*The views expressed in this article are those of the author and do not necessarily reflect the official policy of the Department of Defense or other departments of the U.S. Government.
In the following brief article I discuss the unique contributions of embedded operational psychology. In doing so, the article attempts to highlight the diversity of applied psychological specialties and the demonstrable benefits of embedded psychology in general. The article focuses on a case example of one critically manned special operations community and their use of embedded operational psychologists to enhance the resiliency of their force and the mission performance of their personnel.
Introduction to Applied Psychology
Psychology is a diverse field of study. As the study of human behavior, the human mind, and much more, it contains many sub-disciplines or specialty areas of application. While each specialty leverages common elements associated with principles within behavioral science, each applies these elements in different ways and to different aspects of human experience. According to the American Psychological Association (APA), “psychologists work independently and also team up with other professionals - for example, with other scientists, physicians, lawyers, school personnel, computer experts, engineers, policymakers and managers - to contribute to every area of society. Thus, we find them in laboratories, hospitals, courtrooms, schools and universities, community health centers, prisons and corporate offices.” (APA, 2015). On their “careers in psychology” webpage, the APA’s provides descriptions of 19 different sub-disciplines. Far from an exhaustive list, one finds a description of engineering psychologists, industrial/organizational psychologists, forensic, and social psychologists. In each case, these applied practitioners often operate with third-party clients and from within organizational or corporate settings. Their work is contrasted with psychologists in traditional healthcare roles whose primary activity is focused on health promotion and combating disease processes. The juxtaposition of these two disparate communities of American psychologists highlights the diversity of experience and perspective when considering the practice of applied psychology.
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.
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.
- Collins, C., Hewson, D. L., Munger, R., & Wade, T. (2010). Evolving Models of Behavioral Health Integration in Primary Care. New York: Milbank Memorial Fund.
- 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
- 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.
- 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.
- Strosahl, K. (1998). The dissemination of manual-based psychotherapies in managed care: Promises, problems, and prospects. Clinical Psychology: Science and Practice, 5, 382-386.
- 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.