Feature Article

A vision for the future

The White House and U.S. Congress continue to recognize the importance of psychological expertise and the behavioral sciences, particularly in the military.

By Patrick H. DeLeon, PhD

For those interested in military health care, it is always informative, if not refreshing, to review the administration's budget and the eventual Armed Services and Appropriations Committee agreements with the White House. Evolving policy priorities take time, often significantly longer than those on the frontline might expect. Steadily, however, the importance of psychological expertise and the behavioral sciences is being recognized. Last fiscal year, I was impressed by extent to which the Congress and administration focused on psychology-based issues, including addressing potential suicides by military personnel and developing recovery-oriented innovative treatment initiatives targeting the signature wounds of traumatic brain injuries (TBIs) and posttraumatic stress disorder (PTSD). These provided psychology with exciting opportunities to demonstrate its “value-add” (as Practice Directorate Executive Director Katherine Nordal keeps emphasizing) to the leadership of the Department of Defense (DoD) and Veterans Affairs (VA). President Obama has now signed the Fiscal Year 2014 National Defense Authorization Act and its accompanying Omnibus Appropriations bill. With the late-U.S. Senator Daniel K. Inouye having been involved in their creation, I was pleased that a one-year extension was authorized for accession and retention bonuses for psychologists, as well as incentive special pay for nurse anesthetists.

It seems not that long ago that Vernon McKenzie, the then-Principal Deputy Assistant Secretary for Health Affairs, followed-up repeated expressions of concern by Senator Daniel K. Inouye regarding the utilization of psychologists within the Military Health Care System. He and his staff recommended the following steps:

  • Grant psychology departmental autonomy where the size and staffing of the hospital would justify such action (a concept now followed by the VA).
  • Allow a psychologist, when he or she is senior and capable, to be the head of a mental health department.
  • Improve the promotion opportunities for senior psychologists. One possible approach would be to create a new category or group of present MSc/BSc officers who are involved in direct health care, to include psychology, optometry, podiatry, social work and audiology.

In 2004, I also recall that the President's Information Technology Advisory Committee recommending to President G. W. Bush the following things for a better health care information infrastructure:

  • Electronic health records for all Americans that provide every patient and his or her caregivers the necessary information required for optimal care while zeducing costs and administrative overhead.
  • Computer-assisted clinical decision support to increase the ability of health care providers to take advantage of state-of-the-art medical knowledge as they make treatment decisions (enabling the practice of evidence-based medicine).
  • Computerized provider order entry—such as for tests, medicine and procedures—both for outpatient care and within the hospital environment.
  • Secure, private, interoperable, electronic health information exchange, including both highly specific standards for capturing new data and tools for capturing non-standard compliant electronic information from legacy systems.

I would strongly suggest that frontline providers appreciate that the ongoing advances in telehealth (or telepsychology) are merely a subset of the health information technology world. Fortunately, the American Psychological Association (APA) appreciates the magnitude of evolving change as reflected in its recently adopted Guidelines for the Practice of Telepsychology—developed in conjunction with the Association of State and Provincial Psychology Boards (ASPPB) and the APA Insurance Trust (APAIT). The DoD authorization statute allows the Secretary of Defense to extend the Transitional Assistance Management Program (TAMP) for an additional 180 days for mental health care provided through telemedicine. If extended, the secretary is to provide the committees with a report on the rates of utilization of this coverage, the types of mental health care provided, and an analysis of how the Secretary of Defense and the Secretary of Veterans Affairs will coordinate the continuation of care for veterans who are no longer eligible for TAMP. An additional report is required on the use of telemedicine to improve the diagnosis and treatment of PTSD, TBIs and mental health conditions. Another provision would require the two secretaries to ensure that the departments' electronic health record systems are interoperable with integrated display of data, or a single electronic health record, and that each complies with national standards and architectural requirements. The provision would require each department to deploy modernized electronic health record software supporting clinicians by no later than Dec. 31, 2016. A report is also required of the VA on its centers of excellence in the prevention, diagnosis, mitigation, treatment, and rehabilitation of TBI, PTSD and other mental health conditions. Finally, the highly emotional and complex issue of “sexual harassment” has been of considerable administrative and congressional concern throughout the Fiscal Year 2014 DoD legislative deliberations.

General Casey once said that the military is getting rid of the notion that if there are no holes in the service member, that meant being ready for duty. Robert Gates added that it was impossible to him to fight the resistance to change both the civilian and the military department's personnel and health care bureaucracy. Accordingly, it is imperative that frontline clinicians continue to provide APA's Heather Kelly with suggestions for substantive policy changes that will make a difference in the lives of military personnel, their families and our nation's veterans.

Young Adults

The Institute of Medicine (IOM), under the direction of psychologist Kimber Bogard, recently released its workshop summary on Improving the Health, Safety, and Well-Being of Young Adults , a unique population which is relevant to today's military where young adults ages 20–24 make up the largest cohort of both active duty and reserve military personnel. Among active duty officers, 25- to 29-year-olds represent the largest cohort, whereas young adults make up the smallest proportion of the civilian workforce. Young adults in the military face some unique challenges as well as challenges common to all young adults. They are in many ways an overlooked population who are at a significant and pivotal time of life. They have traditionally been expected to achieve an education, employment, financial independence, marriage and children. Today the achievement of those milestones is much more variable. Young adult years are more fluid and flexible than in the past, and they do not have a single age of majority or rite of passage. They undergo a variety of transitions to adult roles and enhanced autonomy. There are many different paths, although certain patterns in the paths taken are evident. Nowadays, information is not so much passed from elders to youths, as it is transferred horizontally among young adults. Social class distinctions are sharpening, and discrepancies in opportunities and resources are growing. Social mobility and income inequality are increasing trends affecting the lives of young adults. Educational attainment can have a strong effect on the health and well-being of young adults, but the quality of the schooling that adolescents and young adults receive is highly variable. Brain development is continuing in young adults, but this development is not a simple extrapolation of what occurs in adolescence.

The following five themes are needed for the success of parenting young adult children: communication, social support, finances, personal responsibility and connections to other adults and resources. Consideration should be given to the development of a framework that has a developmental within context orientation. Good parenting of young adults is built on a foundation of communication and contains elements of mutual respect, social support, financial knowledge and assistance, and recognition of changing expectations and relationships. Good parenting faces a number of barriers, from both the perspectives of parents as well as young adults. There is much to learn. Aloha.