A new study of mental health treatment in the U.S. Army finds that a small organizational change — assigning but not embedding mental health providers in specific Army units — resulted in a dramatic improvement in how often unit commanders follow provider recommendations for their soldiers.
Against the backdrop of the Army’s ongoing efforts to improve the mental health of soldiers and veterans, Julia DiBenigno, PhD ’16, has defined how groups with differing perspectives can work together for change.
It’s no surprise that organizations interested in change must convince different groups, in this case Army commanders and mental health providers, to cooperate. What does come as a surprise — after efforts to change do not succeed — is the extent to which these groups stick to their ingrained professional subcultures and fail to work together.
Traditional organizational structure is a zero-sum game
In 2007, Congress appropriated more than $2.7 billion to research and treat post-traumatic stress disorder and traumatic brain injury in the over 2 million men and women who served in Iraq and Afghanistan. Up to 30 percent of these soldiers are expected to develop a serious mental health problem. Without proper treatment, many will turn to forms of self-medication such as drugs and alcohol.
With these funds and at the recommendation of the MIT Post Traumatic Stress Innovations team led by MIT Sloan Professor Thomas Kochan and research scientist Jayakanth "JK" Srinivasan, the Army built a dedicated co-located outpatient mental health clinic for every brigade at every Army post around the world. Most clinics were in place by 2014, but there was no single protocol followed for staffing them. This led to different approaches to mental health care and different outcomes for the soldiers who sought care.
As part of this MIT team, DiBenigno spent more than 600 hours on-site interviewing and observing mental health providers, commanders, and other stakeholders at eighteen clinics across four Army posts. In her dissertation she focuses her analysis on four clinics at one post, each serving a different brigade, to illustrate a mechanism and process she observed across all posts. Her research won the INFORMS Organization Science Best Dissertation Proposal Competition in 2015.
At two of the clinics, personalized contact between commanders and mental health providers rarely occurred even though the two groups were co-located. The professional goals of building a mission-ready military or protecting soldiers’ mental health could not be reconciled. Commanders saw mental health providers as taking their soldiers “out of the fight,” while mental health providers saw commanders as impeding their patients’ recoveries.
In these brigades, commanders followed providers’ recommendations only 18 percent of the time. Solutions weren’t always ideal, either. In one case, a soldier placed on 24-hour observation had to sleep on a cot at the unit’s front desk, which was both demeaning and detrimental to recovery.
“Relations between these two professional groups were defined by intractable identity conflict. They saw it as a zero-sum game,” said DiBenigno, who will join the Yale School of Management organizational behavior department as an assistant professor in the fall.
Building relationships, increasing perspective-taking
But the other two clinics were able to achieve success due to an organizational assignment structure that enabled what DiBenigno calls anchored personalization. Providers were assigned to specific units within each brigade, but not embedded within them. This allowed for the development of personalized relationships and perspective-taking between providers and commanders. At the same time, providers remained effective advocates for their patients despite their closer relationships with commanders because they were anchored in their provider identity by the colleagues in their clinics.
Here, commanders followed providers’ recommendations 90 percent of the time. Providers and commanders worked together to develop win-win solutions that helped both soldier recoveries and the unit’s mission. For example, here a soldier also on 24-hour observation was allowed to sleep at a sergeant’s house instead of the unit’s front desk. Providers also customized a soldier’s treatment to include attending a training exercise, but while under increased supervision and after being discreetly assigned to a less stressful role.
“A relatively minor change in the organizational assignment structure led to dramatic changes that helped different professional groups work together more effectively,” she said.
DiBenigno’s research suggests that the one-off training exercises emblematic of corporate retreats — as well as the Army’s “stand-down days” to teach mental health providers about the military — do not stick. Instead, “change needs to be baked into the way work gets done through structural interventions that are longer-lasting and create opportunities for relationships and new ways of interacting,” she says.
“An organizational structure that enables what I call anchored personalization can help different professional groups overcome identity conflict and entrenchment in their home group’s perspective to align their goals, without becoming coopted by the other group’s perspective from personalized contact with the other group,” DiBenigno wrote in her dissertation, which is under pre-publication review.
“My hope is that this organizational structure and concept of anchored personalization can apply not only to the Army, but to other settings where cooperation among different professional groups is necessary to achieve organizational change,” she said.