Initial job analysis of military embedded behavioral health services: Tasks andessential competenciesAlan D. Oglea, J. Brian Rutlandb, Anna Fedotovac, Chad Morrowd, Richard Barkere, and LaQuanya Mason-Coynera

a480th Intelligence, Surveillance, and Reconnaissance Wing, Joint Base Langley-Eustis, Virginia; b20th Medical Group, Shaw Air Force Base,South Carolina; c61st Medical Squadron, Los Angeles Air Force Base, California; d24th Special Operations Wing, Ft Bragg, North Carolina; e336Training Group, United States Air Force, Fairchild Air Force Base, Washington

ABSTRACTUtilization of mental health personnel assigned to operational military units is an area of growth forthe US military. What activities they perform, how requirements may differ from working in clinicalsettings, and how to select and train for these types of positions is still poorly understood. A jobanalysis was conducted of Air Force mental health providers and enlisted technicians embedded inspecial operations, intelligence, and high-risk training units. Participants rated 27 tasks on fre-quency, importance, difficulty, and risks, as well as the importance of 37 knowledge, skills, andabilities (KSAs), with differentiation between KSAs that may be trained versus those that must bepresent to be assigned to the embedded position. Tasks reflected 4 areas of activity: unit embed-ding/engagement, behavioral health consultation and support, performance optimization activ-ities, and operational mission tasks. Tasks varied by professional training (psychologist, socialworker, enlisted technician) and unit type. The KSAs rated as most important were ethical judgmentand ability to manage complex relationships and boundaries while working outside of a clinic,strong interpersonal skills with appropriate assertiveness to advocate for safe, effective courses ofaction, and understanding of unit missions and organizational dynamics. Results have implicationsfor job design, selection criteria, professional disciplines with KSAs necessary to unit-specific tasks,and training of personnel for integrated operational support positions.

ARTICLE HISTORYReceived 13 August 2018Accepted 18 March 2019

KEYWORDSEmbedded behavioralhealth; military mentalhealth; integrated mentalhealth; operationalpsychology; job analysis

What is the public significance of this article?–This study identified core tasks and essential knowl-edge, skills, and abilities for US Air Force behavioralhealth providers embedded in operational units.While clinical expertise is important, additional pro-fessional and interpersonal skills are needed, as isstrong ethical judgement, in order to perform safelyand successfully. Results are important for selection,training, and planning of embedded mental healthservices.The use of mental health professionals in support ofmilitary operations has a history interwoven with theevolution of psychology, psychiatry, and medicine.These contributions draw on multiple distinct areas ofprofessional practice, including clinical services, indus-trial-organizational consultation, operational psychol-ogy, and others, each with a distinct canon ofknowledge, skills, and research (Hawkey, Breedon,Forziat, & Perkins, 2016; Kennedy & McNeil, 2006;Wasserman, 2012; Williams, Picano, Roland, & Banks,2006).

The majority of US military mental health professionalsare assigned to military treatment facilities (MTFs) provid-ing clinical care to servicemembers and families. In recentyears, however, there has been increasing interest in embed-ding mental health services into operational units(Department of Defense Task Force on Mental Heatlh,2007). From such efforts there are clearly both advantagesand hazards, including improved awareness of operationalworking conditions, relationships with servicemembers,improved access and reduction of stigma as positives, withmultiple role relationships, physical demands, and indeedphysical danger recognized as hazards (Bryan & Morrow,2011; Staal, 2015; Staal & King, 2000).

The US Army has a long history of embeddingmental health assets into deploying combat brigades.Dating back to World War I, forward-deployed psy-chiatrists were used to triage “shell shock” cases todetermine those that could be immediately returnedto duty, those who could return after a brief rest justbehind the front lines, and those who needed to beevacuated (Moore & Reger, 2007). This model of

CONTACT Alan D. Ogle alan.ogle@us.af.mil 480 ISRW/SG, 34 Elm Street, Langley Air Force Base, VA 23665-2108.This article has been republished with minor changes. These changes do not impact the academic content of the article.

MILITARY PSYCHOLOGYhttps://doi.org/10.1080/08995605.2019.1598227

© 2019 Society for Military Psychology, Division 19 of the American Psychological Association

embedded mental health services evolved into the USArmy’s Combat and Operational Stress Control units,consisting of small, mobile teams focused on preven-tion and treatment of combat-related stress reactions,and was relied upon heavily in Operations EnduringFreedom and Iraqi Freedom (Ogle, Bradley, Santiago, &Reynolds, 2012; Reger & Moore, 2006).

For in-garrison support, the US Army has imple-mented the Embedded Behavioral Health (EBH) initia-tive (US Department of the Army, 2013). The primaryfeature of EBH is the colocation of a clinic in readyproximity to an operational unit, within walking dis-tance of a soldier’s place of duty, and staffed to providefull-scope outpatient behavioral health services.Typically, a mental health provider is linked to eachbattalion in the brigade, serving as the point of accessto clinical services, prevention, and command consulta-tion on behavioral health matters. The goal of theprogram is to address problems early, reducing missionimpact and risks that arises from higher levels of acuity.One program evaluation study found indirect positiveimpacts such as improved access and higher perceivedorganizational support, though not clear clinical benefitin terms of lower scores on clinical measures (Russellet al., 2014).

The US Navy has an extensive history of assigningpsychologists to aircraft carriers. They serve as thesailors’ treatment provider and leaders’ consultant forbehavioral health needs of the ship’s company.Johnson, Ralph, and Johnson (2005) described theextremely close quarters of carrier duty, the value ofhaving a high degree of awareness of operational mis-sions, working conditions, and personnel throughoutthe ship, and the challenges of complex multiple rolerelationships that must be ethically managed. Based onsuch experiences, they propose a very thoughtful defi-nition of embedded psychology as “psychological prac-tice in an environment characterized by the intentionaldeployment of a psychologist as part of a unit or forcewhen the psychologist is simultaneously a member ofthe unit and legally or otherwise bound to place theunit’s mission foremost” (Johnson et al., 2005, p. 73). Inrecent years, the US Navy has developed additionalservices comparable to the US Army EBH approachof co-locating services in port for submarine squadrons(Rapley, Chin, McCue, & Rariden, 2017). Early effortshave resulted in reduction of clinical distress and lossesof personnel for psychiatric illness reasons.

The US Navy also provides support to US MarineCorps personnel through Operational Stress Controland Readiness (OSCAR) teams (Hoyt, 2006). Composedof mental health providers, chaplains, enlisted psychiatrycorpsmen, and senior noncommissioned officers, the

teams bring their areas of expertise to improve individualMarine’s functioning, and also provide integrated, orga-nization-wide changes to increase resilience. Hoytemphasized that it is the granular, nuanced understand-ing of the context that distinguishes the “generalist” pro-vider assigned toMTFs from a provider who is an organicmember of the unit and a trusted agent of change. “Thecontextual knowledge of leadership, corporative, or indi-vidual experiences, and mission training ultimately payssignificant dividends in the efficacy and breath of inter-vention strength” (Hoyt, 2006, p. 314).

An additional application of embedded psychologistsorganic to line units is the emergence of operationalpsychology (Kennedy & Williams, 2011; Williams &Johnson, 2006). They do not serve as clinical careproviders but rather apply their expertise to supportthe effectiveness of personnel and the organization. Anoperational psychologist is attached to a special opera-tions combat unit, intelligence organization, or otherunit types to help execute combat missions.Operational psychology has its roots in psychologicalassessment of special mission personnel, such as avia-tors and special operations forces, but their roles haveexpanded over time as operational psychologistsdemonstrated the application of psychological scienceto a range of operational factors to enhance missionperformance and decision-making (Picano, Williams, &Roland, 2006; Staal & Stephenson, 2013).

Recently, the US military’s Special OperationsCommand has fielded EBH assets as part of theirPreservation of the Force and Family (POTFF) initia-tive (US Air Force [USAF], 2018). These teams includecivilian clinical social workers as care providers, as wellas active duty operational psychologists, medical provi-ders, and chaplains, physical therapists, and strengthand conditioning coaches. These services are collocatedwith operational units and, like the US Army’s EBH,seek to provide early intervention and prevention toboth the service members and their families, as well asconsultation and improvement activities for theorganization.

Embedded psychology—a civilian comparison

Similarities to military embedded mental health may beseen in psychologists working in civilian police depart-ments. This application has an extended history ofservice, with psychologists conducting not just clinicaland family treatment but also a range of activities suchas fitness for duty evaluations, screening for hiring ofpolice officers, selection screening for special units (e.g.,SWAT), consultation to investigations and hostagenegotiation situations, and other consultation services

2 A. D. OGLE ET AL.

(Kitaeff, 2011). Aumiller and Corey (2007) identifiedfour domains of competencies performed by policepsychologists, including assessment of jobs, candidates,fitness for duty, and related actions, behavioral healthrelated interventions, organizational improvement con-sulting, and operational support. Brewster and collea-gues highlight the importance of advanced training towork safely and effectively, such as postdoctoral fellow-ship and supervision, and developing in-depth under-standing of law enforcement activities and personnel,organizational and occupational cultures, and how towork effectively with diverse professionals “while main-taining a firm commitment to the practice guidelines,ethical principles, and standards of psychology”(Brewster, et al., 2016).

US Air Force embedded applications

Embedded mental health in the USAF has primarilybeen in support of high-risk, high impact operationalunits. These include special operations forces (SOF);intelligence, surveillance, and reconnaissance (ISR);remotely piloted aircraft (RPA) units, units conductingpsychologically hazardous/high-risk training (e.g.,Survival, Evasion, Resistance, and Escape [SERE]), andother missions. Embedded personnel apply theirknowledge of psychology and related disciplines tosupport and enhance individual and organizational per-formance. Types of services delivered range broadly,from primarily EBH support on one end of the spec-trum to direct mission consultation on the other, witha range of consultative activities to support healthyfunctioning and performance at levels of individuals,teams, units, and overall organizations.

ISR and RPAISR and RPA units have grown exponentially tobecome integral to 21st century warfighting. AirmanResiliency Teams (ARTs) are comprised of medical andmental health officers and enlisted professionals, part-nered with chaplains and their enlisted counterparts,that work on behalf of these “deployed-in-place” war-fighters (USAF Air Combat Command, 2016). ARTsprovide support to unit members, advise commanderson issues that have impacts on human performance(e.g., shift work schedules), and other organizationalconsultation activities. Typically ARTs are composedof six staff (including a mental health provider andtechnician) supporting units of 800–1,600 personnel.

Air force SOFAir Force SOF coordinate precision air to groundmunitions deployment, among other missions. They

use POTFF teams for a range of services to enhancemission effectiveness. Services include consultationwith individuals to overcome barriers to performanceduring rigorous training and operational duties, perfor-mance impairment assistance by clinical social workersto overcome behavioral health issues, and transitionsupport to return to civilian life. Consultation alsofocuses on team and unit effectiveness. POTFF teamsare staffed with 8–9 helping professionals, including anoperational psychologist and a clinical social worker, tosupport units of 180–600 personnel.

High-risk trainingSome training situations, due to situational hazards ofdifferential power and role demand, present a high riskfor negative psychological impact and adverse out-comes. Two such training venues employ embeddedpsychologists and technicians. The Military TrainingConsult Service is embedded in USAF Basic MilitaryTraining and executes instructor selection and training,leader organizational consultation, and behavioralhealth support to 700 instructors, leaders, and staff(Air Education and Training Command, 2014; Barron& Ogle, 2014; Ogle, Barron, & Fedotova, 2016). SEREschool includes captivity simulation exercises that bringpotential hazards of behavioral drift from safety stan-dards, and psychology staff screen instructors andmonitor operations to ensure training is conducted inaccordance with Department of Defence requirements(Department of Defense, 2013). Psychology personnelalso screen and support students as the nature of thetraining may elicit emotional responses. The AirForce’s SERE school is staffed by three psychologistsand eight technicians in support of operations by 600training staff and leaders.

Professional disciplinesPsychologists embedded in USAF operational units areexperienced clinicians who have completed additionaltraining to prepare them for work in specific opera-tional communities. Training requirements and mis-sion-essential tasks for each community are specifiedin guidance, ranging from completion of additionalcourses and supervision to postdoctoral fellowship(Air Force Special Operations Command, 2013;Department of Defense, 2013; USAF Air CombatCommand, 2016).

Social workers are primarily utilized as embeddedbehavioral health providers. Their expertise in clinicalcare to individuals and families, leveraged by co-location in units, make them readily accessible andapproachable partners for unit members experiencingdistress. This accessibility also makes them ideal case

MILITARY PSYCHOLOGY 3

managers as they can track real time care and return toduty decisions throughout the unit.

Enlisted mental health technicians (MHTs) serve undersupervision of psychologists in ART, training, and otherunits. Because of proximity in rank, technicians are oftenthe preferred initial helping agent for enlisted populations.At a subclinical level, MHTs operate fairly independently,providing primary and secondary prevention services aswell as referral to appropriate treatment services whenneeded.

Current study

Despite this being an area of growth in the USmilitary, andother than general descriptive efforts (Hawkey et al., 2016),we are not aware of a systematic study to date to understandthe major activities and the knowledge, skills, and abilities(KSAs) needed to successfully and safely perform in thesepositions as distinct from a “generalist” working ina traditional military mental health clinic. Working outsideof a traditional medical clinic setting presents uniquerequirements, opportunities, and risks for which mentalhealth personnel may not be prepared. A job analysis wasconducted to empirically identify tasks and KSAs to informselection, training, and continuing development of AirForce embedded mental health services.

Method

Participants

The study used a panel of subject matter experts (SMEs),that is, mental health personnel with experience serving inan embedded mental health assignment (meanmonths = 37.2, SD = 27, range = 6 months to 10 years).A total of 24 Air Force personnel participated, including 10uniformed psychologists, 13 enlisted MHTs, and one civi-lian social worker. Two psychologists had served in morethan one embedded position, and provided unique ratingson each, for a total of 27 ratings. Although this sample sizewould be small for clinical or attitudinal research it issufficient for this type of job analysis to providemeaningfulinformation regarding the nature and requirement of theirpositions (Gatewood, Field, & Barrick, 2008). Due to only

having one of each in the sample, the EBH social workerand corrections MHT were included in results for totalsample but not in analyses by unit types. Three unit typeswere represented—ART (psychologist and MHT), high-risk training (HRT; psychologist and MHT), and SOF(psychologist only; see Table 1).

Job study survey

Job study items were developed through a review ofoperating instructions, program descriptions, and poli-cies as available for each position. In addition, wereviewed tasks and KSAs identified in existing job ana-lyses of potentially comparable mental health occupa-tions (e.g., psychologist, counselor, educator) availableon O*NET Online (US Department of Labor, 2017).Finally, a brief survey was sent to job incumbents regard-ing activities they perform and skills believed to beneeded. Synthesis of these data resulted in 27 tasks and37 KSA items. These items were then developed intoa job study survey administered to the participants.Task statements and KSAs are included in the appendix.

Task ratingsParticipants rated the frequency with which they performeach task on a 5-point scale ranging from 1 (not performedat all) to 5 (almost all the time). Based on the recommenda-tion of the Office of Personnel Management a mean scoreof 3 or higher was used to classify as amajor task, that is, anactivity commonly performed in the position (US Office ofPersonnel Management, 2017). Participants for whom anitem is amajor task also rated that task on three dimensions.They rated the importance of performance of that task intheir unit on a 5-point scale ranging from 1 (of no impor-tance) to 5 (extremely). As a measure of task difficulty, theyalso rated the degree to which being able to perform a taskdiscriminated between superior and adequate employeeson a 5-point scale ranging from 1 (not at all, task is easyenough to perform that virtually everyone consistently han-dles it competently) to 5 (a great deal, the task is extremelydifficult to perform; only a few superior employees are able toconsistently handle the job task competently). These partici-pants also rated howmuch damagewould likely occur if an

Table 1. Unit types.

n %

Intelligence, surveillance, and reconnaissance 11 40.7High-risk training units 11 40.7Special Operations 4 14.8Other 1 3.7Total 27 100.0

aA mental health technician embedded in a corrections unit.

4 A. D. OGLE ET AL.

error were made in performing the task on a 5-point scaleranging from 1 (virtually no damage) to 5 (extreme).

KSAsParticipants rated the 37 KSA items on two areas. Theyrated the importance of the KSA to successful perfor-mance in their embedded position on a 5-point scaleranging from 1 (not at all) to 5 (extremely). Participantsalso indicated whether each KSA was essential to havethrough training or demonstrated performance prior tostarting in the position on a 2-point scale ranging from1 (essential, must have) to 2 (not essential to startposition). KSAs that 66% or more of participants iden-tified as essential were so classified.

Results

Embedded task domains

Tasks were reviewed and categorized by author con-sensus into four groups by likeness of activities andpurpose, and were somewhat similar to the police psy-chology domains suggested by Aumiller and Corey(2007). Resultant categories were (a) embedding andunit engagement activities, (b) behavioral health sup-port, (c) performance optimization activities, and (d)applying psychological expertise in an operational mis-sion task. Task rating results are presented by thesecategories in Tables 2–5. In the present sample mentalhealth providers and MHTs engage in the first twocategories, whereas the third and fourth are primarily

Table 2. Total sample ratings of embedded and unit engagement task frequency, importance, difficulty, and damage risk.

Tasks Provider MHT Importance Difficulty Damage risk

Understand unit missions, stressors, and challenges 4.69 (.48) 4.69 (.48) 4.65 (.49) 3.69 (.74) 3.62 (.98)Circulate to build relationships with unit members and leaders 4.46 (.78) 4.54 (.52) 4.67 (.56) 3.85 (1.13) 3.67 (.92)

Note. MHT = mental health technician. Frequency scores in bold indicate this is a major task/job activity.

Table 3. Total sample ratings of behavioral health consultation and support task frequency, importance, difficulty, and damage risk.

Tasks Provider MHT Importance Difficulty Damage risk

Educate individuals with subclinical problems 4.38 (.87) 3.77 (.93) 4.52 (.59) 3.96 (.68) 3.75 (.53)Tailor health promotion programs to unit needs 3.69 (1.03) 3.31 (.86) 4.36 (.84) 3.48 (.85) 3.09 (.75)Advise leaders on how to support distressed personnel 3.62 (1.04) 3.62 (.65) 4.50 (.51) 4.04 (.75) 4.04 (.69)Triage to right clinical or nonclinical services 3.31 (1.03) 3.38 (.87) 4.81 (.40) 3.67 (.97) 4.33 (.73)Develop relationships with support agencies 3.23 (1.64) 3.31 (1.38) 4.06 (.90) 3.35 (.93) 3.47 (.62)Educate, coach, or counsel couples 2.92 (1.11) 1.46 (.66) 4.20 (.63) 3.50 (1.2) 3.50 (.53)Support personnel returning from deployment 2.69 (1.55) 1.77 (1.83) 3.92 (.90) 3.54 (.93) 3.5 (1.0)Guide individuals experiencing a crisis 2.54 (.52) 2.62 (.96) 4.80 (.56) 3.87 (.74) 4.47 (.64)Participate in treatment meetings 2.31 (1.32) 2.08 (1.32) 4.00 (.71) 3.0 (1.12) 3.25 (.71)Assist in grief support 2.23 (.83) 1.69 (.75) 4.13 (.84) 3.7 (.82) 3.88 (.84)Assess personnel for suitability to deploy 2.15 (1.34) 1.23 (.6) 4.50 (.54) 3.96 (.53) 4.13 (.83)Provide clinical care 2.00 (.91) 2.23 (1.30) 4.80 (.42) 4.18 (.75) 3.90 (.74)

Note. MHT = mental health technician. Frequency scores in bold indicate this is a major task/job activity.

Table 4. Total sample ratings of operational performance optimization task frequency, importance, difficulty, and damage risk.

Tasks Provider MHT Importance Difficulty Damage risk

Assess and coach leadership skills 3.54 (1.13) 2.50 (1.00) 3.89 (.58) 3.85 (.88) 3.11 (.90)Assess and train team functioning 3.46 (.66) 2.62 (1.04) 4.0 (.75) 3.63 (.83) 3.21 (.92)Personnel assessment and selection for special duties or missions 3.38 (1.61) 2.85 (1.63) 4.56 (.89) 3.92 (.63) 4.25 (.93)Human performance/sport psychology training 3.31 (.95) 2.38 (1.12) 4.31 (.48) 3.56 (.75) 3.44 (.51)Organizational consultation and development interventions 3.23 (.93) 2.46 (.88) 3.8 (.56) 3.96 (.84) 3.0 (.66)Integrate human factors into mission planning 3.23 (1.30) 2.23 (1.17) 3.86 (.66) 3.71 (.91) 3.71 (.91)Conduct unit needs assessments 3.23 (.93) 2.69 (1.11) 3.89 (.57) 3.58 (1.02) 3.17 (.86)Psychological research on hazards and potential improvements 2.85 (1.14) 2.15 (1.35) 4.17 (.84) 3.67 (1.07) 3.33 (.78)Train mental health personnel to serve as embeds 2.85 (.99) 2.46 (1.33) 4.31 (.48) 3.56 (.75) 3.44 (.51)

Note. MHT = mental health technician. Frequency scores in bold indicate this is a major task/job activity.

MILITARY PSYCHOLOGY 5

performed by psychologists. There were important dif-ferences by unit type, as discussed below. Full taskstatements are included in the appendix.

Unit embedding and engagement activities

Time spent circulating throughout unit spaces, enga-ging with unit members and leaders, building relation-ships and mission knowledge appear to be central tothese positions. They were the most important andfrequently performed of all tasks across all unit typesand professions. Outreach efforts, known as “battlefieldcirculations” or “walkabouts” allow unit members tomeet the embeds, building familiarity and trust whileallowing embeds to learn about missions, working con-ditions, and organizational culture. Missing the markwith these areas can compromise long-term embed-ment efforts. These basic unit engagement activitiesappear to be relatively nontechnical (easy) and equallyimportant for providers and technicians.

Embedded behavioral health consultation andsupport

The next most widely used task by embeds was educa-tion and coaching of unit members experiencing sub-clinical problems. This task was also rated as among themost important and moderate in difficulty. If notaccomplished in a skilled way, potential damage toindividuals, unit, or credibility of the embedded teamwould be significant. Misinformation, poor delivery,and inappropriate timing are probably the quickestroad to ineffectiveness and general mistrust forembedded mental health teams.

Collectively, raters agreed that the ability to provideclinical care was among the most important and mostchallenging of tasks. Frequency of treatment in theseunits was low, however, as at the time of this study AirForce medical service policy permits only limited scopecare (e.g., short in duration, conditions with low safetyrisk, etc.) outside of a medical treatment facility. It isunsurprising then that, among the most critical taskswith the highest potential for damage were crisis inter-vention and triaging individuals to appropriate services.Relatedly, advising leaders on how to support personnelin distress was also rated as important, risky if doneincorrectly, and as particularly difficult. Tailoring train-ing to the units’ needs, fostering cooperative workingrelationships with installation support agencies, andcouples’ counseling were all rated as important tasks,though the frequency, difficulty, and potential damagewere rated only as moderate.

Performance optimization activities

The third task category is applying skills to enhanceperformance and effectiveness within the unit—in indi-viduals, teams, and as an organization. These occurredin ARTs, SOF teams, and HRTs, and are primarilyperformed by psychologists. These performance opti-mization tasks are not commonly covered in depth inclinical psychology training but, as noted for police andpublic safety psychology, are drawn from long-standingindustrial-organizational, sports, and performance psy-chology fields.

Assessment and selection of personnel for readinessand “goodness of fit” was rated as very important,difficult, and with high potential risk. Additional tasksmost routinely performed within this realm are leader-ship assessment and coaching, training unit personnelin human performance enhancement skills, interven-tions to improve team functioning, and organizationaldevelopment interventions. Linking mission demandknowledge with human performance expertise, somealso consult to mission planning.

Another task rated as important is conducting needsassessments and psychological research within the unit.These activities range from informal needs assessments,such as interviews and observations that arise frommission monitoring activities, to more rigorous datacollection and analysis. The results of these inquirieshelp to guide both short-term and local interventions aswell as long-term and enterprise-wide strategicapproaches. Of note, these tasks were rated as moreimportant by ART and HRT psychologists than by SOFpsychologists or by MHTs. Such tasks, especially on themore formal end of the continuum, typically requiregraduate-level psychology training in research designand statistical analysis.

Operational mission tasks

Ultimately the military’s raison detre is to accomplishoperational missions. Some embeds, primarily theoperational psychologists and those in HRT units, pos-sess expertise for consultation or direct participation inmission tasks, taking on nontraditional roles and per-forming tasks most removed from clinical care. Theapplication of psychological expertise to support a linemission task in a deployed location was universallyrated as most important, relatively difficult, and havingthe highest potential for negative consequences. Onsitetraining safety monitoring was similarly rated as highlycritical, with great potential for damage, difficult for allembedded positions, and frequently performed by HRTand SOF teams. Embedded safety monitoring can be

6 A. D. OGLE ET AL.

one of the toughest jobs because it requires not justunderstanding of the nuances of dangerous activitywithin a particular mission but also, when an activityis judged as exceeding tolerable risks, being able toeffectively communicate the concern while preservingthe organizational relationship. Quick decisions regard-ing timing, details of the message, tone, and the recei-ver of the communication, to include third-ordereffects, must be on the forefront of the embed taskedwith the onsite safety monitoring.

Embed competencies

Task–KSA linkagesIdentifying the relevance of specific KSAs to types oftasks was accomplished through review and consensusratings, with the authors as a SME panel. Each KSA waslinked to the task area(s) for which it was assessed ashighly relevant. Several KSAs were linked to multipleareas.

Important competenciesThe most important KSAs across all four taskdomains and unit types are the ability to practiceeffectively and ethically outside a traditional clinicalsetting and to communicate with leaders effectivelyregarding ethical and appropriate courses of action(COAs). Also broadly applicable across domains andunit types are having very good interpersonal com-munication skills and confidence to engage with unitmembers, to successfully integrate into a unit, and totailor efforts to unit culture and context. Knowledgeand skills requirements varied by unit type and pro-fession—for example, HRT embeds needed to com-plete SERE psychology courses and ART and SOFembeds needed top secret clearances to work intheir units. Of note, solid clinical skills and knowl-edge of military medical and mental health servicesand processes, among other prerequisites, were ratedas essential prior to placement in an Air Forceembedded setting. See Table 5 for KSAs and theirratings.

Discussion

This study represents an initial empirical effort to identifykey tasks and KSAs performed by embedded mentalhealth personnel in several USAF mission sets. Weacknowledge multiple limitations. The study useda convenience sample of personnel in embedded posi-tions in the USAF, so results may not generalize to otherpopulations or mission sets. Also, although sufficient fora SME panel job analytic approach, a larger, systemati-cally selected sample would allow better representation ofunit types and more sophisticated statistical methods toidentify task domains (e.g., factor analysis). In addition,this study did not include unit leaders’ ratings on tasksand skills they value. That may be a very important anduseful dataset to help target activities and professionalskillsets that different units value. Further research isrecommended. There are valuable implications fromthis as an initial study, however, as discussed below.

The US military currently has mental health provi-ders and technicians embedded in a variety of missionsets, and this usage is expected to expand. The results ofthis study provide some initial data regarding the taskscommonly performed, and knowledge, skills, and abil-ities needed to be successful. This may inform fora more systematic approach to select, train, and fieldmental health embeds than has been used to date.

Primacy of successful embedding

Regardless of discipline successful embedding is essen-tial across all task areas and unit types studied.Understanding the unit’s mission, stressors, and chal-lenges, and building relationships are the most widelyemployed and important tasks across all settings. Inline with recommendations of Hoyt (2006) andBrewster and colleagues (Brewster et al., 2016), theseactivities are essential to building awareness of thecultural norms and context of the organization, itsmission, pace, demands, pressures, and major stressors,and are foundational to being trusted and successful forproviding unit-centric rather than “industrialized,”one-size-fits all consultation and support.

Table 5. Total sample ratings of operational mission task frequency, importance, difficulty, and damage risk.

Tasks Provider MHT Importance Difficulty Damage risk

Safety consultation to high risk training 3.00 (1.78) 3.08 (2.2) 4.80 (.41) 4.12 (.52) 4.67 (.62)Develop training curriculum for instructors 3.00 (1.47) 2.23 (1.01) 4.15 (.8) 4.04 (.54) 3.54 (.78)Apply expertise for a mission task, e.g., HUMINT analysis 2.00 (1.29) a 1.31 (.63) 5.00 (0) 4.17 (.38) 4.75 (.5)Provide line support activities downrange 1.62 (.96) a 1.31 (.75) 4.75 (.50) 4.08 (.28) 4.25 (.50)

Note. MHT = mental health technician; HUMINT = human intelligence. Frequency scores in bold indicate this is a major task/job activity.a Special operations forces operational psychologists rated these as major tasks in their positions.

MILITARY PSYCHOLOGY 7

The KSAs necessary for embedding were the highestrated—9 of the top 10. This speaks to the need to bepresent and available in the unit rather than part of anexternal organization that visits periodically. Belongingto the unit would appear an essential condition forsuccessful, effective embedding for shared identity aswell as allocation of time. Being “owned” by a medicalunit, even in the best of circumstances, places limita-tions and extra tasks that are at least time demands, ifnot preventative of success. Indeed, two of the authorswere assigned to the local medical unit with freedom oftime to spend in the operational unit—even in this case,however, it was still necessary to learn and respond totwo chains of command, two sets of organizationalpolitics and processes.

Embeds must take great care to practice within thescope of their expertise and competence, obtainingsufficient training, supervision, and peer consultationto expand skill sets, basing recommendations in validsources of data, and remaining grounded in profes-sional ethics. Embedded psychologists must keep lea-ders informed of their limitations, lest leaders assignmore weight to recommendations than would bejustified.

Behavioral health consultation and support

It is a core purpose of embedding to be readily acces-sible and accepted by unit members to encourage seek-ing assistance early, and this focus on early intervention

Table 6. Important knowledge, skills, and abilities for performance in embedded position.

KSA Task area Provider MHT

Ability to work ethically and effectively outside of a medical unit 1, 2, 3, 4 5 (0) a 4.69 (.63) a

Interpersonal skills and confidence to engage and build rapport with unit members at all rank levels 1, 2, 3 5 (0) a 4.77 (.44) a

Able to be appropriately assertive to leaders on appropriate COAs and ethical issues 1, 2, 3, 4 4.96 (.25) a 4.46 (.66) a

Knowledge of unit mission, specialties, training 1, 3 4.85 (.38) 4.31 (1.03)Work effectively as a member of a team 1, 4 4.72 (.63) a 4.46 (.66) a

Able to tailor communication and presentations to line unit audience 1, 3 4.96 (.28) a 4.15 (.9)Understand and manage organizational dynamics internal and external to unit 1, 3 4.88 (.36) a 4.15 (.9) a

Able to innovate services to unit needs, problems, and situations 1, 2, 3 4.75 (.44) a 4.15 (.9) a

Able to work flexible hours as needed 1 4.6 (.65) a 4.08 (1.04) a

Able to create engaging briefings and programs 1 4.51 (.66) a 3.85 (.9) a

Knowledge of military ranks, structures of units on base 1 4.26 (.93) 3.92 (.86) a

Can obtain and maintain a Top Secret security clearance 1 4.2 (1.52) a 2.54 (1.8)Knowledge of how to lead, supervise, develop, and rate enlisted members 1 3.6 (1.04) 3.23 (1.34)Knowledge of the intelligence community 1 3.3 (1.75) 2.46 (1.56)Aeromedical psychology training 1, 3, 4 2.59 (1.04) 1.54 (.97)Skills in crisis assessment, intervention, and referral to appropriate services 2 4.36 (1.12) a 4.31 (.95) a

Knowledge of combat/operational stress prevention and interventions 2, 3, 4 4.2 (.9) 3.69 (1.18) a

Knowledge of base and local treatment resources 2 3.91 (1.34) 3.54 (1.05)a

Knowledge of military medical system 2 3.89 (1.5)* 3.77 (1.01)a

Knowledge and skill in mental health assessment and treatment 2 3.89 (1.5) a 3.69 (.75) a

Knowledge/skill in assessment and intervention for sleep problems 2 3.68 (1.26) 3.46 (1.27)Knowledge/skill in substance abuse assessment and treatment 2 3.27 (1.79) * 3.62 (1.21) a

Knowledge/skill in family maltreatment assessment and interventions 2 3.12 (1.55) 3.08 (1.19)Skill in motivational interviewing 2 3.12 (1.34) 3.85 (1.4) a

Knowledge of security clearance threats and processes 2 2.87 (1.4) 2.62 (1.26)Knowledge and skill in couples counseling 2 2.73 (1.32) 1.92 (.86)Knowledge/skill in interventions for pain and health issues 2 2.4 (1.2) 3.08 (1.38)Knowledge of human factors and human performance optimization 3 4.21 (.83) 4.0 (1.22) a

Knowledge/skill in teambuilding 3 3.84 (.9) 3.38 (1.04) a

Knowledge of executive coaching and leader development 3 3.6 (1.26) 3.15 (1.28)Knowledge/skill to create and conduct surveys 3 3.44 (1.26) 2.38 (1.12)Skill at collecting and managing data 3 3.29 (1.18) 2.77 (1.3) a

Knowledge/skill to conduct research 3 3.21 (1.23) 2.46 (1.2)Knowledge/skill providing emotional intelligence training 3 2.87 (1.21) 3.0 (1.53)Knowledge/skills in psychological testing for special duties assessment & selection 3, 4 4.37 (1.11) a —

DoD SERE Psychology certification 4 2.89 (1.75) 2.62 (1.85)SERE Psychology RT-Qualification 4 2.89 (1.89) 3.23 (2.0)

Note. KSA = knowledge, skills, and abilities; COA = course of action; MHT = mental health technician; SERE = Survival, Evasion, Resistance, and Escape. Skillarea: 1 = unit embedding/engaging, 2 = behavioral health support, 3 = performance optimization activities, 4 = operational mission task.

aIndicates 66% or more rated KSA as essential to start in position.

8 A. D. OGLE ET AL.

rather than waiting for pathology is a distinct hallmarkof an embedded mental health professional. Thoughdirect clinical care is rarely provided in the presentsample, nevertheless competence in this realm isdeemed to be of the utmost importance. Fundamentalknowledge of mental health conditions and skills incrisis intervention, proper triage and referrals, coordi-nation of care, following up on care delivery are essen-tial. Solid clinical skills and the ability to translateclinical jargon into easily digestible recommendationsare highly important in advising leaders on support topersonnel in distress, which was identified above asamong the most difficult yet highly valued tasksembeds perform.

Advanced tasks and skill sets

The potential impacts of embedded teams grow signifi-cantly as their foci move beyond helping individualswith behavioral health problems. By leveraging therelationships and unit-attunement from successfulembedding combined with performance optimizationexpertise, psychologists can serve as trusted-agents-forchange as Hoyt (2006) described, facilitating improve-ments in contexts within their organizational culture,skills, values, and processes for healthy functioning andperformance. These include multiple approaches toenhance performance of individuals, teams, and orga-nizations, to develop leaders, to help find the mostuseful fit among many highly skilled potential hiresinto an organization, and other activities.

Implications for service planning, selection, andtraining

There are several implications of these findings. It willbe important to identify the types of services that unitsneed with the KSAs needed (e.g., psychologists, MHTs,social workers). At least in the present sample of USAFapplications, it appears that psychologists have thebroadest skill set for embedded tasks beyond EBH.Given limitations in numbers of military psychologistsavailable leaders may be required to prioritize perfor-mance optimization support (psychologists) by risks orcriticality of unit mission, or other factors. Also,although some KSAs would be trainable (e.g., knowl-edge of military unit missions, ranks, etc.), others arelikely not. First and foremost, although diagnosing andtreating mental health conditions is infrequently per-formed in the present sample, when it is called upon itis essential that it be handled expeditiously and with thehighest competence. It is highly recommended that

providers and technicians have significant clinicalexperience beyond entry-level training before movingto these positions.

Clearly good clinical skills and knowledge are necessarybut not sufficient for success in embedded positions. Theconstellation of KSAs that contribute to the ability to effec-tively integrate and communicate with operational person-nel and their leaders are vital. Training platforms that arebased in theMTF, such as residency programs for providers,may already provide some basic training in command con-sultation and outreach, which can serve as the starting point.There is a gap, though, between this training in clinical skillsand training for embedded service in an operational unit.The current study identifies tasks providers and MHTsperform, and KSAs that are most common and most vitalacross embedded mental health contexts.

Selection of personnel to fill embedded roles is a moredifficult challenge. Though this study identified tasks andKSAs that are important, many of them do not lend them-selves to objective selection criteria. Some SOF units con-duct selection processes of psychologists comparable tothose for operators, however these processes are not basedon objective selection criteria for embed psychologists.Future research is recommended to aid in develop ofempirically based selection processes.

Another area worthy of future research concerns theratio of embeds to population served. Given the importanceand leverage gained through rapport and relationships, it islikely very important how much contact and accessibilityunit members can have with embeds. Thinking as wellabout US Army and Navy applications of co-located carein which a behavioral health team may support severalthousand personnel, most of whom will not have frequent,routine contact with embeds, there may be limitations towhat can reasonably be considered effective.

Finally, and relatedly, research is needed to identifyuseful metrics of performance and outcomes ofembedded services of the various task areas/types.Clinical conditions may not vary greatly from popula-tion base rates, and may not be the right metrics forprimary and secondary prevention, let alone readilyapplicable to organizational consultation and develop-ment activities. EBH support may indeed result in anincrease of mental health utilization due to loweringstigma and aiding in referrals. The limited researchattempted so far gave consideration to some organiza-tion factors; further research may better explore whatcan and should be expected from embedded teams.

Disclosure statement

No potential conflict of interest was reported by the authors.

MILITARY PSYCHOLOGY 9

Funding

This work was supported by the none: [Grant Number none].

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Appendix: Task Statements

Unit embedding and engagement activities

1. Develop and maintain understanding of unit and sectionsmissions, stressors, and human performance challenges tounit personnel and leaders

2. Make frequent informal contact through circulation andinteraction in unit work spaces to build and maintainpositive relationships and familiarity with unit membersand leaders

Behavioral health consultation and support

3. Subclinical support: Educate, coach, or counsel individualsregarding sub-clinical problems, such as stress, substancemisuse, and family situations, to modify behavior or toimprove personal, social, and vocational adjustment

4. Develop and present psychological health education andpromotion programs, such as training workshops and pre-sentations tailored to unit needs

5. Advise unit leaders on how to support personnel who arecoping with problems such as stress, adjustment issues,depression, substance abuse, and family situations inorder to modify behavior or to improve personal, social,and vocational adjustment

6. Develop and maintain cooperative working relationshipswith agencies and organizations providing medical andother supports to unit personnel

7. Triage a member’s presenting complaint and functionalimpairment to appropriately refer him/her to psychoedu-cation, non-clinical resources, or to formal mental healthtreatment

8. Educate, coach, or counsel couples regarding communica-tion and relationship issues/skills, to modify behavior or toimprove personal, social, and vocational adjustment

9. Support personnel returning from deployment10. Support and guide individuals experiencing a personal or

family crisis, thoughts of suicide, family maltreatment, orother mental health emergency

11. Attend and participate in treatment team meetings andHigh Interest List meeting discussions regarding unitmembers

12. Assist in casualty notification and/or grief support tounits and families

13. Assess personnel for suitability to deploy14. Clinical care: Treat individuals experiencing clinical pro-

blems, such as mental health conditions, substance abuse,and family situations, to modify behavior or to improvepersonal, social, and vocational adjustment

Performance optimization activities

15. Assess and coach leaders on skills, characteristics, and/orbehaviors to improve leadership skills and/or impact onunit members and performance

16. Assess and train individuals and groups on team func-tioning to improve team functioning and cohesion

17. Conduct personnel assessment and selection for fitness &suitability for hiring into the unit, or for assignment forspecial duties/missions

18. Provide human performance/sport psychology training toenhance unit member performance

19. Provide organizational consultation and developmentinterventions to promote optimal unit functioning andculture

20. Consult with unit leaders to integrate human factorsconsiderations into planning of operational missions

21. Conduct unit needs assessments of areas such as workenvironments, organizational issues, communication,group interactions, morale, stress or motivation to assessand improve unit functioning

22. Conduct psychological research studies of health andhuman performance factors in the unit to identify hazardsand potential improvements

23. Provide training to other mental health personnel to serve ina line-embedded mental health role

Operational mission tasks

24. Provide onsite safety monitoring and consultation forhigh risk training such as Survival, Evasion, Resistance,and Escape (SERE), combat swimmer, or other course/activity

25. Assist in development of training curriculum and trainingof unit instructors

26. Apply psychological expertise to perform or assist ina line mission task (such as human intelligence collection,information operations, etc.)

27. Provide your line support activities in downrange location

KSA statements

1. Ability to work ethically and effectively outside ofa medical unit, within boundaries of professional compe-tence, dual/multiple role relationships, and with objectivity

2. Interpersonal skills and confidence to proactively andpositively engage and build rapport with unit members atall rank levels

3. Ability to be appropriately assertive to leaders at all levelsregarding appropriate COAs and ethical issues

4. Knowledge of unit mission, unit members’ specialties,training, and mission tasks

5. Ability to work effectively as a member of a team6. Ability to tailor communication and presentations to line

unit audience (i.e., can “speak line” vs medical)7. Knowledge and skills to conduct psychological testing and

assessment for selection of personnel for specialized duties,missions, teams, or units

8. Ability to understand and manage “politics” and organiza-tional dynamics internal and external around the unit

MILITARY PSYCHOLOGY 11

9. Ability to innovate services and interventions to unitneeds, problems, and situations as they arise

10. Ability to work flexible hours such as nights and week-ends as needed

11. Knowledge and skills in crisis assessment, intervention,and referral to appropriate services

12. Ability to create engaging briefings and programs foryour unit

13. Knowledge of human factors and human performanceoptimization

14. Knowledge of military ranks, unit structures, and roles ofsupported and other units on the base

15. Knowledge of combat/operational stress reactions, pre-vention, and intervention strategies

16. Knowledge of military medical system17. Knowledge and skill in assessment and treatment of

mental health disorders18. Knowledge of base and local resources for assessment and

treatment of mental health, substance abuse, and familymaltreatment

19. Knowledge and skill in teambuilding strategies andmethods

20. Knowledge and skill in assessment, education, and inter-vention for sleep problems

21. Skill in motivational interviewing22. Knowledge and skill in assessment and treatment of

substance use disorders23. Knowledge of how to lead, supervise, develop, and rate

enlisted members24. Knowledge of executive coaching and leader assessment

and development25. Ability to obtain andmaintain a top secret security clearance26. Knowledge and skill in the assessment and intervention

for family maltreatment and violence27. SERE Psychology Resistance Training Qualification28. Skill at collecting and managing data29. Knowledge and skill providing emotional intelligence training30. Knowledge of the intelligence community31. Knowledge and skill to create and conduct surveys32. Knowledge of threats, protections, and adjudicative pro-

cesses of security clearances33. Knowledge and skill to research studies34. Knowledge and skill in psychological interventions for

pain and health issues35. DoD SERE Psychology certification to support personnel

recovery36. Knowledge and skill in couples counseling37. Aeromedical psychology training

12 A. D. OGLE ET AL.