Counseling Today, Member Insights

Effective treatment of military clients

By Keith Myers August 1, 2013

militaryThere is sound research available that demonstrates the efficacy of certain evidence-based treatments when working with the military population. However, most of that research seems to disregard the necessary prerequisite for counselors in achieving reliable treatment outcomes — the ability to build trust with a client population that has a general disposition to distrust others, especially those outside of the military, which probably includes most of you reading this article. The prerequisite of trust illustrates the primary importance of establishing a level of multicultural awareness that will empower clinicians to achieve a more meaningful therapeutic relationship with military clients. In turn, this will lead to an improved quality of life for those clients.

Trust is the foundation for all meaningful personal and professional relationships. It is what causes a child to laugh when his father hoists him high into the air, knowing that he will always catch him on the way down. If a veteran does not trust you, then your treatment outcomes will have poor results virtually every time. One of my former military clients put it to me bluntly: “I’m not going to let you screw with my mind before I get to know who you are and what you represent.”

Therefore, each clinician should work diligently to establish that level of trust before proceeding with more intensive treatment such as trauma work or other aspects of a mental health treatment plan. Whether you currently work with this population or are simply considering it, I would like to offer some practical ways to build trust with military clients.

Be aware of their grit and character

Merriam-Webster dictionary defines grit as “sand, gravel; a hard, sharp granule.” Another definition includes “firmness of mind or spirit; unyielding courage in the face of hardship or danger; indomitable spirit.”

If you are planning on working with military veterans or active-duty members, then you should be aware of their inner character and grit. This grit is what helps keep them alive in theater, motivates them in spite of roadblocks and allows them to persevere under dire conditions. Military training and culture advances and enhances this inner fortitude.

This culture of character is evident in the language taken from an actual Army NCO Evaluation Report (officer evaluation). It states, “Army Values: Loyalty — bears true faith and allegiance to the U.S. Constitution, the Army, the unit, and other Soldiers; Duty — fulfills their obligations; Respect — treats people as they should be treated; Selfless Service — puts the welfare of the nation, the Army, and subordinates before their own; Honor — lives up to all the Army values; Integrity — does what is right legally and morally; Personal Courage — faces fear, danger, or adversity.” Each branch of service has its own set of values by which its members are expected to live and conduct themselves, but they all speak to an overarching theme of maintaining a high moral and ethical code.

It has been my experience that military clients can activate this grit while in treatment and that it can motivate them to achieve outcomes that might be more difficult for nonmilitary clients to achieve. Having an awareness of this “hard, sharp granule” within military clients gives you more insight into this population, thereby helping you to form trust and rapport earlier in the therapeutic process.

Respect their service

My late father, a World War II Navy combat veteran, would become both angry and empathetic when viewing TV footage of Americans belittling, mocking and even spitting on returning Vietnam veterans. He would exclaim, “How dare those people spit on our troops’ faces when those are the same people for whom they lost their lives!”

Regardless of your personal political views on the Vietnam War, I hope all of us can acknowledge the disrespect our own culture showed Vietnam veterans after they returned from service. It stands as a horrific example of how not to treat our veterans. Sometimes, the best lesson for learning what to do is deduced from learning how not to behave.

On the other hand, one practical way that counselors can show respect for their military clients is to honor all military holidays in their own practice or clinical setting. At the same time, counselors should be mindful that the holidays could invoke memories of buddies who were lost in service or some intrusive thoughts surrounding combat trauma. Some of these holidays include Memorial Day, Veterans Day and birthdays of the different branches of service.

Be comfortable with spirituality

Among the spiritual statements I have heard previous military clients make are, “I don’t know what happened. My spirit died out there” and “Before deployment, God told me that I would return injured but promised me that he would not let me die.”

It is common for spirituality and the veteran population, especially combat veterans, to be intertwined. Therefore, being comfortable with veterans exploring their faith and/or spirituality during a counseling session is vital to building trust and effectively treating this population.

Edward Tick, a clinical psychotherapist who has worked with veterans for more than 30 years, authored the influential book War and the Soul, which contends that posttraumatic stress disorder is a psychospiritual condition or “soul wound.” On the basis of his work during the past three decades, Tick further asserts that a significant part of this wound is caused and further exacerbated by the absence of warrior rites of passage that were present in ancient civilizations. He explains that these spiritual and communal rites of passage are oftentimes missing within the U.S. military system, especially when military members return home. Tick cites storytelling and reconciliation retreats as two such spiritual rites of passage. He further explains, “Reconciliation retreats are one of the most effective tools for addressing the healing needs of both veterans and nonveterans. Such retreats incorporate the individual, group, aesthetic and spiritual dimensions of healing, while relying on the healing power of the story.”

To maintain multicultural relevance and effectively treat combat veterans, counselors and other mental health clinicians must possess knowledge about spirituality and faith as well as the spiritual effects of war.

Use some disclosure to enhance rapport

Regarding my own establishment of professional boundaries with clients in the past, I always erred on the side of caution when disclosing any personal information. Ethically speaking, disclosure comes with certain risks, including the possible crossing of boundaries. It can open the door for a role reversal of sorts if the client listens to the counselor’s issues and begins providing emotional support. As I often emphasize to my students, “You are the therapist, not the client.”

However, aren’t we being incongruent if we believe that authenticity is vital for clients yet never disclose any personal information at all in our role as counselors? Is there a way to balance being genuine with clients while simultaneously keeping other meaningful parts of our lives private? I believe this balance must exist if we are to be effective in treating veterans. Some amount of disclosure during the intake session can enhance rapport and trust, which strengthens the therapeutic alliance going forward in treatment.

I typically share three disclosures with military clients after informed consent: the personal meaning I derive from serving veterans, my previous work in clinical settings and that members of my family have served in the military. For example, I often inform these clients that helping them is rewarding to me because it allows me to “serve those who served,” which I consider to be one of the highest honors. Furthermore, I explain to them that I feel this allows me to give back in some indirect way to my family members who have served. Therefore, my “service” of working with veterans and active-duty members enriches my own purpose and meaning both on the professional and personal levels.

Several clients have reported that these disclosures significantly reduced their initial distrust of me and allowed them to be more open-minded in developing a therapeutic relationship.

Advocate for them

According to the Online Etymology Dictionary, the word advocate is a technical term derived from Roman law that refers to “one whose profession is to plead cases in a court of justice.” It can also mean “one who intercedes for another” or “a pleader.”

If counselors wish to build rapport and establish professional relationships with military clients, then they need to develop the skill of interceding on behalf of their clients. Counselors would be wise to learn from the sister profession of social workers, who have gained a reputation for being master advocates for the clients they serve. In order to remain true to the ACA Code of Ethics, counselors should be aware of the role that advocacy implies and address these expectations clearly with clients before moving forward.

Some practical ways to advocate for veteran clients include communicating treatment goals and progress with their other providers (such as primary care physicians and other providers within the Department of Veterans Affairs) and linking these clients to other community resources. A client once informed me, “I know you care because you are willing to be my voice.”

At times, clients have asked me to accompany them to their physician appointments so I could help articulate their needs. Because I work with clients in an intensive outpatient program, it is possible for me to meet that request. Depending on your practice setting and the level of care you provide, accompanying your client to appointments may not be convenient or even possible. But you might be able to help articulate your client’s needs to other providers by writing a letter that the client presents at these appointments.

Getting started

Maybe you are a clinician and have always been interested in working with the veteran population but are confused about where to begin. As many of us probably realize, the Department of Veterans Affairs has been slow to recognize professional counselors as having equal standing with social workers in job placement. There are a few other possibilities available for exploration, however.

First, it is helpful to discover the location of your closest Wounded Warrior Project chapter. Wounded Warrior Project is a national nonprofit organization whose mission is “to empower and honor wounded warriors.” This mission is accomplished in part by holding community events, providing mental health education to warriors and their families, and promoting recreational interests that connect wounded warriors with each other. By networking with your local chapter of the Wounded Warrior Project, you will be exposed to opportunities for obtaining counseling referrals to work with the veteran population.

Second, if you are independently licensed by your state, have graduated from a counseling program accredited by the Council for Accreditation of Counseling and Related Educational Programs and are providing therapy in a private practice setting, another option involves enrolling with the TRICARE panel. TRICARE is the insurance plan for the Department of Defense (DOD). Getting listed as a TRICARE in-network provider will make it possible to receive counseling referrals directly from the DOD. The American Counseling Association website has a “Private Practice Pointers” section that includes helpful information on starting the application process for TRICARE (from counseling.org, click on “Knowledge Center” and then “Private Practice Pointers”). Unfortunately, this process can take several months, so considerable patience is required.

A final helpful tip for getting started is to attend national, regional and local conferences that offer education about veterans. Whether it is the national ACA Conference or a local conference offered by your state counseling branch, this can be a relatively simple way both to absorb more knowledge about this culture and to network with other clinicians about possible referrals.

Final thoughts

A client recently shared with me that another therapist had made the following statement to him during a session early in the counseling relationship: “Trust me. I’m your therapist.”

This phrase was insulting to the client because actions speak louder than any attempt at shallow reassurance. If simply offering verbal reassurance of your trustworthiness as a therapist was a helpful intervention with veteran or active-duty clients, this article would have been composed of one succinct paragraph. However, it is never that simple with any population, much less with veterans and active-duty members who have a heightened tendency to be guarded with others.

Developing practical skills related to how to “treat” military clients will bolster your ability to connect with them and advance the goal of building trust in the therapeutic relationship. Accomplishing this prerequisite goal will help your military clients to achieve greater clinical outcomes and ultimately lead them to an enhanced quality of life.

 

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Keith Myers is a licensed professional counselor in Georgia, where he works at the Shepherd Center’s SHARE Military Initiative program in Atlanta serving active-duty members and veterans who have traumatic brain injury and posttraumatic stress disorder. He is intensively trained in eye movement desensitization and reprocessing therapy and is a doctoral student in counselor education and supervision at Mercer University, Atlanta. He also serves as an adjunct faculty member with both Argosy University in Atlanta and Point University in East Point, Ga. Contact him at doc355@yahoo.com.

Letters to the editor: ct@counseling.org

 

5 Comments

  1. Natosha Monroe

    Thank you for this article, Keith–my fellow ACA Veterans Interest Network member!
    You are right on target: In our field we hear much about cultural competency…and much about wanting to help Veterans and their Families. Yet unfortunately I see many non-military professionals not taking steps toward cultural competency with military clients.
    -We ARE different in many ways and we DO have a distinct culture!
    -It’s annoying, distracting, and rapport-damaging to be a Veteran in a session with a “professional” who has not taken
    the time or interest to learn things such as basic military rank structure.
    -Things such as this are easily available online.
    After YEARS of seeing my fellow Troops drugged up and diagnosed unnecessarily, I want them to have access to MORE COUNSELING. I encourage everyone to take part in being an advocate for the END of exclusion of our profession in the VA systems and also in the positions of “Behavioral Health Officer” in ALL MILITARY BRANCHES (currently Counselors and Therapists are not allowed to serve as a Behavioral Health Officer in the Army, Navy, Air Force, etc.).
    *If you are an ACA member interested in such things, please consider joining the Veterans Interest Network (check out the Community section of ACA’s webpage for details). We’d love to have you :)
    -Natosha

    Reply
  2. Keith Myers

    Thanks Vinnie and Natosha for your replies!!

    Natosha, you make some excellent points. Thanks for contributing via the VIN.
    Keith

    Reply
  3. Rebecca Weller

    Hello,
    I have a Case Study for my grad class, and in the study the client is suffering from PTSD and was witness to the accidental shooting of a family while on tour. The lead officer covered up the misfire and reported that the family shot first, thus their reaction was justified. This traumatic event still affects the client. Would a therapist have to report this event to the Military?

    Reply
  4. Keith Myers

    Hi Rebecca,

    Since this is an assignment for your class, I would be short-circuiting your process by giving you an answer. My advice would be to utilize an ethical decision-making model to arrive at your answer. Good luck!

    Reply

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