Mark A. Staal, PhD, ABPP, and Joseph L. Bonvie, PsyD, ABPP
In the wake of nearly 15 years of sustained combat, military psychologists remain heavily employed. The intensity of this employment as well as the unique demands placed on psychologists serving in the military has contributed to job strain and subsequent burnout (Linnerooth, Mrdjenovich, & Moore, 2011). Some have attributed this to operational tempo and nature of the conflict. (Sargent, Millegan, Delaney, Roesch, Sanders, Mak, Mallahan, Raducha, & Webb-Murphy, 2016). The following article discusses job strain and burnout as they relate to the work of military psychologists. The expansion of service provision models and the unique stresses placed on military psychologists are also addressed.
The views expressed in this article are those of the authors and do not necessarily reflect the official policy of the Department of Defense or other departments of the U.S. Government.
Burnout and Job Strain
Burnout is a concept that first appeared in the psychological research literature in the 1970s. Since that time, there has been a general consensus that burnout consists of three distinct dimensions including: emotional exhaustion, depersonalization, and a loss in personal accomplishment (Maslach & Jackson, 1981; Morse, Salyers, Rollins, Monroe-DeVita, & Pfahler, 2012). Providers experiencing emotional exhaustion tend to describe themselves as feeling fatigued or depleted. Depersonalization refers to the experience of cynical attitudes toward work and clients and a sense of reduced personal accomplishment or self-efficacy related to negative appraisals of one’s effectiveness at work. Research examining the rates of burnout among the U.S. labor market suggests that over a third of U.S. workers experience this type of job strain. Similar investigations of mental health (MH) providers indicate that this rate may be much higher (Sargent, et al, 2016).
Compassion fatigue, in the context of MH care, has become commonly associated with the concept of burnout. Compassion fatigue results from vicarious trauma experienced among MH providers who work heavily with patients who suffer from trauma exposure. It has been suggested that such work may make such providers more vulnerable to burnout (Canfield, 2005; Clifford, 2014). Based on the differential prevalence of PTSD and other trauma-related conditions facing military MH providers, one may assume that these providers are at greater risk than their civilian counterparts for compassion fatigue and burnout. For example, annual prevalence rates for PTSD among civilian populations is 3.6% whereas among returning military deployers the rates are 4-5 times greater (Ballenger-Browning, Schmitz, Rothacker, Hammer, Webb-Murphy, et al., 2011).
The consequences of burnout among healthcare providers are significant. Various studies have identified work absence, illness, higher rates of attrition, and reduced performance as some of the risks. Such employees are also at greater risk for suicide, marital discord, and substance misuse (Ballenger-Browning et al, 2011).
Models of Military MH Employment
Traditionally, military MH has been restricted to the provision of services from within a military treatment facility (MTF) or MH specialty clinic. However, based on operational requirements for service portability, the desire to improve access to care and in an effort to de-stigmatize MH in general, various models of psychological utilization have developed. In fact, never before have so many military medical professionals been dispersed throughout the force. Although the MTF remains the mainstay of MH care, psychologists have increasingly been embedded among primary care clinics, forward aid stations, and operational line units. Each of these settings has contributed in unique ways to MH burnout.
Military Treatment Facility
The MTF is the Department of Defense’s medical stronghold for its most robust multidisciplinary medical capability. MTF’s are usually located “in garrison,” or in stateside hospital settings, with a full complement of specialty care. Most psychologists working in the military are clinical psychologists, engaged in the direct provision of healthcare. MTF’s also house each of the services’ clinical psychology training programs so there is an active academic and training role at some of the major MTF’s. At larger MTFs, there may be a number of psychologists working within a MH specialty clinic; however, at smaller bases there may be only one psychologist working among other MH specialists (social workers, psychiatrists, marriage-family life counselors, etc).
Integrated Primary Care Psychology
In an attempt to extend traditional MH and provide secondary prevention services, psychologists in the military have been integrated into primary care settings in a number of MTFs. As a platform for the prevention of disease and promotion of health, integrated primary care models have demonstrated great success (Strosahl, 1998). This embedded model has a number of advantages to include a greater likelihood that clients will attend their appointment (and therefore receive care) as compared to clients referred to an offsite specialty MH provider. Integrated models of MH delivery have received strong support from within the military (Johnson & Johnson, 2008) and appear to not only enhance the utilization of services but also cost savings (Staal, 2015; USAF, 2014).
Primary care is not the only setting employing embedded military psychologists. The military began embedding MH providers within their operational line units over 30 years ago. In 2004, the US Navy and Marine Corps began integrating psychologists through their Operational Stress Control and Readiness (OSCAR) program (Hoyt, 2006). After identifying deficiencies in the traditional hospital-based model for the provision of care, the Navy and Marines recognized the need to employ MH resources at tactical and operational levels. The specific advantages of the embedded model identified by the Navy and Marine Corps included,
“(a) significantly enhanced understanding of contextualized issues necessary for accurate assessment, intervention, and mission enhancement; (b) increased prevention, early intervention, and systemic implementation emphasis; and (c) greater accuracy of dispositional recommendations, with resultant increases in their utilization due to perceived credible and knowledgeable performance.” (Hoyt, 2006, p. 312)
While the majority of military psychologists are employed as MH providers, there is a group of psychologists who have specialized training in the areas of human performance, personnel selection, survival training, human intelligence, and information operations (Staal & Stephenson, 2013). To help differentiate what they do from traditional healthcare providers, and with respect to the aims of their behavioral science consultation activities, these individuals identify themselves as operational psychologists. Operational psychologists are embedded within an operational unit often assigned to the commander as a special staff officer. Their primary duties may not include healthcare provision, although they can act as the commander’s consultant for MH-related initiatives. Instead of focusing on MH and disease processes, these psychologists use their expertise in behavioral science to enable operational efforts to enhance performance, job suitability screening, and/or intelligence function integration.
MTF MH Provider Burnout
Although very little research has been conducted differentiating rates of burnout among practitioners operating across the military spectrum, there is some evidence to suggest that traditional MH service providers are at greater risk than embedded providers. Fernandez (2012) found that MTF MH clinicians “are more likely to be burned out working in garrison, in the hospital environment, responding to this increasing patient load as compared to working closer to the front lines in the deployed or operational environment” (p.83). One factor that may account for this finding relates to higher job satisfaction among psychologists working in embedded environments. Because embedded psychologists are typically woven into the fabric of their units, they can see the tangible results of their work and often have a more diverse set of duties than their MTF counterparts.
Some research has raised concerns over the negative impact of frequent deployments among members assigned to operational units. However, Sargent et al, (2016) found no relationship between the frequency of deployments and rates of burnout among military healthcare providers. Supporting this, a recent Navy psychology study examining psychologist’s deployment experiences reported that over 80% described their overall deployment as positive (COSC, 2014). More in line with the MTF milieu, Ballenger-Browning et al. (2011) found higher rates of burnout among military MH providers with high caseloads, who worked longer hours and who were less experienced.
With greater emphasis on embedded healthcare, MTF-centric psychologists often see more complex cases. Most embedded providers are directed toward primary preventative services. Many of these providers, unless operating within the MTF, are enjoined from engaging in tertiary prevention or more definitive care (USAF, 2014). As a result, these more complex MH cases are necessarily referred to the MTF and MH specialty clinics for disposition and treatment.
This may be particularly salient in that uniformed psychologists must essentially complete two careers with very different expectations simultaneously—one as a military officer and one as a health care provider.
The majority of MTF psychologists are on active duty or are government employees, often with prior military service or a family connection to the active duty military component. A personal connection to the military is important in that such clinicians’ reactions to working with combatants and veterans may be more intense than those without such connections. (Voss Horrell, Holohan, Didion, & Vance, 2011), perhaps increasing the risk of compassion fatigue. Although compassion fatigue has been differentiated in the literature from burnout, the two concepts and their effects on clinicians can be similar. Moreover, it should be understood that a large percentage of military psychologists working in MTFs are early career practitioners. Despite being less experienced many of these providers have also deployed and been exposed to trauma themselves (Voss Horrell et al, 2011). Sober and Regehr (2006) found that one of the primary predictors of vicarious trauma was the number of hours spent working with traumatized patients. Considering the frequency of posttraumatic stress among returning service members, it is not hard to see why many military mental health professionals may be at greater risk for such trauma (Ballenger-Browning et al, 2011). MTF psychologists may also be dually burdened by both a high degree of trauma cases and a lack of diversity in their practice making them vulnerable to emotional exhaustion and a reduced sense of job satisfaction (Johnson, Bertschinger, Snell, & Wilson, 2014). This may be particularly true of younger providers who tend to report lower satisfaction and higher burn out (Fernandez, 2012).
Research conducted with VA MH providers (Garcia, Finley, McGeary, McGeary, Ketchum, et al., 2015) pointed to the importance of organizational factors, including lack of control, organizational politics, and bureaucracy as predictive of workplace burnout. In military medicine, the emphasis placed on provider productivity while simultaneously demanding care that meets or exceeds civilian standards is one organizational factor potentially contributing towards burnout. This may be particularly salient in that uniformed psychologists must essentially complete two careers with very different expectations simultaneously—one as a military officer and one as a health care provider. Military officers are directed toward leadership development activities (as part of any officer’s progression), and skill in performance of administrative duties. The dual obligations of these two roles, along with ever-increasing clinical requirements, which also at a time of war with its accompanying deployments and family separations place unique stressors on the military psychologist. Such demands may lead to a perceived lack of control, which may be a key factor in burnout of military psychologists.
In a 2014 study of Department of Navy MH providers, where MTF psychologists accounted for greater than 70% of the sample, over 20% endorsed high levels of stress which appeared mostly attributable to difficulty balancing work and family life (COSC, 2014). Since clinical excellence is insufficient for an active duty psychologist to professionally progress (achieve promotion) in the military environment, these additional career requirements impose burdens that are often in direct competition with family or personal goals.
The Stress of Embedded Practice
While operating within the MTF carries many stressors that embedded providers may be able to avoid, there are in turn a number of unique factors contributing to occupational stress for those directly attached to operational units. An ongoing occupational stressor in deployed settings is the challenge of multiple relationships and related ethical concerns. Embedded MH providers must balance operational demands that may require third party consultation with command leadership with client privacy. This is true of MTF psychologists as well; however, the separation of clients and third party consultation is easier to maintain in the hospital or MTF setting as compared to the embedded environment. While identifying the government as “client” does not absolve one’s responsibility to the service member, it does result in a multiple relationship that often brings with it competing obligations (Johnson, Ralph, & Johnson, 2005; Staal & King, 2000). As in many small communities, multiple relationships can take on various forms to include social, personal, and even supervisory relationships, all factors likely to affect embedded MH providers. In many units there may only be a single psychologist or MH provider. In such instances, these officers are placed in a difficult situation. Is it appropriate for them to provide healthcare services to their co-workers and colleagues? It is for this very reason that they are employed in the operational environment, but the increased risk of dual agency is clear. In order to be effective, embedded psychologists must build relationships with enlisted personnel, fellow officers and command leaders—the very elements that increase the risk of dual relationships and potential ethical violations.
Embedded psychologists cannot simply refer unit members in need of services to external providers. Further, it is impossible to anticipate who within a unit may at some point require intervention. In other words, embedded providers cannot avoid all multiple relationships. Fortunately, although often presenting unique challenges to navigate, multiple relationships do not inherently constitute an ethical violation but rather an area of ethical concern and consideration (APA, 2011). Readers are directed to Staal and King (2000) who provided a discussion of these issues as applied to military psychology as well as a decision making framework to assist practitioners as they address various multiple relationship issues.
Operating as an embedded provider presents additional professional challenges. These include additional training and screening requirements prior to deployment, suspension of expected professional accommodations, and the need to assimilate to the unit culture with its unique organizational demands. Other specialized training may include support for military intelligence, SERE (Survival, Evasion, Rescue and Escape) training, and force protection training to include support personnel combat skills. These additional requirements are inherently challenging, and some psychologists may not be capable of performing them. Thus, deployed positions represent an exciting opportunity to support operational military personnel, the physical challenges, frequency of family absences, and expanded training requirements can be daunting and stress inducing. Advance screening of MH providers is essential to ensure they are capable of managing demands of deployment.
The Stress of Operating in Emerging Practice Areas
The evolution of military psychology to include operational providers tasked with accruing skills not expected of most psychologists has taken time, effort, and education. There have been growing pains and an evolution in concepts and employment of embedded services. As with any new or emerging practice area there can be tension between practitioners of the expanded service (who necessarily push the traditional bounds of their profession) and their colleagues whose work sustains the status quo.
At the heart of this tension lie concerns over legal and ethical issues. For example, in the case of embedded psychology, issues arose almost immediately from specialty clinic-based MH providers regarding standards of care and informed consent. Senior operational psychologists have responded to this charge in asserting that, “a formal, written, informed consent document is neither required nor recommended” in the deployed environment. Similarly, experts in this emerging field have contended, “…the ‘standard of care’ for specialty MH clinics does not apply” to embedded behavioral health care services (USAF, 2014, p. 46).
In other words, embedded providers cannot avoid all multiple relationships.
A similar tension has risen regarding operational psychology. The American Psychological Association (APA) recently released an investigative report commissioned to examine complaints alleging collusion between the APA and DoD on psychologists’ support to detainee interrogation (Hoffman, 2015). The report claimed that leaders within APA colluded with the DoD in order to “curry favor” and subsequently changed APA ethical guidelines so that DoD psychologists could ethically support interrogation missions. As a result, a handful of APA leaders have been dismissed or allowed to resign and the APA Council of Representatives voted to establish a policy prohibiting psychologists from providing support to any military or national security related interrogation or detention operations. Military psychologists supporting these intelligence collection activities have been forced to suspend their work. Threats of loss of licensure and professional censure have followed, in spite of the fact that no military psychologist has been found culpable of ethical violations in performing such duties (Harvey, et al, 2015). Such actions by the APA cast a shadow over other military psychologists, who may feel betrayed by their governing organization for actions they perceive as reactionary and capricious. The effects on military morale are obvious, and add to the occupational stressors experienced by military psychologists.
Recommendations and Other Considerations
New practice models present new challenges and often require innovation and adaptation by their community of origin. This can be a difficult experience for those practitioners not operating within their profession’s traditional frameworks. However, history is replete with such examples that illustrate the value in pushing conventional boundaries in order to expand professional services. This innovation has required a progressive adoption of new models and community education. Expansion of services also requires corresponding expansion of practice standards, and the development of ethical and regulatory guidance and relevant scholarship and research literature in three key areas: screening and selection, training and mentorship.
Screening and Selection
Given the various challenges described above, screening of psychologists for new roles is essential. Screening elements may include psychological testing and interviews, medical and physical standards, and specific work center or job-related assessments. Both professional leaders and command leadership may be involved in decisions regarding a psychologist’s suitability for various operational assignments. It is recommended, particularly for embedded support roles, that all MH providers be screened in order to identify any vulnerability in their suitability to perform these unique functions. Currently, MTFs screen prospective military psychologists through internships, post-docs, and direct accession interviews. Each military service is provided the opportunity to identify psychologists suitable for military service. With embedded psychology in increasing demand, leadership from each service has been examining potential models of employment. As military MH moves forward, a greater emphasis on identifying suitability characteristics for would-be embedded providers is advised.
Much has been referenced already about the lack of training and preparation when transitioning from a traditional model of MH provision to an emerging area of practice. To help alleviate this burden and the stress it places on providers and organizations, sufficient training courses and programs of study should be developed in advance of these transitions to ensure psychologists are able to meet the operational requirements of the job and manage the strain of the transition. History has shown that some of this training is likely to be developed alongside emerging areas of practice; however, where and when it can be anticipated, such training that includes clear and consistent position descriptions and standard operating procedures should be put in place in advance of practitioners operating in the field (Fernandez & Sherry, 2012).
The former APA Ethics office chief used to say, “Never worry alone” (Stephen Behnke, personal communication). His point was obvious, but too often practitioners operate in isolation from their professional peers. This is particularly problematic when operating in emerging areas or when engaged in duties with limited written authority, practice standards, or ethical guidelines. When in doubt, consult. Part of good consultation is establishing a mentor or at least identifying a collection of capable peers to lean on, and to reach out to, for various professional needs. A pragmatic way of implementing this at the local level within the Navy has been to establish a mentor program where junior psychologists are paired with more seasoned Navy psychologists, and Sub-Specialty leaders (i.e. Neuropsychology, Carrier Psychology, Operational Psychology, etc), who are responsible for managing the unique issues within their respective sub-specialties of Navy Psychology.
Disparities between field practice and current ethical and regulatory guidelines have resulted in severe consequences for military psychology. In terms of the mission to support national security via involvement in detainee operations, the mission itself has been directly affected. To avoid this type of situation in the future, leaders in each community overseeing emerging areas of specialty or domains of practice are urged to develop appropriate regulatory guidance, in conjunction with ethical practice standards, as soon as possible. Such standards take time to create and establish. For example, at the APA sub-specialty level initial guidelines were formally drafted by the forensic psychology community in 1991 but were only recently “ratified” by the APA (APA, 2013).
Military psychology is one of the most diverse and challenging fields in the profession. These challenges can be exciting opportunities but they often push the boundaries of comfort, competence, and current interpretations of ethical practice. Military psychologists must, then, develop new skills, standards and procedures while at the same time engaged in non-traditional practice areas. This may impose pressures that can over time lead to emotional exhaustion, depersonalization, and a decrease in job satisfaction or sense of accomplishment. To combat this negative outcome, we recommend an organizational architecture that reinforces a sense of equity and workplace autonomy. Leadership that communicates effectively, encourages commitment to the common cause, and instills a sense of teamwork and patriotism is also recommended. Suitability screening of would be psychologists for various subtypes of military service is also recommended to ensure goodness of fit to the unique demands of such assignments. While there is a degree of this already occurring by recruiters and internship or residency sites, enhancing this screening with a particular concern for personal and professional resiliency should be included. Training that prepares psychologists for the demands of the operational environment and written authority that guides them in navigating various ethical challenges is advised. Greater active relationship with the APA’s Division 19 (Military Psychology) leadership and involvement with the larger body of military psychology would also be useful to young or inexperienced military psychologists. Such involvement would facilitate the development of mentoring relationships between our most vulnerable population of providers and senior members of the community.
1The views expressed in this article are those of the authors and do not necessarily reflect the official policy of the Department of Defense or other departments of the U.S. Government.
Col Mark A. Staal is the Senior Air Force Special Operations Command Psychologist. He serves as Special Staff Officer to the Commander and Surgeon General for all behavioral science initiatives and activities. Col Staal has a PhD and is board certified in Clinical Psychology, and completed a Post-Doctoral Fellowship from NASA in Human Factors Engineering.
CDR Joseph Bonvie is the Navy operational psychology sub specialty leader. He serves as a Special Staff Officer to the Commodore of Naval Special Warfare Group TEN for all behavioral health and behavioral science initiatives and activities. CDR Bonvie has a PsyD and is board certified in Clinical Psychology.
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