After examining conflict between commanders and mental health professionals in the U.S. Army, a new School of Management study found that professionals who were assigned to work with specific commanders, while remaining embedded in mental health clinics with other providers, were most successful at resolving conflict.

Written by SOM professor of organizational behavior Julia DiBenigno, the papers were published in advance online on June 16, 2017, and Jan. 22, 2019, in the journal Administrative Science Quarterly.

“It was fascinating to me how such a small change in the organizational design around how providers were assigned to work with commanders and their units could lead to such a dramatic difference in how these two groups worked together toward improving soldier mental health and fielding a mission-ready force,” DiBenigno said.

In her first study, DiBenigno used data from a 30-month field study of four U.S. Army combat brigades to examine the effects of the army’s different organizational structures on providing mental health care services to soldiers. Commanders and mental health providers faced inter-group conflict regarding different priorities in three main areas: focusing on subunits’ welfare versus individual soldiers’ welfare, sharing versus protecting soldiers’ health information and instilling mental toughness versus reducing the stigma of seeking help.

DiBenigno found that an organizational design called “anchored personalization” — in which providers served as points of contacts to specific sets of commanders and their soldiers, while remaining embedded in their mental health clinics — enabled providers and commanders to develop relationships and cooperate in ways that benefited both the soldier’s recovery and the commander’s mission.

Providers who were not assigned to specific commanders lacked the opportunity to develop personalized relationships with them. This organizational structure perpetuated the enduring identity and goal conflict between providers and commanders — they stereotyped each other and viewed their goals as zero-sum.

On the other end of the spectrum, providers who were fully embedded into brigades had personalized relationships with commanders, but were also at high risk of losing sight of their own goals of improving soldier mental health, because they were not surrounded by colleagues in the mental health clinics who had similar goals.

According to DiBenigno, one limitation to the anchored personalization approach is that it may cause a loss in efficiency. For example, providers who work in a clinic without anchored personalization can see any soldier from any unit, enabling them to efficiently fill their schedule. But providers in clinics that use an anchored personalization approach can only see soldiers from their assigned units and cannot cover for other providers. However, she added, when the mental health of soldiers is at stake, the effectiveness gains may offset any efficiency losses.

DiBenigno built on the first study by examining more Army posts with the anchored personalization structure to identify how some providers are able to quickly build strong relationships with commanders to influence them to follow their soldier care recommendations — even though they lacked formal authority over them — before conflicts arise. She termed this “rapid relationality.”

One possible way to encourage “rapid relationality,” DiBenigno said, is to give mental health providers time to introduce themselves and familiarize themselves with commanders, so their first interaction is not over a conflict. Professionals also need time in their schedules to devote to relationship building and maintenance with commanders. Providers who had a higher patient load and no time to liaise with commanders largely failed to develop any influence over commanders in convincing them to follow their recommendations.

“While both papers are intended to help improve Army mental health, they also are meant to impart lessons applicable to any organization about how good organizational design choices can facilitate productive conflict resolution among different professional groups in organizations and about how those who have the expertise, but lack formal authority in organizations can become influential and have their expertise taken seriously,” DiBenigno said.

Howard Waitzkin, a sociology professor emeritus at the University of New Mexico and clinical professor of medicine at the University of Illinois, who was not involved in the study, stressed the seriousness of military mental health issues: About one active duty soldier commits suicide per day, and many soldiers go absent without leave because they do not receive adequate mental health care in the military.

DiBenigno agreed that over the past 15 years, there has been a notable increase in soldier mental health problems. Most research in this area focuses on the clinical side, while much less work is focused on the organizational side — which includes understanding how to assist soldiers while they are still on active-duty.

Early intervention is key, she said, since once soldiers are veterans in the civilian sector, they may face issues that have gone untreated for years and even decades, making recovery more difficult.

According to Ilan Harpaz-Rotem, a psychiatry professor at Yale School of Medicine who researches posttraumatic stress disorder, stigma surrounding mental health treatment prevents many soldiers and veterans from seeking treatment for mental health issues.

There have been efforts recently to educate higher ranking officers about the role that adequately addressing their soldiers’ mental health issues has on their units’ readiness to engage in the next conflict, said Harpaz-Rotem, who was not involved in the study. However, the hierarchical and diverse nature of the Army means that whether a soldier receives appropriate mental health treatment depends on their direct supervisor’s views and their specific cohort’s culture.

DiBenigno expressed hope that the Army would put a greater emphasis on training new mental health providers on how to build working relationships with commanders.

“When I was conducting my study, there was over a decade’s worth of animosity between these two groups, with each stereotyping and looking down on the other group,” DiBenigno said. “My hope is that with more Army posts adopting the anchored personalization approach, such long-standing tensions will dissipate.”

Between 11 to 20 percent of veterans who served in Operations Iraqi Freedom and Enduring Freedom have PTSD in a given year, according to the National Center for Post-Traumatic Stress Disorder.

Eui Young Kim | euiyoung.kim@yale.edu