Serving Those Who’ve Served

By Felisa Gaffney and Morgan Sammons, Winter 2010 - Online Exlusive

"He SRP’d then IA’d to the AOR, boots on ground at 0100, with 80 pounds of battle rattle and ended up down range in a COP outside Al Rutbah by 0445 on 15 March 2010. As an IA, he had some problems with his chain, got Boxer’ed and early returned. He fought an ADSEP but couldn’t get RTDed and got out with a general."

This language, likely incomprehensible to the average clinician, is common in the military. What may seem to be meaningless gibberish is actually a combination of military argot and highly compressed bits of information useful to service members and commanders. As more and more veterans return from service in combat and seek assistance, psychologists and others will see more and more active duty service members, veterans and their dependents. Understanding the military as a culture is an important aspect of the therapeutic relationship. Service members, veterans and their dependents have unique cultural perspectives that are deeply embedded in their communications, lifestyles, and even thought processes. While the core values for each of the branches of the military differ in certain respects they share common elements Those core values are integrity, service before self, and excellence in all you do. Knowing basic military customs, core values, courtesies, and having some familiarity with the special language spoken by military personnel allows you to better understand, show gratitude for the sacrifice of the service member and his or her family providing the basis for a healthy therapeutic relationship. In other words, helping those who are serving and have served involves more than recognizing the presenting symptoms of PTSD.

Military and civilian therapists must strive to overcome an often deeply held stigma associated with seeking therapy amongst service members. Military members diagnosed with PTSD or other psychological problems are often viewed in a negative light by superiors, peers and subordinates. Mental health diagnosis and psychotropic medications affect service member’s ability to perform assigned tasks, pay, security clearances, and camaraderie within the unit because other members will have to perform their duties. In the past, providing mental health services in the deployed environment was often not considered a priority but due to increased operational tempo, length of deployment, rise in sexual assaults, suicide and divorce the military is making a much needed shift. This attitudinal shift among military leaders has undeniably led to changes in thinking regarding the necessity of treatment; nevertheless the negative stigma is still present. This stigma, along with other attitudinal characteristics common to military personnel, often complicates the therapy process, even among willing participants.

In addition to cultural aspects, military directives and instructions that affect service members in ways unexpected for civilians must be appreciated. Since 2005, for example, service members in all branches of the military have been given the choice of whether or not to disclose the identity of perpetrators of certain types of domestic violence and sexual assault when seeking treatment for the consequences of such assaults. In contrast, most states mandate that victims of assault identify perpetrators if their identity is known. This controversial rule, known as the “restricted reporting” regulation, was enacted in the hopes that victims of assault would feel more able to seek treatment if their military careers or the career of a perpetrator would not be jeopardized by disclosure. In this regard, the regulation has been a success – the number of service members seeking treatment for assault has increased substantially. Whether this rule has allowed a larger number of perpetrators to go undetected and unpunished remains unanswered. Merely seeking mental health or medical treatment may also have unforeseen consequences for service members. Rendering certain medical or mental health diagnoses can end a service members career – a diagnosis of a psychotic spectrum disorder is almost certain to result in a medical discharge, and a diagnosis of depression can end the career of a military pilot, along with as seemingly benign diagnoses such as hypertension. Treatment with psychotropic medications can likewise result in military aviators being permanently “grounded”, although newer regulations are more permissive than in the past. The “Boxer” law, named for its principal Senate sponsor Barbara Boxer, was enacted 10 years ago in an attempt to make mental health services less threatening to service members. Under the provisions of this law, service members cannot be involuntarily referred for a mental health evaluation unless stringent protections are afforded. Nevertheless, a mental health evaluation can often be a step in the involuntary separation of a service member.

While PTSD has become, along with traumatic brain injury, the “signature injury” of the wars in Iraq and Afghanistan, clinicians need to be aware that in spite of the public attention given to these diagnoses, other problems are likely more common and more troublesome to service members and their families. Substance abuse, depression, and domestic and occupational dysfunction are often as not presenting problems that affect careers and families alike.

The increased operational demands (“operational tempo”) associated with the current conflicts also negatively affects military families. Many service members begin treatment for PTSD and as symptoms improve redeploy before they have gained skills needed to cope with additional traumas. Deployments pose substantial challenges for all members of the family, not only the service member. Newly married dependents that have little experience navigating the military life style are often left alone during the deployment cycle adding stress to an already stressed service member. Understanding the deployment timeline and reintegration is essential in helping the family to readjust.

Once the service member is discharged they are considered veterans. As veterans services are limited due to the demand being placed on the Department of Veterans Affairs. Transitioning to civilian life, residual effects of PTSD and lack of available services compound and contribute to other mental health conditions. These veterans often end up displaced and ultimately in your office. Your understanding of challenges faced when on active duty and ability to understand military culture will allow you to better serve those who served.

Ultimately this article is meant to acquaint clinicians with common challenges providing services to service members and veterans. As clinicians we have to be aware of the cultural implications regarding this unique group of people. Best practices for civilians may not be best practice with service members, veterans and their families. Understanding your role, as a clinician and the impact therapy could have on the career of a service member is key to building trust and rapport allowing them to continue fighting for the rights most of us take for granted.

The following are a few websites to assist with understanding the military as a culture.
Department of Defense Dictionary of Military Terms
Military Pre-deployment Guide
Department of Defense Sexual Assault Regulation