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QUESTIONS SUBMITTED BY SENATOR DANIEL K. INOUYE

NONPHYSICIAN MENTAL HEALTH CARE PROVIDERS

Senator INOUYE. Admiral Zimble, previous surveys have suggested certain morale problems among military nonphysican mental health care providers, such as clinical psychologists, social workers, and psychiatric nurses. Are there openings in these specialties that are unfilled? What actions have been taken or are anticipated by the services to improve their recruitment and retention, provide training funds which will augment proficiency commensurate with their education and training? Do substantial differences exist for doctorate level nonphysician health care providers within the DOD?

Admiral ZIMBLE. There are 18 vacancies in the clinical psychology community which has 106 billets. Sustained efforts since 1986 by the Navy Recruiting Command, including advertising in the American Psychology Association publication, Monitor, increased contacts with university training programs, and mailings to licensed clinical psychologists, have resulted in only one licensed clinical psychologist being accessed into the Navy during the last three years. Advertisement in the same publication, however, has produced an increase in the quantity and quality of intern applicants. As a result, Navy is looking very closely at increasing the number of training slots for clinical psychologists.

Because accession appears to be a problem with clinical psychologists, a study group is evaluating ways to improve Navy accession and to enhance retention of existing providers. Among the factors being considered are professional pay for licensed clinical psychologists, board certified pay for long-range retention and quality of care, and enhanced outservice training in post-doctoral study. Additional enhancements include the recent establishment of a separate department of Psychology and Psychiatry at Naval Hospital Bethesda. This action will allow clinical psychologists to obtain department-head status and, based on nine months of experience, appears to be a successful endeavor.

Concerning training, I have proposed that each Medical Department officer be given the opportunity to attend a graduate medical education seminar each year. For clinical psychologists, the opportunity exists for post-doctoral education. At present there are three post-doctoral fellowship students and three candidates are scheduled for next fiscal year.

Promotion is based on each officers qualifications and is made within the DOPMA guidelines of promotion opportunity and flow points.

There are 18 billets for social workers and all positions are filled. Social workers are more easily recruited because pay is commensurate with or exceeds salaries in the civilian community. At present, we have one social worker attending full-time outservice training.

Our psychiatric nurse community has 54 positions and there are presently 40 psychiatric nurses onboard. Full-time outservice training is available to those qualified who request it and are selected. We have two nurses in full-time outservice training in psychiatric nursing, with another nurse preparing to begin outservice training. We also have nurses working in psychiatric nursing positions to gain the experience needed. Experienced nurses are encouraged to take the certifying examination. Within this nurse specialty, upward mobility is available to head nurse and department head.

There is no inconsistency within the Navy in the scope of practice, educational opportunities, and training of doctorate level psychiatric non-physician health care providers.

Senator INOUYE. General Becker, previous surveys have suggested certain morale problems among military non-physician health care providers such as clinical psychologists, social workers, and psychiatric nurses. Are there openings in these specialties that are unfilled? What actions have been taken or are anticipated by the services to improve their recruitment and retention, to provide training funds which would augment proficiency, increase promotion rates, and assure that their sphere of clinical practice is commensurate with their education and training?

General BECKER. The authorized and assigned strengths for each of these specialties are presented below:

Specialty

Authorized

Assigned

Clinical psychology.
Social work...

108
218

105 242

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These numbers, alone, do not adequately demonetrate the true status of these specialties. In clinical psychology, there is concern that the number of accessions into the Army is declining which could cause a future shortage. The Clinical Psychology Internship Program (CPIP) is the prime means for recruiting this specialty. Each year, spaces for 16 interns are made available. Traditionally, the Army has attracted a sufficient number of applicants to fill this program. However, the number of applicants has declined to the point where there will only be 13 interns starting in fiscal year 1989. The number of applicants may be due to an increase in civilian internship programs in recent years. This is an area of concern and efforts are under way to improve recruitment and retention. The personnel status of social workers is currently in a favorable posture. The Army Medical Department will remain vigilant toward monitoring the status of this specialty over time. While the status of psychiatric nurses appears to be short, the Army Nurse Corps does not experience a shortage in this area because of dual preparation (secondary specialty) and on the job training programs.

There has been increased emphasis placed upon recruiting these specialists. The number of medical recruiters has been increased, advertising in the psychology journals has been initiated, and increased missions for recruiting social workers and clinical psychologists are anticipated to begin in fiscal year 1989. Efforts are underway to improve retention of clinical psychologists by improving their practice patterns. The Army Medical Department Professional Short Course Program provides biennial courses for Clinical Psychologists (Army Clinical Psychology Course). Social Workers (Social Work Practice Course) and Psychiatric Nurses (Psychiatric Mental Health Nursing Course). These courses are funded by the Office of the Surgeon General and afford officers in these specialties the opportunity to augment their proficiency. Additionally, these officers are provided the opportunity to attend a Continuing ealth Education course, seminar, or conference each year subject to the availability of funds. These two programs are designed to maintain the professional competence of each specialty at the highest level. There have been no efforts taken within the Army Medical Department to increase the promotion rates of Clinical Psychologists, Social Workers, or Psychiatric Nurses. The promotion rates for these specialties are consistent with or exceed the rates of other specialties in their competitive categories. For example, the three year average for promotion to Colonel and Lieutenant Colonel in the area of Clinical Psychology is actually above the rate for the balance of the Medical Service Corps, the competitive category to which this specialty belongs. These three year rates are as follows:

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In the Clinical Psychology area their sphere of practice has recently been expanded to include approving physical profiles for 30 day periods, serving on various boards such as competency and sanity boards, and completing the psychological assessment on physical examinations. In the areas of Social Work and Psychiatric Nursing, the current roles defined for these specialties adequately utilize their education and training.

PSYCHIATRIC NURSES

Senator INOUYE. General Chesney, previous surveys have suggested certain morale problems among military nonphysician mental health care providers such as clinical psychologists, social workers, and psychiatric nurses?

General CHESNEY. We have never had a problem recruiting psychiatric nurses. Currently all unit manning document authorizations are filled for psychiatric nurses. It is anticipated that any normal attrition can be replaced through recruiting. As with other specialties, we experience shortages from time to time as a result of an inability to recruit or when there is a downturn in morale. Currently, neither situation exists.

Senator INOUYE. Are there openings in these specialties (Clinical Psychology and Social Work) that are un led?

General CHESNEY. As of April 1988, we were slightly overstaffed in social workers and essentially fully staffed in clinical psychologists. We attribute the significant improvement in clinical psychologist staffing to excellent recruiting efforts to obtain fully-qualified individuals from the civil sector; this success coupled with our having increased our clinical psychology internship program from 18 to 23 spaces (FY88) should keep our authorizations filled with quality professionals for the foreseeable future. We have also been able to maintain and provide some nontraditional opportunities for both social workers and clinical psychologists that directly benefit the Air Force (i.e., Family Support Center Directors, staff officer in the Office of Family Support, instructors in Psychological Operations Course, Human Factors positions, OSI, etc.)

BATTLE FATIGUE CASUALTIES (MENTAL HEALTH CARE)

Senator INOUYE. Dr. Mayer, manpower in war has been diminished due to battle fatigue casualties. Future wars will likely be characterized by particularly high rates of lethality and this phenomenon may be expected to further exacerbate the problem. Protracted low intensity combat will also probably result in large numbers of personnel being lost to the Commander due to battle fatigue. Are existing authorizations for mental health providers adequate to cope with battle fatigue? Since it appears that the military maintains insufficient in-house psychiatric resources to handle even the peacetime requirements for emotional problems of CHAMPUS and active duty beneficiaries, how can it handle the additional workload generated by war?

Dr. MAYER. Based on our experience in Viet Nam, we anticipate that very few personnel will be lost due to battle fatigue in a low intensity conflict. Therefore, I would anticipate that the scope of low intensity combat operations, even protracted ones, would not overtax our mental health capabilities. In the event of a full scale war, medical treatment facilities within the Continental United States (CONUS) would greatly limit or totally eliminate health care provided to dependents and retirees depending on the prevailing circumstances. That care is now authorized on a “space available” basis only, and would further be curtailed by the limited number of mental health specialists available in CONUS. As with all other health care disciplines, the services would rely on the Reserve components to augment the active duty peacetime force to help meet the mental health demands of military personnel in wartime.

MENTAL HEALTH CONSULTATION TEAMS Senator INOUYE. Have the military departments established highly mobile, immediately available mental health consultation teams to respond to large scale disasters involving military members or their families? (Recent examples might be the Grandor air crash and the attack on the U.S.S. Stark.)

Dr. MAYER. Yes. Rapidly deployable mental health crisis response teams are inplace in overseas theaters of operations and the Continental United States. These teams provide psychological and mental health services to active duty members and dependents during both large and small scale disasters. The recent tragedy aboard the U.S.S. Stark was supported through the joint deployment of mental health professionals to the scene where psychological support and intervention was provided to crews of fleet units. Additionally, a Special Psychiatric Rapid Intervention Team was deployed to U.S.S. Stark's homeport, Mayport, Florida, to augment and support local resources with 24-hour availability of mental health services. Among the many support services provided, these teams provided individual, small and large group therapy and informational sessions; provided recommendations to commanding officers on how to deal with developing morale problems; and, established support systems for crew members requiring follow-up care.

(Whereupon, at 4:15 p.m., the subcommittee was adjourned.]

INDEX

А

65

Page
Active component accessions

36, 130
Active duty dependent's monthly premium rates

599
Active force ....

210
Strength levels.
Active/Reserve mix

16, 85, 489
AIDS diagnosis .....

591
Air Force Reserve

462
Air Force ROTC

76
Air National Guard.

396
Aircraft system, T-45 trainer

199
Airline hiring trends ....

164
All-Volunteer Force

21, 264
Antidrug program, DOD.

24
Appropriations...

419
Appropriated fund (APF) support to morale, welfare, and recreation (MWR) 247
Army National Guard accessions

37
Army Reserve

457
Retention in the.......

491
Attrition rates, improving.

198
Aviation career incentive pay (ACIP].

271, 488
Aviation officer continuation pay (AOCP]

165
Aviation pilot training shortfall

199

B

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