Our Mission: Better Serving Those Who Serve

More than two million people are serving either in active duty in the armed forces or in the reserves. And the United States is home to more than 18.6 million living veterans.

Service members and veterans experience high levels of post-traumatic stress disorder (PTSD), risk, suicide, depression, and grief. How can behavioral health professionals do a better job of serving those who serve?

A Cultural Humility Approach

The concept of cultural humility goes beyond the idea of cultural competence. It begins with listening to and honoring the stories and experiences of people whom we interact with. And it involves honoring their wisdom and experience. Cultural humility has no end point; it is an ongoing process of listening, responding, and striving to center on the client as the expert on their own experiences and life.

Many behavioral health professionals are familiar with cultural humility when it comes to working with clients from marginalized groups. But this approach also applies to active and former service people. Cultural humility is an important foundation upon which to build rapport, trust, and safety. It also promotes communication and collaboration in clinical settings.

The military is a culture, after all. So if we don’t know much about their world, we need to start by asking.

Step 1: Ask

In the Connecticut Women’s Consortium training, “Serving Those Who Serve,” Amy B. Otzel, LPC, LMHC, explores approaches to serving active and retired military personnel. Otzel emphasizes that many initial screenings and intake processes neglect the question that is perhaps most important to those who serve: “Are you a military member, veteran, or family member?” 

Asking shows that you care about this important aspect of someone’s life and paves the way for a productive therapeutic relationship.

Not everyone is certain of their military status — or ready to disclose it — but asking the question early in the relationship may shape the direction of future conversations. It can also aid in the ability to mobilize additional resources, including referrals.

Basic Training on Military Structure 

There are six branches of the U.S. armed forces: Army, Air Force, Navy, Marines, Coast Guard, and Space Force. All but the Space Force have a reserve component, and the Army and Air Force have National Guards. 

The military ranks are structured as officers, warrant officers (except in the Air Force and Space Force), and enlisted personnel. 

• Active duty service members are federal employees who answer to the commander-in-chief, the president of the United States. They are full-time and deployable at any time. 
• Reserve members are also part of the federal government. Their status is pat-time, and they serve one weekend a month, plus two weeks a year. They are deployed in times of war, national disaster, or threats to national security.
• National Guards are state-controlled but federally funded. Their commander-in-chief is the governor of the state. Their status is also part-time, serving one weekend a month and two weeks a year. Their activation is periodical in times of local emergency, national disaster, and threats to national security. During wartime, the National Guard is Federalized, meaning it answers to the president.
• AGR stands for Active Guard/Reserve. It includes members of the Reserve or Guard who are full-time and work to keep the units mobilized and ready at any time.

What Makes Someone a Veteran?

A veteran is someone who served in an active armed service capacity and was discharged or released under conditions other than dishonorable. Veterans are entitled to a number of benefits: federal, state, community, nonprofit, and university/college. 

The eligibility for veterans’ benefits varies depending on the program, their status, the discharge type, length and period of service, and a number of other factors.

What Is a Military Family Member?

A military family member is the dependent of a current military service member, military retiree, or 100% service-connected disabled veteran. That could be a current married spouse, unmarried biological, adoptive, or stepchildren up to the age of 21 or 23, other minors of legal guardianship, financially dependent parents, in-laws, or stepparents.

Stresses of Military Service

There are many reasons why service members and veterans experience high levels of stress. Operational stressors include accidents, injuries, and fatalities; numerous deployments; and relationship separations. Bioecological stressors include seasonal and time zone changes, sleep disruptions, chemical and toxin exposures, and food and water access. 

If military members suspect they have been exposed to environmental hazards, the 

U.S. Department of Veterans Affairs tracks exposures and connects veterans to benefits.

Social stressors are also common among service members. They may experience relationship strain, financial and economic difficulties, relocation and cultural assimilation difficulties, challenges to personal space and privacy, and concerns about the chain of command and colleagues.

Women Warriors

Women are the fastest-growing group of veterans. As of 2020, there were nearly two million women veterans, 10% of the total. Because of outdated stereotypes, women are less likely to view themselves as veterans, yet they face many obstacles to health and wellness. For example:

• Women veterans are 250% more likely than civilian women to complete suicide.
• When women are discharged from service, they lose an important protective factor: social support. Many female veterans report a lack of belonging and connection.
• Government and nonprofit care systems are not adequately serving women. Women who do not use VA services have a 98% increased rate of suicide completion.

Military Sexual Trauma

Military sexual trauma (MST) is pervasive in the military, and sexual assault and harassment cause unspeakable damage to veterans and their families. The Department of Defense defines sexual assault as “intentional sexual contact, characterized by the use of force, threats, intimidation, abuse of authority, or when the victim does not or cannot consent.” 

• Military sexual trauma is underreported, but according to this study, the rate of reports is rising.
• In 2018, 20,500 service members were sexually assaulted or raped: 13,000 women and 7,500 men. 
• For women veterans, the rate of MST increased by over 50%.
• 69% of women who reported a penetrative sexual assault were assaulted by someone with a higher rank than theirs, and 24% were assaulted by someone in their chain of command.
• More than 1 in 4 victims who did not report feared retaliation from their command or coworkers.
• The conviction rate for sexual assaults has been plummeting.

PTSD and Service Members

Treating active and veteran service members means understanding the fundamentals of post-traumatic stress disorder. The VA estimates that 7 out of every 100 veterans (7%) will have PTSD. It is more common among women than men, and more common among Vietnam veterans than veterans of other conflicts.

PTSD Symptoms

PTSD is different in every person, but in general, it is a mental health condition that develops after someone experiences or witnesses a life-threatening event. It can develop immediately or take years to produce symptoms. The four most common symptoms of PTSD are: 

1. Reliving the event: nightmares, flashbacks, or triggers.
2. Avoiding situations or events that remind the person of the event.
3. Having more negative thoughts and feelings than before a traumatic event. This can include numbness, blocking memories, thinking the world is dangerous and no one can be trusted, or feeling guilt or shame.
4. Feeling on edge (hyperarousal). This could mean feeling jittery, angry, irritable — or having trouble sleeping or concentrating. Some people with PTSD might act in unhealthy ways like smoking, using substances, or driving aggressively.

The key word in PTSD is trauma. People who serve have often experienced trauma and require trauma-specific or trauma-informed care.

The VA has many PTSD measures available for clinicians. These screens can help pinpoint the types of trauma experienced and inform treatment plans.

Veterans and Suicide

Suicide among service members and veterans is unacceptably high. The 2022 National Veteran Suicide Prevention Annual Report shows that in 2020, there were 6,146 veteran suicide deaths in the United States. Suicide was the 13th leading cause of death among veterans overall and the second leading cause of death among veterans under age 45.

Suicidal thoughts and behaviors need to be addressed immediately. If a veteran is in crisis, they should call the 988 crisis line and select 1. Or they can text 838255. Even people not enrolled in VA health care are eligible for emergency mental health care if they meet certain conditions.

The VA’s guide for family and friends lists the following signs that someone may be considering suicide:

• Seeming sad, depressed, anxious, or agitated most of the time
• Sleeping either all of the time or not much at all
• Not caring about their appearance or what happens to them
• Withdrawing from friends, family, and community
• Losing interest in work, school, or other things they used to care about
• Expressing feelings of excessive guilt, shame, failure, lack of purpose, or feeling trapped
• Performing poorly at work or school
• Acting violently or taking risks
• Giving away personal items, making a will, or seeking access to pills or guns

 The Veterans Self-Check Quiz is a safe, confidential way to assess risk. 

Learning What to Ask

When behavioral health professionals approach those who serve with compassion and cultural humility, they can help them understand how to process and heal from their trauma. Sometimes that starts with asking questions to learn more about the person’s experiences. You could ask:

• Have you ever served in the military?
• When did you serve?
• Which branch and component did you serve in?
• What is/was your rank?
• What were your reasons for entering into service?
• What type of work did you do?
• Were you deployed? 
• What is your expectation for separation?
• What type of discharge did you receive? 
• Do you and your dependents have military ID cards? (If they don’t, point them to RAPIDS ID Card Office Online.)
• Do you have any illnesses or injuries as a result of your service?
• Did you experience any head trauma or loss of consciousness (LOC)? 
• Did you experience any unwanted sexual attention, like verbal remarks, touching, or requests for sexual favors? 
• Did anyone ever use force or the threat of force to have sex with you against your will?
• Are you enrolled in the VA health care system? 

The list is not comprehensive, but it can help clinicians understand where the person is in their healing journey and meet them where they are to develop a plan for therapy.

The Wellness Mission

For current and former members of the military, adjusting to civilian life can be challenging. As behavioral health clinicians work to create an atmosphere of trust, presence, cultural humility, and alliance, they can help clients create a new sense of purpose: a wellness mission.

This reframing can inspire service members to live in the present and reframe their trauma. The result can be new (and healthier) operating orders, better connections, and empowerment.