Thursday, 4 October 2012

Mental health issues differ in military

Op-Ed: Chinlund - Mental health issues differ in military
A recent Observer column by Kelly Henry, a U.S. Naval Academy graduate and retired naval officer, eloquently laid out the need for mandatory mental health screenings for active duty military personnel.

Henry has worked in the trenches with military personnel in crisis. She is quite familiar with hardships associated with the military lifestyle, and how they have an impact on emotional and mental health. I respect her views, and could not agree with her more in regard to the need for more intensive intervention in assessing the mental health status of our active duty personnel and veterans.
However, as a mental-health professional whose practice is devoted largely to soldiers, airmen and to their dependents, I fear that screenings such as the ones recommended would fall short of what we would hope to achieve.

Unlike physical exams and dental checkups, mental health screenings attempt to identify symptoms that are often not physically evident. Accurate diagnosis of many psychological disorders relies heavily the report of others close to the patient or on a patient's self-report, and many are not going to self-disclose.

Reasons for non-disclosure include the following:

poor insight into attitudes or behaviors and failure to recognize certain patterns as maladaptive;

a general acceptance in the machismo military culture of behaviors such as excessive alcohol use and aggression;

fear of being embarrassed, stigmatized or disciplined;

fear of loss - of authority, reputation, marriage or custody of children; or
reluctance to stop behaviors that have served as a means of coping with circumstances beyond the scope of what many of us can even imagine.

Most active-duty personnel are not going to seek mental health services of their own volition unless the risk of not seeking care is exponentially greater than the benefits of remaining silent.

Given the perceived risks of reporting mental health problems and the ease with which such problems can be denied, it is no wonder that military personnel are slipping through the cracks in alarming numbers.

Some disorders cause critical deficits in functioning but may not be apparent in casual observations - the highly publicized and prevalent Post-Traumatic Stress Disorder; mood disorders with risks of suicide; substance-use disorders; personality disorders and impulse-control disorders, to name a few.

The presence of these disorders is not likely to be captured in a one-shot, self-administered checklist. Just as malingerers know how to respond to fit a clinical profile, genuinely symptomatic individuals who don't wish to be identified are keenly aware of just how not to respond.

Precise diagnosis typically occurs in a context involving repeated contact and the development of a trusting relationship between the patient and the provider. The soldier may not trust an on-post provider whom he feels is accessible and accountable to his chain of command, regardless of that provider's competence and empathy. Some soldiers complain that they are unable to get prompt appointments on post or that appointments are frequently cancelled. Getting an appointment with an off-post provider can be equally problematic, in that it requires obtaining a referral from the soldier's primary care manager and navigating the frustrating labyrinth of Tricare authorization.

The solution to the military mental health conundrum must not only safeguard the careers and reputations of soldiers seeking mental health treatment, but also improve soldiers' access to competent and confidential treatment from providers whoh are well-trained in military culture as well as in diagnosis and treatment of complex disorders.

Proper diagnosis and intervention require the ability to distinguish between pre-existing vulnerabilities and symptoms precipitated by injury and exposure to combat or extreme stress; between malingering and the legitimate presentation of illness; between typical responses to life stresses and more maladaptive behaviors indicative of disorder.

The solution will involve not only addressing the needs of the soldier, but also working with the system within which the soldier lives and operates.

Fortunately, efforts are being made from within the military power structure to challenge prejudicial attitudes that associate emotional and behavioral vulnerability with weakness. Those efforts must be intensified to ensure that those who have served, and who continue to serve, are given what they have given to us - their best.

Alicia Lopes Chinlund is owner and director of Wellspring Center PLLC of Hope Mills, which provides counseling, consulting and psychological services. She is a former member of the Observer's Community Advisory Board.

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