Tag Archives: PTSD

Controversies in the evolving diagnosis of PTSD

By Lennis G. Echterling, Thomas A. Field and Anne L. Stewart February 29, 2016

PTSD headshotsTrauma is as old as humanity itself. In fact, for nearly 3,000 years, such epic poems as The Odyssey and The Iliad have given eloquent voice to the psychic scars of war. These “hidden wounds” of combat included overwhelming feelings of anxiety, horrific nightmares, heightened startle reactions, flashbacks of battle scenes and a profound sense of alienation years after the conflicts had ceased. Despite powerful accounts over the millennia of the psychic impact of trauma, it was only 35 years ago that the Diagnostic and Statistical Manual of Mental Disorders (DSM) introduced the condition known as posttraumatic stress disorder (PTSD). Since then, the evolving diagnosis of PTSD has generated numerous and intense controversies. Only dissociative identity disorder has stirred up more debates among researchers and practitioners.

Now that counselors are playing an increasingly important role as service providers for both military and civilian survivors of trauma, it is vital that we become familiar with the historical context and current issues regarding PTSD.

Conceptualizations of trauma

The origins of the PTSD diagnosis stem from two dramatically different conceptualizations of its cause and symptoms. The psychological movement began in the 1790s and considered the syndrome to be primarily a mental one involving altered consciousness and amnesia, which later became known as dissociation.

The somatic movement, which conceptualized a physiological basis for the syndrome, began in England during the 1860s, when researchers described “railway spine” as a consequence of the physical traumas of railroad accidents. During the past 150 years, wars have spurred health care providers to consider, to varying degrees, these contrasting perspectives in hopes of better understanding and treating the psychiatric casualties of combat.

Trauma and wars

From the U.S. Civil War to the recent conflicts in Iraq and Afghanistan, researchers and practitioners have returned again and again to the impact of war-related violence on the psyches of military troops. In the past, however, the prior lessons learned were largely abandoned and ignored in the decades of peacetime that followed wars.

For example, many physicians who were followers of the somatic movement proposed that traumatized Civil War combat veterans were suffering from a cardiac injury, which they labeled “soldier’s heart.” At the same time, other health care providers relied on a psychological conceptualization of the condition, which they referred to as “nostalgia.”

In World War I, psychiatrists originated the term “shell shock” because they considered the symptoms to be physiological reactions to the intense shock waves that emanated from artillery explosions. Other mental health practitioners, influenced by Sigmund Freud’s theories, diagnosed the condition as “war neurosis.”

With the beginning of World War II, many service members once again experienced the horrors of combat. Initially, those who developed posttraumatic reactions were discharged. However, when psychiatrists found that the degree of relatedness in the military unit was a protective factor, they developed treatment strategies for what they termed “combat fatigue.” These treatment strategies emphasized emotional support and rapid return to active duty.

Again, interest in trauma faded once World War II came to an end. Nevertheless, we should note that the first use of the term “posttraumatic” occurred in a follow-up study on veterans who had been diagnosed with combat fatigue. In the heat of battle in the Korean War, the American Psychiatric Association published the first edition of the DSM. The new manual briefly acknowledged that combatants experienced short-lived psychological reactions to war but did not label the syndrome a psychiatric disorder.

Not until the Vietnam War did the demand for a combat-related trauma diagnosis reach a tipping point. In the early 1970s, many returning U.S. veterans exhibited problematic and life-threatening behaviors. At first these behaviors were attributed to noncombat-related neurosis or psychosis. However, with public war protests growing, veterans began advocating for a new disorder called “post-Vietnam syndrome.” Mental health professionals began holding “rap groups” with Vietnam veterans about their experiences and led panel discussions at professional conferences. These efforts led to the American Psychiatric Association’s decision in 1980 to formally accept PTSD as a legitimate diagnostic category in the DSM-III. 

The long-term conflicts in both Iraq and Afghanistan once again have focused attention on the traumas that combatants endure and the pervasive impact of PTSD on the lives of returning veterans. The Rand Corp. estimated the prevalence of PTSD in Iraq and Afghanistan war veterans to be 14 percent, which is twice the estimated lifetime prevalence rate for civilians. With multiple and longer deployments, the risk of military combatants developing PTSD is even greater.

Trauma and the DSM 

In 1951, the DSM-I, which was a slim volume of 130 pages, introduced the syndrome “gross stress reaction.” Although not a disorder, the inclusion of this reaction proved to be both significant and influential for two reasons. First, it acknowledged that the syndrome was a risk not only for veterans of war but also for civilian survivors of catastrophic events. Second, it asserted that this syndrome applied to “normal” persons who experienced intolerable stress, thus disagreeing with the then-dominant psychodynamic assumption that these psychiatric casualties were vulnerable individuals who possessed predisposing neurotic conditions.

In the second edition of the DSM, published in 1968, the American Psychiatric Association revised the title of the syndrome to “transient situation disturbances,” a label with a more clearly negative term. Still, it was not considered a disorder.

Finally, in 1980, PTSD was included as a mental disorder in the DSM-III. It also became the first disorder to include a diagnostic criterion — a traumatic event — that was entirely external to the individual and outside the range of usual human experience. Examples of traumatic events included rape, combat, accidents and disasters. If the event was a “normal” one, such as the loss of a job or divorce, the person’s reaction was diagnosed as an adjustment disorder. Other criteria for PTSD included re-experiencing symptoms, engaging in avoidance and having arousal symptoms.

The addition of PTSD to the DSM-III was not without controversy. Given the disorder’s emphasis on combat-related trauma, there was concern the Vietnam War had politicized the decision with its emphasis on the hidden wounds of combat veterans. Because their dysfunction now was directly tied to military service and not to personality flaws, the Veterans Administration (now the Department of Veterans Affairs) was required to offer services to affected soldiers. In addition, PTSD was recognized as a disorder that merited disability status. Consequently, the Veterans Administration requested more government funding to meet the increased need for psychological services.

Seven years later, the DSM-III-R (revision) appeared with several minor refinements to the diagnosis of PTSD, including operationalizing the symptom clusters. A major contribution of this edition was to identify, for the first time, age-specific features that children and adolescents exhibit in response to trauma.

In 1994, the DSM-IV eliminated the requirement for the precipitating stressor for PTSD to be outside the range of normal human experience. It also expanded the definition of traumatic events to include the indirect experiences of observers and the loved ones of the victims. As a consequence of adding vicarious traumas, the number of qualifying events for PTSD increased by 59 percent. No other diagnosis in the history of the DSM had undergone such a drastic expansion (known as “conceptual bracket creep”) from one volume to another. The DSM-IV-TR (text revision) was introduced six years later and tightened the definition of a traumatic event to something that is “extreme” and “life threatening.” It also added several diagnostic specifiers, such as “acute,” “chronic” and “delayed onset.”

After many postponements, the DSM-5 was finally released in 2013 in a massive volume of 947 pages. The most obvious change in this current edition is that PTSD is no longer classified as an anxiety disorder. Instead, it is included in a new chapter titled “Trauma- and Stressor-Related Disorders.” Another significant change is that the DSM-5 now places restrictions on the operational definition of a traumatic stressor. For example, witnessing an event no longer qualifies as a traumatic stressor unless the person is physically present. In most cases, observing an event through the media is excluded. The DSM-5 also no longer requires an intense emotional reaction to the event because this lacked predictive utility. A new specifier now includes dissociative symptoms such as depersonalization and derealization.

Swinging pendulum

Like a pendulum, the conceptualization of PTSD has swung back and forth over the past century. In the time of Freud, its cause was attributed largely to the individual’s character deficits. During World War II, it was understood to be a normal reaction to persistent combat exposure. Thus, the pendulum moved toward identifying the traumatic event itself as the chief culprit of dysfunction. Following the war, most mental health practitioners gave greater weight to the extreme stressor as the primary cause. This view was reflected in the first edition of the DSM, when it was posited that any “normal” individual would develop symptoms after exposure.

As traumatized veterans returned from the Vietnam War, special interest groups began advocating for the addition of PTSD to the DSM-III to publicly acknowledge the hidden wounds of war. Perhaps most important, by requiring that the stressor had to be outside of normal human experience and so severe that any normal person could be affected, the DSM-III definition of PTSD reflected theBranding-Images_PTSD farthest swing of the pendulum toward placing onus for dysfunction on the traumatic event.

On the basis of new evidence that the majority of survivors did not develop PTSD after exposure to traumatic events, the DSM-IV represented the pendulum’s move back toward the interaction between internal and external causation, judging the individual’s emotional reaction to be just as crucial in the development of psychopathology. In other words, the event itself was no longer considered the sole cause of PTSD. Instead, traumatization was defined both as exposure to an event and an individual’s subsequent response of intense fear, helplessness or horror.

During development of the DSM-5, some scholars suggested that the event should be removed entirely as a diagnostic criterion for PTSD, resembling a return to Freud’s conception of dysfunction being attributed solely to the individual.

A developmental perspective

One serious limitation of the first three editions of the DSM was the lack of consideration of any potential developmental differences in reactions to extreme stress. Therefore, a major contribution of the DSM-III-R was to identify age-specific features that children and adolescents exhibit. For example, the DSM-III-R noted that young children were more likely to relive the trauma in repetitive play.

Still, researchers and clinicians working with children noted that the PTSD criteria in the DSM were not developmentally sensitive and did not capture clinically relevant symptoms for children living in chronically unsafe conditions. A proposal to include a new diagnosis, developmental trauma disorder (DTD), was considered for inclusion in the DSM-5. This diagnosis was proposed on the basis of findings from developmental psychopathology, clinical presentations of children exposed to chronic interpersonal violence and emerging evidence from the field of neurobiology regarding the impact of trauma on brain development. Ultimately, the proposal for DTD was not accepted for inclusion in the DSM-5. The discussion of the merits of an alternative classification system for children experiencing complex trauma is continuing.

Current issues

In addition to the controversies regarding the definition and criteria of PTSD, criticisms have continued to emerge regarding the transparency, representation and integrity of the DSM revision process. Critics have cited the secrecy of the DSM-5 development process and the apparent lingering presence of pharmaceutical company influence on DSM task force members as factors affecting the process.

Many advocates are worried that PTSD is underdiagnosed and undertreated among veterans of both current and past conflicts. For example, an estimated 271,000 Vietnam veterans continue to suffer from PTSD, according to a recent study by Charles Marmar published in JAMA Psychiatry. The New York Times reported that the incidence of PTSD among current military personnel more than doubled between 2005 and 2010, resulting in an overburdened Veterans Affairs (VA) health system. In 2011, the 9th U.S. Circuit Court of Appeals demanded that the VA overhaul its mental health services because delayed and inadequate services were being provided to returning U.S. veterans with PTSD. Harkening back to the conceptualization of “shell shock” in World War I, there now is growing recognition that primary blast waves have caused serious and permanent traumatic brain injuries among veterans of the Iraq and Afghanistan wars.

The prevalence of PTSD among civilians is also a serious problem. The National Sexual Violence Resource Center reported that half of the survivors of sexual assault are estimated to meet diagnostic criteria for PTSD. The high incidence of wide-ranging traumatic events among both children and adults has led many to recommend the use of trauma-informed care involving collaborative, supportive and skill-based interventions that address the pervasive impact of trauma. Recent research also has underscored the need to refine our conceptualization of PTSD by recognizing the crucial role that shame can play in its dynamics. Anxiety regarding external dangers has long been considered the primary emotion of PTSD, but the perceived internal threat of exposing one’s shame often predominates for many survivors, especially among those who have experienced interpersonal violence.

In marked contrast to the issue of underdiagnosis of PTSD, many professionals who intervene after disasters typically provide public education that normalizes reactions to catastrophes. Their criticism of the DSM is that broadening PTSD diagnostic criteria may have the unintended consequence of pathologizing natural human reactions to highly disturbing incidents. A related current issue is that many researchers and practitioners are calling for greater awareness of the phenomenon of posttraumatic growth, suggesting that the majority of trauma survivors eventually achieve higher levels of personal maturity, wisdom and well-being.

In our current environment, PTSD remains a diagnosis that involves controversies. As promoters of human growth and development, counselors are in a unique position to be active participants in this conversation. We can engage most effectively by contributing to refinements in conceptualization, discoveries through research, innovations in practice and empowerment through advocacy efforts that promote the resilience of trauma survivors. Given the prevalence of PTSD and the severity of its impact on individuals, families, relationships and communities, it is our duty as counselors to play a crucial role in alleviating the anguish and pain of those who suffer the consequences of this disorder.

Yes, trauma is as old as humanity. But as our theory, research and practices continue to evolve in the midst of PTSD controversies, we can envision a more humane future in which the diagnosis and treatment of trauma survivors offers healing and hope.

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences

Lennis G. Echterling is a professor of counselor education and director of the Ph.D. in counseling and supervision program at James Madison University in Harrisonburg, Virginia. His most recent book is Thriving! A Manual for Students in the Helping Professions. Contact him at echterlg@jmu.edu.

Thomas A. Field is an associate professor and associate program director in the master’s counseling program at City University of Seattle. He also works as an independent contractor at a private practice in the Seattle area. Contact him at tfield@cityu.edu.

Anne L. Stewart is a professor in the Department of Graduate Psychology at James Madison University. She is the president of the Virginia Play Therapy Association, and her most recent book is Play Therapy: A Comprehensive Guide to Theory and Practice. Contact her at stewaral@jmu.edu.

 

Letters to the editor: ct@counseling.org

 

 

Exploring the impact of war

By Keith Myers September 26, 2014

A small town celebrates a homecoming. Parties are given in honor of the combat veteran who has returned home triumphantly. Families and loved ones are reunited, and community leaders show honor to the warrior by offering laud in public ceremonies. All appears to be whole again.

But as the dust settles and the town returns to its normal quiet state, they emerge. Silence seems to activate them. Attempting to sleep exacerbates them. Panic, fear and horror accompany them. They Camo-face-Smallare a reminder of personal losses, and they are joined by a feeling of intense guilt. They are war memories.

These memories are much different from the typical memories one might have about a past life event. For one thing, they are traumatic in nature and carry with them a tidal wave of emotional surge. They overwhelm the body with their intense physiological manifestations. They overwhelm the soul via spiritual and moral injuries. They overwhelm the mind with their unrelenting and intrusive presence. They demand full attention, often invading precisely when their host is trying to avoid them.

War memories are one of the hallmark symptoms of combat trauma and a primary stressor experienced by many combat veterans. Learning about common war stressors provides counselors with a necessary foundation for working with this population. It also helps counselors to better understand the military culture as it relates to the overall clinical context of combat trauma.

In the seminal work on combat trauma, Combat Stress Injury: Theory, Research and Management, William Nash, a U.S. Navy psychiatrist and director of a Marine Corps program to prevent combat stress injuries, speaks of war stressors and the critical role they play in modern warfare. He teaches that war stressors can be divided into five groups: cognitive, emotional, social, physical and spiritual. In this article, I will examine these five categories of combat stress mostly within the context of Operation Iraqi Freedom (OIF, Iraq conflict), Operation Enduring Freedom (OEF, Afghanistan conflict) and Operation New Dawn (OND, Iraq conflict since 2010). 

Cognitive stressors

Changing rules of engagement: A primary cognitive stressor that is common in operational conflicts is the ambiguous or changing “rules of engagement” (ROE). ROE include the standards that determine when military personnel are permitted to fire their weapons and at whom. In the OIF, OEF and OND conflicts, U.S. troops are not allowed to use deadly force unless a clearly armed adversary poses a clear and immediate threat to U.S. troops or civilian life.

As Nash explains in Combat Stress Injury (2006), “This is a laudable standard, one that all honorable warriors hope to meet at all times. But in the three years since the U.S. invaded Iraq, for example, a number of ambiguous situations have become almost commonplace for soldiers and Marines. One is the use by Mujahadeen of civilians, including women and children, as human shields. This was encountered in many areas of Iraq, particularly where fighting was the bloodiest and most contested, such as in An Nasiriyah during the initial push toward Baghdad and during the second battle of Al Fallujah in November 2004.”

These types of ambiguous situations were very common in OEF and OIF. Such impossible choices cause increasing cognitive stress burdens within the context of a traumatic combat environment. 

Boredom: Another cognitive stressor of combat trauma is monotony or boredom. Military clients speak of this often when recalling their deployment experiences. They talk about how their day-to-day work was mostly boring and consisted of long periods (from several hours to several days) with very little action. Some military personnel may constantly patrol the same areas over and over again with nothing significant to report.

Often, the operational activities of a combat zone include a systematic monotony that provides limited recreational activity. However, it is important to note that during these periods of boredom, warriors are still expected to remain on “high alert” because the enemy could strike at any time. This state of being on guard even during periods of boredom and monotony has a significant effect on cognitive stress.

Emotional stressors

Fear and horror: Combat veterans often report that losing buddies and being killed or seriously injured are common fears that everyone experiences on the battlefield. Many of these veterans have directly experienced firefights and enemy ambushes or witnessed the death and injury of multiple buddies in combat. This fear exists on a continuum, ranging from the anticipation and dread of preparing to deploy into a combat zone to the terror that accompanies the threat of being severely injured. The greatest fear for warriors is not being killed or losing a buddy, however. The greatest fear is losing their honor on the battlefield. This kind of honor is upheld in the values and oaths of the different military branches.

The death of friends: Military personnel who deploy and serve in combat zones together form the most intimate of bonds. Nash explains that the emotional impact of losing a close comrade in war is not unlike the loss a mother experiences when her child dies. The levels of disbelief, shock, guilt, shame and longing may be much the same for both.

However, unlike the grieving parent, the warrior has little opportunity to fully experience the intense feelings that accompany the loss or to do the necessary cognitive work that might help him make sense of things. The warrior cannot allow himself to grieve; he must remain partially numb to the loss so that he can continue to do his job. Therefore, numbness becomes adaptive within the work environment of the combat theater.

Guilt and shame: Military leadership places a high priority on responsibility in decision-making because one wrong decision in combat can result in the loss of many lives. Even though this level of responsibility is adaptive and needed, it can contribute to the guilt a warrior experiences. It is not uncommon to hear military clients talk about this guilt, commonly referred to as survivor guilt, when describing their buddies who died in combat. Some warriors state, “I should have been the one who took the fall,” or “I shouldn’t be sitting here right now,” or “I should have done something different.” Sometimes the feelings of intense guilt are manifested in nightmares as the combat veterans’ war memories replay during sleep.

Although it is difficult at times for warriors to overcome this guilt, many of them do not have significant trouble acknowledging it. This acknowledgment should be viewed as a strength and can lead to growth and change when receiving counseling.

Other emotions are related to a sense of shame, such as feeling like a failure on the battlefield. These shame emotions are much more difficult for warriors to acknowledge or express.

Killing: In his masterful and insightful book On Killing: The Psychological Cost of Learning to Kill in War and Society, first published in 1995, Lt. Col. Dave Grossman attests that the act of killing another human being is a traumatic stressor for many combat veterans. He writes that all humans may have an intrinsic aversion to killing members of their own species, an aversion that must be overcome on the battlefield to engage in interpersonal violence. Grossman explains the practical ways that the military desensitizes its members to achieve this purpose. Regardless, killing other humans still remains one of the greatest stressors in combat.

Relationship issues at home: It is well documented that families of military members experience significant stress when their loved one is deployed. It is especially stressful when they may not know where their loved one is or what kind of danger he is experiencing on a daily basis.

This situation is stressful for the warrior as well, especially if some sort of conflict is occurring within the family environment at home. Regardless of whether the issue involves a death in the family or a recent argument with a spouse, the warrior must attempt to continue performing his job well, even while knowing that he cannot address the problem when he “gets off work” later that night, like so many other Americans are able to do. It may be weeks or even months before he is able to fully process the loss of a loved one or address the conflict with his spouse.

Social stressors

Lack of privacy or personal space: Deployed warriors are commonly surrounded by a large number of their comrades, both when sleeping and working. Most of the time, this cannot be avoided, and this lack of personal space is often likened to being packed like a “can of sardines.” For the most part, this tightknit environment is a positive aspect because it enhances the cohesion of the group. This cohesion is vital in combat situations, where warriors must trust one another with their very lives.

However, it also means a near total absence of privacy and the need to share almost all equipment and spaces. This lack of privacy can be stressful, especially when the only items considered personal belongings are weapons and uniforms. Most other items are freely shared among the community of warriors. 

Media, public opinion and politics: It is easy to see the devastating effects that the national media and public opinion had on returning Vietnam War veterans and their families. Many were mocked, ridiculed and spat upon in public and in private. Fortunately, the media and public opinion are much more supportive of combat veterans who have served in the Iraq and Afghanistan conflicts. 

The national media and public opinion wield power to validate or invalidate the sacrifice and service of warriors. Furthermore, every criticism of these more recent wars or the way they were handled inflicts emotional and social wounds on the warriors who faced death each day. On a political level, when wars are not properly funded or when debates rage in Congress, it has a direct impact on the warriors who are fighting to uphold those same political freedoms. However, politicians and media members are rarely held responsible for the influence they have on warriors in theater.

Physical stressors

Harsh conditions: Nash explains that certain regions in the Middle East and Southwest Asia can reach 120 degrees Fahrenheit in the summer, while lows in the winter can go below freezing. Furthermore, the effects of the heat are amplified by the body armor that military personnel wear, including Kevlar (helmet), flak jacket (armored vest) and new ceramic SAPI (small arms protective insert). Wearing this protective gear can raise the temperature underneath the body armor an additional 10-20 degrees. That level of heat makes staying hydrated a significant challenge, while simultaneously making both physical and mental exertion more difficult.

Sleep deprivation: Very few military personnel in a combat zone achieve six to eight hours of sleep every day. On average, combatants are forced to function on four hours of sleep or less. Some veterans in war zones become so sleep deprived that they experience visual and auditory hallucinations. Sleep deprivation affects many levels of functioning, including attention, memory and higher levels of thinking and decision-making. This combat stressor overlaps with many different elements and could also be placed under the cognitive or emotional stressors. 

Pain or injury: During the course of a seven- to 14-month deployment, it is almost impossible to avoid occasional experiences of pain, illness or injury. In fact, many military personnel continue to work through pain and injury.

During a period from 2003-2006, the Department of Defense reported that 18,572 troops were wounded during combat in Iraq. More than half (10,064) returned to duty. According to Nash, this means they returned to their units in Iraq soon after their injuries, usually while still recovering. Some of those injuries were considered to be minor, such as lacerations or eardrum injuries from improvised explosive devices. However, some of those injuries were not so minor. I find the level of resilience and determination that combat veterans exhibit while serving their country in a hostile environment amazing. 

Spiritual stressors

Crises of faith: One common stressor that is rarely discussed is the crisis of faith that many combat veterans experience. Spiritual stressors sometimes occur when one is faced with life-or-death decisions, and this is particularly true in combat. Belief in God can be threatened or challenged when encountering the chaos and helplessness of combat situations. This is especially evident when the warrior has a belief in a benevolent God.

A common question is, “How can God allow this evil to exist when He is supposed to be good?” Some warriors find it impossible to continue believing in this view of God and experience a crisis of faith that affects them on many levels (cognitive, emotional and so on). On the other hand, some veterans’ faith and religious convictions are deepened by their experiences. But no matter whether their faith is ultimately strengthened or weakened, most veterans face spiritual stressors.

Struggle with forgiveness: Nash explains this concept, stating, “Awful things happen in war; they are often unavoidable. And even the bravest and strongest can be pushed to the point of acting in ways that later may be deeply regretted. Finding a way to forgive oneself … can be a significant challenge.”

I have also discovered this to be true in my work with military veterans. It is common for warriors to have an easier time forgiving others than forgiving themselves. Part of this may be attributed to (usethis)military-homewarriors holding themselves to such high personal and professional standards or the level of responsibility that the military instills in them. However, further research is needed in this area before definite conclusions are drawn. An important part of treatment with this population should include a focus around self-forgiveness by the warrior.

Evidence-based treatments for combat trauma

What evidence-based treatments can counselors utilize for posttraumatic stress disorder (PTSD) related to combat? While various types of treatments can be helpful with this population (biofeedback and stress inoculation training, for example), there is not enough space to discuss all of them. Therefore, I will focus on the three empirically based treatments given an A-plus rating by the Army surgeon general in 2012 for reducing combat-related PTSD symptoms among veterans.

EMDR: Eye movement desensitization and reprocessing (EMDR) is an evidence-based psychotherapy treatment that was originally designed to alleviate the disturbance associated with traumatic memories. The Adaptive Information Processing Model posits that EMDR facilitates the reprocessing of traumatic memories to an adaptive resolution. After successful treatment with EMDR, affective distress is relieved, negative beliefs are reformulated and physiological arousal is reduced.

During EMDR, the client attends to emotionally disturbing material in brief sequential doses while simultaneously focusing on an external stimulus. Therapist-directed lateral eye movements are the most commonly used external stimulus, but a variety of other stimuli include hand-tapping and audio stimulation (see emdr.com). A treatment course of 12 sessions is common. I utilize EMDR in my clinical work with combat veterans and have achieved some significant clinical outcomes over the past three years. For information on receiving intensive training in EMDR, see emdrhap.org.

CPT: Cognitive processing therapy (CPT) is derived from cognitive behavior therapy (CBT). According to the National Center for PTSD (ptsd.va.gov), CPT includes four main parts of treatment:

1) Having clients learn about PTSD symptoms and how treatment can help

2) Getting clients to become aware of their thoughts and feelings

3) Having clients learn skills to challenge those thoughts and feelings (cognitive restructuring)

4) Helping clients understand the common changes in beliefs that occur after going through the trauma

CPT puts less focus on the traumatic event itself and more focus on the beliefs resulting from the trauma and the impact those beliefs have had on the person’s life. From there, it is about the client deciding whether those beliefs are accurate or inaccurate. For a helpful and free web-based learning course, visit cpt.musc.edu/. For additional training, check the Center for Deployment Psychology at deploymentpsych.org/workshops.

Prolonged exposure: Prolonged exposure also has its roots in CBT. It focuses on repeated exposure to the traumatic event(s) and the accompanying thoughts, feelings and situations to reduce feelings of anxiety and disturbance.

The National Center for PTSD highlights the four primary elements of prolonged exposure:

1) Education: Having clients learn about their symptoms and how treatment can help

2) Breathing training: To help clients relax and manage distress

3) Real-world practice (in vivo exposure): Reducing clients’ distress in safe situations that they have been avoiding

4) Talking through the trauma (imaginal exposure): Helping clients get control of their thoughts and feelings about the trauma 

Prolonged exposure typically involves eight to 15 sessions, with several homework assignments given in between sessions. For more information on trainings, refer again to the Center for Deployment Psychology. 

Final thoughts

Perhaps you are a professional counselor who has always wanted to serve veterans in your private practice, or perhaps you are a counselor who is already working with this population. Either way, given that it is estimated that up to 20 percent of combat veterans will develop PTSD, it is important that counselors acknowledge and understand the common stressors of war combat. In gaining this knowledge, you can better connect with the military client who is (or who will be) sitting in your office or agency. And by being familiar with the effective treatments and where to obtain training, you will be better equipped to effectively help this client deal with the effects of combat trauma and PTSD.

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Keith Myers is a doctoral student in counselor education and supervision at Mercer University in Atlanta, Ga. A licensed professional counselor and intensively trained eye movement desensitization and reprocessing therapist, he is also a member of the American Counseling Association’s Traumatology Interest Network. Visit his website at keithmyerslpc.com and contact him at keithm355@gmail.com.

Letters to the editorct@counseling.org

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Related reading: See Myers’ piece from August 2013, “Effective treatment of military clients”: ct.counseling.org/2013/08/effective-treatment-of-military-clients/

Promoting understanding of PTSD

By Bethany Bray June 27, 2014

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Image via http://www.ptsd.va.gov/

If there’s one thing Hallie Sheade wishes people knew about post-traumatic stress disorder (PTSD), it’s that the disorder is actually the human body’s natural reaction to trauma.

“PTSD is a very normal response to a very abnormal experience,” says Sheade, a licensed professional counselor (LPC) who runs an equine-assisted therapy program in Texas. “There’s nothing wrong with [people with PTSD]. This is how we would expect somebody to react to a traumatic event.”

About 3.6 percent of U.S. adults ages 18- 54 (or approximately 5.2 million people) present with PTSD during the course of a given year. Prevalence is higher among women and deployed military personnel.

June is PTSD Awareness Month, and the National Center for PTSD has spent the past four weeks focusing on spreading public awareness and promoting understanding of the disorder.

Congress has designated Friday, June 27, as nationwide PTSD Awareness Day.

According to the National Center for PTSD, it is normal to have post-trauma stress reactions such as upsetting memories of the event, increased jumpiness or trouble sleeping. A person should seek help if these symptoms get worse or do not go away over time.

PTSD is a complicated, multifaceted disorder that affects not only those who suffer from it, but also those close to them.

The good news is that counselors are well-trained to help, says Carlos Zalaquett, a counseling professor at the University of South Florida who has counseled people affected by trauma, including victims of violence and political unrest in his native Chile, for three decades.

A variety of evidence-based treatments have been shown to help those with PTSD, says Zalaquett, from trauma-focused cognitive behavior therapy to eye movement desensitization and reprocessing (EMDR).

“I feel that we’ll see more and more veterans who need help and support for PTSD. As counselors, we need to be prepared to help them,” says Sheade.

Sheade, a registered play therapist and national certified counselor, often uses horses in her treatment of clients, from children to veterans of the Vietnam War, regardless of whether they have PTSD.

Numerous relationship and trust issues are common in those with PTSD, says Sheade. Through equine-assisted therapy, the horse — a gentle and nonjudgmental companion — can help these clients take a first step in connecting with others again.

In addition to social anxiety and trouble with relationships, those with PTSD can develop depression, substance abuse, sleep disorders and panic attacks, according to Sheade and Zalaquett.

Sometimes, the effects of trauma are so deeply rooted or long-lasting that a client doesn’t even realize it is the foundation for other problems such as sleep disorders, says Zalaquett, a member of ACA.

PTSD in children is often misdiagnosed because their struggles to pay attention and with acting out are labeled as attention-deficit/hyperactivity disorder (ADHD), says Sheade, an American Counseling Association member who is working on a doctoral dissertation concerning veterans, PTSD and equine-assisted therapy at the University of North Texas.

In the case of military veterans, PTSD is often compounded by a host of other issues, from the stigma the military culture attaches to seeking help for mental health issues to the adjustment of returning from deployment overseas, which can create unanticipated challenges in relationships with a spouse or children.

Those who have served in the military often feel like others don’t understand them – or understand the challenges they face returning to civilian life — or want them to just “get over it,” says Sheade.

In her experience, Sheade often sees veterans with PTSD who try to self-medicate with alcohol or other drugs.

The first step, says Sheade, is to get the veteran to acknowledge that he or she has a problem. From there, Sheade tries to move the client toward realizing that PTSD is a normal response to trauma and that with treatment, he or she can move beyond it.

“[I try to] help them understand that and feel a sense of hope … help them accept their experience and that there’s nothing wrong with them,” she says.

For many veterans, the thought of seeking help and going to therapy carries a negative stigma. They are also more likely to have trouble trusting civilian counselors, who can be unfamiliar with military culture, Sheade says.

“Especially if they’re active duty, there’s a lot of worry about going to see a counselor and how that could affect their military career going forward,” she says. “There’s still such a need for veterans to find services that are acceptable to them — services that they can afford [and that offer] quality care.”

However, counselors shouldn’t assume that every military client will have PTSD, says Zalaquett. Although PTSD is more prevalent among veterans, the majority of service members will not develop the disorder.

Proper assessment and diagnosis is key, Zalaquett stresses. It is also important to understand that not everyone who experiences trauma — whether service member or civilian — will develop PTSD.

“Make sure treatment [for PTSD] is really needed,” says Zalaquett. “Treating for the sake of treatment, without a clear need, has been shown to do more harm than good in some cases. … For a while, we tried to intervene very early to prevent PTSD in those exposed [to trauma]. It turns out that in some cases, this immediate intervention caused more PTSD than no intervention [would have].”

In cases of PTSD, counselors should use therapies that play to the client’s strengths, skills and interests, Zalaquett says.

“Evidence-based therapy is important, but a counselor needs to tailor therapy to the uniqueness of a client also,” he says. “… I have the utmost respect for and I value what the person brings with him or her [to a session]. We use what’s there to build a potential solution.”

 

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For more information

 

American Counseling Association practice brief on PTSD (written by Zalaquett): counseling.org/docs/practice-briefs/post-traumatic-stress-disorder.pdf

 

ACA podcast on counseling military families: counseling.org/knowledge-center/podcasts/docs/aca-podcasts/ht029-counseling-military-families

 

Information and resources from the National Center for PTSD: ptsd.va.gov

 

The National Center for PTSD’s page on changes made to PTSD diagnostic criteria in the fifth edition (2013) of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5): ptsd.va.gov/professional/PTSD-overview/diagnostic_criteria_dsm-5.asp

 

The National Center for PTSD’s “About Face” awareness campaign: ptsd.va.gov/apps/AboutFace/

 

Washington Post article: Roughly half of veterans diagnosed with PTSD last year after serving in Iraq and Afghanistan received treatment: washingtonpost.com/world/national-security/report-half-of-vets-with-ptsd-got-treatment/2014/06/20/cb020834-f89a-11e3-af55-076a4c5f20a0_story.html

 

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Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org

 

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook: facebook.com/CounselingToday

 

web_PTSDawareness_Poster2014

EMDR for the co-occurring population

By Jeanne L. Meyer May 29, 2014

In my work with clients with co-occurring mental health and substance use disorders, it became clear to me early on that most have experienced trauma in their lives — trauma that they must resolve to achieve and maintain a healthy recovery.

These traumas are sometimes categorized as little “t” or big “T” traumas. Big “T” traumas include childhood sexual, physical or emotional abuse, natural disasters, war experiences, severe car accidents and rape. Little “t” traumas can be just as damaging, especially because they tend to occur over time and build on each other. This complicates the overall effects of the trauma as well as the trauma treatment. Some examples of little “t” traumas include ongoing emotional abuse or neglect, experiences of shame, being humiliated and being bullied. Incidents involving racism, sexism or homophobia could be classified as either big “T” or little “t” traumas depending on the severity. These traumas might involve one or two distinct incidents, or be more complex, ongoing experiences. The result is a primary belief that the world is not safe. In some cases, individuals who are traumatized learn to expect pain, dishonesty and betrayal from the people they love the most.

In the case of clients with addiction, even if they have not experienced trauma prior to the onset of their disease, they most likely have experienced violence, rage, betrayal, abuse (sexual, physical or emotional), incarceration, homelessness or a whole host of other negative experiences while using alcohol or other drugs.

There are two clinically appropriate strategies for treating posttraumatic stress disorder (PTSD) with people in substance abuse recovery. One strategy is to address the trauma or abuse immediately as the client enters the beginning stages of recovery. The other is to wait until the client’s ability to achieve and maintain abstinence has stabilized.

How do we know which strategy will be successful? Ultimately, the client is the one who knows. If the ability to maintain abstinence from alcohol or other drugs is precarious or impaired due to memories, suicidal ideation or self-harm, it is essential to treat the cause of these symptoms from the beginning. For these clients, recovery will likely remain elusive until their trauma is addressed. If the client is relatively stable, however, waiting until the later stages of recovery is indicated. Clients who are pressured into addressing their trauma issues before they are ready are likely to relapse into active addiction.

According to recent brain research described in Uri Bergmann’s 2012 book Neurobiological Foundations for EMDR Practice, when someone experiences an event or multiple events that cause intense fear, it can change the neural pathways, or maps, in the brain. Whenever something is experienced as a reminder of the trauma, clients can relive that trauma, making them afraid of certain places, tones of voice, objects or even other people with certain body types. Smells can also trigger intense anxiety and fear. The repetitive experience of anxiety and fear can result in panic attacks, health problems, chronic pain, sleeping difficulties and eating difficulties. The individual eventually becomes self-centered, focusing so much on self-protection that there is little objectivity or ability to have empathy for others. This makes every relationship unstable.

eyeThe good news is that several proven therapeutic techniques, including eye movement desensitization and reprocessing (EMDR), can alleviate symptoms stemming from past traumas. EMDR uses the mechanism by which information from frightening and horrifying events is processed into memory and stored in the brain. By manipulating the brain’s intrinsic information processing scheme, a practitioner can help clients release themselves from the intense hold those memories have on them. EMDR combines sensory bilateral stimulation (visual, auditory or physical sensations) with emotional memory and the underlying belief system to lessen the intensity of the experience. It does not erase the memory, but it can reduce or alleviate many of the associated symptoms.

The mystery of EMDR

It is not known precisely how EMDR works, but various research studies have verified its effectiveness in the treatment of trauma. Twenty-four randomized controlled (and 12 nonrandomized) studies have been conducted on EMDR. Most of these studies address simple rather than complex trauma. For a list of these studies, visit the EMDR Institute website at emdr.com and click on the “Research Overview” link under the General Information tab.

In developing EMDR, Francine Shapiro postulated that PTSD is caused by a disruption in the adaptive information processing system. Because the fear and helplessness experienced by clients stays attached to the memory of the traumatic event, it creates havoc in their lives. It is as if the trauma is continuing to happen to them. Because it is still occurring neurologically, it cannot be processed as a memory.

EMDR changes the configuration of the neural connections or map of that event, detaching the dysfunctional physiological and emotional components so that it becomes a more manageable memory. This helps the client “let go” of the past because the neurons are literally letting go of some connections and replacing them with new ones.

In my experience, EMDR is the fastest, most effective and least intrusive way to help clients release trauma, regardless of whether it stems from childhood abuse, sexual abuse or assault, accidents, disasters or combat, and regardless of whether it is the result of a single event or multiple experiences. I have also seen EMDR reduce or eliminate chronic pain, headaches, fibromyalgia and cravings for alcohol and other drugs. One of the best things about EMDR is that it doesn’t require clients to retell their horror stories. In my view, when people don’t have words to describe what they are experiencing, don’t remember the original incident, have somaticized their pain or are too emotionally raw to put the experience into words, it is essential to offer treatment that does not require verbalization.

 

p 56 chart

[Click on the image to see the chart in full size]

The eight phases

To practice EMDR, a clinician must have a master’s degree, counseling experience and the proper EMDR training. Although the process may seem simple to an outside observer, it requires both an understanding of how the brain and emotions work with trauma and a specific protocol. As shown in the table below, there are eight phases of treatment.

We’ll use “Carrie” to highlight how each phase of the EMDR treatment protocol might be carried out with a client.

  • History taking and treatment planning (Phase 1): This is used in most counseling therapies. The therapist and client review biopsychosocial history and trauma history, assess client resources and strengths and determine the frequency and level of any dissociation symptoms. The therapist will suggest different targets and strength-building skills depending on the overall emotional stability of the individual.

“Carrie” comes to the clinic requesting help with night terrors and anxiety. While obtaining her background history, it becomes clear she has survived many traumatic events, has few financial or social resources and is currently separated from her abusive husband. She smokes cigarettes, uses marijuana, uses some mindfulness tools and practices breathing techniques to manage her distress and anxiety. The therapist determines it is essential to improve her emotion regulation and distress tolerance skills, along with targeting various symptoms such as her recurring nightmare.

  • Preparation (Phase 2): The therapist explains the adaptive information processing system and how trauma disrupts it. The mechanics of treatment are reviewed. Emphasis is placed on clients nonjudgmentally observing their reactions and awareness, and communicating those observations to the therapist. Rapport is established. Relaxation and self-soothing techniques are taught and practiced.

In Carrie’s case, she is able to best understand the adaptive information processing system with the help of a simple illustration the therapist draws to engage her in the therapeutic relationship. The therapist says, “I will show you exactly what the technique looks like. We can use eye movements, sounds using headphones, or I can tap the back of your hands. Which feels most comfortable to you?” When Carrie chooses eye movements, they arrange the chairs so Carrie and the therapist are facing each other. The therapist holds a pen in front of Carrie and asks, “Is that comfortable? Do I need to change the distance or the pen I’m using? What I will do is wave my pen back and forth, and you follow it with just your eyes.” The therapist does this, and Carrie follows the pen easily.

  • Assessment (Phase 3): The client and the therapist determine exactly what the target is, including any images, physical sensations or memories that are associated with the emotionally loaded material. They rate the intensity of the feelings that are attached using the Subjective Units of Distress Scale (SUDS). An “irrational belief” (as defined by Albert Ellis) is identified by the client as the negative cognition. The client chooses a more reasonable belief to use as the positive cognition and rates the perceived validity of this statement.

In Carrie’s case, she remembers parts of her dream: She is in a dangerous situation with people looking for her; she crawls through a hole in a wall to discover she is in a bunker with gunfire all around her. She rates the fear she feels as she recalls the nightmare at a SUDS score of 9. She identifies her belief when these feelings come up as, “I am never safe.” The therapist asks her what she would rather believe.

Carrie responds, “That I am safe, I guess.”

“Are you safe?” the therapist asks.

“No, not always,” Carrie says.

“But sometimes you are safe.”

“Yes, sometimes I am safe.”

The positive cognition becomes “I can be safe.”

The therapist asks, “How true does that statement feel right now?”

Carrie rates it on a Validity of Cognition (VOC) scale as a 1, indicating it feels “like a lie.”

  • Desensitization (Phase 4): The cognition, the emotion and body awareness are combined with bilateral stimulation. The therapist changes the bilateral stimulation speed with eye movement, tapping and sounds throughout and between sets. A set is composed of a series of bilateral stimulations. For example, moving the eyes back and forth 10 times would represent a set. The therapist varies the length of a set depending on the intensity of the material the client is experiencing. In between sets, the therapist determines that the process should continue by asking the client if he or she is noticing any changes. This pattern continues until the client reports no change between sets and the SUDS score has been reduced to a 0 or 1.

For example, the therapist tells Carrie, “Bring up that memory, crawling through the hole and being in the bunker. Remember the sounds and smells. Notice how your body feels. Allow the thought, ‘I am never safe,’ to float in your mind. Do not try to direct your thoughts. Let your mind wander. Wherever it goes is where it’s supposed to go.”

Carrie watches the therapist move the pen back and forth, causing her eyes to move from left to right rhythmically. After a set of 10 eye movements, the therapist stops and says, “Take a deep breath. Tell me what you are noticing right now.”

The therapist makes a note of Carrie’s response and starts another series of bilateral stimulations. The process continues until Carrie reports several times that she feels “nothing.” When recalling her nightmare, her SUDS score is 0.

  • Installation (Phase 5): The positive cognition is strengthened for the client. The bilateral stimulation is used as the client thinks of the positive cognition. The sets are shorter and slower to allow the positive experience to establish itself. The VOC is measured again until a score of 6 or 7 (“completely true”) results.
  • Body scan (Phase 6): The therapist asks the client to pay attention to the way her body feels from head to toe (or vice versa) and report it.

Carrie notices some trembling in her hands. The therapist uses more sets of eye movements until the trembling ceases.

  • Closure (Phase 7): The therapist ensures clients are safe to leave the session and navigate their way to their next destination. They are guided through self-calming rituals. The therapist explains that the client may feel spacey or very tired for anywhere from one hour up to a few days. Clients are given an assignment to journal their experiences, emotions, thoughts and dreams until the next session.
  • Reassessment (Phase 8): This phase occurs at the beginning of the following session. The targeted material is recalled and the client’s SUDS score is determined. The VOC of the positive cognition is also reevaluated. Any residual processing that occurred between sessions is discussed. If there is a change in either the SUDS or VOC score, it indicates there are more aspects of the target to process.

At Carrie’s next session, she reports the nightmare has not returned. When she remembers it, her SUDS score is 1. The positive cognition, “I can be safe,” is rated at a VOC of 7 (“completely true”).

Conclusion

When I work with a client, I keep meticulous notes about the intensity of the individual’s negative emotions and the perceived validity of the positive cognitions before and after a treatment. I keep this record partly so that I can review it with the client in the future. Many times, the client possesses no memory of having the original problems and emotions. The client still remembers the traumatic incident and has feelings about it, but the incident does not haunt the client any longer.

My experience of utilizing EMDR with clients has been no less than amazing. I continue to be surprised at its effectiveness addressing a number of concerns. It works relatively quickly, and its results are maintained. After the initial setup, it relies on clients’ own processing and therefore validates their experience completely. With EMDR, there is also a shorter period of intense unpleasant emotion that clients experience than with other talk or exposure therapies. It engages the parasympathetic nervous system, leading to relaxation or drowsiness when the process is complete.

Whether EMDR is used at the beginning of addiction recovery or after a period of abstinence, clients are able to manage their recovery more easily and more successfully when PTSD symptoms are alleviated.

 

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Jeanne L. Meyer, a licensed mental health counselor, licensed professional counselor and master addictions counselor, is a co-occurring therapist with Choices Counseling in Vancouver, Washington. She is also a member of the American Counseling Association Trauma Interest Network. Contact her at jmeyer@ChoicesCounseling.org.

 

Letters to the editor: ct@counseling.org

 

 

A passion to serve: veterans and counseling Q+A

Compiled by Bethany Bray February 18, 2014

SoldiersSuicide rates. Chain of command. Posttraumatic stress disorder (PTSD). Military jargon and slang.

For counselors, working with military veterans brings its own challenges and need for baseline knowledge.

“Just as with any other culture that is different from your own, it is not enough to simply want to help members of the military. There is a need for true cultural knowledge and competency,” says Natosha Monroe, co-leader of the American Counseling Association’s Veterans Interest Network.

The network, composed of roughly 85 counselors, serves as a sounding board for discussion and insights on counseling military service members, both active and retired.

From how better to advocate for nonmedicated therapies to strategies for navigating the Department of Veterans Affairs (VA), members of the interest network strive to learn from each other and stay current on issues that affect the military population, says Monroe.

Monroe, a practicing counselor in the Dallas area, is one of seven people who moderate the Veterans Interest Network. She served 13 years as a behavioral health specialist in the U.S. Army and is a sergeant first class in the Army Reserves. Monroe has provided mental health care, both in humanitarian efforts and support services for U.S. troops, in Haiti, the Dominican Republic, Afghanistan and Guantanamo Bay, Cuba.

“I am not an officer in the Army,” Monroe explains, “because currently no military branch recognizes our profession [of counseling]. All behavioral health care officers/providers are social workers, counseling/clinical psychologists or psychiatrists only.”

 

Q+A with ACA’s Veterans Interest Network

Responses written by Monroe, with input from network co-leaders Patrick Gallegos, Todd Burd, Xiomara Sosa, Keith Myers, Linda Sheridan and Tony Williams.

 

Why should counselors be aware of/interested in veterans issues?

Our group offers ACA members three primary things:

1) A place within ACA for veterans to come together to share and discuss similar interests, support veteran members who are deployed and to interact in a way that will hopefully resemble the camaraderie many of us have experienced in our military service.

2) An opportunity for counselors interested in working with the military population to share ideas and to learn more about the military population through conversation and observation.

3) A place to network with others who have like-minded ideas and issues specific to military counseling-related topics.

 

What challenges do counselors face in this area?

1) Veterans often have decisions made about their best interests but not so often are asked their opinions on what they’d like to see happen. This often leads to gaps in real needs being fulfilled.

2) Oftentimes counselors have never had any military experience and they see military clients without being culturally competent first.

 

What are some trends you’re seeing?

Service members are experiencing an almost exclusively medical model of treatment when they seek mental health help. Most are never given the option for nonpharmaceutical care and in some cases are reporting being given more medication when they report that the medication is “making them feel like a zombie.” It is very difficult for them to see LPCs (licensed professional counselors).

 

What would a new counselor need to know about working with veterans?

1) Just as with any other culture that is different from your own, it is not enough to simply want to help members of the military, there is a need for true cultural knowledge and competency.

2) Don’t jump the gun and take therapy or diagnosis down the wrong track. For instance, truly look at symptoms rather than seeing a person who’s been to war, has nightmares and then “bam,” label it PTSD.

3) Thoroughly examine your client’s previous diagnoses and don’t just go with it. Same with medications.

 

What would a more experienced counselor need to know?

Same response as above.

 

What are some tips or insights you’d give regarding veterans that could be useful to all counselor practitioners?

Out of respect and professionalism, take the time to learn things such as military rank and structure, military language/slang/terms and what current military operations are going on in the world. If you know none of this, what does that say to your client? Ignorance of military culture interrupts the therapeutic experience every time a counselor looks confused or has to stop a train of thought for a definition or clarification.

 

What are some current issues or hot topics that the interest network has been discussing?

We are passionately advocating for members of the military to have equal access to what our profession can bring to the table — nonmedication therapy for their mental health care needs.

1) Right now, the VA system blatantly discriminates and, in most cases, completely excludes [licensed professional counselors] from counseling positions.

2. Currently, there is a complete exclusion of licensed professional counselors in positions of behavioral health care officers in all military branches, making ours the only mental health care profession, along with marriage and family therapists, that is not recognized or allowed to serve in uniform.

3) Grandfathering in of non-CACREP counselors into the VA system and also for various health insurance policies.

4) Increase awareness and respect to the fact that service members fall within a unique micro-culture within the society as a whole and must be given multicultural consideration in therapy sessions by all counselors — meaning too that counselors must be culturally competent prior to beginning work with the military client.

5. Increasing awareness of specific mental health care concerns such as suicide rates.

6. LGBT integration into health and wellness benefits and rights.

 

What makes you personally interested in this area?

I (Monroe) am a veteran, and it’s frustrating not to be allowed to do my job in the Army. Also watching my fellow soldiers constantly being heavily medicated without being offered the option of seeing someone in our profession.

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The Veterans Interest Network is one of 17 interest networks open to ACA members. In the coming months, CT Online plans to highlight each network – from sports counseling to traumatology – with an online Q+A article.

For more information on ACA’s interest networks or to get involved, see counseling.org/aca-community/aca-groups/interest-networks.

 

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Bethany Bray is a staff writer at Counseling Today. Contact her at bbray@counseling.org.

Follow Counseling Today on twitter @ACA_CTonline