Cohesion Assessment Team: A Multidisciplinary Unit Assessment Grounded in Army Doctrine.

INTRODUCTION: The Cohesion Assessment Team (CAT) provides battalion and brigade command teams with actionable insight into the climate of their unit and the presence of certain harmful behaviors. This assessment, initiated by the Vice Chief of Staff of the Army and initially managed by the Headquarters Department of the Army's People First Task Force, employs a framework from the Center for Army Professional Leadership to structure data and findings. MATERIALS AND METHODS: This manuscript describes how to conduct a CAT assessment. To start, two battalions within the same brigade are selected or volunteer for observation based on various metrics. Data are collected from multiple sources including (1) army metrics, such as promotion rates and Uniformed Code of Military Justice actions, (2) subject matter expert in-person observations and interactions, (3) discussions with battalion and brigade staff, (4) survey data from approximately 90% of the soldiers in participating units, and (5) targeted interviews, focus groups, and listening sessions. Onsite data are collected and synthesized with the survey results within a week. Results are presented to battalion and brigade command teams. Briefs highlight key elements of the unit climate that should be maintained or improved. In addition, summarized results are presented to progressively higher echelons of leadership, culminating with the Vice Chief of Staff of the Army for consideration of army-wide changes. RESULTS AND CONCLUSIONS: The CAT focuses on providing leaders at brigade and below with relevant and actionable information to help inform their internal decision-making to improve their unit's climate. This capability is distinct in many ways, including its non-attributional systems focus and its methodical approach to quickly collecting and triangulating multiple data points. Additionally, the CAT helps leaders identify areas under their control that will impact unit climate, similar to the feedback that training events provide on unit readiness. Army leadership deemed the CAT pilot a success, and responsibility for future CATs was transferred to the Training and Doctrine Command (TRADOC) in October 2022.

Far Forward Behavioral Health Service Delivery in Future Combat Environments: A Qualitative Needs Assessment.

INTRODUCTION: It is expected that future multi-domain operational (MDO) combat environments will be characterized by limited capabilities for immediate combat stress control support services for soldiers or immediate evacuation from theater. The operational requirements of the future battlefield make it unlikely that current models for behavioral health (BH) treatment could be implemented without significant adjustments. We conducted a qualitative study with Special Forces medics and operators and soldiers who had deployed to austere conditions in small groups in an effort to inform construction of a BH service delivery model for an MDO environment. The objectives of this study were (1) characterizing stressors and BH issues that were encountered and (2) describing mitigation strategies and resources that were useful or needed in these types of deployments. MATERIALS AND METHODS: Six focus groups were conducted at three army installations with 23 active duty soldiers, including three groups of medics using a semi-structured interview guide focused on stressors they encountered during deployments to austere conditions, and the impact of those stressors on mission and focus. Focus group recordings were transcribed, imported into NVivo software (version 12), and independently coded by two researchers. An analysis was then conducted to develop themes across participants. The study was reviewed by the Walter Reed Army Institute of Research Human Subjects Protection Board. RESULTS: Behavioral health concerns were commonly cited as a stressor in far forward environments. Other common stressors included ineffective or inexperienced leaders, as well as poor team dynamics (e.g., communication and cohesion). Four primary strategies were mentioned as mitigations for deployment stressors: leadership, morale, resilience training, and strength of the team. When asked about resources or training that would have helped with these types of deployments, participants frequently mentioned the availability of BH providers and development of new and realistic BH skills trainings for non-providers and leaders. CONCLUSIONS: Current models for treating BH problems need to be adapted for the future MDO environments in which soldiers will be expected to deploy. Understanding what issues need to be addressed in these environments and how they can best be delivered is an important first step. This study is the first to use qualitative results from those who have already deployed to such environments to describe the stressors and BH issues that were most commonly encountered, the mitigation strategies used, and the resources that were useful or needed.

Return to Duty Practices of Army Behavioral Health Providers in Garrison.

Introduction: While combat readiness is a top priority for the U.S. Army, there is concern that behavioral health (BH) return to duty (RTD) practices may under-represent the number of soldiers available for deployment. Profiling, the official administrative process by which medical duty limitations are communicated to commanders, was recently found to be significantly under-reporting BH readiness levels in one Army Division. This is a safety issue in addition to a readiness problem, and underscores the importance of better understanding RTD practices in order to offer solutions. This study sought to categorize the information and tools used by Army BH providers in garrison to make decisions about duty limitations that can affect BH readiness. Materials and Methods: A qualitative approach was used for this study. Fourteen semi-structured interviews and three focus groups were conducted with a diverse convenience sample of Army BH providers in October 2015, resulting in input from 29 practitioners. Results: Through thematic analysis, it was discovered that profile decisions are driven first by safety of the soldier and secondarily by the needs of the unit. To facilitate their clinical decision-making, providers consider an array of data including standardized scales, unit mission, consultation with unit leadership, meetings with other providers, and, when appropriate, discussion with the friends and family of the soldier. Conclusions: If the military is to address the concern of under-reporting behavioral health readiness levels in garrison, it is critical to develop more predictability in treatment planning and reporting, as well as access to necessary data to make these clinical decisions. The interviews and focus groups revealed that while the technical process for initiating a profile does not vary, there is great disparity about the amount and type of information that is taken into consideration when making profile decisions. Categorization of the information that supports RTD decisions can lead to a better understanding of the process and inform leadership about ways to improve the accuracy of BH readiness reporting.

Minor Behavioral Health Readiness and Profiling Barriers in the U.S. Army.

INTRODUCTION: Medical readiness for deployment is arguably the most important component of personnel readiness in the U.S. Army. Administrative documents called profiles provide individualized medical recommendations to the commander regarding how to best provide for a soldier's health and welfare, and contribute to an aggregated enumeration of a unit's overall readiness to deploy. Profiles that convey behavioral health (BH) limitations thus reflect what can be called the "behavioral health readiness" of the force. In the Army, BH profiles are further broken into major (more severe BH conditions) and minor (less severe) categories. Recent reporting indicates that current profiling (both major and minor) substantially underestimates BH readiness, presenting a significant safety and personnel issue for the Army. Currently, little is understood regarding barriers to profiling. The intent of this paper is to establish a basis for understanding these barriers by examining provider perceptions on the issue. While the results may have broad applicability in determining BH profiling barriers in general, minor BH improvement efforts stand to benefit the most due to more reliance on provider judgment and less on mandatory guidelines. MATERIALS AND METHODS: Selected themes and provider quotes regarding barriers to BH profiling from a qualitative study, "Return to Duty Practices of Behavioral Healthcare Providers in Garrison," are presented. Fourteen semi-structured interviews and three focus groups were conducted with a diverse convenience sample of Army BH providers in October 2015, resulting in input from 29 practitioners. RESULTS: Four general profiling barrier categories were identified and include provider proficiency level, environmental factors, stigma concern, and clinical time constraints. CONCLUSIONS: Suboptimal BH profiling rates suggest that a preponderance of factors currently tip the scale of BH profiling in a lopsided fashion that comes at the cost of soldier safety and increased risk of mission failure. Relief from one or more of the identified profiling barriers would likely be necessary to tip the scale of clinical judgment in favor of increased profiling, and may be more beneficial for improving minor BH profiling deficits in particular. Quantitative exploration of provider and soldier attitudes on this subject is worthy of further pursuit and would shed light on which of the identified barriers are most crucial to reducing BH profile deficits.