ psychological problems, loss of professional identity, and a gradual drift from standards of practice and ethics.
Early indications suggest that military leaders see value in the embedded model. For example, Brigadier General Robert Armfield states, “Psychologists equip the operators with the mental skills to dominate the enemy on the battlefield, maintain high levels of psychological health throughout a career of brutal enemy engagements and thrive at home as they/their families cope with the reality of years of non-stop wartime deployments…The key to the success of this special tactics model is the embedded nature of the work they do” (Armfield, 2015). Another military leader, Colonel William Fischer, says the following about embedded psychologists within his organization: “The embedded psychologists in the 737 Training Group are directly impacting the quality of the Airmen entering the Air Force because they help ensure the professionalism of the training environment and our instructors.” He also states, “In the end, the embedded model of psychological and mental health support works. It not only provides oversight in mission execution and instructor effectiveness, but it also provides strategic insights to leaders when selecting instructors and revising policy” (Fischer, 2016).
We do not believe that all organizations are in need of embedded psychological support; rather, particular types of organizations are more likely to benefit from an embedded provider, in part because of the low probability its members will seek mental health care when offered solely in a traditional clinical setting. Often such organizations’ members are held to more stringent physical and psychological standards such as with special operations forces, aircrew, law enforcement, fire department, and intelligence communities; therefore, they may feel that they have a lot to lose by exposing themselves to what is often viewed as a mysterious mental health system. Individuals from these types of organizations are generally reluctant to see providers who are not familiar with the unit’s mission or who do not appreciate how the need for psychological treatment is perceived by the group’s members.
In the following sections we will briefly explore the following issues related to the embedded model:
- Roles an embedded psychologist might fill
- Qualities of psychologists who might do well in this environment
- Unique challenges associated with working in this context
Additionally, we will offer a few general recommendations for successfully embedding psychologists within an organization.
Focus and Approach
An overarching goal of embedding a psychologist in any organization is to optimize mission performance and enhance the resiliency of its members (Williams & Johnson, 2006). To achieve this, the embedded psychologist will employ a variety of tools to meet the commander’s intent and unit members’ needs. We believe Gardner and Moore’s (2005) Multilevel Classification System for Sport Psychology (MCS-SP) offers a good analog for how an embedded military provider can organize his or her activities. This model suggests the following four areas for sport psychologists to focus their activities:
- Performance development (PD) focuses solely on improving athletic performance
- Performance dysfunction (PDy) emphasizes alleviating minor to mild psychological impairments to performance
- Performance impairment (PI) focuses on treatment of clinical issues
- Performance termination (PT) addresses any issues related to termination of sporting activity
Borrowing from and modifying this multitiered model, we propose that engagement with the client (e.g., commander or active duty service member) would occur mostly in the following areas:
- Performance Development/Enhancement
- Transition Support
Performance development and enhancement activities seek to improve individual and organizational performance and maintain high levels of resiliency throughout the unit. Examples of activities that fall within this category are personnel selection, performance enhancement interventions (e.g., helping someone learn and utilize controlled breathing to maximize success in a challenging course or event), and stress inoculation training (i.e., within the context of a deliberate stress inoculation program).
Consultation with individuals would focus on the following types of issues: minor sleep difficulties (e.g., jet lag), increased hypervigilance/arousal, and relationship difficulties. The role of the embedded psychologist in this domain would be to provide psycho-education and recommendations on commonly occurring issues. Organizational consultation might be focused on issues such as operational tempo, work/rest cycle, morale and so forth.
Treatment is most similar to what one would find in the traditional mental health setting and, as such, has the goal of resolving clinical issues that directly impact performance and quality of life. This activity is similar to tertiary care; therefore, it is associated with documentation. Because of the established rapport, one might expect greater treatment compliance and improved treatment outcomes.
Transition Support has the primary goal of ensuring the unit member’s success in his or her transition to civilian life or another unit. This level of engagement addresses any of the normal psychological factors associated with a life transition. The focus is specific to the person and situation and could include discussions related to purpose, career/mission changes, and future goals. Again, we believe that an embedded provider may be in an ideal position to help with transition issues, in part because of their familiarity with the service member’s current job/roles and unique challenges.
Qualities of psychologists
Several personal and professional qualities are important to consider for successful placement of psychologists within operational units. Training, personality and perspective are just a few such issues.
Successful psychologists will have a strong experience base in clinical applications, such as knowledge of psychopathology, diagnostic ability and treatment application (Staal & Stephenson, 2006). The possession of a strong clinical foundation allows the psychologist to recognize the distinction between relatively minor disruptions in functioning and those symptoms that require more intensive treatment. Additionally, robust clinical experience allows the psychologist to effectively educate the unit member and the commander on the treatment process and expected outcomes.
The concept of “personality fit” refers to the ability of the psychologist to reflect the unit’s culture to such a degree as to be able to build relationships with its members and command in order to effectively apply behavioral science skills and knowledge. Thus, no particular personality profile will always produce success in an embedded position since different organizations possess unique cultures. In general, the embedded psychologist would be adept at managing stress and uncertainty effectively and building social connections, and possess a strong motivation for success.
This refers to how the psychologist views the unit, its members, and his or her role within the unit. Psychologists provide a specific skill set beneficial to the unit, and it is important to remember what that function is. While it may be appropriate to participate in many of the unit training activities in an effort to gain a greater understanding of the mission and unique stressors, it is equally important to not lose focus on the role of the psychologist by overidentifying with the operational members.
Unique Challenges of the Embedded Psychologist
The stigma of seeking mental health care by military members is well-established (Acosta et al., 2014; Britt et al., 2008; Britt, Jennings, Cheung, Pury, & Zinzow, 2015). This is promulgated in part by rumors, myths and partial truths—particularly with respect to concerns about confidentiality and negative career repercussions resulting from mental health care and medical documentation. Military members are apprehensive about seeking mental health treatment because of potential career limiting outcomes (e.g., loss of security clearance, duty restrictions, termination of military service). As a consequence, military members access care at a rate lower than may be indicated by need (Mental Health Advisory Team [MHAT]-V, 2008, as cited in Bryan & Morrow, 2011).
As an example, aviators generally do not trust mental health providers. For this reason, mental health providers must establish trust through consistent contact, rapport and well-suited psychological interventions. Young (2008) posits that pilots are reluctant to seek assistance when needed, thus making assessment and intervention difficult. As one pilot stated, “Aviators are notorious for avoiding flight surgeons and would disavow the very existence of mental health professionals if given the opportunity. Both occupations (flight surgeons and mental health professionals) represent a threat to a pilot’s flying status.”
Experts can extol the virtue of receiving care; however, a more persuasive argument comes from well-respected peers and leaders who personally advocate for support and treatment. As an example, within the SOF community, advocates such as Admiral William McCraven (Navy Ret.) and Sergeant Major Chris Farris (Army Ret.) spoke openly about the benefits of seeking care and actively promoted/funded embedded psychological resources through the Preservation of the Force and Family initiative. This high-level advocacy serves to normalize care, increases accessibility, and promote help seeking behavior.
Ethical consideration sIn the embedded model the persistent presence of providers poses unique ethical challenges to navigate with respect to confidentiality and dual relationships. By embedding a psychologist into the unit, familiarity and trust are gained; therefore, the distinct boundaries more easily maintained in traditional care settings can be blurred. Interactions are no longer limited to a far-removed clinic milieu with strict rules of engagement. While clear communication about confidentiality is necessary in traditional clinical relationships, the limits must be clearer when embedded. One suspected violation of trust can quickly impact trust among all members across the organization, essentially shutting down the business of the embedded provider.
For embedded providers, the nature of relationships with individuals, teams, and leadership is fluid. He or she may alternate among therapist, consultant, coach, team member, and mission support all in the same day. The ability to comfortably switch between roles while maintaining boundaries is critical to building effective relationships and staying true to psychologists’ ethical responsibilities.
Perhaps the greatest challenge is being viewed as an integral member of the team, which requires progressing from an outside observer to a trusted insider at the individual, team, and organizational level. In many respects, the same skills used to build rapport within a therapeutic relationship are used by the embedded provider, to include acceptance, empathy, and active listening (Mozdzierz, Peluso, & Lisiecki, 2009). Critical in this process is for the embedded provider to be genuine while simultaneously blending into the unit, observing and absorbing as much as possible. The provider should not attempt to alter his or her personality to fit the culture as this would be rejected as disingenuous. Another challenge is to find ways to be useful, approachable, and present, while not being invasive. Over time, the embedded provider will begin to know the unit members (e.g., duties, skills, families, personalities), and perceptions of the psychologist’s trustworthiness will develop.
Recommendations and Implications
There are numerous ways to increase the probability of success as an embedded psychologist. First, it is paramount that the psychologist has already established strong foundational skills before he or she can expect to successfully embed in a unit. If he or she is not a competent and confident psychologist, it will be difficult to practice alone in austere environments, and the ability to provide meaningful and impactful recommendations to the unit leadership will be diminished.
Second, it is helpful to consistently study what your commanders or leaders and unit members are studying. This approach for an embedded psychologist will not only ensure he or she begins to understand how his or her client thinks and behaves (i.e., what his or her interests and/or motivations are), but it also allows the embedded psychologist to speak the same language and make “shop-talk,” both of which are influential in building rapport and relationships with unit members (Staal, 2015).
Finally, as much as possible, the embedded psychologist should be involved with unit activities. This could range from being in the gym working out with unit personnel, participating in training events, or traveling with unit members. Typically, the embedded psychologist who is present with unit members, regardless of the location, will be seen as a team member and will be more utilized than one who sits in the office waiting for business.
While there are clearly a variety of ways to enhance individual and organizational effectiveness and resiliency, we feel that the embedded model shows particular promise, especially with those individuals or organizations that are reluctant to utilize more traditional modalities. The greatest challenge is to figure when and where to utilize this model, balancing the desire to bring additional help to unique populations while taking care to maintain our identities as psychologists. Anecdotally, each author has seen an uptick in help seeking behaviors among the individuals they serve. Prior to embedding a provider in their respective units, very few unit members sought help from mental health resources. Within just a few years those rates have increased significantly for each of these units. It is reasonable to suggest this may reduce short- and long-term mental health symptoms and disorders; however, perhaps more importantly, we believe it will enhance the performance capabilities of highly trained and essential members for the current battle space.
While listing all of the potential challenges an embedded psychologist might face is beyond the scope of this paper, our goal was to highlight those that have been repeatedly faced by the authors. These challenges, if not managed well, have the greatest likelihood for diminished results and an uncomfortable embedded experience.
Because of the ambiguity associated with operating in unfamiliar territory, we acknowledge that the professional risks are potentially greater than those within the traditional psychologist setting; however, the need for additional assistance to these organizations is high and the personal and professional rewards for providing this assistance are substantial.
For further information, please contact: Lt. Col. James Young.
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