Professional News
Military Hopes Civilian Clinicians Can Shrink Treatment Gap
Psychiatric News
Volume 44 Number 16 page 16-35

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 experience.

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 in wartime.


"We started with officers giving the talks, but we found that sergeants and other noncoms [noncommissioned officers] worked best," he said.

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 the terms.

"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 North Carolina.

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).

Information on the Citizen Soldier Support Program is posted at<http://archive.constantcontact.com/fs034/1101324710444/archive/1102402957397.html>.

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