The Embedded Psychology Model

Traditionally, clinical psychology falls under the umbrella of healthcare provision. The model most often employed is one of specialty care - set aside from other healthcare practitioners - contained in a clinic, group practice, or individual office. However, over the last two decades, embedded behavioral health models have emerged and established themselves as very useful and effective platforms for the prevention of disease and promotion of health. Kurt Strosahl has pioneered the embedding of psychologists into primary care clinics and, along with others (Hunter, Goodie, Oordt, & Dobmeyer, 2009), has demonstrated the effectiveness of this model over traditional mental healthcare systems. For example, clients referred to an embedded behavioral health provider are much more likely to attend their appointment (and therefore receive care) as compared to clients referred to an offsite specialty mental health provider. According to Strosahl (1998), the magnitude of this difference is 90% in the embedded consultation model as opposed to 15% using the traditional platform. Collins, Hewson, Munger, & Wade (2010) and Cwikel, Zilber, Feinson, & Lerner (2008) found that only 10% of patients followed up with their referrals when the provider was not embedded.  

Embedded psychologists have been employed throughout the military and the results appear to strongly support an integrated model (Johnson, Ralph, & Johnson, 2005). Data coming out of this analysis indicates that embedded support providers enhance service provision across a number of domains. For example, when it comes to cost and utilization of services, the military reports a reduction in inpatient admissions (4%), in emergency room visits (7%), specialty care appointments (2%), pharmacy costs (13%), and overall primary care medical costs (9%) when embedded psychologists are used as opposed to traditional psychological services. Moreover, the Department of Defense has found improvements across eight preventative service measures, an increase in access to support (21%), improvements in logistics to care, and greater client satisfaction when compared to facilities that do not employ embedded behavioral health providers (USAF, 2014). 

The evolution of this model for traditional clinical psychologists has taken time, effort, and education. There were concerns initially about standards of care, informed consent, competence, and other ethical issues. For example, when it comes to informed consent, professionals in the field of embedded behavioral healthcare state that, “a formal, written, informed consent document is neither required nor recommended”. Similarly, experts in the field assert, “…the ‘standard of care’ for specialty mental health clinics does not apply” to embedded behavioral health care services (USAF, 2014, pg 46).

As an analog to embedded clinical psychology, the following section of this article will examine the benefits of embedded operational psychology. Although applying behavioral science principles to non-healthcare related challenges, operational psychologists are often operating in similar embedded environments and their work often benefits from integration with their third party client organization.

Operational Psychology

Most military psychologists are doctoral-level human behavior experts who provide mental health consultation on topics such as depression, stress, and anxiety. However, a small portion of these, have received specialized training in the areas of human performance, personnel selection, survival training, human intelligence, information operations, etc. These individuals often identify themselves as operational psychologists to help differentiate what they do from traditional healthcare practitioners. Operational psychology as an applied specialty is diverse and challenging. It typically includes consultation with operational decision makers regarding a number of operational and organizational activities. One of those activities concerns personnel selection and training (S&T) for selectively manned operational units. In the following portion of the article we examine the value of embedded operational psychology to special duty S&T.

Selection and Training: A SOF Case Study

Special operations personnel constitute a community within the military that is often critically manned. In other words, they are a low density asset to military operational capability that often doesn’t have enough qualified personnel to adequately support the mission. The demand for these individuals has never been greater since the events of 9/11. However, with historically small numbers and challenging training pipelines, it has been difficult to keep up with the demand. Selection, training, and retention remain significant challenges. Attrition during training is a major contributing factor. Therefore, reducing attrition rates can assist special operations forces (SOF) in meeting its operational manning requirements. 

Operational psychologists have been used to assist in the selection and training of SOF personnel for many years. For example, Special Forces (SF) candidates must complete the SF Assessment and Selection course, a month-long test of their mental toughness and suitability. This includes an extensive battery of testing and interviews by operational psychologists. However, their role does not end with selection. The Army employs embedded operational psychologists within each of its SF Groups to assist with training and human performance issues. Similarly, Navy SEAL candidates complete a six-month Basic Underwater Demolition/SEAL (BUD/S) course. Here too, operational psychologists play a key role in selection and training of NAVSOF personnel as embedded assets. An analog exists within the Air Force SOF community and among its Special Tactics (ST) personnel as well. 

ST Combat Control (CCT) 

CCT is critically manned and there just are not enough qualified CCT operators. This is largely the result of two factors: 1) insufficient numbers of capable candidates and 2) high rates of attrition during training. For example, 30% of CCT candidates drop out during the first year. Pre-scuba indoctrination is one of the most challenging phases of CCT training. It is a prerequisite for all ST personnel prior to attending Navy dive school. A significant portion of each class fails this phase, forcing them to be recycled. In some cases, students are recycled several times before they successfully graduate or are dropped from the program. The loss of resources associated with recycling is not insignificant nor is the cost associated with each student that fails to complete the program. 

Most students that struggle with this phase do so because they lack effective technique and water confidence - two human performance problems that can be remedied with proper intervention. Many of the technique-related issues can be resolved by the dive instructor cadre; however, water confidence problems are more complex. Students become anxious and experience stress (even panic) when “drowned-proofing” or engaged in one of the many underwater training exercises. As the student’s anxiety increases, so does their respiration, leading to a decrease in breath control. Moreover, students become preoccupied with their physiological and psychological reactions which further distract them from concentrating on their underwater tasks. Ultimately, they become frustrated and feel incapable of performing adequately which only worsens their condition. In order to reduce this risk for attrition while maintaining training rigor, an operational psychologist is often invaluable. As an embedded member of the unit, he or she is not viewed as an outsider and therefore is perceived more favorably. Furthermore, as an embedded asset, the psychologist is present at the site of intervention (in the context of training). Instead of the individual being pulled from training in order to find the needed support, this resource is available where and when it is needed (a consequence of being embedded). Lastly, while there remains stigma in seeking a healthcare provider for what may be perceived as “a disease process”, this barrier is largely removed when receiving support from an operational psychologist whose focus is performance enhancement from a sports medicine perspective. 

Since the employment of embedded operational psychologists within AFSOF units, there have been numerous instances when potential training losses were recouped and poorly performing operators were brought back to pace with their peers as a result of operational psychology interventions. Such examples, and others like it outside of S&T, provide ample evidence for the value of embedded operational psychologists within operational units.

References 

1. Collins, C., Hewson, D. L., Munger, R., & Wade, T. (2010). Evolving Models of Behavioral Health Integration in Primary Care. New York: Milbank Memorial Fund.
2. Cwikel, J., Zilber, N., Feinson, M., & Lerner, Y. (2008). Prevalence and risk factors of threshold and sub-threshold psychiatric disorders in primary care. Social Psychiatry and Psychiatric Epidemiology, 43, 184–191. doi:10.1007/s00127-007-0286-9 
3. Hunter, C. L., Goodie, J. L., Oordt, M. S., & Dobmeyer, A. C. (2009). Behavioral health in primary care: A practitioner’s handbook. Washington, DC: American Psychological Association. 
4. Johnson, W.B., Ralph, J., Johnson, S.J. (2005). Managing multiple roles in embedded environments: The case of aircraft carrier psychology. Professional Psychology Research and Practice, 36(1), 73-81. 
5. Strosahl, K. (1998). The dissemination of manual-based psychotherapies in managed care: Promises, problems, and prospects. Clinical Psychology: Science and Practice, 5, 382-386.
6. United Stated Air Force (2014). Primary care behavioral health services: Behavioral health optimization program (BHOP). Practice Manual. San Antonio, TX: Air Force Medical Operations Agency.
   

2005 05 24 Interim Guidance on Detainee Care:  This was medical guidance that was provided to all Army medical personnel on the treatment of detainees in US custody.  It included initial guidance for psychologists who provide “any form of assistance with the interrogation process.”

2005 05 24 Martinez Lopez Report:  This was a report of a detailed assessment into the medical support to detainee operations.  It included a review of the use of psychologists supporting interrogation and detention operations.

2005 06 03 Medical Program Principles and Procedures for the Protection and Treatment of Detainees in the Custody of the Armed Forces of the United States:  This was a memorandum from the Assistance Secretary of Defense for Health Affairs articulating the Principles and Procedures for all DoD Health Care Personnel (including psychologists supporting interrogation and detention operations) for working with detainees in US custody.

2008 11 20 SASC Report: The Senate Armed Services Committee Report is the most detailed and accurate rendition of the US’s involvement and actions concerning interrogation from 2001 until 2008.

2009 02 Walsh Report:  This is the report commissioned by President Obama to review the conditions of confinement at Guantanamo Bay, Cuba.  It specially found that the mission of psychologists supporting interrogation operations should be continued.

2006 09 Field Manual 2-22.3:  This is the Army manual (it applies to all uniformed services) that give the doctrine on interrogation operations.  Because of the Detainee Treatment Act, it is also US Law.  It clearly outlines the prohibition of any abuse of detainees.

2006 10 20 MEDCOM Policy:  This is the detailed guidance on how psychologists may support interrogation operations.  It clearly outlines the prohibition of any abuse of detainees.

2008 05 30 Joint Publication 3-63:  This is the joint publication that provides guidelines for planning and executing military detainee operations.  It clearly outlines the prohibition of any abuse of detainees.

2008 10 09 DODD 3115.09 DOD Intelligence Interrogations (2008):  Updated version of the DoD Directive on conducting Intelligence Interrogations.

2005 11 03 DODD 3115.09 DOD Intelligence Interrogations (2005):  This is the DoD Directive that covers Intelligence Interrogations, specifically addressing humane treatment and the use of psychologists who support interrogations.

2005 09 ST 4-02 46 Medical Support to Detainee Operations: This provides the details of the techniques and procedures that govern medical support to detainee operations, including the requirements to report abuse, and the overall function of psychologists who support interrogation operations.

2005 12 30 SECDEF Memorandum - Interrogation & Treatment of Detainees by the Department of Defense:  This implements the Detainee Treatment Act, requiring that only techniques in the Army Field Manual are used in intelligence interrogations, and that all persons held by the Armed Forces shall be treated humanely.

2006 06 06 DODI 231008E Medical Program Support for Detainee Operations: This provides medical policy for the treatment of detainees.   Enclosure 2 gives specific guidance on the use of psychologists who support interrogations.

2006 08 25 DOD IG Investigations of Detainee Abuse:  This is the formal review of the various DoD-Directed Investigations into Detainee Abuse.

2006 09 05 DODD 2310.01E DOD Detainee Program:  The is the Directive that outlines responsibilities and policy for the Department of Defense on Detainee Operations.

Section 1. Behavioral Science Insights Policy Directive.

(a) Executive departments and agencies (agencies) are encouraged to:

(i) identify policies, programs, and operations where applying behavioral science insights may yield substantial improvements in public welfare, program outcomes, and program cost effectiveness;

(ii) develop strategies for applying behavioral science insights to programs and, where possible, rigorously test and evaluate the impact of these insights;

(iii) recruit behavioral science experts to join the Federal Government as necessary to achieve the goals of this directive; and

(iv) strengthen agency relationships with the research community to better use empirical findings from the behavioral sciences.

(b) In implementing the policy directives in section (a), agencies shall:

(i) identify opportunities to help qualifying individuals, families, communities, and businesses access public programs and benefits by, as appropriate, streamlining processes that may otherwise limit or delay participation -- for example, removing administrative hurdles, shortening wait times, and simplifying forms;

(ii) improve how information is presented to consumers, borrowers, program beneficiaries, and other individuals, whether as directly conveyed by the agency, or in setting standards for the presentation of information, by considering how the content, format, timing, and medium by which information is conveyed affects comprehension and action by individuals, as appropriate;

(iii) identify programs that offer choices and carefully consider how the presentation and structure of those choices, including the order, number, and arrangement of options, can most effectively promote public welfare, as appropriate, giving particular consideration to the selection and setting of default options; and

(iv) review elements of their policies and programs that are designed to encourage or make it easier for Americans to take specific actions, such as saving for retirement or completing education programs. In doing so, agencies shall consider how the timing, frequency, presentation, and labeling of benefits, taxes, subsidies, and other incentives can more effectively and efficiently promote those actions, as appropriate. Particular attention should be paid to opportunities to use nonfinancial incentives.

(c) For policies with a regulatory component, agencies are encouraged to combine this behavioral science insights policy directive with their ongoing review of existing significant regulations to identify and reduce regulatory burdens, as appropriate and consistent with Executive Order 13563 of January 18, 2011 (Improving Regulation and Regulatory Review), and Executive Order 13610 of May 10, 2012 (Identifying and Reducing Regulatory Burdens).

Section 2. Implementation of the Behavioral Science Insights Policy Directive. (a) The Social and Behavioral Sciences Team (SBST), under the National Science and Technology Council (NSTC) and chaired by the Assistant to the President for Science and Technology, shall provide agencies with advice and policy guidance to help them execute the policy objectives outlined in section 1 of this order, as appropriate.

(b) The NSTC shall release a yearly report summarizing agency implementation of section 1 of this order each year until 2019. Member agencies of the SBST are expected to contribute to this report.

(c) To help execute the policy directive set forth in section 1 of this order, the Chair of the SBST shall, within 45 days of the date of this order and thereafter as necessary, issue guidance to assist agencies in implementing this order.

Section 3. General Provisions. (a) Nothing in this order shall be construed to impair or otherwise affect:

(i) the authority granted by law to a department or agency, or the head thereof; or

(ii) the functions of the Director of the Office of Management and Budget relating to budgetary, administrative, or legislative proposals.

(b) This order shall be implemented consistent with applicable law and subject to the availability of appropriations.

(c) Independent agencies are strongly encouraged to comply with the requirements of this order.

(d) This order is not intended to, and does not, create any right or benefit, substantive or procedural, enforceable at law or in equity by any party against the United States, its departments, agencies, or entities, its officers, employees, or agents, or any other person.

BARACK OBAMA

THE WHITE HOUSE
September 15, 2015