The Ballistic Missile of Behavioral Health Prevention

By Lt. John Knorek, prevention and outreach officer, Directorate for Mental Health Services at Naval Hospital Okinawa

ExteriorwithlogoWhy go ballistic with prevention?

A proactive approach to universal prevention is our revolution’s secret weapon. We remix an old battle cry with ballistic power. Why, because prevention and ballistic missiles share three common traits and advantages; Long-range Coverage; Rapid Response and Significant Impact.

To return preventive medicine to the front lines of health care, I have re-conceptualized how prevention is approached.  I will describe its application to behavioral health (BH) at Naval Hospital Okinawa and the ongoing revolution. I hope my story inspires you to go ballistic with prevention in your field and to spread the word.

Universal prevention benefits all by maintaining a healthy population without professional assistance.  A universal strategy addresses persistent, inherent pressures of Navy medicine e.g., demand for care and access to care issues, by distributing responsibility and dissolving barriers of healthcare.  Prevention adds value to the Navy by increasing service member time at work, provider availability, and financial savings associated with reduced medical intervention.

However, despite its recognized value in BH, prevention’s chronic troubles (APA, 2007) often lead to unsuccessful implementation. It’s time to renovate our approach to prevention.  As the first officer of prevention and outreach in the Directorate for Mental Health Services at Naval Hospital Okinawa, my work began by re-conceptualizing how to approach BH prevention, addressing historic ailments.

How to approach an uphill fight?

How do you perceive and practice prevention?  Do educational posters and pamphlets, required trainings, and outreach presentations sound familiar?  Prevention is commonly implemented passively with voluntary, internally developed services that often go unheard.  True prevention is about getting to the left of the issue, requiring a proactive approach to prevent disease at a population level (Rose, 1992).  What better way to approach a whole population than to go ballistic: the assertive collaboration is far reaching; it has comprehensive coverage at ground and policy levels, and meaningful resource support.  Adopting a ballistic approach is an essential step to make universal prevention, “BOOM!”

The first strike against prevention is the difficulty conducting effective research and subsequent lack of resource support.  Second, prevention’s historically poor reputation due to chronic flawed implementation has led to its omission in the medical training pipeline (Hage et al., 2007) and the conditioning and disregard of health care providers. Lastly, the coup-de-grace, as a medical community we believe we are in charge of prevention. Strike three!

We are incumbent to inspire universal ownership of wellness and impose this message on the line, auxiliary organizations, and community. So, how has DMH addressed these obstacles and supported the BH prevention revolution in Okinawa where restrictions are significant, service members are separated from social support and op-tempo is high?


First, DMH has adopted the offense-driven, ballistic approach. Among other proactive initiatives, we invested in a provider to identify pre-existing inroads at commands and have made sure we are “seated at the table” with other assets positioned to advise leadership on BH issues. We then got behind the wheel to drive a sustained and insistent effort engaging auxiliary BH program leaders, participate in command meetings, and connect with operational medical assets.  Our initiatives educate, support and include other programs and commands in the management of unit and individual wellbeing.  Persistent communication was a key step to expediting care and coverage, resolving stigma, and distributing ownership of psychological wellbeing outside the hospital.

Commands familiar with BH representatives have demonstrated a shifting culture to become more informed, timelier responders. BH is better positioned to address issues before they escalate, keeping service members at work and mission ready – BOOM… Prevention!

Second, we increased collaboration with other BH assets, improving service coverage and impact at a systemic-level.  Frequent inter-organizational meetings facilitated efficient delivery of services, and identification of gaps, and redundancies in coverage.  Constant contact across BH assets improved relationships with commands, which helped recruit them to join the BH team.

With a team member on-site, issues were identified and addressed before the need for medical intervention at the hospital. With leadership’s support, collaboration also expanded to policy makers who could make a systemic impact.

Collaboration expedited care and teamwork with commands. Communication at different tiers of leadership, from clinical supervisors to III Marine Expeditionary Force representatives, allowed us and other BH assets to inform higher-order decisions that affect the majority – universal, blanket coverage – BOOM!

Third, once we established a foothold with commands and improved connections with BH assets, resource availability and operational leadership support increased.  Recently, the BH revolution experienced a surge in staffing, allocation of physical spaces at remote bases, and a soon-to-be online system of embedded prevention specialists. In turn, services are better organized, received, and tracked.  BH is improving data collection methods to further inform prevention efforts.  With more resources, BH is working smarter and in a more distributed way across Okinawa, rather than working harder and responding defensively when the fight is already at the hospital’s door.

The tides are turning as BH prevention continues on an upward cycle of receiving support to provide data-driven services.


BH prevention and outreach initiatives are relatively fresh out the Naval Hospital Okinawa gate in this revolution, thus ownership of recent victories, e.g., distribution of care outside the hospital, and improved access to care, are due to a collaborative network including MCCS programs and III MEF leadership.

However, battles have been won with our ballistic approach to prevention, which is comprehensive, assertive, responsive, and resource supported. With this approach, prevention is blooming where it has been planted, validating it as a fertile investment.  Next steps include establishing and evaluating measures to assess changes in prevalence of BH issues and developing targeted prevention services (Offord, 2000).

My goal was to return preventive medicine to the front lines in Okinawa.  I can enthusiastically say that BH prevention has been effectively restored by executing a universal strategy imbued with a ballistic approach.

Has the BH revolution inspired you to go ballistic in your field? How has prevention historically served your field in Navy medicine? What would a ballistic approach to universal prevention look like in your region?  Share your battles and how your prevention victories improved Navy health and readiness.

American Psychological Association (2007). The psychological needs of U.S. military service members and their families: A preliminary report. Washington, DC: American Psychological Association.

Caplan, G. (1964). Principles of preventive psychiatry. New York: Basic Books.

Gordon, R. S. (1983). An operational classification of disease prevention. Public Health Reports, 98, 107–109.

Hage, S. M., Romano, J. L., Conyne, R. K., Kenny, M., Matthews, C., Schwartz, J. P., et al. (2007). Best practice guidelines on prevention practice, research, training and social advocacy for psychologists.

The Counseling Psychologist, 35, 493–567.

Offord, D. R. (2000). Selection of levels of prevention. Addictive Behaviors, 25, 833–842.

Rose, G. (1992). The strategy of preventive medicine. Oxford University Press.