1. POLICY BRIEF | MARCH 2011
ENSURING BEHAVIORAL one-third of all servicemembers will
experience significant problems with
HEALTHCARE CAPACITY combat stress, substance abuse,
AND QUALITY depression and/or suicide (DoD Task
FOR SERVICEMEMBERS, Force on Mental Health, 2007; Tanielian
VETERANS AND MILITARY et al., 2008). Beyond the impact on
those individuals, there are effects on
FAMILIES
the family members who send their
loved ones off to war – and to whom the
JAN A. NISSLY AND KELLY L. TURNER servicemembers return home. Many
such family members experience
significant socio-emotional challenges,
A great deal of attention has been paid even so-called “secondary PTSD”, and
in the past few years to the impact of also require professional assistance
war on behavioral health. Statistics now (Chandra et al., 2010; Figley, 1998; Hall,
abound regarding the numbers of 2008). Further, certain aspects of
servicemembers who have deployed to OEF/OIF, beyond the sheer number of
OEF/OIF, the common visible and those who have served, magnify the
invisible wounds, and the high need impact and exacerbate the stresses of
(whether acknowledged by those in war. These conditions include the
need or not) for behavioral health extensive use of Reserve Component
services. There appears to be forces, repeated deployments of enlisted
widespread agreement that the capacity men and women, the absence of a
of our nation’s behavioral health combat “front,” constant exposure to
workforce must increase, and rapidly. threat, rapid return with little time for
Exactly how to go about increasing this mental or emotional calibration, and
capacity – in terms of both quantity and lack of readiness in the civilian culture
quality – is not as clear. This military to understand and absorb veterans
behavioral health policy brief addresses (Burnam et al., 2009; Castaneda et al.,
the development of a high-capacity 2008; DoD Task Force on Mental Health,
behavioral health workforce to care for 2007; Erbes, 2009; Flynn & Hassan,
our nation’s servicemembers, veterans, 2010). For example, reservists deployed
and military families. to Iraq or Afghanistan were later found
to be twice as likely as active duty
personnel to meet screening criteria for
IMPACT OF WAR ON PTSD and depression, suggesting a
BEHAVIORAL HEALTH marked need for mental health services
among this subgroup (Castaneda et al.,
Our nation has been at war for over a
2008; Schell & Marshall, 2008). This is
decade, with more than 2.6 million
not surprising, given the structure of
American servicemembers having been
their service itself: Reserve Component
deployed to Afghanistan or Iraq.
members return from deployment to
Frequently cited statistics estimate that
cir.usc.edu

2. civilian jobs and communities, where there focused on older-generation and more
are often few supports – formal or informal – severely disabled veterans (Schell &
who understand their deployment experience Tanielian, 2011).
and the major adjustment involved in
returning to civilian life. Regardless of the reason, civilian providers
are increasingly called to meet the behavioral
healthcare needs of our nation’s
servicemembers, veterans and military
STRAINED TRADITIONAL families. Civilian education and training
SERVICE SYSTEMS AND THE programs have historically not been oriented
CIVILIAN RESPONSE toward content crucial for work with military
populations, and civilian providers often have
Historically, living arrangements, schools,
minimal understanding of “military culture”
medical services, and other institutions
(Hall, 2008; Tanielian et al., 2008). Without
serving the military and veterans have been
such background, civilians have difficulty in
separated and often isolated from civilian
relating to the experience of veterans, and
programs and services. While these insular
according to anecdotal evidence, are often
systems of care may have been sufficient in
less effective – at least at engaging new
previous generations, they are overloaded
clients - than are uniformed providers. Many
and no longer capable of independently
community mental health providers also fall
meeting the needs of our wounded warriors
short of recommended standards for
and their families (Stahl, 2009). For example,
treatment and care (Burnam et al., 2009;
a military installation in Hawaii was reported
Castaneda et al., 2008; DoD Task Force on
to have had one mental health officer for
Mental Health, 2007; Erbes, 2009). Civilian
every 265 cases, whereas the official military
behavioral healthcare providers may not
standard is 1:50 (Pittsburgh Tribune Review,
realize the harm they are doing, or could do –
2011). Similar examples are evident within
not only by perpetuating beliefs about the
the Department of Veterans Affairs, where
inability of civilian providers to understand,
recent research has borne out longstanding
or to help - but to the individual, family,
anecdotal scenarios of long delays in getting
community, and society by having someone
initial appointments, extended periods
continue to suffer from the invisible wounds
between appointments, and lengthy waiting
of war long after the deployment has ended.
room delays (National Council for Behavioral
Healthcare, 2010; Schell &Tanielian, 2011).
Clearly, not all servicemembers and veterans
seeking care through the DoD or VA are CURRENT RESPONSES TO
currently able to find it, at least in a timely INCREASING CAPACITY
manner. Further, some veterans choose not
to seek care through the VA, sometimes the Huge demand, strained service systems, and
result of logistical barriers, such as the lack of providers relatively unfamiliar with the
proximity to a healthcare facility or extended specific needs of those they seek to serve
hours to accommodate a full-time work point unequivocally to the need for expanded
schedule, and other times due to perceptions behavioral healthcare capacity. The
of VA culture – that the VA is primarily Department of Defense Task Force on Mental
POLICY BRIEF | MARCH 2011 | CIR.USC.EDU 2

3. Health (2007) and RAND (Tanielian et al., RECOMMENDATIONS
2008) provided clear and compelling
arguments and recommendations for an In light of previous literature that makes a
expansion of our nation’s behavioral clear case for expanding our nation’s military-
healthcare workforce. Efforts appear to be trained behavioral healthcare workforce, and
mobilizing, both across the U.S. and across the evidence of a mounting response, we
disciplines: at least four schools of social suggest the following ways to maximize
work and psychology offer degree-based progress in this area:
programs specializing in military behavioral  Behavioral healthcare provider training
health (please see reference list) ; other must include attention to the military as a
degree-granting institutions offer focused culture, and integrate the latest
electives; academic scholarship funding is empirically-supported methods of
available for students planning to pursue intervention.
practice careers with military-related
 Providers of military behavioral health
populations; and several academic
training would serve their students and
institutions, governmental agencies and
their profession well by evaluating the
human services organizations offer
impact of their training. Key outcomes for
continuing education courses for behavioral
inclusion might include context-specific
healthcare professionals on a variety of topics
knowledge, trainee perceptions of
relevant to providing behavioral healthcare
influences on practice, and trainee
to servicemembers, veterans and military
characteristics, such as clinical self
families. Moving a step beyond training,
efficacy, in the context of working with a
leaders in military social work have
military population.
developed a set of guidelines for advanced
practice in military social work (CSWE, 2010),  Accrediting bodies might assess
and a similar document is being developed to educational institutions offering degree
guide behavioral healthcare practice with programs in relation to newly-established
families impacted by military service (A. military behavioral healthcare guidelines
Hassan, personal communication, January 5, such as the Council on Social Work
2011). Education’s Advanced Practice Behaviors
for Military Social Work Practice (CSWE,
What we do not know at this point is how 2010) or the forthcoming set of guidelines
effective are the various programs at for practice with families impacted by
increasing provider capacity, both in volume military service (A. Hassan, personal
and in culturally-relevant, empirically- communication, January 5, 2011).
supported military behavioral health training. Additional guidelines, pertaining to
While recent activity in academia and in the specific areas of military behavioral
service delivery sector suggests that the call healthcare practice, might need to be
for increased capacity has been heard, further developed.
attention needs to be directed towards
 Governmental entities at the national and
understanding the impact, as well as the
state levels could ensure that relevant
quality, of the response.
POLICY BRIEF | MARCH 2011 | CIR.USC.EDU 3

4. training is accessible to current  Federal entities might also consider
behavioral healthcare professionals by working with state licensing boards to
working with the key professional mandate military culture continuing
associations, such as the American education courses for all behavioral
Psychological Association (APA), the healthcare providers. Such efforts are not
National Association of Social Workers uncommon when the relevant issues and
(NASW) and the Association for the populations are important and far-
Advancement of Marriage & Family reaching; for example, the state of CA
Therapy (AAMFT), as well as with large mandates that all Licensed Clinical Social
provider groups (e.g., Give an Hour, Workers have one time and/or recurrent
Soldiers Project). Provision of funding continuing education in domestic
support for workforce training, violence, law & ethics, and aging.
particularly among volunteer providers,
could serve to enhance training
availability and accessibility.
AUTHOR BACKGROUND SUGGESTED CITATION
Jan A. Nissly, PhD is a Research Assistant Nissly, J.A., & Turner, K.L. (2010). Ensuring
Professor at the USC Center for Innovation Behavioral Healthcare Capacity and Quality
and Research on Veterans and Military for Servicemembers, Veterans and Military
Families (CIR). A former military social work Families. Los Angeles: USC Center for
clinician, her current research examines the Innovation and Research on Veterans and
effectiveness of a specialized curriculum for Military Families (CIR).
training military behavioral health providers.
REFERENCES
Kelly L. Turner, PhD is a Senior Research
Associate at the USC Center for Innovation Adler School of Professional Psychology,
and Research on Veterans and Military Doctor of Psychology in Clinical
Families. Psychology, Military Psychology Track:
http://www.adler.edu/page/programs/c
The views expressed in this brief are those of hicago/doctor-of-psychology-in-clinical-
the author and do not necessarily represent psychology-military-psychology-
the views of the USC Center for Innovation track/overview
and Research on Veterans and Military Burnam, A., Meredith, L.S., Tanielian, T., &
Families (CIR) or collaborating agencies and Jaycox, L.H. (2009). Mental health care for
funders. Iraq and Afghanistan war veterans. Health
Affairs, 28(3), 771-782.
FOR MORE INFORMATION
Castaneda, L.W., Harrell, M. C., Varda, D. M.,
Phone: (213) 743-2050 Hall, K. C., Beckett, M. K., & Stern, S.
Fax: (213) 743-2051 (2008). Deployment experiences of guard
Email: cir@usc.edu and reserve families. Santa Monica, CA;
Website: http://cir.usc.edu RAND Corporation.
POLICY BRIEF | MARCH 2011 | CIR.USC.EDU 34

5. Chandra, A., Lara-Cinisomo, S., Jaycox, L. H., Veterans mental health act still not
Tanielian, T., & burns, R. M. (2010). implemented.
Children on the homefront: The
Pittsburgh Tribune Review (2011, February
experience of children from military
6). Program for departing service members
families. Pediatrics, 125(1), 13- 22.
plagued by inconsistencies, indifference.
Council on Social Work Education. (2010).
Schell, T. L., & Marshall, G. N. (2008). Survey
Advance Practice Behaviors for Military
of individuals previously deployed for
Social Work Practice. Alexandria, VA:
OEF/OIF. In Tanielian, T. & Jaycox, L.H.,
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