1 Navy Expeditionary Combat Command UNCLASSIFIEDembedded Mental Health Program (eMHP) IdeaFest: Hampton Roads Innovation Case Study Harold Dennis Kade, PhD, LCP Force Psychologist, eMHP Manager NO2M At the Navy Expeditionary Combat Command, we understand the importance of the individual Sailor because the Sailor is our platform. eMHP is a force extender that directly supports NECC’s force-wide wholeness by mitigating stress injuries & helping maximize Sailors’ psychological resilience, readiness & fitness (one of the eight Total Force Fitness domains) 31-JUL 2013 THIS BRIEF CLASSIFIED: UNCLASSIFIED

2 The Problem 21st Century Sailor & Marine Initiative makes clear the importance of maximizing personal readiness in order to maintain the resiliency for the force & to hone the most combat effective force in the history of the Department of the Navy But current OPTEMPO and reductions in force structure lead to increased psychological stresses & wear-and-tear on Service Members (SM) and their families This has the potential to degrade psychological resilience, readiness & fitness (one of the eight Total Force Fitness domains) Those who are under the most stress are least likely to seek help from any source Efforts to reduce suicides and mitigate combat and operational stress are hampered by the stigma of admitting mental health problems & seeking mental health services At the Navy Expeditionary Combat Command, we understand the importance of the individual Sailor because the Sailor is our platform. Whether psychological stress is sudden and intense OR long term wear & tear. It degrades psychological resilience, readiness & fitness. Those who need psychological help the most are often least likely to seek it. We need to overcome stigma and other barriers to accessing psychological services.

3 Asking the Question RAND report* identified five challenges to resilience programs: Lack of leadership support Logistical obstacles Limited funding for sustainment Poor fit with military culture Mental health stigma Promoting Psychological Resilience in the U.S. Military, ISBN: How can we overcome these challenges & maximize psychological resilience, readiness & fitness? We found a lot of information about the obstacles to solving this problem, but few hints at a solution

4 Challenging the Status QuoLow probability of success in the short run trying to “fix” the barriers to accessing current mental health services Can we build something new to reach those who would not use current services? Yes: eMHP EOD pilot effort commenced July 2010 embedding contract civilian providers Yes: Expanded to NCG in May 2012 Both fully staffed with CIVPERS by Feb 2013 Yes: Green light to expand with MILPERS in FY15 to the rest of NECC Forces We talked to BUMED about what the Navy could do with their Wounded Warrior funding. But the only encouragement we could find came from seeing: Psychologists embedded with Seal Teams & on Air Craft Carriers & the OSCAR program that the Marines were developing

5 Measuring Success Pilot Program in EOD: If we build it, will they come? Yes: eMHP EOD pilot effort commenced July 2010 & in 3 months providers had full counseling caseloads Are we reaching Sailors who would not self-refer to non-embedded mental health providers? Yes: 63%* of Sailors self-referring to eMHP for counseling have never self-referred to counseling before [not to MTF, FFSC, Military One Source, in town, etc.] So NECC funded this withOUT any help from BUMED & did a Pilot embedded mental health Program in EOD: IF we build it – Will they come? Within 3 months they had a full counseling caseload. We’re reaching people who had never IN THEIR ENTIRE LIVES self-referred to mental health services before. * EOD: 280 SMs out of 414 have never self referred = 68% NCG: 152 SMs out of 289 have never self referred = 53%

6 Measuring Success Surprises: Are we reaching SM who need us?Yes: 53% display full PTSD Yes: 70+% with significant post traumatic stress symptoms Surprises: About 15% (737) of 5073 SM take advantage of the 15 minute checkup to talk with the provider for 45 minutes or more about worries & stresses that have accumulated over the past 12 years Within the first year, some Seabee COs wanted to take eMHP providers with them when they deploy The people aren’t just coming in because they’re using an appointment with us to avoid something else. Fewer than 5% give PTSD as the reason they are coming to see us. But most have significant PTSD symptoms One of the surprises is that people come in for checkups & want to talk about 12 years worth of worries & stress. These aren’t the people who are coming for counseling. They just want to ask, “Doc, is this normal?” Seabee Battalion COs went from “This is an EOD program, how’s this going to work for Seabees” to where several battalions have adopted their civilian provider & want to take they when they deploy & don’t want to share them with anybody else [a problem since we’re not staffed at 1 provider per battalion]

7 Measuring Success Are we reaching Sailors who need professional help? Yes: many self-referring for counseling admit degraded resilience & needing help bouncing back I’m a psychologist, so of course I think I can measure resilience. This is a glass half empty for me: 43% of EOD and 66% of Seabees who come in for counseling are having trouble bouncing back. So we are seeing the people who need to see us. -The resilience pie charts come from eMHP data, they represent the sum of all the factors that contribute to Sailor Resilience. -eMHP work to improve coping skills and psychological flexibility that addresses the individual's internal resilience factors. -eMHP Metrics in 2013 are expanding to assess resilience in all deployers seen for checkups -New checkup questions will also assess the Sailor’s perceptions of the most powerful family-resilience-factor (support) & community-factor (belongingness) -Family-level resilience factors, such as family support, are addressed by identifying and solving family problems before deployment; providing family pre-deployment training; promoting healthy communication skills, etc. -Unit-level factors, such as positive command climate, are addressed by instilling discipline; communicating a clear vision; promoting ethics and protecting core values, etc. -Community-level resilience factors, such as belongingness, are addressed by building integration, friendships, including participation in spiritual/faith-based organizations, protocols, ceremonies, social services, schools, and so on, and implementing institutional policies. Additional factors include Cohesion, Connectedness and Collective efficacy. -Resilience requires exposure to adversity (and successfully over-coming it); has both environmental and biological components (both of which are dynamic); develops over time; is inherently strength-based and can be enhanced through training. *Note: average range for resilience measure is => shown above as green Sample Question “I tend to bounce back after illness or hardship” is rated 0 to 4 as follows: _ not true at all (0) _rarely true (1) _sometimes true (2) _often true (3) _true nearly all of the time (4) over the past month

8 Measuring Success Are Service Members benefitting from services?Yes: Sailors in counseling report value of the program in as few as 3 sessions Yes: 99% would recommend the program to a friend in need Is the program worth the investment? Yes: External recognition validates cost taken out of hide As a best practice by Task Force Resilient Final Report April 2013 commissioned by the VCNO to explore factors impacting the resilience of our navy and to make recommendations to improve organization, training, resources and metrics. Lead: RDML W.E. Carter said that eMHP is the cornerstone of NECC’s resilience initiatives As one of three out of 167 Psychological Health Programs given priority for Program Evaluation by Defense Center of Excellence (DCoE) An Executive Order requires DOD to validate the efficacy of all of its programs related to psychological health. The Assistant Secretary of Defense (ASD) Health Affairs (HA) directed a Psychological Health Effectiveness Initiative within the DCoE Division for Program Evaluation to identify redundancies & eliminate gaps in Psychological Health Programs. There were 167 programs reviewed by PHE Initiative's scientific panel. The eMHP was one of three selected to begin their Program Evaluation phase which is planned over the next five years. The Sailors say it helps: and 45% take the time to answer the anonymous surveys! [details of this & other measures are in the backup slides] RADML Carter’s Task Force Resilient looked at programs across the DOD & outside. He told me that the Navy didn’t need to do a pilot program, because NECC had already done a pilot program showing how to build resilience & that the eMHP was the cornerstone. Besides the external recognition mentioned here: Vice ADM Connor has given the green light to a pilot program with Submarine Force Atlantic that is modeled on our eMHP.

9 Keys to Success NECC took it out-of-hide to build the eMHP: 10 CIVPERS Mental Health Providers have a combined total of 40 years of graduate education and 194 years of experience. Provide briefs, advisement to Leadership [especially related to their COSC & COSFA responsibilities] & consultation with organic Medical Providers Direct services to Sailors include counseling plus check-ups and prevention such as building psychological resilience Leadership often signs up first for checkups Word of mouth: “Bubba told me it was helping him” And then when Service Members who have told their peers they are in counseling get promotions If we had waited on BUMED or Big Navy to work this out, we’d still be waiting. So NECC took it out-of-hide to start this program. Though counseling is the core service we deliver, we purposely provide more support in many other ways. IF you want to get down in the weeds with secret ingredients, more keys to success are in the backup slides. COSFA based assessment is indicated for a unit by the same factors that are used for individuals; observable changes in function, statements of distress, or known stress exposure. There are three elements to the assessment. 1. Identify the four sources of stress injuries present in the current situation. 2. Identify behaviors that support or threaten essential needs following trauma or intense stress. 3. Look for areas where a stress injury source intersects with essential needs to produce vulnerabilities or strengths.

10 Case Study Contacts CAPT Bruce A. Cohen, MC, USN NECC Force SurgeonCDR Lee "Jam" Vitatoe Deputy Force Surgeon Harold Dennis Kade, PhD, LCP, C-SUD Force Psychologist, eMHP Manager, NO2M Navy Expeditionary Combat Command (NECC) Joint Expeditionary Base (JEB) - Little Creek 1575 Gator Blvd, Building 3504, Room 117 Virginia Beach, Virginia 23459 (757) x427 Fax in NO2M: (757) HDK BB: (757) HDK Cell: (757)

11 Backup Slides Backup SlidesPsychological fitness (readiness) is defined as the integration and optimization of mental, emotional, and behavioral abilities and capacities to optimize performance and strengthen the resilience of warfighters. The service members’ resilience (ability to withstand, recover, grow, and adapt under these challenging circumstances) is vital to force protection. In addition, without such resilience, service members’ performance (ability to successfully complete tasks) suffers and their fitness and readiness for deployment is adversely affected. CJCS SEP2011 Backup Slides A picture is worth a thousand buzzwords. Hard sciences aren't hard because they use better scientific method: astronomy can't even do experiments. But hard sciences use more graphs and don't quickly change terminology to what's fashionable. ~ HDK, Force Psychologist

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13 Regardless of specific need, eMHP counseling can helpMeasuring Success 440 Service Members from EOD since July 2010 286 Service Members from NCG since May 2012 Regardless of specific need, eMHP counseling can help

14 Regardless of specific need, eMHP counseling can helpMeasuring Success *Previous slide showed that Service Members seek counseling for a wide range of reasons *Here you see that daily functioning is improved by eMHP counseling *This means they’re doing better at work at home in close relationships in general Regardless of specific need, eMHP counseling can help

15 Measuring Success Scientists argue about whether patient’s can judge the quality of their care or if it just shows they’re satisfied with how well their doc communicates with them But these numbers offer strong support of the eMHP 96% of 187 Service Members have been helped to deal more effectively with their problems 99% would recommend the program to a friend in need No Service Member was dissatisfied, felt counseling did not help or made things worse, or would not recommend the program to a friend in need The total satisfaction score across all five questions averages 95% of the possible maximum score 45% of Service Members take the time to fill these out That’s twice the return rate of most voluntary anonymous surveys That shows how much they value the program Bars above show average answer to each question on 1-5 Scale => higher is better “My counselor has helped improve every aspect of my life.” “I’m glad I found such great help!” “The eMHP here has been a tremendous help so far. The staff and doctors are very caring and compassionate people”

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17 Other Keys to Success Reducing barriers to access:Embedded in workspace & learning the local culture (EOD vs. Seabees vs. Combat Camera) via FTX, etc. Attending checkup appointments is required for all deployers, but SM are NOT required to answer questions Checkups create foot traffic in and out of office so those coming for counseling are not obvious Everyone spending 15 minutes with a mental health provider reduces stigma Counseling records are a separate analog file & AHLTA is involved only when a higher level care is needed If needs can be met by outpatient counseling once per week, then admitting symptoms of a diagnosis does not trigger referral to higher level of care

18 The Way Ahead An 80% Solution: by design, the NECC eMHP has overcome all of the 5 barriers to accessing psychological services identified in the 2011 RAND monograph except logistical obstacles of “teaching cognitive skills during pre-deployment when service members are already undergoing rigorous training over very long days and are cognitively depleted… [This will also] make it difficult to find time to practice new skills daily, as recommended.” [p. xvii] Steps: 1) Develop data-driven model that predicts decreases in psychological readiness of personnel 2) Develop & deploy briefs & 1-on-1 coaching for those needing prevention 3) Integrate predictive & proactive maintenance of psychological readiness into Service Members’ schedule Figure out how to be just as successful with the Reserve Component despite the challenge of access only during the brief time they are training or mobilized The same staff who repair what’s broken can do preventive maintenance

19 Emotion Vitality AssistantSmartphone App Navy Center for Innovation IdeaFest 2013 Hampton Roads, VA LT Darryl “D” Diptee, USN EVA

20 Problem: Military Suicide(yes, but not the only problem) Ineffective mental health checkups Gaps in mental health coverage Lack of mental health record continuity Negative stigma related to mental health Nowhere to safely express deep secondary emotions EVA

21 Solution: Smartphone App

22 Smartphone App Extends face-to-face mental health to the virtual space. A safe, confidential place for 24/7 emotional expression. Counselors gain better understanding of patients. Safety planning for bouts of depression or suicidal ideation Live chatting with suicide prevention specialists GPS locator for SAMHSA treatment facilities Instant connectivity to the National Suicide Prevention Lifeline via TALK (8255) EVA

23 My evolution to innovationNon-inquisitive Inquisitive Non-doer Doer Believer Thinker Robot Innovator EVA

24 EVA Screenshots EVA

25 Components of successful grassroots-based, bottom-up, disruptive innovationsEmpathy: EVA’s concept was based on first-hand experience. Empathy allows for total immersion into the problem-space. Passion: With no funding, official Navy support, or promise of success, passion fueled several hundreds of hours researching and designing EVA. Networking: An idea cannot succeed without people to support and implement it. EVA’s concept was presented at an international conference, pitched to dozens of people, and ed to hundreds more. EVA

26 My Steps to Success Be passionate about solving the problemStrive to understand the problem fully Empathize a solution Rapidly test multiple solution prototypes Isolate your best “solution”, continue to fine tune Survey your peers for feedback of your solution. Push your solution and supporting survey data to every SME / PhD / anyone who will listen; their support will help give your concept validation. EVA

27 What to Expect Very few will immediately recognize your brilliance or hard work Experts may ignore or ridicule your idea Pushback from people you least expected Frustration, moments of self-doubt Periods of slow or no progress EVA

28 Untapped Potential “Deckplate innovation originates within the problem-space and is absolutely priceless; until leadership recognizes its value, sailors will continue to represent an immense reservoir of untapped potential.” - LT Darryl “D” Diptee, USN EVA