Written By Spring 2022 M-VETS Student Advisor Hannah Petruzzi.
**Military Crisis Line: 800-273-8255, then press 1; or text 838255 to access online chat**
Awareness of mental health issues, especially those pervasive throughout the armed services, has grown substantially over the last decade. Prior research found high rates of mental health problems among United States servicemembers and Veterans, including post-traumatic stress disorder (PTSD), depression, substance use, and suicide. Unfortunately, servicemembers are often hesitant to obtain assistance due to the stigma surrounding mental health conditions and (often well-founded) concerns about reporting requirements and potential negative effects on career advancement. Military servicemembers report barriers to seeking care, primarily the fear of negative consequences for using mental health services and lack of clarity surrounding confidentiality.
QUESTION 1: How many servicemembers experience a mental health issue?
As of 2014, twenty-five percent of U.S. military members had some sort of mental disorder, including panic disorder, ADHD, or depression. Despite a long-list of mental health conditions which are disqualifying for military service, two-thirds of those individuals had their condition prior to enlisting. Mental health issues persist once the individual completes a term of service as well. During the period from 2008 to 2017, more Veterans committed suicide “than the total number of US service members who died during the entire Vietnam War.” As of 2018, Veterans were more than twice as likely as civilians to commit suicide. Strikingly, nearly one third of the service members who returned from Iraq or Afghanistan reported developing a mental health condition or experiencing a traumatic brain injury during deployment. Roughly eighteen percent of them returned with PTSD or depression, and others experienced a range of issues including anxiety, suicidal thoughts, alcoholism, and drug addiction.
QUESTION 2: If I obtain counseling, will my sessions be confidential?
Generally, yes. The majority of counseling treatments and services create protected information and are kept confidential. However, there are several exceptions servicemembers should consider prior to obtaining counseling. Individuals should review privacy limitations with their provider from the outset. Specifically, servicemembers should have an open discussion with their psychologist or counselor and ask about the counselor’s note taking practices. All psychologists are mandated to break confidentiality to report suspected child abuse or dependent-adult abuse, protect clients from self-harm, and warn identified third parties of imminent harm. Military psychologists may also be required to disclose confidential information to assist in lawful military investigations, conduct suitability screenings or command-directed mental health evaluations, and report spousal abuse or other criminal behavior.
Servicemembers can be assured that the Health Insurance Portability and Accountability Act of 1996 (HIPPA) does apply to the Department of Defense (DoD). However, HIPAA itself includes an armed forces exception. There are nine categories which fall under the HIPAA armed services exception. These are the primary avenues through which information may be made accessible to command once counseling is provided to a servicemember.
HIPPA’s armed forces exception provides that “a covered entity, including a covered entity not part of or affiliated with the DoD may use and disclose protected health information of individuals who are armed forces personnel for activities deemed necessary by appropriate military command authorities to assure the proper execution of the military mission.” However, in 2011 the DoD issued an instruction entitled “Command Notification Requirements to Dispel Stigma in Providing Mental Health Care to Servicemembers.” That instruction requires healthcare providers to follow a presumption of NOT notifying a servicemember’s commander when that service member obtains mental healthcare or substance abuse educational services unless that presumption is overcome by one of the nine enumerated standards. Furthermore, in making such permitted disclosures the provider must provide the minimum amount of information to the commander concerned as required to satisfy the purpose of the disclosure. The nine enumeration notification standards are detailed below. Note that while the DoD instruction (DoDI) requires disclosure on these nine criteria, the DoDI does not mandate blanket disclosure of violations of the Uniform Military Justice Code (UCMJ) or the law of international armed conflict if such information does not otherwise fall under one of these categories.
- Harm to Self. This applies where the provider perceives a serious risk that the servicemember will cause harm to themselves either as a result of the condition or as result of medical treatment of the condition.
- Harm to Others. This applies where the provider believes the servicemember poses a serious risk of harm to others as a result of the condition or resulting from medical treatment of the condition, including child abuse or domestic violence.
- Harm to Mission. This applies only where the provider perceives a serious risk of harm to a specific military operational mission, generally including disorders that significantly affect impulsivity, insight, reliability, and judgment.
- Special Personnel. This exception applies where the individual is in the Personnel Reliability Program (DoDI 5210.42), Nuclear Weapons Personnel Reliability Program, or a position that has been pre-identified by service regulation or command as having responsibilities of such sensitivity or urgency that normal notification standards would risk mission accomplishment.
- Inpatient Care. This applies when the service member is admitted or discharged from any inpatient mental health or substance abuse treatment facility.
- Acute Medical Conditions Interfering with Duty. This applies when the individual is experiencing an acute mental health condition or engaging in treatment that impairs his or her ability to perform assigned duties.
- Substance Abuse Treatment Program. This applies where the individual has entered or is discharged from a formal outpatient or inpatient treatment program for rehabilitation for alcohol and drug abuse for the treatment of substance abuse or dependence.
- Command Directed Mental Health Evaluation. This applies when the mental health service is obtained pursuant to a command-directed mental health evaluation consistent with the DoD Directive on mental health evaluation.
- Other Special Circumstances. This applies where the import of executing the military mission outweighs the interests served by avoiding notification and is determined on a case-by-case basis by a healthcare provider at the O-6 or equivalent level or above or a commanding officer at the O-6 level or above.
QUESTION 3: Once I feel comfortable obtaining counseling, what are my options within the military?
There are counseling options within the DoD system. Military OneSource counselors are available for free, short-term, confidential non-medical counseling services for a wide range of issues from marital conflict to stress management to coping with loss and deployment. These sessions are available in person at military installations worldwide, over the phone, or via secure video or online chat. All active-duty service personnel are eligible for OneSource counseling, including members of the Army, Marine Corps, Navy, Air Force, and Space Force. Visit https://www.militaryonesource.mil/ for additional information on scheduling an appointment.
Military and Family Life Counseling (MFLC) is another DoD program providing free non-medical counseling for service members and their families. Also provided by OneSource, this program provides support for family challenges unique to military life in sessions one-on-one, to couples, or in groups. Assistance can cover deployment adjustments, stress management, moving preparations, relationship building, problems at work, the grieving process following the death of a loved one or colleague, and much more. Services obtained through this program are confidential, not reported to the command, and do not impact a servicemember’s security clearance.
QUESTION 4: Are there counseling options outside of the military?
Yes, if you have a mental health diagnosis or are able to pay out-of-pocket. You may wish to seek counseling outside of available military resources. Civilian psychologists, especially in private-practice settings, “typically have greater control over client records and [may be able to] limit access to therapy notes.” The major difference with these psychologists is they have a professional duty “solely to the service member seeking treatment,” as opposed to military counselors and therapists who may have conflicted interests because of their own duties to command. However, servicemembers should consider potential drawbacks, such as whether the particular civilian psychologist has sufficient experience working with the military population to understand the military culture and relevant stressors.
Servicemembers should also consider the cost of obtaining medical or mental health counseling outside of military resources. Some providers may accept TRICARE directly and other organizations have established a network of therapists who provide TRICARE-covered mental health services via secure video chat. For example, Telemynd is a “nationally recognized partner for Tele-behavioral Health under TRICARE.” However, TRICARE only covers services that “fall under the definition of medical counseling, or counseling for the purpose of treating one or more diagnosed mental health conditions.” Thus, a servicemember wishing to obtain counseling outside of the military network will likely have to pay the entire cost of service and should discuss the price and budgetary restrictions with each provider to make an informed decision.
QUESTION 5: Are there alternatives to therapy or medical counseling?
Yes. Active-duty personnel may also consider meeting with a military chaplain. While chaplains are not licensed medical professionals, they are “bound by absolute confidentiality.” They are also trained in counseling servicemembers and often have a solid foundation of experience helping individuals with a broad array of issues including combat stress, deployment, marriage and family, substance abuse, grief, and finances. Relevant contact information for your installation’s chaplain is readily accessible on your installation’s website.
QUESTION 6: Are there alternatives if I think I have an alcohol or substance abuse problem?
Absolutely. Alcoholics Anonymous (AA) meetings are widely available on military installations and in civilian communities. AA and Narcotics Anonymous (NA) provide a useful alternative to counseling services and other substance abuse treatment programs which may lead to command notification. These follow 12-step models which involve: “[admitting] that you cannot control your addiction or compulsion, [recognizing] a higher power (as you understand) that can give you strength, [examining] past mistakes with the help of a sponsor (experienced members), [making] amends for these mistakes, [learning] to live a new life free from old, unhealthy habits and behaviors, [and helping] others who suffer from the same addiction or compulsions.”
Many active-duty servicemembers participate in AA or NA. Stories of Alcoholics Anonymous actively involved in or retired from the armed forces can be found here: https://www.aa.org/aa-and-armed-services. One Veteran with experience in the programs stated, “Alcoholics Anonymous provided a practical program of action that was SIMPLE. It wasn’t affiliated with the military in any way and most importantly it was discreet . . . [so] my command wasn’t kept in the loop. I was surprised to see support available in every country I’ve been stationed, either in person or online.”
Servicemembers can be assured information obtained in counseling sessions will only be shared with command in dire circumstances. In the majority of situations, obtaining counseling through OneSource or a private therapist, or speaking with your installation’s chaplain, can provide guidance on managing the challenges of military life without involving command. Alternatively, where alcohol or substance use is causing concern, an anonymous twelve-step group can provide a lifeline for recovery without risking one’s career.
 Title 45 C.F.R. § 164.512(k).