Tag Archives: Military


Addressing the Afghanistan humanitarian crisis

By Justina Wong February 16, 2022

In August 2021, Americans who were already dealing with the upheaval and roller coaster of emotions caused by the ongoing COVID-19 pandemic faced another frustration when the U.S. military suddenly withdrew from Afghanistan. The humanitarian crisis in Afghanistan has caused many mixed emotions for individuals who identify with the military community. And for most Afghan refugees, the struggle is not over.

According to the United Nations High Commissioner for Refugees (UNHCR), nearly 6 million Afghans have been forcibly displaced from their homes, with over 3.5 million people currently displaced within Afghanistan and 2.6 million living in other countries. As of Jan. 2022, more than 76,000 Afghans have been brought to the United States.

What counselors should know

Relocating to another country can be a traumatizing experience. In the United States, Afghan refugees often spend weeks in cramped quarters on military bases not knowing when they will be able to leave and start their lives in America. Once they do leave the base, they face a new set of obstacles in the host country.

Affordable housing is a significant challenge for many refugees, who often flee with only the shirts on their back. They do not have any money or belongings, and this issue can be exacerbated for refugees who resettle in areas with exponentially high costs of living such as Los Angeles and New York City. The refugees who are approved to leave the military base typical stay in a room at a motel, hotel or Airbnb or in the house of a host family. Their housing is paid for by nonprofit organizations or private donors. Finding a sustainable way of providing long-term housing is another concern. They usually do not have a place to call their own.

Other obstacles include language barriers, employment, financial insecurities, transportation, food insecurities and other basic necessities for daily living. Most of them are still trying to process the trauma they experienced fleeing their home country, living on military bases and being relocated somewhere else. A lot of these refugees left their families or extended family members behind in Afghanistan.

It is important for counselors to understand the experiences that Afghan refugees went through to come to the United States. Their courage, bravery and perseverance are closely intertwined with fear, despair and trauma. Counselors should refrain from making the following assumptions:

  • All Afghan refugees want to live in the United States.
  • Mental health services are easily accessible for Afghan refugees.
  • Afghan refugees should be grateful that they are living in the United States.
  • Afghan refugees are taking away jobs from American citizens.
  • All Afghan refugees want to adapt to American culture, including customs, societal norms and foods.

Instead, counselors should be knowledgeable about specific concerns that Afghan refugees face, which include the following:

  • Refugees experience a high level of racism if they live in communities different from their own. One of the reasons they are being placed in California and New York is because these states already have established Afghan communities.
  • Acculturation can be a struggle because of cultural differences in language, customs, social norms and foods.
  • Refugees are less likely to access mental health services because of barriers and mental health stigmas. Some might not understand what mental health means or what mental health services have to offer them because in their home country, these services are not available or mental health is not often discussed.
  • Mental health services and insurance are expensive and viewed as luxuries instead of necessities. With little financial assistance from the U.S. government, most families cannot afford insurance copays or services. Their main focus is providing food and shelter.
  • There are few counselors that are competent in providing mental health services to refugees in their native language.
  • Afghan culture teaches individuals to face the trauma they have experienced, keep their heads down and keep going on with their lives. In doing so, this creates generational trauma.

Being aware of refugees’ struggles and challenges will equip counselors when advocating for Afghan refugees as well as help them build a stronger therapeutic alliance with any potential future refugee clients.

How counselors can help Afghan refugees

Some counselors might think they are not well equipped to support Afghan refugees because of language barriers or lack of knowledge about Afghan culture. However, counselors can support them using basic counseling skills. Instead of focusing on how they are different from refugees, counselors should concentrate on the ways they are similar.

To illustrate this point, consider the following case vignette:

Hamid is a 42-year-old man who left Afghanistan with his wife Zeia and their three sons (ages 5, 3, and 6 months) and relocated to Los Angeles. Hamid and his family are temporarily staying in a building behind the main house of a host family. He expresses frustration regarding being unable to afford food for his family, so the host family refers him to see a Hispanic, female counselor named Theresa, who works at a nonprofit organization that provides wraparound services for refugees.

In their initial session, Theresa has a hard time understanding Hamid because of his limited proficiency in English. After reading his intake paperwork, Theresa believes Hamid could use therapy to discuss his past trauma of escaping Afghanistan and receiving constant death threats for helping the U.S. military as an interpreter, but Hamid is more concerned about having food for his family. They are both frustrated with their inability to understand each other.

Theresa decides to use her love of art to create a visual aid for Hamid, so she can understand his needs better. During their second session, Theresa presents the visual aid — a pyramid of Maslow’s hierarchy of needs she created using pictures — to Hamid, who enthusiastically nods his head and smiles in approval. Hamid immediately points to the picture of food and water and then to the picture of a family. Theresa points to the picture of food and asks if Hamid needs food for his family. Hamid nods.

Theresa then creates a checklist of all of Hamid’s needs using the visual aid. At the end of their session, Theresa concludes that food is Hamid’s main concern. Theresa gestures for Hamid to follow her, and she brings him to one of her coworkers who is a licensed social worker. Theresa asks her coworker to help Hamid fill out an application for CalFresh, a Supplemental Nutrition Assistance Program that provides monthly food benefits to people with low income, so he can receive an electronic benefits transfer (EBT) card to buy food for his family.

While not all counselors are proficient in speaking Pashto or Dari (the two mostly widely spoken languages in Afghanistan), they should be proficient in understanding Maslow’s hierarchy of needs and the use of nonverbal cues and body language in counseling sessions. By asking her coworker to help Hamid fill out an application for CalFresh, Theresa has addressed Hamid’s physiological and safety needs. In doing so, she has built a strong therapeutic alliance with Hamid, and he is more likely to come back to see her and discuss his past trauma in future sessions. She has presented herself as someone Hamid can go to if he needs anything.

How counselors can help military veterans

Afghan refugees are not the only ones struggling with the humanitarian crisis in Afghanistan: Military veterans have been significantly affected too. Veterans might be experiencing feelings of guilt, betrayal, shame, anger, hopelessness, worthlessness or resentment. The U.S. withdrawal from Afghanistan has also caused many veterans to struggle with moral injury, which the U.S. Department of Veterans Affairs defines as the distressing psychological, behavioral, social and sometimes spiritual aftermath of being exposed to events that damages or goes against one’s own moral compass.

Ben (a pseudonym) is a former Marine and personal friend of mine, and for the past 15 years, he has worked as a military contractor in Afghanistan. When I asked him how he felt about the U.S. withdrawal from Afghanistan, he expressed feelings of anger, hopelessness and worthlessness regarding the situation. He was angry and frustrated that he could not go to Afghanistan to help the Afghan interpreters with whom he had previously worked. In his mind, he left his “brothers” behind and that was unacceptable. The thought of abandoning those who risked their lives serving as interpreters haunted him.

Leonid Altman/Shutterstock.com

He felt guilty that many of these interpreters were promised safe passage and a special immigration visa (SIV) to enter the United States for their work as U.S. military interpreters only to discover they were later denied entry. Ben has known some interpreters who have been waiting for as long as 11 years for their SIV paperwork to be approved. The more interpreters reached out to him for help with getting their SIVs approved, the more hopeless and worthless he felt.

He also believes the loss of the war makes it seem like all the sacrifices he and his fellow veterans made were for nothing.

Counselors who work with military veterans should know that moral injury is different than having posttraumatic stress disorder (PTSD). Moral injury can be equally if not more traumatizing because it is focused on feelings of guilt, shame and betrayal. And in my work with military veterans, I’ve found that more of them engage in self-destructive behaviors because of moral injury than from a diagnosis of PTSD.

Here are a few questions counselors can ask clients to better understand a veteran’s wounded sense of morality:

  • What are you feeling? Do you feel guilt, shame, betrayal, anger, resentment, regret, hopeless or worthlessness?
  • What happened to make you feel this way?
  • What did you witness that made you feel this way?
  • Do you feel like you failed to prevent certain events or acts that conflict with your own values, beliefs and principles?
  • Have you found yourself ruminating on things since the event occurred?
  • How would you change the outcome if you had a second chance?
  • Have there been other incidents in your past when you have experienced moral injury?
  • How do you view yourself? Sometimes moral injury comes with a sense of self-loathing and feelings of worthlessness.
  • How do you manage your wounded sense of morality (e.g., substance use, anger outbursts, self-harm or self-destructive behaviors, deep breathing or meditation, volunteering with organizations that help veterans, working with fellow veterans)?
  • What do you need to feel a sense of peace and that you did all you could do with what you had?

How counselors can be advocates

As counselors, we owe it to our clients to advocate for not only their mental health but also their human rights. S. Kent Butler’s vision for his ACA presidential year is to #ShakeItUp and #TapSomeoneIn. These two hashtags represent action. Counselors cannot sit back during this humanitarian crisis and simply sympathize or empathize with military veterans or Afghan refugees. They must advocate and take action.

Licensed counselors could provide pro bono counseling services, process groups specifically focused on trauma or moral injury, or psychoeducational groups on parenting, goal setting or stress management. They could also cofacilitate support groups with Afghan refugees to research the needs of the community. Unlicensed counselors and counselors-in-training can provide similar services with clinical supervision.

Counselors can also volunteer to help Afghans as they rebuild their lives in the United States; this could involve teaching them English or about their basic human rights or helping them figure out where to buy groceries or diapers or how to apply for an identification card. And counselors can facilitate support groups or retreats for veterans struggling with moral injury so they know they are not alone.

There is room for everyone. My challenge to you is to fulfill Butler’s vision to #ShakeItUp and #TapSomeoneIn.




Justina Wong

Justina Wong is a new professional currently earning hours towards licensure at a group private practice in California. She serves on the Military and Government Counseling Association’s board of directors and as a graduate assistant to the president of the Association for Multicultural Counseling and Development. Justina is also a member of the American Counseling Association’s Human Rights Committee.

She wrote this article on behalf of the Human Rights Committee.


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.

Afghanistan evacuation kicks up tough emotions for veteran clients and counselors

Compiled by Bethany Bray September 10, 2021

On Aug. 30, the United States withdrew the last of its military troops from Afghanistan. News outlets documented this historic moment with a grainy, green-tinged, night-vision photo of a lone soldier boarding a C-17 cargo plane at the Hamid Karzai International Airport. The man in the photo — Army Maj. Gen. Chris Donahue, commanding general of the 82nd Airborne Division — was the last and final American service member to evacuate from Kabul, Afghanistan, ending a war that began nearly 20 years ago.

Major General Chris Donahue, commander of the U.S. Army 82nd Airborne Division, XVIII Airborne Corps, boards a C-17 cargo plane at the Hamid Karzai International Airport in Kabul, Afghanistan on Aug. 30. (U.S. Army photo by Master Sgt. Alex Burnett/Defense.gov)

This war has claimed the lives of nearly 2,500 American service members and more than 47,000 Afghan civilians, and the United States’ involvement has been debated and discussed for years — and by multiple presidential administrations.

Images and news reports from Afghanistan during the U.S. military withdrawal were chaotic, intense and, for many viewers, heartbreaking. Thousands of people flocked to the Kabul airport, hoping to be included in an evacuation flight out of the country before the Aug. 31 withdrawal deadline set by U.S. President Joe Biden. In the final weeks of August, close to 125,000 people were evacuated on 778 U.S. military and private airplane flights, an estimated 5,500 of whom were American citizens.

The sudden departure has left some to question what could have or should have been done differently — a conversation that will likely continue for years.

And for veterans and military families, it’s all deeply personal. The sudden withdrawal has stirred up difficult and intense emotions for them, and professional counselors who work with the military population are witnessing firsthand the toll it is taking on their clients’ mental health. For practitioners who are veterans themselves, this period has brought an extra layer of difficulty as they’ve needed to work through their own feelings to be able to help clients who are in the midst of similar struggles.

“It [Afghanistan] is definitely coming up in my work with veteran clients,” says Keith Myers, a licensed professional counselor (LPC) who specializes in treating veterans and their families at his private practice in Marietta, Georgia. “The most important thing I’m doing in therapy is acknowledging the events with clients, allowing them a safe space to feel whatever they need to feel and providing them with resources, if needed.”

“I had a former client send me a message a few days ago that went like this: ‘The Afghanistan stuff has been hard to watch. I have been very emotional [during] the few times I watched the news, especially with civilians clinging to that Air Force plane. My heart breaks for the Afghan people that helped the military and now are being left behind’,” says Myers, a core faculty member at Walden University.

Another veteran client recently told Myers, “Alleviating suffering is never in vain, even if the final outcome isn’t permanent. A lot of mistakes were made there, but I don’t want a service member to think that their service and sacrifice there was in vain. Our work should be remembered and honored.”



Counseling Today asked professional counselors who specialize in working with the military population, many of whom are veterans themselves, to offer some suggestions on how best help veteran and military-connected clients who are affected by the U.S.’s withdrawal from Afghanistan.



The recent events in Afghanistan have affected military and veteran clients significantly. Many of them are experiencing a range of emotions: anger, sadness, frustration and hopelessness. The response can be as varied and unique as the veterans and family members experiencing them and is not just limited to those who served in Afghanistan.

Veterans who served in Iraq are experiencing something similar to what they witnessed in 2013-2014, when portions of Iraq were overrun after the military’s withdrawal from that country. Vietnam veterans, of course, are experiencing distress related to repeated comparisons to their own experiences.

For clinicians who are working with service members, veterans and their families, it might be necessary to help clients find alternative responses to the emotions they are experiencing.

For many veterans, the primary emotion that is being expressed is anger. Angry at the military and government for pulling out of Afghanistan, which can also extend to or rekindle feelings of anger and betrayal at their own leadership while deployed. Anger is the emotion that we experience when something we strongly believe in has been violated in some way. Helping the veteran understand and address the underlying core beliefs that they feel have been violated, such as “we never should have been there in the first place” and “all of the sacrifices were meaningless,” can be beneficial, rather than simply raging at current events.

Many veterans are also experiencing significant sadness, considering the lives lost and damaged during the conflict. This can be exacerbated by memorial moments and anniversary reactions, as we are emerging into the historical fall fighting season. For Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF) veterans, the late winter/spring and late summer/autumn months are typically difficult as it was the height of fighting season in both conflicts, and many experienced losses of fellow service members during these months. The upcoming anniversaries of battlefield losses coupled with the current events could exacerbate feelings of sadness and grief.

These current events are ones that can cause grief at the loss of others or grief at the loss of their own capabilities to re-emerge. This “sacrifices were meaningless” self-talk can also demonstrate sadness; however, exploring whether or not the losses were in fact meaningless to the veteran themselves can be helpful in addressing this grief. It can also be beneficial to help the veteran realize how their behavior or outlook changed after the death of their fellow service member: Did they do things differently or convince their chain of command to listen to them?

I am also hearing a lot of confusion, both from clients and from those that I served with, including questions [such as] “Why were we there?” and “What was the point?” These were the same questions that we had while on patrol, sitting in the smoking areas or sitting on a mountainside. The same questions that service members asked while they were deployed. Many service members came to some measure of satisfaction as to why they were serving in combat in that particular time: whether to make life better for the population, to help a country stabilize or to simply take care of those around them.

It can be helpful to allow the veteran to explore how they rationalized their service while in country and to re-engage that rationalization now. The end does not invalidate what has gone before, so the reasons they gave themselves then can be helpful now. And one of the most powerful things that I have seen in the discussion lately is the simple fact of “we were there for each other.” In the middle of the suck, nothing matters but the people to the left and right of you — and that’s who and what we were fighting for, and no amount of current events can take that away from us.

Duane France is a retired U.S. Army noncommissioned officer and combat veteran who practices as an LPC in Colorado Springs, Colorado. He is the director of veteran service for the Family Care Center, a private outpatient mental health clinic specializing in service members, veterans and their families, and the executive director of the Colorado Veterans Health and Wellness Agency, a nonprofit that is affiliated with the Family Care Center. He writes and speaks about veteran mental health on his blog and podcast and is the author of the “From Combat to Counseling” column series at CT Online.




I will sum up my reaction to recent Afghanistan events in two words: complex and jarring. While this subject is nothing new for many veterans who lived and experienced Afghanistan, the abrupt and dramatic details, images and public interests elicit a flurry of emotions and a surreal, isolated overtone.

Veterans’ minds and emotions are intense when watching petrified faces of people we actually knew, the Hindu Kush we saw on the horizon daily, the vehicles we traveled in, and the places we walked and lived. If you are speaking with a U.S. veteran about Afghanistan, here are some ideas and insights to help facilitate a meaningful interaction that may very well be the only one they have. These encompass every reaction I’ve directly heard from veterans (friends and clients) as well as my own.

  • Avoidance, anger and the need for peace: Avoidance and anger are great defense tactics that veterans lean on. It’s easier to have an angry rant or to avoid the subject altogether than to go deeper and search for meaning and healing. Counselors are often the only people to spur that journey to peace, so definitely open up the conversation and work your magic.
  • Complexity: People new to this subject don’t seem to grasp the complexity of the sociopolitical aspects of Afghanistan. There is no simple, clear, truly known explanation or answer to so many questions about what has gone on or is now going on. This makes it difficult to feel, think, articulate and resolve for veterans too.
  • Betrayal, confusion, frustration and embarrassment: Due to explicit language, I can’t share direct quotes, but to combine several, “We all wanted out of there but could it have maybe just been a little bit less of a giant ‘F you’ to everyone?” Veterans (and Afghans) are well aware that their lives are the pieces played on geopolitical chessboards, but it is even more upsetting when their individual experiences are completely ignored and/or erroneously lumped into strong opinions about governmental follies and intentions by friends, family and fellow citizens.
  • Deep compassion, concern, guilt, and helplessness: If you are watching media coverage and feeling deeply for people you’ve never met, just imagine if you knew them by name; laughed at their jokes; shared lamb kabobs their wife made for you; watched young girls boss the boys around; enjoyed broken language conversations and eye contact between burka adornments; placed money into a businesswoman’s hand; [and] listened to stories of “before the Taliban came” and fears of what will come again when the U.S. inevitably leaves.

The haunting possibilities, realities and unknowns leave many of us feeling helpless, angry, confused, misunderstood and isolated in our experiences and feelings. The unique and powerful thing counselors can offer is a strategic space to sort through the complexities and ensure the vital step of dispelling the “it was all for nothing” lie, which is often the sticking point for veterans.

Natosha Monroe is an Army veteran and LPC who specializes in treating clients with trauma and anxiety.




The human spirit and soul are at stake for veterans across all wars who have been deployed in support of combat operations, engaged in warfighting and mobilized for humanitarian missions. The stench of death in field hospitals, tent cities and on the battlefield reminds us of how fragile human life can be for service members, veterans and military families. Healing during phases of a pandemic virus also complicates mental health issues. Providing military mental health requires that we restore the fragmented self, as we place the “in session” sign on our metaphoric exterior door. Thus, as a profession we should be mindful of counselor self-care and be in a mission-forward environment providing competent clinical military counseling services.

The military withdrawal from Afghanistan highlights the perfect storm that reflects a mental health tipping point in military mental health. This is reflected by Magellan’s Federal Military and Family Life Counselors (MFLAC) program which is recruiting for an immediate surge of mental health professionals to provide services on U.S. military bases. This is also seen in longer-than-normal wait times at VA clinics and with private Tricare providers.

The visual media played in real time has created a retraumatization for those who have experienced warfighting in hostile regions of the globe. Many in the military community have pre-existing political ideologies, a cultural belief system, [and] mental health and behavioral practices that help or hinder their coping and resiliency resources. Clients who enlisted after the terrorist attacks of Sept. 11th stated they wanted to “defend their homeland.” Thus, this cultivated some meaning and purpose to their chosen military career. However, many veterans I have worked with are jaded by their military service. As they transition to civilian life, their head is always on a swivel. They train to aggress not stress in the face of adversity because the life and safety of other unit members were dependent upon their quick and decisive actions and reactions. Consequently, current issues of mood regulation expressed as frustration, anger, anxiety, hypervigilance, substance use and other symptoms of an unhealthy nature have created a unique type of complex posttraumatic stress disorder (PTSD). Edward Tick, in his book Warrior’s Return: Restoring the Soul After War, eloquently describes complex PTSD as a moral injury that requires a transformative approach to healing, as opposed to “treating” the symptoms of PTSD and co-occurring mental health conditions.

Becoming a culturally competent clinical military counselor is difficult because training and development is sparse. The current literature in military psychology and counseling recognizes that the military is not one homogeneous group labeled as “the military culture.” Today’s military comprises men and women that identify with various racial and ethnic groups: Hispanic/Latinx, African American, Native American, Asian American, the LGBT community, as well as many other cultural groups. The military culture also reflects within-group differences through branch of service, enlisted versus officer rank, and the distinct military occupational specialties (e.g., infantry, special forces/operations, truck mechanic, logistics and embarkation specialists, communications officer, counterintelligence).

Overall, it is critical as professionals that we understand the unique cultural differences between military and civilian mental health assessment, diagnosis and treatment practices. Restoring the mind, body and spirit after warfighting requires a vision of optimal wellness, guided by transition services, that transforms the wounded warrior’s level of meaning and purpose relating to their military service.

Mark A. Stebnicki is a licensed clinical mental health counselor (LCMHC), professor emeritus at East Carolina University and author of the ACA-published book Clinical Military Counseling: Guidelines for Practice. He is the developer and instructor of the Clinical Military Counseling Certificate (CMCC) program through the Telehealth Certificate Institute. He is an active teacher, trainer, researcher and practitioner with extensive experience in military mental health, posttraumatic stress, chronic illness and disability.




As a military spouse, mother, counselor educator and supervisor, and clinician, these recent times stress the importance of ethical self-awareness and boundaries at a whole new level.

As a military spouse, I understand the stress the coming and going of your service member can put on your relationship as well as your family dynamic. I can empathize with the military couple and family who does everything in their power to prepare to maximize quality time prior to your Marine/sailor/soldier’s departure, but despite all your efforts, you are still running around helping them pack last-minute items. In many movies, the actual stressors of these moments are not emphasized. I can understand the constant worry you have for your loved one when you are apart, whether it is a training or deployment.

Today, I think of the spouse who never wanted their Marine/soldier/sailor to leave but helped them pack. Today, I feel for the children who said, “See you later daddy/mommy,” and never will.

In recent research I have conducted with a colleague [soon to be published in the Journal of Multicultural Counseling and Development], we found that many mental health providers interested in servicing the military-connected population were or are currently military-connected themselves. With that being said, during this time, counselors working with this population are strongly encouraged to take some extra time and reflect upon the recent events. Awareness is key to ensuring best practices are offered to their clients. It is important for counselors to remember that they, too, are human. We need to check in with ourselves and be able to process the events of the world and their professional as well as personal impact on us.

For those of us who are military-connected, these recent events can be very personal as it affects us, our loved ones and our lifestyle. We need to be able to process the [withdrawal] event to ensure we do not create an environment supportive of countertransference. Remembering that counseling is a place which is intended to support our clients’ well-being first and foremost may be difficult when clients present with thoughts and beliefs that are contrary to our own. Ensuring we are at a place where we do not allow for our values and beliefs to impose upon our clients is imperative.

Furthermore, we may have clients that seek us out because we are military-connected. We, as counselors, need to remember this is a counseling relationship. Despite our personal need and desire for support and community at this time, we need to ensure we are at a point to keep our professional boundaries to ensure the well-being of our clients. If in the event, we are unable to do so, this is where we need to seek supervision and consultation. We need to ensure that our clients have continuity of care if we are unable to be fully present with them at this time.

Remember, we are human; the world impacts us too! We need to take a moment, process and find the support we need in this time in order to provide clients with the best care possible.

Nicole M. Arcuri Sanders is an LPC in New Jersey and Texas, LCMHC in North Carolina, licensed professional clinical counselor (LPCC) in California, a counselor supervisor and a core faculty member in counselor education and clinical mental health counseling at Capella University. Her area of clinical focus and research is the military-connected population; she has also 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 Department of Defense Education Activity district military liaison counselor, substance awareness counselor, school counselor, psychiatric assessment counselor, anti-bullying specialist and teacher.


U.S. Marines with the 24th Marine Expeditionary Unit process evacuees as they go through the Evacuation Control Center during the evacuation at Hamid Karzai International Airport, Kabul, Afghanistan, Aug. 28. (U.S. Marine Corps photo by Staff Sgt. Victor Mancilla/Defense.gov)


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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.

Counseling in the trenches

By Lindsey Phillips November 2, 2020

Adrian Marquez, a retired Marine master sergeant and  Marine Raider, woke up one morning during his time in the Marine Corps and couldn’t remember how to get dressed. He looked down at his pile of clothes and mumbled, “Pants first, then shoes?”

Marquez was also experiencing physical aches throughout his body, including radiating pain in his arms and legs. His left arm would sometimes lose strength and go numb. So, he went to his unit’s medical clinic — a team of primary care medical doctors, psychologists, psychiatrists, social workers and physical therapists — and the medical staff told Marquez he was physically healthy compared with peers in his age range across the United States. They determined it was all in his head. The mental health clinicians made assumptions based on Marquez’s extensive combat history and quickly diagnosed him with posttraumatic stress disorder (PTSD), an anxiety disorder and a depressive disorder with severe somatic symptoms.

But the symptoms didn’t go away. Marquez later returned to the clinic because of intense pain in the back of his left eye. This time, the clinic performed an MRI and discovered that he had ocular damage, in addition to possible injuries to his brain. Another MRI was scheduled, and it confirmed that Marquez had a traumatic brain injury (TBI) that caused lesions across his brain, including one in his orbital track. The scan also picked up another issue: Marquez had four compressed disks, two of which had ruptured, so even a moderate impact would lead to paralysis.

Despite his injuries, the Marine Corps insisted that Marquez get ready to deploy again in a few weeks’ time. Learning this, his master gunnery sergeant pulled him aside and told him, “There will be a time when you take your uniform off, and you’re going to have to live with the person underneath it. If you want to have a normal life, you have to take care of yourself.”

The master gunnery sergeant sent Marquez’s paperwork to the Wounded Warrior Regiment, which allowed medical staff to fully evaluate him for a month. According to Marquez, the master gunnery sergeant lost his position over that decision, but Marquez took what his “master gunns” said to heart. During the evaluation, Marquez concluded that he needed to take care of his physical and mental health before deploying again. When he told his new master gunnery sergeant that he wanted to have surgery before deploying, the Marine Corps forced him into medical retirement.

The decision shook Marquez to his core. He had given the Marines 17 years of his life, and now he was left to deal with abandonment issues, depression and anxiety — on top of his physical injuries and TBI. When he started mental health therapy, he quickly realized that the clinicians treating him were knowledgeable about mental health issues, but they didn’t seem to have much of an understanding about military culture.

Improving military cultural competency 

Marquez is now a licensed mental health counselor himself. He created and serves as the director of programming for the Sheepdog Program, a mental health and substance abuse program for veterans and first responders in Melbourne, Florida. The fact that he encountered so many mental health clinicians who were not culturally competent about the military is not shocking given that many practitioners lack specific training in that area and don’t necessarily consider clients who serve in the military as being part of a distinct culture.

But as Marquez points out, the military does indoctrinate people into a unique culture — one that is fast-paced and possesses its own rules, policies and language. Being in the military changes the way that people think and feel, Marquez emphasizes. He compares this new mentality to being a sheepdog because, he says, service members are trained to stand outside and protect the herd by leaving the herd and staring into the eyes of the wolf. They can’t and don’t hide from the ugliness of the world. Instead, they are often exposed to a raw violence. And once exposed, they can’t unsee it, Marquez says. It is imprinted in their minds and shapes the way they view the world.

Keith Myers, dean of clinical affairs and an associate professor of counseling at Richmont Graduate University, conducted interviews with veterans for his recently published book, Counseling Veterans: A Practical Guide, which he co-authored with W. David Lane, a licensed professional counselor (LPC) and professor of counseling at Mercer University. In doing the interviews, Myers says that one topic kept coming up repeatedly: the need for counselors to be culturally competent with this population.

Just like with any other cultural group, counselors have to learn the specific language and customs associated with the military culture, says Taqueena Quintana, an American Counseling Association member and owner of Transformation Counseling Services, a private practice that works with military-connected populations. The language is also specific between military branches, she points out. For example, calling someone in the Air Force a “soldier” communicates a lack of understanding and can cause offense because they are properly referred to as “airmen,” she explains.

Counselors also need to consider these clients’ personal cultural factors — ethnicity, sexual orientation, spirituality, era of service and so on — that further shape their experience both during and after military service.

“Veterans are not cut out from the same material,” notes Tanya Workman, an LPC who is the training director for the licensed professional mental health counselor training program at the South Texas Veterans Health Care System’s Frank Tejeda Outpatient Clinic in San Antonio. “Their overall life experiences, as well as their experiences in the military, will potentially shape their perspective and response to treatment. So, take time to understand the impact that the veterans’ time in service has contributed to their current mental health and function.”

Workman advises counselors to learn about military culture, the various branches of service, the history of the different eras and the veterans’ perceptions of the role they played while in service. Showing interest in the veterans’ experiences builds rapport and helps avoid unintentionally creating barriers by assuming to know what that experience was like for them, she continues. For example, if a veteran is struggling with a moral injury, they may find it difficult to respond to a therapist’s expectation that they are proud of their time in service, she says. So, Workman recommends counselors ask clients, “Why did you join the military? What did your time in service mean to you? What feelings come up regarding your time in the military?”

When she has clients who have retired or finished their time in service, she always asks about their transition from military to civilian life and whether they were ready to retire or separate from the military. Some are ready to be done, she says, but others may feel their time was cut short because of administrative, disciplinary or medical reasons (e.g., not making a designated rank within a specified time period, incurring a medical or mental health condition that prohibits the service member from doing their job). Processing their feelings (such as loss or grief) related to the sudden end of their service can be validating and helps set the tone for future healthy disclosure, she adds.

Myers, an LPC with a private practice serving veterans in Marietta, Georgia, recommends that counselors start by talking to relatives or friends who are veterans and asking them, “What was your experience like? What’s your advice for me as a counselor who wants to work with this population?”

Making counseling relatable

When counselors learn more about clients’ occupations and experiences in the military, they are better able to connect counseling activities and concepts to things that are relatable to the clients, advises Workman, an Army veteran and ACA member who specializes in treating veterans dealing with trauma (including military sexual trauma), substance use disorders and difficulties transitioning from military to civilian settings. For example, she equates the importance of breathing techniques with running and calling cadence or being at a rifle range. All of these activities involve a rhythmic or patterned breathing that some military clients already understand well.

Marquez, owner of the private practice Calm in the Storms, modifies the way he explains mindfulness to his clients. He starts by referring to it as mindfulness training rather than mindfulness meditation. Then he compares mindfulness training to exercise or pistol practice: Clients must repeat the action over and over again for it to work effectively. With meditation, clients are doing a repetitive action — such as focusing on breathing or a certain noise or sensation — to control intrusive thoughts and ground themselves in the present moment, he explains.

Workman, a member of the Military and Government Counseling Association (MGCA), a division of ACA, also uses analogies to explain difficult topics such as hyperarousal, anxiety and avoidance. She often describes hyperarousal as birthday candles setting off smoke detectors and sprinklers to explain how the body’s response to the environment is sometimes more than what is needed. The body — like the alarms — is just responding to a perceived danger. This analogy helps clients understand that hyperarousal is a normal bodily response designed to keep them safe. Then, Workman teaches clients how to be aware of this heightened response and how to calm the body so that the response matches the level of danger.

Marquez also refers to solution-focused therapy as mission-oriented therapy when working with clients affiliated with the military. He describes the approach as a way of addressing the 5-, 10- and 25-meter targets in clients’ lives. He explains that unless the client confronts and takes action on the 5-meter target, it could prevent them from working on their longer-term goals (their 10- and 25-meter targets).

Myers, an ACA member whose clinical specialties include veterans issues, trauma and combat-related PTSD, sometimes makes subtle adjustments to counseling approaches when working with military-connected clients. For example, in couples counseling, Myers often uses John and Julie Gottman’s concept of “accepting influence” from your partner, which involves taking your partner’s opinion into account and being open to using their input to make decisions together.

With military-affiliated couples, Myers brings in a third partner — the military — because the couple must compromise not only with each other but also with the military. When the military deploys the service member or reassigns the service member to a new post, the couple must readjust their plans and deal with these added stressors together.

It’s not all combat-related PTSD

Marquez says he worked with a few therapists who almost did him more harm than good because they assumed that his combat experience was the catalyst for his PTSD. They thought that engaging in military operations and pulling the trigger on his weapon so many times had to be the source of his trauma. They didn’t seem to understand or accept that Marquez was comfortable with the actions he took during his military service.

But one therapist was different. He didn’t presuppose that Marquez’s PTSD was attached to his military service. He set aside his own assumptions and told Marquez, “I can’t pretend to understand what you’ve been through, and I’m not going to. I’m going to ask you questions, hear you talk and connect the dots based on what you say.”

In going through that process with the therapist, Marquez finally discovered that the actual source of his PTSD was his experience of escorting his friend’s body home to Texas. As the escort, he had to view the body and make sure that the uniform was ready for presentation. Seeing his friend’s face — which was almost unrecognizable covered in makeup and saran wrap to preserve the body for the funeral — and confronting the reality of death triggered his PTSD.

Therapists are great at understanding different types of trauma, but some have muddied the water by diagnosing seemingly everything related to the military as PTSD, Marquez adds.

Quintana, an LPC in Washington, D.C., and an assistant professor of counseling at Arkansas State University, agrees that PTSD and TBI are the two mental health issues that people most closely associate with the military. Although a large number of veterans and service members do indeed contend with these issues, they also deal regularly with depression, anxiety, adjustment disorder, co-occurring disorders, substance use disorders, family discord and marital issues, to name a few, Quintana says. Sometimes people connect the military almost exclusively with war and combat, she says, forgetting or not realizing that chaplains, medical professionals and lawyers also serve in the military.

Combat-related PTSD often makes the news, which is good because it raises awareness about mental health and military-connected clients, but it also leads to the common misconception that the majority of veterans have PTSD, says Myers, an MGCA member who previously served on the association’s board of directors. Although PTSD is a common clinical issue, the majority of veterans do not have PTSD. According to the Department of Veterans Affairs, 11% to 30% of veterans have had PTSD over their lifetime.

On the flip side, sometimes clinicians and veterans may assume that certain military service members could not be experiencing PTSD because they have not seen combat in a traditional sense, Workman adds. But trauma is not exclusive to combat occupations, so clinicians should assess all veterans for trauma exposure during service, as well as for trauma that may have occurred elsewhere across the life span, she continues.

For example, she has worked with veterans who served in military intelligence. Their work required them to monitor a computer, and consequently, they were often exposed to the aversive details of violence and war. Even though it would be easy to dismiss their experience as simply sitting in a safe room without the fear of others shooting at them, they still were exposed to combat, just in a different way, Workman says.

Treating co-occurring disorders

Mental health work doesn’t always come neatly packaged with only one presenting problem at a time. Issues often overlap, and Quintana, a deployed resiliency counselor for the Navy, finds that co-occurring disorders are common among military-connected clients.

According to the National Center for PTSD, substance use disorder and PTSD often co-occur with veterans. In the past, mental health and substance use treatment facilities often required clients to be abstinent from substance use before treating them for mental health issues. But this is happening less frequently, and more agencies are taking an integrative approach to care through dual-diagnosis groups, relapse prevention education and comprehensive treatment plans for co-occurring disorders, says Quintana, a member of MGCA and a former school counselor with the Department of Defense Education Activity.

Still, health care professionals too often focus solely on the high intake of substances rather than looking at the big picture or other co-occurring issues, Marquez notes. He says he has known clinics that quickly diagnosed military-connected clients with a substance use disorder and made that the primary treatment plan, or they refused to address trauma at all because they didn’t have the time or resources to handle both the substance use disorder and trauma simultaneously. This experience often causes these clients to either leave counseling or to refrain from talking honestly about their substance use out of fear that they will automatically be labeled with a substance use disorder, he says.

When clients come to Marquez with co-occurring issues such as trauma and substance use, he is honest with them. He informs them that their drinking might technically qualify as a substance use disorder, but he also acknowledges that he knows that behavior is considered acceptable in military culture. He doesn’t ask them to stop, but he does request that they show him that substance use is not a factor in their presenting issue. Often, they stop using substances without any problems. If they don’t, then substance use disorder becomes another part of their treatment plan.

When working with veterans who may have a significant history of alcohol or substance use, Workman advises counselors to be vigilant in looking not just at how much these clients are drinking or using substances but also at their history of trauma, anxiety and other mental health issues. If a person’s anxiety is high and not adequately managed, then it isn’t shocking to find that they are drinking excessively or having difficulty with irritability, anger, or interpersonal interactions at home or work, she says.

Counselors should also do a thorough evaluation if a military-connected client is referred to them for a behavioral problem because, so often, the problem is not the problem, Workman says. “Counselors should ask the veteran, ‘When did this behavior start? What makes it worse? What were you thinking and feeling? What else was going on when you were engaging in this behavior? When was it not like this?’”

It is easy to focus only on the negative behavior, but then the underlying mental health issues that contributed to that behavior often go overlooked and untreated, Workman adds.

Likewise, counselors shouldn’t focus only on the events that happened during clients’ time in the military. Sometimes, past traumas or mental health issues can go untreated, and military experiences only compound the issue. For example, someone who was previously reprimanded for violence might now be applauded and promoted for similarly violent actions performed during their military service. This person is receiving conflicting moral messages, which may compound the emotional wounds they had before entering service, Marquez says.

Co-occurring disorders can also become an issue when symptoms overlap, Myers points out. TBI and major depression can both involve difficulties with attention, depressed mood and trouble sleeping. And irritability and agitation are both symptoms of TBI and PTSD. This overlap can make it challenging to treat, Myers says. Counselors may get stuck trying to figure out the diagnosis — is it TBI, depression or both? “It’s less about deciding what the diagnosis is and more about treating this person holistically,” Myers says.

Marquez says that if counselors focus on a client’s trauma first and wait to address their grief until later, then when they do get around to focusing on the grief, all of the client’s trauma could resurface. That’s why Marquez addresses it all at once. In the Sheepdog Program, which offers a partial hospitalization program and an intensive outpatient program, clients have two to five individual therapy sessions per week, along with other special therapy sessions such as narrative therapy, eye movement desensitization and reprocessing (EMDR), and family therapy that address the specific issues with which they are dealing.

Short-term therapies

Traditional, hourlong counseling sessions aren’t always a possibility for military-connected clients, especially those who are active-duty service members, because they are always in motion, Quintana says. Depending on their duties, some service members may have only a short span of time to meet with a mental health professional, such as during lunch breaks, she points out.

For this reason, Quintana continues, solution-focused therapy, which is a future-focused and goal-oriented approach, can be effective for certain issues within military settings (although not for more serious issues such as trauma and suicidality). If a service member presents with a relationship issue, for example, Quintana empowers the client to identify their own solutions. She may say, “Tell me a time when this issue did not exist. What was different then?” This encourages the client to get away from all-or-nothing thinking and highlight strategies that were helpful previously.

Quintana also believes it is important to build on clients’ strengths. For example, if the client says they are good at communication, she would explore with the client how they could use this skill to improve their relationship. After the client sets goals (with Quintana’s support), Quintana would continue to follow up with the client to monitor success.

Workman fears some veterans may be burned out by solution-focused therapy because it is used so often with service members while in the military setting. In her work with veterans, she uses prolonged exposure for primary care (PE-PC), a type of abbreviated therapy specially designed for the treatment of trauma. It consists of a minimum of six 30-minute sessions provided at the client’s primary care clinic, which tends to be a more convenient and familiar setting for them. This therapy also helps veterans who are not able to dedicate a large portion of their day to counseling and may remove potential barriers to treatment posed by the stigma associated with referral to a mental health clinic, Workman notes.

In these sessions, clinicians teach veterans about common mental health issues such as PTSD. They learn to recognize distressing symptoms and evaluate the intensity of these symptoms by using the Subjective Units of Distress Scale, a self-assessment tool that measures the subjective intensity of disturbances or distress experienced by an individual. Clients track their distress level using this scale before, during and after writing their trauma narrative. By doing this, Workman finds that clients begin to notice improvements in the way they respond to distressing thoughts and memories and that their distress decreases the more they read their narrative out loud. They also have more control and do not experience the same overwhelming symptoms of trauma-related anxiety, she adds.

Clinicians also teach veterans to safely cope with mood distress by using safe grounding and relaxation techniques, Workman continues. The clients work through a prolonged exposure workbook, recording and processing their personal trauma event in a safe and systematic manner with the therapist’s support. The therapist ends each session with a relaxation exercise.

Following this sequence of steps empowers clients to repeat this behavior on their own, she points out. She has found the treatment to be effective, with clients reporting a decrease in severity levels and, more importantly, an improvement in their quality of life.

Marquez finds that virtual reality exposure therapy helps military-connected clients reexperience and remember events connected to emotionally charged memories. Marquez once worked with a client who had dissociative amnesia surrounding an event in which his comrade died in a car. The client felt guilty for not pulling his fellow service member out of the car in time. Marquez positioned the client in front of a black virtual reality screen and asked him to recall the events of that day. At one point, the client described hearing a roar, so Marquez played a few different sounds. When he played a fire sound, the client said, “Yeah, that’s the sound.”

Marquez then turned on the virtual reality screen, and the client saw a vehicle that was on fire. Seeing this image made the client recall that the car had been on fire, so he couldn’t have gone back to save his comrade. The interactive experience restored the client’s lost memories and freed him from the guilt he had felt for years.

Marquez says this therapy helps clients reduce the triggers associated with traditional PTSD responses. It also helps them revisit memories that are often repressed by their military training to react in a rational, nonemotional way. But when they relive the event, they may experience unrecognized emotions associated with it, Marquez points out. So, he uses EMDR to help clients manage the emotional memories that often resurface after virtual reality exposure. “They’re allowing themselves to finally feel the emotions that they never let themselves feel because they were just operating in the rational mind, just following their training,” he explains.

Creating a pipeline for success

Some military families have confided to Quintana that they don’t seek out counseling because they fear they will simply be passed off to someone else or handed a referral list. “Counselors must take time to invest in their clients and ensure they are part of the process,” she stresses.

Quintana takes a collaborative approach with military-connected clients. She believes that partnership is key to facilitating change. In addition to meeting clients where they are, Quintana works with them to highlight their past successes, set goals, and identify tools and resources that can help to address their issues.

Quintana provides an example: A military family is experiencing their second deployment, and the spouse comes to counseling concerned about their child’s social, emotional and behavioral responses to the transition. To better understand this family and their particular needs and strengths, Quintana might explore the family’s past experiences and successes. She might ask the spouse, “What helped your child when they previously navigated challenges related to deployment?” or “Tell me about a time during deployment when this issue was less noticeable. How did you make that happen?” These types of questions help build on what has already worked, highlight the family’s strengths and empower the family to identify solutions.

Through this conversation, Quintana learns that during the previous deployment, the school counselor placed the child in a group with other military-connected children dealing with deployment challenges, and the child found bibliotherapy to be helpful in processing their feelings. Rather than handing the parent a list of resources, Quintana would suggest that the family collaborate with their child’s new school counselor on bibliotherapy strategies that could be used both at school and at home. She would also work with the spouse to access these services within the school and, if needed, the community. “These relationships are meaningful and foster trust, which is critical when supporting military families,” Quintana says.

Myers often seeks to empower his military-connected clients through the use of motivational interviewing. This approach encourages clients to discuss their own reasons and motivations for change. Being able to set their own goals, talk about ways to achieve change and explore their motivations honors their autonomy, Myers says.

Marquez learned the importance of mental wellness the hard way through misdiagnosis and clinicians who were insufficiently trained in the military culture. To correct this issue, he has developed programs and trainings to educate clinicians on working with this population, but he says he would love to see more mental health professionals get involved in creating a pipeline for veterans who want to become counselors and in facilitating peer support specialist groups led by veterans.

Marquez finally found a clinician who took the time to listen and help him figure out the root of his PTSD. Mental health professionals can learn from his experience by becoming more culturally competent and reframing their tools so that military-connected clients do not find themselves alone in the trenches.



Action steps for more information:


Read a companion article to this piece, “Advice for counselors who want to work with military clients,” at CT Online.


Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.com.


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.

Advice for counselors who want to work with military clients

By Lindsey Phillips October 27, 2020

Clinicians often tell Taqueena Quintana, a licensed professional counselor (LPC) in Washington, D.C, that they find it difficult to start working with the military population as a civilian counselor. They want to know how she managed to do it despite not having any personal military experience.

Quintana was first introduced to the military population when she was a counselor at a substance abuse agency. Some of her clients were veterans, and because she hadn’t been trained to work with this population, she started doing her own research.

Then, later as an adjunct instructor of counseling, she had the opportunity to teach a course for combat veterans, and she noticed how their mental health challenges directly affected their personal and professional lives. For example, one student suffered from memory loss because of a traumatic brain injury he received during service. He excelled when he spoke in class, but he had difficulty completing written assignments, which affected his employment and academics.

Through these experiences, Quintana discovered she enjoyed working with veterans, so she decided to do it full-time by working as a counselor on a military base. Now she owns Transformation Counseling Services, a private practice where she works with military populations.

Connect with professionals who work with this population 

Quintana, an assistant professor of counseling at Arkansas State University and a deployed resiliency counselor for the Navy, acknowledges that she wouldn’t have been successful in working with military clients without support from her mentors, supervisors and colleagues. Early in her counseling career, she would go to ACA conferences and attend every military presentation she could – not only to learn more about military mental health but also to make connections with others working in this field.

Quintana also advises counselors to find supervisors and mentors who are connected to the military branches they want to work with. One of her supervisors is a Navy spouse and another is an Army veteran. In addition to providing her with advice on counseling military clients, they refer her for possible job opportunities.

Now Quintana is in a position to support other counselors who want to work with this population. She volunteers with the National Board for Certified Counselors Foundation’s mentor program, which matches counselors who have similar interests and career aspirations. One of her mentees choose Quintana specifically because of the work she has done with the Army. “You seek people in those [military] positions to help you get there yourself,” Quintana says.

Keith Myers, dean of clinical affairs and an associate professor of counseling at Richmont Graduate University, recommends counselors join the Military and Government Counseling Association (MGCA), a division of ACA, or ACA’s Veterans Interest Network, which provide them with access to journals, newsletters and trainings. The Center for Deployment Psychology is another great resource for trainings and education, he adds.

U.S. Marine Corps photo by Lance Cpl. Brendan Mullin/defense.gov

Gain experience with military-connected organizations

Quintana found creating her own knowledge base and foundation in working with this population to be helpful, professionally. “A lot of times, employers want to see that you have some sort of knowledge or experience in [the area in which] you’re working,” she says. “It doesn’t mean you can’t find opportunities. It just means that you have to intentionally position yourself in these spaces where you can gain these opportunities (paid or unpaid).”

Myers, an LPC with a private practice serving veterans in Marietta, Georgia, suggests counselors get involved with military-associated organizations such as the Wounded Warrior Project (which offers programs and resources for wounded veterans who served on or after 9/11) or Give An Hour (which provides free mental health care to veterans and their families).

Tanya Workman, an LPC and the training director for the licensed professional mental health counselor training program at the South Texas Veterans Health Care System’s Frank Tejeda Outpatient Clinic in San Antonio, recommends clinicians look for opportunities at military hospitals and clinics such as the Steven A. Cohen Military Family Clinic at Endeavors, a Texas-based provider that provides mental health care to veterans and their families regardless of their role while in uniform or discharge status. They can also volunteer at the Veterans Crisis Line, which connects veterans in crisis and their families with a U.S. Department of Veterans Affairs (VA) responder, she adds.

There are also training programs geared toward graduate students. The VA’s Office of Academic Affiliations offers a training program for master’s-level counseling students, says Workman, an ACA member and Army veteran. Some of the VA offices are providing internships for these students as a way to train more mental health professional in the specific mental health needs of the military service members and veterans, she explains.

One job position available to counselors is a deployed resiliency counselor, Quintana says. These counselors work for the U.S. Department of Defense or the Navy (but they do not have to be a military member themselves). As Quintana explains, the counselors go on tour with the unit and provide mental health counseling to service members during their deployment.

Find experience outside the VA

“The VA is not the only facility in which [counselors] can work with veterans and active-duty military,” Quintana stresses. “There are organizations and agencies [such as the American Red Cross, Catholic Charities and Salvation Army] that offer opportunities for counselors to position themselves to work with veterans and active-duty military.”

A military family life counselor is another job position that counselors may want to consider, Quintana continues. In this role, counselors are sent to bases in the states or overseas and provide solution-focused, nonmedical counseling to service members and their family. It’s a contracted position with organizations outside the VA and U.S. government and does not require previous experience working with the military, Quintana says.

Myers, an ACA member whose clinical specialties include veteran issues, trauma and combat-related posttraumatic stress disorder, agrees that counselors don’t have to look for organizations that are strictly veteran service providers. Veterans seek help from many different organizations such as psychiatric hospitals or residential treatment centers, he points out.

Myers actually discovered his passion for working with military clients when he took a job at a rehabilitation hospital that had an outpatient service for veterans with traumatic brain injury and mental health issues.

A good fit

Adrian Marquez, a licensed mental health counselor and owner of the private practice Calm in the Storms in Melbourne, Florida, created and serves as the director of programming for The Sheepdog Program, a mental health and substance abuse program for veterans and first responders. He carefully and meticulously selects counselors for this program because he knows the job can be demanding at times. But it’s also rewarding, he adds.

He looks for counselors whose personality would fit in well with the military culture, but that doesn’t mean they must have military experience. For example, one clinician Marquez hired is a world record-holder marathon runner. When Marquez, a retired Marine master sergeant and Marine Raider, discovered the counselor had trained for marathons to the point that his toenails fell off, he knew that this counselor understood what it was like to push yourself beyond your limits. He had the endurance mindset that so many veterans share.

According to Marquez, “It’s finding the right personality, the right character and the people that are willing do [this work] with the right heart.”



Related reading:

See the “From Combat to Counseling” column series at CT Online, including one on this topic, “Getting started in counseling military clients.”

See Counseling Today‘s November magazine for an in-depth feature on working with military and veteran clients, “Counseling in the trenches.”



Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.com.


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 prevention strategies with the military-affiliated population

By Duane France and Juliana Hallows October 29, 2019

Every suicide is a tragedy affecting families, friends and whole communities, but when everyone works together to help those in need, suicide becomes preventable. All of us have a role to play in preventing service member, veteran, and military family (SMVF) suicide.

Within the Department of Defense (DoD), the Department of Veterans Affairs (VA), and the community, professional counselors play a critical role in providing support to this population. Through a community public health approach with dedicated partners and a willingness to learn and adapt to the changing needs of veterans, we can prevent suicide and help individuals live, work and thrive in the community of their choice. Because professional counselors approach mental health from a wellness perspective, they are uniquely qualified to not only support military-affiliated clients, but to advocate for wellness approaches in the communities where they live and serve.

The federal government is working diligently to address suicide in a number of different ways. The Centers for Disease Control and Prevention (CDC) has released a number of strategies created to reduce the number of deaths by suicide, and last year, the VA published a 10-year strategic plan outlining how all parts of the country can work together to support veterans. Additionally, President Trump recently signed an executive order known as the President’s Roadmap to Empower Veterans and End the National Tragedy of Suicide (PREVENTS), which establishes a task force to engage stakeholders nationwide in suicide prevention efforts.

Using a public health approach

Suicide prevention remains the VA’s top clinical priority, but the fact remains that no one person, organization or program can do it alone. The public health approach asks all facets of the community, including mental health professionals, to work together toward a solution. The VA, as a member of the community, has a critical opportunity to meaningfully connect to community stakeholders to save neighbors, family members and friends.

Every VA facility has a suicide prevention coordinator who is asked to step out of their facilities and into their communities to build relationships with community partners that are vested and connected to service members, veterans, their caregivers and their families. Through this model, researchers, clinicians and partners collaborate for suicide prevention by identifying community issues, developing and implementing strategies to address those issues (through maximizing protective factors and minimizing risk factors related to suicide), and creating an evaluative process for those implemented strategies.

Of the 20 million veterans nationwide, less than half use Veterans Health Administration services. That makes it challenging to identify veterans who may be at risk for suicide and to connect them with mental health care professionals, peer networks, employment, and other resources known to bolster protective factors and help with coping. As large and robust of a network as the VA is, this challenge cannot be solved by the VA alone.

Community hospitals, clinics, and health care professionals across the nation play a key role in preventing suicide because they are integrated into the local fabric of the SMVF community. VA partnerships with community health care providers expand access to care to SMVF members in the communities where they live, work and thrive. In addition, not all those who die by suicide necessarily access mental health care services prior to their deaths. This means that community organizations such as veterans groups, recreational teams, faith-based centers, and myriad other community supports can serve as potential collaborators to build on suicide prevention efforts.

Part of improving access and building a public health approach is identifying those who are part of the SMVF community. For example, the New Hampshire Legislative Commission on Post-traumatic Stress Disorder and Traumatic Brain Injury created an initiative for stakeholder agencies to add a question about service member and veteran status, thus improving referral and access to services within the SMVF community. By adding the question “Have you or a family member ever served in the military?” to intake, enrollment and health history forms, counselors create opportunities to discuss military experiences and their impact on clients’ lives. This provides the benefit of informing treatment and connecting individuals to SMVF-specific resources (see askthequestionnh.com/about/why-ask). Identifying the SMVF community can also happen across varying community services, thus strengthening care coordination and supports.

In addition to asking clients about their military status, professional counselors can be particularly helpful in building the public health approach by asking the following questions:

  • How is the community collecting and reporting data on SMVF suicides?
  • How are the local emergency rooms collecting data on suicide attempts?
  • Does the community have a strategic initiative to address SMVF suicides?

If there are no answers to these questions, counselors can work with their communities to implement more effective strategies. Communities can also implement these strategies beyond the service member and veteran populations to include caregivers and loved ones. There still is a long way to go in identifying and understanding all of the risk factors and protective factors for suicide among the spouses and children of service members and veterans.

Although the VA is expanding community care for the SMVF population, community health care providers need to develop the same level of military cultural competence as exhibited by providers within the VA. It is essential that health care providers understand the cultural issues related to military service that may give veterans mixed feelings about receiving health care. These cultural issues include:

1) Concerns that seeking care, particularly mental health care, will harm their careers, whether military or civilian.

2) Fears about how they could be perceived by others for seeking care, such as being seen as “weak” by their peers.

3) The belief that overall mission success is a greater priority than their own well-being.

In Phoenix, VA teams have partnered with the Arizona Coalition for Military Families to provide military culture training to local behavioral health providers. In Richmond, Virginia, the McGuire VA Medical Center partnered with the Richmond Behavioral Health Authority to include VA resources on the state’s behavioral health website.

In addition to building cultural competency, community health care providers need to be able to offer the SMVF population the same type of evidence-based practices provided through the VA. This may be achieved through partnering with local VA providers on trainings that build on clinical skills for suicide prevention. The VA developed a Community Provider Toolkit (see mentalhealth.va.gov/communityproviders/index.asp) to help community providers, including counselors, gain a deeper understanding of military culture.

Through the public health approach, everyone has a role to play in preventing SMVF suicide. By considering level of risk and the factors beyond mental health that contribute to suicide, communities can deliver resources and support to SMVF populations earlier, before they reach a crisis point.

Maximizing protective factors

A critical component of SMVF suicide prevention is identifying the protective factors that prevent these individuals from getting into crisis. As noted in the CDC’s Preventing Suicide: A Technical Package of Policies, Programs, and Practices (2017), there are many strategies to build up protective factors. Some of these protective factors include promoting connectedness, improving economic stability, and increasing education and awareness about suicide within the population and throughout the community. These strategies fit well into Thomas Joiner’s interpersonal-psychological theory of suicidal behavior, in which he proposes that individuals die by suicide when there is a desire and capacity to do so. He posits that a sense of isolation, feelings of burdensomeness, and an ability to engage in self-harm all correlate with increased risk of suicide.


Promoting connectedness in the military population helps to reduce a person’s sense of isolation. This strategy has two critical components: peer norm programs and community engagement activities. 

Counselors in the VA leverage community partnerships, promote family engagement, and encourage those around SMVF populations to ensure they remain connected to their loved ones and peers. The Veteran Resource Locator, for instance, links veterans and their loved ones, or community providers, with programs and services in their area, both within the VA and in the community. Counselors consistently look to engage family members in veterans’ treatment to increase their support systems. Local VA facilities conduct extensive outreach in the community to form partnerships with organizations in which veterans and service members are involved. For example, in Billings, Montana, the VA and community teams developed a local veterans meet-up group to help service members stay connected to their community during transition from active duty. Group members meet regularly for cookouts and conversation.

Counselors in the community can also support efforts to improve connectedness. For example, counselors can become familiar with peer support programs in their communities or get involved in the development of such programs if none exist. If organizations exist within the community that provide opportunities for the SMVF population to engage with others while supporting their community (e.g., Team Rubicon; Team Red, White & Blue; The Mission Continues; Travis Manion Foundation), counselors can get to know who is in the organization. Counselors can provide referrals to these organizations and invite representatives to speak to their colleagues.

Economic stability

A suicidal crisis in a member of the SMVF population does not happen in a vacuum. Increasing economic stability is a significant protective factor in preventing suicide. As service members transition out of the military, whether they have served for four years or 24 years, the majority are young enough to be able to continue in another career. When housing, employment and finances are not stable, this can cause additional stress for this population and increase feelings of burdensomeness.

Counselors in the community can maintain a list of referral agencies that support housing, employment and financial support. These organizations play an important role in reducing SMVF suicide, whether they realize it or not. If a service member or veteran is in financial crisis, they may be in a psychological crisis too.

The VA is increasingly working to support veterans in financial distress through the Financial Assistance for High Risk Veterans program. This program, available at many VA facilities, creates a partnership between local VA facility suicide prevention coordinators and revenue staff. Should a veteran with high risk of suicide also require assistance related to financial distress, the suicide prevention coordinator would connect the veteran to revenue staff. These staff would work personally with the veteran to apply for a VA financial hardship program that best fits the veteran’s financial situation.

As counselors in the community and the VA become aware of how financial stressors are interacting with the sense of burdensomeness in their clients, they can incorporate clinical moments to discuss and assess suicide risk while also developing strategies to build economic support. Together, clinicians inside and outside of the VA can bolster the network of housing, employment and financial assistance through reviewing what is available in the community and developing strong referral processes.

Education and awareness

A third protective factor is increasing community education and awareness about SMVF suicide and suicide prevention. This is yet another area in which professional counselors can make an impact. Counselors who are familiar with suicide prevention efforts can help others become familiar with them too. Providing greater awareness in the community is important. It is also critical to educate medical professionals about the problem. A large number of those who have died by suicide saw their primary care providers a month or less before their deaths (see ncbi.nlm.nih.gov/pubmed/12042175). Counselors can support their communities by facilitating or promoting gatekeeper training for those serving the military-affiliated population.

The VA has invested significantly in education around suicide. VA employees take annual suicide prevention training. VA facilities also conduct extensive community outreach to ensure that partners are aware of resources available to veterans and their families.

Counselors in the community can also take the initiative to become educated on SMVF suicide. The VA has partnered with PsychArmor Institute to provide free online access to the S.A.V.E. suicide prevention training (available at psycharmor.org/courses/s-a-v-e). In addition, VA suicide prevention coordinators partner with community providers to offer in-person training to those who need it. In their role as advocates, counselors can work with local leaders to provide clinical expertise connected to community suicide prevention efforts, whether that be public awareness campaigns or participation in local SMVF suicide prevention efforts.

Minimizing risk factors

Unfortunately, no matter how much we invest in preventive efforts, the possibility still exists that a member of the military-affiliated population will experience a suicidal crisis. When this happens, the community needs to be just as prepared to identify and reduce risk factors as it is to identify and implement protective factors. Both the CDC and the VA have identified more than a dozen risk factors that may lead to suicidal thoughts and behaviors, but there are three areas where professional counselors can be especially helpful.

Access to care

Of all the risk factors and protective factors identified here, the area in which counselors are most likely to be naturally involved is improving access to safer care. When it comes to the military-affiliated population, this means improving culturally competent care, reducing barriers to care, and reducing the mental health provider shortage for those organizations that serve this population.

The VA has done much to improve access to care for veterans, including the expansion and promotion of the Veterans Crisis Line (VeteransCrisisLine.net), a 24-hour service that veterans can call, text, or chat with at any time to receive immediate support. The VA also provides same-day access for veterans in need of mental health care and has built a robust telemental health and call center network that can direct veterans to get the care they need. In addition, the VA sponsors Coaching Into Care (mirecc.va.gov/coaching), a free service that educates, supports and empowers family members and friends who are seeking care for loved ones who are veterans. In addition, the DoD expanded nonmedical mental health services for the SMVF population up to a full year after leaving active duty.

Counselors in the community must be just as ready as their colleagues in the VA to improve access to care. It is incumbent upon counseling professionals to ensure that they develop and maintain an understanding of the unique psychological challenges faced by the SMVF population and that they are available to serve those individuals who do not access care through the VA or DoD.

Community counselors also have the ability to be important advocates for the profession through mentorship, collaboration and consultation. Increasing the number of veterans and military family members who consider careers in the mental health field is an excellent way to improve access to care for this population.

Lethal means safety

One area that deserves discussion but often goes unmentioned is the need for counselors to address the ability of clients to engage in self-harm. This includes talking about lethal means safety, particularly with those in the military-affiliated population.

Veterans are more likely to die from firearm-related suicide than are those in the general U.S. population, according to the VA’s 2019 National Veteran Suicide Prevention Annual Report (see mentalhealth.va.gov/suicide_prevention/data.asp). Safe storage of lethal means is any action that builds in time and space between a suicidal impulse and the ability to harm oneself. It addresses how to be safe from any lethal means, including firearms, prescription medications, and suicide hot spots.

This topic can be sensitive, especially because veterans have experience with and are comfortable with firearms. Effective lethal means safety counseling is collaborative, veteran-centered, and consistent with their values and priorities. Although the most preferred way of preventing SMVF suicide is to keep these individuals from going into crisis in the first place, lethal means safety plans are critical to preparing for suicidal crises should they arise.

The VA has made significant efforts to impact the conversation around lethal means safety. For example, it distributes free gunlocks to veterans and provides safe medication disposal envelopes at facilities across the country. The VA also recently instituted a nationally standardized safety planning template that ensures veterans have high-quality suicide prevention safety plans. Veterans and their providers work together to complete the plans, which identify innovative and feasible actions that can be taken to reduce access to lethal means. Suicide prevention coordinators within the VA have participated in firearm shows and fairs, providing materials and gunlocks directly to gun owners in their communities through partnering with local firearm groups.

Counselors in the community must be just as informed and prepared as counselors in the VA to discuss lethal means safety. They should be aware of locations that provide out-of-home firearm storage in the community and be able to have honest discussions with clients about when and how to use these resources. Counselors can partner with other community agencies to identify these resources. For example, the Colorado School of Public Health and the University of Colorado School of Medicine at the Anschutz Medical Campus have established the Colorado Gun Storage Map, provided for those community members seeking local options for temporary, voluntary firearm storage (see coloradofirearmsafetycoalition.org/gun-storage-map).

Counselors must take the same care when it comes to storage of prescription medications. In addition, community counselors may be more able than their VA counterparts to partner with local law enforcement to identify and mitigate suicide hot spots.


A final area that counselors must address to reduce the risk of suicide in the SMVF population is postvention. Engaging service members, veterans, families, and providers after a suicide loss can promote healing, minimize adverse outcomes for those affected, and decrease the risk of suicide contagion. Postvention is critical to preventing additional suicides in the immediate social network of the person who died by suicide. Those bereaved by another person’s suicide have a greater probability of attempting suicide than do those bereaved by other causes of death. Those bereaved by another person’s suicide are also at increased risk for several physical and mental health conditions.

Community providers play a significant role in postvention. Clients who have attempted suicide are at a higher risk for future attempts unless the underlying problems that led to the attempt are addressed. Community providers are also important in addressing postvention needs in those left behind because of a death by suicide, such as the spouse and child of a service member or veteran. Whereas veterans may be served through the VA and service members may be served through the DoD, spouses and children of service members and veterans may not have access to the resources they need. This is where professional counselors in the community can offer support. For example, SAVE (Suicide Awareness Voices of Education) has excellent postvention resources for coping with loss (see save.org/find-help/coping-with-loss).

The VA has implemented processes to increase postvention efforts in its facilities. The VA provides its staff with suicide postvention guidance that can be tailored to meet the needs of each individual facility. Postvention efforts should include everyone who might have been affected by the death, including veterans, their families, and employees. Following a suicide, efforts are made to promote healing and support the deceased veteran’s family. Many local VA organizations have partnerships with the American Foundation for Suicide Prevention (afsp.org) and the Tragedy Assistance Program for Survivors (taps.org/suicideloss) to provide support to veterans’ family members and friends.

Additionally, the free, confidential Suicide Risk Management Consultation Program (mirecc.va.gov/visn19/consult) is available to assist staff with training on postvention. This program provides consultation, support and resources that promote therapeutic best practices for providers working with veterans at risk of suicide. It offers tailored, one-on-one support with consultants who have years of experience with veteran suicide prevention.

Suicide prevention is everyone’s job

The strategies to prevent suicide in the SMVF population are as complex as the risk factors for suicide itself. Unlike other challenges that SMVF clients face, such as homelessness and unemployment, success in reducing suicide is not clearly defined. If clients are housed, they are no longer homeless, and if clients are employed, they are no longer unemployed. The measure of success in suicide reduction is not just the absence of suicidal self-harm, however, but the presence of a life worth living and an overall level of wellness in the client.

This is where professional counselors can play a role in their clients’ lives and in their communities. Members of the military-affiliated population have sacrificed and served, regardless of when, where and how they served. It is necessary — and possible — to serve them in return, providing them the life of wellness and stability that they desire and deserve.



For more information and resources, visit mentalhealth.va.gov and veteranmentalhealth.com. Additional resources for veterans, families, and community providers can be found at BeThereForVeterans.com and MakeTheConnection.net



Duane France is a retired Army noncommissioned officer, combat veteran, and licensed professional counselor. He is the director of veteran services for the Family Care Center, a privately owned outpatient mental health clinic in Colorado Springs, Colorado, that specializes in serving the military-affiliated population. He also writes and speaks about veteran mental health on his blog and podcast, Head Space and Timing (veteranmentalhealth.com), and writes the monthly “From Combat to Counseling” column for CT Online.

Juliana Hallows is a national board certified and professionally licensed counselor. She serves veterans, their families, and communities through the VA National Suicide Prevention Program, where she is a health system specialist for policy and legislation.


Letters to the editor: ct@counseling.org



Related reading: Counseling Today‘s September cover story, “Making it safe to talk about suicidal ideation




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.