Serving Those Who Served

By Pamela S. Hyde, J.D. & Stephanie Weaver, MPA
January 6, 2015



Serving those who servedDo you know how many of the people you serve are U.S. military veterans? These brave men and women are an elite group, as veterans and currently serving military members account for only 10 percent of the U.S. adult population.

Many of the nearly 22 million U.S. veterans served in a time of war. More than 44 percent of veterans are over the age of 65, indicating service during Vietnam and earlier conflicts. While not all veterans see combat, all experience the stresses of military life.

Behavioral health service providers often treat veterans or family members of military personnel and do not know it. Yet, being a veteran or having a veteran or military personnel in the family may have an impact on service needs and treatment issues.

Intake questions often do not ask about veteran or military status of the individuals seeking services or in their family. Many veterans do not identify themselves as veterans and family members often do not identify the military or veteran status of a family member. This is especially true among female veterans and those who have not experienced combat deployment.

It is critical to ask if the individual or family seeking services is or includes anyone who has ever served in the military. This allows individuals to self-identify and the clinician to further assess the impact of military service on the individual or the family.

Many providers know the importance of cultural awareness when working with individuals from different races, nationalities or others with different customs or beliefs. The military has its own customs and beliefs too. For example, persons who serve in the military may be more deferent to authority, may have a sense of honor and service rather than sacrifice or are more likely to think that asking for help is a sign of weakness. All of these may create barriers to seeking care or may mask issues that need to be assessed and addressed.

The culture of the military often stays with veterans for years after leaving service, which makes it important to understand the basics of military culture. Fortunately, various training opportunities exist with regard to military culture, one example of which is the Departments of Veterans Affairs (VA) and Defense (DoD) free online training for community providers through www.deploymentpsych.org/MilitaryCulture.

While most military members return from deployment, or even peace-time military service, with only minimal readjustment issues, a small percentage will deal with post-traumatic stress disorder (PTSD). Not all PTSD stems from combat. It may also result from physical, emotional, sexual or other trauma that a service member may have experienced while serving in the military.

Approximately 7 percent to 8 percent of the general population experience PTSD at some point in their lives, some stemming from experiences before they enter or after they leave the military. Mental health professionals trained in evidence-based treatments for PTSD and those who appropriately refer those patients to a trained colleague (or VA) are most likely to help veterans heal. Treatments such as Cognitive Processing Therapy (CPT), Eye Movement Desensitization and Reprocessing (EMDR) and Prolonged Exposure (PE) have demonstrated effectiveness in treating PTSD, whether from military or other traumatic experiences.

The VA’s National Center for PTSD provides free clinical overview courses on these therapies and other clinical approaches as well as free continuing education credits. Clinicians seeking face-to-face training or clinical supervision may also consult local resources.

Some veterans may have experienced a traumatic event while in the service, while for others, experiences during their military service may have exacerbated previous trauma. Clinicians who have an understanding of the impact and consequences of such trauma can have a greater positive impact on those they serve. SAMHSA recently published a Treatment Improvement Protocol titled Trauma-Informed Care in Behavioral Health Services (TIP 57). This publication examines the research and offers best practice guidelines for treating individuals using a trauma-informed approach. SAMHSA has a paper called SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach.. It can be downloaded for free at http://store.samhsa.gov/.

For some individuals, untreated trauma can lead to suicidal ideation, attempts or completions. The risk for suicide among veterans is higher than for the civilian population as a whole, and although the reasons are complex and still being studied, traumatic experiences may play a part. In fact, studies show that veterans are two to three times more likely to die by suicide than the general public. This indicates a clear need for suicide prevention efforts focused on this population including clinical assessment for suicide risk.

Psychologists and other mental health providers play a crucial role in preventing suicide. Studies have shown that a substantial proportion of people who died by suicide had either been in treatment or had some recent contact with a mental health professional. Yet many providers report that they feel inadequately trained to assess, treat and manage suicidal patients or clients.

It is critical to know the warning signs of suicidal thinking: talking about wanting to die or to kill oneself, talking about feeling hopeless or having no reason to live, talking about being a burden to others, acting anxious or agitated or withdrawing and feeling isolated. Having access to means such as weapons or medications can also be an issue and needs to be assessed.

One tool for assessing for suicidality is SAMHSA’s SAFE-T [Suicide Assessment Five-step Evaluation and Triage] Cards (available for free through http://store.samhsa.gov/product/Suicide-Assessment-Five-Step-Evaluation-and-Triage-SAFET-T-/SMA09-4432).

SAMHSA’s Suicide Prevention Resource Center provides a best practice registry, resources and training for mental health professionals seeking to assess and prevent suicide. One face-to-face course offered by SPRC is Assessing and Managing Suicide Risk: Core Competencies for Mental Health Professionals, which provides 6.5 continuing education credits through meeting providers’ need for researchinformed, skillsbased training (http://www.sprc.org/traininginstitute/amsr). SPRC also offers free online courses.

While all individuals interpret and experience their environments in their own ways based upon their own histories, there are some commonalities that emerge among specific populations. For service members, this article provides a few options and resources that can enhance a behavioral health professional’s ability to address those needs effectively. Veterans raised their right hand swearing to defend the Constitution on behalf of the American community and they deserve a community that cares about and supports them in return.

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