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The Evolving Role of the Division Psychiatrist MILITARY MEDICINE, 172, 9:000, 2007 The Evolving Role of the Division Psychiatrist Guarantor: MAJ Christopher H. Warner, MC USA Contributors: MAJ Christopher H. Warner, MC USA*; LTC George N. Appenzeller, MC USA†; MAJ Matthew J. Barry, MC USA‡; MAJ Anthony Morton, MC USA§; CAPT Thomas Grieger, MC USN¶ With the recent restructuring of Army infantry divisions in nated a formal centralized mental health section and created a the new brigade combat team model, division psychiatrists modular DMHA. The new modular DMH structure, outlined in are facing new and unique demands. This article outlines Figure 2, includes a division psychiatrist and senior noncom- the varying perspectives of the position and the duties and responsibilities of a division psychiatrist. It provides guid- missioned officer located with the division surgeon at the divi- ance on how to negotiate the myriad of challenges unique to sion headquarters unit and a behavioral health officer (psychol- the position. Discussion includes planning and supervision, ogist or social worker) and an enlisted mental health specialist providing command consultation, educational efforts, ful- assigned to each BCT. Multiple BCTs are under the control of filling the roles of an officer and leader, and future direc- the division, such that six to eight mental health providers tions for the position. (psychiatrists, psychologists, and social workers) can be as- signed to a DMHA during deployment. This new modular design Introduction yields more providers and allows for projection of resources to ehavioral health issues have been documented throughout commanders at lower levels (i.e., battalion and company). With B the history of warfare. Since World War I, the U.S. Army has this rapid expansion and evolution of DMH, the role of the been deploying psychiatrists with infantry divisions to provide division psychiatrist has become more diverse and complex. front line treatment of combat and operational stress.1–3 Since The complex effects of combat on soldiers in modern warfare the Korean War, the division psychiatrist has led the division demonstrate the importance of combat and operational stress mental health (DMH) activity (DMHA) both in garrison and dur- control during deployment and the need to monitor mental ing deployment.1,3 The roles and responsibilities for a division health issues following deployment.7–10 This has led to recent psychiatrist were first outlined in Army Regulation 40-216: Neu- updates in U.S. Army doctrine, but unfortunately little guidance ropsychiatry and Mental Health in 1957.4 on the specific roles of DMH has been provided.11 The purpose of The division psychiatrist serves as the leader of the DMH team this article was to outline the role and utilization of the division whose mission is to assist command in controlling combat op- psychiatrist in both the division and in the DMH activity. We will erational stress through training, consultation, and restora- begin with a literature review, discuss perspectives of the posi- tion.5 Until recently, the DMHA consisted of three providers (a tion, outline various aspects of the job, and conclude with psychiatrist, a psychologist, and a social worker) complimented future directions that address the evolving role of the division by six mental health technicians (Fig. 1). However, in the midst psychiatrist. of the War on Terror, the Army began its largest restructuring since World War II changing the emphasis from the division to the brigade combat team (BCT).6 This restructuring effort is Literature Review designed to make the Army a more modular force, increase efficiency and combat power, and increase BCTs from 33 to 43.6 We conducted an extensive literature review of both Army This restructuring has resulted in explicit and implicit tasks doctrine and the medical literature (MEDLINE) searching spe- and challenges for the behavioral health system. cifically for guidance on performing behavioral health care in an In conjunction with the reorganization, there has been an infantry division and the role of the division psychiatrist. The increase in the behavioral health assets assigned to each divi- search parameters used and number of articles found for each sion. Before the restructuring of the force, each division was are listed in Table I. Although much has been published on the staffed with a DMH section consisting of three providers (a psychological consequences of combat and deployment, little psychiatrist, a psychologist, and a social worker) and six en- has been published on the specific roles of the division psychi- 12–18 listed mental health specialists. The new force structure elimi- atrists in garrison or during deployment. Most of the refer- ences were old or did not address current missions and struc- *Division Psychiatrist, Third Infantry Division, Building 1, Fort Stewart, GA 31314. ture of Army mental health assets. †Division Surgeon, Third Infantry Division, Building 1, Fort Stewart, GA 31314. Army regulations associated with mental health care have not ‡Division Psychiatrist, Tenth Mountain Division, 11050 Mount Belvedere Boule- been updated since 1984 and cite only that the division psychi- vard, Fort Drum, NY 13602. atrist will lead the DMH section, serve as a consultant on neu- §Division Psychiatrist, First Armored Division, Building 1040, Wiesbaden Army Airfield, Germany, APO, AE 09096. ropsychiatric issues, and will provide care to soldiers with neu- ¶Associate Professor, Department of Psychiatry, Uniformed Services University of ropsychiatric conditions.4 Field Manual 8-51 was released the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814. initially in 1994 and then updated in 1998.5 It provided an Presented at the 2006 U.S. Army Force Health Protection Conference, August 7–11, outline of the overall mission and role of the DMHA and gave 2006, Albuquerque, NM. This manuscript was received for review in January 2007 and was accepted for some additional insight into the roles and responsibilities of the publication in June 2007. division psychiatrist as a supervisor. This manual was recently Reprint & Copyright © by Association of Military Surgeons of U.S., 2007. updated to outline Combat and Operational Stress Control in Military Medicine, Vol. 172, September 2007 918 Division Psychiatrist 919 Fig. 1. Previous structure of DMHA. Fig. 2. Current structure of DMH in modular army. BHO, Behavioral Health Officer (psychologist or social worker). Field Manual 4-02.51, but provides little guidance on the oper- TABLE I ation of a DMHA or on the roles and responsibilities of a division 11 RESULTS OF MEDLINE LITERATURE SEARCH psychiatrist. Other resources were found in textbooks. The “War Psychia- Search Term(s) No. of Results try” volume of the Textbook of Military Medicine had two chap- Military psychiatry 407 ters which outlined the historical roles and development of DMH Army psychiatry 525 and the position of the division psychiatrist. Glass1 discussed the Military division psychiatrist 138 role of “Psychiatry at the Division Level.” This in-depth review Military combat stress 718 outlined the specific principles for evaluating, treating, and dispo- Military division mental health 112 sition of soldiers in a combat environment. Additionally, this chap- Army mental health 267 ter provided historical data analysis, but unfortunately, the data Army military division psychiatrist 16 are from World War II.1 Rock et al.3 discussed the historical devel- Division mental health opment of U.S. Army mental health resources in “U.S. Army Military Medicine, Vol. 172, September 2007 920 Division Psychiatrist Combat Psychiatry.” This chapter provides insight to changes that were made in doctrine and in the development of DMH units from World War I through Vietnam. However, as Army mental health care evolved into the 1980s, it moved away from the roles of the divisional units and focused on the development of nonembedded combat stress control units.3 Although both chapters are an excellent source of information on the historical development of military mental health sys- tems and the treatment role of a division psychiatrist, they provide little guidance on other duties and responsibilities of the position. In 1993, two articles were published in Military Medicine. Engel and Campbell13 noted the challenges facing a DMH unit. They discussed the minimal attention focused on their role while not deployed and noted the importance of ongoing preven- tive missions based on their lessons learned from deployment to Operation Desert Storm.13 Ritchie and White14 outlined the Fig. 3. Perspectives on the position of the division psychiatrist. guidelines for becoming a successful division psychiatrist pro- viding practical guidance for preparing psychiatrists who were expect the psychiatrist to provide assistance in planning for the relatively new to the military to interact and engage with infan- behavioral health aspects of the entire spectrum of operations try commanders. Additionally, the latter article outlined the and coordinating behavioral health support resources for garri- various duties and responsibilities of the position including (in son and deployed activities. They expect the division psychia- their listed order of importance): behavioral health provider, trist to be able to identify the behavioral health threats to the supervisor of other behavioral health providers, educator of di- units and make recommendations on preventive mechanisms vision medical providers, administrative psychiatry, consulta-
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