Stories - Blogs

By Debra Nofziger, Psy.D.

Culturally, we use the word “tired” to describe so much – being mentally and/or emotionally drained, overly frustrated, sleep deprived, physically spent, and lots of stuff in between. These states are not caused or cured by the same thing. But they can basically be divided into two categories – tiredness/sleepiness and fatigue. This difference isn’t something I had ever considered before being diagnosed with Multiple Sclerosis. But, given one of my most prevalent symptoms of MS is fatigue, I soon realized just how much people don’t understand the difference.

What is the difference? Google’s AI overview actually does a good job describing this: “Tiredness makes you feel sleepy; fatigue makes you feel worn out but not necessarily sleepy.” Tiredness/sleepiness is a temporary state fixed by sleep. Fatigue is a more long-lasting feeling of being drained that persists despite adequate sleep/rest. I explain fatigue as that feeling you get after a cross-country airplane trip, or better yet, transatlantic. You get to your final destination and collapse on the hotel bed, absolutely drained. But you aren’t tired, so you aren’t going to sleep. You simply have absolutely no energy left. Regardless of how much the kids want to go to the Disneyland park immediately upon arrival, they are out of luck!

To make matters more interesting in my particular case, insomnia is also widely prevalent with MS. A recent meta-analysis looking at sleep disorders and MS showed that 1 in 2 adults with MS endorsed poor sleep quality and 1 in 5 were diagnosed with insomnia. Many other neurological disorders, from MS to long covid, have higher rates of insomnia along with fatigue. I am one of the unlucky ones who now has both – random bouts of insomnia and chronic, debilitating fatigue. How do I stay functional through the fatigue? A steady dose of stimulants – something that can rapidly mess with my sleep and trigger insomnia. It is an interesting balance that I manage. And a common conundrum faced by many who have both.

As a clinical psychologist, and one of the CDP instructors who teaches CBT for Insomnia, I find it interesting how little we talk about what to do for patients who experience fatigue but not insomnia, or for patients who have both. Many of our patients have underlying medical conditions, from MS to long Covid, and their fatigue and/or tiredness is enmeshed with their other behavioral health symptoms, like depression and anxiety.

I think a starting place for all of us is making sure our assessment is correct in that we are assessing for both tiredness/sleepiness and fatigue and recognizing that these can be caused by different things. The usual tools can be confusing for this. For example, the Insomnia Severity Index (ISI) is widely used to screen for sleep problems and it does a good job for this in general. But it depends on the patient understanding the difference between sleepiness and fatigue, and I’ve found many do not. If I feel drained of energy all day, I might assume that is because my sleep is not good. That would lead me to answer questions on the ISI, or other measures, expressing my dissatisfaction with my sleep and how much that is impairing my life. This, in turn, could lead to a treatment plan including treatment for insomnia, which isn’t going to help general fatigue at all if it is linked to a medical condition.

It becomes even more convoluted when a patient experiences both insomnia and fatigue. Although they aren’t the same thing, the feelings they produce in the body are incredibly similar, if not the same in some cases. So how do we identify which symptom descriptions are linked more to which problem? For example, if I am physically fatigued I feel similar to when I haven’t slept much – weaker and slower in general. If my insomnia is treated and I sleep well, I am still not going to feel rested upon awakening due to my underlying chronic fatigue, so how do I know if I’m “doing better” with better sleep? I’ve noticed that interview forms often mix fatigue and tiredness questions together which is not helpful. True, fatigue can be a symptom of tiredness, but it can also be something completely separate.

The initial challenge for providers is to educate patients on the difference between tiredness and fatigue while they are in the assessment stage and ensure our assessment tools help us distinguish between the two. We must also ask about any medical conditions that may lead to either or both. It is a challenge. Even as a provider with both fatigue and periodic insomnia, I sometimes find it hard to distinguish with patients. But I think the key is to remember this basic truth – if you are tired/sleepy, you can actually lie down and go to sleep. Your sleep drive is high. If you are only fatigued, you won’t sleep because it isn’t linked to your sleep drive.

Treatment planning for tiredness, fatigue, or both is beyond the space I have for this particular blog. But basically, we know that the plan for tiredness will depend on the specific sleep disorder identified (happily, we have good treatments for many of these). The same is true for fatigue – the treatment is going to depend on the underlying medical condition. That is where it gets tricky because there are so many different conditions involved. Medication is a common answer. Behavioral treatments aimed at maximizing and strategically using available energy are also generally used. Unfortunately, behavioral treatments for fatigue are not widely taught or even known about by general providers. They are more utilized within health specialty clinics.

Our starting point is assessment. You have no idea how much rapport and credibility a provider instantly gets from me when, on their own, they acknowledge that tiredness and fatigue are two different things. I instantly think “yes, they get it!” More often than not, however, I am educating my providers on the difference. So please, be sure you are acknowledging the difference. If your patients don’t seem to understand, educate them. That way both of you can explore how to best approach treatment and how to have realistic expectations on treatment outcomes.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Debra Nofziger, Psy.D., is a Senior Military Behavioral Health Psychologist and certified Cognitive Processing Therapy Trainer with the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.

CITATION:
Zeng, X., Dorstyn, D. S., Edwards, G., & Kneebone, I. (2023). The prevalence of insomnia in multiple sclerosis: A meta-analysis. Sleep Medicine Reviews, 72, Article 101842.
https://doi.org/10.1016/j.smrv.2023.101842

By Diana Dolan, Ph.D., CBSM, DBSM

Recently a case was shared with me in consultation that perked my ears up. He had a number of disruptions related to his sleep, including difficulty staying asleep, nightmares, a diagnosis of obstructive sleep apnea (OSA), and a history of two traumatic incidents. Worse, he had started grinding his teeth to the point of wearing through over the counter mouthguards. He was described as an “extreme case” that had failed prior evidence-based treatment and would not likely benefit from say Cognitive Behavioral Therapy for Insomnia (CBT-I).

SGT B is a married early-40s Army SGT who was screened by a behavioral health provider in primary care after a recent visit with his primary care provider. He reports sleep problems for at least several years, and is currently attempting to use continuous positive airway pressure (CPAP) after a polysomnography or sleep study confirmed a diagnosis of OSA a year ago. He falls asleep for a few hours fairly quickly, then wakes up usually between 0200 to 0300 if not sooner, increasingly, but not solely due to nightmares which also started a year ago and seem to be worsening. As he awakens, he is aware of pulling off his CPAP mask. Some nights he will lay in bed for a bit before he musters the motivation to resume, what he describes as “fighting the fight” with his sleep, putting his mask back on until he eventually returns to sleep, which sometimes doesn’t take long, but other nights is an hour or more. Other nights, he does not put the mask back on at all. Recently, he has started grinding his teeth at night, to the point that his teeth are cracked despite wearing a mouthguard. He notes he’s “tried that behavioral stuff” in the past, and is frustrated that it was not very helpful, so does not feel very interested in CBT-I. Oh, and as the appointment was about to wrap up, he admits that earlier in his career, he witnessed some events that friends have told him could be traumatic, but he was reluctant to share.

SGT B’s provider is recently trained in CBT-I, and is concerned his case is so complex and unusual he will not benefit from the protocol. Besides, even if he otherwise would, he says he has already tried behavioral treatment. His provider wants to know, isn’t this case a lost cause?

Interestingly, while SGT B himself probably feels like a lost cause, hopeless and helpless, his situation is not that atypical from what we often see with military-connected patients who have co-morbid OSA, insomnia, and trauma. Let’s unpack everything, starting with OSA as that has been previously diagnosed. He dislikes the CPAP, but denies purposefully removing it as he is half-asleep. It’s not surprising that since he’s not able to use his CPAP regularly, he would still have the associated symptoms, like excessive daytime sleepiness, attention and memory difficulties, and reduced productivity at work. There seems to be a relationship between untreated OSA and nightmares, so his report of increasing nightmares over time, despite what he believes is sufficient CPAP use isn’t too surprising. There also may be a relationship between untreated OSA and bruxism, or detrimental teeth grinding. Mostly, the challenge for SGT B is going to be using his CPAP for more time during the night – which admittedly, is a challenge, if he does not fully realize he isn't doing it.

Next, SGT B clearly has evidence of impaired sleep ability, as even on nights without using his CPAP, he has difficulty, and he will wake during the night at times even without nightmares. Although he says he has tried behavioral treatment, it turns out, he completed a sleep log for a few weeks, but did not get out of bed, as recommended by his previous therapist more than a few nights, and did not stick with a sleep schedule. It is likely his sleep inability, or insomnia, is contributing to taking his mask off as he becomes more aware of it on awakening, as well as contributing to his nightmares as we may remember nightmares more so if we awaken from them.

It also seems SGT B has a strong potential for screening positive for PTSD. Of course, sleep disruption can exacerbate symptoms of PTSD, and PTSD would, in turn, contribute to further sleep disruption and nightmares.

Take a moment to pause here before reading on. What do you think now that you know more details – is SGT B’s case treatable with behavioral interventions? What would you recommend as next steps?

Read on from here if you would like my take. In short, I don’t think SGT B is really an extreme case, even though it probably feels that way to him. He is not alone in the presence of these comorbidities. If he feels up to it, I might recommend a trial of CBT-I with motivational enhancement strategies, clearly assisting him in differentiating this from his prior attempt. I would anticipate if he can sleep more solidly, he will have fewer awakenings and thus fewer instances of pulling off his mask and nightmares. At the same time, I would encourage him to speak with his sleep medicine physician to perhaps find a more comfortable mask and setting option. After CBT-I and optimizing his CPAP comfort, his bruxism may also improve. Once his sleep is improved, he may feel he has the energy and mental resources to explore his trauma history and complete treatment for PTSD, if diagnosed. On the other hand, if he does not feel up to starting with CBT-I, he might be open to starting with a discussion of trauma; evidence-based PTSD treatment would be expected to decrease nightmare frequency, which would reduce associated awakenings and again decrease pulling off his mask. If insomnia is still clearly present, which will likely be the case, as it is one of the most common post-PTSD treatment residual symptoms, he could revisit CBT-I as an option then. Or, he could even start with addressing either the insomnia or potential PTSD and while he is working with sleep medicine, he could set up a mask desensitization protocol with his therapist and decide whether to address insomnia or potential PTSD directly down the road.

It would be easy in a case like this to worry there is too much going on for a behavioral health provider to play a role. However, in looking at the options above, behavioral interventions play a key role in all of them! SGT B’s provider felt more confident with potential options and reassurance that he would likely improve to some extent, and ultimately he chose to tackle CBT-I first. As providers, and especially if we are feeling uncertain or even overwhelmed, it can be very helpful to take a step back and think through our case conceptualization with a colleague or consultant. At CDP, we have consultation tools and resources for you. Feel free to reach out to us!

For more information about consultation options, vist the "Consultation Services" section here.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Diana Dolan, Ph.D., CBSM, DBSM, is a clinical psychologist serving as an Assistant Director of Training & Education with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland..

By Adria Williams, Ph.D.

Quick question for my military couples: “How did you make it through the pandemic?” Answers range from “It brought us closer” to “We didn’t.” For me and my husband, the answer was couples counseling.

As a therapist, I wish I could say that I share this response with pride. I do say it openly—to model healthy behavior for clients, friends, family, and the public—but inside, I’ve felt a twinge of discomfort. Call it fear (of judgment), doubt (about whether it’ll work for us), or embarrassment (about exposing marital imperfections). Whatever the label, these emotions are worth examining because if I, as a mental health professional, feel them, imagine how someone with little to no exposure to therapy must feel. Those feelings create tremendous barriers to seeking help.

Yet, when I schedule a doctor’s appointment for myself or my husband, I don’t feel fear, shame, or embarrassment. In fact, I might even feel responsible, proactive—maybe even a little proud. And when it comes to preventative care!? Woo wee!! I’m nailing this adulting thing! I just know these actions are improving my health and quality of life.

So What’s the Difference?
 The gap between seeking medical care and seeking couples’ therapy stems from two key factors: lack of information and stigma. Social norms tell us that needing therapy signals weakness or failure. Add in the common misconception that “it won’t make a difference,” and many people are discouraged from seeking help. But the research tells a different story. Long-term partnership with high relationship satisfaction is good for your health (Rhoades & Stanley, 2014)!

The Solution: A Logical Application of the Transitive Property
 Bear with me, it’s about to get a little “mathy”. The transitive property states that if “B” leads to “C” and “A” leads to “B” then “A” leads to “C” and vice versa. I am going to apply this logic as a way to overcome the barriers above.

B Leads to C
 Marital/relationship satisfaction is linked to far-reaching positive health and quality of life outcomes, such as overall better health, lower rates of disease, and lower mortality rates (Robles et. al., 2014). It is also linked to improved mental health (Downward et al., 2022) and financial communication (Saxey, et. al., 2023). Conversely, marital/relationship distress is consistently linked to mood disorders, anxiety disorders, substance use disorders, and increased physical health problems (Lebow, 2019). According to the DoD’s Annual Report on Suicide in the Military, the top psychosocial stressor associated with both suicide deaths and attempts is intimate relationship problems (Department of Defense, 2024). Additionally, the adverse impact it has on children is so noteworthy that it is now its own condition according to the DSM-5 (Bernet et.al., 2016). Thus, high relationship satisfaction (B) leads to improved physical and mental health (C).

Marital Health by the Numbers
 Since we’ve established that healthy relationships lead to better health and longevity and that relationship distress leads to increased health problems and poorer outcomes, let’s take a look at marital health. In the general population, divorce rates remain between 40-50% for first marriages (U.S. Census Bureau, 2001). According to the CDC (2002), the median length of marriages that end in divorce is 7-8 years—meaning couples endure years of marital dissatisfaction and distress before ending the relationship. That is a long time to be miserable.

On top of the stressors that lead to these outcomes for civilian couples, military couples face unique stressors. Deployments, PCS moves, unpredictable schedules, limited family and social support, and high-pressure work environments put additional strain on marriages.

On average, service members marry younger and at higher rates than civilians. More than 50% of married service members do so before age 25. One of the strongest predictors of divorce is age at first marriage, which likely contributes to divorce rates in the military being higher than in the general population (Hogan & Seifert, 2010).

A Leads to B
 The good news? Couples counseling works!

Research shows that 60-80% of distressed couples benefit from behavioral and emotion-focused therapies (Bradbury & Bodenmann, 2020). The average person receiving couples therapy fares better than 70-80% of individuals who don’t (Bradbury & Bodenmann, 2020). Emotionally Focused Therapy (EFT) helps 70% of couples become symptom-free by the end of treatment (Spengler, et. al., 2024)

That said, couples therapy isn’t a magic fix. Anywhere from 35-50% married couples who engage in therapy still divorce—but that’s lower than the rate for couples with similar issues who never seek help (Snyder & Balderrama-Durbin, 2020). A critical factor? Timing.

Both military and civilian couples wait anywhere from 2 and a half to 7 years after issues begin before seeking therapy (Doherty, 2021; Jarnecke, 2020). Earlier engagement could significantly improve outcomes.

Thus, couples counseling (A) leads to increased relationship satisfaction (B).

A Leads to C
 What if we treated couples counseling like dental checkups? We don’t wait until we have cavities or gum disease before seeing a dentist. Regular teeth cleanings prevent major dental issues and even reduce risks for heart disease, diabetes, and other systemic conditions.

What if we applied the same approach to relationships? Preventative couples counseling—regularly scheduled, even when things are “fine”—could prevent major breakdowns and improve long-term relationship health, leading to better overall physical and mental health. Plus we are addressing stigma by normalizing and establishing preventative relationship health as a priority.

Couples Counseling as an Essential Component to Mission Readiness
 Strong, satisfying marriages aren’t just good for our well-being—they’re critical to overall health and thus, mission readiness. High relationship satisfaction is linked to lower rates of disease and lower mortality rates. According to Kornblum and colleagues (2021), it’s also associated with improved mental resilience, financial stability, and success in attaining career goals —key factors for military personnel and their families. Service members undergo medical, dental, and readiness screenings before deployments, sea time, or PCS moves. These transitions are some of the most stressful events a military couple can face—so why isn’t relationship health part of the checklist?

Including couples counseling in pre-deployment training, PCS preparation, and reintegration programs could set military families up for success. Imagine how much we could improve overall health and military readiness if we routinely strengthened relationships before high-stress periods instead of waiting until things fall apart.

BOTTOM LINE: Couples counseling leads to improved physical and mental health or, A leads to C.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Adria Williams, Ph.D., is a Military Behavioral Health Psychologist at the Center for Deployment Psychology (CDP) with the Uniformed Services University of the Health Sciences. Dr. Williams is a suicide prevention subject matter expert and trainer.

References
 Bernet, W., Wamboldt, M. Z. & Narrow, W. E. (2016). Child Affected by Parental Relationship Distress. Journal of the American Academy of Child & Adolescent Psychiatry, 55, (7), 571 - 579. https://doi.org/10.1016/j.jaac.2016.04.018

Bradbury, T. N. & Bodenmann, G. (2020). Interventions for Couples. Annual review of clinical psychology, 16 (1), 99 - 123. https://doi.org/10.1146/annurev-clinpsy-071519-020546

Centers for Disease Control and Prevention (2002). Cohabitation, marriage, divorce, and remarriage in the United States (Vital and Health Statistics Series 23, No. 22). https://www.cdc.gov/nchs/data/series/sr_23/sr23_022.pdf

Department of Defense. (2024). Annual report on suicide in the military for 2023. https://www.defense.gov/News/Releases/Release/Article/3964785/department-of-defense-releases-its-annual-report-on-suicide-in-the-military-for/.

Doherty, W.J., Harris, S.M., Hall, E.L. and Hubbard, A.K. (2021). How long do people wait before seeking couples therapy? A research note. J Marital Fam Ther, 47: 882-890. https://doi.org/10.1111/jmft.12479

Downward, P., Rasciute, S. & Kumar, H. Mental health and satisfaction with partners: a longitudinal analysis in the UK. BMC Psychol 10, 15 (2022). https://doi.org/10.1186/s40359-022-00723-w.

Hogan, P. F., & Furst Seifert, R. (2010). Marriage and the Military: Evidence That Those Who Serve Marry Earlier and Divorce Earlier. Armed Forces & Society, 36(3), 420-438. https://doi.org/10.1177/0095327X09351228

Jarnecke, A. M., Ridings, L. E., Teves, J. B., Petty, K., Bhatia, V., & Libet, J. (2020). The path to couples therapy: A descriptive analysis on a veteran sample. Couple and Family Psychology: Research and Practice, 9(2), 73–89. https://doi.org/10.1037/cfp0000135

Kornblum, A., Unger, D., and Grote, G (2021). How romantic relationships affect individual career goal attainment: A transactive goal dynamics perspective. Journal of Vocational Behavior, 125, 103523. https://doi.org/10.1016/j.jvb.2020.103523

Lebow, J. L. (2019). Divorce today. In J. L. Lebow, Treating the difficult divorce: A practical guide for psychotherapists (pp. 35–55). American Psychological Association. https://doi.org/10.1037/0000116-003

Robles, T. F., Slatcher, R. B., Trombello, J. M., & McGinn, M. M. (2014). Marital quality and health: A meta-analytic review. Psychological Bulletin, 140(1), 140–187. https://doi.org/10.1037/a0031859

Saxey, M. T., LeBaron-Black, A. B., Dew, J. P., Yorgason, J. B., James, S. L., & Holmes, E. K. (2023). Money to Marriage, or Marriage to Money? Examining the Directionality Between Financial Processes and Marital Processes Among Newlywed Couples. Journal of Social and Personal Relationships, 40(8), 2445-2465. https://doi.org/10.1177/02654075221149967

Snyder, D.K. and Balderrama-Durbin, C.M. (2020). Current Status and Challenges in Systemic Family Therapy with Couples. In The Handbook of Systemic Family Therapy (eds K.S. Wampler and A.J. Blow). https://doi.org/10.1002/9781119790945.ch1

Spengler, P. M., Lee, N. A., Wiebe, S. A., & Wittenborn, A. K. (2024). A comprehensive meta-analysis on the efficacy of emotionally focused couple therapy. Couple and Family Psychology: Research and Practice, 13(2), 81–99. https://doi.org/10.1037/cfp0000233

United States Census Bureau (2001). Number, Timing, and Duration of Marriages and Divorces: 2001. https://www.census.gov/library/publications/2005/demo/p70-097.html

By Kristyn Heins, Ph.D.,

When you’ve decided to officially share a life with someone, maybe through marriage, civil union, common law, or any other way, you may go into it with the assumption this is 50/50. This is a partnership where together we will put effort into building a life we love. Few of us have an outright conversation about expectations and roles, we just think, “I love this person and they love me and we will figure out our own way”. For a while it probably works well, little issues may arise, but everything is manageable. But after a period of time you may start to think “why am I doing the dishes all the time?” or “when is the last time they made dinner”. Slowly we may start keeping score of the inequities in the union. The give and take may look like who is doing more house work? Who’s career are we more focused on? Who gets to accept a job out of state, and who has to follow? Who’s paying more bills? Who’s taking care of the kids? When children are brought into the relationship there is even more compromise needed. Who is doing drop off? Who picks up? Who makes sure school projects are taken care of? Who’s getting snacks for soccer on Saturday? Military spouses know this world of give and take better than most. As I write this I think of a friend of mine who has a masters degree but never was able to obtain a job where she used it due to her husband’s frequent relocation.

There are times that we are close to 50/50, but it might never feel like an even split. Someone is giving 40, the other 60, the work is divided and everyone is feeling fulfilled. But also, in more difficult circumstances it may be a 90/10 split and someone is carrying the majority of the weight. Isn’t this the “for better or worse”? The “in sickness and in health”? Why didn’t vows include “when my career takes precedence over yours” or “when my tee time overrules your plans”. Are we ever prepared for this shift in responsibility and effort? If not appropriately addressed, this compromise crossroad can lead to discord. Enter Gottman’s famed four horsemen of the apocalypse- criticism, contempt, defensiveness, and stonewalling (Gottman.com). Ultimately these can bring couples to break up or divorce when not addressed in therapy.

As providers, especially those working with the active duty population, addressing this even split myth can be beneficial in therapy. There is opportunity for great understanding and growth when couples are able to openly discuss expectations and roles. Starting with identifying thoughts can allow for the discussion for change. Working with couples on communication styles and effective interpersonal communication is another way to address this. When someone has reached the point of resentment, they are likely communicating in an aggressive manner. Helping people to understand assertive communication skills may lead to more effective exchanges. Along with couples counseling, working to dispel this myth of the even split relationship is another way providers can help. This can be done professionally, maybe through workshops and therapy. 

As educators and professors, this can be discussed in the classroom with future mental health professionals. As people ourselves, we can discuss this relationship myth with people in our own lives. On a personal level this is a conversation I have had with many of my friends, the reality of the scales being unbalanced. Supporting our friends and family, and discussing the fact that relationships are not 50/50 can help normalize our experiences and give perspective. We can help with adjusting expectations in therapy, but as mental health professionals let's also work on dispelling this myth and not allowing it to continue, because we know partnership is never an even split.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Kristyn Heins, Ph.D., is a Licensed Professional Counselor serving as a Military Behavioral Health Counselor for the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. In this role, she supports the CDP’s efforts of training clinicians in evidenced-based practice focused on suicide prevention.

By Amanda McCabe, Psy.D.

As a continuation of last week's blog about readiness assessments, we now attempt to answer questions about the civilian providers' role within these assessments. For example, do civilian providers need to make a readiness determination? What does it mean if a civilian provider does make a readiness determination? What if a civilian provider doesn’t want to provide readiness feedback?!

These are all great questions! The biggest expectation of providers in the community is that they conduct good, ethical, effective care for service members. There is no expectation that network providers would be making decisions on readiness. However, there are times when a service member may get flagged in the system, necessitating a readiness assessment. These flags may be due to a pending large-scale training exercise, a deployment, or the service member themselves endorsing behavioral health symptoms at their yearly physical. At these times, a military provider should reach out to the service member, and let them know that they are flagged, requiring a behavioral health evaluation to determine their individual readiness status (no duty limitations vs duty limitations). If this is the case, the service member and the evaluator will likely want to hear from you, the network behavioral health provider, to hear your perspective as it relates to the client’s case (such as the service member’s stability, prognosis, and ongoing treatment needs). You may be wondering what this process looks like and if it is ethical and/or legal for you to communicate your patient’s healthcare status. Before discussing a step by step plan, it is important to discuss HIPAA compliance. There is a military clause under HIPAA that permits communications on certain topics with a service member’s command team. It does not necessitate disclosure and its incredibly important to verify to whom the information is disclosed, in order to protect the patient. Please check out the resources below to learn more about this clause. Now, here are some definitive steps on how to respond when someone wants to hear from you about your service member patient.

1. Talk to the service member. What event initiated this request? Is there a pending training exercise? Is there an upcoming deployment? Is the assessment due to a profile that was initiated after a yearly physical? The implications are different depending on what is the cause of this recent request for information.

2. How does the service member feel about this initiating event? It is good to know the concerns for the service member, their motivations, and thoughts. While this is not the only consideration to be used in determining readiness, it is important to know.

a. If it’s a field exercise, do they want to go? Do they feel ready to go? Do they have the coping skills to be effective during this exercise? Do they have the resources they need? Do we expect their symptoms to worsen if they are in an extended training event? How long will this event be? How do they see themselves coping?

b. If it’s a pending deployment, the same questions above apply. This time though, think about a longer timeline (e.g., 3-9 months) and how it impacts all of the above questions.

c. If they have a profile that was initiated after a physical, what does the service member think of the profile? Do they want it? Do they want to stay in the military? Do they think they cannot sustain and want out? Are they bothered by the thought of having a profile?

3. Who is the information going to? Do they want it to go to a medical provider, a nurse, a case manager or do they want it to go to command, or all of the above?

4. What information does the patient want released? What information does the patient not want to be released? How do they want it released? Do they want to be present in the room during conversations when you release information or do they want a copy of what is being released?

5. What potential repercussions does the service member anticipate from the release of this information? Patients do not always have an accurate read on this! Sometimes they do, and sometimes they do not because this is a complex process. Communicating with military providers can really help service members achieve their military goals. Occasionally, service members are kept on duty limitations because it is unclear the status of their treatment progress from their network provider; consistent communication can help alleviate any treatment questions. Finally, it could be beneficial to consult someone familiar with the military system if there are any outstanding questions. Find a military specialist to contact.

6. Finally, how do YOU as the provider feel about releasing information? If you are not comfortable, releasing the bare minimum required, a treatment summary or just your notes is sufficient and a step in the right direction for establishing what the next steps for your patient will be. Also, there are many people you can consult with, generally speaking, to help you gain more comfort in working with military personnel.

7. When you are ready to release information, ensure that you have a signed release from the service member!

Once a Network Provider has been able to communicate the current status of their patient in terms of diagnosis, stability, and risk, a provider within the DoD will then most likely meet with that patient and help determine that service members’ readiness, ie, the need for any duty limitations. This is a complex evaluation that considers a variety of issues and information, as well as regulations and policies.

Again, providing ethical, effective care is the most important consideration when working with military members. We are lucky to have providers in the community helping our military personnel every day! If someone from the military ever reaches out about one of your patients, following these guidelines is an effective way to steer you and your patient in the right direction.

Resources:
DHA Privacy and Civil Liberties Office Fact Sheet: The Military Command Exception and Disclosing PHI of Armed Forces Personnel

Health.mil: Military Command Exception

US Army Ft. Bliss Legal Assistance Office: The Military Command Exception to the Health Insurance Portability and Accountability Act

Look for upcoming webinar through the CDP-P on Wednesday, July 9th.
Title: Assessing Readiness for Service Members Receiving Private-Sector Behavioral Health Care: Insights from a Recent RAND Report
Presenters: Jessica Sousa, MPH, MSW and Kimberly Hepner, Ph.D.

For Questions about this blog please reach out to: cdp-tpr-ggg@usuhs.edu

Click here for Part 1: "What is Readiness and Why is it So Important?"

Click here for Part 2: "Overview of Military Readiness Assessments"

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Amanda McCabe, Psy.D., is a Military Behavioral Health Psychologist with the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. In this capacity, she develops and delivers training on a variety of evidence-based therapies. Prior to the CDP, Dr. McCabe served as a clinical psychologist in the Army from 2013 to 2024.

By Amanda McCabe, Psy.D.

Military readiness is a critical measure to ensure that service members are both physically and
mentally prepared to carry out their duties. As was highlighted in last week’s blog, readiness
assessments are vital for maintaining operational effectiveness and helping to ensure that the
military is taking care of its service members by identifying problems early and ensuring access
to treatment. These evaluations consider both physical and behavioral health; however, today’s
post will focus on the behavioral health portion and what specific domains are assessed. 

Readiness evaluations are conducted by providers within the DoD due to ever-changing rules
and regulations.  If you are a civilian network provider, know that these assessments will not be
demanded of you; however, your input is imperative to ensure the relevant factors are considered
when making a readiness determination. Therefore, it is good to have background knowledge of
these assessments if you are a provider working with service members.

The current guideline that regulates Military Readiness assessments is the Department of
Defense Instruction (DoDI) 6130.03 Vol 2. This specifies the criteria for all readiness
evaluations within the Department of Defense, in other words, each branch of service. It outlines
three main domains within the Behavioral Health section of a readiness evaluation that will be
reviewed today, as well as one additional topic: psychotropic medications. These domains are
safety, symptom severity, and specific diagnoses. Once the assessment has been completed
providers will establish if any duty limitations are needed.

One thing to note, before the readiness assessment domains are reviewed, are the options for the
final disposition. Readiness assessments conclude with a decision about the need for duty
restrictions for service members. Sometimes during treatment, duty limitations are initiated to
help the service member focus on treatment and recovery. Upon the conclusion of readiness
assessments, providers will notate one of three dispositions: no temporary duty limitations,
temporary duty limitations, or permanent duty limitations which would require a medical
evaluation board. Temporary duty limitations would mean that the service member is put on a
profile, if they are in the Army or Air Force, or put on Limited Duty (LIMDU) if they are in the
Navy or Marines. To ensure clarity, it is important to state that if a service member is on profile
or LIMDU they most likely are considered temporarily non-deployable. This status would also
warrant a discussion with the service member’s Command team (see our next article in the blog
series for further information). Your role is to provide the necessary treatment to the service
member with the ultimate goal of being returned to duty with no limitations; however, that will
be determined by a military provider following the completion of treatment or potentially at a
midpoint in treatment. Now that the conclusions of readiness assessments have been reviewed,
the next step is to discuss the domains evaluated within these assessments.

1. Safety: To Self and Others
Service members are often placed in high-stress, dangerous, and complex situations, therefore,
safety is paramount. The evaluation of safety includes two important facets: safety for the
individual service member and safety of others.  These are complex assessments with multiple
factors considered, the scope of which is beyond this blog for today, but a summary will be
given.

Self-Safety: The first domain to be evaluated in readiness assessments is the risk of suicide.
Suicide risk assessments are vital for all behavioral health patients, but within the military, they
have a different lens due to patients having consistent access to lethal weapons as part of their
daily jobs. Service members who are considered higher risk for suicide (please see DHA AI
6025.06 for break down of appropriate risk levels within the Defense Health Agency care) are
given temporary duty limitations that would limit their access to weapons for work and allow
them to access treatment consistently (helping minimize any occupational barriers that might
prevent this) as well as, access multiple levels of resources (intensive outpatient programs,
inpatient care, residential care) until their risk of suicide consistently decreases. With temporary
duty limitations, such as a profile or LIMDU, due to high risk for suicide, patients are able to
access treatment on a routine basis, have access to case managers, and higher levels of
consultation and review, as well as any other required care.

Safety to Others: Equally important to assess for in readiness evaluations, is the risk of harm to
others. If a service member’s current mental health symptoms manifest as wanting to hurt or kill
others, then that person will be evaluated to see if duty restrictions are warranted. This evaluation
would help determine if limiting access to their occupational weapons is needed as well as
inpatient services or if legal action would be required at that time. Individuals who may exhibit
impulsive, unpredictable, or violent behavior pose a risk to the safety of those around them.
In summary, providers assessing for readiness are examining risk factors of harm to self or
others to determine if duty limitations are necessary.

2. Symptom Severity
Beyond ensuring safety, military readiness assessments focus heavily on the severity of
symptoms related to mental health conditions. Providers within the DoD system assess for
symptom severity because it can directly affect service members' ability to perform their duties. 
Mild to Moderate Symptoms: Service members with mild symptoms of conditions, like anxiety
or depression, will likely not require any change of duties since their symptoms are manageable
and do not significantly impair their work. Counseling or other forms of treatment can be
prescribed to help them cope with the stresses of military life while maintaining their duties. A
moderate symptom presentation does not always require duty limitations either. A moderate
symptom presentation that would require duty limitations would be determined based on the type
of impairment experienced, symptoms manifested, service member occupational demands, and if
any safety concerns are present.

There is one exception to the rule for moderate symptoms. Substance use that rises to the level of
diagnosis, and has demonstrated any type of impairment, does lead to temporary duty limitations
to help the service member start and work through a substance treatment protocol.
 Severe Symptoms: Service members with severe symptoms that cause significant impairment
socially and/or occupationally can be viewed as warranting temporary duty restrictions. These
duty restrictions limit what the individual can do occupationally, temporarily, while facilitating
consistent access to care. For example, if a service member is in the middle of treatment for
Major Depressive Disorder while their unit comes on orders for a month-long training exercise,
that is away from home, these duty limitations allow the service member to remain at their
normal duty location (at home), and continue to receive their needed treatment. 

In summary, during brief readiness assessments, service members in treatment often have mild
to moderate symptoms requiring no need for duty restrictions.  When conditions result in
significant impairment, then temporary duty limitations are placed.  Finally, if any of these
conditions require a year or more of treatment (or they have been in treatment for a long time and
expect treatment to continue for a long time), a permanent profile may be issued. The permanent
profile would initiate a medical review board, which would determine if a service member can be
rehabilitated in the near future or would need a medical retirement due to their conditions.
 
3. Specific Diagnoses: Psychotic Disorders and Bipolar I Disorder
The nature of being in the military and having access to weapons make for an environment that
is unsustainable for certain diagnoses. Psychotic disorders, like Schizophrenia and
Schizoaffective disorder, as well as Bipolar I Disorder, require permanent duty limitations and
service member’s will be referred for a medical review board upon initial diagnosis. The nature
of these diagnoses and their treatment requirements are beyond the scope of the Active Duty
component (however, it is very much integral to the Veteran Affairs medical which is not limited
to medicine, but also housing assistance and career assistance). These diagnoses often warrant
long-term treatment with medication, therapy, and case management services that are not
available in all geographic locations and specifically within an austere environment of a
deployed setting or long training mission. This would significantly impact the training, location,
and job abilities of the service member, therefore permanent duty limitations are placed and a
medical evaluation board is initiated.  
 
4. Specific Medications: Antipsychotics and Mood Stabilizers
Each military branch has its own regulations on specific types of psychotropic medications,
especially those prescribed for long-term mental health management, such as antipsychotics and
mood stabilizers. The differing regulations stem from the different constraints placed on various
occupations and the availability of medications and services. An example of differing medication
requirements can be seen when looking at the occupational requirements for a pilot versus a
supply specialist. With that said, psychotropic medications are frequently used within the
military services. Service Members, once having established there are no significant side effects

upon initial use, oftentimes do not require duty limitations and can work as usual. When
considering a deployment, different geographic locations have different mandates on
medications due to the availability of services in that region. Prior to deployments, service
members undergo readiness screeners to ensure that their medications fall within the parameters
of that region or see if there is a possibility to obtain a waiver for those medications. 
A good rule of thumb for any military service is if antipsychotics and mood stabilizers are
required for stabilization and long-term care, then permanent duty limitations would be placed
and a medical retirement is likely warranted. These medications carry potentially significant side
effects, require consistent monitoring, and would be difficult to store and dispense in austere
environments.

In summary, each military branch has its own regulations governing medication use within their
services. Also, psychotropic medications are commonly used within the DoD’s Behavioral
Health system. Screeners are therefore conducted by their behavioral health personnel to help
determine if duty limitations are required due to the service member’s specific job constraints
and deployment needs. 
 

Conclusion
Military readiness assessments occur consistently throughout the DoD/DHA Health Services.
These evaluations help determine if service members require temporary or permanent duty
limitations, which impacts overall mission readiness for commanders. The behavioral health
aspect of these evaluations considers safety, symptom severity, diagnoses, and medications as
crucial pieces for determining duty limitations. These evaluations not only protect the individual
service member but also ensure the safety of their peers and the overall success of the mission.
By carefully balancing the need for mental health treatment with the demands of military service,
the Armed Forces strive to maintain a force that is both healthy and ready for the challenges they
may face.

Click here for Part 1: "What is Readiness and Why is it So Important?"

Click here for Part 3: "Private Sector Providers and Readiness"

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Amanda McCabe, Psy.D., is a Military Behavioral Health Psychologist with the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. In this capacity, she develops and delivers training on a variety of evidence-based therapies. Prior to the CDP, Dr. McCabe served as a clinical psychologist in the Army from 2013 to 2024.

By Amanda McCabe, Psy.D.

As behavioral health providers who work with military service members, we hear the term ‘readiness’ often and may wonder what it means and how it could impact our work with our military clients. Generally speaking, readiness refers to the military’s capability to do its job, whether that’s during training, combat operations, or humanitarian missions. In order to ensure that the military can meet its missions, commanders need to know if their service members are able to deploy or work in an austere environment for an extended period of time. For example, work in an austere environment might look like a unit getting called up on an urgent tasker to respond to the wildfires on Maui. The commander for the unit would need to know, in a timely manner, who is available to deploy and who may not be available due to medical or behavioral health reasons. Another example of an austere environment, is a National Guard member or Reservist who has to perform their annual training for two to four weeks at a remote training location. There will be further discussion below on the different types of austere environments in which service members may work.

To maintain visibility of personnel who are ready and able to work in austere environments, readiness assessments are conducted by military providers, including behavioral health providers, at routine appointments. An example of this can be seen when a service member meets with their physician for symptoms of a cold; the physician treats the service member and also conducts a routine readiness assessment. Readiness assessments can also be done systematically to prepare for upcoming missions. Prior to deployment, the members of an entire unit undergo a medical screen or examination. During these assessments, providers will evaluate if there are any medical or behavioral health reasons that a person cannot currently perform their job deployed and also at home, oftentimes referred to in the military as in garrison. However, before we discuss the elements of a readiness evaluation, let's learn more about their benefits, answering the essential question, why does the military require these readiness assessments?

1. Early Identification of Potential Issues

Aside from ensuring an operationally effective force, regular readiness assessments allow for the early detection of issues that could impair a service member's ability to perform their duties in the long term. This includes physical injuries, mental health concerns, and personal circumstances that may affect a person’s focus or performance. Early identification enables timely intervention, whether it’s through medical treatment, counseling, or support services, helping to prevent minor issues from escalating into major problems that could impact the individual or their unit. An example of such a situation is a service member who fractured their wrist and cannot take part in attending the weekly range exercise for risk of further damaging their arm. Another example is a service member who has a parent who’s been diagnosed with a terminal illness and is requesting a compassionate reassignment in order to live close to that parent to be able to assist with their medical care. A final example, pertaining to behavioral health, highlights the importance of a walk-in clinic, which can help identify preliminary signs of stressors that arise due to a pending month-long training exercise. Early identification and targeted treatment allow stressors to stay at the “problem” level without escalating to a diagnosable behavioral health condition. Identifying medical concerns or behavioral health problems at the lowest level prevents issues becoming chronic and recalcitrant to treatment.

2. Ensuring Access to Care

Assessing readiness regularly allows the military to identify the needs of service members and ensure that they are sent only to locations that have the resources available to support them. service members train and deploy throughout the year in austere environments and it is imperative to ensure that the service member will have access to any needed care wherever they go. Austere environments can look like a multitude of situations. For example, Navy personnel can expect to serve sea duty, and be on the water for months at a time. Internet capabilities, mail, and medical resources, beyond a typical physician or behavioral health therapist, may be limited. Submariners often have limited access to the internet, fresh food, and communication with the outside world. Reservists and National Guard members have to conduct extended annual training that usually occurs at a remote site with limited electricity, internet, hot food and all with significant exposure to the elements for weeks at a time. Reservists and National Guard members do this annual training while trying to balance a civilian job oftentimes simultaneously. Active Duty members not only have the potential to deploy, but experience multiple training exercises throughout the year, which can lead to being gone for months at a time. They can also be moved, or PCSed (Permanent Change of Station), to different locations around the world that have limited resources. Therefore, it is imperative that the military ensures that they are not sending service members to areas or exercises that would aggravate their medical and behavioral health needs or the Military needs to ensure that the necessary medical and behavioral health resources are available at the next location, whether that is a PCS, deployment, or extended training exercise.

To look at an example of the Military ensuring resources for its service members, an example of an overseas move makes a great illustration. For instance, OCONUS assignments (a location Outside of the CONtinental United States) often have limited physical and behavioral health services. Therefore, service members undergo medical screenings prior to assignments to ensure the needed medical resources are available at their next duty station. One OCONUS location, South Korea, has less extensive behavioral health services available in the community due to language barriers, as such there are no partial hospitalization or residential programs within the country to send service members in need. This is an extremely limiting factor when considering the behavioral health options for service members, therefore, people who require more than routine outpatient behavioral health services would not be moved to an OCONUS assignment until they had completed treatment and demonstrated stabilization. To further illustrate, the example of a service member receiving orders to move to South Korea within three months is used. If this service member is currently undergoing significant behavioral health treatment, beyond the scope of outpatient services, their move may be delayed a month or two to allow their condition to stabilize or complete treatment. There are also times when orders are completely rescinded because the necessary treatment is not available at the next duty location. Regular readiness assessments allow service members to identify their treatment needs and move and train to only locations that maintain those required services.

3. Ensuring Long-Term Health and Sustainability

Military service is demanding, both physically and mentally. Continuous readiness assessments are essential for ensuring that the demands placed on service members do not exceed their capabilities, leading to burnout or long-term health issues. By monitoring physical and mental health, the military can provide necessary support, such as rest periods, medical care, or behavioral health counseling, which helps to sustain the force over the long term. This approach not only protects the well-being of service members but also preserves the effectiveness of the military force as a whole. If a service member’s medical needs, to include behavioral health, have been identified as becoming complex or chronic, medical retirement with access to VA (Veterans Affairs) and DoD (Department of Defense) services will be considered.

Conclusion

Continually assessing the readiness of military service members is a fundamental aspect of maintaining a capable, resilient, and effective force. It ensures operational success through early identification of issues and maintains access to care thereby protecting the well-being of service members. As the nature of global challenges continues to evolve, the importance of readiness assessments will only grow, ensuring that military forces are prepared to meet the demands of future conflicts.

Click here for Part 2: "Overview of Military Readiness Assessments"
Click here for Part 3: "Private Sector Providers and Readiness"

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Amanda McCabe, Psy.D., is a Military Behavioral Health Psychologist with the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. In this capacity, she develops and delivers training on a variety of evidence-based therapies. Prior to the CDP, Dr. McCabe served as a clinical psychologist in the Army from 2013 to 2024.

By Diana Dolan, Ph.D., CBSM, DBSM,

If you have insomnia, you have a number of different behavioral treatment options available. These options offer effective, long-term benefits without the need for sleep aids or ongoing medication. However, you may not know where to go to look for them or which is the right fit for you. In this article, let’s unpack and compare these options to get started.

Considering behavioral treatment for insomnia is a wise choice; after all, it’s widely considered the gold standard treatment (Schutte-Rodin et al, 2008; Qaseem et al, 2016, Edinger et al, 2021) and is recommended by VA/DoD clinical practice guidelines (Department of Veterans Affairs, 2019). The continuum of options ranges from self-help all the way to individually tailored treatment with a trained behavioral sleep medicine clinician.

Step 1: Self-Help

The least intensive treatment option is via self-help. This can be unguided, such as via reading books and attempting to track your own sleep and implement the strategies described. Examples of this approach include the “Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain” workbook by Colleen Carney, Ph.D. and Rachel Manber, Ph.D., recognized experts in the field, or “The Insomnia Workbook: A Comprehensive Guide to Getting the Sleep You Need” by Stephanie Silberman, Ph.D. and Charles Morin, Ph.D., also well-known sleep psychologists. Both books cost between $20-25.

Self-help can also be guided such as via apps that provide feedback on your sleep inputs and suggested changes. Some examples of this include the Insomnia Coach app developed by the VA (https://mobile.va.gov/app/insomnia-coach) and the Path to Better Sleep website hosted by the VA (https://www.veterantraining.va.gov/sleep/index.asp) that offers four modules, including a self-check, psychoeducation, and a walkthrough of Cognitive Behavioral Therapy of Insomnia (CBT-I) for self-implementation. Both are offered for no cost. Some apps even offer a sort of coaching model, where you may receive occasional contact from a person who reviews your app data (usually this is someone without advanced training in behavioral health or sleep medicine).

Outcome data suggest self-help approaches can indeed be helpful, but may fit better for those who approach them already motivated and committed to adhering to the guidance they learn, and may not be as long lasting as more intensive options (Gao et al, 2022).

Step 2: Structured Clinician-Guided Treatment

This category includes treatment with a provider who may or may not have specialized training in behavioral sleep medicine, but is following an evidence-based protocol, with individuals who are expected to largely independently implement changes with only some guidance. For example, CBT-I in a group setting is guided and has a relatively short time commitment. CBT-I group usually ranges from four to six appointments lasting 60 to 90 minutes each, for a total in-person range of four to six hours. Group sizes are usually up to about seven people, allowing individuals to get to know each other and receive support in making changes, with a cost less than that of specialty individual care at the next level up.

Another low-time commitment option is Brief Behavioral Treatment of Insomnia, or BBTI, typically offered individually. BBTI can be implemented by a paraprofessional or nurse, or by a therapist such as a clinical social worker or psychologist. While BBTI does require active effort to make changes in sleep-related behavior, it can be offered in easily accessible locations, such as a primary care or other medical clinic, and involves five contacts lasting an average of 30 minutes each, for a total in-person commitment of only two to three hours. The cost can vary, but would typically be at one’s usual medical visit copay or is covered for those receiving BBTI in DoD military treatment facilities. Full disclaimer, I both offer and train other providers in BBTI including ongoing consultation and I believe it is a helpful treatment to the majority of those who adhere to the plan, although some may have unhelpful sleep-relevant beliefs that need to be addressed outside of the protocol or may require additional appointments.

Outcome data suggests both of these options not only last longer than self-help options, but result in more noticeable improvement (Koffel, Koffel, & Gehrman, 2015; Gao et al, 2022). Clinician-guided treatment at this next step up above self-help may fit better for those who would like to improve their sleep and are willing to build on a proivded plan, but prefer scheduled access to an identified provider who gives information, encouragement and support for problem-solving any questions that may arise.

Step 3: Specialty Level Treatment

At the highest level of stepped care would be full implementation of the gold standard treatment, individual CBT-I. Clinicians who provide CBT-I may range from those who have initial training in the basics of the CBT-I protocol and offer straightforward implementation with some appropriate adaptations as needed, all the way to experienced clinicians who specialize in behavioral sleep medicine and offer treatments not only for insomnia but for nightmares, circadian rhythm disorders, adjunctive obstructive sleep apnea and narcolepsy support and more. While CBT-I training is open to providers of many backgrounds (see https://cbti.directory/ for a list of self-identified CBT-I trained clinicians), a Diplomat in Behavioral Sleep Medicine is the board credential denoting expertise available for this specialty area (see https://www.bsmcredential.org/index.php/bsm-diplomates for the roster).

The gold standard for a reason, CBT-I interventions are specifically tailored to address each individual’s unique relevant contributors and any comorbid mental or medical health concerns with a detailed plan and flexible appointment range, resulting in long lasting outcomes even in more complex situations (Gao et al, 2022). While this kind of approach would benefit anyone with insomnia, those who are not yet sure about making changes around their sleep, those who want to more collaboratively develop a plan or have more ongoing face to face support, and those who want a provider who can simultaneously weave in factors such as decreased mood, anxiety and trauma would do well at this step.

A helpful note to keep in mind about the stepped care model is that if one step does not sufficiently address insomnia symptoms, it does not mean that behavioral treatment has failed. Rather, it indicates that a higher step would be more appropriate. Even within a step as noted, differential levels of intensity exist. For those debating options, I encourage you to give the most readily accessible one a try for a starting point. You may feel more comfortable trying an intervention knowing options still remain if needed. Generally, the different steps can all have good outcomes, but the wild card is you. If you are motivated to make changes in your behavior in order to sleep better in the long run, you will get out what you put in – so go for it!

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Diana Dolan, Ph.D., CBSM, DBSM, is a clinical psychologist serving as an Assistant Director of Training & Education with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland..

References

Baglioni, C., Espie, C.A., Altena, E., Gavriloff, D., Jernelov, S., Holzinger, B., … & Riemann, D. (2023).
      Cognitive behavioural therapy for insomnia disorder: Extending the stepped care model. Journal
      of Sleep Research 32(6):e14016. https://doi.org/10.1111/jsr.14016
 Department of Veterans Affairs & Department of Defense (2019). VA/DoD clinical practice guideline for
      the management of chronic insomnia and obstructive sleep apnea.
      https://www.healthquality.va.gov/guidelines/CD/insomnia/VADoDSleepCPGFinal508.pdf
 Edinger, J. D., Arnedt, J. T., Bertisch, S. M., Carney, C. E., Harrington, J. J., Lichstein, K. L., … & Martin, J. L.
      (2021). Behavioral and psychological treatments for chronic insomnia disorder in adults: An
      American Academy of sleep medicine clinical practice guideline. Journal of Clinical Sleep
      Medicine, 17(2), 255–262. https://doi.org/10.5664/jcsm.8986
 Gao, Y., Ge, L., Liu, M., Niu, M., Chen, Y., Sun, Y., ... & Tian, J. (2022). Comparative efficacy and
      acceptability of cognitive behavioral therapy delivery formats for insomnia in adults: A
      systematic review and network meta-analysis. Sleep Medicine Reviews, 64, 101648.
     https://doi.org/10.1016/j.smrv.2022.101648
 Koffel, E.A., Koffel, J.B., Gehrman, P.R. (2015). A meta-analysis of group cognitive behavioral therapy for
      insomnia. Sleep Medicine Reviews 19: 6-16.
 Qaseem, A., Kansagara, D., Forciea, M.A., Cooke, M., & Denberg, T.D. (2016). Management of chronic
      insomnia disorder in adults: a clinical practice guideline from the American College of Physicians.
      Annals of Internal Medicine 165(2): 125-133.
 Schutte-Rodin, S., Broch, L., Buysse, D., Dorsey, C. & Sateia, M. (2008). Clinical guideline for the
      evaluation and management of chronic insomnia in adults. Journal of Clinical Sleep Medicine
      4(5): 487-504.

By Timothy Rogers, Ph.D.

According to the 2023 match statistics from the Association of Psychology Postdoctoral and Internship Centers (APPIC) there are 774 internship sites and a total of 3,620 accredited internship positions. The US military offers nine accredited internships sites and a total of 58 internship positions across the different branches, representing 1% of the overall training opportunities for those seeking to complete their doctoral psychology training requirements. With so many options available, why should someone focus on the 1% offered by the U.S. military?

That is a fair question. I would like to provide a response based on my experience as a former military psychology intern, as well as other experiences I have had from different professional roles. When applying to internships, I applied to the VA, college counseling centers, forensic settings, as well as military internship sites. During the course of my doctoral program, I worked in a range of clinical settings which resulted in applying to a variety of internship sites. I ended up going on over 10 interviews in different states to look at various training programs. As a result of this process, one of the things that stood out to me very clearly was the abundance of training opportunities that the military provided. In particular, the number of different clinical rotations and amount of evidence based treatments you could receive training in seemed to exceed what other training programs had to offer. Additionally, I liked the idea that the military internship program would not only help me to learn how to be an excellent psychologist, but I would also learn how to be an effective leader as an officer.

As I progressed in my career, I also had the fortunate opportunity to serve as an Associate Program Director for one of the military psychology internship sites. As part of my responsibilities, I would go over the program evaluation data completed by faculty members, current interns and those who graduated from our program. When examining the results, graduates from military internship programs would consistently note that compared to their peers they received more training (e.g., amount of supervision, training in diverse clinical topics). This feedback resonated with my own experience as a former military psychology intern, and even why I ranked military internships at the top of my list was because of the training opportunities that these internships provided.

In addition to being a former military intern, and serving as an Associate Program Director, I have also had the opportunity to visit different military internship sites as an APA Commission of Accreditation internship site visitor. As a site visitor, you have to review every aspect of a training program to examine the extent to which the program is adhering to relevant accreditation standards. It is a very in-depth process that culminates with an in-person visit to the site and interviews with everyone involved in the program (e.g., faculty members, program leadership, administrative support personnel, current interns, and graduates). Every site visit I have made to a military internship program has reinforced my understanding of the amazing opportunities afforded to students to develop their clinical skills as future psychologists and grow in leadership skills.

If you are interested in learning more about military psychology internships, the Center for Deployment Psychology holds trainings twice a year to talk about career pathways. You can find out more information on our website at: https://deploymentpsych.org/pathways-to-military-careers. We also have a section on our website dedicated to providing information about requirements to join the military, military health careers for psychologists and social workers, as well as general information (e.g., benefits associated with military service).

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Timothy Rogers, Ph.D., is an Assistant Director of Online Training, Technology and Telehealth for the Center for Deployment Psychology (CDP) at the Uniformed Services University for the Health Sciences in Bethesda, Maryland.

By Debra Nofziger, Psy.D.

I recently sat in on a discussion with Ukrainian providers who were discussing how to handle provider burnout. These were primarily providers who are directly working with fighting troops or providers who work with families who evacuated and have loved ones fighting. One of the providers shared feeling helpless when it comes to being able to help, from a behavioral health perspective, people who are experiencing ongoing war. This feeling was quickly confirmed by the other providers on the call. It got me thinking of the difference between working with patients after an event versus working with patients during an ongoing traumatic/war situation.

From my experience, there is definitely a difference with how to approach behavioral health care. In a combat situation, you can’t “fix” what is wrong. I’d go as far to say that you can’t “treat” them, unless you pull them out of the combat environment. They are in an ongoing life-and-death situation where they are repeatedly exposed to traumatizing experiences. It is similar, if not the same, to helping a patient who is in an ongoing abusive environment. I believe feeling helpless is normal for providers in these cases, given they know that the person they are working with is going to keep experiencing trauma. So how do we as providers cope with our sense of helplessness, knowing that whatever we do our patients are simply going to walk right back into their life-and-death struggle?

I believe the answer is centered around the idea of “finding peace”. When I was embedded with a forward deployed unit during my time in Iraq, I quickly discovered that I couldn’t fix what was “wrong” with those individuals who sought me out. They were experiencing understandable stress that was unfathomable. Depression, extreme grief, and trauma reactions were expected. But what I could do was help them find a sense of peace around whatever they were struggling with, which is what I honestly believe they were looking for in the first place. They didn't want me to “fix” them. They were simply seeking a sense of peace with their turmoil.

My job was to help them find that peace and whatever that meant. Focusing on how to help bring some sense of peace is what I did to combat my own sense of helplessness. I remember thinking how messed up it was, that my job was to keep them together enough so they could get back into the fighting. My job was weapon’s repair, not treating them to get back to actual mental health in the conventional way. I constantly reminded myself, though, that my goal in combat was to actually help them survive to make it home. I’d deal with the fallout of combat and “treatment” then.

What do I mean by helping patients find peace during an ongoing struggle? I found that a sense of peace can be found for a variety of reasons, traumatic experiences and what they discover they are capable of during war being common ones. Sometimes warfighters struggle to understand why they acted a certain way during an incident. Helping them understand their actions in reference to the fight/flight response, their emotional mindset, their training, or simple mission needs and the need to do whatever it takes to save their comrades can go a long way with helping them find peace with their actions. I then normalized their emotional reaction to it, pointing out that their struggle with their actions and what they witness is proof that their humanity and “soul” remains intact. I think this is a common concern that warfighters struggle with – that they are losing their sense of humanity and soul. The look of relief I’ve seen after this discussion is how I know that I’ve helped that person have a bit of peace around this worry of theirs.

Often, I found warfighters struggling with how “senseless” the deaths and overall destruction was, knowing that it wasn’t over and they would continue to experience these things. I remember how disheartened I felt with this came up, because in a very real sense they were right. This is one area where how I dealt with it during combat is close to how I deal with it now, after the fact. The key to finding peace in this case is to help them create meaning from the situation. For example, if someone died, instead of focusing on the senselessness of the death, how do they honor that person’s legacy and make it so their life and possibly death is not meaningless? What was important to the deceased? How did they impact the world in a positive way? How can the individual honor them and continue the deceased’s legacy in the world? I’ve had patients, for example, find ways to comfort others in the way the deceased used to, or volunteer for organizations that were important to the deceased. Regarding the senselessness of the overall war situation and things they see not involving death of a comrade, I help them consider how they can engage in reparation. Perhaps this meant a specific kindness to a civilian in the combat zone. Or more internal, personal actions such as saying a prayer for those negatively impacted.

I also remember helping soldiers find peace regarding their mindset, specifically around being okay with dying. What do I mean by “being okay with dying”? It is important during combat for warfighters to accept that they might die and, in fact, be okay with that fact. Having this mindset allows them to not only do what is needed during combat, but also helps them cope with the anxiety and fear about possible death. This mindset, however, can create conflict between being “okay” to die but knowing they have family back home who need them. One gentleman I talked to was struggling with how he could be okay to die when he had children back home who would miss him if he were gone. We talked awhile about how he had already impacted his children’s lives and his legacy with them, regardless if he returned home or not. He in particular sticks in my mind because I distinctly remember wondering at some point in our discussion if I was helping him at all, feeling helpless as a provider. But then, at the end, he thanked me, stating that our talk had helped a lot. That helped me so much in my discovery about the importance of helping them find peace.

Another soldier I recall talking to in the warzone was angry about what he perceived were the political reasons we were in Iraq in the first place. We know from research that soldiers can really struggle if they do not support the reason for the mission, so it is important to help them find peace on this topic. How did I do it? This soldier came in yelling about the politics, the stupidity of it all, and wondering why he continued to go out on convoys every day “just to get blown up”. He argued that he shouldn’t be going out to fight anymore for the political reasons he cited. I pushed right back at him, stating that it wasn’t about politics and the reason he went out there every day was because there was no way he was going to let his guys go out there without him. He calmed right down, stating I was right. I had refocused the purpose of why he fought from politics to thinking about his colleagues and doing what he could to protect them. A key saying with the military is that the reason they fight is because of the person to their left and to their right. No warfighter in the history of warfare has ever fought for a political cause – politics is just what gets them to a location, but it isn’t why they fight. They fight for each other. Period. So if you have a person struggling with the mission reason, refocus them onto their comrades. In this, they will find peace for why they fight.

Helping warfighters find peace isn’t always about what is happening in the combat zone. Sometimes what is weighing heavily on them has to do with things back home. In those cases, it was a lot like the therapy I’d do outside a warzone, if not exactly the same. But it had a different spin on how important it was – in a warzone it can be very dangerous if a soldier’s mind is being distracted by concerns at home. And if some of their depression or stress can be “fixed” because it isn’t related to ongoing war/trauma, then it feels even more important to remove that load given the expected emotional stress that war creates. It is like being able to lighten the load where you can, so that the added load won’t tip them over the edge.

One soldier I worked a lot with while deployed struggled with his connection with his wife. They had a lot of problems in their relationship, and he honestly didn’t know if he still loved her. We worked a lot on understanding his struggles with attachment in general and how this impacted his marital relationship. We also worked on communication skills, so he could better talk with his wife about their problems. When he came back from R&R (a two-week “vacation” from combat), he reported having talked with his wife and working a lot of their difficulties out. For the first time, he was looking forward to the end of deployment and returning home, excited to continue working on his marriage. His actual quote – “I don’t know if we will make it, but I know I love my wife and I’m going to try.” I remember this quote with tears, because two days after he said this, he died. I struggled a lot afterwards with how I felt about this. Yes, it was horribly sad that he never got home, but it was more than that. I finally realized that there was an emotion I don’t think we have an English word for, combining grief and satisfaction, perhaps? I realized that the day he died, he knew he loved his wife and she loved him. Remembering his smile, I know that in this, at least, he knew peace.

Focusing on helping patients find peace isn’t just about ongoing war and trauma. It is something I think we can focus on after the trauma is over as well – finding peace with their history and experiences. Nothing will “make it okay”, but they can be okay with living with it. I hope that my thoughts above will not only help providers in active combat but also those working with anyone who has experienced trauma. I truly believe that it is normal to sometimes feel helpless when working with people experiencing ongoing trauma. It is also normal to sometimes feel helpless with those not in active trauma situations, given the intensity of what patients sometimes experience. The key is to know we aren’t alone in this feeling, and to know that this sense of helplessness is probably coming from our drive to “fix” things and do a treatment that will take away a mental health diagnosis and the person’s overall struggle. When we feel helpless, we need to adjust what we are focused on. My default is to consider how to help the person find peace with their situation and experiences. I believe that much of the time, this is what they are truly looking for anyway, not to have their situation “fixed” but to be at peace with it.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Debra Nofziger, Psy.D., is a Senior Military Behavioral Health Psychologist and certified Cognitive Processing Therapy Trainer with the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.