Effective military mental health considerations in Navy basic training

ABSTRACT

The U.S. military has been met with challenges in manning to meet mission requirements over the past several years. As the number of waivers approved has progressively increased over the last decade, the question of long-term service and performance has emerged. A longitudinal analysis was performed to assess time-in-service outcomes from individuals who received a waiver for a mental health condition while in Basic Military Training (BMT). Population data were retrieved from the Authoritative Data Environment (ADE) and aggregated using Tableau Software. A comparative classification analysis was conducted to determine, within the population of individuals who received waivers for mental health while at Recruit Training Command between 2014 and 2022, those still in active duty who have completed their initial service obligation, and those who separated early from the Navy. Results indicate nearly 93% of 1,356 approved waivers are still actively serving or have completed their initial service contract. While current data show a majority of individuals with approved waivers are still actively serving, the process must continue to be comprehensive in accordance with relevant Department of Defense Instructions. The importance of this research is crucial to the entire military, not just the Navy. It is recommended that each military branch complete a similar longitudinal study that evaluates the continued service engagement of recruits recommended for a waiver and, furthermore, devise a way to track performance, utilization of medical and mental health care, career advancement, and success in a specified branch to determine if guidelines should be adjusted.

What is the public significance of this article? — Comprehensive military assessments are essential to determine that the most qualified, mentally stable, and motivated service members are recommended for continued service in order to best ready our military across the global landscape.

Introduction

Recent years have challenged the U.S. military in navigating how to recruit the right person, at the right time, for the right job. The military has faced a global pandemic, rising inflation, fluctuating unemployment, and geopolitical tension. As a result, all recruiting commands have a difficult challenge to overcome to ready the military service branches and maintain sufficient numbers for national security. With less than 1% of the eligible population serving at any given time, the demand for qualified candidates will continue to be a forefront issue to address while problem solving and developing creative, innovative ways to ready the force (Correll, 2022).

According to Navy Recruiting Command (2023), in February of 2023 the active duty component of the Navy totaled more than 337,000 active duty sailors and approximately 58,000 reservists supporting multiple contingencies worldwide. With fluctuating attrition and retention creating a challenge to meet manning requirements, it remains an essential mission to continue to ensure all component parts have well-equipped, adequately trained sailors. While recruiting mission objectives are dynamic in nature, there are intentional, well-designed efforts in multiple different recruiting and training specialties that have strategically implemented procedures, operations, and actions to ensure military personnel have support.

According to the National Review (2023), it is imperative the United States continue to adjust to “pacing threats during great power competition in an environment where China and Russia” have made valiant efforts to prepare their armed forces “ … to act across the entire spectrum of armed conflict (Jacob et al., 2023, p. 9). Without taking proper precautions to continue to scale our military, especially the Navy, we could find ourselves undermanned in a great power competition compared to the militaries of our near-peer competitors, which could directly threaten United States’ national security (Jacob et al., 2023, p. 9). While the Navy’s recruiting efforts are a fraction of the larger picture, every military component must do its part to contribute to the great sum-end game—meeting mission demands.

Navy basic training at Recruit Training Command (RTC), Great Lakes Naval Station

For the past three decades, every enlisted sailor joining the Navy has come through Great Lakes Naval Station, IL. An annual average of more than 41,000 sailors over the past five years have entered basic training with hopes of becoming a U.S. sailor (Navy History and Heritage Command, October 31, 2018). Basic training is intentionally designed as an early filter to ensure recruits will meet the requirements of military service. It takes true mind, body, and spirit commitment to make it through the intense training boot camp entails. The most common reasons recruits are separated during basic training include physical fitness standard failures, medical disqualifications for incompatible conditions, and current or historical mental health symptoms or diagnoses resulting in disqualification (Correll, 2022).

When cases arise requiring an exception to policy, a waiver is created and routed to the appropriate command authority for consideration. In these situations, command authority can approve or deny exceptions to policy based on recommendation made by the subject matter expert (SME). Ultimately, command authority will consider the SME’s recommendation, current needs of the Navy, and any associated risk when making an exception to policy.

Medical personnel supporting Recruit Training Command are SMEs in the recruit screening and selection process. Each SME works with recruits, instructors, and the RTC Commanding Officer (CO) as the command authority to ensure recruits are appropriately screened and fit to train. The number of requests for waivers for disqualifying conditions varies throughout the year, while in general, the summer months are busiest for RTC because this is when most candidates graduate from high school and are able to first begin training. As the training year continues, recruit totals will fluctuate until the next anticipated summer surge.

When holistically examining candidates entering the military, each recruit comes in with a different level of awareness, motivation, expectation, and resilience—all of which are critical elements of success in boot camp. The mental health team at RTC has mastered the art of examining suitability for service with the intention of ensuring safety, first and foremost, while challenging those recruits who need additional motivation to continue training in a calculated and deliberate manner. From a mental health perspective, recruits can be divided into three distinct groups: recruits who will excel and pass without issue; recruits disqualified within the first hours or days, who are often experiencing new or worsening disqualifying symptoms after leaving their home of record; and recruits who need additional attention, guidance, mentorship, or supportive services to make it through boot camp. The main mental health assessment clinic at RTC is the Recruit Evaluation Unit (REU), which is made up of a multidisciplinary team specializing in the assessment of Naval recruit suitability for service.

Recruit Evaluation Unit (REU) Intervention Programs

The REU is a satellite clinic of the Captain James A. Lovell Federal Health Care Center (FHCC) and comprises more than 45 military and civilian personnel including psychologists, social workers, physician assistants, mental health nurses, administrative support, and behavioral health technicians. Each has an essential and defined role in different treatment programs that address specific stressors and symptoms during specific iterations of boot camp. During the first week, phase one of stress inoculation training is implemented through a psychoeducational presentation during the initial days of arriving at boot camp that normalizes and sets expectations for the physical and mental stress that recruits are going to endure with general recommendations on how to manage it. If a recruit experiences an injury or needs to remain on a medical hold status, they are placed in the Recruit Convalescent Unit (RCU). While in RCU, a recruit may engage with the Psychological Resilience Office (PRO). It is a program designed to keep sailors motivated, engaged, and resilient. The PRO team utilizes mindfulness techniques, motivational interviewing, and educational curriculum on different military and motivation-based topics to help keep recruits engaged in training while they are recovering from a medical injury or awaiting a medical waiver decision. At any point throughout training, when recruit symptomology and distress crosses the threshold of normative stress to “at-risk,” a mental health consultation phone service is available to help aid the decision-making process of whether to refer for care, continue in training, or refer for further evaluation.

While a full range of treatment is offered, the main objective and mission of REU is to assess a recruit’s fitness for duty through comprehensive mental health assessments. In a given year, REU will evaluate and treat more than 5,000 sailors in a variety of different programs aimed at increasing access, quality, and frequency of care throughout the recruit area of operation and, most importantly, determine suitability for service. There are multiple ways a recruit could be referred to REU for evaluation, and it is essential that a recruit have an appropriate referral to ensure they are not missing valuable training. Instructor-driven referrals help recruits stay engaged in training as opposed to allowing ambivalent recruits who are questioning their decision to serve to be self-referred for a fitness for duty evaluation. The more engaged recruits remain, the more likely they are to continue and complete boot camp. Additionally, there are strategically scheduled screening points that can lead to an evaluation during the course of boot camp.

Referrals

Throughout basic training, there are multiple referral points that can lead to a recommendation for a mental health evaluation to be considered for a waiver. Those referral points include “moment of truth” (MOT), medical in-processing screening, drill instructors known as Recruit Division Commanders (RDCs), and any medical staff member or chaplain who has a concern can refer to REU. Waivers can be given at any point for a variety of different conditions to include before service members join the military at the Military Entrance Processing Station (MEPS) as well as during a service member’s career, as medical and mental health conditions can change or originate at any point. In some instances, service members are screened out at MEPS before they even make it to basic training. For the focus of this article, it will address only waivers recommended while at Navy basic training. Any service member’s waiver that is recommended (or not) for a mental health history or current symptomology starting at basic training, originates with the Recruit Evaluation Unit after a mental health evaluation is completed.

In the first three days of basic training, a Navy recruit is given a “moment of truth” opportunity where integrity and honesty are encouraged to disclose any history or symptoms not previously indicated on their military entrance application. There is an immediate triage evaluation for recruits that could lead to a comprehensive mental health evaluation referral if the behavioral health specialist determines it is appropriate. The following week, a recruit is medically screened for fitness for duty, which could lead to a more thorough evaluation. The initial medical processing during the first week of basic training is the largest and most frequent referral source for mental health evaluations. For example, if a recruit displays or endorses any concerning mental health symptoms (i.e., notable depression or morbid thoughts) or if a medical provider finds a notable history of mental health diagnoses or treatment that could be disqualifying based on their history, they would be referred for a comprehensive mental health evaluation at REU. As training and stress continue, drill instructors known as Recruit Division Commanders (RDCs), who are assigned to divisions throughout a recruit’s boot camp experience, are given the monumental task of molding, training, and mentoring a group of civilians into U.S. Navy Sailors. If they observe any concern from a recruit during training, they can utilize the mental health consultation line as to what an appropriate and calculated referral would be and then implement it. Additionally, any medical professional or chaplain can also utilize the mental health consultation line to ask for further guidance or place a direct referral to REU in order to assess for appropriateness of a comprehensive mental health evaluation.

The Evaluation

Fitness for duty evaluations make up a broad field because of the wide variety of duties, expectations, responsibilities, work environments, and skills needed by the many different types of jobs performed in the miliary (Kennedy & Zillmer, 2006, p. 35). According to Kennedy and Zillmer’s comprehensive book on Military Psychology (2006) addressing military fitness-for-duty evaluations, it is essential to evaluate multiple realms of a service member’s life to make the best determination with the information available. This should include an overview of their biology, social, psychological, academic, and occupational functioning within the environment in which they are operating. The military operates within the most austere environments with difficult decisions to make that test the stress threshold of each service member, which is why it is imperative that a comprehensive evaluation take place. That evaluation determines suitability in case there is any history of a mental health condition(s) or current concern of dysfunction (Kennedy & Zillmer, 2006). The comprehensive pillars of military psychological evaluations and assessments have their roots and foundation from the initial work of thousands of military psychologists after WWI and leading into WWII who performed research and assessments to resolve issues of “selection, placement, and training” of all the service members (Krueger, Smelser & Baltes, 2001, p. 1).

The REU has integrated the military psychology principles of a comprehensive evaluation to help better assess fitness for duty to help guide the decision-making process. While no evaluation is perfect and it can be difficult to predict future behavior, the historical principles of the Adverse Childhood Experiences (ACE) research over the course of the past several decades has gauged REU’s focus on evaluating the risk factors in service members’ lives and histories that have been found to lead to negative life outcomes that could impact military service and performance (Biosnich et al., 2014). Some of those risk factors include parental separation, exposure to domestic and community violence, poverty, mental illness, criminal behavior, abuse (emotional, physical, and/or sexual) as well as neglect (physical and/or emotional) (Webster, 2022). In reviewing the study on the impact of adverse childhood experiences on the health and development of young children (Webster, 2022), the major factors leading to resilience and positive adaption were employment as well as social support. In combining the principles of evaluating risk factors with performance at basic training, REU is deliberate with allowing acclimation to the environment. It facilitates trials of training and allows for the structure, purpose, and meaning of military employment and service as well as the comradery of social support to influence service members fostering positive adaption and resilience.

The task of determining suitability for service sounds simple. However, it is complex and incorporates many data points essential to consider when making a determination for continued service. A comprehensive evaluation incorporates five major components that are needed to make the most informed determination. The first, and most important, is the comprehensive biopsychosocial intake evaluation, which collects a recruit’s detailed history including sections such as medical, physical, mental health, legal, financial, educational, and social histories. Second, all relevant medical and academic records are initially requested from their source. When received, they are reviewed and incorporated into the decision-making process. These records are essential, as they can substantiate a recruit’s report or provide additional information not initially disclosed, which leads to a more calculated review of information omitted. Third, if appropriate and clinical rationale are provided, psychological and personality testing can be administered, which can provide a more objective clinical picture. Fourth, collateral information is very helpful. When assessing for suitability for service, trials of training are recommended to allow for a longer assessment process incorporating multiple data points. An RDC’s feedback on a recruit’s performance throughout 10 weeks of training holds a notable amount of weight, as they are with a recruit everyday through multiple stressful periods of training and can observe how they perform, react to stress, interact with peers, and accomplish tasks. Lastly, the recruit’s overall performance in basic training is considered. Recruits with potentially disqualifying conditions who are afforded trials of training are evaluated on each task, phase, and test during boot camp, which will result in an individual grade equating to passing or failing. Some recruits with more extensive disqualifying histories may require all steps of this evaluation to be considered. Others with less extensive histories may not. This is why clinical subject matter expertise is a key component of the decision-making process.

Recommendations to Command Authority, Military Instruction, and Fitness for Duty

The REU team are SMEs in the intersection of military regulation, medical readiness, and mental health conditions. The Department of Defense Instruction (DODI) 6130.03: Medical Standards for Military Service: Appointment, Enlistment, or Induction (2021) provides a guide as to what conditions are considered disqualifying when joining the military. While many mental health conditions are considered disqualifying per the DODI, a recruit could be considered for a waiver based on recommendations from the REU mental health team. The decision to make a recommendation would be determined by the frequency, intensity, duration, and onset of the disqualifying condition and associated symptoms and whether the entirety of the aforementioned mental health evaluation process was recommended or not.

Trials of Training and Command Authority

In early 2020, REU leadership instituted trials of training for recruits who displayed situational distress upon first entering boot camp or had disqualifying mental health diagnoses that may have previously disqualified them. The trials allow for extra time and additional information to be collected to ensure each recruit who is safe to train has an opportunity to prove that they have what it takes to graduate from boot camp. In order to avoid over-pathologizing a normative transition to boot camp, REU mental health providers assess recruits who are having a normative transitional response to basic training and gauge what is normal and what is “marked distress that is out of proportion to the severity and intensity of the stressor, taking into account external context and the cultural factors that might influence symptom severity and presentation” (American Psychiatric Association, 2013, p. 289). Normative recruit stress often includes feeling homesick, general sadness about being in a restricted environment, worry about training, fatigue, and lack of sleep. These symptoms are often more profound in the first one to three weeks of training and slowly decrease over time for the majority of recruits as they acclimate to the stressful environment and firm expectations of military lifestyle and training. When the symptoms persist, that is when they can become dysfunctional and diagnosable, leading to a disqualifying condition that would result in separation from basic training as opposed to being considered for a waiver to continue in the Navy.

Per DODI 6130.03 (2021), an adjustment disorder that is current or within the past six months could be disqualifying. In this example, if the recruit was motivated to continue in basic training, they could be considered for a trial of training to prove they can meet the basic requirements and expectations of Navy basic training without decompensating or experiencing debilitating symptoms. If they demonstrate adequate performance and receive a positive RDC rating and feedback, the evaluating provider could recommend a waiver for continued service despite having a disqualifying condition. Conversely, not every recruit who wants to be considered for entry into the Navy will be appropriate for a trial of training.

At the end of the evaluation, each provider will gather all relevant information based on their clinical judgment and make the best recommendation to the local waiver authority for review and submission to the RTC CO. When a waiver is approved, the RTC CO is acknowledging the condition is disqualifying, authorizing an exception to policy, and accepting the risk in order to meet mission demands.

Methodology

REU leadership acknowledged that the logic behind recommending more waivers is not a zero-risk exercise and explored options for tracking sailors who had received a waiver longitudinally over the course of their first tour and beyond. Each service member who graduated from RTC between January 2014 and December of 2022 with an REU recommended waiver approved was followed through military service using their DOD identification number. The Naval Service Training Command (NSTC), Training Operations Department, ran a longitudinal analysis to assess which individuals were still in the Navy and which had been separated early from the initial service obligation, whether it be administratively, medically, or another category.

Population data were retrieved from the Authoritative Data Environment (ADE) and aggregated using Tableau Software (Tableau, Seattle, WA). A comparative classification analysis was conducted to determine, within the population of individuals who received waivers for mental health while at RTC, those still on active duty and those separated from the Navy. The criteria used restricted the search to only individuals who had received an approved waiver for retention from the Commanding Officer of RTC for a current and/or history of mental health disorder diagnosis. Utilizing the DODID provided by REU, these were extracted from ADE to provide output variables of active duty or separated, the year of separation, the job category the individual had while serving active duty, and the duty station where separation occurred. The separated population was explored and subdivided into those who had reached their completion of active duty service and those who had been separated before the end of initial service obligation, the latter of which are referred to as “separated for cause.”

Results

The cumulative number of mental health waivers approved at RTC since 2014 is 1,365, with 72 individuals separating from RTC before graduation, 60 separating upon completion of active service, one transitioning to officer accessions, 101 separating for cause, and the remainder remaining in active military service. These data, further detailed in a year-by-year breakdown in Table 1, demonstrates an average boot camp graduation rate of 95% for those with an approved mental health waiver, meaning 95% of individuals who received an approved waiver for their mental health diagnosis ultimately graduated from RTC. Out of that 95%, the average fleet retention rate was 92.7%, referring to the rate at which graduates from RTC who had received a waiver ultimately completed their initial service obligation and/or are still actively serving. The involuntary separation from active duty rate of 7% is half of the average fleet-wide annual attrition rate of 15% (internal data provided by Naval Service Training Command).

Table 1.

Year-to-year number of approved waivers with percent of separation from the Navy.

Waiver Year	Number of approved waivers	Percent graduated	Number of fleet early separations	Percent early separation
2014	14	86%	3	21%
2015	37	95%	5	14%
2016	31	91%	8	26%
2017	44	95%	4	9%
2018	76	97%	12	16%
2019	110	97%	12	10%
2020	219	94%	29	14%
2021	362	97%	23	6%
2022	472	93%	5	1%
Totals	1365	95%	101	7%

Of the 72 separations that occurred from RTC prior to graduation, the most common reason was erroneous entry, which typically refers to an administrative error or series of errors that results in a recruit being unable to complete their enlistment; however, these individuals are given a discharge code that allows them to re-enlist at a later time. The second most common reason was entry-level performance and conduct. This does not include physical performance or any medical or mental health diagnoses but is more specific to academic performance and behavior. All other reason codes were infrequent events including but not limited to CNDs (Condition Not amounting to a Disability), misconduct, and drug abuse. The most common reason for those separated for cause was CND, accounting for approximately 29% of the early separations. CNDs are medical or mental health conditions that do not qualify for Veterans Administration service connection as result of exacerbation or cause by military service. In these instances, service members are not fit for continued military service, and they are administratively separated without follow-up medical care or compensation from the Veterans Administration. The next most frequent reason for early separations were drug abuse, accounting for 17%, and misconduct, accounting for 15%. Other reasons were medical disability, failure to meet physical and performance standards, and erroneous enlistment.

Because active duty may deploy at any time, consistent and reliable access to mental health care resources will always be a challenge. The data gathered did not look at the amount of “shore duty” or those who are not deployed compared to “sea duty”/those who deploy outside of the United States over the course of their career, and neither guarantees access or availability of resources. Performance metrics on individuals’ evaluations were not gathered or available. It is worth mentioning that there was a wide diversity of rates within this dataset, including engineering, surface operations, supply & logistics, special operations & special warfare, security, nuclear, medical, aviation, admin, and information warfare. There were no trends on higher separation rate or retention rate after controlling for individual community size.

Discussion

Approved mental health waivers totaling 1,365 over the past eight years can seem small since the average is only 170 per year. However, more than 75% of the approved waivers occurred during the three-year period from 2020–2022 (Refer to Graph 1). During this time, there was a change in both leadership structure and procedures within REU, resulting in an increased number of waivers recommended to RTC CO. A plausible outcome to the leadership change resulted in more waivers, which encouraged providers to assess recruits for a potential trial of training, allowing more time for recruits to acclimate to their environments. Additionally, in close proximity, a mental health consultation phone service was added that increased access to mental health consultation and resource referral across the enterprise of RTC, affording all personnel who interact with recruits the opportunity to consult with the mental health team. This allowed the clinic to establish a templated format that was referral based, preventing inappropriate referrals such as recruits who had no disqualifying conditions but wanted to leave the Navy from being referred for an emergency mental health evaluation and triage. This process change helped increase appropriate resource utilizations such as additional mentorship from RDCs, supportive counseling from chaplains and the mental health counseling services available on site, as well as additional time to acclimate to the environment and adjust to the military cultural lifestyle.

Graph 1.

Breakdown of sailors service status who received mental health waivers.

There were two notable changes that occurred. First, every waiver, whether it was recommended or not, would first be presented to the local (REU) waiver authority for review before being forwarded to the RTC CO for final decision. This process allowed for administrative oversight and consistency of review across multiple providers’ clinical evaluation, risk threshold and tolerance, and recommendations. Second, more waivers were recommended during this time due to a change in leadership approach to mental health risk tolerance as well as clinical and ethical justification. The most common diagnoses that received waivers were adjustment-related anxiety and depression, attention deficit hyperactivity disorder (ADHD), generalized anxiety, and mild learning disorders. These conditions, when in isolation with a period of stability and positive performance, have a very low risk threshold that usually result in waiver recommendations.

It is imperative that clinical leaders recommending waivers have military experience in both clinical and administrative areas of responsibility. The experience of training, military schools, mentorship, and clinical experience that comes with wearing the uniform is unmatched in the private sector. Would it be possible for a civilian to gain the same level of competence? Yes. However, the perspective of uniformed clinicians is an invaluable resource to the evaluation process. We recommend leadership overseeing military waiver recommendations to either be in uniform or have practical clinical military experience.

In reviewing the 72 recruits who separated before graduating, there are multiple reasons that could have led to that result. With many recruits coming into basic training without much physical preparation, intense physical exercise throughout multiple weeks of training could result in a failure to meet the standard or notable injury, resulting in a medical or administrative separation. The same experience applies to mental health conditions and development of disqualifying symptomology.

Separations for cause could be any medical, administrative, or legal problem or uniform code of military justice (UCMJ) infraction leading to a legal separation. Of the 101 recruits separated for cause, direct causality could not be determined between a mental health condition and the reason for separation. While possible that the mental health condition influenced the behavior that resulted in the separation for cause, it is also possible they were unrelated.

Leadership and mental health team support has been crucial to the REU’s success. The Defense Health Agency and Navy Medicine, in partnership with the FHCC, has continued to provide budgetary, staffing, and resource support, which enables the team to function optimally. The necessary resources and staffing are essential to REU when providers are tasked with evaluating thousands of recruits annually, as it is much easier to recommend separation than it is to justify or recommend waiver approval, as the latter takes much more time, clinical reasoning, and evidence as well as documentation to justify the recommendation. The other successful component of REU’s leadership and chain of command is providing the right balance of authority and responsibility that has fostered a mutually beneficial, positive working environment with increased team cohesion, contributing to the continued success of the clinic.

In summary, nearly 93% of boot camp graduates with approved mental health waivers successfully completed their initial service obligation or are still actively serving. These results are extremely positive and reinforce current REU procedures. However, the process will need to continue to be comprehensive and include as much data into making an informed decision in accordance with Department of Defense standards.

Conclusion

The current waiver process at Navy boot camp for sailors with histories of disqualifying mental health conditions continuing to serve in the Navy has proven to be effective. While no system is perfect, and separation and attrition still occur, the Navy’s REU has highlighted some best practices of affording recruits the opportunity to prove they have what it takes to be a U.S. sailor despite a disqualifying mental health history. The REU standard operating procedures, as well as lessons learned, can be replicated in other military branches or in similar systems that assess for suitability for military service.

Future Research

The importance of this research should be of interest to the entire military, not just the Navy. It is imperative that each military branch consider a similar longitudinal study that evaluates continued service engagement of recruits recommended for a waiver. As a force-shaping approach, the military branches should devise a way to track performance, utilization of medical/mental health care, rank and career advancement, and success in a specified branch to determine if medical disqualification guidelines should be re-evaluated and potentially revised to afford even more people the opportunity for military service. Additionally, further longitudinal tracking is recommended to assess the continued career trajectory and service completion rates while analyzing trends of diagnoses that could impact service completion.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Data Availability Statement

The data that support the findings of this study are not publicly available due to the sensitive nature of the mental health diagnoses and military service records that could compromise the privacy of research participants. Further inquiries regarding data analyses should be directed to corresponding authors [MBB, MAS]