Tag Archives: veterans

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

Effective treatment of military clients

By Keith Myers August 1, 2013

militaryThere is sound research available that demonstrates the efficacy of certain evidence-based treatments when working with the military population. However, most of that research seems to disregard the necessary prerequisite for counselors in achieving reliable treatment outcomes — the ability to build trust with a client population that has a general disposition to distrust others, especially those outside of the military, which probably includes most of you reading this article. The prerequisite of trust illustrates the primary importance of establishing a level of multicultural awareness that will empower clinicians to achieve a more meaningful therapeutic relationship with military clients. In turn, this will lead to an improved quality of life for those clients.

Trust is the foundation for all meaningful personal and professional relationships. It is what causes a child to laugh when his father hoists him high into the air, knowing that he will always catch him on the way down. If a veteran does not trust you, then your treatment outcomes will have poor results virtually every time. One of my former military clients put it to me bluntly: “I’m not going to let you screw with my mind before I get to know who you are and what you represent.”

Therefore, each clinician should work diligently to establish that level of trust before proceeding with more intensive treatment such as trauma work or other aspects of a mental health treatment plan. Whether you currently work with this population or are simply considering it, I would like to offer some practical ways to build trust with military clients.

Be aware of their grit and character

Merriam-Webster dictionary defines grit as “sand, gravel; a hard, sharp granule.” Another definition includes “firmness of mind or spirit; unyielding courage in the face of hardship or danger; indomitable spirit.”

If you are planning on working with military veterans or active-duty members, then you should be aware of their inner character and grit. This grit is what helps keep them alive in theater, motivates them in spite of roadblocks and allows them to persevere under dire conditions. Military training and culture advances and enhances this inner fortitude.

This culture of character is evident in the language taken from an actual Army NCO Evaluation Report (officer evaluation). It states, “Army Values: Loyalty — bears true faith and allegiance to the U.S. Constitution, the Army, the unit, and other Soldiers; Duty — fulfills their obligations; Respect — treats people as they should be treated; Selfless Service — puts the welfare of the nation, the Army, and subordinates before their own; Honor — lives up to all the Army values; Integrity — does what is right legally and morally; Personal Courage — faces fear, danger, or adversity.” Each branch of service has its own set of values by which its members are expected to live and conduct themselves, but they all speak to an overarching theme of maintaining a high moral and ethical code.

It has been my experience that military clients can activate this grit while in treatment and that it can motivate them to achieve outcomes that might be more difficult for nonmilitary clients to achieve. Having an awareness of this “hard, sharp granule” within military clients gives you more insight into this population, thereby helping you to form trust and rapport earlier in the therapeutic process.

Respect their service

My late father, a World War II Navy combat veteran, would become both angry and empathetic when viewing TV footage of Americans belittling, mocking and even spitting on returning Vietnam veterans. He would exclaim, “How dare those people spit on our troops’ faces when those are the same people for whom they lost their lives!”

Regardless of your personal political views on the Vietnam War, I hope all of us can acknowledge the disrespect our own culture showed Vietnam veterans after they returned from service. It stands as a horrific example of how not to treat our veterans. Sometimes, the best lesson for learning what to do is deduced from learning how not to behave.

On the other hand, one practical way that counselors can show respect for their military clients is to honor all military holidays in their own practice or clinical setting. At the same time, counselors should be mindful that the holidays could invoke memories of buddies who were lost in service or some intrusive thoughts surrounding combat trauma. Some of these holidays include Memorial Day, Veterans Day and birthdays of the different branches of service.

Be comfortable with spirituality

Among the spiritual statements I have heard previous military clients make are, “I don’t know what happened. My spirit died out there” and “Before deployment, God told me that I would return injured but promised me that he would not let me die.”

It is common for spirituality and the veteran population, especially combat veterans, to be intertwined. Therefore, being comfortable with veterans exploring their faith and/or spirituality during a counseling session is vital to building trust and effectively treating this population.

Edward Tick, a clinical psychotherapist who has worked with veterans for more than 30 years, authored the influential book War and the Soul, which contends that posttraumatic stress disorder is a psychospiritual condition or “soul wound.” On the basis of his work during the past three decades, Tick further asserts that a significant part of this wound is caused and further exacerbated by the absence of warrior rites of passage that were present in ancient civilizations. He explains that these spiritual and communal rites of passage are oftentimes missing within the U.S. military system, especially when military members return home. Tick cites storytelling and reconciliation retreats as two such spiritual rites of passage. He further explains, “Reconciliation retreats are one of the most effective tools for addressing the healing needs of both veterans and nonveterans. Such retreats incorporate the individual, group, aesthetic and spiritual dimensions of healing, while relying on the healing power of the story.”

To maintain multicultural relevance and effectively treat combat veterans, counselors and other mental health clinicians must possess knowledge about spirituality and faith as well as the spiritual effects of war.

Use some disclosure to enhance rapport

Regarding my own establishment of professional boundaries with clients in the past, I always erred on the side of caution when disclosing any personal information. Ethically speaking, disclosure comes with certain risks, including the possible crossing of boundaries. It can open the door for a role reversal of sorts if the client listens to the counselor’s issues and begins providing emotional support. As I often emphasize to my students, “You are the therapist, not the client.”

However, aren’t we being incongruent if we believe that authenticity is vital for clients yet never disclose any personal information at all in our role as counselors? Is there a way to balance being genuine with clients while simultaneously keeping other meaningful parts of our lives private? I believe this balance must exist if we are to be effective in treating veterans. Some amount of disclosure during the intake session can enhance rapport and trust, which strengthens the therapeutic alliance going forward in treatment.

I typically share three disclosures with military clients after informed consent: the personal meaning I derive from serving veterans, my previous work in clinical settings and that members of my family have served in the military. For example, I often inform these clients that helping them is rewarding to me because it allows me to “serve those who served,” which I consider to be one of the highest honors. Furthermore, I explain to them that I feel this allows me to give back in some indirect way to my family members who have served. Therefore, my “service” of working with veterans and active-duty members enriches my own purpose and meaning both on the professional and personal levels.

Several clients have reported that these disclosures significantly reduced their initial distrust of me and allowed them to be more open-minded in developing a therapeutic relationship.

Advocate for them

According to the Online Etymology Dictionary, the word advocate is a technical term derived from Roman law that refers to “one whose profession is to plead cases in a court of justice.” It can also mean “one who intercedes for another” or “a pleader.”

If counselors wish to build rapport and establish professional relationships with military clients, then they need to develop the skill of interceding on behalf of their clients. Counselors would be wise to learn from the sister profession of social workers, who have gained a reputation for being master advocates for the clients they serve. In order to remain true to the ACA Code of Ethics, counselors should be aware of the role that advocacy implies and address these expectations clearly with clients before moving forward.

Some practical ways to advocate for veteran clients include communicating treatment goals and progress with their other providers (such as primary care physicians and other providers within the Department of Veterans Affairs) and linking these clients to other community resources. A client once informed me, “I know you care because you are willing to be my voice.”

At times, clients have asked me to accompany them to their physician appointments so I could help articulate their needs. Because I work with clients in an intensive outpatient program, it is possible for me to meet that request. Depending on your practice setting and the level of care you provide, accompanying your client to appointments may not be convenient or even possible. But you might be able to help articulate your client’s needs to other providers by writing a letter that the client presents at these appointments.

Getting started

Maybe you are a clinician and have always been interested in working with the veteran population but are confused about where to begin. As many of us probably realize, the Department of Veterans Affairs has been slow to recognize professional counselors as having equal standing with social workers in job placement. There are a few other possibilities available for exploration, however.

First, it is helpful to discover the location of your closest Wounded Warrior Project chapter. Wounded Warrior Project is a national nonprofit organization whose mission is “to empower and honor wounded warriors.” This mission is accomplished in part by holding community events, providing mental health education to warriors and their families, and promoting recreational interests that connect wounded warriors with each other. By networking with your local chapter of the Wounded Warrior Project, you will be exposed to opportunities for obtaining counseling referrals to work with the veteran population.

Second, if you are independently licensed by your state, have graduated from a counseling program accredited by the Council for Accreditation of Counseling and Related Educational Programs and are providing therapy in a private practice setting, another option involves enrolling with the TRICARE panel. TRICARE is the insurance plan for the Department of Defense (DOD). Getting listed as a TRICARE in-network provider will make it possible to receive counseling referrals directly from the DOD. The American Counseling Association website has a “Private Practice Pointers” section that includes helpful information on starting the application process for TRICARE (from counseling.org, click on “Knowledge Center” and then “Private Practice Pointers”). Unfortunately, this process can take several months, so considerable patience is required.

A final helpful tip for getting started is to attend national, regional and local conferences that offer education about veterans. Whether it is the national ACA Conference or a local conference offered by your state counseling branch, this can be a relatively simple way both to absorb more knowledge about this culture and to network with other clinicians about possible referrals.

Final thoughts

A client recently shared with me that another therapist had made the following statement to him during a session early in the counseling relationship: “Trust me. I’m your therapist.”

This phrase was insulting to the client because actions speak louder than any attempt at shallow reassurance. If simply offering verbal reassurance of your trustworthiness as a therapist was a helpful intervention with veteran or active-duty clients, this article would have been composed of one succinct paragraph. However, it is never that simple with any population, much less with veterans and active-duty members who have a heightened tendency to be guarded with others.

Developing practical skills related to how to “treat” military clients will bolster your ability to connect with them and advance the goal of building trust in the therapeutic relationship. Accomplishing this prerequisite goal will help your military clients to achieve greater clinical outcomes and ultimately lead them to an enhanced quality of life.

 

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Keith Myers is a licensed professional counselor in Georgia, where he works at the Shepherd Center’s SHARE Military Initiative program in Atlanta serving active-duty members and veterans who have traumatic brain injury and posttraumatic stress disorder. He is intensively trained in eye movement desensitization and reprocessing therapy and is a doctoral student in counselor education and supervision at Mercer University, Atlanta. He also serves as an adjunct faculty member with both Argosy University in Atlanta and Point University in East Point, Ga. Contact him at doc355@yahoo.com.

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