Tag Archives: Military

Military

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

By Bethany Bray September 12, 2016

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

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

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

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

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

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

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

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

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

Other key findings in the VA report include:

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

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

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

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

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

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

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

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

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

 

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Read the VA report in full here

 

Read a VA press release about the report here

 

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

 

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

 

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

 

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

 

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

 

 

Adding a counselor’s voice to law enforcement work

By Bethany Bray March 17, 2016

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

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

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

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

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

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

Gregory Moffatt, LPC and professor of counseling at Point University

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

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

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

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

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

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

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

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

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

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

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

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

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

 

Q+A: Gregory Moffatt

 

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

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

 

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

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

 

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

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

 

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

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

 

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

 

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

 

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

Controversies in the evolving diagnosis of PTSD

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

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

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

Conceptualizations of trauma

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

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

Trauma and wars

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

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

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

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

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

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

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

Trauma and the DSM 

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

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

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

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

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

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

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

Swinging pendulum

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

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

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

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

A developmental perspective

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

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

Current issues

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

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

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

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

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

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

 

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

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

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

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

 

Letters to the editor: ct@counseling.org

 

 

A first step toward stemming veteran suicide

By Bethany Bray February 11, 2015

A bill aimed at improving suicide prevention and mental health services for veterans has sailed through both houses of Congress this winter.

President Barack Obama signed the Clay Hunt Suicide Prevention for American Veterans Act (also veteranflagcamoknown as the Clay Hunt SAV Act) into law on Thursday, Feb. 12.

The bill, named for a Marine sniper who died by suicide in 2011, calls for an audit of all mental health and suicide prevention practices and programs at the U.S. Department of Veterans Affairs (VA).

“Today, we honor a young man who isn’t here, but should be,” President Obama said at Thursday’s bill signing. “Every single veteran in America has something extraordinary to give to this country. Every single one. … If you are hurting, know this: You are not forgotten. You are not alone. You are never alone. We are here for you.”

Although the bill is a good step, supporting and helping veterans ” is not just a job for government,” said Obama. “Every community, every American can reach out and do more for our veterans. This has to be a national mission.”

Passage of the bill is good news for the veteran community and a first step toward further improvements, says Jeff Hensley, a Navy veteran, American Counseling Association member and licensed professional counselor intern.

In 2012, the VA reported the eye-opening statistic that 22 American veterans die by suicide every day of the year.

“This seems so counterintuitive to those who are part of this [veterans] community, and very scary,” says Hensley, a program counselor at a therapeutic riding center in Wylie, Texas, who does equine-assisted therapy with veterans.

Veterans met the 2012 report with “shock, followed by indignation that we were allowing this to happen here in this country,” Hensley says. “That was the motivation [for the Clay Hunt bill].”

The legislation introduces several measures meant to improve veterans’ access to mental health care, including:

  • Evaluating all mental health care and suicide prevention practices and programs at the VA for the purpose of making recommendations to improve care
  • Requiring the VA to create a website to serve as a centralized source of information regarding all VA mental health services for veterans
  • Authorizing the VA to set up a student loan repayment pilot program to recruit and retain psychiatrists
  • Extending by one year the “combat eligibility” period that veterans of the Iraq and Afghanistan wars have to register for VA health care without having to first prove a service-related disability
  • Establishing a peer support and outreach pilot program to assist newly discharged service members with accessing VA mental health care services

 

“Getting help really does make a difference, and this legislation will encourage more veterans to get help,” says Hensley. “It will make a smoother transition for those going from active duty to civilian life – continued access to care, all the way.”

The Clay Hunt SAV Act is the culmination of an intense year of grassroots and lobbying work by the Iraq and Afghanistan Veterans of America (IAVA), a nonprofit organization that represents post-9/11 veterans.

Hensley, an IAVA leadership fellow, came to Washington, D.C., last March to talk with legislators and campaign for the bill. He was part of an IAVA team that planted 1,892 American flags in the ground of the National Mall between the Washington Monument and the U.S. Capitol. Each flag represented a veteran who had committed suicide between January and March of that year.

A poignant image of the event, captured by a news photographer, shows Hensley having an emotional moment as he knelt among the flags. A retired Navy commander, Hensley was a fighter pilot who saw combat deployments in Iraq.

Thanks to the efforts of IAVA, the Clay Hunt SAV Act went from conception to the president’s desk in a little less than one year, says Hensley. Both houses of Congress passed the bill unanimously, an exceptional feat in an age known for partisan gridlock. It was passed by the House of Representatives in January and by the Senate on Feb. 3.

“It’s not a perfect bill, but it’s a foot in the door,” Hensley says. “It creates a national conversation about the problem. … It’s not a perfect piece of legislation, but it’s a very good start.”

When veterans come off of active duty, it is up to the individual to take the initiative to register with the VA. This can be a big obstacle for those who are hurting, according to Hensley.

It is estimated that less than half of post-9/11 veterans register with the VA, and it is impossible to know whether those who don’t register are getting mental health care outside of the VA or not at all, Hensley says.

“A lot of veterans fall off our radar,” he says.

Hensley sees the impact of this reality firsthand in his work with veterans at the therapeutic riding facility in Texas.

“Most of the [veterans] who are coming to us aren’t in the VA system. We may be the only help they’re getting,” he says. “I see it every day. If they reach out and get help, it can make a big difference. … From a counseling perspective, it’s hard to watch this population not get help, to be struggling. But because of stigma [surrounding mental illness], or limited access to care, or whatever reason, they don’t reach out.”

IAVA polls its members each year to collect data and find out what issues are most important to them. The Clay Hunt SAV Act was borne out of member survey data that indicated suicide prevention was a top priority.

(IAVA has 300,000 veteran and civilian members; the 2014 survey was taken by a little more than 2,000 of its veteran members.)

Last year, 40 percent of IAVA members who took the annual survey reported that they knew at least one veteran of the Iraq or Afghanistan campaigns who had committed suicide. Thirty-one percent of respondents said they had thought about taking their own life since joining the military.

Clay Hunt, a Purple Heart awardee who served in Iraq and Afghanistan, was seeking care from the VA for post-traumatic stress disorder before he committed suicide at age 28.

“While we are a little bittersweet, because it is too late for our son Clay, we are thankful knowing that this bill will save many lives,” said Susan Selke, as the bill named for her son was passed by the Senate last week. “No veteran should have to wait or go through bureaucratic red tape to get the mental health care they earned during their selfless service to our country. While this legislation is not a 100 percent solution, it is a huge step in the right direction.”

 

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For more information on IAVA and the Clay Hunt SAV Act, visit IAVA.org/SAVACT

 

More details and the full text of the bill is posted here: congress.gov/bill/113th-congress/house-bill/5059/text

 

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

 

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

 

Exploring the impact of war

By Keith Myers September 26, 2014

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

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

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

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

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

Cognitive stressors

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

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

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

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

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

Emotional stressors

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

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

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

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

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

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

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

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

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

Social stressors

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

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

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

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

Physical stressors

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

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

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

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

Spiritual stressors

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

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

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

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

Evidence-based treatments for combat trauma

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Final thoughts

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

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

Letters to the editorct@counseling.org

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