Tag Archives: veterans

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.

 

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Action steps for more information:

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

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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.

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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.

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.”

 

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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.”

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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.

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

Suicide 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.

Connectedness

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.

Postvention

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.

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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

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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

 

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

 

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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.

From Combat to Counseling: Comprehensive mental health in the military-affiliated population

By Duane France October 17, 2019

Often, when talking about mental health in the military-affiliated population, the first thing that comes to many people’s minds is posttraumatic stress disorder (PTSD). This is true of mental health professionals as well.

Once, a colleague asked me how many deployments I had in my military career. When I told her that I had five combat and operational deployments, she said, “Well, of course you have PTSD!” In reality, the number of deployments doesn’t dictate the level of traumatic events to which a service member has been exposed. A client could have multiple deployments and not have experienced anything worse than separation from family, whereas another client could have experienced only one very serious and traumatic deployment.

It is important to understand what we are talking about when we discuss mental health in the military-affiliated population. It is critical to understand the culture of the military and to understand who we are talking about. However, as mental health professionals, it is equally important to understand the potential psychological impacts that our clients have experienced.

 

PTSD

Although PTSD is not representative of everything that service members deal with after the military, it is a condition that any counselor working with the military population must understand. It has been described in a number of different ways throughout history, including “soldier’s heart” in the Civil War, “shell shock” in World War I, and “battle fatigue” in World War II and the Korean War. After the Vietnam War, the symptoms that would come to signify PTSD were called “post-Vietnam syndrome.” It wasn’t until the third edition of the Diagnostic and Statistical Manual of Mental Disorders, published in 1980, that PTSD became an official diagnosis.

There are a number of PTSD diagnostic criteria outlined in the DSM-5, the most significant of which is that the service member must have been exposed to an event that resulted in death, threatened death, actual or threatened serious injury, or sexual violence. The service member or veteran must have been exposed either through direct exposure, witnessing the trauma, learning that a relative or close friend was exposed to such trauma, or experiencing indirect exposure to details of the trauma in the course of professional duties. This is significant. Just because a service member was deployed to a combat zone does not mean that the service member was exposed to an event that meets this criterion; this was certainly true for three of my five deployments. Being able to differentiate between PTSD and other psychological conditions is critical to supporting the client.

 

TBI

Another condition emerging as an important consideration is traumatic brain injury (TBI), which is also known as a concussion or mild, moderate, or severe TBI. Military equipment and medical response have improved significantly over the past 50 years, resulting in greater survivability on the battlefield. Injuries that previously might have been fatal are now being treated quickly and effectively. While this development has reduced the mortality rate in recent conflicts, it has led to an increase in the number and severity of catastrophic injuries.

Further complicating TBI is the fact that many of its symptoms overlap with those of PTSD, and many of the conditions that could cause TBI also meet criterion A for PTSD. Whether it is a blunt force trauma concussion from a direct blow to the head or a diffuse TBI caused by blast overpressure from an explosion, the causes of TBI could also be causes for PTSD (and vice versa).

 

Addiction

Addiction is another important mental health consideration in the military-affiliated population. This of course includes substance use. Many of us who served know that the military is a drinking culture. Drinking is normalized and used to relax, to celebrate, to memorialize. Regardless of rank or branch of service, alcohol is acceptable and available.

It is problematic, however, when the reason for alcohol use changes from celebration to self-medication, or using alcohol to reduce discomfort from psychological concerns. Additionally, the opioid epidemic in the veteran population typically begins during active duty. Because of the extreme chronic pain that results from multiple injuries, pain management is a necessary consideration, and painkillers are readily available.

In addition to substance use, it is also imperative to explore process addictions in the military-affiliated population. Whether it involves gambling, viewing pornography, compulsive eating or shopping, compulsive and addictive behaviors can cover the veteran’s or service member’s underlying concerns.

 

Photo by U.S. Army Sgt. Victor Perez Vargas/defense.gov

Emotional dysregulation

Difficulty tolerating and managing emotions is another significant aspect of mental health for the military-affiliated population. While there are certainly emotional components to PTSD, TBI and addiction, it is also possible for emotional challenges to exist apart from substance use, trauma exposure or physical injury. For many service members and veterans, the typical dysregulated emotions are depression, anxiety and anger.

Among the nontraumatic causes for an inability to manage these emotions are toxic leadership and systemic harassment. An inability to escape from an adverse situation can lead to feelings of helplessness and hopelessness. I will emphasize again that there are many situations in the military that could cause anger, anxiety and depression that have nothing to do with exposure to traumatic events. It is necessary to determine whether emotional dysregulation or substance use is the result of traumatic exposure or another cause.

These aspects of mental health are not unique to the military of course. Combat trauma is not the only cause of PTSD, and any significant blow to the head can cause TBI. Addiction is not a problem just for the military population, and emotional concerns such as depression and anxiety are widespread. Additionally, these conditions follow the medical model of mental health; there is a diagnosis for each of them and corresponding medications for each of them. Although these conditions can be debilitating in and of themselves, there are other factors unique to the military population that can complicate attempts to treat service members, veterans and their families.

 

Meaning and purpose

Although service in or affiliation with the military can be difficult, it can also be extremely satisfying. There is a collective effort toward a common goal, a sense of shared culture and community, and a feeling that the work you’re doing is important. Many veterans, upon leaving the service, struggle to find the same satisfaction in their post-military careers. Many are able to build a meaningful life after the military, but it is not automatic.

There is also the challenge of navigating an identity shift. Whether it’s for four years, 14 years or 24 years, the service member’s identity is closely tied to the military. We were Soldiers, Airmen, Sailors, Marines, or Coast Guardsmen literally 24 hours a day. Even if not serving full time, as is the case in the National Guard or Reserve components, service members are always aware of a type of double life. When we leave the service, many of us ask ourselves, “Who am I if I’m not a soldier?” A friend of mine, a medically retired Green Beret, expressed this quite well when he stated, “The Army said I couldn’t be me anymore. What do I do now?

 

Moral injury

Another concept that has emerged over the past 25 years is moral injury. PTSD, at a very basic level, is an injury of the behavior. It is classic conditioning: When a triggering event occurs, a certain reaction is initiated. It is, of course, more complicated than that, but a significant aspect of PTSD is stimulus response. TBI, on the other hand, is a physical injury of the brain. Moral injury can be described as an injury of the soul: What a service member believes to be right and wrong with the world has been fundamentally changed.

In one of the first articles to fully develop an explanation of moral injury, Brett Litz and colleagues described moral injury as “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.” There is some disagreement as to whether moral injury is an aspect of PTSD or its own distinct condition. the fact is that one can have a morally injurious event that is not traumatic, and there are a number of traumatic events that are not morally injurious. Regardless, it is beneficial for anyone interested in working with the military population to familiarize themselves with moral injury and to at least explore the concept with these clients.

 

Needs fulfillment

The military is a highly connected communal society where tasks are divided among its members. When I was in Iraq and Afghanistan, I didn’t have to worry about where my food and water would come from because there were other service members or contractors who provided that. When my family and I arrived at a new duty station, we were provided housing, and there were people on base who gave us guidance on schools for our children.

Of course, when service members leave the military, those same needs still have to be fulfilled, but now it must be done in different ways. This isn’t to suggest that service members aren’t capable on their own, but challenges related to employment and housing — those lowest levels of Maslow’s hierarchy of needs — are widely known in the veteran population. Even our psychological needs, such as belongingness and esteem, are part of the military framework. Our peer group is provided for us; like them or love them, the people you serve with are your family. Your effort is recognized with rank or reward. Outside of the military, however, we have to learn how to meet those old needs in new ways … and for some service members, that can be difficult.

 

Relationships

The final aspect of mental health in the military-affiliated population that I’ll discuss is relationships. Our mental health affects our interactions with others, and our interactions with others affects our relationships. Whether it is frequent separation, moving households every three or four years, or relationships with people who are literally on the other side of the world, the relationships of those in the military population are necessarily different from those who have never served.

When considering how military service impacts relationships and vice versa, it is important to understand that this doesn’t just refer to intimate relationships such as spouses and children, or even parents and siblings. This also includes peer relationships (friends and acquaintances) and work relationships. Understanding how to integrate into a community that has a different cultural orientation than you do is difficult. Even if none of the other psychological concerns mentioned in this article are prominent, adapting relationships to a new lifestyle can be challenging.

 

Considering all aspects of psychological wellness

It can be daunting to consider how these various aspects may interact to provide an almost never-ending combination of circumstances for members of the military-affiliated population. One thing is clear though: The more of these areas that the service member, veteran, or military family member has difficulty in, the more at risk they are.

As professional counselors, we need to be able to understand the complexity of our clients’ conditions. We need to ensure that we have a full picture of their needs and then address those needs if possible. If an area is outside of our expertise — if we are not trained in an evidence-based practice for PTSD, for example — then we have an ethical responsibility to refer that client to someone who can meet their needs.

In this way, we are providing the best possible care for those who serve, those who have served, and those who care for them.

 

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Duane France, LPC

Duane France is a retired U.S. Army noncommissioned officer and combat veteran who practices as a licensed professional counselor 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. He is also the executive director of the Colorado Veterans Health and Wellness Agency, a 501(c)3 nonprofit that is professionally affiliated with the Family Care Center. In addition to his clinical work, he writes and speaks about veteran mental health on his blog and podcast at veteranmentalhealth.com. Contact him at duane@veteranmentalhealth.com.

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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.

From Combat to Counseling: Service members, veterans and military family mental health

By Duane France July 14, 2019

 

This is the debut article of what is intended to be a monthly online column about counseling military-affiliated clients.

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Service members, veterans and their families face some unique challenges both during and after military service. There’s the stuff that is widely known — deployments, constant moving, a regimented lifestyle — and then there’s the stuff that isn’t so well-known. This includes the experience of living in a mutually supportive community; a lack of individualism and getting used to relying on others while others rely on you; for veterans, a lack of purpose and meaning in post-military life; for family members, experiencing the aftermath of the military, because it’s a stressful job. No one is getting out of the military without a couple of dents in the fender.

Sometimes, the challenges faced by the military population turn into crisis. The high rate of suicide in the service members, veterans and their families (SMVF) community is well-known. Given a higher level of exposure to trauma, service members and veterans may be more likely to develop posttraumatic stress disorder and other psychological conditions. And with greater physical danger comes a higher risk of catastrophic injury, which comes with its own problems, including the need to adjust to a new reality.

This is where the counseling profession comes in. As clinical mental health professionals, we are uniquely qualified to help the SMVF population live the life that they desire and deserve. We look at mental health from a wellness perspective, not an illness perspective. People with a military background will reject the concept of “sickness” and “brokenness” because, to them, that’s equal to weakness. If someone approaches a service member, veteran or military family member with pity, as if they’re a broken-winged bird, there will probably be a bit of a confrontation.

I know, because I’m a member of this community.

Who am I?

I retired from the U.S. Army in 2014 after a 22-year career. After retiring, I took on a new mission to help my brothers and sisters in arms, and their families, adjust to the circumstances that put some of those dents in their fenders. After several years of clinical work, I realized that my lived experience combined with my clinical background could help others. Which is where this column comes in.

Over the coming months, I’ll be sharing some of my insights about the culture and character of the military. Even though the need is great, the counseling profession doesn’t include a lot of people like me — former service members who have become professional counselors. As a matter of fact, that is what brought me to the profession — a chance encounter at just the right time and someone saying exactly the right thing to someone who was open to hearing it.

I was not a mental health professional when I was in the Army. I was in logistics, which is the Army’s euphemistic way of describing supply and transportation. In 2007, knowing that I would eventually have to leave the military, I started going back to school while I was deployed to Iraq. I was looking for a degree with the least amount of math possible and came across an associate degree in counseling and applied psychology. I thought that might make me a better leader, and I was interested in psychology, so I figured why not?

Fast-forward nearly a year. My unit was redeploying from Iraq after 15 months, and we were participating in post-deployment reintegration sessions. We all went to a conference center at a local hotel, where we were presented with breakout sessions on not going too wild with our drinking, not being mean to the neighbors … that kind of thing.

One of the breakout sessions was led by a counselor from the local Vet Center. For those of you not familiar with Vet Centers, they are outpatient mental health clinics that are part of the Department of Veterans Affairs (VA) but separate from the main VA health care system. The counselors at the Vet Centers are typically veterans themselves, as was the case with this clinician. She introduced herself and said that she was a retired Air Force officer. I don’t remember much of what she talked about that day, but something she said struck me then and stays with me now: “By the way, if any of you are interested in psychology, consider a career in the mental health industry. There are not enough combat veterans in our field.”

That’s all it took. Up until that point, I had not considered becoming a mental health counselor. After that, I started on the path that I’m on now and, with the help of many mentors along the way, currently work as a counselor at a private outpatient clinic in Colorado Springs, Colorado, that primarily serves the military population.

What the counselor said that day was correct then, and it still holds true now: There are not enough veterans in the counseling career field serving others in the military population. At the same time, that truth does not minimize the need for mental health counseling for the military population. There are two solutions to this: Bring more veterans into the counseling profession, and help those clinicians in the counseling profession who are not veterans to understand more about the unique needs of the military population.

As professional counselors, we recognize the need to be culturally competent with whatever client populations we work. We can’t work with someone from another culture without knowing about that culture; the ACA Code of Ethics clearly identifies this.

In that sense, the military population is an entirely different culture. Anything that defines the characteristics of a culture — ways of dressing, language, conceptualization of the world — applies to the military. I often describe it this way: It’s as if I went to England to live for 22 years and then moved back to the United States. Sure we spoke the same general language in those two countries, but there were also significant cultural differences between them and, therefore, adjustments that I needed to make. That’s how service members and their families feel after military service.

So, the goals of this column will be:

  • To provide insights into the culture of military-affiliated clients
  • To support counselors who find themselves working with service members, veterans and their families
  • To answer questions (if you have any, feel free to drop me a line at duane@veteranmentalhealth.com)

Thank you for your willingness to serve the military-affiliated population and for your willingness to learn more. Your efforts are greatly appreciated

 

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Duane France, LPC

Duane France is a retired U.S. Army noncommissioned officer and combat veteran who practices as a licensed professional counselor 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. He is also the executive director of the Colorado Veterans Health and Wellness Agency, a 501(c)3 nonprofit that is professionally affiliated with the Family Care Center. In addition to his clinical work, he writes and speaks about veteran mental health on his blog and podcast at veteranmentalhealth.com. Contact him at duane@veteranmentalhealth.com.

 

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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.