Tag Archives: veterans

VA expands policy to allow service dogs

By Bethany Bray August 31, 2015

The Department of Veterans Affairs (VA) has amended its policy to allow all types of trained service dogs in VA facilities, including canines that support people with mental health and emotional issues.

Previously, the only animals allowed in VA facilities were guide dogs, with few exceptions.

Keith Myers, an American Counseling Association member and licensed professional counselor ServiceDog(LPC) in Georgia who specializes in trauma and veteran’s issues, calls the change “a needed policy shift.”

“I witness firsthand the positive effects service dogs [have when] coming alongside a veteran,” he says. “Whether the dog is a calming influence for anxiety or a grounding presence for certain intrusive symptoms of posttraumatic stress disorder (PTSD), a service dog provides the veteran with a battle buddy, so to speak, that can help [in] many stressful environments. Unfortunately, these stressful environments can also include the local VA, such as a crowded waiting room or confusing parking deck. This policy change is long overdue at VA Medical Centers (VAMCs). I’m very happy with it, and I believe my clients with service dogs will also appreciate the change.”

The VA policy change takes effect this fall (September 2015). Now, any service dog, defined as “dogs that are individually trained to perform work or tasks on behalf of an individual with a disability,” will be allowed.

“Other animals will not be permitted in VA facilities, unless expressly allowed as an exception under the regulation for activities such as animal-assisted therapy or for other reasons such as law enforcement purposes,” the VA announced in a press release. “The regulation further confirms that service animals may access VA property subject to the same terms that govern the admission of the public to VA property, and may be restricted from certain areas on VA properties to ensure that patient care, patient safety and infection control standards are not compromised.”

Amy Stevens, an LPC who runs a Facebook group for female veterans in Georgia, thinks the policy change is good news, although its implementation remains to be seen.

“This is exciting news for many [service] women who have service dogs for emotional support as well as physical needs. The regulation is still not completely clear on how it will be implemented,” says Stevens, a service-disabled Navy veteran. “The question remains on how the service animal will be approved and what kind of documentation will be required to verify the training and roles in place. … Physical needs for injuries needing balance support or help with fetching and retrieving items can be readily apparent. The emotional needs of a veteran with PTSD are not so clear. The calming influence of a trained emotional support animal is very important, but it may not initially be clear what the ‘task’ might be. For example, when the veteran feels threatened or fearful, the task may be protective, such as the animal placing herself between the threat and the veteran. It does not mean barking or attacking the threat. The presence of the animal can also provide ‘grounding’ for a veteran who is mentally distressed by physical contact. Awareness of the animal … can help the veteran come back to herself and manage better. … We look forward to hearing more about this [policy change] in the near future as implementation begins.”

Stevens, a Cold War-era veteran, previously served as director of psychological health for the Georgia National Guard. She and Myers are both members of the American Counseling Association’s Veterans Interest Network.

 

 

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Related reading

 

See the VA’s original press release here: 1.usa.gov/1JyIivj

 

Coverage by Military Times: “VA amends access rules for service dogs at facilities

 

For more information on a counselor’s role in certifying emotional support animals, see Counseling Today’s online exclusive: “Confirming the benefits of emotional support animals

 

 

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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

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/

Promoting understanding of PTSD

By Bethany Bray June 27, 2014

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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For more information

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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A passion to serve: veterans and counseling Q+A

Compiled by Bethany Bray February 18, 2014

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

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

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

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

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

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

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

 

Q+A with ACA’s Veterans Interest Network

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

 

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

Our group offers ACA members three primary things:

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

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

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

 

What challenges do counselors face in this area?

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

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

 

What are some trends you’re seeing?

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

 

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

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

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

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

 

What would a more experienced counselor need to know?

Same response as above.

 

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

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

 

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

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

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

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

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

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

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

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

 

What makes you personally interested in this area?

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

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

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

 

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

Follow Counseling Today on twitter @ACA_CTonline