By Navy Lt. Ashley Shenbergerhess, Psy.D.
Jan. 7, 2019

U.S. Navy photo

In 1996, Navy aircraft carriers began to embed psychologists to address the concerns of medical evacuations from the ships. However, the benefit of having a psychologist aboard was quickly realized and gradually both Navy and Marine commands began to embed a variety of mental health providers into military units. The submarine community was one of the last communities, but given that 30 percent of all losses to the submarine force were due to mental health diagnoses, a pilot program was initiated in 2012 and stood up in 2013. By the end of 2016, all seven submarine ports had a mental health provider attached or devoted to their squadron(s).

While all military populations have unique and significant stressors inherent to the job, submariners exist in a compressed arduous environment with little outside influence, even creating their own oxygen. Submarines are propelled by a nuclear reactor and contain the most complex and deadly weapon system in the world. Consequently, it's vital for embedded providers to understand the culture, operational environment, different submarine rates (i.e., type of job), and unique stressors. Boat (submariners call subs boats, not ships) rides, mentorship, standing watch with members, reading books about the history of submarining, and interacting with people to understand their perspective can help to develop the skills necessary to be successful in this community.

Due to the high degree of operational stress and performance standards, there's a need to maximize resources and access to care for this force. In order to be effective, the mental health presence needs to be organic to the unit and primarily focused on outreach, prevention and early intervention. The embedded mental health (EMH) model strives to get ahead of the problem and minimize the impact to the sailor, command, and mission. It spotlights stress management and psychological toughness from the top to the bottom of a submarine chain of command. EMH thrives in the delicate space between the desire to seek help and the need to remain tough in the face of adversity; therefore reducing stigma through presence (or close proximity) is key.

As with other embedded providers, effective communication with line leaders is a must so that leaders can make informed decisions about individuals, the crew, and specific missions. For example, it's important for the provider to understand operational constraints (e.g., it can take up to three weeks to pull a boat off mission to medevac a submariner). Key elements when engaging the line include a BLUF (bottom line up front) approach, honesty, and proven results. Commanding officers want to see that if sailors work with you, they're able to remain on board and markedly improve.

The approach to embedded care is very different from the traditional model used within military treatment facilities. It is important for embedded providers to be trained in a performance psychology model and move away from a pathological model. Submariners most frequently present with normal reactions to a stressful environment and not pathological reactions to a normal environment. Performance optimization and innovation in mental health treatments needs to be encouraged in the expeditionary setting.

In short, the embedded care model requires providers to be assertive, transparent, authentic, and dedicated to a mission which helps service members stay in the fight, remain in cohesive units, and (most importantly) thrive.

Lt. (Dr.) Ashley Shenbergerhess is a Navy psychologist and currently serves as the embedded provider for Submarine Group 10 and as the base psychologist for Submarine Base Kings Bay.