For U.S. Army, Improving Mental Health Care Meant Breaking Down Barriers Between Teams

Long deployments in Iraq and Afghanistan have contributed to an increase in mental health issues in the U.S. military, with many soldiers struggling to cope with post-traumatic stress, depression, and other mental health conditions. In a military culture, coping with these issues isn’t easy: seeking help is stigmatized, and soldiers are often expected to simply “get over” their troubles.

Military leaders have sought to improve mental health services, but balancing the need for mental health care with the need for soldiers to perform on the job is challenging. And that effort has floundered—in part because different teams working toward that common goal failed to cooperate effectively, according to research by Julia DiBenigno, an assistant professor of organizational behavior at Yale SOM. DiBenigno found that commanders and mental health providers often clash over care recommendations that required soldiers to refrain from field exercises or other duties; commanders feel these directives detract from their units’ readiness for deployments, while providers consider them essential to their patients’ wellbeing and recoveries.

DiBenigno’s research on the military may hold lessons for improving team performance at many organizations. Similar conflicts can arise whenever members of distinct professions need to work collaboratively toward strategic goals.

In a study published in Administrative Science Quarterly, DiBenigno found that these conflicts can be successfully addressed by assigning members from one group to serve as points of contact for the other group, while maintaining close ties with their home group. This organizational structure promoted forming long-term relationships between providers and military units while mitigating concerns about providers becoming coopted by the interests of the more powerful commanders. According to DiBenigno, this organizational design choice worked because it allowed commanders and care providers to connect and see one another as individuals rather than faceless, oppositional entities. Breaking stereotypes by forming these connections helps resolve conflict, DiBenigno says. At the same time, because these point of contact providers still worked surrounded by their own professional colleagues, they were protected from cooptation from their closer relationships with commanders.

Typically, organizations try to solve conflicts through superordinate goals, inter-team meetings, co-location, and strategic planning, among other strategies. But these strategies frequently fail, because they don’t account for the differences in professional identities that often lie at the heart of the conflict. “When different professional groups work together, things often fall apart because each group is focused on the part of the overall goal that aligns with their professional identity,” DiBenigno says. “Even though the army adopted this overarching goal to care about not only mission readiness but mental health, different professional groups that had to deliver on that goal were each focused only on their part.”

DiBenigno spent 30 months studying how the U.S. Army handled the tussle between commanders tasked with creating a mission-ready force and mental health providers aiming to rehabilitate soldiers.

Conflicts emerged in many areas. For example, commanders typically needed to have at least 90% of their sub-units ready for deployment, a goal they were assessed on regularly. Reaching that goal required an ethos that put the team’s needs above those of any individual soldier. When providers limited a soldier’s ability to work because of their mental health, “it degrades our troops’ ability to accomplish a mission,” a commander said.

Providers, on the other hand, were focused on individual soldiers’ wellbeing. “Even if I can’t get him back to duty, it’s also about helping someone become a good human being when they go back to society,’’ one provider said. Care providers’ need to guard patients’ health information often conflicted with a commander’s need to know whether a soldier was mentally prepared for battle. And while providers aimed to reduce the stigma associated with seeking mental health care, many commanders thought soldiers should simply toughen up and cope. These differences led to an intractable conflict, where both commanders and providers stereotyped the other group (“bullies” vs. “Berkeley hippies”), and viewed their goals as opposing ones.

As part of her study, DiBenigno examined four brigades, each of with approximately 3,600 soldiers who reported to a division commander, as they tried to resolve this conflict. Two of the brigades, dubbed A and B, moved clinics physically closer to the soldiers. But co-location alone did not improve provider-commander relationships since each provider worked with dozens of commanders, and commanders interacted with many different providers who were treating their soldiers. Intractable identity conflict persisted, hurting both soldier care and mission-readiness.

Brigades C and D were also co-located but took what DiBenigno calls an “anchored personalization” approach. Each clinician was assigned to work exclusively with a few sub-units within the brigade, working closely with 6 to 12 commanders, and each commander’s unit interacted with a specific mental health professional. While care providers were assigned as points of contact to units, they continued to maintain ties with their own peers from working together in their clinics and meeting with other care providers and discussing cases.

In brigades C and D, DiBenigno says, “this subtle difference in organizational design made a dramatic impact on how providers and commanders worked together. By getting to know each other on a first-name basis, they started interacting with each other in a different way.” Commanders and clinicians started to see each other “as partners that could work together to come up with ways of helping soldiers.”

Brigades A and B saw little change. Commanders in these units continued to feel that the mental health team detracted from their efforts to prepare soldiers for missions. Providers’ recommendations that a soldier’s duties be limited for mental health reasons were only followed 18% of the time; commanders ignored prescriptions that they considered “unnecessary” or “out of touch.”

But in brigades C and D, commanders followed 90% of such recommendations, even if they limited a soldier’s duties, and 79% of commanders said that mental health providers helped rather than detracted from their goal of being mission-ready. Commanders and mental health providers worked together to solve soldiers’ problems—and to prepare for missions.

DiBenigno analyzed how providers and commanders handled similar conflict situations. Take, for example, the response to soldiers who have panic attacks inside tanks prior to an important field exercise. In cases like these, providers in A and B prioritized the soldiers’ mental health and recommended against the soldier joining the field exercises; commanders in these subunits often ignored their providers’ advice and took the soldier along. In C and D, providers and commanders came up with win-win solutions to these same conflicts—in this case, by assigning the soldier to another role that did not involve being in tanks, providing additional supervision, and making the exercise part of the soldier’s evaluation and therapy. Commanders had their troops in the field, and providers were satisfied that their patients were making progress toward recovery.”

“It was really interesting to see how such a small change in the organizational structure could matter so much,” DiBenigno says. “We’re talking about the same number of providers and soldiers—it’s just how they were assigned that made the difference.”

The reason, she says, is because under the anchored personalization approach, commanders and providers got to know each other as individuals, not just representatives of a group with differing goals.

And by having increased personalized contact while remaining embedded in their home groups, providers remained committed to soldiers’ mental health and were not overly swayed by commanders’ mission-readiness goals. DiBenigno also studied another group of fully embedded providers who trained and deployed with each brigade and did not work full-time in the clinics. These embedded providers, without the anchor that comes from working surrounded by their mental health colleagues, sometimes ended up being more committed to their commanders’ mission-readiness goals. “Having an organizational design that supports not only connection across groups but also anchoring within groups was key,” DiBenigno says.

The situation DiBenigno found in the Army isn’t unique. Similar conflicts occur widely in many organizations—for example, when marketing and engineering teams or hospital administrators and physicians must work together.

Her study shows “the power of organizational design for facilitating relationships across different departments,” DiBenigno says. Imagine, for example, a human resources department trying to implement a new initiative. The traditional approach is for organizations to structure themselves with a centralized HR department, or embed HR professionals within business units.

“This research suggests an alternative approach that fosters anchored personalization would be to have HR representatives assigned to work as points of contact to different units throughout the organization while being co-located with their HR colleagues,” she says. “This way they can develop personalized relationships with those units and an understanding of their needs without becoming coopted by them to stay true to the initiative they are implementing.

“Any organization where different professional groups have strong commitments to their identities can benefit from thinking about whether their organizational design and structure are promoting different groups working together toward a broader goal or not.”

While the anchored personalization structure provided the opportunity for a personalized relationship to develop, it did not guarantee it. In a follow-on study, also in Administrative Science Quarterly, DiBenigno examined more brigades at additional Army installations with the anchored personalization structure to understand why some providers succeeded at building personalized and influential relationships with higher-power commanders while others failed. The paper examines the many barriers facing providers as low-power peripheral experts who had the expertise but lacked formal authority over commanders to get their care recommendations for soldiers followed.

When DiBenigno analyzed the relational histories of commander-provider dyads, she found that successful providers were able to use “rapid relationality tactics” to quickly build influential relationships before inevitable conflicts threatened their relationships. Failed providers either did not use these tactics or did not use them quickly enough before the window of opportunity closed. She also found that gender and providers’ civilian status created additional barriers that meant that some mental health providers needed to use more time-intensive tactics and took longer to achieve the same relational influence as others.

“We usually think of professional expertise as a source of power—but it wasn’t their knowledge of mental health conditions that mattered most for getting their recommendations followed,” says DiBenigno. “Providers who tried to rely solely on their expertise failed. What mattered was relationships and using relationships as a source of power, especially when you have few other avenues of power available to you.”

The findings of both papers should be instructive to managers of organizations in which functional teams see each other as annoyances rather than sources of value, DiBenigno says. “As organizations continue to turn to experts to solve pressing problems, it is imperative we understand how these experts can be more than just window-dressing, to actually influence line managers so their organizations can meaningfully benefit from their knowledge and skills.”

Learn more:
The findings of the follow-on study, “Rapid Relationality: How Peripheral Experts Build a Foundation for Influence with Line Managers,” are featured in an episode of The Power Pod, a podcast hosted by DiBenigno and her Yale SOM organizational behavioral colleagues Michael Kraus and Heidi Brooks that explores themes from Yale SOM’s core Power and Politics course. Listen.