Clinical Military Counseling E-Book

Mark A. Stebnicki

• Herausgeber: John Wiley & Sons
• Kategorie: Bildung
• Sprache: Englisch

Veröffentlichungsjahr: 2020

Beschreibung

Clinical Military Counseling provides current research and ethical practice guidelines for the assessment, diagnosis, and mental health treatment of active-duty service members, veterans, and military families in a 21st-century multicultural environment. Author Mark Stebnicki discusses contemporary military culture; the medical and psychosocial aspects of military health, including the neuroscience of military stress and trauma; suicide; chronic illnesses and disability; and blast and traumatic brain injuries. In addition, he offers integrative approaches to healing the mind, body, and spirit of service members and veterans dealing with clinical issues, such as spirituality, moral injury, and trauma; complex posttraumatic stress disorder and co-occurring mental health conditions; the stresses of the deployment cycle; and military career transitions.

*Requests for digital versions from ACA can be found on www.wiley.com.

*To purchase print copies, please visit the ACA website

*Reproduction requests for material from books published by ACA should be directed to [email protected]

Leseprobe

TABLE OF CONTENTS

COVER

TITLE PAGE

COPYRIGHT PAGE

PREFACE

ABOUT THE AUTHOR

PART I: THE MILITARY CULTURE

CHAPTER 1: THE CULTURALLY COMPETENT CLINICAL MILITARY COUNSELOR

TRAINING UP FOR OMC

UNDERSTANDING THE MILITARY AS A CULTURE

MILITARY VERSUS CIVILIAN TRAUMA: REACTIONS AND CONSEQUENCES

WAR STORIES IN THE MILITARY CULTURE

GUIDELINES FOR PRACTICE

CONCLUDING REMARKS

REFERENCES

MILITARY RESOURCES TO EXPLORE (MRE)

CHATPER 2: SOCIETAL MYTHS, STEREOTYPES, AND STIGMA OF THE U.S. MILITARY CULTURE

THE IMPACT ON MILITARY CULTURE

MILITARY MYTHS COMMON TO THE CULTURE

BEST PRACTICES FOR CLINICIANS

CONCLUDING REMARKS

REFERENCES

CHATPER 3: COUNSELING ISSUES FOR WOMEN AND OTHER MINORITIES IN MILITARY LIFE

WOMEN IN THE MILITARY

MST

AFRICAN AMERICANS IN THE MILITARY

HISPANICS AND LATINOS/LATINAS IN THE MILITARY

ASIAN AMERICANS AND PACIFIC ISLANDERS IN THE MILITARY

AMERICAN INDIANS AND ALASKA NATIVES IN THE MILITARY

LGBT MILITARY SERVICE MEMBERS, PARTNERS, AND FAMILIES

BEST PRACTICES FOR CLINICIANS

CONCLUDING REMARKS

REFERENCES

PART II: MEDICAL AND PSYCHOSOCIAL ASPECTS OF MILITARY HEALTH

CHATPER 4: MAPPING THE MILITARY BRAIN

THE MILITARY NEUROSCIENCE RESEARCH AGENDA

EARLY BEGINNINGS IN NEUROSCIENCE RESEARCH

NEUROSCIENCE RESEARCH FOR THE 21ST CENTURY

NEUROBIOLOGICAL EXPRESSION OF STRESS AND TRAUMA

THE IMPACT OF COMBAT OPERATIONAL STRESS ON THE BRAIN

NEUROPATHOPHYSIOLOGY OF THE MILITARY BRAIN

THE NEUROSCIENCE OF COMPLEX PTSD AND TBI

NEUROSCIENCE AND MILITARY MENTAL HEALTH

REMAPPING THE MILITARY BRAIN

CONCLUDING REMARKS

REFERENCES

CHATPER 5: PSYCHOSOCIAL ASPECTS OF MILITARY SUICIDE

EPIDEMIOLOGY OF MILITARY SUICIDE

VETERAN SUICIDE

MILITARY SUICIDE RISK FACTORS

SUICIDE RISK FACTOR OF MST

OTHER SUICIDE RISK FACTORS IN MILITARY LIFE

MILITARY SUICIDE ASSESSMENT

MILITARY SUICIDE PREVENTION AND TREATMENT

PSYCHOSOCIAL ASPECTS OF MILITARY SUICIDE

CONCLUDING REMARKS

REFERENCES

CHATPER 6: PSYCHOSOCIAL ASPECTS OF CHRONIC ILLNESS AND DISABILITY IN VETERAN HEALTH

MONITORING THE HEALTH NEEDS OF VETERANS

HEALTH DISPARITIES AMONG VETERANS

VETERANS LIVING WITH CHRONIC ILLNESSES AND DISABILITIES

MILITARY TBI

OTHER CHRONIC HEALTH CONDITIONS

PSYCHOSOCIAL ADJUSTMENT TO CHRONIC ILLNESS AND DISABILITY

PSYCHOSOCIAL STAGE MODELS OF DISABILITY

COPING STRATEGIES

BEST PRACTICES FOR VETERAN PSYCHOSOCIAL ADJUSTMENT

CONCLUDING REMARKS

REFERENCES

CHATPER 7: PSYCHOSOCIAL ASPECTS OF CHRONIC PAIN AND OTHER MEDICAL CONDITIONS IN MILITARY LIFE

PREVALENCE AND INCIDENCE OF CHRONIC PAIN IN THE MILITARY

CLASSIFICATION AND ASSESSMENT OF PAIN

THE PSYCHOSOCIAL ASPECTS OF PAIN IN THE MILITARY

OTHER MEDICAL CONDITIONS ASSOCIATED WITH CHRONIC PAIN

TREATMENT, MANAGEMENT, AND PREVENTION OF CHRONIC PAIN

CONCLUDING REMARKS

REFERENCES

CHATPER 8: BLAST INJURIES AND TRAUMATIC BRAIN INJURY IN THE MILITARY

BLAST INJURIES IN THE MILITARY

TBI

CATEGORIZATION OF TBI

BRAIN INJURIES REQUIRING CRITICAL CARE

TBI ASSESSMENTS AND CONCUSSION SCREENINGS

FUNCTION AND STRUCTURE OF THE BRAIN AND RESIDUAL FUNCTIONAL CAPACITY

CTE

PSYCHOSOCIAL ASPECTS OF BLAST INJURIES AND TBI

CONCLUDING REMARKS

REFERENCES

PART III: CLINICAL ISSUES IN MILITARY COUNSELING

CHATPER 9: SPIRITUALITY, MORAL INJURY, AND TRAUMA IN MILITARY LIFE

CONCEPTUALIZING SPIRITUALITY IN CLINICAL PRACTICE

INTEGRATING SPIRITUALITY IN CLINICAL MILITARY COUNSELING

SPIRITUALITY AND MORAL INJURY

INTEGRATING PSYCHOSPIRITUAL ISSUES IN THERAPY

CONCLUDING REMARKS

REFERENCES

CHATPER 10: MILITARY FAMILIES AND THE DEPLOYMENT CYCLE

MILITARY FAMILIES IN THE NEW DECADE

PSYCHOSOCIAL STRESSORS IN THE MILITARY FAMILY SYSTEM

MILITARY CHILDREN AND ADOLESCENTS

TALKING WITH CHILDREN AND ADOLESCENTS ABOUT MILITARY LIFE

THE DEPLOYMENT CYCLE

BUILDING MILITARY FAMILY COPING RESILIENCY

CONCLUDING REMARKS

REFERENCES

CHATPER 11: CAREER TRANSITIONS IN MILITARY LIFE: THE TRANSITION MISSION

OTR

PSYCHOSOCIAL ADJUSTMENTS IN THE TRANSITION MISSION

WORK AND VETERANS WITH DISABILITIES

CAREER RESILIENCY AND THE CAREER RESILIENCY PORTFOLIO (CRP)

CAREER COUNSELING EXPLORATION QUESTIONS FOR THE CRP

PERSONAL LIFE STORY OR TESTIMONIAL FOR CRP

CAREER SELF-ASSESSMENT

APPLICATIONS, COVER LETTERS, RESUMES, AND THE JOB INTERVIEW

CONCLUDING REMARKS

REFERENCES

MILITARY RESOURCES TO EXPLORE (MRE)

CHATPER 12: BECOMING A COMPETENT CLINICAL MILITARY PRACTITIONER: EARNING THE CIRCLE OF TRUST

THE ART OF CLINICAL MILITARY COUNSELING

USE OF EMPATHY AS A THERAPEUTIC AND LEADERSHIP TOOL

DEALING WITH RELUCTANCE, RESISTANCE, AND DEFENSIVENESS

ELEMENTS OF THE MILITARY PERSON-CENTERED INTERVIEW

EARNING THE CIRCLE OF TRUST THROUGH OPEN-ENDED QUESTIONS

THE MILITARY INTAKE INTERVIEW

GENERAL INTAKE INTERVIEW SAMPLE QUESTIONS

FAMILY-RELATED SAMPLE QUESTIONS

DEPLOYMENT-RELATED SAMPLE QUESTIONS

CONCLUDING REMARKS

REFERENCES

CHATPER 13: COMPLEX MILITARY PTSD AND CO-OCCURRING MENTAL HEALTH CONDITIONS

PREVALENCE AND INCIDENCE OF MILITARY MENTAL HEALTH CONDITIONS

MILITARY ADJUSTMENT DISORDERS

MILITARY PTSD

THE EXPERIENCES OF COMBAT OPERATIONAL STRESS AND TRAUMA

ANXIETY DISORDERS IN THE MILITARY

MAJOR DEPRESSIVE DISORDER IN THE MILITARY

INSOMNIA IN THE MILITARY

SUBSTANCE USE IN THE MILITARY

OPIOID USE DISORDERS IN THE MILITARY

CONCLUDING REMARKS

REFERENCES

CHATPER 14: MILITARY RESILIENCY AND INTEGRATIVE TREATMENT STRATEGIES IN OPERATION MILITARY COUNSELING

WHAT IS INTEGRATIVE HEALTH IN THE MILITARY?

HOW EFFECTIVE IS COMPLEMENTARY AND INTEGRATIVE HEALTH?

MILITARY RESILIENCY

INTEGRATION OF RESILIENCY, WELLNESS, AND HEALTH

OMC: STRATEGIES FOR A NEW CLINICAL COUNSELING PROFESSION

A PARADIGM SHIFT IN MILITARY COUNSELING

FOUNDATIONS OF OMC

CLINICAL MILITARY COUNSELING AS A NEW SPECIALTY WITHIN THE COUNSELING PROFESSION

CONCLUDING REMARKS

REFERENCES

INDEX

TECHNICAL SUPPORT

END USER LICENSE AGREEMENT

Guide

Cover

Table of Contents

Begin Reading

Pages

i

ii

iii

vii

viii

ix

x

xi

1

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

35

36

37

38

39

40

41

42

43

44

45

46

47

48

49

50

51

52

53

54

55

56

57

58

59

60

61

62

63

64

65

67

69

70

71

72

73

74

75

76

77

78

79

80

81

82

83

84

85

86

87

88

89

91

92

93

94

95

96

97

98

99

100

101

102

103

104

105

106

107

108

109

110

111

112

113

114

115

116

117

118

119

120

121

122

123

124

125

126

127

128

129

130

131

132

133

134

135

136

137

138

139

141

142

143

144

145

146

147

148

149

150

151

152

153

154

155

156

157

158

159

160

161

163

164

165

166

167

168

169

170

171

172

173

174

175

176

177

178

179

180

181

183

185

186

187

188

189

190

191

192

193

194

195

196

197

198

199

200

201

202

203

204

205

206

207

208

209

210

211

212

213

214

215

216

217

218

219

220

221

223

224

225

226

227

228

229

230

231

232

233

234

235

236

237

239

240

241

242

243

244

245

246

247

248

249

250

251

252

253

254

255

256

257

258

259

261

262

263

264

265

266

267

268

269

270

271

272

273

274

275

276

277

278

279

280

281

282

283

284

285

286

287

288

289

290

291

292

293

294

295

297

298

299

300

301

302

303

304

305

306

307

308

309

310

311

312

313

314

315

316

317

318

319

320

321

322

323

324

325

326

327

328

329

330

331

332

333

334

335

336

337

MARK A. STEBNICKI

CLINICAL MILITARY COUNSELING

GUIDELINES FOR PRACTICE

6101 Stevenson Avenue, Suite 600Alexandria, VA 22304www.counseling.org

Copyright © 2021 by the American Counseling Association. All rights reserved. Printed in the United States of America. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the written permission of the publisher.

AMERICAN COUNSELING ASSOCIATION6101 Stevenson Avenue, Alexandria, VA 22304

Associate Publisher • Carolyn C. Baker

Digital and Print Development Editor • Nancy Driver

Production Manager • Bonny E. Gaston

Copy Editor • Tyler Krupa

Cover and text design by Bonny E. Gaston

LIBRARY OF CONGRESSCATALOGING-IN-PUBLICATION DATA

Names: Stebnicki, Mark A., author.Title: Clinical military counseling : guidelines for practice/ Mark A. Stebnicki.Description: Alexandria, VA : American Counseling Association, [2020] | Includes bibliographical references and index.Identifiers: LCCN 2020027778 | ISBN 9781556203992 (paperback)Subjects: LCSH: Veterans—Mental health services. | Post-traumatic stress disorder.Classification: LCC RC451.4.V48 S74 2020 | DDC 616.85/212—dc23LC record available at https://lccn.loc.gov/2020027778

DEDICATION

To all my family members who have served in the U.S. Army, Navy, and Marines.

To all those serving now and who have served in the U.S. Armed Forces.

To the unseen service of those professionals who serve the military community.

To my wife Bonnie, daughter Sarah, son Mark D., and their loving spouses (Brandon and Leigh), and to my grandson Noah, who is a new light shining in this world.

★ ★ ★

PREFACE

In the early morning hours of September 11, 2001, one of the deadliest attacks in the history of the United States took place, in which 2,977 Americans were killed, and more than 6,000 others were severely injured, causing permanent chronic illnesses and disabilities. Two commercial jetliners, American Airlines Flight 11 and United Airlines Flight 175, were hijacked by 19 al-Qaida terrorists and crashed into the North and South Towers of the World Trade Center in Lower Manhattan. It took only about 90 minutes for the Twin Towers to burn and collapse. A third jetliner, American Airlines Flight 77, crashed into the Pentagon, which led to a partial collapse of the building’s west side. A fourth plane, United Airlines Flight 93, was heading toward Washington, DC, but crashed into a field in Stonycreek Township near Shanksville, Pennsylvania, where several heroic passengers thwarted the terrorist hijackers’ efforts. Hence, the global war on terrorism ushered in the 21st century.

American citizens are now in the crosshairs of asymmetrical radicalized enemy combatants spreading hate throughout the globe perpetrated by extremist groups that go by the names of ISIS (Islamic State of Iraq and Syria), ISIL (Islamic State of Iraq and the Levant), the Taliban, Al-Shabaab, al-Qaida, and Boko Haram. The U.S. military is duty bound to bring the fight to places such as Afghanistan, Iraq, Syria, and many parts of Africa.

At the time of this writing, the Coronavirus (COVID-19) pandemic has emerged as a significant concern during its first wave of infection. The medical, physical, and mental health of military and civilians alike have been compromised. Health care workers are challenged by a lack of resources (e.g., hospital beds, N95 masks, ventilators) and readiness to fight this common viral enemy. From a military logistics, planning, and unified command and control perspective, COVID-19 requires a highly organized and collaborative effort between civilians and the military to activate a disaster response to fight a biological enemy. At times in the United States and around the globe, COVID-19 has mimicked a zombie apocalypse as seen in Hollywood-style movies. Overall, the military has an important role in filling medical gaps in service through use of materials, medical treatment facilities on land and water, medical personnel, and other resources.

I propose that we are in a paradigm shift in the counseling and psychology profession. We have trauma fatigue, which is a new type of complex acute and posttraumatic stress requiring vital healing resources. For many, the Earth does not feel like a safe place to live. Global terrorism and pandemics have fundamentally altered and behaviorally changed the way in which we live our everyday lives. This transformation is apparent in airports, shopping malls, schools, restaurants, entertainment venues, federal and state buildings, and other institutions. Homegrown terrorism is on the rise in the United States, requiring teams of first responders, disaster mental health specialists, and critical incident stress debriefers. Our own historical trauma from September 11 is reinforced and magnified by 24-hour media coverage unfolding in real time. We are consumed with graphic images of horrific scenes of terrorist attacks, wars, civil unrest, and other conflicts around the globe.

After more than 20 years of war and mission creep (i.e., the gradual expansion of a mission beyond its original scope), we have a multigenerational group of military service members and veterans who have fought in Operation Iraqi Freedom, Operation Enduring Freedom, Operation New Dawn, and Operation Inherent Resolve (which started in August 2014). There were many wars that came before these operations, and many more will follow. At this point in the war on terrorism, there are two generations of parents and their children who potentially could be enlisted together as well as training and fighting alongside one another. The long-term mental, physical, and psychological effects of warfighting are mapped into our mind, body, and spirit.

So, who are the people who represent the less than 2% of Americans in the U.S. Armed Forces? Who are the individuals who volunteer to defend the security of the United States and swear an oath to fight enemies, both foreign and domestic? The foundation for this book was inspired by family members, friends, and clients who have served in the military. My extensive experiences as a counselor educator, researcher, and practitioner working with active-duty Marines, veterans, veterans with disabilities, and military families are memorialized in this book. The designation of clinical military counselor throughout this book depicts professionals who work in the fields of mental health, rehabilitation, clinical addiction, and school counseling as well as psychologists, social workers, and other behaviorally licensed practitioners.

Presently, we need “all hands on deck” to train up for Operation Military Counseling. I coined this mission in 2015 when I developed the Military and Trauma Counseling certification program at East Carolina University. This mission expanded in 2016 to the Clinical Military Counseling Certificate program that I developed, which is offered through the Telehealth Certification Institute of New York.

Clinical Military Counseling takes a holistic approach to working with the military. It integrates current research and clinical practice guidelines for working with the medical, psychosocial, spiritual, psychological, vocational, career, family, and cultural aspects of the military. Guidelines for best practices are offered to assist in earning “the circle of trust” of service members and veterans to facilitate screening, prevention, treatment interventions, and other resources for the military community.

Clinical Military Counseling discusses new issues related to military medical, physical, behavioral, and psychological health. Complementary and integrative health resources are offered to practitioners for cultivating resiliency and coping skills. These approaches are critical because newer studies suggest that the use of first-line, evidence-based practices treating complex posttraumatic stress disorder (PTSD) are only 30%–50% effective. Studies suggest that 80% of service members and veterans frequently use integrative health approaches, such as mindfulness-based stress reduction, meditation, yoga, Reiki, and acupuncture.

Part I of Clinical Military Counseling helps differentiate military versus civilian mental health counseling practices, identifying commonly held societal myths and stereotypes of the U.S. military and discussing the military from a multicultural perspective. Historically, the military culture has reflected mostly White heterosexual men. However, today there is not just one type of military service member. Rather, the military comprises a diverse group of individuals who possess different racial, ethnic, sexual identity, and other cultural characteristics.

Part II of Clinical Military Counseling honors the collective wisdom of the expanding clinical military medical and mental health practices. It delivers new directions to clinicians in military policies and resources that reflect current clinical military counseling and psychological practices for the 21st century. Contemporary topics are discussed, such as the neuroscience of military stress and trauma, military suicide and co-occurring mental health conditions, psychosocial aspects of chronic illnesses and disability in veteran health, and the signature disabling conditions of blast and traumatic brain injuries.

Part III of Clinical Military Counseling addresses important clinical mental health issues in military life. The integration of spirituality and identification of moral injury, as it relates to military trauma, assists clinical military counselors in healing the mind, body, and spirit of service members and veterans. Military families and deployment cycle issues are discussed because of the important role that military families have in creating coping and resiliency skills for military service members and veterans. Other key aspects in Part III explore career transitions in military life and the psychosocial adjustment required to function medically, physically, and psychologically at an optimal level after a career in military service.

The essential strength woven into Part III, as well as into other chapters in Clinical Military Counseling, emphasizes how to provide competent and ethical clinical military counseling services. Earning the circle of trust of service members and veterans is underscored throughout this work, demonstrating the essential elements in the assessment, diagnosis, and treatment of complex PTSD and co-occurring mental health conditions.

The concluding chapter on military resiliency and integrative health approaches explores, discusses, and applies vital research on the impact that extraordinary stressful and traumatic events have on active-duty service members, veterans, and military families. There is strong evidence in the research suggesting that integrative health practices are beneficial in decreasing symptoms related to posttraumatic stress, anger, depression, anxiety, and substance misuse behaviors as well as military suicidality. Holistic health approaches—such as mindfulness-based stress reduction, breathing meditation, yoga, animal-assisted therapy, expressive art, and other integrative approaches—provide a new horizon for healing the mind, body, and spirit of service members and veterans.

Overall, the work presented in Clinical Military Counseling is a model for training and education in best practice for clinical military counselors. The comprehensive medical, physical, and mental health aspects of this work are driven by research and clinical practice. Clearly, both civilian and military researchers support a wellness agenda for living optimally in mind, body, and spirit throughout one’s military career and beyond.

ABOUT THE AUTHOR

MARK A. STEBNICKI, PhD, LCMHC, DCMHS, CRC, CMCC, is professor emeritus and former coordinator of the Military and Trauma Counseling certificate program, which he developed in 2015 at the Department of Addictions and Rehabilitation at East Carolina University. Professor Stebnicki also developed the national Clinical Military Counseling Certificate program—a 12-hour continuing education program offered nationally through the Telehealth Certification Institute of New York. Professor Stebnicki is a counselor educator, researcher, and practitioner with more than 30 years of experience in rehabilitation and mental health. He has worked with both adolescents and adults, specializing in stress, trauma, grief, loss, and the psychosocial aspects of chronic illness and disability. His primary focus is working with military service members, veterans, veterans with disabilities, and military families. Professor Stebnicki has published nine professional textbooks as well as 40 journal articles and book chapters. In addition, he has given more than 100 national, regional, and statewide presentations. He has served on many statewide and national professional counseling boards.

PART ITHE MILITARY CULTURE

CHAPTER 1THE CULTURALLY COMPETENT CLINICAL MILITARY COUNSELOR

Three rules for a gunfight. One, bring a gun. Two, bring all your friends with guns. Three, never bring a knife to a gunfight.

—Anonymous

★ ★ ★

The mission I refer to as Operation Military Counseling (OMC) began in 2015 when I developed one of the first graduate certificates in military counseling within a Council for Accreditation of Counseling and Related Educational Programs (CACREP)-accredited counselor education program. The Military and Trauma Counseling certificate program, offered at East Carolina University, was designed to help bridge the gap between military and civilian or community mental health research and practice. The mission and core values of OMC are reflected in the current national certificate that I developed in 2016, the Clinical Military Counseling Certificate program, as well as the comprehensive work in this book.

Clinical Military Counseling offers extensive research and qualitative data collected from focus groups of active-duty personnel, veterans, veterans with disabilities, and military families. Guidelines for practice are also offered to the reader for consideration in the assessment, diagnosis, and mental health treatment of military clients. Thus, the present work advances the role and function of clinical military counseling as a dynamic and evolving specialty area of the counseling profession. The philosophical foundation in Clinical Military Counseling is for practitioners to consider the theories, knowledge, and skills that they have acquired in psychology and counseling and facilitate therapeutic strategies and approaches through the cultural lens of the military.

Historically, mental health counselors have not had the opportunities in their graduate training programs to achieve military cultural competence. This deficiency is due in part to the lack of available training in most graduate curriculums, where assessment, diagnosis, and mental health treatment for military populations is rarely discussed other than in occasional seminars, attending guest lectures, and classroom assignments for military counseling–related issues (Stebnicki et al., 2017). Recognizing that the military is a unique culture unto itself, some newer multicultural counseling texts now offer a separate chapter in military culture counseling. Some CACREP-accredited programs are now advancing their curriculum in military counselor training through departmental and college coursework that is cross-disciplinary. Indeed, graduate training in the assessment, diagnosis, and treatment of military mental health conditions (e.g., posttraumatic stress disorder, major depressive disorder, anxiety, substance use disorders, suicidality, and other co-occurring mental health disorders) has been slowly evolving in counselor education.

Historically, psychologists and clinical social workers have had a long-standing advantage of being eligible for careers as independent practitioners working within the federal government system of medical and mental health care (e.g., Veterans Health Administration) where they can obtain third-party reimbursement through private insurance (e.g., Humana Military, Medicare, TRICARE) and work on military bases and installations. Accredited programs in psychology and social work have evolved more rapidly and early on to offer academic certifications and graduate programs that prepare students to work competently and ethically with military service members and veterans. For instance, American Psychological Association–accredited programs have partnered with the U.S. Army to establish the Health Professions Scholarship Program (U.S. Army, 2019). This program provides scholarship opportunities for doctoral-level clinical and counseling psychologists to work alongside U.S. Army health care professionals. They work for 2 years and complete an active-duty training program at selected sites. Other branches of the military have similar programs.

Currently, there is movement toward parity across the various counseling disciplines. In 2018, the U.S. Department of Veterans Affairs (VA) issued new qualifications and standards allowing licensed mental health counselors to be eligible for jobs and careers within the VA system. The revised standards clarify the scope of practice that enables licensed mental health professionals to fully participate as independent practitioners. At the time of this writing, interpretive guidelines by the federal government’s Office of Human Resources Management are slow in being issued to the VA hospitals and clinics across the United States (American Counseling Association, 2018). Regardless of educational and professional background, clinical military counselors have the competence to understand the unique cultural and within-group differences by earning the “circle of trust” while engaging in therapeutic interactions with military clients.

TRAINING UP FOR OMC

Becoming a culturally competent clinical military counselor requires an understanding that there is not one homogeneous group labeled “the military culture.” Rather, the military comprises individuals who identify with various racial and ethnic groups (e.g., Hispanic Latino/a, African American, Native American, Asian American); the lesbian, gay, bisexual, and transgender community; as well as many other cultural groups. The U.S. Armed Forces of the 21st century, unlike previous generations, have multiple identities that demographically represent the U.S. population.

The military culture also reflects within-group differences, which are illustrated by the distinct military occupational specialty (MOS) types (e.g., infantry, special forces/operations, mechanic, cook, communications officer, counterintelligence). There are personnel who are assigned to combat and noncombat units. Service members are deployed and mobilized on humanitarian missions. Some service members are deployed to hostile geographic locations outside the continental United States (referred to as OCONUS), whereas others are mobilized to bases within the continental United States (CONUS), such as Hawaii or Alaska. Other service personnel are deployed to ally nations across Europe (e.g., Italy, Spain) and Asia (e.g., Japan, South Korea). There are also cultural differences in officer versus enlisted and non-commissioned officer ranks.

One of the most notable differences in the military culture relates to the specific branch of service defined under the general title of the U.S. Armed Forces, which include the Army, Navy, Marine Corps, Air Force, and Coast Guard (U.S. Department of Defense [DoD], 2020). In December 2019, the U.S. Congress created a sixth and independent branch of the Armed Services: the Space Force (Gould & Insinna, 2019). The command structure for the Space Force is organized under the Air Force. A Chief of Space Operations command position has been created; this person will report directly to the Secretary of the Air Force and will become a member of the Joint Chiefs of Staff. At the time of this reporting, Congress prohibited any new billets given the already enormous costs of adding another branch of service to the DoD budget. Therefore, the newly formed Space Force staff will be composed of existing staff, with about 151 Air Force, 24 Army, as well as 14 Navy and Marine Corps personnel. There will be an additional nine members from the Joint Chiefs of Staff, the Office of the Secretary of Defense, and the intelligence community. Given this newly created branch of service, the organizational structure will be dynamic and fluid at various points in its early history. Overall, each branch of service reflects different mission objectives, weapon systems utilized, ranks, organizational structures, values, as well as many more characteristics.

There is a shortage of qualified mental health practitioners to work competently with military service members, veterans, veterans with disabilities, and their families. Although most mental health professionals are not veterans themselves, they can still serve as allies in forming therapeutic alliances with their military clients by earning the circle of trust. The literature in military psychology and counseling recognizes the unique cultural differences between military and civilian mental health (Adler & Castro, 2013; Carrola & Corbin-Burdick, 2015; France, 2018; Hobbs, 2008; Redmond et al., 2015; Stebnicki, 2016; Stebnicki et al., 2017; Westwood et al., 2014).

Training in clinical military counseling practices becomes problematic when guidelines for the assessment, diagnosis, and mental health treatment of service members and veterans do not translate well from nonmilitary or civilian populations. The assumption appears to be that generally the principles, theories, and strategies in psychology and counseling can apply to all clients regardless of cultural identity. However, the military clients whom I have had in my psychotherapy practice discussed past negative experiences with mental health treatment from providers who reportedly were not familiar with military culture. Anecdotally, common concerns of military clients have been that their therapist (a) did not understand the military culture, which was not related to the mental health provider being of veteran status; (b) appeared to feel uncomfortable when they discussed their combat experiences, and in many cases the therapist shifted the conversation to another topic; (c) was not a TRICARE provider, so it was difficult to find a therapist or continue in therapy as a private-pay client; or (d) worked for the VA, which had long waiting lists and would frequently have a different therapist for each visit, resulting in their therapist always wanting them to retell stories of their combat experiences.

UNDERSTANDING THE MILITARY AS A CULTURE

Clearly, the military meets the definition of a culture. For instance, the military has its own operational language, rituals, customs, traditions, values, beliefs, mission, as well as organizational and sociopolitical structures. Within-group differences exist regarding mission, values, language, and other cultural characteristics that exist across the different branches of the U.S. Armed Forces (i.e., Army, Navy, Marine Corps, Air Force, Coast Guard, Space Force). The indoctrination process into the military culture is exemplified in boot camp or basic training, where the ethos, or cultural identity, is formed as it relates to the occupation itself. The culture is contextualized especially by the jargon of written, spoken, and nonverbal language.

As an example of military culture, the Marine Corps has the core values of honor, courage, and commitment. These values translate into mission objectives and determine how each Marine thinks, acts, and fights. The Marines were founded in 1775 and have a proud and long-standing legacy of being a forward-deployed fighting force on land, at sea, and in the air. As many Marines will state with pride, “We are the first in and last out,” or “We are the tip of the spear.” Another cultural aspect that I have learned through my family members and clients who served in the military is that many Marines tend to state in the present tense “I am a Marine” even long after they have separated from service, whereas those who have served in the other branches of service typically state, “I am retired from [or used to be in] the Navy/Army/Air Force/Coast Guard.” The motto “Once a Marine, always a Marine” is a strong cultural trait of this branch of service. Another example within the military culture is that the term “soldier” is specifically designated for those attached to the Army. You should never call a Marine a “soldier” because this designation will hinder credibility and make it difficult to earn the circle of trust with your military clients.

As in many cultures, if the active-duty service member does not comply with the military code of conduct—or accept or acculturate into its branch of service, mission, values, beliefs, customs, traditions, and so forth—then military life can be harsh in some circumstances. In other situations, the service member may be rejected by their culture because they did not accept prominent aspects of military life. Other unique characteristics that prevail in military culture are the strict laws, ethics, and policies that govern military behavior and conduct. If these policies are not followed correctly, it can lead to punitive actions and consequences enforced by the Judge Advocate General’s Corps guided by the military’s code of conduct (DoD, 1993).

It may appear to some outside the clinical military counseling profession that there is only one culture that represents “the military.” This view is easily understood because military life has a unique indoctrination, ethos, and cultural shaping that require all those in service to accept the same identity, traditions, rules, and laws that govern behaviors and other operational and mission-related values and beliefs. However, there are within-group differences in its language and jargon. For instance, as a cultural greeting or expression of enthusiasm, Marines say “Oohrah” and “Booyah,” Army soldiers say “Hooah,” Navy sailors say “Hooyah,” and Air Force airmen say “HUA” (loosely described as an acronym for “heard, understood, acknowledged”). There is also jargon you may have heard and other common military expressions, such as “Whiskey Tango Foxtrot,” “roger that,” “zero dark thirty,” “outside the wire,” or “got your six.” To gain some level of acceptance, service members must know how to speak the language of their culture. This ability helps service personnel both personally and professionally.

The military culture is defined from the core values and skills earned during specialized training, such as acquired for one’s MOS. Most individuals in the military will tell you that their military achievements were “earned”; there are no “participation trophies” awarded after boot camp; and promotion, rank, and other achievements such as patches and medals are based on stringent productivity requirements. Military service members, regardless of gender, must function optimally by passing regular mental and physical fitness evaluations. There is unit pride because the service member understands that they have achieved much more in the military than they could on their own in civilian life. This is due in part to the high levels of motivation, drive, and leadership skills acquired while in service to their country.

In civilian life, there are many employees who have contributed high levels of energy and effort to their job, company, or organization where they work. They are proud of what they do, and some give 100% productivity. In military life, high levels of productivity are required by all, not just a few. Unlike civilian occupations, the military contract asks individuals for a long-term commitment—24 hours a day, 7 days a week, 365 days a year. Particularly during mobilizations or deployments, there are no days off. The life and safety of others in the kinetic environment of the battlefield and military culture depend on the quick and decisive actions of others in the unit. Thus, during deployment, your “head is always on a swivel,” there may not be regular mealtimes, and sleep deprivation is common. Any pain experienced by the service member is known as “weakness leaving the body.”

Operation tempo is critical to the mission. The DoD describes and measures this component by the service members’ speed, intensity, pace, and response time based on critical events that unfold in whatever environment they are placed. The U.S. military does a good job of preparing, planning, organizing, and executing mission objectives for multiple situations and environments. As a result, job performance and productivity are constantly being assessed. Overall, there are multiple challenges for individuals in the military to do their job well. Ultimately, failure is not an option because it risks the health, safety, and lives of others in their unit.

The point is that military culture itself is founded on individuals adopting, accepting, and acculturating into this same identity regardless of gender, race, and ethnicity. There is little flexibility and, in many situations, zero tolerance for those actions and behaviors that differentiate self from others in the unit and command structure. The service member must wear the uniform with pride and honor. Individuals who enlist in the military are contractually (legally) and culturally bound to accept military life for an average of 4 years, depending on the branch of service and MOS. Overall, there is no other occupation like the military in the U.S. labor market. Those who do not adjust well to military life often experience a psychological, emotional, physical, and occupational or career cost. Competent clinical military counselors understand these unique aspects of the military culture. Otherwise, clinicians may misrepresent, stereotype, and even reinforce negative myths about the military culture. However, having awareness, knowledge, and skills will assist you to gain credibility, earn the circle of trust, and form a therapeutic relationship with your military clients.

Becoming a competent and ethical clinical military counselor will take some time and experience. The reader should consult the Military Resources to Explore (MRE) section at the end of this chapter. As a side note, the acronym MRE is also used to describe “meals, ready-to-eat,” which is an operational field ration introduced in 1975 and typically used during times of combat deployments. C-rations, the older version, were considered inedible by many service members because of the texture and taste. Current MREs average 1,250 calories, 13% protein, 36% fat, and 51% carbohydrates; contain many food sources; are prepared in approximately 24 different entrees; and taste better when heated (U.S. Army, 2018). Just as in many cultures, food is an important aspect of the culture itself.

MILITARY VERSUS CIVILIAN TRAUMA: REACTIONS AND CONSEQUENCES

One important area to highlight in military culture is how exposure to trauma is expressed. As suggested by Adler and Castro (2013), one of the unmistakable cultural differences between military and civilian life is that the demands of killing, avoiding being killed, caring for the wounded, and witnessing death and injury are all part of military service training. In addition, there are frequent geographic relocations; separations from family, friends, and loved ones; and the demands of 24 hours, 7 days per week availability where one is always on call. The occupation requires that the service member be optimally mentally and physically fit for duty.

As Adler and Castro (2013) have suggested, one of the fundamental aspects of exposure to trauma in the military is that service members are not passive victims of a critical incident. Rather, military personnel train for the physical and psychological demands of combat on an ongoing basis, whereas civilians do not. Thus, for military service members, the physiological and psychological reaction to combat is to “aggress—not stress.” In civilian life, most individuals naturally react as victims because they are not prepared mentally and physically to be confronted or aggress against such unpredictable traumatic experiences such as combat.

Therefore, civilians typically experience an acute onset of the full range of posttraumatic stress symptoms (PTSSs), such as intrusive, intense, and prolonged traumatic memories; persistent avoidance of the trauma triggers; hypervigilance; detachment; isolation; and withdrawal. When military personnel experience catastrophic injury or death on the battlefield, it is “mission forward” because the life and safety of their fellow comrades depend on their quick and decisive actions to neutralize any enemy combatants or targets. Thus, the service member must perform at a high level, physically and mentally, to adapt and cope during combat operations.

A critical point in military versus civilian exposure to extraordinary stressful and traumatic incidents is that it is not possible to begin the grieving process while one is fighting for survival. Hence, military personnel typically do not experience the full range of PTSSs or symptoms related to loss and grief during a state of high alert or sympathetic arousal. Consequently, PTSSs may be delayed, and the full range of negative medical and mental health conditions may not be experienced until after deployment. These important issues are dealt with in greater detail in the chapters that follow.

Veterans’ reactions to PTSSs and their consequences may be transient as they go through periods of exacerbation and remission, whereas others experience chronic and persistent symptoms with varying degrees of intensity throughout their lifetime. Although both civilians and military service members may experience extraordinary stressful and traumatic events, many civilians have much earlier access to mental health services than military personnel.

One reason for the delayed onset of both symptoms and treatment is that there are no rewards for active-duty service members to seek mental health counseling or to be diagnosed with a mental health condition (e.g., posttraumatic stress disorder, major depressive disorder, anxiety, substance use disorder). The stigma of seeking mental health services can compromise the service member’s security clearance, rank, and promotions as well as produce a negative perception of their ability or fitness to serve (DoD, 2013). Indeed, there are multiple lost opportunities for mental health treatment throughout the deployment cycle, which has long-term medical, physical, and mental health consequences, particularly after the service member transitions to civilian life.

WAR STORIES IN THE MILITARY CULTURE

One common characteristic in the military community is the untold stories of warfighting. I have been told by many veterans that the “real warfighters” (e.g., Army Special Forces; Delta Force; Marine Corps Special Operations Command; Navy Sea, Air, and Land [SEAL] teams) never talk to anyone about their missions. There are multiple war biographies, historical books, and personal accounts of warfighting as seen in videos, movies, and documentaries by individuals who were at the epicenter of conflict. However, outside of these storytelling platforms, many veterans do not want to discuss their experiences with civilian friends, families, intimate partners, or anyone else who was not present with them during combat operations. There is a certain level of trust between military service members who can communicate their combat experiences to one another.

Vietnam War veterans were particularly closed to discussing their wartime experiences with anyone other than unit members or members of some military service–related organizations, such as the Veterans of Foreign Wars. For Vietnam veterans, the awareness, knowledge, and acceptance of medical and mental health treatment for complex posttraumatic stress disorder (e.g., traumatic brain injury, blast injury) had minimal support. VA disability treatment and benefits were offered only to those who exhibited severe medical and mental health symptoms. Some of these attitudes and perceptions toward the silence of warfighting prevail today among military service members deployed to hostile regions OCONUS. I have heard some of the most horrific stories imaginable from my active-duty and veteran clients. I felt that it was both a privilege and therapeutic opportunity after they disclosed the deepest, darkest level of their humanity. This point in therapy is always where posttraumatic growth and combat resiliency can be achieved.

There is a common jargon of warfighting, as many military counselors can attest to. Many of my active-duty and veteran clients have expressed phrases to me such as “I only got 2 hours of sleep while on deployment,” “I’ve seen some of my unit buddies blown up and burned alive,” and “One of my worst fears was not that I would be killed in action but the thoughts of being captured and tortured.” There are countless other stories that depict the mental, emotional, psychological, and physical exhaustion related to being at the epicenter of combat operations. The upcoming chapters address these issues that clients bring to the therapeutic environment. Guidelines and best practices for the reader are offered because it is critical that we offer our full attention to a military client who may want to discuss issues related to reconciliation and forgiveness of their sins or explore the “ghosts of past enemy combatants or civilians” whom they have killed. There is indeed a moral injury, existential anxiety, and a psychological cost to killing another person—particularly if the enemy combatant was a military-age adolescent.

Regardless of the issues, therapists should not anticipate or expect that service members and veterans will discuss war stories, which may be the deepest and darkest moments of their lives, for several reasons. One reason is because of the operational security nature of the mission and the inability to disclose sensitive information, as found in an after-actionreport (i.e., a summary of the multiple details related to a combat mission, such as its analysis, the nature of the operation, the unit personnel involved, and successes and challenges of the mission). Circling back to the foundation of the culturally centered therapeutic environment is the critical lesson of earning the circle of trust with your military clients.

Regarding war stories, it is critical to be present with the individual military client who may want to discuss their combat-related experiences. Competent clinical military counselors use a high level of attending, listening, and empathy skills to earn the circle of trust. They allow their military clients to (a) disclose at the level they feel most comfortable, (b) facilitate approaches and strategies that give permission in a confidential and safe environment to discuss their warfighting experiences, and (c) be open to the idea that therapy is difficult but has rewards. Facilitating a safe environment for military clients to communicate thoughts, feelings, and experiences is essential for optimal therapeutic value and moving forward in the therapeutic process. Restoring the mind, body, and spirit after warfighting or military life can be exhausting work for the client and therapist.

GUIDELINES FOR PRACTICE

The following guidelines for practice are offered to military counselors for cultivating optimal therapeutic engagements. These principles will assist military counselors during their assessment, diagnosis, and treatment of mental health conditions and related issues:

Apply the theories, knowledge, skills, and therapeutic strategies in psychology and counseling by facilitating therapeutic approaches through the cultural lens of active-duty service members, veterans, veterans with disabilities, and family members.

Know that being a service member or veteran mental health practitioner may not assist you in earning the circle of trust because there is not just “one military” service member or veteran. Rather, there are many within-group differences among the different branches of service, MOS types, and enlisted versus officer ranks; in addition, individuals also have different gender, racial, ethnic, and cultural traits. Becoming a competent clinical military counselor extends beyond knowledge of the military culture. It involves an understanding of the medical, psychosocial, vocational, transition, mental health treatment, and family dynamics within the military.

Demonstrate the core and foundational skills of person-centered counseling through attending, listening, and using the skills of empathy to earn the circle of trust. There may be language used in session that you do not understand (e.g., “I was on a FOB”; “I did reconnaissance”; “I am an E-4 11 Bravo”; “My gunny told me we had CAS”; “A 60-cal round hit near me”; “I ran exfil-ops in a CH-47”). However, asking unnecessary or irrelevant questions (e.g., “What is 11 Bravo?” “Who is gunny?” “What is a CH-47?”) will only hinder the flow of the therapeutic relationship and will demonstrate your lack of knowledge of the military culture itself.

CONCLUDING REMARKS

The demands of being trained to kill enemy combatants, avoiding being killed, caring for the wounded, and witnessing death and injury indeed have a medical, physical, psychological, emotional, social, spiritual, and occupational cost. Military service members must be in a constant state of mental and physical readiness with a total focus on the mission. Thus, it is difficult to turn off sympathetic arousal as the service member transitions to veteran status in society. The shift from active duty to civilian life is a major cultural shift in which the veteran is challenged with integrating a new identity and life sometimes after years of military service that has been indoctrinated into their mind, body, and spirit. Competent and ethical clinical military counselors understand some of the unique cultural differences in the assessment, diagnosis, and treatment of active-duty personnel, veterans, veterans with disabilities, and military family members.

REFERENCES

Adler, A. B., & Castro, C. A. (2013). An occupational mental health model for the military.

Military Behavioral Health, 1

(1), 41–51.

https://doi.org/10.1080/21635781.2012.721063

American Counseling Association. (2018, July 20). VA issues new qualification standards for professional counselors.

ACA Government Affairs Blog.

https://www.counseling.org/news/aca-blogs/aca-government-affairs-blog/aca-government-affairs-blog/2018/07/20/va-issues-new-qualification-standards-for-professional-counselors

Carrola, P., & Corbin-Burdick, M. F. (2015). Counseling veterans: Advocating for culturally competent and holistic interventions.

Journal of Mental Health Counseling, 37

(1), 1–14.

https://doi.org/10.17744/mehc.37.1.v74514163rv73274

France, D. (2018).

Combat vet don’t mean crazy: Veteran mental health in post-military life.

NCO Historical Society.

Gould, J., & Insinna, V. (2019, December 10). Congress creating Space Force with limited headroom.

Defense News.

https://www.defensenews.com/congress/2019/12/10/congress-creating-space-force-with-limited-head-room/

Hobbs, K. (2008). Reflections on the culture of veterans.

Workplace Health & Safety, 56

(8), 337–341.

https://doi.org/10.1177/216507990805600803

Redmond, S. A., Wilcox, S. L., Campbell, S., Kim, A., Finney, K., Barr, K., & Hassan, A. M. (2015). A brief introduction to the military workplace culture.

Work, 50

(1), 9–20.

https://doi.org/10.3233/WOR-141987

Stebnicki, M. A. (2016). Military counseling. In I. Marini & M.A. Stebnicki (Eds.),

The professional counselor’s desk reference

(2nd ed., pp. 499–506). Springer.

Stebnicki, M. A., Clemmons-James, D., & Leierer, S. (2017). A survey of military counseling content and curriculum among Council on Rehabilitation Education- and Council for Accreditation of Counseling and Related Educational Programs-accredited programs.

Rehabilitation Research, Policy, and Education, 31

(1), 40–49.

U.S. Army. (2018, March 8).

Lifestyles: Meals, ready-to-eat.

https://www.goarmy.com/soldier-life/fitness-and-nutrition/components-of-nutrition/meals-ready-to-eat.html

U.S. Army. (2019, April 25).

Army medicine: Health Professions Scholarship Program (HPSP).

https://www.goarmy.com/amedd/education/hpsp.html

U.S. Department of Defense. (1993, August).

Joint Ethics Regulation (JER)

(DoD 5500.7-R).

https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodm/550007r.pdf

U.S. Department of Defense. (2013, February).

2011 Department of Defense Health Related Behaviors Survey of Active Duty Military Personnel.

https://www.murray.senate.gov/public/_cache/files/889efd07-2475-40ee-b3b0-508947957a0f/final-2011-hrb-active-duty-survey-report.pdf

U.S. Department of Defense. (2020, January).

DOD dictionary of military and associated terms.

https://www.jcs.mil/Portals/36/Documents/Doctrine/pubs/dictionary.pdf

U.S. Department of Veterans Affairs. (2018).

VA handbook 5005/106: Licensed Professional Mental Health Counselor qualification standards.

Office of Human Resources Management.

https://www.va.gov/ohrm/

Westwood, M., Kuhl, D., & Shields, D. (2014). Counseling military clients: Multicultural competence, challenges, and opportunities. In C. C. Lee (Ed.),

Multicultural issues in counseling: New approaches to diversity

(4th ed., pp. 275–293). American Counseling Association.

MILITARY RESOURCES TO EXPLORE (MRE)

Books and Reference Works

Mullaney, C. M. (2009).

The unforgiving minute: A soldier’s education.

Penguin Books.

Tick, E. (2014).

Warrior’s return: Restoring the soul after war.

Sounds True.

Tzu, S. (2013).

The art of war: Classics of Eastern thought

(L. Giles, Trans.). Barnes & Noble. (Original work published ca. 500 B.C.E.)

U.S. Department of Defense. (2020, January).

DOD dictionary of military and associated terms.

https://www.jcs.mil/Portals/36/Documents/Doctrine/pubs/dictionary.pdf

Other Resources

Center for Deployment Psychology—Common military acronyms and terminology

http://deploymentpsych.org/system/files/member_resource/Common%20Military%20Acronyms%20and%20Terminology_CDP_8May13.pdf

Center for Deployment Psychology—Military culture course modules

http://deploymentpsych.org/military-culture-course-modules

Enlisted and officer rank and insignia

https://www.defense.gov/Resources/Insignia/#enlisted-insignia

Military alphabet

http://www.militaryspot.com/military-alphabet/

Military code of conduct

https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodm/550007r.pdf

Military time chart

http://military.onlineclock.net/chart/

Military Times

http://www.militarytimes.com/

Military unit size/structure

http://www.cfr.org/world/modern-military-force-structures/p11819

National Guard

http://www.nationalguard.mil/

Security clearances

https://www.clearancejobs.com/security_clearance_faq.pdf

U.S. Air Force

https://www.af.mil/

U.S. Army

https://www.army.mil/

U.S. Coast Guard

https://www.uscg.mil/

U.S. Marines

https://www.marines.mil/

U.S. Navy

https://www.navy.mil/

U.S. Space Force

https://www.spaceforce.mil/

CHATPER 2SOCIETAL MYTHS, STEREOTYPES, AND STIGMA OF THE U.S. MILITARY CULTURE

Me: Thank you for your service!

Him: Well I didn’t do much except drink a lot . . . but the Navy did help me refine my drinking skills.

—Conversation with one of my military clients

★ ★ ★

Myths, stereotypes, and stigma have existed throughout the centuries concerning military service members. Approximately 2,500 years ago, Sun Tzu (ca. 500 B.C.E./2013) wrote The Art of War, a text on warfighting and the classical philosophies of Eastern thought. It addressed such issues as preparing for battle during wartime and taking tactical advantages on enemy armies; it also contained reflections on the writings of Confucius and philosophies of Taoism that, in part, have formed the foundation of today’s military culture. In this extensive work, Tzu also discussed expected behaviors, morals, and ethics of conscripted military personnel and high-ranking officers as well as many more military-related issues that reflected the culture at the time. The influence of this and other historical references (e.g., writings of Carl von Clausewitz and Napoleon, memoirs of great generals of past wars) may have been responsible in part for Western societies’ perceptions and attitudes regarding the military culture within the United States.

Numerous studies address the myths, stereotypes, and stigma associated with the military culture’s impact on various racial and ethnic groups; gender-related issues; the lesbian, gay, bisexual, and transgender community; persons with HIV/AIDS; as well as persons with disabilities. However, few studies have explored the myths, stereotypes, and stigma relating to the military culture (Ashley & Constantine Brown, 2015; Griffin & Stein, 2015; Kim et al., 2016; Pietrzak et al., 2009; Quartana et al., 2014; Stebnicki et al., 2016; Vogt et al., 2014). The purpose of this chapter is to highlight some of the more prevalent societal and clinician myths, perceptions, and attitudes regarding the military culture and how these factors hinder, challenge, and affect service members’ and veterans’ motivation for seeking medical and mental health treatment.

THE IMPACT ON MILITARY CULTURE

Cultural myths and stereotypes regarding the military community can be both negative and positive. Some individuals in American society as well as clinical providers see military service members as possessing a high level of courage, honor, loyalty, confidence, toughness, and resiliency. Others in society may portray this group as possessing the potential to act in violence, having low impulse control, or having poor mental and physical health (Ahern et al., 2015; Currier et al., 2017; Quartana et al., 2014; Vogt et al., 2014). Theoretically, stigmas regarding the military culture are based on public perceptions of individuals not associated with the military. Service members and veterans can also internalize public stigma and adopt these negative perceptions of themselves, which may hinder good mental health and wellness.

Skopp et al. (2012) developed the Military Stigma Scale, a 26-item scale designed to measure public and self-stigma within two dimensions (public and self-stigma). Interested readers should consult the references section for details of this scale development study. However, public and self-stigma have been shown to produce lasting negative effects on the mental health and well-being of service members and veterans. The most harmful effects are that stigma is directly associated with mental health treatment seeking and may even counteract or nullify positive treatment outcomes.

As a direct result of negative military cultural myths, stereotypes, and stigma, medical and mental health professionals may directly/ indirectly or consciously/unconsciously be facilitating treatment approaches based on cultural myths. The psychosocial impact on the service member or veteran may include the following:

The client may feel “broken,” possess low self-esteem, and have difficulties assimilating or transitioning into the civilian culture.

Clinicians and society may project negative attitudes and perceptions that can create a reluctance and resistance on the part of the service member or veteran seeking medical and mental health treatment. This behavior reinforces the military identity that no one understands the culture except those who have served. Consequently, they may reject nonmilitary medical and mental health providers altogether.

Many indigenous cultural groups or foreign nationals distrust the American military, particularly while they are on deployment in hostile countries. Many indigenous groups were taught to fear Americans. They are viewed and portrayed as violent people, which is reinforced by American movies, electronic media, and political propaganda. Thus, if the service member overpersonalizes this stereotype, they may endorse this belief about themselves or not feel committed to a combat mission.

Stigma associated with the “suck it up” mentality, warrior ethos, indoctrination rituals, and other cultural attributes in the military hinders service members’ and veterans’ ability to seek mental health treatment. Submitting to the values of seeking psychotherapy disavows military cultural philosophy and ideology.

Many factors influence clinical providers’ and society’s attitudes and perceptions toward social and interpersonal interactions with the military culture. Some of these factors relate to the unique characteristics of each war and generation. For instance, rarely did Vietnam War veterans hear the phrase “thank you for your service,” whereas this phrase is commonly heard today by those who have served in the war on terrorism after 2001. Additionally, many Vietnam veterans rarely sought mental health treatment, primarily because conditions such as posttraumatic stress disorder (PTSD), major depressive disorder, anxiety, and substance use disorders—as well as military suicidality—were not readily recognized by the U.S. Department of Veterans Affairs (VA) system of health care.

The level of screening, assessment, diagnosis, and treatment did not exist then like it does now in veteran health care. The numbers of Vietnam War veterans with a VA disability rating of PTSD pale in comparison with Operation Iraqi Freedom, Operation Enduring Freedom, and Operation Inherent Resolve veterans. The veteran psychiatric treatment facilities for Vietnam veterans were reserved only for those with the most severe, chronic, and persistent symptoms of PTSD.

Other influences that mediate attitudes and perceptions toward the military community are related to political rhetoric, governmental policies (i.e., VA, U.S. Department of Defense [DoD]), and various veteran organizations. These influences help to shape both negative and positive attitudes and perceptions toward active-duty service members, veterans, veterans with disabilities, and military families. Unfortunately, many clinical providers who are not culturally competent in providing medical and mental health services to the military may unintentionally accept “Hollywood’s” version and portrayal of the military culture.

As a consequence of military cultural myths, stereotypes, and stigma, clinicians may create barriers that harm the service member’s or veteran’s (a) reintegration and transition into employment and educational opportunities within the labor market (Currier et al., 2017; Farley, 2013; Griffin & Stein, 2015); (b) perceptions of seeking mental health treatment (Quartana et al., 2014; Vogt et al., 2014); (c) security clearance, rank, promotions, and perception of their mental or psychological fitness to serve (DoD, 2013; Stebnicki, 2016); (d) willingness to utilize professional mental health and substance abuse counseling services (Rae Olmsted et al., 2011); (e) utilization of alternative mental health treatment (Kim et al., 2016); (f) psychosocial transition from active duty to civilian life (Derefinko et al., 2019; Gibbons et al., 2014); (g) reconnection and readjustment with family members and intimate relationships (Ahern et al., 2015); and (h) ability to overcome the mental and physical health disparities that exist within the veteran culture (Hobbs, 2008; Stebnicki et al., 2016).

MILITARY MYTHS COMMON TO THE CULTURE

In this section, I present an extensive list of myths attributable to the military culture that potentially may affect the clinician’s perception and attitude toward serving their military clients. Clinical military counselors who are culturally competent understand these cultural myths and the value of earning the circle of trust within the therapeutic relationship with active-duty personnel, veterans, veterans with disabilities, and family members. In addition, they understand the importance of the working alliance and how unintentional actions could adversely affect the therapeutic relationship. The cultural dynamics in session are of paramount importance, and unintended consequences could occur any number of ways, such as verbal and nonverbal communication as well as language that portrays a cultural bias, negative attitude, or perceptions toward a group of individuals. Clinical military counselors should understand that 75% of what we communicate to one another is done by metacommunication.

All military troops serve in combat operations: This myth assumes that all military service members and veterans are warfighters and have served in combat operations. The Pew Research Center’s analysis of information gathered from the DoD’s Defense Manpower Data Center (https://www.dmdc.osd.mil/appj/dwp/dwp_reports.jsp) indicates that in June 2018, there were approximately 1.3 million active-duty military personnel across the U.S. Armed Forces. Approximately 15% of all active-duty service members were deployed overseas—the lowest numbers of troops deployed since 1957. Most troops (70%) were deployed to Asian and European military installations. Only 15% of troops were deployed to Middle Eastern countries (e.g., Iraq, Afghanistan, Syria) and North African nations, whereas 3% were deployed to sub-Saharan Africa or the Americas (e.g., El Salvador). The remainder (14%) were located at sea or in other undisclosed locations around the globe. There was a surge in U.S. troops sent to Iraq in 2007 and 2019. However, these numbers pale in comparison with the Vietnam War, in which 45% of all troops were deployed to combat operations overseas.