Perceptions of Mental Health Confidentiality Policies and Practices in the U.S. Military

Issue

High rates of mental health issues among service members and a reluctance to access mental health services together represent one of the greatest ongoing threats to U.S. military readiness. Concerns about the confidentiality of mental health services received within the military have been documented as a significant barrier to service members obtaining needed treatment. Under certain circumstances, U.S. Department of Defense (DoD) policy states that mental health information can be shared with a member's commanding officer. Department of Defense Instruction 6490.08 (2011), Command Notification Requirements to Dispel Stigma in Providing Mental Health Care to Service Members, lays out these circumstances. Principal among them is whether there is a serious risk of self-harm, harm to others, or harm to a specific military mission.¹ Department of Defense Instruction 6490.08 specifies that providers “shall provide the minimum amount of information to satisfy the purpose of the disclosure,” which includes “ways the command can support or assist the Service member's treatment.”² Department of Defense Instruction 6490.08 also stipulates in its instruction to commanders that information “shall be restricted to personnel with a specific need to know.”³

Commanding officers are entrusted with the responsibility of ensuring the success of military operations and the protection of personnel. Mental health conditions can potentially affect functioning and job performance such that the safety of service members and the military mission can be endangered. At times, disclosing mental health information to commanding officers may be necessary so that informed decisions can be made about duty assignments, needed accommodations, unit resources, or deployments.

Service member concerns about the disclosure of treatment information to the chain of command are closely tied to the potential career consequences that could ensue (e.g., fitness-for-duty limitations that may affect promotion). To the extent that these concerns deter service members from obtaining needed mental health services, military readiness could be undermined. The challenge the U.S. military faces is how to optimally protect service members' privacy so that mental health services are sought and needs are not driven underground—while also ensuring successful execution of the military mission.

The purpose of this study was to assess service members' understanding and perceptions of confidentiality policies and practices and whether these perceptions affect their decisions to seek mental health care. The analysis could inform policy and practices that aim to balance “patient confidentiality rights and the commander's right to know for operation and risk management decisions” (Department of Defense Instruction 6490.08, 2011).⁴ This is the first study to conduct a comprehensive examination of these issues.

Approach

We conducted a mixed-methods study that included developing the 2022 Health Care Privacy in the Military (HCPM) Survey, fielding the survey to the active component, and conducting interviews with service members in key roles associated with mental health care in the military. The HCPM Survey was administered online from August 8 to October 17, 2022, using email recruitment. Our sampling frame comprised all active component U.S. military personnel not enrolled as cadets in service academies, senior military colleges, or other Reserve Officer Training Corps programs as of March 2022, drawn from the Defense Manpower Data Center Active Duty Master File (N = 1,326,607). Flag officers (those at or above the pay grade of O-7) were also excluded to ensure the confidentiality of the results.⁵ Out of 60,623 individuals who had an email address and were randomly selected for an invitation to participate, 1,873 respondents were considered as completing the survey based on a minimum survey response threshold, for an overall response rate of 2.8 percent.⁶

Survey weights were used to ensure that the analytic sample of respondents matched the overall active component on a variety of demographic and military characteristics. We aimed to field a survey that was representative of the active component military, but participants in the HCPM Survey likely included more members who have a personal interest in the survey topic—that is, those who have mental health symptoms or have sought treatment in the past—compared with the active component as a whole. Statistical techniques used to ensure that survey responses are representative of the active component likely could not fully account for this bias. The service members who self-selected into taking the survey represent a group with a particular interest in military policies around mental health care and are likely those for whom the confidentiality policies are designed to reassure and encourage treatment. Thus, these results are still useful for policymakers and provide key insights into how policies in effect during the time of the study that remain unchanged are working for those individuals who are most directly concerned with the confidentiality of treatment. The HCPM Survey provides estimates of the prevalence of perceptions related to confidentiality limits, the implementation of confidentiality policies, and the impact of the policies for the population surveyed, but results cannot be generalized to the larger DoD population.

Semistructured interviews, conducted between December 2020 and March 2022, included three stakeholder groups—commanding officers (O-1 to O-5), military mental health providers (above the rank of O-3), and other enlisted service members—recruited from each service branch (excluding the Coast Guard) and among varying ranks and experiences. We conducted a total of 46 in-depth interviews. Findings from the stakeholder interviews should also be considered in light of certain study limitations. With assistance from the Psychological Health Center of Excellence, the Behavioral Health Clinical Community,⁷ and installation commands, we identified large installations for purposive recruitment of providers and commanding officers. We did not have representation of Army commanding officers and some provider types that deliver care to service members in the Navy and Marine Corps. Nonetheless, the interviews enabled a deeper examination of how confidentiality policies are implemented, particularly with respect to the nature of information sharing between providers and commanding officers within populations that are absent of Army commanding officers and some provider types that deliver care to service members in the Navy and Marine Corps.

Key Findings

Out of 60,623 individuals who had an email address and were invited to participate, 2,069 (3.4 percent) proceeded to the first survey question. The final analytic sample comprised 1,873 respondents, each of whom completed the demographic and military service questions, as well as at least one question about the confidentiality of mental health services, which yielded a 2.8 percent response rate.⁸

Findings from the HCPM Survey and our interviews with key military stakeholders shed light on the various perceptions held by service members on the limits to mental health confidentiality and how policy implementation influences service members' decisions regarding mental health care in the military.

Service members had varied perceptions of the limits to mental health treatment confidentiality in the military. Specifically, the mental health–related circumstances perceived as requiring command notification were subject to varying interpretations:

• Perceptions varied on what constitutes harm to self and harm to others (e.g., suicidal or homicidal ideation versus having a plan).
• Perceptions varied on what constitutes harm to mission (e.g., harm depends on the members' job, and there is higher scrutiny for jobs involving weapons or national security).
• Perceptions varied on what circumstances require command notification. A substantial proportion of respondents held erroneous beliefs, perceiving that command notification was required whenever a service member misses a mental health appointment (56.2 percent), receives prescription mental health medication (31.7 percent), receives a mental health diagnosis (30.9 percent), receives mental health care for any reason (23.3 percent), and is undergoing a marital separation (20.3 percent).

Service members also had varying perceptions regarding what types of information can be shared with command:

• Interpretations varied on what constitutes Department of Defense Instruction 6490.08's (2011) “minimum amount of information” to disclose and the “ways the command can support or assist the service member's treatment.”
• Fifty-eight percent of survey respondents and 80.3 percent of respondents with unmet mental health needs viewed service members as being often or always unsure of what information might be released to commanding officers.⁹

Perceptions related to which personnel or entities can access service members' mental health information also differed. Examples of this include the following:

• Interpretations of Department of Defense Instruction 6490.08's (2011) instructions to commanders to restrict information to “personnel with a specific need to know” ranged from the “leadership triad” (e.g., commanding officer, executive officer, and first sergeant) to being determined on a case-by-case basis.
• Survey respondents were concerned that, if they were to receive mental health treatment, their information would be shared with future nonmilitary employers (55.0 percent), promotion review boards (54.9 percent), future medical insurers (52.7 percent), other providers (51.9 percent), and the Department of Veterans Affairs Veterans Disability Panel (45.5 percent).

We also identified important takeaways regarding the implementation of mental health treatment confidentiality policies and practices, according to service members' perceptions:

• Training and education on confidentiality policies and practices are insufficient for providers, commanding officers, and service members at large.
• Current policy implementation processes may compromise confidentiality (e.g., through informal command notification mechanisms).
• Monitoring and enforcement of mental health confidentiality policies, particularly commanding officers' communication about service members' mental health information, are lacking.

Last, we found that perceptions of limited mental health treatment confidentiality affect service members' decisions regarding mental health treatment and that perceived negative consequences of getting mental health care continue to be a pervasive barrier to care for military service members. Examples include the following:

• More than half of respondents agreed or strongly agreed that the following concerns might affect their decisions to seek mental health treatment: impact on the ability to deploy (61.0 percent), effect on security clearance (59.8 percent), harm to career (57.4 percent), and entry into military training or school (56.3 percent).
• Nearly 90 percent of respondents indicated that they would limit what they would share with military mental health providers because of privacy concerns.
• Approximately half of service members reported they would delay or avoid treatment for issues such as depression (52.6 percent), thoughts of self-harm (48.6 percent), anxiety or worries (48.5 percent), or having trouble adjusting after a stressful life event (47.5 percent) because it could damage their military careers.
• More than 40 percent of respondents reported that they would seek treatment outside the Military Health System (42.7 percent) or that it would be helpful to get care after hours for privacy (44.6 percent).

Perhaps most notably, confidentiality concerns were more prevalent among service members with mental health needs and even more so among the subset with unmet mental health needs than service members with no mental health needs.

Recommendations

We recommend that DoD take the following actions to improve military personnel's understanding of confidentiality policies regarding mental health treatment, strengthen processes to ensure that policies are implemented as intended, and mitigate the consequences associated with limited confidentiality around mental health treatment in the military.

Improve Understanding of Mental Health Confidentiality Policies

• Clarify aspects of policies that are unclear and susceptible to provider and commander discretion and variability in implementation.
• The Defense Health Agency, installation commands, and line supervisors should ensure that policies, manuals, forms, and informational resources are clear and widely accessible.

Strengthen Supports and Accountability Measures to Ensure That Mental Health Confidentiality Policies Are Implemented as Intended

• Enforce mandatory education and training for all military personnel on mental health confidentiality policies and practices. This requires some level of standardization of training materials across services, installations, and provider and commander training programs. Given the number of stakeholders and training settings, specific offices or organizations within DoD should be tasked with leading the development of standardizing materials.
• Use structured documentation to facilitate communications between providers and commanding officers to limit open-ended dialogue and to increase the transparency of the nature of communications so that service members understand what is shared and what is not shared.
• Use structured, standardized documentation to facilitate and limit communications within the chain of command.
• Ensure that policy is revised to include guidance, monitoring, enforcement, accountability, and evaluation of policy compliance when service members' mental health information is disclosed throughout the chain of command.

Mitigate Consequences Associated with Limited Confidentiality Around Mental Health in the Military

• The Defense Health Agency should explore the feasibility of expanding treatment options that afford greater privacy to service members (e.g., telehealth, services during nonwork hours, and services, such as Military OneSource or the Military and Family Life Counseling Program, that are subject to fewer privacy exceptions).
• Modify policies to increase confidentiality protections and minimize adverse consequences associated with limited confidentiality while protecting the needs of the warfighting mission of DoD. Empirical support for the effectiveness of confidentiality policies around military mental health treatment is currently lacking. To best balance service members' right to privacy with commanders' need to know certain information for operational and risk management purposes, future research is necessary to examine whether increasing confidentiality protections (e.g., by restricting disclosure of information to duty limitations) might improve mental health service use and readiness while successfully executing the military mission.