Counseling a Client With Current or Former Military Service

It’s Not All Trauma

There is an unfortunate stereotype that military service is inherently traumatizing and that post-traumatic stress disorder (PTSD) is nearly universal among those with combat experience. PTSD rates hover around 10 percent, although this varies with the time of service. Diagnosing and treating PTSD is of the utmost importance, but counselors should not assume that every military client is traumatized.

It’s sobering to realize that war has been part of the human condition for millennia, although we are getting better at avoiding it. Anthropologists tell us that approximately one-quarter of adult men died in combat during our species’ hunter-gatherer existence, which characterized human history up until the last 10,000 years or so. 

Even the carnage that was the 20^th century cannot come close to this statistic. It is unlikely that minds shaped in this reality would be completely undone by the experience of war. Instead, people, including military personnel, seem to be remarkably resilient. Viktor Frankl lost his pregnant wife, parents, and brother during the Holocaust, undeniably traumatic experiences that shaped his development of logotherapy, or the ability to find meaning during the darkest of times. Many people experience post-traumatic growth. If you think about the question, “What made you the person you are today?” most people describe very difficult times of their lives. 

Focusing exclusively on trauma can lead a counselor to miss other common and significant issues: 

• Sleep disturbance is a very common complaint. Sleep issues might predate military service, but can certainly be made worse by the adherence to strict schedules that are not consistent with chronotype and the effects of hypervigilance when deployed. Many veterans complain that they just can’t sleep the way they used to.
• Alcohol use can be normalized in some military units. This might serve as a tipping point for those who are vulnerable to alcohol use disorder. Against this normalization, identification of problem alcohol use might be delayed.
• General irritability and hypervigilance are actually adaptive during a combat deployment. These behaviors are not like a light switch that can be turned on and off. When they linger after deployment, they can disrupt relationships and well-being. 
• Reintegration following a deployment or at the end of a military career can be tough. Veterans might underestimate the amount of change they will experience over short periods. 
• Like all retirees, finding a new identity and sense of purpose when one chapter of life ends is essential to ongoing mental health. While the military provides transition services, these work better for some than for others. 
• The results of combat or training-related injuries can linger in the form of chronic pain.

Exploring multiple aspects of military mental health with clients should ensure that these common sources of distress are appropriately treated.

Military Culture is a Clinical Variable

A dear friend of ours, a veteran of combat in the Vietnam War, anxiously looked forward to visits from our daughter, a West Point graduate and combat veteran in Iraq. He wanted to “talk Army.” Another friend retired from a distinguished career as a professor at West Point and transitioned to a leadership training role at a tech firm. He said it took him a while to get accustomed to his 30-year-old pink-haired, pierced boss with a PhD. Our daughter received her master’s degree from a prestigious civilian university, which offered a very different experience from her days as a West Point cadet. She complained about the level of sexual harassment and said that if such behavior occurred on an Army base, she could have the perpetrator jailed. Military life is not civilian life.

There are distinct differences from civilian culture that could impact military mental health:

• The military has a strictly hierarchical structure. Everyone knows their position in the hierarchy and who salutes and follows orders from whom. We have bosses in civilian life, but the lines are not nearly so clearly drawn. It is not uncommon for a tenured professor to disagree vehemently with a dean or college president. Workgroups of “peers” establish their own informal pecking orders. Moving from a formal hierarchy to a fluid, informal one can be disruptive to former military personnel.
• The military is mission-oriented. In leadership research, we call this “task orientation,” and it takes precedence over all other goals. In civilian life, “people orientation” often takes at least as large a role in group process as task goals. The civilian leader who focuses on task at the expense of caring about people risks a mutiny.
• Military life is substantially more collectivist than civilian life. Individuality is given small scope for expression, as even the color of lipstick is the subject of regulation. At the same time, bonding within a unit is highly encouraged. Moving from this support system to civilian life, especially when support from family is lacking, can be highly disruptive.
• A well-defined identity comes with military service. You have a rank. You have a job. You have a record of accomplishments on your chest that others recognize and understand. This provides a greater degree of clarity than anything experienced in civilian life.
• Toughness and self-reliance are expected. Self-regulation of emotional expression is a given. Transitioning to a civilian world, and a counseling setting in particular, where emotions and inner thoughts are expected to be shared, takes time and patience.

Moral Injury

Moral injury results when a person violates or witnesses the violation of deeply held beliefs and standards. When our daughter was about to deploy to Iraq, her father had a heartfelt conversation about how she had been raised in a “thou shalt not kill” environment, yet she would soon be called upon to protect herself and her soldiers. George Patton perhaps said it best: “No bastard ever won a war by dying for his country. He won it by making the other poor bastard die for his country.”

Individuals witnessing or being asked to participate in atrocities and poor leadership are faced with an unenviable conflict. Defy orders and risk the consequences, or go along and experience moral injury. Moral injury can lead to intense shame and guilt, anger, and spiritual crises. Building trust with clients experiencing moral injury is typically a long process requiring significant patience.

For the counselor, moral injury can present similarly to PTSD. The major defining difference is that PTSD is primarily fear-based (fight/flight), whereas moral injury involves more guilt and shame. Therapy focuses on self-compassion and forgiveness.

How to Prepare to Work With Military Mental Health

Counselors wishing to engage with military mental health could benefit from the following strategies:

• Obtain education regarding military culture.
• Obtain training in moral injury frameworks.
• Collaborate with VA or community veteran networks.
• Obtain education on suicide risk assessment tailored to military populations.

Military service and the military’s structure continue to evolve. Counselors wishing to contribute to the well-being of military personnel must also be agile and continuously update their skills.