Charles C. Engel, MD, MPH

Confidentiality is the foundation of effective mental health care. Few clinicians or patients would debate the point. Our patients’ problems are deeply personal and private. Wherever we as mental health clinicians practice, our offices become the pain-strewn battlefields in prolonged wars of attrition fought against enormous personal hardships.

In civilian practice, the rules of confidential engagement in these wars against mental injury and adversity-while containing important limits-are quite clear. And clear they must be, otherwise few if any of our patients would entrust us with a privileged place in their emotional foxholes. Nor should they, because too much is at stake-invisible but potentially mortal wounds, ugly confrontations, embarrassing angst, crippling self-doubt, and even future insurability. The privacy and security of our offices-the therapeutic bunkers within which our wounded patient-warriors hunker down against an unseen enemy-provide the fundamental first barricade between private sufferings and the potential for public humiliation.

Consider the following situations from the patient’s perspective.

• Imagine you work the cash register at a local drug store. The shift leader has been making unwelcome and sexually suggestive comments around you with increasing frequency. You don’t want to report the shift leader, even though the situation is causing you great distress. You just want to do your job. You’ve called in sick a couple times in the past week to avoid the situation. You would like to talk with a therapist, but the only option under the store’s health insurance is to see a company therapist. You’ve seen the therapist and the shift leader eating lunch together at company headquarters.

• Imagine you work for a local utility. You’ve worked there for 15 years, and you’ve been a good employee. The pension benefits are decent, and you hope to stay with the company until you can retire in another 5 years. You have a history of depression that has been well controlled with sertraline, but of late the depression has been worsening. You’ve overslept a couple of times recently after lying awake during much of the night. One day, you come in to work and your supervisor informs you that your psychiatrist has recommended separation and the company has decided to terminate you.

• Imagine you work as a firefighter in a major city. After 12 years of marriage, you are shocked when your spouse tells you she is having an extramarital affair. You are distraught and seek psychiatric assistance at an emergency room. You tell the on-call psychiatrist that you’re having fleeting thoughts of suicide, but you have no history, plan, or intention of making an attempt. The emergency room psychiatrist calls the fire station where you work and requests a workplace suicide watch.

For our men and women in uniform, these seemingly absurd vignettes are more than mere fantasy. The threat and reality of analogous situations play out routinely in the US Armed Forces. Over the past decade, there has been increasing discussion of stigma around mental health care in the military, about the troops’ reluctance to seek assistance, and about the military’s culture of machismo. The not-so-subtle effect of this discourse is to suggest that we expect our men and women in uniform to dig deep and take responsibility. If they can conquer the fear of battle, then isn’t it time they conquer their fear of mental health treatment?

There is no mistaking that stigma exists in the military just as it does across American society. But let’s be clear: the problem in the military is fundamentally different. The problem in the military boils down to the jarring and institutionalized military failure to place adequate boundaries between the workplace and the therapist’s office. The state of the situation-including chapter and verse of the relevant military regulations-is thoroughly reviewed in Army Major Jennifer A. Neuhauser’s 

 article, “Lives of Quiet Desperation: The Conflict Between Military Necessity and Confidentiality.”

 Neuhauser lays out her case for confidentiality, a case that is fair, thoughtful, persuasive, and dispassionately argued.

Here I offer only a few of Neuhauser’s central points; I encourage you to read the article for yourself. She starts with a review of the Health Insurance Portability and Accountability Act, known to us as HIPAA, and moves from there to discussion of the analogous Department of Defense regulation DoD 6025.18-R,

 which in Neuhauser’s words “provides a general prohibition on disclosure or use of identifiable health information of individuals, except for ‘specifically permitted purposes.’”

 She continues to explain, quoting from DoD 6025.18-R,

 how, while ostensibly protecting the service member’s privacy, the regulation then proceeds to virtually eviscerate these protections by allowing the disclosure of PHI (Protected Health Information) “. . . for activities deemed necessary by appropriate military command authorities to assure the proper execution of the military mission” without the consent of the military member.

Neuhauser writes, “These activities include determining both the service member’s fitness for duty and fitness to perform any particular mission, assignment, order or duty, and ‘to carry out any other activity necessary to the proper execution of the mission of the Armed Forces.’” When reviewing the Army version of the regulation, Army Regulation 40-66,

 Neuhauser notes that “exception swallows the rule for those commanders who seek PHI on their soldiers . . . to ensure the proper execution of their mission, whether it be turning wrenches or ‘kicking in doors.’”

 Neuhauser quotes an executive director of the National Institute of Military Justice to say that the exceptions are so overbroad that “you could drive a truck through them.”

Neuhauser points out that while there are penalties for violation of these regulations, they are all but unenforceable. She observes, “Issues may arise when a commander or executive officer pressures a brigade surgeon to access psychotherapy notes, such as when the commander wants to know if the soldier is malingering in order to get out of a duty or deployment. . . . Though the vast majority of healthcare practitioners are undoubtedly ethical, the potential for abuse is present.” To fully appreciate the complexity of the situation she describes, readers should know that the brigade surgeon and the soldier whose medical records are sought might both work for the commander doing the pressuring.

Perhaps most challenging for psychiatrists and other mental health professionals will be Neuhauser’s observation that while current regulations severely limit the confidentiality of mental health records-far outstripping conventional civilian limits on confidentiality-military chaplains enjoy essentially absolute confidentiality in their discussions with military members, including when they are engaged in pastoral counseling. Attorney-client privilege in the military approximates civilian standards.

This would be easy to accept if it were constructive. However, not only do weakened confidentiality limits make it difficult for military members to get the mental health care they need, but also there is no compelling logic or evidence to suggest these limits improve military readiness, discipline, or function.

Neuhauser argues compellingly that easy command access to mental health records is harmful in many ways. It hobbles military capacity to provide effective mental health services because military members rightly perceive that seeking treatment can harm their careers. It puts the responsibility for determination of military member reliability in the hands of mental health professionals who only see military members for a few hours in an artificial office context. It absolves military leaders of their institutionalized responsibility to know the status of the military members who work for and with them, usually for several hours of every day. And, ultimately, it is unnecessary, given that commanders already can and do refer some military members for “command-directed mental health evaluations,” evaluations that result in written feedback to the commander who is concerned about a military member’s mental health and dependability.

I have previously called for the institution of civilian standards of mental health confidentiality in the military.

 Neuhauser’s article further cements my views in this area. Given that rates of military suicide have risen to unprecedented levels-surpassing civilian suicide rates for the first time in modern American history-the burden of empirical proof in support of weak military mental health confidentiality standards is squarely on the military. If the military must, to use Neuhauser’s expression, “eviscerate” civilian confidentiality standards-ostensibly for the purpose of good military order and a high state of readiness-then it’s time to do the science to ascertain the empirical impact of these policies.

 Neuhauser JA. Lives of quiet desperation: the conflict between military necessity and confidentiality. 

. 2011;44:1003-1044. https://dspace.creighton.edu/xmlui/bitstream/handle/10504/40730/42_44CreightonLRev1003%2820102011%29.pdf?sequence=1. Accessed October 21, 2014.

 Winkenwerder W Jr. Department of Defense. DoD Health Information Privacy Regulation. DoD 6025.18-R. January 24, 2003. http://www.dtic.mil/whs/directives/corres/pdf/602518r.pdf. Accessed October 21, 2014.

 Department of the Army. Army Regulation 40-66. Medical Record Administration and Healthcare Documentation. January 4, 2014. http://www.apd.army.mil/pdffiles/r40_66.pdf. Accessed October 21, 2014.

 Engel CC. Suicide, mental disorders, and the US military: time to focus on mental health service delivery. 

Articles

Given that rates of military suicide have risen to unprecedented levels, the burden of empirical proof in support of weak military mental health confidentiality standards is squarely on the military.

Compromised Confidentiality Is Harmful: Military Owes Proof to the Contrary

In civilian practice, the rules of confidential engagement in these wars against mental injury and adversity-while containing important limits-are quite clear. And clear they must be; otherwise few if any of our patients would entrust us with a privileged place in their emotional foxholes. Nor should they, because too much is at stake-invisible but potentially mortal wounds, ugly confrontations, embarrassing angst, crippling self-doubt, and even future insurability. The privacy and security of our offices-the therapeutic bunkers within which our wounded patient-warriors hunker down against an unseen enemy-provide the fundamental first barricade between private sufferings and the potential for public humiliation.

Consider the following situations from the patient’s perspective:

• Imagine you work as a firefighter in a major city. After 12 years of marriage, you are shocked when your spouse tells you she is having an extramarital affair. You are distraught and seek psychiatric assistance at an emergency room. You tell the on-call psychiatrist that you’re having fleeting thoughts of suicide, but you have no history, plan, or intention of making an attempt. The emergency room psychiatrist calls the fire station where you work and requests a workplace suicide watch. 

Lives of Quiet Desperation: The Conflict Between Military Necessity and Confidentiality

 Neuhauser lays out her case for confidentiality, a case that is fair, thoughtful, persuasive, and dispassionately argued

Here I offer readers only a few of Neuhauser’s central points, while encouraging them to read the article for themselves. She starts with a review of the Health Insurance Portability and Accountability Act, known to us as HIPAA, and moves from there to discussion of the analogous 

Department of Defense regulation DoD6925.18-4

 “provides a general prohibition on disclosure or use of identifiable health information of individuals, except for ‘specifically permitted purposes.’”

Neuhauser writes, “These activities include determining both the service member’s fitness for duty and fitness to perform any particular mission, assignment, order or duty, and ‘to carry out any other activity necessary to the proper execution of the mission of the Armed Forces.’” When reviewing the Army version of the regulation, 

rates of military suicide have risen to unprecedented levels, surpassing civilian suicide rates for the first time in modern American history

the military fails to place adequate boundaries between the workplace and the therapist’s office

weakened confidentiality limits make it difficult for military members to get the mental health care they need

there is no compelling logic or evidence to suggest these limits improve military readiness, discipline or function

Neuhauser points out that while there are penalties for violation of these regulations, they are all but unenforceable. She observes, “Issues may arise when a commander or executive officer pressures a brigade surgeon to access psychotherapy notes, such as when the commander wants to know if the soldier is malingering in order to get out of a duty or deployment. . . . Though the vast majority of healthcare practitioners are undoubtedly ethical, the potential for abuse is present.”

 To fully appreciate the complexity of the situation she describes, readers should know that the brigade surgeon and the soldier whose medical records are sought might both work for the commander doing the pressuring.

This would be easy to accept if it were constructive. However, not only do weakened confidentiality limits make it difficult for military members to get the mental health care they need, but also there is no compelling logic or evidence to suggest these limits improve military readiness, discipline or function. Neuhauser argues compellingly that easy command access to mental health records is harmful in many ways. It hobbles military capacity to provide effective mental health services because military members rightly perceive that seeking treatment can harm their careers. It puts the responsibility for determination of military member reliability in the hands of mental health professionals who only see military members for a few hours in an artificial office context. It absolves military leaders of their institutionalized responsibility to know the status of the military members who work for and with them, usually for several hours of every day. And, ultimately, it is unnecessary, given that commanders already can and do refer some military members for “command-directed mental health evaluations,” evaluations that result in written feedback to the commander who is concerned about a military member’s mental health and dependability.

 of mental health confidentiality in the military.

 Neuhauser’s article further cements my views in this area. Given that rates of military suicide have risen to unprecedented levels, surpassing civilian suicide rates for the first time in modern American history, the burden of empirical proof in support of weak military mental health confidentiality standards is squarely on the military. If the military must, to use Neuhauser’s expression, “eviscerate” civilian confidentiality standards-ostensibly for the purpose of good military order and a high state of readiness-then it’s time to do the science to ascertain the empirical impact of these policies.

Dr Engel is Senior Health Scientist at the RAND Corporation in Washington, DC. His last military assignment before retiring as an Army colonel was Associate Chair for Research, Uniformed Services University of the Health Sciences, department of psychiatry, in Bethesda, Md.

https://dspace.creighton.edu/xmlui/bitstream/handle/10504/40730/42_44CreightonLRev1003%282010-2011%29.pdf?sequence=1

 Winkenwerder W Jr. Department of Defense. DoD Health Information Privacy Regulation. DoD 6025.18-R. January 24, 2003. 

http://www.dtic.mil/whs/directives/corres/pdf/602518r.pdf

 Department of the Army. Army Regulation 40-66. Medical Record Administration and Healthcare Documentation. January 4, 2014. 

http://www.apd.army.mil/pdffiles/r40_66.pdf

The privacy and security of our offices-the therapeutic bunkers within which our wounded patient-warriors hunker down against an unseen enemy-is the fundamental first barricade between private sufferings and the potential for public humiliation.

Compromised Confidentiality in the Military Is Harmful

 column on mental health issues and psychiatric practice as they relate to military personnel and veterans. As a psychiatrist, health policy and services researcher, and war veteran who spent 31 years in the Army and 18 years in academic medicine, I look forward to discussing a variety of related issues and perspectives of importance to psychiatry, the military, and both veterans and their families. Frequently we will welcome guest authors who will explore a variety of ideas and issues.

Psychiatrists might ask, “Why should I care?” The question is a reasonable one and the place where we will start. Each one of you is a scarce resource within our larger society. If your bandwidth is like mine, it fills fast and has limits on what it can digest and act on. So allow me to suggest a few reasons-by no means an exhaustive list-why what’s happening in the mental health world of the military and veterans is of great interest to you.

1. The local impact of the past 13 years of armed conflict is greater than many think and much greater than simply the number of veterans in your practice or your community.

When speaking before groups, I often start with a question: “How many Americans would you estimate have deployed to Iraq and Afghanistan since September 11, 2001?” Mostly I get a few bashful guesses. Seldom does more than one person offer an estimate much higher than 500,000.

There are gasps when these audiences hear that well over 2.5 million Americans have deployed about 3.5 million times. This number, as large as it is, hints at another challenging fact: only about two-thirds of a percent of all Americans have deployed to these conflicts. For most American families, their only direct exposure to the military is in an airport.

A closer look shows that the deployment figures are large but the impacts of these wars are larger still. Consider this: in 2008, Nobel Laureate economist Joseph Stiglitz and colleague Linda Bilmes estimated the cost of the Iraq War alone at between $2 trillion and $5 trillion.

 (This broad range is based on how the economic effects of some factors are valued, but is striking even if the most conservative estimate is used.)

Can these figures be credible? As the US entered the Vietnam War in the early 1960s, some Americans were still receiving compensation for Civil War health effects. It is this lengthy economic tail-some resulting from direct benefits and compensation but perhaps mostly the consequence of more insidious long-term health effects on individual productivity-that is the major driver of the costs of war.

2. The contrast between military and civilian culture can challenge our notions of where social values end and hard evidence begins.

Anyone raised in America is likely to view certain ways of thinking as self-evident, even though sometimes a global majority thinks of the same issues in starkly different terms.

The most poignant example that comes to mind is the tension between personal autonomy and collective responsibility. For millennia, nearly all people sought survival in small groups, and a large (though decreasing) portion of the world still does. This lifestyle offers little room for autonomy; everyone’s role is essential and only collective efforts can sustain the group. In this context, the boundaries of individuality are narrow and breaching accepted roles can carry a harsh penalty.

In contrast, in Western civil societies, people are mobile, adults live independently from neighbors and extended family, and social institutions are diverse and subspecialized. Autonomy and expression are fundamental rights. Neighborhood and family engagement is viewed as charitable but discretionary. When failures occur, we look first for institutional failures and tend to see individuals as victims of powerful institutions.

I believe that many misunderstandings across the civil-military divide occur because the military is a throwback to an ancient way of thinking, an outlook that arises when survival depends on sustaining the viability of a small group or unit. In this context, each member of a small group lives and dies together on behalf of one another.

Think of the badly wounded soldier who expresses an intense and seemingly almost delusional desire to return to combat and his or her unit. The obligation is to self-sacrifice for the good of the unit; personal autonomy is nice but only a luxury. In return, if a soldier “falls out,” the group must rein the soldier in (consider the expression, “leave no soldier behind”). There are limits, however; if one repeatedly breaks from the group, the group is endangered and the consequences are reprimand or even rejection. In this reality, when bad things happen, the individual is to blame, so that the group can survive to the next day.

Military veterans are ubiquitous in our practices and in our lives, and often we are unaware of this fact. With any luck, this column will provide you with some basis for reexamining patients’ circumstances, dilemmas, and behavior through the lens of military culture and values. It might increase your “military cultural competence” or provide a lesson for more general clinical use.

3. Emerging military social trends, military-related health problems, and changes to Department of Veterans Affairs and Department of Defense (DOD) health systems often have national implications.

For example, military recognition of the need to better characterize the mental health consequences of World War II led directly to the earliest iteration of our current psychiatric diagnostic system. Later, characterization of the symptoms of returning Vietnam War veterans led to the formalization and adoption of PTSD in DSM-III. The conflicts in Iraq and Afghanistan have served to broaden public awareness and deepen neuropsychiatric appreciation for the physical and mental health challenges associated with repeated concussions.

Important social trends are played out in the military. The military was perhaps the first major American workplace to achieve successful racial integration. Now it is making slow but incremental progress in career opportunities for women and in equal rights for lesbian, gay, bisexual, and transsexual people-progress that results from and has an impact on our broader national scene.

Finally, the federal health systems that serve the military and its veterans are important in ways that go well beyond the latest headlines. Some view these systems as the earliest initiators of the community mental health movement in the late 1950s. Today, the military and VA health systems serve tens of millions of beneficiaries at an annual cost of over $100 billion-and that figure is rising. Enormous recent attention to stigma and barriers to psychiatric care in the military and VA health systems have increased the implementation of effective primary care–based mental health delivery models to increase access to psychiatric services and improve outcomes.

4. As psychiatrists, we must each take personal responsibility for the health systems designed to support military members, veterans, and family members.

It is too easy to blame others for the consequences of military actions or the failures of federal health systems. In spite of how it sometimes may seem, the DOD-Army, Navy, Air Force-and Veterans Affairs are accountable to each one of us. If we don’t own that responsibility, then we are arguably the source of their failures and can expect no rewards when they succeed.

I hope this column can provide a useful place to explore openly the ways that we as a community of concerned psychiatrists can make our voices heard in matters relevant to the military, the VA, general public service, and military members past and present and their families.

: Dr Engel invites readers to send him ideas for future topics at 

This article was originally posted on 8/5/2014 and has since been updated.

The Three Trillion Dollar War: The True Cost of the Iraq Conflict

. New York: WW Norton & Company, Inc; 2008.

Military veterans are ubiquitous in our practices and in our lives. The impact of the past several years of armed conflict is greater than many think-and much greater than simply the number of veterans in your practice or your community.

Charles C. Engel, MD, MPH

Articles

Compromised Confidentiality Is Harmful: Military Owes Proof to the Contrary

Compromised Confidentiality in the Military Is Harmful

Military and Veteran Mental Health: Why Should Psychiatrists Care?