The Basics of Veteran Culture and Its Impact on Clinical Work

Link to Timothy’s presentation

Articles:

• Substance Abuse Resources for Veterans
• Veterans and PTSD
• 3 Ways to Promote Veteran Mental Health

Welcome to The Community Education Series, hosted by The Recovery Village and Advanced Recovery Systems. Hey everybody, thanks for showing up to this. It’s nice to get together with folks for an hour that isn’t trying to pick apart clinical details through a video. This is really relieving; I’m sure all of us clinicians are feeling that a little bit. So what I’m going to do is — you all can keep doing the chat — I’m going to go ahead and do a screen share and dive in a little bit. Since we only have the hour, I might move a little fast through this, just to make sure that we really get through enough material. What you’re going to get today is a really brief, basic view of veteran culture. This is by no means going to make you entirely competent if you’re not familiar — it’s going to give you what you need to get competent. It’s going to give you some questions to ask yourself about your practice, about the community. It’s going to give you some resources on how to find more and hopefully open you up to some of the common mistakes that clinicians make, who aren’t trained.

The reason why I’m the one to do this training specifically is I spent five years in the Air Force and served as an intelligence analyst, which was really not as exciting as it sounds. I was a victim advocate for military sexual trauma survivors, which is how I got my foot in the door for mental health support, and I was the primary trainer for the bystander intervention program. This was back in the days when they finally figured out that talking to the people around the people who were likely to be victimized was the best way to stop violence. It was a lot of fun; it was my favorite job in the world. I got to “talk Airmen into punching rapists,” was the joke. It was a great, great gig.

Then when I got out, I went to the Auraria campus. I took a peer support program with two members, mentoring about 30 people a semester, to a group that mentored every single veteran that signed up for benefits on the entire campus, netting a staff of about 20. The best part of that time was I got to facilitate an exploratory group that studied factors for survivability of suicide, and I got to facilitate the meetings of 20-year clinicians, which was pivotal in my growth as a clinician. It really opened my eyes up to a lot of what’s in this training. I took that out to a local trauma center and developed their Safe Harbor program, which was training all the trauma clinicians on how to serve the veteran population on reduced costs. Since then, I’ve been in private practice for four years, doing these trainings and having a third of my practice being first responders and veterans. So that’s where this experience is coming from.

We’re going to start with some of your — well, let me keep going with this a little bit. Why this training is important: Back in 2013, the VA was instructed to open up their doors to clinicians that weren’t part of their system. The only barrier they had was a bureaucratic one, and if you could apply for an insurance panel, you could become a Tri-Care provider. Then, they did a follow-up study to figure out what was going on with the providers they let in, and they figured out that 84% of the mental health professionals that were serving weren’t competent to serve the population. The main reason for that was they weren’t using evidence-based techniques, they weren’t trauma-informed and only 8% of non-affiliated clinicians were deemed culturally competent for the population. I think by now, “trauma-informed” is becoming a byword in the community. I think more and more clinicians are getting that, which is really comforting to me. Today, we’re going to cover the cultural components.

If you can go into your chat, I’m going to stop screen share so I can see what y’all are chatting. What is something — what is one thing that people assume about you when you tell them you work in mental health? The first thing that comes to mind. “Crazy.” That you “work in a medical model.” I get both of those. Now we’re going to go over to the next question. What do you assume about someone when they say they’re a veteran, or you see a license plate or a hat? Or, if we have other veterans in the room, what are things that you notice people assume about you when you disclose that you’re a veteran? “Shutdown, resistant to treatment, that they’ve seen things that you can’t imagine, they’ve unresolved or unintegrated emotional aftermath of a traumatic experience, that you’re angry and that you’re gonna snap without notice.” Good assumption that they may not necessarily want to be identified as a veteran — for some of us, it was a time of our life; it’s not an identity we wear every day. This might go into the “they’ve seen things that are there that I can’t imagine,” right? They’ve seen it, they’ve been in it, they’ve seen too much. So every veteran has got a lot of “too much,” a lot of overwhelmed, a lot of assumptions for trauma. “High likelihood of vicarious trauma,” yeah. “You’ve seen that they compartmentalize, they hold back parts of themselves.” Okay, that’s pretty good. I get that one a lot too.

One of the things that I love about this exercise is it’s actually incredibly comparable. The military is an incredibly broad experience. Between the branches, the different jobs, the different roles and the different activities that they’re involved in, it’s even more varied than our field. And we’re going to get back into the slides a little bit to cover some of that. For me, since I hold both of these identities, I haven’t been exposed to violence. I consider myself a nonviolent and competent person, but none of that was in the military. I was an intelligence analyst. I sat in front of computers my entire five years. I’m not Republican, I don’t own any weapons, I’m not Christian, I don’t tend to snap without notice unless I’m really hungry. I did ironically have unintegrated emotional aftermath of traumatic experiences until I started having to get ready for this job and have to actually do the work, right? I’m pretty sure most of you can imagine the things I’ve seen — if nothing else as clinicians, we’re really good at imagining because we’ve gotten a lot of stories from people. I’m gonna go back to the slides now, and we’re gonna talk about this a little bit.

So, the big cultural differences that you’re going to see is that in American culture, we are an incredibly individualistic culture. And I think this is one of the bigger things that the military struggles with, like people that identify with that veteran experience or don’t have been shaped by this. Civilian culture is about your grade, your job, your paycheck, your family, your house. In the military, it’s about the mission. It’s about us; it’s about the unit. It goes back into an individual achievement. Did you get that promotion? Did you earn that accolade in the military? We actually get uncomfortable more often than not when we get accolades. It’s about what the unit accomplishes, not about us.

Individual culture is all about personal freedom. You know, live your truth, be who you want to be, chase down the American dream. And in the military, it’s absolutely not about the personal freedom. It’s about the devotion to duty. It’s about the flexibility to complete the mission. In civilian culture, we are really about socially fluid relationships, the lines at different companies, different schools between professors, power dynamics — they’re all really muddy, and every group seems to have a different way to come at it. That’s all individually driven; in the military, it’s a very rigid social structure. You do not spend time socially with people that are higher ranking than you. You do not have the ability to call them by their first name, to talk about their families. You are locked in with your peer group, and those peer groups are incredibly regimented.

None of these things are bad, and this is really important. The idea of a collective is culture versus an individual’s culture. People like to romanticize either, depending on what they’re talking about, and the reality is there’s pros and cons to each. There are going to be different ways to come at it. Most veterans, if they’ve been out for a little bit, do fairly well in living in both worlds. They’ve done one, they’ve got some skill out of it, and it’s going to be important to recognize that. If they’re newly out, there is going to be a large culture shock. “I don’t know why I didn’t meet that promotion. I’ve done the best work, but he goes out to coffee with this other guy all the time. I don’t understand what happened there. I feel like I got passed over. I don’t know why people get really angry when I’m very direct. It doesn’t make sense to me. If there’s a problem, I’m going to say something and do something.”

So, the branches are comparable to social workers, LPC’s, career counselors and school counselors. An experienced career counselor at a high school has seen a lot of trauma, has been involved in a lot of things, but their role is to help people find their future. They’ll know referrals to make, they’ll know how to support that work, but it’s not theirs. A social worker, they’re going to be really good at systems work; they’re going to be about finding the resources. Clinical social workers, five years in, are going to be just as good as any LPC, but their training is going to be more broad and knowing those resources, and we appreciate the differences. We all picked our credential for a reason. We all value the distinctions, and the public doesn’t understand it, right? If you say you work in mental health, they assume that you are all of these things, and they don’t really know which is which. Same thing with the military. You choose the Army for a reason — you identify with that culture. There are differences between the Army, Navy Marines, Coast Guard and the Air Force. There’s a value in an earned title that’s important to recognize. So when someone says they’re a veteran, a really good follow-up is, “Which branch did you serve? What title did you make?”

The differences are pretty stark by on what their operational footprint is. The Army is the largest branch, and they have the most varied duty. So when someone says they were a soldier, you really can’t assume anything about their experience. The Army literally has almost every job that the other branches have because they’re just so huge. Cooks, lawyers, combat specialists — they have more boats than the Navy, believe it or not, which I think is hilarious. The sailor tradition is the oldest. It’s kind of like the elder branch because they’re taking tradition from the 1400s from England. They also have the most time away from home outside of combat because of the ship life, and a surprisingly large amount of sailors never get on a boat or a ship, so that’s going to be important to take in. The thing that’s funny there is they have more planes than the Air Force, which ours are better though, so don’t worry about that. We have the best planes.

The Air Force is really going to be the technical branch; 70% of the Air Force is in technical fields. It’s almost all aimed at keeping really expensive, very powerful hardware and supply to the people that are on the ground. It’s more of a corporate culture. Some Airmen get uncomfortable talking about it like that, but that’s the best way to look at it from the outside. My Marines, I love my Marines. They’re actually the main population that I end up working with now, and their focus is on being a warrior, being a fighter or being a rifleman. Every Marine, on some level, was ready and willing to be in violence when they join, while that is not always true for the rest of the branches. They’re also the most culturally rigid. They are — there’s no, like, Marine that “gets out.” You’re a former Marine, you’re always a Marine. It’s a lifetime identity piece that they try to really put into you. The Coast Guard is probably the most discounted branch. If you’re talking about times of service, before the war on terror, they actually had more combat experience than most of the other branches during the war on drugs. After 9/11, they got upgraded to a military branch, and I actually run into them a lot more in Colorado than you would think.

Military families: This is going to be the one that comes up a lot for people. The transition out of the military is essentially like losing the family member that was in control. The way to look at a military family is there is an extra person in that family, and they take preeminence. Military families have to give over everything to the mission. The spouse’s life is around the mission before it’s around the family. To give you an idea on how stringent that is in the military, if you have children, it’s required that you have a family care plan. And what that means is that you have someone on file within your command that, in 24 hours, will take your children. That you will be able to leave and go do whatever the mission requires in 24 hours’ notice, and that your children will have somebody to be handed to. The military structure is really designed to have a partner in service and a partner managing the family. Dual military spouses are becoming more and more common, and what that means is they have to have somebody on deck for this. To give you an idea on how serious that is, if you’re called up and your unit decides they need you to go somewhere and you say that you can’t get your children cared for, you can lose rank. It has serious financial and social consequences to not have that happen.

They’re also much more likely to marry young. They’re constantly disrupted spouses. It’s incredibly hard to have a career in a military family because of all the relocation. They’re expected to move about every two to three years, about 10 times more often than civilian families. They’re also pretty heteronormative. The spouses tend to be under 35 and largely female; only 5% of military spouses are men. They get married and have children a lot younger because the structure encourages deep commitment early. So when I was in training, I was actually in training for a very long, long time. My training was a year long in two six-month stints, and you’d meet somebody on the training base, out in the public or within your unit, and you had six months to determine whether the relationship was worth continuing or not. And if it was, that person had to move with you.

On top of that, if you do get married, you get to live off of base or get a house away from the dormitory’s barracks where all the other guys and gals are sleeping, and you basically double your paycheck because they give you a stipend to support your family. So it’s financially incentivized, it’s romantically incentivized, and its relationship and connection incentivized. All of this means that they’re doing this a lot younger than their peers and that when they rejoined civilian life, there’s a huge power vacuum. The mission is no longer there. The preeminence of the partner’s career that was serving is no longer there. You may have a spouse that’s been waiting their turn, you may have a very rigid sense of order that is no longer being provided from the outside. Really, treat it like an estrangement from the powerful member of the family if you work with those families when they get out.

Mental health struggles: I’m not going to train you how to diagnose. I’m assuming that you’re going to get that training other places. What this is about is what diagnosis generally means to the people you’re talking to and what happens for them. So, depression and anxiety — just like everywhere else in the country, everybody’s anxious and depressed right now as far as I can tell. I don’t think there’s a clinician that can use the diagnosis code for generalized anxiety and not in some way be correct. For the military members and their transition on the way out — and this is going to be my focus here because it’s where my focus has been in my career — it makes a lot of sense that people are struggling with sadness and stress. They miss the camaraderie. In the military, you don’t choose who you’re with, so you’re forced to value them. I was an intel analyst. I worked shifts, which meant that I was doing 12- to 15-hour days, and we would swap days and nights. We would do three days at times, so your schedule is chaotic. You never know what day of the week it is.

So you’re spending your time, both at work and off, with the people that you serve with. For me, it was around 10 people that were always together because who else were we going to hang out with at two in the morning on a Tuesday, getting ready for your next set. So even though I would never spend time with these people outside — we didn’t share politics, we didn’t share hobbies, we didn’t share cultural background, we didn’t share age, I was much older than most of the people I served with — we were forced into very close camaraderie that we maintain to this day. You lose that. You lose the easy friendships that come from just consistent exposure and forced time. You also make no decisions when you’re in the military. You don’t choose who you spend your time with, you don’t choose where you live, you don’t choose the career you get, you don’t choose the posting you did. You can have influence and get lucky, but at the end of the day, it’s all needs of the service.

So you haven’t made a life direction choice other than who you marry for the entire length of your service, and now you’re flooded with choice once you get out. You’re also feeling different. A lot of people — just like when people come home from college or they come home from living somewhere else, where they expect the world to have stayed the same and it hasn’t — they also expect to engage that world in the same way, but they’re different from their experiences. The military members are also classically bad at financial management because finances are so secure. You’re paid like clockwork, your food and board is taken care of for you. You’ve never had to really figure out how to manage those, so it’s not uncommon not to know what to do with money or what to do without money.

So this is an important statistic when we talk about that repressed trauma. When we talk about combat experience, only 6% to 10% of Iraqi and Afghanistani veterans are affected by PTSD or TBI. And this is really important to understand — only one in 10 military members will be exposed to combat. For every person that’s in the field that’s in harm’s way, there are literally nine people standing behind them, making sure they have everything they need to be as safe and as effective as possible in that environment, which means that most of us weren’t exposed to that. In addition, combat does not have to be a negative experience. I’m going to say that again: Combat does not have to be a negative experience. There’s poetry written about it. It’s a classic test through the time of humanity that people have sought to test themselves.

One of the struggles I see a lot in the field is that many of us are pacifist in nature — we’re abhorred by violence. We’re really invested in the idea that you use your words; it’s what we work with. It’s our skillset. So coming across somebody who values being violently competent can be jarring. Be ready for that. The other thing is that that story that the public has, veterans have too — most veterans are terrified of that post-traumatic stress diagnosis. It’s what they assume they have when they’re struggling. When really, it might just be transition struggles, it might be depression. It might be, “I can’t find a job. I don’t know what to do with me and my wife now that we’re out of the situation and we don’t seem to like each other.” It’s a much broader perspective on the health and that.

The way that the military’s ad campaigns framed it is a normal reaction to an abnormal situation. It’s a really common theme because they really beat it into the media in the military for about 15 years, that was the awareness campaign. There’s the common social stigma that no one likes — I don’t know, a veteran that relates to the TV ads that shows like the screaming veteran with a gun to his head flashing back to combat experiences, trying to make public awareness. That’s a really offensive ad campaign that impacts us. Almost no veteran I know is comfortable with the idea of the diagnosis until they’ve been educated by someone like you. The other thing is that TBIs can mirror post-traumatic stress. There’s also different things that have come up.

There’s a malaria drug that was utilized for veterans — for about 15 years — going down in South America or going into any jungle environment. They figured out much later about 6% of the folks that got it would get chemical brain damage, which mirrored PTSD and TBI. What you’ll see a lot of times is it’s really hard to assess TBI without really specific training. So it’s not expected for clinicians to have that, right? It’s okay if you misdiagnosed for post-traumatic stress. What you want to watch for is we know that post-traumatic stress is curable. We know that the skills using DBT, using MDR, using all of the different skill sets we have — most of the time, our clients are going to get better. If you’re not seeing improvement and you see dedication and commitment to the treatment and your client, get those follow-up tests for that TBI. See what else has happened to them. Don’t just sit there for two months of the treatment, not seeing any improvement. That’s what you want to watch for.

Okay, TBI. This is the funny one that I didn’t know — athletes are actually the most common occurrence for TBI. We’re also consistently learning more and more about the brain. I know all of you have had some kind of training in neurology and what’s happening in the brain. It seems like every year, they’re figuring out something new that’s been consistent with TBI as well. It doesn’t really matter whether somebody had a concussion or not. If they were inconsistent little explosions, if they were injured in other ways where they got shaken around — it’s pretty common for those light jarrings, those lighter hits that we didn’t used to associate to cumulative effects, to have problems. And again, since it’s with the brain and it’s literally your brain getting damaged from trauma, the symptoms are incredibly broad. So be aware of that. Unless you have specific training in TBI, refer out to get it tested. That’s okay; don’t expect that to be in your skill set if you’re not trained for it. I don’t have it. I refer out for it.

Military sexual trauma. This is a really big passion of mine. I’ve spent fully 15 years of my life working against this in multiple communities. Roughly one in four females and 1% of males are reporting experience with sexual assault and trauma in the military, which is almost perfectly mirrored with college experience. Sexual assault is a societal problem and is not a military problem, and to frame it as such is really unfortunate. The difference is the military, culturally, is framed as a large family. So what you will tend to see are themes closer to incest due to the cultural values of the military. If the mission comes first and someone in my unit did this to me, and I know that it’s going to split the unit if I report and come forward, I won’t. I will put the mission first ahead of my trauma. The military justice system struggles very similar to the civilian courts.

It’s not that the punishments aren’t there. It’s not that the stringent consequences aren’t there — it’s that proving sexual assault is incredibly difficult due to the nature of sexual assault. The other thing that tends to happen is it’s incredibly difficult for many survivors post-service to prove a service connection, because they often don’t report during their service. And the way that benefits go for the military is you have to prove the service connection, so it’s incredibly difficult for those folks. The other thing that’s different is military members are denied friend peer support through this process because every uniformed person is a mandated reporter. If I’m a uniformed person — I don’t have special training and a special role — and someone comes to me and says they were assaulted by another member, I can be disciplined if it’s found out that I know and didn’t report it. And that sounds horrible; it sounds antithetical to getting people to support. It’s a reach by commanders and by the command structure to show that they are intolerant of this behavior, that it’s against the military values and they want to punish and get the people out of the military that do this. So while it’s misaligned, it’s coming from a very strong, very caring place from the command structure. It’s important to recognize that.

The other thing that I’m seeing a lot of is one of the female providers that I work with: Military men will not report. So my last year in, I was now kind of a subject matter expert. I trained the bystander program to most of the bases in England. I was kind of a sought-after resource in Colorado, and I was tagged to come help train the next set of folks before I got out. And I was really heartened because everybody that showed up for the last training that I was part of volunteered, which is actually really rare. More often than not, people are assigned duties. Everybody that was there volunteered to be there, and they were passionate about taking on this problem.

The training was a week long, we were four days in, and then again, it had been a great group — really vulnerable, really honest, angry where I wanted them to be angry, committed, and passionate where I wanted to be passionate. More empathetic than I experienced before with people in uniform. We then watched a video where a former police officer discloses a sexual assault that he experienced while on duty. The officer was alone in his cruiser. He saw a trash can in an alley. He decided to walk and remove the hazard. Someone put a gun to his head and assaulted him — two men assaulted him. The entire room erupted in anger that this police officer would let that happen to him. This incredibly kind, dedicated, passionate group of people were appalled that a man in uniform that was armed would let that happen and wouldn’t choose to die trying to stop it. So if you get the gift of a man coming forward and acknowledging this, be incredibly delicate with that.

Addiction. Veterans drink heavy in service; 70% of us struggle with alcohol at some point in their lifetime. This comes with common additives, right? Drinking like a sailor. A common tradition across all branches is something called dining, in where it is not uncommon to see a unit commander doing a kegstand. I was stationed in Korea. The common tradition there — Korea is probably one of the harder drinking cultures because its culture’s frozen a little bit in time — was, we call it, “green bereting” a new member. The local liquor in Korea is called soju, and soju’s kind of mythical power is you can’t really taste it with any kind of mixer. It’s an incredibly insidious alcohol and it’s not regulated over there, so it doesn’t always come out as the same alcohol property. It’s incredibly difficult to gauge how much you’ve had.

What they would do is they would take the new member — and the drinking age over there was 18, so it’s every new member — they would sit them on a barstool and they would continue to pour liquor to them until they fell out of the barstool. That’s still happening today. That’s the culture around drinking. The other thing is the mission comes first. So if I’m in pain, if I’m struggling, if I’m dealing with things that need to numb, alcohol is the one thing I can go to that I’m allowed to. I’m not allowed to smoke pot. I’m not allowed to take time off. I’m not encouraged to go through medical — and to be honest, medical’s response tends to be much more problem-oriented than health-oriented, so they’re not going to give me anything different. This is also a really common theme with veterans that are out of the service with bad paper, meaning that they were left under other-than-honorable terms, they got a DUI, they got in fights, they showed up to work drunk, they had a domestic violence incident at home that kind of tossed out. You’ll find alcohol is really tied to this because essentially, what that means is they failed to cope along the way, and the one tool that was handed at some point was the alcohol. So watch the screening for them.

Suicide. This is pretty common now, right? Everybody’s aware that veterans struggle with suicide. The number 22 is a pretty accepted number across a number of platforms. That’ll move a little bit, depending on where you look. The important part of this is, just like police and other people that are exposed to violence, we have a plan. If I was to kill myself, I know how I do it. I came up with it on set, talking with my peers at two in the morning, really bored one night, trying to figure out the best way to do it, to hurt the fewest people, to make sure I left my family with my life insurance. That’s something that we did because we have a plan for everything. There’s a plan for every violent outcome — that’s part of our training. We’re also exposed to more lethality than our civilians. We know what death is, we’re around it, we’re trained around it. So we’re more likely to be successful, and that also lowers the barrier between us and the violence that causes us to be successful in a suicide attempt.

Female veterans follow the same statistics that their civilian counterparts do. They’re just more successful because they’re not using pills, they’re not using the softer methods, they’re much more likely to use lethality — firing a weapon at themselves. This is the one place where the VA has really turned things around and become a very active resource. Getting somebody in for general mental health at the VA in most places is still an incredible struggle. It is still really hard to get in, and there’s a month wait and then they’re likely to come to somebody like me outside the system. If you, as a clinician, call the crisis line — and I’d highly recommend it if you’re gonna work with veterans — call the crisis line as a provider and just tell them, “Hey, I’m a provider. I’m looking to learn more about your resource and to figure out how to integrate my care with it successfully.” It’s very supportive. I can’t speak well enough to those. Combat veterans are not the most at risk. Combat does not incline you to suicide. In fact, what we found is during service, combat veterans are the most resilient against suicide. Our non-deployed members were the ones we were losing during service.

Once they’re out of service, that might change, but people that have gone through combat have some resiliency, even if it traumatized them and they have struggled since. The most at risk in younger populations are non-combat-deployed Marines. Every Marine is a rifleman. Their purpose is combat. If they never got to see combat, they did not meet their purpose. They’re ridiculed within that service, they are less than in that service, and they own that. They’ve been indoctrinated into that. Aging veterans is actually who we lose the most — veterans over 60, veterans with health problems, which is more common with our population. The things they give us, the things we do, the things we’re exposed to in our life means we’re far more likely for complex health issues later in life. This has been highlighted over and over with Vietnam veterans, and it’s coming up more with Iraq veterans. We don’t age well, we have complex medical issues and we value functionality and not being a burden on our families. So that’s the population that you really want to watch out for.

The other thing that happened is was the Army, back in I think it was 2011, their suicide rate in one year doubled. Which terrified them, as it should, and they did a postmortem study and tried to look through and figure out what was happening, why they lost all these people. And they expected it to be because our operations tempo; the Army at the time was doing longer deployments and they were doing back-to-back deployments. They were really being awful, due to the operational tempo, to the people that were doing it. What they found was it wasn’t their combat veterans; more often than not, it was people with less than a year of service. And the further they were away from the cultural norm of the military — which is white, male, 19, heterosexual, Christian, American — the further away they were from those points, the more likely they were to have committed suicide. Their risk factors skyrocketed. The other thing to notice is that, a lot of veterans, their trauma doesn’t come from their service — their service was their escape from their trauma. It was my way out; it was how I got out of the inner city, it was how I got away from the home that hurt me, it’s how I got out of financial destitution. It was my opportunity to get out. So these were people that came in with trauma were looking for a solution and didn’t find it. That data continues to be true once they’re outside of the military, because their relationship to the military was probably strained.

Common barriers to care: Non-trauma-informed clinicians is a big one. Sadly, our programs — our master’s degree and our PhD programs — don’t put an emphasis on trauma. However, most centers do, so that’s changing, which is nice to see. Many veterans don’t have a sense that they merit care. For an example for this — just from a personal story — part of my job when I was doing the transition program on campus was to help people get guided to resources and an incredibly in-depth network. I knew what was available. I knew how the resources wanted to be used. And I have a disability rating; I have injuries from my service. I didn’t get them for the first year until one of my students that I was working with called me out on it. I was talking him through his process, and I would do a little shame sometimes to get them to take the help, and then the guy just looked at me. He’s like, “So what do you got going on? You were telling me your shoulder’s bummed, you know. Did you get help?” Oh no, man. I don’t want to walk down this.

So he’s just like, “That’s convenient, so you come at us about it.” It took one of my guys coming at me to get me to do it. There’s always someone worse off than you. If you show up to the VA for care, inevitably, you’re going to see somebody without a limb. You’re going to see an elderly veteran that you know, by his hat, served in some serious things. Just looking like he’s in pain — like he doesn’t have anything — but you’re going to go in ‘cause you got tinnitus. You’re going to go in ‘cause you got nightmares and, you know, the system is bogged down. So we don’t feel like we merit care. Now, the other thing is many veterans feel judged by clinicians. We know that caregivers are often nonviolent people. The same assumptions that you were talking about, where they assume that you’re liberal, and if you’re liberal, then you don’t support people that have been to war. All of those polarizing kind of tribal things that are happening in our country right now land just as hard on them.

The other thing is the military’s approach to health care is focused on function and not wellbeing; it’s all mission first. It’s the difference between me taking a pill that’s going to make it so I’m not in pain versus fixing the issue, but the pill will get me back to work tomorrow versus six months of recovery. I’m going to take the pill and the doctor’s going to tell me to take the pill. Mental health care in the military is also very similar. It’s about getting them back to work. It’s not about getting them better, and that’s not because they’re bad clinicians — it’s because it’s what the clients want. It’s what the system wants. It’s what’s important to them. So be very ready to unpack slower moving tools with people that already sought help. You see that on a lot of folks that have been on multiple deployments. Care between deployments has been normalized, so they’ll come in with some skills, they’ll come in with having some therapy, but you really need to frame it out that we’re going to do deeper work. We’re to resolve these things as opposed to band-aid them to get you better. And there’s an actively earned distrust with the resources that are available — that the VA has a very sordid history, the government has not handled veteran care well.

Other cultural factors to pay attention to is generational struggles. Iraq veterans are going to have different struggles than I have Afghanistan veterans. Korea veterans are going to be very different from Vietnam veterans. “Peacetime” veterans, and the reason I’m doing air quotes for peacetime is because we have been an armed conflict since World War I. We may not have declared war, but we’ve been in combat the entire time. They’re going to have different feelings around it. Politics of service members. So, when you all were talking, somebody put down that they took on the politics of the service. That’s not quite true. What happens is when I’m in uniform, my only political voice is my vote. I’m not allowed to caucus. I’m not allowed to run for office. I’m not allowed to publicly express political opinion, and I’m certainly not allowed to critique the policies of the administration. I’m allowed to vote.

The military structure is just like the American structure. The people at the top are white, older, educated males with money who tend to skew Republican. So that’s where the voice for the military comes from. Some of them will really identify with that, some of them will really wear that identity, just like other people in the country. They’re going to be varied in their opinion.
They’re going to be committed to it in various ways, and they’re getting more and more polarized as time goes by, just like everybody else. So be ready for that. The military rank structure is going to make for very different experiences in the military. Someone who served as a junior enlisted and got out as a junior enlisted is going to have very different experiences from someone who was an NCO, versus someone who was an officer, versus someone who was a senior officer.

The biggest way I can highlight this is to talk about the officer’s structure. So, you have to have a bachelor’s degree to become an officer in the first place. There are nine ranks all the way up in the officer corps. To get past a third rank in every branch, you have to have acquired a master’s degree on your own time. From then on, every time you progress in rank, you get another degree. They send you back to school every time. So by the time someone’s a Colonel or a Navy captain, they have at least four master’s degrees, if not a PhD. Their struggles are going to be very different as far as what their responsibilities were. Pay attention to that and learn the differences. I’ve talked a lot about the struggles when leaving service.

Common clinical mistakes: We know that trauma and trauma response is pretty universal. We know that the body is going to react in a certain way. However, what I hear a lot of is clinicians overreaching for connection by disclosing or trying to normalize a traumatic response. The most common one I hear from both my responders and my veterans is they’ll come in, they’ll be talking about their trauma response and they’re coming to a specialist. The military respects specialists, and that’s what they expect you to be. They expect you to be a specialist. They expect you to know your lane. However, when you say something like, “Oh, you know, it’s really normal that you’re having nightmares. My daughter was in a really traumatic car accident when she was 16 and she still has nightmares five years later, occasionally, about that accident.” We know that the traumatic response nightmares is going to be common; however, you just compared a car accident to military sexual trauma to combat trauma. That’s not the same frame, and it’s gonna make them feel unheard and like you don’t understand. It’s okay to be curious. It’s okay to not fully understand and speak the language — just don’t make those overreaches.

The other one that I hear is, oddly, a lot of us are married to pilots. I don’t know what that’s about. I hear this all the time where someone will say, “You know, it was really hard. I missed three of the five years of my child’s life and my wife has really struggled with that.” And they’ll say, “Oh, you know, I can really relate. My partner travels for work all the time; it does make it really hard at home.” While that’s kind of true, you weren’t worried about your partner not coming home, you weren’t worried about this happening. A very dear friend of mine went from their most intense combat experience of their career, in which they were awarded a bronze star, and two days later, they were holding their son for the first time. It’s more complex than that. Don’t overreach for those clinical connections.

I know I blitzed through this. It was really, really fast; we barely scratched the surface on what’s available. What you can do now is two things. The first one I want to mention is remember that you are a dedicated, well-trained, caring professional. If a veteran walks in right now and all you’ve had is this, you know how to connect with people. You know how to be kind, you know how to do your job well, and that’s going to go farther than anything else. So, own your expertise. You can also do a little bit more to learn about your clients so they’re not having to educate you as much, right? They need you, they need access to you, they need this normalized. You’ve got the open door to that. Make sure that in your practice, you say that you’re open to working with veterans. Write something up about why and how you want to work with them and what you appreciate about them. Get some more education. I’m going to talk a little bit about that. Find local allies and advocates and specialists to consult with. If any of you ever need 15 minutes for a client consult, please reach out to me. As a community, we should all be willing to give somebody 15 minutes in our specialty to make sure that the people that we care about — the people that brought us to this field — are getting the best service possible from a broadest range of folks. Find those people and trust yourself.

For resources, I cannot recommend PsychArmor.org more. It’s a nonprofit, it’s free, it’s very polished. They’ve got hundreds of hours of different courses on a very broad range of topics. Most of the information I use for my longer training comes from them. If you’re looking for a little bit more in-depth and more modern and, like, the cutting edge of trainings, you’re getting the deployment psychology. The Center for Deployment Psychology is amazing, but they’re all kind of nerds. They’re big data geeks. So they’re really boring, like endless. So unless you’re really into the information, that’s kind of hard to connect to. But it’s astounding, and they’re always putting out what they’re finding. It’s really, really good — in-depth.

Readings and social media: On Killing by David Grossman was the highly recommended book for me when I was starting out. I haven’t talked to a clinician that works with combat freshmen where that isn’t the first recommendation. I also just recommend this for anybody working with anybody in the community, particularly men. Tribe: On Homecoming and Belonging by Sebastian Junger is an absolutely wonderful book. It’s a short read. He does the reading. You can get it on Amazon. He’s got a TED talk if you wanna check that out; it’s a great bit of information. The Invisible War is free and available on Amazon Prime. It follows what happens to, I think, about a dozen veterans that were struggling with military sexual trauma. My caveat to that is make sure that you are watching the full version. I have real issues with how they cut it down and what they did as far as what their information was and the stew that it gives it, if you don’t watch the full version of that. Okay, so we blitzed through; I’m trying to respect your time. I know we’re at the hour mark. I can hang out a little bit for folks, like for questions. If you need to run, please email me and I’ll get back to you.

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