To support Mental Health Awareness Month in May, experts from Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) invited questions from health care providers who treat members of the military. The questions and answers appear below.

• Q: “Is there anything in the DoA/DoD regulations or elsewhere indicating that a service member must be chapter separated if the member demonstrated suicidal behavior (parasuicide) only once and was subsequently diagnosed with a personality disorder (borderline personality disorder)? A driving factor in this specific case is that the service member is a military police officer.”

  Sheila B. Albers, LCSW, CAP, ASAP Counselor

  A: There are many policies in place across the Defense Department, services, and specific military occupational communities that spell out requirements for military readiness and specifically state service members must be medically qualified. Often, these policies mention specific disorders (such as personality disorders) and risk factors (such as suicidal behaviors) that warrant special attention, require additional assessment, or compel additional considerations. For some military occupational specialties that have high risk-management requirements, such as air traffic control, nuclear reactor operation and air combat, the need for optimal medical readiness and high occupational functioning is obvious. In other cases, policies can be overly restrictive and may seem prejudicial to those who have a psychological condition or mental health treatment documented in their health records.

  Diagnosed personality disorders are not automatically disqualifying. They usually require corroborating evidence that a service member’s condition causes poor adaptation to the military, interferes with the performance of duties, or represents a continuing, unmanageable risk of harm to self or others.

  In the example you present, a comprehensive clinical evaluation and a careful assessment of current and ongoing risk, usually by a psychiatrist or clinical psychologist, would need to be performed. Based on this assessment, a recommendation for administrative separation might be made. The Army requires an additional review and endorsement by the Army Surgeon General’s office. For additional information on administrative separations for personality disorders, please see Army Regulation 635-200 for qualification/disqualification for military police, see Army Regulation 190-56.

  Navy Capt. (Dr.) Anthony Arita
  Deployment Health Clinical Center director

• Q: “What role do you think post traumatic growth and factors of resilience can or will play in the care of veterans?”

  Thad S. Rydberg, MA, LCPC

  A: Posttraumatic growth refers to the experience of positive change that occurs as a result of struggling with highly challenging life crises. These positive changes can take many forms, including increased appreciation for life, more meaningful interpersonal relationships, a greater sense of personal strength, changed priorities, and more spiritual life.

  The Defense Department definition of resilience is the ability to withstand, recover and grow in the face of stressors and changing demands. Resilience factors include viewing situations in ways that provide positive meaning and expectations, using active and problem-focused coping strategies, being able to act and respond effectively despite feeling fear, attending to one’s physical well-being, and reaching out for support from leaders, families and communities. These resilience factors can hasten the recovery process for those who have had traumatic exposures, and in fact, most people show natural resilience in their responses to trauma.

  Resilience factors and posttraumatic growth can play an important role in the care of veterans. Many of the evidence-based psychotherapy options include a focus on elements of resilience and posttraumatic growth, and it is common for providers to integrate these factors into care.

  Dr. Mark Bates
  Deployment Health Clinical Center associate director psychological health promotion

• Q: “Are there recommended treatment modalities for use with sub-threshold PTSD symptoms in a nonmedical setting?”

  Stacie Coduto, MSW, LCSW

  A: It’s important to note that “sub-threshold PTSD symptoms” can mean several things:

  • symptoms aren’t so intense that they’re significantly disruptive or distressing
  • symptoms do not include at least one avoidance symptom
  • symptoms have not persisted the length of time required to meet the diagnostic threshold for PTSD

  Although the diagnosis and treatment of PTSD is conducted in medical settings by medical providers, there are a variety of non-medical support services that may be able to assist with specific issues related to sub-threshold post-traumatic stress (PTS) symptoms. These resources include the Military and Family Life Counselor program, chaplains, nonclinical social workers, wellness centers and self-help technology resources.

  Nonclinical providers can help address a range of potential PTS-related issues in a way that complements the natural PTS symptom recovery process. These issues include anger, grief and loss, stress management and coping challenges, sleep issues and relationship problems. Nonclinical providers can also help enhance problem-solving skills, which help people reach their goals, decrease stress and restore a sense of control. They also help people build and maintain a personal support network, including communicating effectively and identifying ways to be creative, relax and enjoy spending time with others.

  Chaplains are often the first line of defense for service members wrestling with moral and spiritual concerns. The chaplains’ pastoral approach can help people process memories, find more effective ways to understand their experiences, and increase a sense of meaning and purpose.

  Finally, Defense Department self-help technology resources like the AfterDeployment website and the PTSD Coach mobile app offer self-guided assessments and self-care strategies. The Breathe2Relax mobile app provides excellent coaching for diaphragmatic breathing, which is a powerful stress management tool often used as part of treatment for PTS symptoms.

  Dr. Mark Bates
  Deployment Health Clinical Center associate director psychological health promotion

• Q: “I would like information on treatment for veterans with PTSD that includes a significant focus on moral injury.”

  Lia Pendergrass, LCSW

  A: As you’re likely aware, moral injury is not clinically defined and is not captured by a formal diagnosis, so clinical practice guidelines have not been developed specifically for it. However, Defense Department mental health providers often address moral injury when treating a mental disorder.

  A patient being treated for PTSD, depression or other mental health diagnoses may disclose information that indicates a moral injury (for example, guilt over accidentally killing a civilian during a combat operation or another dilemma). When this occurs, mental health providers often help the patient explore the event they experienced or actions they took or failed to take that conflict with their values or deeply held beliefs. There is a lot of meaning to explore, and the exploration must be done without judgment, haste or expectation of a linear path to resolution.

  To the degree that a moral injury relates to spiritual matters, a collaborative care or support approach involving a chaplain might be helpful. This process, of course, depends on the nature and extent of the patient’s symptoms, the presence of co-occurring conditions (such as alcohol or substance misuse), current life circumstance (demands and overall stressors), available support resources, and the character and value system of the individual. As a clinician, you can help the patient appreciate the impact of his struggle on his personal, occupational, and interpersonal functioning, while also helping to scope and prioritize areas of clinical attention and targets for intervention.

  Navy Capt. (Dr.) Anthony Arita
  Deployment Health Clinical Center director