Implementation and Evaluation of a Military–Civilian Partnership to Train Mental Health Specialists

Scott A Simpson; COL Matthew Goodwin; LTC Christian Thurstone

doi:10.1093/milmed/usy358

. 2019 Jan 24;184(7-8):e184–e190. doi: 10.1093/milmed/usy358

Implementation and Evaluation of a Military–Civilian Partnership to Train Mental Health Specialists

Scott A Simpson ¹, Matthew Goodwin ^1,², Christian Thurstone ^1,²

PMCID: PMC8055066 PMID: 30690507

Abstract

Introduction

Mental health specialists (MHS, or 68X) play a central role in meeting the growing demand for combat stress care among Service Members. Partnering with civilian institutions may enhance the MHS training experience beyond Advanced Individual Training (AIT).

Methods

We describe a novel military–civilian collaboration to train U.S. Army Reserve MHS’s in the psychiatric emergency service (PES) of a public, safety-net hospital. Details of implementation are described. The training rotation was evaluated after 1 year through a comprehensive chart abstraction of patients seen as well as surveys of MHS’s and civilian partners.

Results

The roles of MHS and physician officers in this rotation are described. Over 9 days in the PES, the MHS team evaluated 26 patients. MHS’s described a high-quality training environment (83% rated very good or excellent) in which they frequently saw high-risk patients relevant to military practice. Experience with a certain patient presentation was correlated with comfort assessing and managing that presentation (p < 0.01). Many civilian staff (40%) felt the PES operated better with the presence of the Army team and 50% of civilians agreed their impression of the U.S. Army Reserve improved as a result of the partnership. Hundred percent of specialists and 80% of civilians reported very good to excellent rapport between military and civilian staff. Two civilian respondents (11%) expressed concern that the military team’s presence impeded patient care.

Conclusion

This is the first military–civilian training collaboration for behavioral health specialists, who have already completed AIT. This program provided well-received and mission-relevant training for MHS’s without notable adverse effects on patient care or team functioning in a civilian environment. Our findings are based on a small sample size, and no other such programs exist against which to compare these results. We propose that such educational partnerships, which have long been effective for other clinical specialists, may benefit the military, civilian communities, and the country.

INTRODUCTION

The burden of combat stress and psychiatric illness among active duty Service Members and veterans is a growing concern. Over 2 million persons are at risk of post-traumatic stress disorder (PTSD) and other psychiatric disorders from service in the Iraq and Afghanistan conflicts alone.¹ Despite the risks of combat stress and psychiatric illness,^1,2 many Service Members and veterans do not seek treatment even when indicated.³ Barriers to obtaining care include stigma and cultural factors, obstacles in access, and perceptions of quality.^2–5 Particular challenges remain in meeting the needs of female Service Members and Service Members’ children.^6,7 In this context, the suicide rate among active duty personnel has increased over the last decade and now exceeds that among age-matched civilians.^8,9

Much mental health care for active duty Service Members is delivered by Mental Health Specialists (military occupational specialty of 68X). The duties of a Mental Health Specialist (MHS) include acting as a force multiplier by collecting psychosocial and physical data, assisting in the care of patients with psychiatric and substance use disorders, and performing psychotherapy as indicated.¹⁰ U.S. Army MHS’s have a high school degree (or equivalent) and complete 10 weeks of Basic Combat Training followed by 20 weeks of Advanced Individual Training (AIT). During AIT, they learn basic skills related to mental health assessment, triage, and management in classroom and clinical environments. There is no direct civilian equivalent to the MHS role, whose duties in civilian settings may be completed by a combination of behavioral health technicians, nurses, social workers, and professional counselors. Many Reserve MHS’s do not have civilian experience in mental health fields and therefore do not regularly use skills learned in AIT. Ongoing MHS training after completion of AIT is important for skill retention and enhancement.

Given MHS’s importance in providing combat stress and psychiatric care at a time of increased need among Service Members, it is vital that MHS’s receive relevant, high-quality training. Clinical rotations in civilian settings may provide such training. Military trauma clinicians including surgeons have long had fruitful educational partnership with civilian counterparts: military surgeons maintain and advance skills through work in civilian trauma centers,^11,12 and civilians have been successfully integrated into military surgical settings.¹³ Civilian–military partnerships have also been used to train general practitioners.¹⁴ To our knowledge, however, no such partnership has existed to train Mental Health Specialists.

In this paper, we describe the development and implementation of a unique military–civilian partnership for training U.S. Army Reserve MHS’s. Then we report an evaluation of this program that describes MHS’s training experience, MHS’s comfort-level managing common psychiatric presentations, and the acceptability of this program among civilian partners.

METHODS

Program Implementation

One author (C.T.) evaluated interest and support for a clinical training rotation among the U.S. Army Reserve 1835th Medical Detachment. Widespread interest was noted among MHS’s, who did not necessarily have prior civilian clinical experience. Army leadership favored the program to enhance deployment capability.

The author approached leaders at Denver Health Medical Center, where he is a faculty physician. Denver Health is a nationally recognized, integrated, public, safety-net health system. Denver Health Medical Center includes a level I trauma center and Colorado’s only Psychiatric Emergency Service (PES). The PES is an 18-bed unit dedicated to the treatment of behavioral emergencies, including patients with suicidal and violent ideation, substance use disorders, co-morbid medical illness, and undifferentiated psychiatric symptoms. The PES is staffed by board-certified psychiatrists 24/7 as well as behavioral health technicians, nurses, physician assistants, and social workers dedicated to the unit. The PES treats approximately 6000 patients annually. Health professions trainees on site include medical, physician assistant, nurse practitioner, and paramedic students as well as postgraduate trainees in psychiatry, psychology, and internal medicine. Interest among Denver Health’s leaders included contributing to the U.S. Army through a training program. The PES was considered an ideal training site given the high volume and acuity of patients as well as its experience successfully integrating a range of trainees.

A memorandum of understanding (MOU) was written and agreed upon between the U.S. Army and Denver Health. The MOU covered expectations for the frequency of on-site trainings, onboarding, liability, licensing, and supervision. A copy of the MOU is included in Appendix A. Two physician officers (MG, CT) were credentialed at Denver Health and had suitable medical staff privileges.

The Army team typically included five staff: 1–2 psychiatrists (60 W) including the Officer in Charge (OIC) and 2–4 MHS’s (68X), including a non-commissioned officer in charge (NCOIC). MHS responsibilities on the training rotation were designed by the authors, who are leaders in the PES (SS) and the U.S. Army Reserve Medical Detachment (MG, CT). The design of the rotation was for MHS’s to evaluate new patients arriving to the PES, including collecting a history, obtaining collateral information, writing a safety plan, and arranging follow-up care consistent with best practices in emergency psychiatry. Junior enlisted MHS’s were supervised by an MHS NCOIC and a psychiatrist OIC. MHS’s presented cases to the OIC, who made final clinical decisions. While on site, MHS’s wore civilian clothing appropriate for the work environment.

The goals of the rotation were to improve skills in the following areas: assessment and triage, presentation of cases, verbal de-escalation, motivational interviewing, brief crisis therapy, coping skills training, mindfulness skills training, and milieu management. The OIC and NCOIC gave informal trainings to Soldiers in these areas before the clinical training began.

Program Evaluation

A multimodal program evaluation was undertaken one year after initiation of the training rotation. All data collection including surveys were completed in Redcap, a secure online database built for managing online surveys and databases.¹⁵

Chart Abstraction

A retrospective chart review of all patients seen by the MHS team was undertaken to describe the patient population seen. Patients were identified through the presence of a note by the OIC. Patient encounters were randomly divided between two authors for abstraction using a standardized abstraction form. From each author’s assigned patient list, two patients were randomly selected to be blindly re-reviewed by the other author to ascertain interrater reliability. The abstraction form is included in Appendix B.

MHS Survey

MHS’s in the Combat Stress Detachment completed an electronic survey disseminated via Redcap. The 50–52 question survey asked about clinical work prior to enlistment, experiences on the PES rotation, and comfort-level managing certain case scenarios. All but two open-text responses were multiple choice. The MHS survey is included in Appendix C.

The MHS survey included the perceptions of teaching subscale of the Postgraduate Hospital Environment Measure (PHEEM), an instrument for evaluating the clinical educational environment.¹⁶ This PHEEM subscale contains 15 items that the respondent rates on a Likert scale from 0 to 4; a total score of ≥46 suggests a model teaching environment. This instrument has been used previously for evaluating multidisciplinary teaching programs.¹⁷

Staff Survey

To ascertain the acceptability of the Detachment’s rotation among civilian staff, all 74 faculty and staff who work in the PES were invited to complete an anonymous electronic survey. Four email invitations were sent over a 4-week period from June to July 2018.

The staff survey was 8–19 questions. Respondents described their role in the PES and used a continuous 5-point Likert scale to describe their familiarity and general impression of the U.S. Army Reserve; assessment of the U.S. Army Reserve team; and impact of the team’s presence on the PES’ functioning. A final section allowed text responses. The staff survey was distributed via Redcap and included in Appendix D.

Analyses

Responses were aggregated and analyzed using Excel (Microsoft, Redmond, WA) and Stata (StataCorp, College Station, TX, USA). All statistical tests were two-sided and selected using a published algorithm.¹⁸ Qualitative responses were reviewed to identify opportunities to improve the rotation.

Human Subjects Approval

This work was approved as a program evaluation activity by the Colorado Multiple Institutional Review Board.

RESULTS

Training Rotation

The Medical Detachment began seeing PES patients in May 2017 and came roughly monthly thereafter for a total of 9 clinical days. On clinical rotation days, the MHS team arrived to the hospital 10 minutes before shift change (0700) in their personal vehicles. The team joined rounds and identified patients that they would treat. The Army team completed all clinical tasks for those patients; the OIC and NCOIC consulted with the civilian attending psychiatrist as necessary to facilitate care. At the end of the day, an in-person After Action Review was conducted.

In the first year of practice, the MHS team saw 26 patients whose characteristics were ascertained by chart review and are described in Supplementary Table 1. There were no missing data in the chart abstraction forms. A blinded re-review of 4/26 randomly selected patient charts (15%) by the other author demonstrated exceptional interrater reliability (κ = 0.84).¹⁹

Quality of Training

All six specialists (100%) returned surveys. Five MHS’s (83%) had at least some health care experience prior to being in the reserve. Most (5/6, 83%) rated the overall quality of the educational experience as very good or excellent, with the other MHS reporting a neutral opinion. The mean PHEEM perception of teaching subscale score was 54/60 (SD ± 6) consistent with a model teaching environment.¹⁶ All MHS’s reported rapport between the MHS team and civilian staff to be good or excellent. There were no missing data in the MHS surveys.

Specialists described the types of patients that they saw and their comfort level in seeing those patients. Figure 1 summarizes the frequency with which MHS’s saw 11 different patient presentations. Specialists were then asked to describe their comfort managing particular patient presentation on a 5-point Likert scale (“very uncomfortable” to “very comfortable”) – these data are also summarized in Figure 1.

Specialists’ reported comfort in completing certain clinical tasks core to the rotation’s objectives is described in Figure 2. The only tasks which any MHS reported feeling uncomfortable performing were making a diagnosis (1/6, 17%) and recommending treatment (1/6, 17%).

We evaluated whether experience with a particular patient presentation was associated with comfort assessing and beginning to manage that presentation. Each of six specialists reported the frequency with which they saw 11 types of patient presentations as well as a corresponding comfort level with that presentation. The resulting 66 descriptions of comfort level were analyzed using analysis of variance grouped by specialist’s report of never, once, or more than once seeing a patient with that presentation. Experience seeing a patient presentation was correlated with greater comfort managing that presentation (p < 0.01, R² = 0.17). When stratifying the analysis of variance by specialists’ prior health care experience, the association remained strong for one specialist with no prior health care experience (p < 0.01, R² = 0.69) but failed to reach statistical significance among specialists with minimal (p = 0.06) or greater prior health care training (p = 0.81).

Civilian Acceptability

Twenty-eight civilian faculty and staff (38%) responded to the staff survey. Most respondents were nurses (n = 16, 57%) or physicians (n = 5, 18%). Of 28 respondents, 20 (71%) had firsthand contact with the MHS team.

Most staff respondents reported a somewhat or very favorable view of the U.S. Army Reserve (18/28, 64%) prior to the training rotation, with the other 10 respondents being neutral. However, only 8 (29%) expressed familiarity with the U.S. Army Reserve or the specific role of an MHS.

When asked how their thoughts and opinions had changed as a result of the Reserve team’s work, most civilian respondents agreed that they were more familiar with the U.S. Army Reserve’s work and the MHS role and had a more positive impression of the U.S. Army Reserve (Fig. 3). Compared to staff who did not have direct contact with the MHS team, respondents with direct contact more often reported familiarity (55% v 38%, p = 0.46) and a positive impression (55% v 38%, p = 0.62) with the U.S. Army Reserve, although these differences were not statistically significant.

FIGURE 3. — Civilians’ opinions of working with mental health specialist team

Civilian staff who worked directly with the MHS team reported the team to be very good to excellent at collaboration with PES staff (n = 16, 80%), dedication to patient care (n = 18, 90%), and professional (18, 90%). Only 7 civilians felt the team’s clinical skill was very good or excellent (n = 7, 35%); most respondents reported being neutral or unsure (n = 12, 60%). Rapport among the civilian and military teams was typically described as good to excellent (16, 80%).

Eight civilians (40%) felt the PES team functioned better with the Army Reserve present, although 3 (15%) felt the team functioned worse. Two respondents (11%) described instances in which the MHS team negatively impacted patient care. Those two respondents described difficulty in locating the team at times and a slower pace of care delivered by the MHS team compared to regular civilian clinicians.

The only missing datum was from one civilian respondent who failed to describe their role on the PES team.

DISCUSSION

We describe the first civilian–military training partnership for U.S. Army Mental Health Specialists. This training rotation provided a high-quality training environment in which MHS’s treated a range of mission-relevant clinical presentations – including suicidal and violent ideation and substance use disorders, which are frequently seen among Service Members.^5,8 Civilian staff welcomed the specialists and agreed that this collaboration enhanced their impression of the U.S. Army Reserve.

MHS’s described the quality of training as very strong. Specialists reported a high degree of comfort with clinical skills considered core to the rotation’s objectives. All but one described the rotation as very good or excellent, and assessment of the educational environment using a previously validated measure suggested a model teaching environment.^16,17 The training rotation appeared particularly useful for specialists with less clinical experience from civilian careers. The strength of the training environment likely reflects MHS’ enthusiasm for clinical care in this setting, positive rapport with civilian staff, and this PES’ strong track record of incorporating and supporting trainees. The finding that clinical experience with certain patient presentations is unsurprising,^20,21 although we lack assessment data to corroborate MHS’s self-reported comfort with objective skills competency.

Civilian impressions of the training rotation were also encouraging. Civilian respondents generally held a positive impression of the U.S. Army Reserve but were unfamiliar with the MHS role. After the training rotation, civilians’ impression and familiarity of the Army Reserve improved. Those staff interacting directly with the team in patient care were impressed by their professionalism and dedication to patient care. The support of civilian leadership and staff is a critical component for the sustained success of this training partnership. Civilians noted that the Army Reserve team was somewhat slower and less familiar with clinical processes. The MHS team’s efficiency will likely improve along with their clinical acumen and familiarity with the unit over time. The potential for the MHS team to augment the service of the PES was noted by several respondents.

That this training environment took place in a PES proffered particular advantages and disadvantages. Specialists gained extensive experience with high-acuity presentations: suicidal ideation, violence risk, and assessment for psychiatric hospitalization. Most MHS’s saw patients on involuntary treatment orders. However, specialists felt less comfortable making a diagnosis or recommending treatment. These tasks are more challenging in an emergency environment characterized by short encounters and broad differentials that including delirium, substance use, and malingering.^22,23 These relative shortcomings of the rotation may be addressed through a greater focus on diagnosis, treatment planning, and single-session therapies applicable to the ED^24–26 during bedside teaching and After Action Reviews by the OIC and NCOIC. Extending training programs to non-emergent environments may improve exposure to diagnosis and treatment planning for a broader range of conditions.

That MHS’s reported a low frequency of encounters of patients with PTSD is potentially a notable training gap and somewhat surprising. The estimated 25% prevalence of PTSD among emergency department patients exceeds that among veterans.^27,28 Thus, this low reported frequency likely reflects a focus on other, emergent conditions driving patients’ PES visit (e.g., intoxication or suicidal ideation). Also, many patients with PTSD may have been categorized by MHS’s as patients with anxiety disorders. Clinical supervision will be adapted to help MHS’s recognize the broad range of post-traumatic pathology among patients.

There are limitations to this program evaluation. As the only program of its kind, there are no data to which to compare our success in training MHS’s. This training rotation took advantage of a PES with a uniquely robust record of health professions teaching. The evaluation methodology is entirely retrospective and thus subject to limitations of subjects’ memories and bias, although use of a chart review for all patients seen by the MHS team provided an objective record of clinical experiences. Despite being a commonly reported outcome for assessing teaching interventions, MHS’s self-reported comfort does not necessarily correlate with clinical competence.^29,30 Our conclusions correlating clinical experience and comfort are based on a small sample size. Similarly, our civilian survey is likely biased towards those staff who worked with the Army team and may overstate the positive impression made among civilians. The limitations may be addressed through more prospective data gathering and skills assessment.

CONCLUSIONS

Military readiness, civilian communities, and the country may all benefit through mental health training partnerships that both enhance the clinical expertise of military specialists and also provide psychiatric services in demand among civilians and Service Members. This program illustrates the feasibility of implementing such a training program and the value of this program for improving the clinical experiences and training of Mental Health Specialists.

Supplementary Material

Supplementary Data

Click here for additional data file.^{(132.4KB, pdf)}

Supplementary Data

Click here for additional data file.^{(65.5KB, pdf)}

Supplementary Data

Click here for additional data file.^{(84.6KB, pdf)}

Supplementary Data

Click here for additional data file.^{(64.4KB, pdf)}

Supplementary Data

Click here for additional data file.^{(77.7KB, docx)}

ACKNOWLEDGMENTS

This project’s use of Redcap is supported in part by NIH/NCRR Colorado CTSI Grant Number UL1 RR025780. Contents are the author’s sole responsibility and do not necessarily represent official NIH or U.S. Army views.

REFERENCES

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary Data

Click here for additional data file.^{(132.4KB, pdf)}

Supplementary Data

Click here for additional data file.^{(65.5KB, pdf)}

Supplementary Data

Click here for additional data file.^{(84.6KB, pdf)}

Supplementary Data

Click here for additional data file.^{(64.4KB, pdf)}

Supplementary Data

Click here for additional data file.^{(77.7KB, docx)}

[usy358C1] 1. Wells TS, Miller SC, Adler AB, Engel CC, Smith TC, Fairbank JA: Mental health impact of the Iraq and Afghanistan conflicts: a review of US research, service provision, and programmatic responses. Int Rev Psychiatry 2011; 23(2): 144–52. [DOI] [PubMed] [Google Scholar]

[usy358C2] 2. 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(9): 1023–32. [DOI] [PubMed] [Google Scholar]

[usy358C3] 3. Hoge CW, Grossman SH, Auchterlonie JL, Riviere LA, Milliken CS, Wilk JE: PTSD treatment for soldiers after combat deployment: low utilization of mental health care and reasons for dropout. Psychiatr Serv 2014; 65(8): 997–1004. [DOI] [PubMed] [Google Scholar]

[usy358C4] 4. Naifeh JA, Colpe LJ, Aliaga PA, et al. : Barriers to initiating and continuing mental health treatment among soldiers in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Mil Med 2016; 181(9): 1021–32. [DOI] [PMC free article] [PubMed] [Google Scholar]

[usy358C5] 5. Lazar SG: The mental health needs of military service members and veterans. Psychodyn Psychiatry 2014; 42(3): 459–78. [DOI] [PubMed] [Google Scholar]

[usy358C6] 6. Boyd MA, Bradshaw W, Robinson M: Mental health issues of women deployed to Iraq and Afghanistan. Arch Psychiatr Nurs 2013; 27(1): 10–22. [DOI] [PubMed] [Google Scholar]

[usy358C7] 7. Siegel BS, Davis BE: Committee on psychosocial aspects of child and family health, section on uniformed services. Health and mental health needs of children in US military families. Pediatrics 2013; 131(6): e2002–2015. [DOI] [PubMed] [Google Scholar]

[usy358C8] 8. Hyman J, Ireland R, Frost L, Cottrell L: Suicide incidence and risk factors in an active duty US military population. Am J Public Health 2012; 102(Suppl 1): S138–146. [DOI] [PMC free article] [PubMed] [Google Scholar]

[usy358C9] 9. Reimann CA, Mazuchowski EL: Suicide rates among active duty service members compared with civilian counterparts, 2005–2014. Mil Med 2018; 183(suppl_1): 396–402. [DOI] [PubMed] [Google Scholar]

[usy358C10] 10. US Army . Mental health specialist (68X). Careers & Jobs2018. Available at https://www.goarmy.com/careers-and-jobs/browse-career-and-job-categories/medical-and-emergency/mental-health-specialist.html; accessed July 29, 2018.

[usy358C11] 11. Uchino H, Kong VY, Oosthuizen GV, et al. : Can we train military surgeons in a civilian trauma center? World J Surg 2018; 42(1): 26–31. [DOI] [PubMed] [Google Scholar]

[usy358C12] 12. Hight RA, Salcedo ES, Martin SP, Cocanour CS, Utter G, Galante JM: Level I academic trauma center integration as a model for sustaining combat surgical skills: the right surgeon in the right place for the right time. J Trauma Acute Care Surg 2015; 78(6): 1176–81. [DOI] [PubMed] [Google Scholar]

[usy358C13] 13. Knudson MM, Evans TW, Fang R, et al. : A concluding after-action report of the Senior Visiting Surgeon program with the United States Military at Landstuhl Regional Medical Center, Germany. J Trauma Acute Care Surg 2014; 76(3): 878–83. discussion 883. [DOI] [PubMed] [Google Scholar]

[usy358C14] 14. Kitchener SJ, Rushbrook E, Brennan L, Davis S: Training Australian Defence Force Medical Officers to civilian general practice training standards – reflections on military medicine and its links to general practice education and training. Med J Aust 2011; 194(11): S79–83. [DOI] [PubMed] [Google Scholar]

[usy358C15] 15. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG: Research electronic data capture (REDCap) – a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009; 42(2): 377–81. [DOI] [PMC free article] [PubMed] [Google Scholar]

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PERMALINK

Implementation and Evaluation of a Military–Civilian Partnership to Train Mental Health Specialists

Scott A Simpson

COL Matthew Goodwin

LTC Christian Thurstone