Issue
The fiscal year (FY) 2019 National Defense Authorization Act (NDAA), Section 702, directed the U.S. Department of Defense (DoD) to “carry out a pilot program to assess the feasibility and advisability of using intensive outpatient treatment programs to treat members of the Armed Forces suffering from posttraumatic stress disorder [PTSD] resulting from military sexual trauma, including treatment for substance abuse, depression, and other issues related to such conditions” (Public Law 115-232, 2018). The Psychological Health Center of Excellence (PHCoE) commissioned the RAND Corporation's National Defense Research Institute to conduct supplemental analysis to support its response to Congress.
Topics and Approach
PHCoE asked RAND researchers to examine three research topics:
- An analysis of data from the military workplace on the prevalence of sexual trauma among personnel with mental health conditions.
- A programmatic review of four intensive outpatient programs (IOPs)—two in the private sector and two in DoD—to understand different program components available to active-duty service members who have experienced sexual trauma and other trauma.
- A review of policies to understand TRICARE authorization procedures and other regulations governing IOPs.
To conduct this research, we examined data from the 2014 RAND Military Workplace Study survey, reviewed relevant policies, and interviewed personnel from IOPs to obtain contextual information to inform PHCoE's response to Congress.
Key Findings
- Our secondary data analysis revealed that, in a hypothetical group of 100 servicewomen with probable PTSD, we would expect that 40 had been sexually assaulted in their lifetimes. For 15 of the 40, they would have been sexually assaulted within the previous year.
- The demand for services is a key driver of decisions about how, when, and where to implement an IOP model of care. If a clinic or hospital serves a large enough group of service members with PTSD, it might be able to support specialized sexual trauma–informed care.
- Using our programmatic review, private-sector and direct-care IOP programs use evidence-based treatment approaches and have established processes for treating active-duty service members.
- Our policy review and discussions with program officials indicated that the TRICARE application process, accreditation, state licensing, and credentialing were not identified as barriers to private-sector IOP authorization and practice. Other policies, related to reimbursement, referral, leave, and privacy, were identified as potential barriers.
Knowledge Gaps
Our reviews revealed many knowledge gaps surrounding the experiences, treatment needs, and the effectiveness of different treatment components and models of care for active-duty victims of sexual harassment and sexual assault experiencing PTSD and related mental health problems. These knowledge gaps suggest additional areas of study for PHCoE and the Defense Health Agency (DHA) to explore to further their understanding of this important topic.
What are the treatment preferences of active-duty victims of sexual harassment and sexual assault with psychological health needs?
Our analysis highlights the need to collect data on the preferences of this population for seeking care in the private sector versus direct care at a military treatment facility (MTF). Furthermore, it would be useful to understand why certain active-duty service members may prefer a private-sector IOP; understanding those reasons may help the DoD improve care at MTFs.
Are IOPs effective? If so, what makes them effective? Are they more effective than traditional outpatient treatment for active-duty service members who have experienced sexual harassment or sexual assault during military service?
More research is needed before implementing the IOP model as a standard of care. It would be important to understand whether the benefits of IOP care relative to traditional outpatient level of care are enough to warrant the increased cost of implementing and relying on IOPs for the targeted patient population. The experts with whom we spoke and the literature we reviewed raise other important hypotheses and areas of study, such as whether attrition rates or key features of an IOP (e.g., group therapy) predict the IOP's effectiveness. An evaluation would identify the key predictors of treatment outcomes, the trade-offs associated with rolling or cohort-based admissions, and where to host an IOP.
Is DoD equipped to meet the psychological health need(s) of these service members?
Determining current utilization rates of outpatient DoD and private-sector IOPs is a starting point. DHA should assess the ability of DoD to meet the demand for IOP care among active-duty service members who have experienced sexual trauma and the availability of private-sector or U.S. Department of Veterans Affairs (VA) IOPs should DoD's capacity fall short.
Further Considerations for the DHA
DHA might consider establishing a research roadmap for how best to address these and other knowledge gaps about the optimal treatment for active-duty service members with problems stemming from a military sexual assault. Some key topics, as summarized in Table 1, consist of treatment effectiveness, patient preferences, and military health system (MHS) and TRICARE capacity. A necessary next step would be consideration of clinical management and care coordination policies and procedures, particularly when referrals are made to private-sector programs. In our policy review, we did not identify standardized guidance for referring clinicians, but additional research to assess the availability of clear policies and procedures for behavioral health providers is needed.
Table 1. Topics for Future Research
| Approach | Research Areas |
|---|---|
| Treatment effectiveness | |
| Program evaluation | Assess multiple program components, such as program length, treatment approaches, group size, and location |
| Standardize clinical procedures to enhance evaluation | |
| Comparative effectiveness trials | Compare outpatient programs with IOPs |
| Compare direct-care with private-sector or VA outpatient and IOP | |
| Patient preferences | |
| Interview and survey | Assess preferences for types of therapy, length, and setting |
| Consider preferences in subpopulations (e.g., at-risk groups) | |
| MHS and TRICARE capacity | |
| Cost benefit analysis | Determine demand for services |
| Assess availability of services in MTFs and the private sector | |
| Assess cost implications of treatment delivered in MTFs, VA, and private sector | |
| Consider transaction costs of partnering with non-DoD organizations | |
| Clinical management | |
| Provider assessment | Evaluate clinical coordination procedures (e.g., referral, medical charting, discharge plans) |
| Care coordination | Assess whether clear policies and procedures exist and are accessible for behavioral health providers to refer, communicate with private-sector program staff, and receive service members back for additional treatment |
| Policy analysis | Assess appropriateness of existing travel and lodging reimbursement procedures |
A systematic evaluation of the topics we have described is a necessary next step to understanding the appropriateness of utilizing IOPs to treat service members' mental health consequences of experiencing sexual trauma in the military. The review described in this study highlights the promising outcomes of IOPs and suggests that DoD should continue to evaluate the use of these programs to treat service members experiencing mental health consequences of sexual trauma.
