Barriers to Engaging Service Members in Mental Health Care Within the U.S. Military Health System
Abstract
Objective:
Methods:
Results:
Conclusions:
Methods
Patients
Providers
Care Managers
Analysis
Results
Enhanced care (N=19) | Usual care (N=19) | Total (N=38) | ||||
---|---|---|---|---|---|---|
Characteristic | N | %a | N | %a | N | %a |
Male | 13 | 68 | 12 | 63 | 25 | 66 |
Age (M±SD) | 32±6.9 | 29±6.7 | 30±6.9 | |||
Rank | ||||||
Enlisted | 10 | 53 | 9 | 47 | 19 | 50 |
Officer | 8 | 42 | 8 | 42 | 16 | 42 |
Missing data | 1 | 5 | 2 | 11 | 3 | 8 |
Marital status | ||||||
Single | 9 | 47 | 11 | 58 | 20 | 53 |
Married or living with partner | 4 | 21 | 3 | 16 | 7 | 18 |
Separated, divorced, or widowed | 5 | 26 | 3 | 16 | 8 | 21 |
Missing data | 1 | 5 | 2 | 11 | 3 | 8 |
Characteristic | N | % |
---|---|---|
Male | 17 | 55 |
Setting | ||
Primary care clinic | 22 | 71 |
Specialty clinic | 4 | 13 |
Embedded in operational unit | 5 | 16 |
Provider type | ||
Behavioral health (psychologists, social workers, and psychiatrists) | 18 | 58 |
Primary care (physician assistants, nurse practitioners, and medical doctors) | 13 | 42 |
Structural Issues
Patientsa (N=38) | Providers (N=31) | Care managers (N=7) | |||||
---|---|---|---|---|---|---|---|
Perception | N | %b | N | %b | N | %b | Examples |
Limited provider capacity restricts timely access to appointments | 6 | 16 | 4 | 13 | 5 | 71 | “The workload is very high. I am new and the population of clients coming through the door is nonstop.” [BH provider] |
“Capacity to serve the high need for care is an issue. . . . I am running out of places to send my patients. I don’t have any place to send acute patients. We need more capacity.” [PC provider] | |||||||
“Patients are unable to get appointments, which disrupts continuity of care.” [BH provider] | |||||||
“What we’re having is not enough appointments for the soldiers, they’re only booked once a month, so they feel like they’re not getting enough care, as much as they need.” [care manager] | |||||||
“I just want to know what’s going on. When you’re told you may have a problem . . . I want some answers sooner than three weeks away.” [enhanced collaborative care patient] | |||||||
“My next appointment should be in the next week, and I have an appointment every 2–3 weeks or so. If I feel like it needs to be more—they talked about referring me off-post.” [usual care patient] | |||||||
“One month I could go to this particular care provider, and then not even a week later, I’m speaking with someone else. And it’s one of those things where the turnover rate or whatever was like super high.” [usual care patient] | |||||||
“Some of the appointment wait times are 2–3 weeks.” [BH provider] | |||||||
“Most PTSD clinics or Wounded Warrior clinics are full and the wait times are long.” [PC provider] | |||||||
“Some of the challenges might be availability. We don’t have enough staff to see people on a weekly basis. We have struggled to see suicidal patients weekly. [We have seen] 800 patients last monthly 3 weeks. We have three full-time therapists and two part-time therapists.” [BH provider] | |||||||
There are constraints on provider’s time for appointments and follow-up | 0 | — | 12 | 39 | 4 | 57 | “Another part of the issue is my time. If I had the time to make phone calls and do virtual follow [follow-up by phone or email], I would do it.” [PC provider] |
“I have had a hard time contacting service members who work the same hours that I do.” [care manager] | |||||||
“And every time I called back it was, ‘Oh, call back next week. Call back next week.’ Sometimes one of the big things is just the feeling I get is . . . especially if you’re trying to get the information over the phone . . . is you get the feeling that it’s not really their priority to get you.” [usual care patient] | |||||||
“Limitations make it tough to treat PTSD. Providers have limitations in terms of duration of time and numbers of appointments. I am supposed to limit visits to four per problem. This is not set in stone. My appointments are also limited to 30 minutes.” [BH provider] | |||||||
“In terms of appointment time, an 8- to 15-minute allotment is not enough time.” [PC provider] | |||||||
“In addition to the large patient load and the short appointment times, the overall complexity of PTSD is the issue.” [PC provider] | |||||||
“I think the main issue is time. The therapies are supposed to be 90 minutes long, but we don’t have time for that. Most appointments are 60 minutes. So we don’t follow that guidance.” [BH provider] | |||||||
“We do use those evidence-based practice (EBP) skills, but we need to modify them because of the constraints of 30-minute appointments that are short-term. I modify the EBPs to help the patient.” [BH provider] | |||||||
“As an embedded provider, we are limited in time—so we can’t spend as much time or have as many visits as we would have had we been in traditional behavioral health settings. You can request additional visits, but must get authorizations after significant justification for the ‘extra’ time. We are limited to 30–40 minute sessions.” [BH provider] | |||||||
Work hours conflict with clinic hours | 12 | 32 | 0 | — | 0 | — | And that’s why I didn't go to like that support group that I was recommended, because it’s hard to get off work during the day and then be gone without having to make up a lie about why I’m leaving.” [usual care patient] |
“That is a lot of it because like our unit, they don't like us—like Mondays, Wednesdays, and Fridays have pretty much [been] deemed out, you know, you can’t have appointments on these days unless they’re after hours. And, you know, just having Tuesdays and Wednesdays or, you know, trying to make an appointment on an evening, a lot of times you can’t, you know.” [usual care patient] | |||||||
“Well since I have to now keep appointments for my assessments to get out of the Army, half the time I don’t tell them if it’s a medical appointment or one of those. So they just assume it’s one of the med board assessments, and I’m able to get off work. So I don’t really tell them what the appointment is for, and I’m able to go to it easier.” [enhanced collaborative-care patient] |
Institutional Attitudes and Culture
Patientsa (N=38) | Providers (N=31) | Care managers (N=7) | |||||
---|---|---|---|---|---|---|---|
Perception | N | %b | N | %b | N | %b | Examples |
Perceived leadership attitudes and perceptions influence soldiers’ willingness to access care | 15 | 39 | 12 | 39 | 6 | 86 | “My chain of command does not believe me either. I guess they don’t think anything is wrong with me . . . so they’re really giving me a hard time.” [enhanced collaborative care patient] |
“The major challenge we face is really being able to ensure the soldier can get time off to attend visits and get the needed care. They have difficulty getting chain of command to allow them time off or getting excused from the field.” [PC provider] | |||||||
“They [chain of command] give me a hard time for going to appointments. They say I always have appointments and they always want me to bring a note in, bring a note after I’m done.” [usual care patient] | |||||||
“The command is not very willing to release patients for therapy. When soldiers are in the field, they cannot leave.” [BH provider] | |||||||
“Sometimes I don’t think they understand the challenges that I’m facing, and there isn’t a lot of empathy for—and I guess they don’t understand the need for me to have an appointment during the work day. So it makes it very difficult. . . . I have like three appointments a month, I already get a lot of flak for that, and I’m definitely looked down upon.” [enhanced collaborative care patient] | |||||||
“As much as they talk about getting help if you need it, they still have this tendency to portray that it’s weakness. The sergeant major in my unit has told people to stop making appointments or they can’t have any more appointments for now and to stop making appointments to get out of work.” [enhanced collaborative care patient] | |||||||
“I have to go to [name of supervisor] all the time, and it doesn't do anything. I just want to get out because I can't do anything with that Army anymore.” [enhanced collaborative care patient] | |||||||
“Availability is an issue. Command support for time away is another issue. Command support of behavioral health could be improved. It is variable from person to person.” [BH provider] | |||||||
“Follow-up is good. We have good relationships with the chain of command. Our physician assistants can also follow up well.” [BH provider] | |||||||
Accessing care may have a negative career impact | 15 | 39 | 0 | — | 6 | 86 | “They’re petrified, a lot of them, that if they tell you what’s going on, that they will be kicked out of the service, even though they’re told they’re not going to, that stigma is still there for a lot of soldiers.” [care manager] |
“That’s why most of the time they just don’t say anything. Because they’re afraid that, because of the downsizing, that they’ll be—end up getting chaptered out.” [care manager] | |||||||
“And you don’t want to tell your boss that you have an appointment for something behavioral health. You like to hide those problems. I feel that I look inferior if I, you know—I just like to tell them, hey, I have this issue and I'm dealing with it. But if I, you know, have to bring it up every couple weeks to say I have an appointment—I have to go here for this–you don't want it that visible. You want to look like you can always do your job, no matter what.” [enhanced collaborative-care patient] | |||||||
“I can’t receive the treatment that I need because of my job. So it comes down to a point where I can choose my professional career and what supports my family or what I actually need. And it’s sad that it’s like that.” [usual care patient] | |||||||
“I don’t want to tell my boss that, ‘Hey, I got a counseling appointment.’ You just always want to appear that you can do everything and you don’t need help. I think maybe they just wouldn’t look at me the same. It’s one thing to say—because I had to tell my boss that I have a problem going into the OR. I got a little PTSD stuff going on with that. And it’s one thing to tell her that and, ‘Hey, I’m trying to work on it; I’m getting a little counseling.’ It’s another to go up every week or two and say, ‘Hey, I got to go for an appointment. I’m leaving a few hours early.’ I think you just don’t look quite as competent, not as self-sufficient, you know?” [enhanced collaborative care patient] |
Recommendations for Improving Access and Receipt of Care
Patientsa (N=38) | Providers (N=7) | Care managers (N=7) | |||||
---|---|---|---|---|---|---|---|
Recommendation | N | %b | N | %b | N | %b | Examples |
Expand access to off-post resources | 31 | 82 | 2 | 29 | 6 | 86 | “The only thing I’d think of is if there would be a way that they could either contract out to civilian doctors off-post or something like that. That way they would be able to lower the caseload and not have to wait a month, month-and-a-half, for your next appointment.” [enhanced collaborative care patient] |
“I think it’d be easier to have more stuff [we] can do outside of work . . . as well as having places that you can go outside of work . . . so having an option to go to after duty hours or on weekends or something like that would be nice.” [enhanced collaborative care patient] | |||||||
“[Off-post provider] has been a lot better and talking to [my care manager] on the phone has been good enough. I don’t think he [off-post provider] comes from [a perspective of] defending the military and telling me that it’s OK what they are doing to me. He’s not like the lady I was seeing who was military. He listens to how I feel and helps me cope with it better. He’s not telling me how they [the military] see it or trying to make me change my opinion. I can tell him exactly what’s on my mind and how I feel without him telling me that I knew that when I joined or that’s how it is.” [enhanced collaborative care patient] | |||||||
“I would say the only thing would be to work on not having it [be] so difficult to go to a civilian provider. The process of having to go on-post for X amount of visits before you can get a referral to go see somebody else is kind of ridiculous, because if you have somebody like me—like if I could have I would have gone off-post immediately because I don’t want to have anything to do with the on-post counselors because of the generalization and the ‘stigmatism’ that carries. I would have gone off post originally. But a lot of times that isn’t a very easy option.” [usual care patient] | |||||||
“It’s worlds different. I think the thing with on-post is they just, in their mind, they already have an agenda and they already think they know what you're going to say. So I felt like they anticipate because they already have it all figured out what you’re going to say and what their prognosis or diagnosis of you is and what they think about you. They already have all that planned out before you even start talking to them.” [usual care patient] | |||||||
Provide better training for leadership | 9 | 24 | 3 | 43 | 1 | 14 | “The leaders need more training on how to deal with us. They need more training on how not to call us out about our issues or call[ing] us weak. I think they need training because the ones saying these things need help themselves. I think training the leaders is the first step and then training the soldiers with the families is important too.” [enhanced collaborative care patient] |
“Educate commands to encourage their soldiers to go get help. Or even bring in—I know when I was in my first tour, we had somebody come in one day when the whole group was there and just kind of give us an overall kind of class on, you know, different things that could have been going on and just kind of a gateway to, OK, well, that’s going on in my life. Maybe I should set up an appointment.” [enhanced collaborative care patient] | |||||||
“It has to start from the top. It has to be something from way high up to come down to say, ‘Hey, this is [name of superior]’—you know, they—pretty much they have to figure out how to make the units—at the highest level, make the lowest level [unit leaders] understand that something’s got to be done in certain situations or [telling them that] needing help is OK.” [usual care patient] | |||||||
“The better the chain of command is with their support, the easier it is for the soldiers to make them want to go to it—or not make them—encourage them to go to these services that the Army has available.” [enhanced collaborative care patient] | |||||||
Encourage communication between providers and command | 4 | 11 | 3 | 43 | 1 | 14 | “I feel like—like if I had an appointment tomorrow and I feel like one of the people, providers should have one of these nurses or somebody send out an e-mail to my chain of command, be like [name of soldier] has an appointment tomorrow. Please allow [the soldier] to come, or something like that.” [usual care patient] |
“Maybe send a letter out to them [leadership or command] explaining what the program is about and stuff like that because I don't think anybody really knows about [this program] unless you go through [the medical clinic] and stuff like that. Like all they know about is behavioral health. They don't have any idea about STEPS-UP.” [enhanced collaborative care patient] |
Discussion
Conclusions
Footnote
References
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Cover: Anniversary Tin: Candelabra, anonymous artist, ca. 1880–1900. Tin with sand-weighted base. Collection American Folk Art Museum, New York City. Gift of Mr. and Mrs. James D. Clokey, III, 1984.29.1A. Photo: John Parnell. Photo credit: American Folk Art Museum, Art Resource, New York City.
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