OFFICE OF THE SECRETARY 1000 NAVY PENTAGON … · u ii EPA RTMENTOF THE NAVy OFFICE OF THE SECRETARY 1000 NAVY PENTAGON WASHINGTON, O,C, 20350.1000 SECNAVINST 6320.24A BUMED-03L SECNAV

@u ii EPA RTMENTOF THE NAVy

OFFICE OF THE SECRETARY

1000 NAVY PENTAGON

WASHINGTON, O,C, 20350.1000 SECNAVINST 6320.24ABUMED-03L

SECNAV INSTRUCTION 6320.24A16 February 1999

From: Secretary of the NavyTo: All Ships and Stations

Subj : MENTAL HEALTH EVALUATIONS OF MEMBERS OF THE ARMEDFORCES

Ref: (a)

(b)

(c)

(d)

(e)

(f)

(g)

(h)

(i)

(j)

(k)

(1)

(m)

(n)

DoD Directive 6490.1, “Mental Health Evaluations ofMembers of the Armed Forces,” of 1 Ott 97 (NOTAL)Public Law 102-484 “National Defense Authorization Actfor Fiscal Year 1993,” of 23 Ott 92DoD Directive 7050.6, “Military WhistleblowerProtectionr “ of 12 Aug 95 (NOTAL)National Center for State Courts’ Guidelines ForInvoluntary Civil Commitment, 1986 (NOTAL)American Psychiatric Association’s Task Force Report,“Involuntary Commitment to Outpatient Treatment,”19871American Psychiatric Association, “Guidelines forLegislation on the Psychiatric Hospitalization ofAdults, ” American Journal of Psychiatry, 140:5, May83 (NOTAL)American Psychiatric Association, “The Principles ofMedical Ethics with Annotations Especially Applicableto Psychiatry,” 19951

..

American Psychological Association, “EthicalPrinciples of Psychologists and Code of Conduct,”19922National Association of Social Workers’ “Code ofEthics,” 19963Chapter 47, of Title 10, U.S. Code, “Uniform CodeMilitary Justice,” (UCMJ)DoD Directive 6400.1, “Family Advocacy Program(FAp),” 23 Jun 92 (NOTAL)

of

DoD Directive 1010.4, “Alcohol and Drug Abuse by DoDPersonnel,” 3 Sep 97 (NOTAL)DoD Instruction 1010.6, “Rehabilitation and ReferralServices for Alcohol and Drug Abusers,” 13 Mar 85(NOTAL )DoD Directive 6040.37, “Confidentiality of MedicalQuality Assurance (QA) Records,” 9 Ju1 96 (NOTAL)

'AvailablefromtieAmericanPsychidticAssociation,1400KS&eeCW, Wnshtigton,DC 20005

2AvailablefromhebencanPsychologicalAssociation,750FtitStieet,~,wastigtoUDC20002

3AvailablefromtheNationalAssociationofSocialWorkers,750FirstSheet,NE,Suite700,Washington,DC20002

SECNAVINST

‘=eAgl%(P)

(q)

Encl: (1)(2)

(3)

(4)

(5)

6320.24A

.. .—Section 1102 of Title 10, U.S. CodeAmerican Psychiatric Association (APA), “Diagnosticand Statistical Manual of Mental Disorders,”(DSM-IV), Fourth Edition, Washington, DC, APAPress, 1994SECNAVINST 1730.7A, “Religious Ministries Within theDepartment of the Navy” (NOTAL)

DefinitionsSample Letter, Commanding Officer Request for Routine(Non-emergency) Mental Health EvaluationSample Letter, Service Member Notification ofCommanding Officer Referral for Mental HealthEvaluationSample Letter From Mental Health Care Provider toService Member’s Commanding OfficerGuidelines for Mental Health Evaluation for ImminentDangerousness

1. Purpose

a. To issue Department of Navy (DON) policy, assignresponsibility, and prescribe procedures per reference (a) forthe referral, evaluation, treatment and administrative managementof service members who are directed by their commands for mentalhealth evaluation and/or assessment of risk for potentiallydangerous behavior. This instruction is a complete revision andshould be reviewed in its entirety.

b. To establish the rights of service members referred bytheir commands for mental health evaluations.

c. To establish procedures for outpatient and inpatientmental health evaluations that will provide protection to membersreferred by their commands for such evaluations.

d. To prohibit the use of mental health evaluation referralsby commands in reprisal against whistle blowers for disclosuresprotected by references (a) through (c).

e. To provide guidance to mental health care providers andcommanding officers on evaluation, treatment, and administrativemanagement of service members who may suffer from serious mentaldisorders and who may be imminently or potentially dangerous.

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SECNAVINST 6320.24A16FEE1999

f. To establish procedures for the psychiatrichospitalization of active duty service members modeled afterguidelines prepared by professional civilian mental healthorganizations for psychiatric hospitalization and treatment ofadults, per references (d) through (q).

2. Cancellation. SECNAVINST 6320.24.

3. Background

a. Military members play an important role in maintainingaccountability and responsibility in Government and should beencouraged to come forward with information that may ultimatelyhelp to improve the function of Government, including the DON.They should not be subjected to unwarranted mental healthevaluations or involuntary hospitalization as a form ofharassment or in retaliation for revealing flaws within the DON.Regardless of the reason for the referral or hospitalization,such decisions must be based upon objective standards. Servicemembers must not be arbitrarily subjected to mental healthevaluations.

b. Service members determined to be imminently orpotentially dangerous pose a heightened risk to themselves and toothers. Commanding officers and mental health professionals mustrecognize this risk and take appropriate action to ensure thesafety of the service member and others.

4. Applacability

a. This instruction applies to: all DON civilianemployees, active duty military personnel (both Regular andReserve), special Government employees, personnel of non-appropriated fund activities, and midshipmen of the U.S. NavalAcademy. This instruction also pertains to officers and enlistedpersonnel of the inactive U.S. Naval and Marine Corps Reserve onactive duty for training, and other persons performing duties forthe DON employed within military treatment facilities (i.e.,Public Health Service personnel and contract employees).

b. This instruction does not apply to voluntary self-referrals; diagnostic referrals requested by non-mental healthcare providers not part of the service member’s chain of command

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as a matter of independent clinical judgment and when the servicemember consents to the evaluation; responsibility and competencyinquiries conducted under the Rule for Court Martial 706 of theManual for Courts-Martial; interviews conducted under the FamilyAdvocacy Program; interviews conducted under drug or alcoholabuse rehabilitation programs; and evaluations expressly requiredby applicable Service regulation for special duties oroccupational classifications.

5. Definitions. See enclosure (l).

6. DON Policy

a. Commanding officers and officers in charge (hereafterreferred to as COS) , when practicable, shall consult with amental health provider prior to referring a service member for amental health evaluation.

b. A service member shall be afforded the rights andprotections accorded by references (a) and (b) and thisinstruction when referred for mental health evaluation.

c. No person shall refer a service member for a mentalhealth evaluation as a reprisal for making or preparing a lawfulcommunication to a Member of Congress, any appropriate authorityin the chain of command of the member, an inspector general (IG),or a member of a DoD audit, inspection, investigation, or lawenforcement organization.

d. No person shall restrict a service member from lawfullycommunicating with an IG, attorney, Member of Congress, chaplain,or others about the service member’s referral for a mental healthevaluation.

e. Mental health care providers shall provide COS timelyinformation concerning service members referred for mental healthevaluations. At a minimum, that information will include:diagnosis; treatment recommendations; and administrativemanagement recommendations.

f. Nothing in this instruction shall be construed to limitthe authority of COS to refer a service member for emergencymental health evaluation or treatment when circumstances suggestthe need for such action.

9. Upon request by a service member for advice from anattorney, an attorney who is a member of the Armed Forces or

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SECNAVINST 6320.24A/6FEB1998

employed by the Department of Defense shall be appointed at nocost to the service member to advise the service member. If amilitary attorney is not reasonably available, every effortshould be made to provide legal consultation by telephone.

7. Enforceability

a. Violation of paragraph 6C or 6d by any person subject toreference (j) is punishable as a violation of the Uniform Code ofMilitary Justice (UCMJ), Article 92 (Violation of a LawfulGeneral Regulation).

b. Violation of paragraphs 6C or 6d by civilian employees ispunishable under regulations governing civilian disciplinary oradverse actions.

c. Failure to comply with other provisions of thisinstruction shall be addressed through appropriate action.

8. Procedures

a. Non-emergency Mental Health Evaluation Referrals

(1) Commanding Officer Actions

(a) The responsibility for determining whether areferral for mental health evaluation should be made rests withthe service member’s designated CO at the time of referral. Thisauthority may not be delegated.

(b) When a CO determines it is necessary to direct aservice member for mental health evaluation, the CO first shallconsult with a mental health care provider to discuss the servicemember’s actions and behaviors. The mental health care providershall provide advice and recommendations about whether anevaluation should be conducted, and whether any needed evaluationshould be done on a routine or an emergency basis. If a mentalhealth care provider is not available, the CO shall consult aphysician, if available, or the senior privileged non-physicianprovider present. For non-emergency referrals, the CO shallforward to the CO of the medical treatment facility (MTF) orclinic a letter, formally requesting a mental health evaluation.(See enclosure (2).)

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SECNAVINST 6320.24AI8FEE1999

(c) COS of MTFs or clinics who wish to refer aservice member for a non-emergency mental health evaluation shallforward to the director of that mental health department a letterformally requesting a mental health evaluation. (See enclosure(2)).

(d) The service member’s CO shall ensure the servicemember is provided a written letter, per enclosure (3), at leasttwo business days before a non-emergency referral for mentalhealth evaluation. This letter shall include, at a minimum, thefollowing:

1. A brief factual description of the behaviorsandlor verbal communications that led to the CO’s decision torefer the service member for mental health evaluation.

2. The name of the mental health care providerwith whom the CO—consulted before making the referral. If aconsultation with a mental health care provider was not possible,the letter shall state the reasons why.

3. Notification of the service member’s rightsper reference (by and enclosure (3).

4. The date, time, and place the mental healthevaluation is sc=eduled and the name and grade or rate of themental health care provider who will conduct the evaluation.

5. The titles and teleDhone numbers of otherauthorities, inciuding attorneys, IGs, and chaplains, who canassist a service member who questions the necessity of thereferral.

6. The name and signature of the CO.—

(e) Service members shall acknowledge having beenadvised of the reasons for the mental health referral andacknowledge having been advised of their rights by signing theletters. If service members refuse to sign, the CO shall notethe refusals on the letters, in addition to any reasons servicemembers may have given for not signing.

(f) Copies of the signed letters shall be provided toservice members and to the mental health care providers who willconduct the evaluations.

(g) Service members may not waive their right toreceive the written letters and statements of rights describedabove in subparagraph 8a(1) (d).

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SECNAVINST 6320.24AIEFE81998

(2) Mental Health Care Provider Action

(a) Before a non-emergency mental health evaluationoccurs, the mental health care provider shall determine ifprocedures for referral for mental health evaluation have beenfollowed per reference (a) and this instruction. The mentalhealth care provider shall review the signed letter, includingthe Statement of Service Member’s Rights forwarded by the servicemember’s CO.

(b) Whenever there is evidence that indicates themental health evaluation may have been requested improperly, themental health care provider shall first confer with the referringcommand to clarify issues about the process and procedures usedin referring the service member. If, after such discussion, themental health care provider believes the referral may have beenconducted improperly, per references (a) through (c) and thisinstruction, the mental health care provider shall report suchevidence through his or her chain of command to the next higherlevel of the referring CO.

(c) The mental health care provider shall advise theservice member referred for mental health evaluation of thepurpose, nature, and likely consequences of the evaluation beforethe evaluation begins, and shall advise the service member theevaluation is not confidential.

(d) Absent an emergency, when a mental health careprovider both evaluates and provides therapy to a service memberreferred by the service member’s CO, the possible conflict ofduties should be explained clearly to the service member at thebeginning of the therapeutic relationship. (See Section 4 ofreference (g); Principle B (Integrity), Principle D (Respect forPeople’s Rights and Dignity), and Principle E (Concern forOther’s Welfare) of reference (h); and Principles of Dignity andWorth of the Person, Importance of Human Relationships, andIntegrity of reference (i).)

(e) Following evaluation, the mental health careprovider shall forward a letter to the service member’s CO toinform the CO of the results of the mental health evaluation andprovide recommendations, see enclosure (4). (See also paragraph8(g) for those service members evaluated as imminently orpotentially dangerous. )

I 7

‘~~fi~~@$T 6320.24A

b. Emergency Evaluations

(1) CO Actions

(a) Whenthe service member’sfirst priority shallfrom harm.

the CO makes a clear and reasoned judgmentsituation constitutes an emergency, the CO’Sbe to protect the Service member and others

(b) The CO shall make every effort to consult amental health care provider, or other privileged health careprovider if a mental health care provider is not readilyavailable, prior to referring or sending a service member foremergency mental health evaluation.

(c) The CO shall safely convey the service memberthe nearest mental health care provider or, if unavailable, aphysician, or the senior privileged non physician providerpresent, as soon as is practicable.

an

to

(d) If, due to the nature of the emergency, the COwas unable to consult with a mental health care provider or otherprivileged health care provider, the CO shall forward a letterdocumenting the circumstances and observations of the servicemember that led to the CO’s decision to refer the service memberon an emergency basis. This letter shall be forwarded byfacsimile, overnight mail or courier to the treating health careprovider as soon as is practicable.

(e) The CO shall, as soon as is practicable, providethe service member a letter and statement of rights as describedin subparagraph 8(a) (1)(d).

(2) Mental Health Care Provider Actions

(a) Before an emergency mental health evaluationoccurs, the mental health care provider shall determine ifprocedures for referral for emergency mental health evaluationshave been followed using the guidelines of this instruction.

(b) Whenever there is evidence which indicates themental health evaluation may have been requested improperly, themental health care provider shall first confer with the referringcommand to clarify issues about the process and procedures usedin referring the service member. If, after such discussion, themental health care provider believes the referral may have been

8

‘lc~&fll~fIT6320.24Aconducted improperly, per references (a) through (c) and thisinstruction, the mental health care provider shall report suchevidence through his or her chain of command to the next higherlevel of the referring CO. The provider will not delay theevaluation, regardless of procedural concerns.

(c) The mental health care provider shall advise theservice member referred for mental health evaluation of thepurpose, nature, and likely consequences of the evaluation beforethe evaluation begins, and shall advise the service member thatthe evaluation is not confidential.

(d) Following the evaluation, the mental health careprovider shall forward a letter to the service member’s CO toinform him or her of the results of the mental health evaluationand provide recommendations, see enclosure (4). (See paragraph8(g) for service members evaluated as imminently or potentiallydangerous. )

c. Involuntary Hospitalization for Psychiatric Evaluationandlor Treatment

(1) An involuntary hospital admission is appropriate onlywhen a provider, privileged to admit psychiatric patients, makesa reasoned, good faith clinical judgment the service member has,or likely has, a severe mental disorder and poses a danger tohimself or herself or others, so the evaluation or treatmentcannot reasonably be provided by a less restrictive level of careor when less intensive treatments would result in inadequatemedical care. Hospitalization is appropriate only whenconsistent with the least restrictive alternative principle asdescribed in reference (h), and defined in enclosure (2).

(2) COS shall coordinate with health care providers, assoon after admission as the service member’s condition permits,to inform the service member of the reasons for his or heradmission, the likely consequence(s) of the evaluation and anytreatment, and the service member’s rights.

(3) The service member shall have the right to contact arelative, friend, chaplain, attorney, andlor an IG as soon afteradmission as the service member’s condition permits.

(4) The service member shall be evaluated by theattending privileged psychiatrist, or another privilegedphysician if a psychiatrist is not available, within 24 hours

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SECNAVIN T 6320.24AI6FEBId

after admission to determine if continued hospitalization and/ortreatment is clinically indicated or, alternately, to determineif the service member should be discharged from the hospital.

(5) If the attending privileged psychiatrist, or anotherprivileged physician if a psychiatrist is not available,determines continued hospitalization is clinically indicated, theservice member shall be notified orally and in writing of thereasons for continued hospitalization.

(6) Independent Review Requirement

(a) Within 72 hours of admission, an independent,privileged psychiatrist, or other medical officer, if apsychiatrist is not available, shall review the factors that ledto the involuntary admission and shall assess the clinicalappropriateness of continued involuntary hospitalization. Thereviewer shall not be in the member’s immediate chain of command,shall be an 04 or greater (or civilian equivalent), and shall bean impartial, disinterested party appointed by the medicaltreatment facility CO.

(b) The review procedure shall include a review ofthe medical record, referral letter, and an examination of theservice member.

(c) The reviewer shall notify the service member ofthe right to have legal representation during the review by ajudge advocate or by an attorney of the service member’schoosing, at the service member’s own expense, if reasonablyavailable.

(d) The reviewer shall introduce himself/herself tothe service member, indicate the reasons for the interview, andindicate he or she shall conduct an independent, impartialreview of the reasons for the service member’s involuntarypsychiatric hospitalization.

(e) The reviewer shall determine and document in theinpatient medical record whether continued involuntarypsychiatric hospitalization and/or treatment is clinicallyappropriate. If indicated, the reviewer shall specify theclinical conditions fortreatment; the clinicalthe hospital; and shall

continued involuntary inpatientconditions required for discharge fromdetermine when the next independent

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SECNAVINST 6320.24A16FE61999

review for continued involuntary hospitalization shall occur.(Independent reviews must be done at least every five businessdays. ) The service member shall be notified of the reviewer’srecommendations and the date of the next review.

(f) The reviewer shall determine if proper proceduresfor the mental health referral were followed. Whenever there isevidence which indicates the mental health evaluation may havebeen requested or conducted improperly, the reviewer shall firstconfer with the referring command and the admitting mental healthcare provider to clarify issues about the process or proceduresused in referring and/or admitting the service member. If thereviewer determines the referral or admission was madeimproperly, the reviewer shall report the finding through his orher chain of command to the next level above the referringcommanding officer or admitting physician for furtherinvestigation and for possible referral to the DON IG or the DoDIG.

d. Special Procedures for Imminently or PotentiallyDangerous Service members

(1) CO Actions

(a) A CO shall refer a service member for anemergency mental health evaluation as soon as is practicablewhenever a service member, by actions or words, intends or islikely to cause serious injury to himself, herself or others andwhen the facts and circumstances indicate the service memberpossesses the ability to cause such injury and when the CObelieves the service member may be suffering from a seriousmental disorder. Prior to such referral, the CO shall attempt toconsult with a mental health care provider, or other health careprovider, if a mental health care provider is not available.

(b) COS shall consider information and recommenda-tions about service members provided by social workers or otherDoD personnel assigned duties under the Family AdvocacyProgram, operated under the authority of reference (k), or therehabilitation and referral programs for alcohol and drugabusers, operated under the authority of reference (1) andreference (m).

(c) Only DoD psychiatrists, doctoral level clinicalpsychologists or doctoral level clinical social workers withclinical practice privileges have authority to clinically

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SECNAVINST 6320.24A16FEB1999

evaluate a risk for imminent dangerousness. Only these providersmay perform mental health evaluations of service membersidentified within the scope of this subsection.

(d) Other privileged health care providers frequentlyperform routine clinical evaluations of service members in whichassessment of potential dangerousness may be an element. Thisinstruction does not restrict such evaluations.

(e) Whenever a privileged health care providerconcludes, in the course of a mental health evaluation, that aservice member may be imminently dangerous, the health careprovider shall refer the service member to a privileged, doctorallevel mental health care provider for evaluation and assessmentof risk for imminent dangerousness.

(f) In those rare instances in which a privilegeddoctoral level mental health care provider is not readilyavailable, a CO may refer a service member, who the commandingofficer suspects is imminently dangerous, to a physician, ifavailable, or to the senior privileged non-physician providerpresent for initial evaluation, pending subsequent evaluation bya privileged doctoral level mental health care provider.

e. Requirements for Conducting Emergency Mental HealthEvaluations for Imminent Dangerousness

(1) Emergency evaluations of service members believed tobe imminently dangerous shall be conducted as soon as possible,but within 24 hours of the initial request. Meanwhile, the COshall take action to protect the service member’s safety and thesafety of others.

(2) Mental health evaluations shall be conducted in amanner consistent with applicable clinical standards of care, assupplemented by enclosure (5). Such evaluations shall include adetailed patient history, a mental status examination, laboratorystudies, and, to the extent clinically indicated, a physical andneurological examination.

[3) In cases in which a mental health evaluation isindicated, and there is athe service member may bedisorder, and the serviceimminently dangerous, andcannot be conducted as an

clear and reasonable basis to concludesuffering from a serious mentalmember is judged to be or may becomea complete and thorough evaluationoutpatient within an acceptable time

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SECNAVINST 6320.24A1EFEB1099

period (usually less than 24 hours), the service member may beadmitted to a psychiatric unit (or medical unit, if a psychiatricunit is not available) for an inpatient evaluation.

(4) The decision to admit a service member for aninpatient mental health evaluation or treatment rests solely witha mental health care provider who has approved hospital admittingprivileges. In cases of deployed units, or isolated geographiclocations where no mental health care providers are available, aphysician, if available, or the senior privileged non-physicianprovider present, shall take actions and/or make recommendationsto the service member’s CO to protect the service member’s safetyand that of others, until such an evaluation can be conducted.

(5) When a mental health care provider performs acomprehensive mental health evaluation and determines a servicemember is at significantly increased risk of imminentlyor potentially dangerous behavior, the provider also shall takeprecautions, contained in reference (a) and this instruction.

(6) The responsible privileged health care provider shalldocument in the medical record the clinical assessment, includingthe assessment of risk for imminent dangerousness, treatmentplan, progress of treatment, discharge assessment,recommendations to COS, and any notification of potential victimsas required by reference (a), subparagraph D7 and thisinstruction.

f. Health Care Providers Duty to Take Precautions AgainstThreatened Injury

(1) In any case in which a service member hascommunicated to a health care provider with clinical practiceprivileges an explicit threat to kill or seriously injure aclearly identified or reasonably identifiable person, or todestroy property under circumstances likely to lead to seriousbodily injury or death, and the service member has the apparentintent and ability to carry out the threat, the provider shalltake precautions against such threatened injury. Suchprecautions may include any of the following:

(a) Notification of the service member’s CO thatthe service member is imminently or potentially dangerous.

13


(b) Notification ofenforcement authority where the

(c) Notification ofvictim(s) of the threats made.

the military and/or civilian lawthreatened injury may occur.

any identified potential

(d) Recommendation to the service member’s CO thatappropriate precautions be taken.

(e) Admitting the service member to an inpatientpsychiatric or medical ward for evaluation and/or treatment of amental disorder.

(f) Referral of the service member’s case to theService’s physical evaluation board per reference (a),subparagraph D6c(1).

(g) Recormnendation to the CO the service member beadministratively separated for personality disorder per reference(a), subparagraph D6c(2) or other applicable separationauthority.

(2) Prior to discharge of an imminently or potentiallydangerous service member from inpatient status, a health careprovider shall notify the service member’s CO, and anyidentifiable individuals who may be at risk of serious injuryfrom the service member, about the service member’s pendingdischarge.

(3) The health care provider shall document in themedical record the date, time and name of each person and agencycontacted when taking precautions against threatened injury.

(4) The health care provider shall inform the servicemember these precautions have been taken.

9. Recommendations to COS

(1) Upon completion of a mental health examination ofan imminently or potentially dangerous service member, the mentalhealth care provider shall immediately provide to the servicemember’s CO a letter that shall address at a minimum thediagnosis, prognosis, treatment plan, and recommendationsregarding fitness and suitability for continued service and shall

I 14


make recommendations for precaution(s) , if appropriate, andadministrative management of the service member. (See reference(a) subparagraph D6, and enclosures (4) and (5) of thisinstruction. )

(2) The mental health care provider shall review with theservice member the clinical summaries, letter, andrecommendations made to the CO.

h. Actions by Cos

(1) Whenever a privileged mental health care providermakes a recommendation to the service member’s CO on animminently or potentially dangerous service member, the CO shallmake a written record of the actions taken and reasons therefore.

(2) Whenever a mental health care provider recommends toa service member’s CO the member be separated from militaryservice due to a personality disorder and imminently orpotentially dangerous behavior, that recommendation shall be co-signed by the mental health care provider’s CO. If the servicemember’s CO declines to follow the recommendation(s) of theprovider, the service member’s CO shall forward a letter tohis or her immediate superior in the chain of command within twobusiness days of receiving the recommendation(s), explaining thedecision to retain the service member against medical advice.

i. Medical Quality Management Case Review

(1) Every mental health evaluation or treatment case inwhich a service member ultimately commits an act resulting insuicide, homicide, serious injury or significant violence, shallbe systematically reviewed per the MTF’s plan for improvingpatient care and health outcomes. Assessment of findings shallbe used to design and measure improvements of patient careprocesses, risk-management, and MTF staff competence.

(2) Reviews shall focus particularly on clinicalassessment, treatment, progress, administrative recommendationsand administrative follow-through, as documented in the medicaland personnel records.

(3) Case reviews shall be included in ongoing qualitymanagement activities. Such reviews shall include lessonslearned and recommendations for improvement in the future medicalmanagement of service members at increased risk of dangerousbehavior.

15

(4) Medical quality management case review activitiesshall be coordinated as appropriate with other Serviceinvestigations.

(5) Medical quality management case review records shallbe confidential per references (n) and (o).

9. Responsibilities

a. The Chief of Naval Operations and Commandant of theMarine Corps shall:

(1) Ensure COS follow the requirements of the pertinentDoD and Service directives, instructions and regulations for themanagement of imminently or potentially dangerous service membersand the procedures for proper referral of those service membersfor mental health evaluations.

(2) Ensure COS consider recommendations made by mentalhealth care providers in cases involving imminently orpotentially dangerous service members and ensure they takenecessary precautions to appropriately manage those servicemembers.

(3) Ensure mental health care providers follow therequirements of the pertinent DoD and Service directives,instructions and regulations for the management of imminently orpotentially dangerous service members.

(4) Ensure appropriate periodic training is conducted forall DON service members and civilian employees in the initialmanagement and referral of service members who are believed to beimminently dangerous. Such training shall include therecognition of potentially dangerous behaviors; appropriatesecurity responses to emergency situations; and administrativemanagement of such cases. Training shall be specific to theneeds, grade or rate, level of responsibility and assignment ofthe service member or civilian employee.

b. The DON IG shall:

(1) Report to the DoD IG, within ten working days ofreceipt, all allegations submitted by the service member or theservice member’s legal guardian to the DON IG, a service memberwas referred for a mental health evaluation in violationof this instruction. The notification shall be made in writingand shall include the following:

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SECNAVINST 6320.24AI6FE8 1998

(a) Grade or rate, name and duty location of theservice member.

(b) Synopsis of the specific allegation(s) and thedata received by the IG.

(c) Grade or rate, name, and duty location of theproposed investigator.

(2) Unless notified the DoD IG assumes investigativeresponsibility for a particular matter, initiate or cause to beinitiated, an investigation of the issues raised in theallegation(s) .

(3) If the investigation is not completed within 90 daysof receipt of an allegation, provide an interim report to the DoDIG on the 90th day and supplement it every 60 days thereafter,until the final report is submitted.

(4) Provide the DoD IG, a copy of the final report ofinvestigation with attachments within one week of completion ofthe final report of investigation.

(5) Provide to the DoD IG, a written report of anydisciplinary and/or administrative action, and the naturethereof, taken against any individual in connection with theinvestigation, within one week after such action is taken.

10. Reports. The reporting requirements contained in thisinstruction are exempt from reports control by SECNAVINST5214.2B.

~L~ ~

IJe ry MacArthur HultinUn er Secretary of the Navy

Distribution:SNDL Parts 1 and 2MARCORPS PCN 71000000000 and 71000000100

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SECNAVINST 6320.24AIoFEE1890

DEFINITIONS

1. Emerqencv. A situation in which a service member isthreatening, by words or actions, to imminently cause harm tohimself or herself, or to imminently destroy property undercircumstances likely to lead to serious p“ersonal injury or deathand where delaying a mental health evaluation could endanger theservice member or others. An emergency may also be construed tomean an inability by the individual to care for himself orherself to the extent that delaying a mental health evaluationcould endanger the life of the service member.

2. Imminent Dangerousness. A clinical finding or judgment by aprivileged, doctoral level mental health care provider, basedupon a comprehensive mental health evaluation, an individual isat substantial risk of committing an act in the near future whichwould result in serious injury to himself or herself or anotherperson, or would destroy property under circumstances likely tolead to serious injury, and the individual manifests the intentand ability to carry out that action. A violent act of a sexualnature is considered an act which would result in seriouspersonal injury.

3. Insuector General (IG). The Inspector General, DoD, and amilitary or civilian employee assigned or detailed under DoDcomponent regulations to serve as an IG at”any command level inone of the DoD components.

4. Least Restrictive Alternative Princiule. A principle underwhich a member of the Armed Forces committed for hospitalizationand treatment shall be placed in the most appropriate andtherapeutically available setting that is no more restrictivethan is conducive to the most effective form of treatment, and inwhich treatment is available and the risk of physical injuryand/or property damage posed by such a placement are warranted bythe proposed plan of treatment.

5. Mental Disorder. As defined by reference (p), a mentaldisorder is:

A clinically significant behavioral orpsychological syndrome or pattern that occursin an individual and is associated withpresent distress (e.g., a painful symptom) ordisability (e.g., impairment in one or more

Enclosure (1)

SECNAVINST 6320.24A18 FEB 1999

important areas of functioning) or with asignificantly increased risk of sufferingdeath, pain, disability, or an important lossof freedom. In addition, this syndrome orpattern must not be merely an expectable andculturally sanctioned response to aparticular event; for example, the death of aloved one. Whatever its original cause, itmust currently be considered a manifestationof a behavioral, psychological, or biologicaldysfunction in the individual. Neitherdeviant behavior (e.g., political, religious,or sexual) nor conflicts that are primarilybetween the individual and society are mentaldisorders unless the deviance or conflict isa symptom of a dysfunction in the individual,as described above.

6. Mental Health Evaluation. A clinical assessment of a servicemember for a mental, physical, or personality disorder, thepurpose of which is to determine a service member’s clinicalmental health status and/or fitness and/or suitability forService. The mental health evaluation shall consist of, at aminimum, a clinical interview and mental status examination andmay include, additionally: a review of medical records; a reviewof other records, such as the Service personnel record;information forwarded by the service member’s CO; psychologicaltesting; physical examination; and laboratory and/or otherspecialized testing. Interviews conducted by the Family AdvocacyProgram or the Service’s Drug and Alcohol Abuse RehabilitationProgram personnel are not considered mental health evaluationsfor the purpose of this instruction.

7. Mental Health Care Provider. A psychiatrist, doctoral levelclinical psychologist or doctoral level clinical social workerwith necessary and appropriate professional credentials who isprivileged to conduct mental health evaluations for DoDcomponents.

8. Potentially Danqerous (Not Imminently Dangerous)-. A clinicalfinding or judgment by a privileged, doctoral level mental healthcare provider, based on a comprehensive mental healthevaluation, an individual has demonstrated violent behavioragainst himself or herself or another person, or of destroyingproperty under circumstances likely to lead to serious personal

Enclosure (1) 2

SECNAVINST 6320.24AI6FEB 1699

injury or death, or possesses longstanding character traitsindicating a tendency towards such violence, but is not currentlyimmediately dangerous to himself, herself or to others. Aviolent act of a sexual nature is considered an act which wouldresult in serious personal injury.

9. Protected Communication. Any lawful communication to aMember of Congress or an IG. ‘A communication in which a memberof the Armed Forces communicates information the memberreasonably believes evidences a violation of law or regulation,including sexual harassment or unlawful discrimination,mismanagement, a 9ross waste of funds or other resources, anabuse of authority, or a substantial and specific danger topublic health or safety when such communication is made to any ofthe following: A Member of Congress; an IG; a member of a DoDaudit, inspection, investigation, or law enforcementorganization; or any other person or organization (including anyperson or organization in the chain of command) designated underDoD component regulations or other established administrativeprocedures to receive such communication.

10. Self-Referral (or Voluntary Referral) . The process ofseeking information about or obtaining an appointment for amental health evaluation or treatment independently initiated bya service member.

11. Senior Privileged NonDhvsician Provider. In the absence ofa physician, the most experienced and trained health careprovider who holds privileges to evaluate and treat patients,such as a clinical social worker, a nurse practitioner, anindependent duty corpsman, etc.

3 Enclosure (1)

SECNAVINST 6320.24AI B FEe 199a

From:To:

Subj :

Ref :

Encl :

SAMPLE LETTER

COMMANDING OFFICER REQUEST FOR ROUTINE(NONEMERGENCY) MENTAL HEALTH EVALUATION

FOR OFFICIAL USE ONLY6320SerDate

Commanding Officer, (Name of Command)Commanding Officer, (Name of medical treatment facilityor clinic)

COMMAND REFERRAL FOR MENTAL HEALTH EVALUATION OF (SERVICEMEMBER RANK, NAME, BRANCH OF SERVICE AND SSN)

(a) DoD Directive 6490.1, ,,MentalHealth Evaluations Of

Members of the Armed Forces,” 1 Ott 97 (NOTAL)(b) SECNAV Instruction 6320.24A, “Mental Health

Evaluations of Members of the Armed Forces,”(c) Section 546 of Public Law 102-484, “National Defense

Authorization Act for Fiscal Year 1993,” Ott 1992(d) DoD Directive 7050.6, “Military Whistleblower

Protection, “ 12 Aug 95 (NOTAL)

(1) My ltr (SSIC, serial #, date)

1. Per references (a) through (d), I hereby request a formalmental health evaluation of (rank and name of service member) .

2. (Name and rank of service member) has (years) and (months)active duty Service and has been assigned to my command since(date). Armed Services Vocational Aptitude Battery scores uponenlistment were: (list scores). Past average performance markshave ranged from _to (give numerical scores). Legalaction is/is not currently pending against the service member.(If charges are pending, list dates and UCMJ articles) . Pastlegal actions include: (List dates, charges, nonjudicialpunishments and/or findings of Courts Martial.)

FOR OFFICIAL USE ONLY

Enclosure (2)

SECNAVINST 6320.24A

16FEfI1998FOR OFFICIAL USE ONLY

Subj : COMMANDREFERRAL FOR MENTAL HEALTH EVALUATION OF (SERVICEMEMBER RANK, NAME, BRANCH OF SERVICE AND SSN)

3. I have forwarded to the service member a letter thatadvises (rank and name of service member) of his (or her) rights.This letter also states the reasons for this referral, the nameof the mental health care provider(s) with whom I consulted,and the names and telephone numbers of judge advocates, DoDattorneys and/or Inspectors General who may advise and assist him(or her). A coPY of this letter, enclosure (1), is attached foryour review.

4. Should you wish additional information, you may contact (nameand rank of the designated point of contact) at (telephonenumber) .

5. Please provide a summary of your findings and recommendationsto me as soon as they are available.

(Signature)Name of commanding officer

Enclosure (2)


2

SECNAVINST 6320.24A

I@FEB 1999

SAMPLE LETTER

SERVICEMEMBER NOTIFICATION OF COMMANDING OFFICERREFERRAL FOR MENTAL HEALTH EVALUATION

FOR OFFICIAL USE ONLY6320SerDate

From: Commanding Officer, (Name of Command)To: Commanding Officer, (Service member’s rank, name and SSN)

Subj : NOTIFICATION OF COMMANDING OFFICER REFERRAL FOR MENTALHEALTH EVALUATION (NON-EMERGENCY)

Ref: (a)

(b)

(c)

(d)

DoD Directive 6490.1, “Mental Health Evaluations ofMembers of the Armed Forces,” 1 Ott 97 (NOTAL)SECNAV Instruction 6320.24A, “Requirements for MentalHealth Evaluations of Members of the Armed Forces”Section 546 of Public Law 102-484, “National DefenseAuthorization Act for Fiscal Year 1993,” Ott 1992DoD Directive 7050.6, “Military WhistleblowerProtection,” 12 Aug 95

1. Per references (a) through (d), this letter is to inform youI am referring you for a mental health evaluation.

2. The following is a description of your behaviors and/orverbal expressions I considered in determining the need for amental health evaluation: (Provide dates and a brief factualdescription of the service member’s actions of concern.)

3. Before making this referral, I consulted with the followingmental health care provider(s) about your ,recent actions: (listrank, name, corps, branch of each provider consulted) at (name ofmedical treatment facility (MTF) or clinic) on (date(s))(Rank(s) and name(s) of mental health care provider(s)) concur(s)this evaluation is warranted and is appropriate.

ORConsultation with a mental health care provider prior to thisreferral is (was) not possible because (give reason; e.g. ,geographic isolation from available mental health care provider,etc.)


Enclosure (3)

SECNAVINST 6320.24AIfiFElj 1999


Subj : NOTIFICATION OF COMMANDING OFFICER REFERRAL FOR MENTALHEALTH EVALUATION (NONEMERGENCY)

4. Per references (a) and (b), you are entitled to the rightslisted below:

a. The right, upon your request, to speak with an attorneywho is a member of the Armed Forces or is employed by theDepartment of Defense who is available for the purpose ofadvising you of the ways in which you may seek redress should youquestion this referral.

b. The right to submit to the DON Inspector General or tothe Department of Defense Inspector General (DoD IG) forinvestigation, an allegation that your mental health evaluationreferral was in reprisal for making or attempting to make alawful communication to: a Member of Congress; any appropriateauthority in your chain of command; an IG; or a member of a DoDaudit, inspection, investigation or law enforcement organization.

c. The right to obtain a second medical opinion and beevaluated by a mental health care provider of your own choosing,at your own expense, if reasonably available. Such an evaluationby an independent mental health care provider shall be conductedwithin a reasonable period of time, usually within 10 businessdays, and shall not delay nor substitute for an evaluationperformed by a DoD mental health care provider.

d. The right to communicate, without restriction, with anIG, attorney, Member of Congress, or others about your referralfor a mental health evaluation. This provision does not apply toa communication that is unlawful.

e. The right, except in emergencies, to have at least 2business days before the scheduled mental health evaluation tomeet with an attorney, IG, chaplain, or other appropriate party.If I believe your situation constitutes an emergency or yourcondition appears potentially harmful to your well-being and Ijudge it is not in your best interest to delay your mental healthevaluation for 2 business days, I shall state my reasons inwriting as part of the request for the mental health evaluation.

f. If you are assigned to a naval vessel, deployed orotherwise geographically isolated because of circumstances


Enclosure (3) 2

—

SECNAVINST 6320.24Ai6 FEB 1999


Subj : NOTIFICATION OF COMMANDING OFFICER REFERRAL FOR MENTALHEALTH EVALUATION (NONEMERGENCY)

related to military duties that make compliance with any of theprocedures in paragraphs 3 and 4, impractical, I shall prepareand give to you a copy of the letter setting forth the reasonsfor my inability to comply with these procedures.

5. You are scheduled to meet with (name and rank of the mentalhealth care provider) at (name of MTF or clinic) on (date) at(time)

6. The following authorities can assist you if you wish toquestion this referral:

a. Military Attorney: (Provide location, telephone numberand available hours of nearest Naval Legal Service Office.)

b. Inspector General: (Provide rank/title, name, address,telephone number and available hours for service and DoD IG. TheDoD IG number is 1-800-424-9098.)

c. Other available resources: (Provide rank, namecorps/title of chaplains or other resources available to counseland assist the service member.)

(Signature)Name of commanding officer

I have read the letter above and have been provided a copy.Service member’s signature:Date:

ORThe service member declined to sign this letter which includesthe service member’s Statement of Rights because (give reasonand/or quote service member) .

Witness’s signature:Date:

Witness’s printed/typed rank and name:

(Provide a copy of this letter to the service member.)


3 Enclosure (3)

SECNAVINST 6320.24AI8 f[e 1998

SAMPLE LETTER

FROM MENTAL HEALTH CARE PROVIDERTO SERVICEMEMBER’S COMMANDING OFFICER


6320SerDate

From: (Rank and Name of Mental Health Care Provider)To: Commanding Officer, (Service member’s command)Via: Commanding Officer, (Medical treatment facility or clinic)

Subj : MENTAL HEALTH EVALUATION IN THE CASE OF (SERVICE MEMBER’SRANK, NAME AND SSN)

Ref : (a) DoD Directive 6490.1, “Mental Health Evaluations ofMembers of the Armed Forces,” 1 Ott 97

(b) SECNAV Instruction 6320.24A, “Mental HealthEvaluations of Members of the Armed Forces”

1. In compliance with references (a) and (b), the above namedservice member was seen on (date) at (location) by (mental healthcare provider’s rank and name) after referral by (rank and nameof service member’s commanding officer) for an emergencyevaluation because of (brief summary of pertinent facts)

ORfor a nonemergency command directed evaluation because of (briefsummary of pertinent facts)

2. The evaluation revealed (brief description of findings) .

3. The Diagnosis(es) is/are

Axis I-is IIAxis III

4. The servicemember is deemed unsuitable for continuedmilitary Service on the basis of the above diagnosis .(Provide explanation on how the service member’s personalitydisorder or substance abuser for example, is maladaptive toadequate performance of duty.)


Enclosure (4)

SECNAVINST 6320.24A16 FE8 1990


Subj : MENTAL HEALTH EVALUATION IN THE CASE OF (SERVICE MEMBER’SRANK, NAME AND SSN)

Secret Special Compartmentalized Clearance) should be (retained/rescinded) .

AND/OR

d. Other (describe)

8. The above actions and recommendations have been discussedwith the service member who acknowledged he/she understood them.

ORThe service member’s condition (diagnosis(es)) prevent(s)

him/her from understanding the actions taken and recommendationsmade above.

9. If you do not concur with these recommendations, reference(b) requires that you notify your next senior commanding officerwithin 2 business days explaining your decision to act againstmedical advice regarding administrative management of thisservice member.

(Signature)Mental health care provider’sname, rank, corps, branch ofservice

1 FOR OFFICIAL USE ONLY

3 Enclosure (4)

SECNAVINST 6320.24A16FEB 1990

GUIDELINES FOR MENTAL HEALTH EVALUATIONFOR IMMINENT DANGEROUSNESS

Clinical evaluations should include:

I. Record Review

A. Medical Record

1. History of2. History of

treatment3. History of

treatment

pertinent medical problems and treatmentsubstance abuse evaluations and/or

mental health evaluations and/or

B. Family Advocacy Program (if applicable)

c. Service Personnel Record (if available)

D. Review documentation for disciplinary problems andcounseling

II. History

A. History as obtained from the Service member andassessment of reliability

1.

2.

3.

4.

5.

6.

7.

History of past violence towards others: (”Haveyou ever hurt anyone physically? Who? What didyOU do? How badly was the person hurt? How didyou feel about it afterward? HOW do you feelabout it now?”)

Alcohol and illicit substance abuse/dependence

Personal/marital problems

Recent losses (job/family)

Legal/financial problems

History of childhood emotional, sexual and/orphysical abuse or witnessing abuse

Past psychiatric history

Enclosure (5)

SECNAVINST 6320.24A

IEFEB 1998

8. Past medical history and current/recent medications

B. Information from command representative on Servicemember’s behavior, work performance and generalfunctioning

c. Pertinent information from family or friends

III. Mental Status Examination (emphasis on abnormalpresentation)

A.

B.

c.

D.

E.

F.

G.

H.

1.

J.

Appearance (ability to relate to the examiner, eyecontact, hygiene, grooming)

Behavior (psychomotor agitation or retardation)

Speech (rate, rhythm)

Mood (service member’s stated predominant mood)

Affect

Is examiner’s observations of member’s affectconsistent with stated mood?

If inconsistent, in what way?

Thought Processes: Is there evidence of psychoticsymptoms, paranoid thoughts or feelings?

Thought Content: What does the service member talkabout spontaneously when allowed the opportunity? Howdoes the service member respond to specific questionsabout the facts or issues which led to his/herpsychological evaluation? Is there evidence of anirrational degree of anger, rage, jealousy?

Cognition: Is the service member oriented to person,place, time, date, and reason for the evaluation? Canhe/she answer simple informational questions and dosimple calculations?

Enclosure (5) 2

SECNAVINST 6320.24AI6FEe1998

IV.

v.

VI

K. Assessment of Suicide Potential:

1.

2.

3.

4.

5.

Ideation: Do you have or have you had any thoughtsabout dying or hurting yourself?

Intent : Do you wish to die?

Plan: Will you hurt yourself or allow yourself tobe hurt “accidentally or on purpose?” Do you haveaccess to weapons at work or at home?

Behaviors: Have you taken any actions towardshurting yourself; for example, obtaining a weaponwith which you could hurt yourself?

AttemDts: Have vou made Drier suicide attemDts?When?” What did you do? How serious was the injury?Did you tell anyone? Did you want to die?

L. Assessment of Current Potential for Future DangerousBehavior

1.

2.

3.

4.

5.

Ideation: Do you have or have you recently hadany thoughts to harm or kill anyone?

Intent : Do you wish anyone were injured or dead?

Plan: Will you hurt or try to kill anyone?

Behaviors: Have you verbally threatened to hurtor kill anyone? Have you obtained any weapons?

Attempts: Have you physically hurt anyonerecently? (Describe.)

Psychological Testing Results (if applicable)

Physical Examination and Laboratory Test Results (ifapplicable)

Assessment Shall Include:

A. Axis I through III diagnoses, as indicated, and AxisIV and V assessments

3 Enclosure (5)

SECNAVINST16F[E199S

B.

6320.24A

A statement of clinical assessment of risk fordangerous behavior, supported by history obtainedthe Service member and others, the mental statusexamination, pertinent actuarial factors and if

from

pertinent, the physical examination and laboratorystudies results.

VII. Recommendation/Plans Shall Address:

A. Further clinical evaluation and treatment, asindicated.

B. Precautions taken by the provider and recommendationsto the service member’s commanding officer.

c. Recommendations to the service member’s commandingofficer for administrative management.

VIII. Documentation I

A. Documentation of the history, mental statusexamination, physical findings, assessment, andrecommendations shall be recorded in the inpatient andoutpatient record.

B. In those cases of individuals clinically judged to beimminently or potentially dangerous, a letterdocumenting the summary of clinical findings,precautions taken by the provider, verbalrecommendations made to the service member’scommanding officer, and current recommendations shallbe forwarded by the mental health care provider viathe medical treatment facility commanding officer tothe Service metier’s commanding officer within 1business day after the evaluation is completed. Seeenclosure (4).

Enclosure (5) 4

Documents

OFFICE OF THE SECRETARY 1000 NAVY PENTAGON … · u ii EPA RTMENTOF THE NAVy OFFICE OF THE SECRETARY 1000 NAVY PENTAGON WASHINGTON, O,C, 20350.1000 SECNAVINST 6320.24A BUMED-03L SECNAV