Counseling Veterans and Military Personnel

10 minutes

Counseling veterans and their families is a specialized field within mental health services. Veterans often return from service with experiences that set them apart from the civilian population, including exposure to combat and the difficulties of transitioning back to civilian life. These experiences can lead to a range of mental health issues, such as: 

  • PTSD 
  • Depression 
  • Anxiety 
  • Substance use disorders  

Similarly, the families of veterans face their own set of challenges, dealing with the stresses of military life, such as prolonged absences and the adjustments required during reintegration. 

Effective counseling for this group requires understanding military culture, the psychological impacts of military service, and the dynamics of military family life. Counselors in this field need to be empathetic, knowledgeable, and skilled in offering evidence-based treatments and connecting veterans and their families with additional resources and support.  

Recommended course: Postcombat-Related Disorders: Counseling Veterans and Military Personnel 

Counseling Veterans: Understanding military mental health cultural norms  

Counseling veterans and their families requires understanding the unique culture of mental health in the military. In the military, a strict hierarchy and chain of command dictate interactions, fostering a culture of obedience and respect for authority.  

In contrast, mental health services often operate on principles of equality and collaboration, where the client’s voice is as important as the therapist’s. This shift can be challenging for veterans accustomed to hierarchical structures, potentially causing discomfort or reluctance in seeking or fully engaging with mental health services. 

Strength and stoicism vs. vulnerability 

Military culture often emphasizes strength, resilience, and stoicism, where showing vulnerability may be perceived as weakness. This principle can conflict with the core tenets of mental health care, which encourage openness, vulnerability, and emotional expression. Veterans might struggle to reconcile these opposing values, leading to a reluctance to admit mental health struggles or engage in therapy. 

Collective identity vs. individual therapy 

The military fosters a strong sense of collective identity and camaraderie, focusing on the group over the individual. Mental health services, on the other hand, often emphasize individual treatment and personal introspection. This shift from a collective to an individualistic approach can feel alienating to veterans, potentially impacting their willingness to seek and persist in individualized mental health treatment. 

Stigma and perceptions 

There is often a stigma attached to mental health issues in the military, where seeking help might be seen as a sign of weakness or inability to cope. This stigma can persist even after leaving the military. This can deter veterans from accessing mental health services due to fear of judgment or misunderstanding. 

Understanding and addressing these cultural differences is crucial in providing effective treatment when counseling veterans. This understanding ensures veterans feel comfortable, understood, and supported in their mental health journey. 

Challenges of transitioning and reintegration of military personnel 

Combat veterans and their families often encounter challenges when transitioning from deployment and reintegrating into civilian life. Counseling veterans means recognizing and understanding these challenges, which might include: 

  1. Psychological adjustments: Transitioning from a highly structured and adrenaline-driven environment to civilian life can be disorienting. Coping with traumatic experiences and readjusting to a peaceful environment can also be a challenge. 
  1. Physical health issues: Many veterans return with physical injuries, which may lead to chronic pain or disability. Adapting to these physical limitations and navigating healthcare systems can be difficult for both the veterans and their families. 
  1. Re-establishing family roles: Deployment can significantly alter family dynamics. Spouses may have taken on new responsibilities in the veteran’s absence, and children might have adjusted to life without one parent. Re-establishing roles and reconnecting emotionally can be a slow and challenging process. 
  1. Financial stability and employment: Veterans often face challenges finding employment after service. The skills acquired in the military may not directly translate to civilian jobs, and some employers may not fully understand or value military experience. This can lead to financial stress and uncertainty. 
  1. Social reintegration: Veterans may feel isolated or disconnected from friends and communities who may not understand their experiences or challenges. Rebuilding social connections or forming new ones can take time and effort. 
  1. Cultural readjustment: The military has a unique culture and way of life vastly different from civilian society. Adjusting to the less structured norms of civilian life can be disorienting for veterans accustomed to the discipline of military culture. 
  1. Communication challenges: Veterans and their families may struggle with communication about experiences during deployment. Veterans might find it hard to express what they went through, while family members may not know how to ask about or respond to these experiences. 

Identifying Post-Traumatic Stress Disorder when counseling veterans 

Post-traumatic Stress Disorder (PTSD) is characterized by a set of symptoms that occur following exposure to a traumatic event. The symptoms of PTSD fall into 4 categories: 

  • Intrusive symptoms: Recurrent, involuntary, and intrusive distressing memories of the traumatic event; traumatic nightmares; flashbacks where the individual feels or acts as if the traumatic events are recurring. 
  • Avoidance: Persistent avoidance of stimuli associated with the traumatic event, including thoughts, feelings, or conversations about the event, and avoidance of places, people, activities, objects, and situations that may trigger distressing memories. 
  • Negative changes in cognition and mood: Inability to remember an essential aspect of the traumatic event, persistent and exaggerated negative beliefs about oneself, others, or the world, persistent distorted thoughts about the cause or consequences of the traumatic event that leads to blaming oneself or others, persistent negative emotional state or feelings of detachment from others. 
  • Alterations in arousal and reactivity: Changes in arousal and reactivity associated with the traumatic event, including irritable behavior and angry outbursts, reckless or self-destructive behavior, hypervigilance, exaggerated startle response, problems with concentration, and sleep disturbance. 

For a diagnosis of PTSD, symptoms must last for at least one month and cause significant distress and impairment. 

Types of PTSD 

Though PTSD is one condition, there are various subtypes of the disorder depending on the type of symptoms one experiences. Some types of PTSD include: 

  • Uncomplicated PTSD: This type involves PTSD symptoms without other comorbid psychiatric conditions. It is typically associated with a single major traumatic event rather than multiple or long-lasting traumatic events. 
  • Complex PTSD: Complex PTSD is also known as C-PTSD. This type occurs due to exposure to prolonged or repeated traumatic events, such as repeated childhood sexual or physical abuse. It includes the core symptoms of PTSD along with additional symptoms such as difficulty controlling emotions, negative self-perception, difficulty relating to others, and a sense of hopelessness.  
  • Dissociative PTSD: Dissociative PTSD is a form of PTSD where a key feature is experiencing dissociative symptoms, such as depersonalization, derealization, or emotional detachment. The characteristics of dissociative PTSD include dissociative flashbacks and amnesia, a significant history of early life trauma, and more severe PTSD symptoms. 

Prevalence and diagnosis of PTSD and depression in combat veterans 

PTSD and depression are common mental health conditions that occur in combat veterans. Understanding how prevalent these conditions can be when counseling veterans is crucial. 

The prevalence of PTSD among combat veterans varies but is significantly higher than in the general population. Studies have reported rates ranging from 11% to 30%, depending on the conflict, with higher rates observed in veterans of high-intensity conflicts. 

Depression 

Like PTSD, depression is more common in combat veterans than in the general population. Rates vary but are often reported to be around 23% for active military and 20% for veterans. The prevalence of depression depends on factors like deployment length, combat exposure, and post-deployment support. 

To be diagnosed with depression, individuals must experience five or more symptoms during the same 2-week period, with at least one of the symptoms being either depressed mood or loss of interest/pleasure. Other symptoms include: 

  • Significant weight loss or gain 
  • Insomnia or hypersomnia 
  • Psychomotor agitation or retardation 
  • Fatigue 
  • Feelings of worthlessness or excessive guilt 
  • Diminished ability to think or concentrate 
  • Recurrent thoughts of death 

Understanding the prevalence of depression and PTSD in military personnel can help provide effective diagnosis and treatment for those counseling veterans. 

Effective treatment plans for counseling veterans 

Treating veterans with PTSD and depression who also experience suicidal behaviors, substance use, and traumatic brain injury (TBI) requires a comprehensive and multi-faceted approach. The complexity of these co-occurring conditions means that treatment plans must be individualized and often involve a combination of pharmacological and non-pharmacological interventions. 

Suicidal behaviors 

Comprehensive assessments and immediate intervention are crucial for any veteran exhibiting suicidal behaviors. This may involve crisis hotlines, emergency room visits, or crisis stabilization units. Once stabilized, therapists can focus on using evidence-based approaches to address suicidal thoughts and behaviors. Some therapeutic methods effective for suicidal ideation are: 

  • Cognitive Behavioral Therapy (CBT): CBT for suicide prevention focuses on identifying patterns of negative thinking and behavior and developing coping strategies. 
  • Dialectical Behavior Therapy (DBT): Effective for individuals with severe emotional dysregulation and self-harm behaviors. It focuses on building skills in distress tolerance, emotion regulation, mindfulness, and interpersonal effectiveness. 

While no medications are approved explicitly for treating suicidal ideation, antidepressants, and mood stabilizers may be used to treat underlying depression and mood disorders. When counseling veterans, these medications are often used in combination with therapy. 

Another way to address suicidal behaviors in veterans is safety planning. This is a collaborative development of a written plan that includes identifying the following: 

  • Warning signs 
  • Internal coping strategies 
  • Social settings and people who provide distraction 
  • People to ask for help 
  • Professionals or agencies to contact during a crisis 
  • And making the environment safe 

Recommended course: Suicide Awareness and Prevention 

Substance use 

Effective treatment for addressing substance use in veterans may include detox and medical management. This helps to manage any withdrawal symptoms. Behavioral Interventions for addressing substance use include: 

  • Motivational Interviewing (MI): A person-centered counseling style for addressing ambivalence about change. 
  • Contingency Management (CM): This approach provides positive reinforcement through rewards to reinforce desirable behaviors and maintain sobriety. Rewards might include money or vouchers for positive behaviors like providing negative drug tests. 
  • Medication-Assisted Treatment (MAT): MAT combines medications with behavioral therapies. This approach is mainly for alcohol and opioid use disorders and uses medications like naltrexone, disulfiram, or buprenorphine. 

Participation in support groups like Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) can also provide peer support and a sense of community. There are even specific support groups geared towards veterans. These resources are vital to know for those who specialize in counseling veterans. 

Traumatic Brain Injury (TBI) 

TBIs are relatively common among veterans due to explosions or experiences during combat. These conditions can disrupt normal functioning and exacerbate symptoms of other mental health conditions. To effectively treat TBIs when counseling veterans, it is crucial to encourage comprehensive neurological evaluation and rehab. This might include physical therapy, occupational therapy, and speech therapy. 

Therapies focused on improving memory, attention, executive functioning, and other cognitive domains affected by TBI are also crucial to addressing TBIs. 

Medications can also be used to manage symptoms such as headaches, sleep disturbances, or mood swings, including antidepressants, anti-anxiety medications, or stimulants for cognitive symptoms. 

For veterans with co-occurring PTSD, depression, suicidal behaviors, substance use, and/or TBI, integrated treatment plans that address all conditions simultaneously are most effective. Care coordination among healthcare providers across disciplines is a key component for providing counseling for veterans. 

Conclusion 

Counseling veterans is an indispensable service. The role of counselors in assisting veterans to navigate the difficult journey of reintegration into civilian life while dealing with the psychological aftermath of their experiences cannot be overstated. Through a comprehensive understanding of military culture, empathetic engagement, and the provision of specialized therapeutic interventions, counselors play a critical role in facilitating healing and growth for veterans. 

Resources 

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Editor’s note: this post was originally published on May 8, 2024 and updated on May 27, 2024.

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