By Timothy Hsu MD, FAPA
April 1, 2019

U.S. Air Force photo illustration by Airman 1st Class Sahara. L. Fales

Alcohol has played a prominent role in military life throughout recorded history. However, it has been a mixed blessing, especially when alcohol misuse adversely affects psychological health, discipline, productivity, and readiness.

Overall, most service members use alcohol responsibly, though findings from the 2015 Department of Defense Health Related Behaviors Survey indicate that occasional risky drinking is fairly prevalent among service members who use alcohol, with approximately 30 percent reporting binge drinking in the past 30 days. Binge drinking is defined as consuming five or more drinks on one occasion for men, or four or more drinks for women.

While most alcohol misuse can be addressed through brief intervention, each year 1.5-2 percent of active-duty service members receive treatment for alcohol use disorders.

While service members are encouraged to self-refer for problematic drinking patterns, they are often reluctant to do so for fear of career-limiting consequences. As a result, providers in the Military Health System often encounter service members only when already in mandated treatment and tagged with a nondeployable condition following an alcohol-related incident – at which point the situation has been reported to the command, potentially with adverse impact on the member's service record and career prospects. In turn, seeing their colleagues experience duty restrictions and other such adverse consequences may deter proactive help-seeking by other service members concerned about their own alcohol use.

As a result of unintended consequences of current policies creating barriers to care, the services have explored ways to provide incentives for self-referral. The Army recently conducted a pilot study involving 5,892 soldiers who voluntarily received alcohol-related outpatient behavioral health care without enrollment in mandatory substance abuse treatment, and found that it led to a 34 percent reduction in the deployment ineligibility of soldiers receiving mandatory alcohol treatment. Based on these results, which support the value of earlier intervention, the Army has issued a new directive providing soldiers who meet specific criteria, including absence of an alcohol-related incident, with the option of voluntarily receiving or re-entering alcohol-related behavioral health care as needed without mandatory command notification and enrollment in substance abuse treatment.

Provider Awareness

Military mental health providers across the full range of treatment settings and areas of specialization are in a position to support service members in addressing alcohol-related concerns. In their efforts to support the readiness and well-being of active-duty service members, mental health providers should keep the following in mind:

• There are several factors that inform a service member's openness to self-referral for alcohol-related assessment and treatment, including:
  • Self-awareness and concern regarding a problematic misuse of alcohol
  • Willingness to engage in some level of intervention
  • Level of fear about adverse consequences resulting from full disclosure and referral
• There are opportunities to intervene with service members seeking clinical attention for other matters when a problematic relationship with alcohol use becomes evident or is disclosed incidentally during treatment.
• Providers in primary care or behavioral health specialty clinics may be particularly well-positioned to raise awareness among service members in the course of general psychoeducation, and to encourage proactive self-referral.
• While alcohol-related incidents will result in mandated referral and reporting, instances of alcohol misuse that do not rise to that level are common. If patients disclose such unreported "near-miss" incidents, this may represent a safe and effective starting point to introduce interventions within the context of your current treatment, or to refer for specialized treatment. The latter may be particularly appropriate if misuse continues following initial brief intervention, or if the service member reports an inability to control misuse on his or her own.

Talking Points to Encourage Self-Referral

Where supported by guidance and regulation, the following points may facilitate self-referral by service members:

• For soldiers who make a qualifying self-referral without an associated incident, Army providers may offer referral for education or office-based treatment without notifying the command. In addition, the Limited Use Policy prohibits the use of protected alcohol-related evidence (e.g., written or verbal disclosures about misuse, treatment-related blood or urine test results) against a soldier in proceedings under the Uniform Code of Military Justice (UCMJ) or in characterization of service for separation (AR 600-85).
• The Navy requires that all periods of treatment and education are reported to the command, but members may self-refer to a qualified referral agent for alcohol abuse counseling and/or treatment without risk of disciplinary action, provided they have not incurred an alcohol-related incident (OPNAV5350.4D).
• Air Force commanders may similarly offer members making a qualifying self-referral limited protection in actions taken under the UCMJ or in administrative proceedings involving characterization of service in a separation (AFI44-121).
• Seeking treatment shortly after onset of alcohol misuse is less likely to yield negative career repercussions than later treatment-seeking, as the symptoms may progress. Providers should make every effort to emphasize the importance of obtaining appropriate treatment, and the sooner the better. In most instances, demonstrating a genuine interest in seeking help, following through, and addressing the problem will favorably influence command decisions.
• Innovations in telehealth and electronic recordkeeping now provide greater anonymity for members and their beneficiaries.
• Self-referred treatment is associated with fewer duty restrictions and fewer provider disclosures to command than command-referred treatment.
• Disclosing mental health or substance misuse treatment does not, in and of itself, adversely impact one's ability to gain or retain a security clearance. In fact, seeking help may favorably impact one's eligibility for a national security position.

Of note, there are branch-specific differences in clinical guidance and self-referred treatment options for alcohol misuse and service members in a special duty status adhere to duty specific instructions. Providers should check the policies within their respective branches before advising service members.

Dr. Hsu is a psychiatry subject matter expert at the Psychological Health Center of Excellence. He is a licensed physician, board-certified in psychiatry, and a Fellow of the American Psychiatric Association.

The author wishes to acknowledge Army Maj. John Hunsaker and Navy Lt. Cmdr. Heather Hauck for their contributions to this article.