The military health system is pressed to provide mental health care for
troops returning from Iraq and Afghanistan and is looking to civilian
clinicians to help ameliorate the problem. The need is especially significant
for members of the National Guard and Reserves, who return to their homes
after their tours of duty, often to small towns or rural areas far from the
nearest military or Veterans Affairs medical facility.
Many civilian practitioners willing to provide services have hesitated to
do so because they are unfamiliar with military life. At the same time, many
veterans of the current fighting mistrust therapists without military
Now, a combined federal, state, and university initiative in North Carolina
is attempting to bridge that gap.
The Citizen Soldier Support Program (CSSP) seeks to improve service access
for Reserve and National Guard combat veterans and their families. The CSSP
was created by Congress and is based at the Odum Institute for Research in
Social Science at the University of North Carolina at Chapel Hill. The program
was first organized in one of the nine federally funded Area Health Education
Centers in the state, which provide continuing medical education to medical
personnel, but now has spread throughout the state.
The goal is to ensure that there are "no wrong doors" to bar
entry for troops or their families, said psychiatrist Harold Kudler, M.D.,
mental health liaison for the Veterans Integrated Service Network 6 in Durham,
N.C., who helped develop the CSSP curriculum. They call it "Painting a
Moving Train," a reference to the difficulty of keeping up with a
constantly changing situation.
The program targets two audiences, mental heath professionals and primary
care physicians, each of which had to be approached differently, explained
Kudler in an interview with Psychiatric News.
"We found that primary care people won't go to mental health provider
meetings," he said. "They won't give up their work day, and they
want evening sessions—with dinner."
So Kudler and the rest of the CSSP team developed a double-barreled
curriculum. Kudler spoke to the primary care doctors in the evening and to the
psychiatrists and mental health professionals the next day.
Kudler explained to the clinicians how to recognize and treat common
sequelae of combat, such as posttraumatic stress disorder (PTSD), traumatic
brain injuries, depression, and anxiety.
But the core of the program comes when a soldier or marine talks about life
"We started with officers giving the talks, but we found that
sergeants and other noncoms [noncommissioned officers] worked best," he
This "Boots on the Ground" talk starts with a basic
introduction to military culture—the discipline, loyalty, shared
rituals, and group cohesion that help a unit work together under fire while
also forming deep personal and professional bonds. Even language is important,
such as the acronyms by which service members refer to their war zones: OIF
(for Operation Iraqi Freedom) or OEF (Operation Enduring Freedom for the
fighting in Afghanistan).
Communication also means understanding and respecting the differences
between the service branches. A "marine" is not a"
soldier," as either will immediately inform anyone who confuses
"Understanding military culture is important so you don't turn off
the people who come in to see you," said Bob Goodale, M.B.A., the
program's administrator. Goodale is not a clinician, but Kudler gives him
credit for moving the CSSP from the idea stage to reality. He's an organizer,
a former supermarket executive, and former assistant secretary of commerce in
The military speakers also give slide presentations showing them and their
comrades in the field in Iraq or Afghanistan, vicariously putting the audience
into the context of war, said Kudler.
"That resulted in better attention during the following medical
talks," he said. "The attendees identify with the troops as their
friends and neighbors."
Understanding that military context grows more important the farther one
gets from military bases. For example, around the Marine Corps base at Camp
LeJeune, N.C., teachers know when mothers and fathers have deployed overseas
and can adjust their views of students accordingly. But National Guard and
Reserve troops may come from any of the state's 100 counties, so a teacher
just 50 miles away, for example, may chalk up a difficult child's behavior to
his being a "bad kid" rather than a child who is enduring a
parent's yearlong absence.
Kudler delves into the clinical aftermath of war but takes his audience
beyond PTSD and traumatic brain injury issues. He reminds them that the stress
experienced by troops in the field is more than a Humvee getting blown up. It
can also involve receiving word of problems back home and worries about
family. Psychological trauma can present indirectly as worsening of existing
health problems, onset of new somatic symptoms, substance abuse, or vague
complaints of low energy or sleep difficulties. Troops and their families are
stressed at every step of the deployment cycle—before, during, and after
service members go overseas.
So clinicians should ask if a patient has served in the armed forces, has
been deployed to the current war zones, or is related to someone who has.
Reservists may face additional hurdles to care and support. They return to
their hometowns, not to military bases, so they miss some of the
postdeployment support from their unit mates. In addition, they may return to
civilian jobs just days after they return from the battlefield.
For these and other reasons, many current veterans will seek care from
civilian practitioners outside the usual military or VA systems. So will
members of their families, who may not be eligible for government care.
To connect more clinicians with service members and their families, CSSP
tries to encourage the former to join TRICARE, the contractor that manages
medical care for the Defense Department. Many clinicians have complained that
TRICARE's bureaucracy is slow to accept credentials, offers low reimbursement,
and is late to pay. The CSSP program includes a TRICARE representative who
seeks to counter these impressions. For instance, the representative tells
listeners that the TRICARE HMO plan does pay less than other systems, but that
providers can make up the difference in patient volume. Since the program
began, more than 150 new providers have signed up with TRICARE.
So far the CSSP has trained more than 1,600 clinicians in North Carolina.
Program staff survey attendees six to 12 months after they complete the
program to see how many have incorporated its ideas into their practice, even
if it is simply asking if a new patient is a military veteran.
The program offers online courses and reference material available to
anyone (free registration may be required).