Knowledge Share

It’s not all guns and PTSD: Counseling with a cultural lens

Natosha K. Monroe November 1, 2012

When one counsels military service members and their families, the existence and impact of military culture on the client and the therapeutic process is an important consideration. Many in our profession are ready and willing to help address the social and psychological challenges that many service members face. These challenges can include marital discord, sleep disturbances, military downsizing, residual effects of combat exposure and mild traumatic brain injury.

On the basis of their years of therapeutic experience, treatment expertise, vast knowledge and the purest of intentions, counselors working with troops have much to offer. What might be missing from some counselors’ practice, however, is cultural competence. When the military culture is not clearly understood or not properly accounted for during provision of services, even the best counselor can inadvertently damage client rapport, limit the quality of care or even misdiagnose.

The idea of the military representing its own distinct culture may not cross the mind of every counselor. After all, the U.S. military is composed of people of many different ethnicities, races, cultures, socioeconomic backgrounds, ages and even countries of origin. It may seem odd to regard a client who is a military veteran as being from another culture when he or she shares commonalities with the counselor such as race, ethnicity or geographical area. However, as defined in the social sciences, members of the military clearly meet the criteria for possessing their own culture.

The term culture is often mistaken as referencing only ethnicity or race. But take the “American” culture, which is unquestionably composed of people from many different races and of many different ethnicities. When an American visits another country, however, others may quickly identify him or her as being “American.” This is because people outside of the American culture notice subtle and not-so-subtle factors that distinguish our culture from their own.

In its glossary of terms, the ACA Code of Ethics defines culture as “membership in a socially constructed way of living, which incorporates collective values, beliefs, norms, boundaries and lifestyles.” Although specific definitions of culture vary depending on the source, cultural components consistently include language, cuisine, music, dress, government, gestures, grooming and technology.

On the basis of those criteria, it is easy to see the influence of military culture on a male Army soldier, for instance. His language includes words and phrases (Charlie Foxtrot, Class Six, jacked up, civvies, rack, FUBAR, Hooah and roger, for example) that differ from those used by other Americans. His dress is the ACU (Army combat uniform). Music on his iPod may include “The Army Song” or even his favorite running cadence. His cuisine for the day may consist of two MREs (meals ready to eat) or something from the “gut wagon” or “chow hall.” His “government” (although still the U.S. government) includes his commanding officer and a court-martial if he is accused of a crime. His grooming is clearly defined by his extremely short, barely there haircut (a mandatory style for which he can face discipline if not adhered to).

The American Counseling Association is not the only professional organization to emphasize culturally appropriate practice. The American Psychological Association also encourages professionals to use a “cultural lens” and to place cultural competence at the forefront of their professional encounters on all levels. It is vital for counselors to keep in mind that cultural factors can have a very real influence not only on the client’s behaviors but on the counselor’s behaviors as well. The counselor who views the client and the therapeutic process through the appropriate cultural lens begins by acknowledging the influences of culture and then approaches work with the military client with increased respect and competence.

In fact, all professional counselors are ethically compelled to obtain and exhibit multicultural competence when working with their clients. The ACA Code of Ethics defines multicultural/diversity competence as the “capacity whereby counselors possess cultural and diversity awareness and knowledge about self and others, and how this awareness and knowledge is applied effectively in practice with clients and client groups.”

When the choice is made to view the military client through the appropriate cultural lens, professionals increase their odds of avoiding many pitfalls in therapy.

Wasting valuable time on content rather than process

A common mistake counselors make when working with military service members is not taking the time to learn basic information such as rank structure and the differences between military branches. For example, the Navy rank of captain is much higher than the Army rank of captain. Another common misconception is that everyone in the military is a “soldier,” when in fact, this term only describes those in the Army. There are also Marines, airmen, sailors and others. The military client will not expect a nonmilitary counselor to know everything about the military lifestyle, but it can quickly become a distraction and an annoyance if the client regularly has to stop to answer a counselor’s questions about the military, clarify a word or phrase, or address the confusion written across the counselor’s face.

These interruptions can, in fact, hinder the therapeutic process for both counselor and client. Consider the following: Military clients become aware that the counselor hasn’t taken the time to get to know basic military information and doesn’t understand their lifestyle. When their focus shifts to explaining basic terminology or having to “dummy down” the conversation for the counselor, they are not able to give themselves over fully to the therapeutic process.

The counselor’s focus is diverted away from the therapeutic process due to the distraction of the content as well. When the counselor’s focus shifts to content in a struggle to understand what the client is saying, the counselor is not able to give himself or herself over fully to the process either, thus not giving the client the level of service he or she deserves.

Stereotypes and bias

Counselors who have never served in the military themselves (and even those who have) should be aware of the potential to stereotype. The media tend to focus on theatrical drama, so extreme cases are often showcased rather than the norm, which is the more resilient, “typical” returning veteran. Exposure to these negative and inaccurate portrayals of veterans in movies and other forms of media is inevitable and can create bias. Self-awareness and consistent self-monitoring on the part of the counselor are vital.

When counselors notice they are quickly jumping to conclusions or patterns of thought, this should be addressed internally. For instance, not all veterans returning from a combat zone have seen combat; not all Marines have killed; not all military wives are stay-at-home mothers; not all enlisted troops are without a college degree; not all clients with nightmares have posttraumatic stress disorder (PTSD); not all troops have been deployed overseas; and, most important, not all counselors are smarter, wealthier, classier, more educated or better adjusted than their military clients.

There can be a fine line between informed multicultural consideration and stereotyping, so it is important to remain clear regarding the differences between the two. It is a good idea to periodically refresh one’s memory of what was learned during that graduate-level multicultural counseling course. It only takes a moment to search an online bookstore to download a book onto an e-reader or to read an article online. At the very least, one can set aside time to conduct a quick Internet search on stereotypes versus bias versus cultural considerations in therapy.

Although much of the difference is defined by intent and accuracy, a counselor can still accidentally possess or exhibit bias toward a military client despite having good intentions and accurate information. Of course, harboring or exhibiting bias — regardless of intent — goes deeper than just being unprofessional and disrespectful. The counselor’s role in the diagnosis of mental disorders is addressed under Standard E.5. of the ACA Code of Ethics. Standard E.5.c. speaks to the more specific dangers that lingering bias and stereotyping may have in our profession, making it vital for counselors to be culturally competent: “Counselors recognize historical and social prejudices in the misdiagnosis and pathologizing of certain individuals and groups and the role of mental health professionals in perpetuating these prejudices through diagnosis and treatment.” This is a hefty ethical principle — one that probably should be read several times and taken to heart to emphasize how important our role as counselors can be in someone’s life and in society.

Misinterpreted affect or expression

At times, the military client may exhibit a lack of expression that appears robotic or cold to the point of seemingly justifying the descriptive “blunted affect.” At other times, the client’s tone, rate of speech, emotion or expression might seem off or inappropriate. But is this truly “off,” or does the client’s expression differ from the “norm” because of cultural factors?

In the military culture, displaying emotion or lack of control is commonly viewed as weakness, while composure is regarded as strength. For example, a Marine would most likely be shunned or even disciplined for being visibly confused or breaking down and crying in front of others. So, what the counselor perceives might just be the client attempting to appear composed according to the norms of the military culture.

It may also appear to the counselor that the military client is disconnected or otherwise acting inappropriately if the client comes across as unremorseful or emotionless when describing a situation in which the client killed another individual. But before passing judgment or reaching a conclusion, the counselor must also consider the situation in which the killing occurred and how this might affect the client’s reaction. Although it might be a difficult concept to grasp, the context of death in military culture can differ, thus potentially influencing reactions and expressions of emotion.

Should killing in war automatically elicit guilt? What about in cases of self-defense? What about to ensure survival? What about if the act was committed to save a child’s life or to stop a rape? When should a counselor be concerned about the military client displaying (or not displaying) a certain emotion? When should a client’s reaction be questioned and brought to his or her attention?

The counselor must understand military culture and, more important, must know the client very well to correctly interpret what is going on and what is appropriate or inappropriate. This is part of what makes the practice of counseling necessary, albeit challenging. It requires not only knowledge, experience and skill, but also the ability to connect with another individual in a way that is unique to his or her profession and interaction style.

Misdiagnosis and inaccurate assessments

Clearly, not all veterans who have nightmares have PTSD, although many professionals jump to this conclusion, neglecting the rest of the criteria in the Diagnostic and Statistical Manual of  Mental Disorders that must be met to justify the assignment of this disorder. Although it may become standard practice to automatically screen every service member for PTSD, it is irresponsible to assume the majority of military clients will have the disorder. Another mistake is to put too much faith in assessment tools that were standardized on nonmilitary populations. For example, many responses provided by someone in a combat zone to questions on the Minnesota Multiphasic Personality Inventory would surely indicate abnormal personality traits, but in fact, the responses would be quite normal given the person’s environment and culture.

A prevalent issue with service members is sleep disturbance and nightmares. Counselors could jump to the conclusion that sleep disturbance results from exposure to combat or other potentially traumatic events when, in fact, different factors might be the culprits. For example, if the client is an airman, he might live near an airfield where jets are repaired at night, making it difficult to sleep. Or the client’s work schedule may have flipped from the day shift to the night shift recently. Another common experience on deployments or while living on military installations is shared living spaces, where sleep is disturbed by roommates making noise or coming and going at all hours of the night.

It might be simpler to highlight “post-combat nightmares” and even recommend pharmaceutical treatment, but to do so without thoroughly exploring the many other possible contributing factors is shortsighted and may result in poor quality of service to the client. It is important that counselors take their role in diagnosis seriously and consider the impact on the client. An overwhelming percentage of military clients walking through the door should not have the same one or two mental health disorders.

Especially in certain work environments such as military installations or Veterans Affairs hospitals, what is written in a service member’s records will, unfortunately, be provided to many people. Privacy is not as much of a luxury in the military as it is in the civilian world. It is a sad reality that a service member’s supervisor or leadership may see mental health care service (especially diagnosis) as a weakness or even use this information against the service member.

As more professionals in our field begin working with the military, cultural competence must be emphasized and given appropriate consideration. Thanks largely to the efforts of ACA and counseling professionals passionate about offering services to military members and their families, jobs are slowly opening up that used to be offered exclusively to social workers and psychologists. Although there are rarely prerequisites (such as graduate program requirements) to one’s first job working with military veterans, counselors must continue seeking ways to broaden their knowledge and deepen their perceptions of the military culture. Seeing things through the cultural lens will help to ensure a stronger foundation for therapeutic relationships and quality service between professional counselors and their military clients. u

Knowledge Share” articles are based on sessions presented at ACA Conferences. Natosha K. Monroe has been an Army behavioral health specialist for more than a decade. Her work has included assignments to Afghanistan, Guantanamo Bay, Haiti and the Pentagon. She advocates for increased hiring of professional counselors to work with veterans and for obtaining recognition of the counseling profession in all military branches. She currently works as a contracted researcher/analyst on a project for the FBI and lives in Northern Virginia. Contact her at Natoshakm11@gmail.com.

Letters to the editor: ct@counseling.org

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6 Comments

  1. Bana

    Thanks for the article. However, I believe that you may have missed a key point regarding re-integrating ex-military clients into mainstream American culture. Clients who have concluded their service time in the military may find it difficult to readjust to civilian life. Nontheless, helping ex-military clients to reacclimate to civilian life is also necessary … as they will be military for but a while … but they will be Americans all of their life.

    Reply
  2. Bana

    In this very real sense, military clients do not divorce the day to day experience of being American simply because they also have a military background … anymore than any other bi-cultural or multi-cultural American. While I understand the importance of recognizing the client’s military culture, I believe that the client’s military culture is an extention of the client’s American cultural identity … therefore not completely defining the client … which makes your argument that clients are damaged by well meaning counselors a bit far fetched in my opinion. Yes, the client’s military experience may forever shape the client … but so does the client’s experience of being an American in other respects.

    Reply
    1. Keith Myers

      Bana,

      It’s not about an extension. It’s about the total identity. “Once a Marine, always a Marine.” That’s the culture. It’s about the identity, not some sort of additional extension of being an American.

  3. Natosha Monroe

    Bana,

    Thanks for your comments.

    Reintegrating military members once they leave military service was not “missed” but that is quite a different topic–this article was on the topic of cultural considerations of counseling members of the military in general and not to address approaching specific presenting issues such as reintegration.

    I’m not sure you quite understood the point of the article–at no point did it ever indicate that any one aspect of a person “completely defines” him/her. A person’s culture is but one aspect of them. It is of course the counselors duty to get to know the client to better understand him/her as a whole person. This article is to assist counselors to take into account the very real cultural aspects of military life. As an outsider, to view the military culture as “an extension” is not necessarily “damaging” but can greatly limit the therapeutic interaction if the counselor does not acknowledge or have a certain level of understanding regarding unique cultural differences.

    Hope this helps! :)

    Natosha

    Reply
  4. Keith Myers

    I have been working with military active duty and veterans for the past 2 years, and your article is very accurate and needed! Good work.

    Reply
    1. Natosha Monroe

      Thank you, Keith, not only for your comment but for your work with such an amazing group of people.
      I’m glad to have written something of value to help counselors who perhaps have not yet put on their “military lens” in their work with Veterans :)
      -Natosha

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