Tag Archives: Military

Military

Using reality therapy to help military families

By Nicole M. Arcuri Sanders June 14, 2019

Military children are the “Children of the world, blown to all corners of the world. [They] bloom anywhere.” Just like dandelions, military children never know where they will go and where they will grow.

Diane Townsend Davis is credited with creating the dandelion motto for military children. Understanding this motto is imperative for any counselor who wishes to work with military children, but especially for school counselors. The Department of Defense Dependents Education (DoDDE) estimates that 80% of military children (approximately 1.2 million) attend public schools.

Counselors who work with military children must understand the unique stressors that these children face, but counselors also must be prepared to help meet these children’s needs in a short amount of time because their families move often. To avoid having these children slip through the cracks, school counselors must be knowledgeable about rapport-building strategies with this population and meet their needs in a realistic time frame.

 

Reality therapy

Working with clients from their worldview is not a new concept for counselors. This is particularly important when working with a population connected to the military because these clients’ perspectives differ drastically from those of the civilian population. Being knowledgeable about the unique needs of the military culture is a necessity for effective counseling work. For instance, often as military children begin to find their niche in a school, their families will receive orders for relocation. Military families relocate 2.4 times more often than do civilian families (on average, military families relocate every two to three years).

Reality therapy offers this population an honest evaluation of their current choices and behaviors to determine if change is needed to obtain their desired outcomes. This modality offers something that is very important to consider for this population —an emphasis on what aspects of life the client has control over.

As noted, military children move often and therefore tend to be the new kid in school quite frequently. But these children are not like most other new children in school. These children:

  • Have parents who are willing to sacrifice their lives for the well-being of the nation and to safeguard its people
  • Have parents who often leave for extended periods of time to either train for combat-related situations or as part of combat-related missions
  • Know that a great deal of risk is associated with their parents’ jobs
  • Don’t always know whether their mom or dad made it back safely from work
  • Can go for months without being able to see their parent(s)

In an age of social media, these children may at times be able to connect with their parents, but they also might see or hear reports of attacks on the news. When a member of a military unit is killed in action, all communication is cut off at their deployment station to ensure that the family of the service member is notified prior to receiving any other communication. When military children are unable to connect with their parent, the fear of the death being their father or mother is very real. All of the above noted aspects are the reality for military children, and all of these aspects are out of their realm of control.

Reality therapy offers these clients the opportunity to form a relationship with their counselor based on understanding and nonjudgment. Clients have a voice when working with counselors who use reality therapy. The clients become empowered by being afforded the idea of having control over their behaviors and actions.

A basic tenant of reality therapy is aiding clients in having their basic needs met. Creating a safe place in which clients do not feel judged but do feel empowered is therapeutic in itself.

Reality therapy is founded on the idea that everyone is seeking to fulfill five basic needs:

1) Love and belonging

2) Power or sense of worth

3) Freedom or independence

4) Fun or a sense of pleasure

5) Survival (which is based on knowing that one’s basic needs are being met)

When one of these needs is not being met, mental health issues can arise.

For clients connected to the military, feeling loved and belonging might look different than it does for other clients. Because these clients are frequently separated from loved ones and move often, meeting their need to feel loved and belong can be challenging. Reality therapy provides these clients with the understanding that they cannot change or control others. So, the practical approach will be to solve problems through their ability to control themselves and their own behaviors and thus make choices that support their needs and desired goals.

Within the military, very little power is offered to the family or the service member. Ultimately, the family and service member follow orders from a multitude of levels within the Department of Defense (DOD). Yet each military-connected member can feel a sense of accomplishment through actions they choose to control. For instance, helping clients make a list of goals that they want to accomplish while living somewhere (i.e., making the best out of each duty station) can be empowering to them.

Gaining knowledge of a new area through exploration can also be empowering. Helping clients identify their interests (and what makes them unique) can further support their independence and wellness. Fun can also be part of that experience.

Of course, with each transition that military-connected clients face, their survival needs will be tested. For instance, they may need to realign their thoughts regarding shelter (housing). Yet helping these clients differentiate what is out of their control and what is in their control can aide them in pursuing actions that support the desired outcomes that are within their control. Clients may still be angry, confused or saddened by aspects that are outside of their control. But counselors can help clients see that rather than blaming others or relying on these aspects as an excuse, they can focus on and take ownership of their present time and actions.

Reality therapy sessions are structured around the WDEP system — the client’s wants, doing, evaluation and planning. The counselor meets the client in the here and now and explores what the client wants. This realistic exploration of attainment notes what is in the client’s control and what is not. Clients then share what they are doing to help themselves achieve their wants. Next, the counselor helps clients evaluate whether what they are doing is supportive of or detrimental to their goals. Then, together, the counselor and client plan ways to change detrimental behaviors and fine-tune supportive behaviors to allow for the client to obtain his or her wants.

As the client is faced with new areas of need, the same WDEP system can be applied. Military-connected clients are faced with many hardships fostered by their culture. But reality therapy offers this population a real chance to be resilient by adapting to change and overcoming challenges.

 

Resilience

Military child resiliency largely resembles how well the stay-behind parent is doing. If the parent is unable to cope or transition with the needs of the family when the service member is not available to assist them, then a domino effect will occur. Children will have to fulfill adult responsibilities in the absence of the service member. The parental stressors will then be placed on the children’s shoulders.

For some parents, missing a spouse may be too much for them to handle. Other parents who are left behind may not be married or may not currently be together with the service member, but they may still rely on the service member for support with the children.

When there is a lack of available support, the additional stressors put these families at risk. A 2008 report from the Military Family Research Institute found studies to support that since 9/11, when the number of deployments for service members increased, military families experienced increased rates of marital conflict, domestic violence, child neglect or maltreatment, parenting stress, anxiety and depression.

On the opposite side, when the parent left behind is able to successfully juggle the transition and continue meeting both personal and family needs, children experience less turmoil. These children are better able to continue on as normal with minimal changes to other aspects of life. However, having resources available to these parents to support them in filling roles for which the service member parent was typically responsible is imperative.

Civilian school counselors and community mental health counselors should consider that the resources that military families rely on may not be readily available. For instance, counselors should note whether additional family support is local versus distant and how long the family has called its current community home. Again, reality therapy can provide these clients with a realistic perspective of addressing their needs. Therefore, it is important for counselors to know what additional supports are available to these families.

 

School counselors

According to the National Center for Education Statistics, children across the United States spend an average of 6.64 hours a day and a 180 days per year attending public schools. As noted previously, 80% of military children attend public schools.

Public schools have a duty to be aware of the needs of military children. In its 2012 national model, the American School Counselor Association (ASCA) asserts the necessity for school counselors to understand their students’ culture in order to provide effective support for students’ academic, career and personal/social development. ASCA further proclaims in its 2012 executive summary that school counseling programs can be effective only when a collaborative effort exists between the school counselor, parents and other educators, thus creating an environment that promotes student achievement.

School counselors who use reality therapy can support students’ academic, career and personal/social development. For each of these areas of development, the school counselor can address the student client’s wants and doing while also aiding the student in evaluating such efforts and making plans that support success. Yet without understanding the unique needs of the military lifestyle, school counselors will be unable to support these children in the schools or locate appropriate community resources to provide support outside of school. Therefore, when assessing the student client’s wants, a realistic perspective of the stakeholders involved will aid in developing goals that the student client has control over.

 

Community counselors

The same notion of understanding the unique needs of military children and military families is true for civilian community counselors. According to the ACA Code of Ethics, the primary responsibility of a counselor is to respect the dignity and promote the welfare of clients (Standard A.1.a.). This notion alone requires counselors to take the specific needs of their clients into consideration.

To best do this, counselors should not impose their own values on clients (A.4.b.) but instead should honor the diversity of clients and their uniqueness within their social and cultural contexts. Reality therapy promotes this understanding by developing a therapeutic relationship that embraces the client’s worldview and operates from that perspective in developing realistic goals.

 

Realistic intervention

As military children, family members and service members are blown to all corners of the world, professional counselors should be asking themselves a question: “How can we best serve these clients so that they can bloom?”

All counselors should have the same mission when working with this population — namely, devising goals that are realistic and attainable for these clients. Counselors must make themselves knowledgeable of the specific resources that are available to this population to promote therapeutic growth rather than presenting yet another barrier that these clients must face. There are many resources available exclusively to service members, veterans and their families of which civilian counselors may not be aware. When working with military families, it is imperative that counselors do their homework regarding these resources before leading clients blindly with an analysis of client control in establishing wants or goals.

Toward the end of this article, I will share a number of resources that are available to assist military families living off base. But let’s next consider what civilian counselors can do.

For starters, civilian counselors will want to build rapport with the military-connected client while being mindful of their cultural worldview (just as they would with any other client). This will require the counselor to be knowledgeable about the military population and the client’s role within the military family. As noted earlier, this is a unique culture, and being able to understand this lens of perception will be helpful when clients are processing and trying to navigate scenarios for realistic solutions or coming to terms with aspects that may be troublesome (again, following the tenets of reality therapy).

Second, whether working with the service member, the child or the stay-behind parent, consider infusing into the treatment plan the power of resiliency. Due to their lifestyle, military-connected clients are typically used to a great deal of adjustment in various aspects of their lives on a regular basis. Helping clients build off of their past successes to navigate new challenges can be empowering. Reality therapy supports counselors in evaluating with clients what is working and what is not.

In 2008, the Military Family Research Institute found that the following stressors were considered normative for military children but not for civilian children:

1) Regular, and at times lengthy, separations from parents

2) Lengthy parental work hours

3) Permanent changes of station

4) Deployments for multiple and various purposes

5) Exposure to combat-related activities and equipment, including training

Just because the stressors are considered normal for the population, the events and circumstances experienced are not to be inferred as easy for military children to manage. Just like with any stressor for any client, the more sudden, serious, ambiguous or traumatic the loss, the more difficult the stress will be to manage. Many of these same stressors are applicable both to the parent who is left behind and to the service member.

It is common for military couples to experience marital distress due to a multitude of these stressors. Commonly seen mental health issues in the military population for the service member and veteran include mood disorders, trauma/posttraumatic stress disorder, sexual assault, suicide, addiction, adjustment issues and relationship concerns. Commonly seen mental health issues among military spouses and children include mood disorders, trauma, adjustment issues and relationship concerns.

To explore an issue that may plague any member of a military family, we will focus on working with a military-connected client who is experiencing relationship issues. Guiding these clients in exploring how to communicate with their families despite the physical distance between them and how to involve family members in their life even from afar can help with feelings of detachment. Reality therapy offers clients the ability to come to terms with aspects of their lives that are in their control as well as outside of their control.

Finding ways to help clients embrace the family dynamic even when changes occur can help sustain the idea of their family system. Highlighting previous resiliency efforts to help clients explore this new change, come to accept it, and adapt how they now fit into their family system can reinforce the idea of maintaining relationships. WDEP analysis for each consideration posed by clients offers not only a realistic evaluation of their current circumstance, but also celebrates their small victories and offers opportunities to modify aspects that are not supporting their desired wants.

Navigating the change within the family while assessing client strengths and processing their feelings regarding the change (as well as the realistic desires of the client, while still being mindful of the military lifestyle) can aid the client in managing more healthy relationships. This can be extended to other relationships outside of the family as well.

The idea of resiliency and understanding military culture is at the core of helping these clients. Reality therapy offers counselors the ability to seamlessly integrate into each session regardless of how much time they ultimately have with these clients.

 

Resources for all

To provide additional effective supports when working with children and families connected to the military, it is necessary to know where to turn. These additional supports are very important because these clients move frequently and are often far from family and friends who might normally offer assistance. And counselors cannot do it all by themselves.

The resources mentioned below are only a few of the many available to military families. However, they are a great place to start, whether you counsel military-connected children and their families in the school setting or in the community.

American Red Cross: Offers support with emergency communications with service member while deployed, financial assistance, information and referral services, deployment services, and Reunification Workshops.

Exceptional Family Member Program (EFMP): Program is intended to support service member dependents who have ongoing medical, mental health or special education needs (on both spectrums — gifted as well as challenges). To enroll, service members should complete and submit 1) DD Form 2792, the Family Member Medical Summary or 2) DD Form 2792-1, the Family Member Special Education/Early Intervention Summary to their installation EFMP office.

MIC3 (mic3.net/): This is the official website of the Military Interstate Children’s Compact Commission. The goal of the interstate compact is to replace the widely varying policies affecting transitioning military students with a consistent policy in every school district and in every state that chooses to join.

Military Child Education Coalition: The coalitions three goals are the following:

1) Military-connected children’s academic, social and emotional needs are recognized, supported and appropriate responses provided.

2) Parents, and other supporting adults, are empowered with the knowledge to ensure military-connected children are college, workforce and life ready.

3) A strong community of partners is committed to support an environment where military-connected children thrive.

Military family life counselors: Intention is to support service members, their families and survivors with nonmedical counseling worldwide. Counselors provide face-to-face counseling services, briefings and presentations to the military community both on and off the installation.

Military and Government Counseling Association (MGCA): MGCA is a division of the American Counseling Association with the mission of servicing those who serve. Its website says, “The purpose of MGCA is to encourage and deliver meaningful guidance, counseling, and educational programs to all members of the Armed Services, their family members, and civilian employees of Local, State and Federal Governmental Agencies. … Develop and promote the highest standards of professional conduct among counselors and educators working with Armed Services personnel and veterans. Establish, promote, and maintain improved communication with the nonmilitary community; and conduct and foster programs to enhance individual human development and increase recognition of humanistic values and goals within State and Federal Agencies.” MGCA publishes the peer-reviewed Journal of Military and Government Counseling. The journal publishes articles on all aspects of practice, theory, research and professionalism related to counseling and education in military and government settings.

Military Kids Connect: Military Kids Connect is an online community for military children (ages 6-17) that provides access to age-appropriate resources to support children dealing with the unique psychological challenges of military life.

Military OneSource: Military OneSource offers a range of individualized consultations, coaching and counseling services for many aspects of military life. Services include confidential nonmedical counseling, spouse education and career opportunities, document translation, financial and tax consultation, special needs, spouse relocation and transition, and education.

U.S. Department of Defense Education Activity school liaison officers: The purpose of this position is to serve as the primary point of contact for school-related matters; represent, inform and assist commands; assist military families with school issues (to include providing parents with the tools they need to overcome obstacles to education that stem from the military lifestyle); coordinate with local school systems; and forge partnerships between the military and schools.

Many of the resources available to military service members and their dependents (spouse and children) are free of charge. Noting this may be the difference in whether military families seek these resources out.

 

Summary

I hope this article has provided some insights regarding the needs of military children and their families. In order to provide effective school and community resources for this population, it is important to be aware that these children are not located only on military installations; they are also on public school campuses and in civilian communities. To safeguard the well-being of these children and their families, it is also imperative to understand the uniqueness of military culture.

Currently, there is a gap in services for military families living in the civilian realm. The purpose of this article is to build confidence among civilian school counselors and community counselors by suggesting realistic resources that will help them to better support this population. You never know if a dandelion will blow into your community and need assistance to bloom.

 

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Nicole M. Arcuri Sanders is a licensed professional counselor and core faculty at Capella University within the School of Counseling and Human Services. Clinically, she engages in practice with the military-connected population. Within this specific area of focus, she has also completed research, published, and presented at local, regional and national conferences to advocate for effective clinical services to meet this population’s needs. She has previously worked as a DoDEA district military liaison counselor, substance awareness counselor, school counselor, psychiatric assessment counselor, anti-bullying specialist and teacher. Contact her at Nicole.ArcuriSanders@capella.edu.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

Hooah! Thoughts and musings on Operation Immersion

By Janet Fain Morgan January 3, 2017

Hooah: Military slang referring to or meaning “anything and everything except ‘no.’” Used predominantly by soldiers in the U.S. Army.

 

My father was in the U.S. Army for more than 30 years. I grew up as a military dependent, relocating every few years (and attending more than 20 schools) until I graduated high school. I joined the Army Reserve, later married my husband, a U.S. Navy submariner, and he eventually ended up retiring from the Army after 20 years. My eldest son joined the Army out of college and is currently on active duty.

I have been a licensed professional counselor in Augusta, Georgia; Bamberg, Germany; Lakewood, Washington; Fort Knox, Kentucky; Columbus, Georgia; and most recently, Somerset, Kentucky. As a member of the American Counseling Association and the Military and Government Counseling Association (a division of ACA), I am concerned about the rising number of suicides among our military veterans. On a related note, I am also concerned by the limited number of education and training opportunities available to counselors who are dedicated to the specific needs of military clients.

This past year, the Kentucky Counseling Association (KCA), a state branch of ACA, advertised a training program for counselors called Kentucky Operation Immersion. The program offered an immersion experience into military culture that aimed to help counselors become aware of the unique culture and specific needs of military clients. The training educated counselors on how better to help soldiers as they transition back from wartime environments overseas and reintegrate into a civilian society.

Only about 1 percent of the U.S. population actually serves in the military. Many people do not understand the difference between the military mindset and the civilian frame of mind. For that reason, I was impressed and excited to see that KCA was addressing a very important topic that can make a difference to our military members.

As a counseling professional and former soldier, I jumped at the opportunity to train with the Army National Guard at the Wendell H. Ford Regional Training Center. The Kentucky Department for Behavioral Health, Developmental and Intellectual Disabilities (DBHDID) and the Kentucky Army National Guard presented and sponsored the training, and many of their respective department members joined in the training. I had no idea what I had signed up for, but sometimes ignorance is bliss.

I arrived to join approximately 30 other participants from a variety of specialties, including drug and alcohol counselors, psychologists, school counselors and Kentucky Department of Veterans Affairs employees. The participants ranged in age from their 20s to their 70s.

Day One: Basic training

On the first day — basic training — we were introduced to the training leaders, department heads and Army National Guard soldiers who would mentor us throughout the training. We were issued our field equipment, including Kevlar helmets and flak jackets, which we would wear during our training for the next three days. Removing the metal plates that are normally part of the bulletproof garment decreased the flak jacket’s weight. Even so, the jacket was still heavy and served as a constant reminder of what soldiers wear to protect themselves during deployment.

Our first training exercise was an introduction to platoon formation and marching, but this version was much kinder than what I had experienced in my Army basic training days. Regardless, I found myself unable to maintain the pace of the platoon. This bruised my ego and provided a gentle indicator of the physical limitations I might encounter in the training exercises to come. And come they did …

The author, second from right in the back row, with fellow members of her Operation Immersion training squad.

The Field Leadership Reaction Course was a team-building exercise (obstacle course) that further introduced me to my counselor peers. We had fun coordinating our navigation of the ropes, walls and boards to achieve successful outcomes. Then Kentucky weather intervened, and we headed for shelter from tornadoes, storms and heavy rains. Chow took place in the mess hall with service members who invited us to ask them questions about the military and their military experience.

That evening we met Bobby Henline, an American hero, comedian and motivational speaker who served four tours of duty in Iraq. During his fourth tour, he was the sole survivor of a roadside bombing that left a third of his body burned. He shared his survival story and his outsize sense of humor with us. Bobby participated with us throughout the training and was an inspiration to us all. His humor helped lighten the serious moments, and his encouragement was invaluable. It was a true honor to meet him and a blessing to spend time with him.

Sleep was sweet after such a full first day.

Day One counseling takeaway: Military training is demanding physically and challenging mentally. Build relationships with military clients by asking about their training and work environments. Ask questions about any military-specific acronyms that they use. Many people know what an MRE (meal ready to eat) is, but fewer are familiar with what FOB (forward operations base) or TOC (tactical operations center) represent. Get to know these clients’ personal stories. This can shed light on what might be troubling them and why they are seeking counseling.

Day Two: Mobilization

Day Two arrived early — at 5 a.m. — and there we were, in formation, doing PT (physical training). Mobilization day started with breakfast in the chow hall, and then we had a class on sexual assault prevention. That morning we also heard personal stories of deployment from individual soldiers. Their stories spoke of bravery, tragedy, courage and, sometimes, boredom. All the stories touched our souls. In fact, when the program participants looked back over those days of classes, physical challenges and training, we decided the deployment stories were what we would remember most.

After a class on combat-related trauma, we headed to the SIM (Simulation) Center, where we ate MREs and enjoyed the virtual combat simulators in the forms of EST (Engagement Skills Training with Night Vision), IED (Improvised Explosive Device training instruction), HEAT (Humvee Egress Awareness Training Simulator) and CSF2 (Comprehensive Soldier and Family Fitness).

That evening, we were briefed by the commander, Capt. Michael Moynahan, and heard another personal deployment story from Maj. Amy Sutter, a licensed clinical social worker. Her mental health perspective on deployment was invaluable, and we also gained insight on deployment from a female viewpoint.

Day Two counseling takeaway: Deployment is rough, both mentally and physically. The living arrangements are complex, and soldiers have many challenges related to isolation and loneliness. At the same time, privacy is often limited. Build the therapeutic relationship by asking your military clients about any and all deployments. Each deployment offers military members challenges and unique perspectives. These could be explored through open-ended questions about their personal experiences. Be aware that some of these clients have seen or done things that they do not want to disclose or remember.

Day Three: Deployment

Deployment day again came early, with PT that included a warmup and running track. Classwork began with a briefing on substance abuse, posttraumatic stress disorder and traumatic brain injury. After listening to a suicide prevention panel, we headed out on a bus to the Gwynn City MOUT (Military Operations on Urban Terrain) site for our deployment training.

The Army National Guard launched a few simulated IED attacks in the direction of our bus and also created a machine gun simulation to get us “in the mood” for our urban warfare exercises. Command Sgt. Maj. Matthew Roberge led the military demonstrations and the exercises to prepare us for clearing a building of enemy personnel. The smooth, precise and sharp Army National Guard soldiers modeled the intricate procedure for us, and in teams of four, we attempted to reproduce the action with our military-style paintball weapons.

Our attempt was a less than perfect assault, with paintballs flying everywhere and Kentucky counselors doing their best to come out of the training exercise unscathed. That said, there was much laughter and excitement throughout, and everyone emerged feeling abundant respect for our U.S. military, and especially the group of professionals who worked with us during our training experience.

Dinner that evening was a relaxing outdoor cookout, during which we said goodbye to many of the soldiers who were leaving for their drill weekend. Awards were given, speeches were made and the treasured “challenge coins” — engraved with a unit’s or organization’s insignia or motto and given as a sign of respect — were secretly passed from palm to palm.

Day Three counseling takeaway: Military members face death often and rely on their training and peers to stay safe. Their training is precise and has to be executed perfectly every time, or the soldiers and their companions run the risk of becoming casualties. A high level of stress accompanies each operation, and sometimes that stress may last for days, weeks or even months, with little or no downtime for the soldier. The residual effects from this intense training and the soldier’s subsequent experiences can last a lifetime. Counselors should understand the deleterious effects of combat. Even if operations are carried out perfectly, casualties can occur, accidents can happen and the effects can be devastating.

Day Four: Demobilization

Demobilization day was early to rise — 4:50 a.m. — so we could clean the barracks, pack our bags and return the gear. Breakfast was quick, but then our first speaker arrived to awaken our senses. Capt. Phil Majcher spoke about his role as battalion chaplain and the duties that were part of the military chaplaincy. He didn’t sugarcoat anything, giving many of us moral points to ponder.

Linda Ringleka, military and national liaison from Lincoln Trail Behavioral Health System, joined Capt. Majcher. Together, they led a workshop on suicide prevention and ACE (Ask, Care, Escort) training. The counselors participated in small group activities that included role-plays and real-time suicide scenarios.

Sgt. Brooks, a female soldier, offered to speak with the female trainees about her experiences as a woman in the military with two deployments under her belt. Gathering together as women, we heard her personal story of courage, determination, struggling as a single mom and the challenges of being female in the Army. Her story was incredible and touched each of us. I must also mention that watching Sgt. Brooks throughout the entire training was like witnessing a master of all trades. She did everything that her male counterparts did, and with effortless perfection.

As we wrapped up the training, pictures were taken and awards were announced. Heath Dolen, DBHDID program administrator, presented each of us with a certificate, and a coveted challenge coin was passed secretly in a handshake.

As I drove home, I reflected on the immense amount of information and knowledge we had all gained as mental health professionals. This training was invaluable in providing us with skills to help soldiers as they return from difficult and sometimes horrific experiences. Many of these potential clients need to know that the counselors assisting them do actually understand some of the hardships they have endured. Counselors must gain the trust of hurting service members before many of them will disclose the horrors that they witnessed or even participated in during a deployment to a war zone.

The rules that we typically live by in our society do not always correspond to the experiences that soldiers see and live through. The camaraderie of this very tightknit community is exceptional, and counselors must understand the underlying military culture and gain the trust of these soldiers to be as effective as possible. Of that, I am certain.

I highly recommend that all mental health care professionals who take care of our soldiers undergo the type of training offered in Operation Immersion. Our heroes deserve the best that mental health professionals can give them, and this training definitely moved us in that direction.

 

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Janet Fain Morgan is a military family life counselor licensed in Kentucky and Georgia. She is a faculty member of William Glasser International and a member of the Military and Government Counseling Association, a division of ACA. She is also a former soldier. Contact her at JMFainMorgan@gmail.com.

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Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having your article accepted for publication, go to ct.counseling.org/feedback

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Suicide statistics highlight veteran population’s acute need for counseling, inside and outside of the VA

By Bethany Bray September 12, 2016

The rate of veteran deaths by suicide increased 32 percent between 2001 and 2014, according to a recent report by the U.S. Department of Veterans Affairs (VA). When compared with the U.S. civilian population, veterans have a 21 percent higher risk of dying by suicide.

The VA is calling the report, released in August, its most comprehensive analysis of rates of veteran suicides. The agency compiled data from more than 55 million veterans records from 1979 to 2014 from every U.S. state.

Among the findings was that between 2001 and 2014, the rate of suicide deaths among U.S.

U.S. Navy photo by Seaman Clark Lane/defense.gov

U.S. Navy photo by Seaman Clark Lane/defense.gov

veterans who used VA services increased 8.8 percent, whereas the suicide rate among veterans who did not use VA services increased 38.6 percent during that time frame.

In 2014, an average of 20 veterans died by suicide each day; approximately six per day were users of Veterans Health Administration (VHA) services.

“The VA’s latest report on veteran suicide is the most comprehensive to date and should be a call to arms for everyone in our profession who works with this population,” says Jeff Hensley, a Navy veteran who is an American Counseling Association member and a licensed professional counselor (LPC) in Texas.

“The data clearly shows that getting help, helps,” continues Hensley, a leadership fellow with Iraq and Afghanistan Veterans of America (IAVA) and director of clinical and veteran services at Equest, a therapeutic riding program in North Texas. “Those veterans who seek care have a suicide rate significantly lower than those who get no care at all. However, the VA is stretched to capacity — and many of those veterans who need help the most are either not registered with the VA or ineligible due to their discharge status. This leaves a significant gap between those who need help and the resources available to provide it. As professional counselors, we can step in and meet this need. Whether we work in community agencies serving veterans or volunteer our time with nonprofits like Give An Hour, counselors are in a unique position to significantly lower this troubling statistic.”

Other key findings in the VA report include:

  • In 2014, veterans made up 8.5 percent of the U.S. adult population, yet they accounted for 18 percent of all deaths by suicide. In 2010, veterans composed 9.7 percent of the U.S. population and accounted for 20.2 percent of deaths by suicide.
  • In 2014, roughly 67 percent of all veteran deaths by suicide involved firearms.
  • Roughly 65 percent of veterans who died by suicide in 2014 were age 50 or older.
  • In 2014, rates of suicide were highest among veterans ages 18 to 29. Rates of suicide among veterans age 70 or older were lower than were rates of suicide for the civilian population in the same age group.

Overall, U.S. rates of suicide have increased by 24 percent during the past 15 years.

The rate of veteran suicide gained public attention in 2012, when the VA released a report saying that 22 American veterans died by suicide every day of the year. That number has decreased to 20 per day (in 2014) in this most recent report.

In response, the VA has beefed up support services, including the creation of a toll-free crisis hotline and expanding telemental health care programs.

However, these efforts don’t address one glaring omission: Professional counselors are often excluded from jobs at VA facilities. A 2006 law recognized “licensed professional mental health counselors” and “marriage and family therapists” as mental health providers within the VA health care system. However, 10 years later, few VA job postings include counselors as candidates to fill those positions, and even fewer licensed counselors are actually hired.

“It’s noteworthy that within the ‘nation’s largest analysis of veteran suicide,’ there is no mention of words such as ‘medication,’ ‘pharmaceuticals,’ ‘counselor’ or ‘counseling,’” says Natosha Monroe, an Army veteran and Texas LPC who is a co-leader of ACA’s Veterans Interest Network. “I would be interested to know what exactly isn’t working in current treatment trends. I would love to see veterans have just as much access to nonpharmaceutical treatments such as professional counseling as they do VA psych meds.”

As Monroe recounts, “While working at the Pentagon [as an operations noncommissioned officer for comprehensive soldier fitness], I was literally told by a decision-maker that licensed professional counselors are not needed in the Army and that I should stop asking because that wasn’t going to change. I was told that ‘the current behavioral health providers are adequate.’ Well, the statistics say otherwise. I think it’s time to allow LPCs and licensed marriage and family therapists (LMFTs) to do our jobs. Our professions are the most specifically qualified to address the issues that troops and their families most often face: cognitive issues, transition issues and family challenges.

“It’s unfortunate that counselors and therapists are the only [mental health] professions completely excluded from every military branch,” Monroe says. “It’s frustrating that I am not allowed to be a behavioral health officer because I am a highly qualified LPC,” she continues. “Our professions are also the only ones blatantly discriminated against within the VA system despite Congress mandating our equal hiring — it still isn’t happening.”

“I’m not saying that correlation is causation, but I am definitely saying that veteran suicide rates are increasing, and there is persistent discrimination and exclusion of our profession,” Monroe concludes.

 

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Read the VA report in full here

 

Read a VA press release about the report here

 

Contact the Veterans Crisis Line or find out more at veteranscrisisline.net

 

Get involved with or find out more about ACA’s Veterans Interest Network here

 

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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 at facebook.com/CounselingToday.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

 

Adding a counselor’s voice to law enforcement work

By Bethany Bray March 17, 2016

For Gregory Moffatt, counseling and crime solving go hand in hand.

Moffatt, a licensed professional counselor (LPC), runs a private practice in which he specializes in working with children who have experienced physical or sexual abuse. He is also a professor of counseling at Point University in West Point, Georgia.

The other half of his career, however, is a little more unconventional. He’s a risk assessment and psychological consultant for businesses, schools and law enforcement agencies. Moffatt has done everything from assisting with hostage situations and unsolved cold case investigations to teaching at the FBI National Academy in Quantico, Virginia. In addition to providing training and consultation, he evaluates police officers who have been involved in a duty-related shooting to determine if they’re ready to return to active work on the force.

He’s also filming on-camera commentary as a psychological consultant for a new cable television show on hostage situations. The program, titled “Deadly Demands,” premiers March 21 on Investigation Discovery, a network of the Discovery Channel.

After years of working with corporations and law enforcement agencies, Moffatt is often the person they call to evaluate unusual situations, such as when an employee is making co-workers uneasy or

Gregory Moffatt, LPC and professor of counseling at Point University in West Point, Georgia

Gregory Moffatt, LPC and professor of counseling at Point University

a case arises that doesn’t fit the norm. It’s not a niche that he initially set out to carve for himself, but rather one that he entered “through the back door,” he says.

When Moffatt first started teaching at Point University more than three decades ago, he was the only professional counselor on campus. One day, the university’s administration approached him and asked for his help with a situation involving a student who was stalking another student.

“Stalking laws weren’t in place. Back then, even the term [stalking] wasn’t an everyday term,” says Moffatt, an American Counseling Association member. “Back then, hardly anyone did work in violence risk assessment.”

As he got involved in the case, Moffatt started researching risk assessment methods, which grew into a personal area of interest. He eventually established his own consulting business, through which he provides workplace violence assessment and training. The FBI contacted him to provide training at its academy in Quantico after he published an article in an academic journal on violence risk and assessment.

Law enforcement agencies are good at lots of things, but threat assessment isn’t always one of them, Moffatt says. That’s where his skills as a professional counselor can help fill in the “why” of a situation, he says.

Moffatt uses his counselor training to look at a specific situation’s “collection of evidence,” he says. For instance, how does the person tell his or her story? What indicators can be found in the language the person uses? What does his or her past behavior indicate? What coping skills does the person have?

“My job is to tell them [a company or law enforcement], ‘This is what I think; this is what you’re looking for,’” Moffatt says. “The question for us, in mental health, when someone’s sitting in our office is, ‘Is this person a risk?’ Sometimes the answer is yes. … How many coping skills does he [the client] have in his toolbox? If it’s a pretty empty toolbox, then I’m worried.”

For example, Moffatt was contacted by local law enforcement to evaluate the threat level of some letters a judge was receiving in the mail. Officials suspected the letters were being written by a man who had come through the judge’s courtroom for a minor infraction, he says.

Moffatt looked at the man’s behavior history (he had brandished a firearm in the past but never fired at anyone) and the language used in the letters. His counselor training helped him pick up clues — for example, symptoms of delusion and other things that would make a person unpredictable — to determine that the man was a “big talker,” but that the letters were most likely a way of “puffing out his chest” rather than an actual threat.

“I thought there was a very low possibility that he would shoot this judge. Years later, nothing has come of it,” Moffatt says.

Today, he works regularly with the Atlanta Police Department’s cold case squad and writes a regular column on children’s and family issues for The Citizen, a newspaper distributed in Fayette County, Georgia.

Moffatt says he is drawn to the sometimes gritty specialty of crime and violence assessment because he likes being part of the solution and helping to bring some closure to the victims of crimes.

“The world is not made up [solely] of bad guys and good guys,” he says. “If you go to any prison in the country, you will find a small percentage [of the inmates who] are horrible and need to stay locked up for the rest of their lives. The rest are human beings who have made a mistake. The hardest part about our job [as counselors] is to have compassion. We can take people, in any condition, and help them become more functional.”

 

Q+A: Gregory Moffatt

 

You encourage all counselors to learn more about risk assessment, whether through reading, professional development, trainings, etc. Why do you feel this particular topic is important for counselors to know?

Risk assessment is necessary in any clinical context. Violence happens in homes, schools, workplaces, on the bus, on the street and in the synagogue/cathedral. Assessing for violent behavior against others is just as important as assessing for suicide risk, [which is] something we do regularly. You don’t have to specialize in workplace violence or school violence for this to be part of your assessment toolbox.

 

Do law enforcement professionals often think of or turn to psychologists first when looking for help with mental health expertise? From your perspective, what can a professional counselor offer in this area that is different than other helping professions?

Actually, I don’t think most law enforcement people know the difference. Even when they do, they often have limited or no budgets for outside consultation. Professional counselors are cheaper than psychologists, typically. Counselors are just as competent to offer fitness for duty interventions/assessments, post-shooting intervention, violence intervention/anger management and other common needs in law enforcement as any psychologist — assuming, as always, that one is trained to deal with that population. This training is readily available to LPCs.

 

What suggestions would you give to counselors looking to help or make a connection with their local law enforcement or violence prevention agencies?

Law enforcement agencies are notoriously fraternal, and even agency to agency there is little cooperation. A given agency believes it is better than any other agency, and going outside law enforcement is seen as a negative. However, developing relationships and bringing skills to the table — especially if it is cost-effective — is the way in the door over time.

 

What are some of the main takeaways that you’ve gleaned from your work with law enforcement and risk assessment that you want professional counselors to know?

Behavioral/mental health issues are present in all corners of life. Finding a way to apply your interests in mental health in specific climates — e.g., schools, law enforcement, court — is what makes one’s career fascinating and rewarding. I look back on 30 years of work — opening doors, looking for opportunities and taking those opportunities — and I couldn’t be happier. I’ve helped hundreds of children, written hundreds of articles and numerous books, spoken to thousands of audiences and helped put many bad guys in jail — hence, making the world safer and people happier. Who could ask for more?

 

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Read more about Gregory Moffat’s work and find a list of suggested resources on trauma, violence, parenting and other topics at his website, gregmoffatt.com

 

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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 at facebook.com/CounselingToday.

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