Adrian Marquez, a retired Marine master sergeant and  Marine Raider, woke up one morning during his time in the Marine Corps and couldn’t remember how to get dressed. He looked down at his pile of clothes and mumbled, “Pants first, then shoes?”

Marquez was also experiencing physical aches throughout his body, including radiating pain in his arms and legs. His left arm would sometimes lose strength and go numb. So, he went to his unit’s medical clinic — a team of primary care medical doctors, psychologists, psychiatrists, social workers and physical therapists — and the medical staff told Marquez he was physically healthy compared with peers in his age range across the United States. They determined it was all in his head. The mental health clinicians made assumptions based on Marquez’s extensive combat history and quickly diagnosed him with posttraumatic stress disorder (PTSD), an anxiety disorder and a depressive disorder with severe somatic symptoms.

But the symptoms didn’t go away. Marquez later returned to the clinic because of intense pain in the back of his left eye. This time, the clinic performed an MRI and discovered that he had ocular damage, in addition to possible injuries to his brain. Another MRI was scheduled, and it confirmed that Marquez had a traumatic brain injury (TBI) that caused lesions across his brain, including one in his orbital track. The scan also picked up another issue: Marquez had four compressed disks, two of which had ruptured, so even a moderate impact would lead to paralysis.

Despite his injuries, the Marine Corps insisted that Marquez get ready to deploy again in a few weeks’ time. Learning this, his master gunnery sergeant pulled him aside and told him, “There will be a time when you take your uniform off, and you’re going to have to live with the person underneath it. If you want to have a normal life, you have to take care of yourself.”

The master gunnery sergeant sent Marquez’s paperwork to the Wounded Warrior Regiment, which allowed medical staff to fully evaluate him for a month. According to Marquez, the master gunnery sergeant lost his position over that decision, but Marquez took what his “master gunns” said to heart. During the evaluation, Marquez concluded that he needed to take care of his physical and mental health before deploying again. When he told his new master gunnery sergeant that he wanted to have surgery before deploying, the Marine Corps forced him into medical retirement.

The decision shook Marquez to his core. He had given the Marines 17 years of his life, and now he was left to deal with abandonment issues, depression and anxiety — on top of his physical injuries and TBI. When he started mental health therapy, he quickly realized that the clinicians treating him were knowledgeable about mental health issues, but they didn’t seem to have much of an understanding about military culture.

Improving military cultural competency 

Marquez is now a licensed mental health counselor himself. He created and serves as the director of programming for the Sheepdog Program, a mental health and substance abuse program for veterans and first responders in Melbourne, Florida. The fact that he encountered so many mental health clinicians who were not culturally competent about the military is not shocking given that many practitioners lack specific training in that area and don’t necessarily consider clients who serve in the military as being part of a distinct culture.

But as Marquez points out, the military does indoctrinate people into a unique culture — one that is fast-paced and possesses its own rules, policies and language. Being in the military changes the way that people think and feel, Marquez emphasizes. He compares this new mentality to being a sheepdog because, he says, service members are trained to stand outside and protect the herd by leaving the herd and staring into the eyes of the wolf. They can’t and don’t hide from the ugliness of the world. Instead, they are often exposed to a raw violence. And once exposed, they can’t unsee it, Marquez says. It is imprinted in their minds and shapes the way they view the world.

Keith Myers, dean of clinical affairs and an associate professor of counseling at Richmont Graduate University, conducted interviews with veterans for his recently published book, Counseling Veterans: A Practical Guide, which he co-authored with W. David Lane, a licensed professional counselor (LPC) and professor of counseling at Mercer University. In doing the interviews, Myers says that one topic kept coming up repeatedly: the need for counselors to be culturally competent with this population.

Just like with any other cultural group, counselors have to learn the specific language and customs associated with the military culture, says Taqueena Quintana, an American Counseling Association member and owner of Transformation Counseling Services, a private practice that works with military-connected populations. The language is also specific between military branches, she points out. For example, calling someone in the Air Force a “soldier” communicates a lack of understanding and can cause offense because they are properly referred to as “airmen,” she explains.

Counselors also need to consider these clients’ personal cultural factors — ethnicity, sexual orientation, spirituality, era of service and so on — that further shape their experience both during and after military service.

“Veterans are not cut out from the same material,” notes Tanya Workman, an LPC who is the training director for the licensed professional mental health counselor training program at the South Texas Veterans Health Care System’s Frank Tejeda Outpatient Clinic in San Antonio. “Their overall life experiences, as well as their experiences in the military, will potentially shape their perspective and response to treatment. So, take time to understand the impact that the veterans’ time in service has contributed to their current mental health and function.”

Workman advises counselors to learn about military culture, the various branches of service, the history of the different eras and the veterans’ perceptions of the role they played while in service. Showing interest in the veterans’ experiences builds rapport and helps avoid unintentionally creating barriers by assuming to know what that experience was like for them, she continues. For example, if a veteran is struggling with a moral injury, they may find it difficult to respond to a therapist’s expectation that they are proud of their time in service, she says. So, Workman recommends counselors ask clients, “Why did you join the military? What did your time in service mean to you? What feelings come up regarding your time in the military?”

When she has clients who have retired or finished their time in service, she always asks about their transition from military to civilian life and whether they were ready to retire or separate from the military. Some are ready to be done, she says, but others may feel their time was cut short because of administrative, disciplinary or medical reasons (e.g., not making a designated rank within a specified time period, incurring a medical or mental health condition that prohibits the service member from doing their job). Processing their feelings (such as loss or grief) related to the sudden end of their service can be validating and helps set the tone for future healthy disclosure, she adds.

Myers, an LPC with a private practice serving veterans in Marietta, Georgia, recommends that counselors start by talking to relatives or friends who are veterans and asking them, “What was your experience like? What’s your advice for me as a counselor who wants to work with this population?”

Making counseling relatable

When counselors learn more about clients’ occupations and experiences in the military, they are better able to connect counseling activities and concepts to things that are relatable to the clients, advises Workman, an Army veteran and ACA member who specializes in treating veterans dealing with trauma (including military sexual trauma), substance use disorders and difficulties transitioning from military to civilian settings. For example, she equates the importance of breathing techniques with running and calling cadence or being at a rifle range. All of these activities involve a rhythmic or patterned breathing that some military clients already understand well.

Marquez, owner of the private practice Calm in the Storms, modifies the way he explains mindfulness to his clients. He starts by referring to it as mindfulness training rather than mindfulness meditation. Then he compares mindfulness training to exercise or pistol practice: Clients must repeat the action over and over again for it to work effectively. With meditation, clients are doing a repetitive action — such as focusing on breathing or a certain noise or sensation — to control intrusive thoughts and ground themselves in the present moment, he explains.

Workman, a member of the Military and Government Counseling Association (MGCA), a division of ACA, also uses analogies to explain difficult topics such as hyperarousal, anxiety and avoidance. She often describes hyperarousal as birthday candles setting off smoke detectors and sprinklers to explain how the body’s response to the environment is sometimes more than what is needed. The body — like the alarms — is just responding to a perceived danger. This analogy helps clients understand that hyperarousal is a normal bodily response designed to keep them safe. Then, Workman teaches clients how to be aware of this heightened response and how to calm the body so that the response matches the level of danger.

Marquez also refers to solution-focused therapy as mission-oriented therapy when working with clients affiliated with the military. He describes the approach as a way of addressing the 5-, 10- and 25-meter targets in clients’ lives. He explains that unless the client confronts and takes action on the 5-meter target, it could prevent them from working on their longer-term goals (their 10- and 25-meter targets).

Myers, an ACA member whose clinical specialties include veterans issues, trauma and combat-related PTSD, sometimes makes subtle adjustments to counseling approaches when working with military-connected clients. For example, in couples counseling, Myers often uses John and Julie Gottman’s concept of “accepting influence” from your partner, which involves taking your partner’s opinion into account and being open to using their input to make decisions together.

With military-affiliated couples, Myers brings in a third partner — the military — because the couple must compromise not only with each other but also with the military. When the military deploys the service member or reassigns the service member to a new post, the couple must readjust their plans and deal with these added stressors together.

It’s not all combat-related PTSD

Marquez says he worked with a few therapists who almost did him more harm than good because they assumed that his combat experience was the catalyst for his PTSD. They thought that engaging in military operations and pulling the trigger on his weapon so many times had to be the source of his trauma. They didn’t seem to understand or accept that Marquez was comfortable with the actions he took during his military service.

But one therapist was different. He didn’t presuppose that Marquez’s PTSD was attached to his military service. He set aside his own assumptions and told Marquez, “I can’t pretend to understand what you’ve been through, and I’m not going to. I’m going to ask you questions, hear you talk and connect the dots based on what you say.”

In going through that process with the therapist, Marquez finally discovered that the actual source of his PTSD was his experience of escorting his friend’s body home to Texas. As the escort, he had to view the body and make sure that the uniform was ready for presentation. Seeing his friend’s face — which was almost unrecognizable covered in makeup and saran wrap to preserve the body for the funeral — and confronting the reality of death triggered his PTSD.

Therapists are great at understanding different types of trauma, but some have muddied the water by diagnosing seemingly everything related to the military as PTSD, Marquez adds.

Quintana, an LPC in Washington, D.C., and an assistant professor of counseling at Arkansas State University, agrees that PTSD and TBI are the two mental health issues that people most closely associate with the military. Although a large number of veterans and service members do indeed contend with these issues, they also deal regularly with depression, anxiety, adjustment disorder, co-occurring disorders, substance use disorders, family discord and marital issues, to name a few, Quintana says. Sometimes people connect the military almost exclusively with war and combat, she says, forgetting or not realizing that chaplains, medical professionals and lawyers also serve in the military.

Combat-related PTSD often makes the news, which is good because it raises awareness about mental health and military-connected clients, but it also leads to the common misconception that the majority of veterans have PTSD, says Myers, an MGCA member who previously served on the association’s board of directors. Although PTSD is a common clinical issue, the majority of veterans do not have PTSD. According to the Department of Veterans Affairs, 11% to 30% of veterans have had PTSD over their lifetime.

On the flip side, sometimes clinicians and veterans may assume that certain military service members could not be experiencing PTSD because they have not seen combat in a traditional sense, Workman adds. But trauma is not exclusive to combat occupations, so clinicians should assess all veterans for trauma exposure during service, as well as for trauma that may have occurred elsewhere across the life span, she continues.

For example, she has worked with veterans who served in military intelligence. Their work required them to monitor a computer, and consequently, they were often exposed to the aversive details of violence and war. Even though it would be easy to dismiss their experience as simply sitting in a safe room without the fear of others shooting at them, they still were exposed to combat, just in a different way, Workman says.

Treating co-occurring disorders

Mental health work doesn’t always come neatly packaged with only one presenting problem at a time. Issues often overlap, and Quintana, a deployed resiliency counselor for the Navy, finds that co-occurring disorders are common among military-connected clients.

According to the National Center for PTSD, substance use disorder and PTSD often co-occur with veterans. In the past, mental health and substance use treatment facilities often required clients to be abstinent from substance use before treating them for mental health issues. But this is happening less frequently, and more agencies are taking an integrative approach to care through dual-diagnosis groups, relapse prevention education and comprehensive treatment plans for co-occurring disorders, says Quintana, a member of MGCA and a former school counselor with the Department of Defense Education Activity.

Still, health care professionals too often focus solely on the high intake of substances rather than looking at the big picture or other co-occurring issues, Marquez notes. He says he has known clinics that quickly diagnosed military-connected clients with a substance use disorder and made that the primary treatment plan, or they refused to address trauma at all because they didn’t have the time or resources to handle both the substance use disorder and trauma simultaneously. This experience often causes these clients to either leave counseling or to refrain from talking honestly about their substance use out of fear that they will automatically be labeled with a substance use disorder, he says.

When clients come to Marquez with co-occurring issues such as trauma and substance use, he is honest with them. He informs them that their drinking might technically qualify as a substance use disorder, but he also acknowledges that he knows that behavior is considered acceptable in military culture. He doesn’t ask them to stop, but he does request that they show him that substance use is not a factor in their presenting issue. Often, they stop using substances without any problems. If they don’t, then substance use disorder becomes another part of their treatment plan.

When working with veterans who may have a significant history of alcohol or substance use, Workman advises counselors to be vigilant in looking not just at how much these clients are drinking or using substances but also at their history of trauma, anxiety and other mental health issues. If a person’s anxiety is high and not adequately managed, then it isn’t shocking to find that they are drinking excessively or having difficulty with irritability, anger, or interpersonal interactions at home or work, she says.

Counselors should also do a thorough evaluation if a military-connected client is referred to them for a behavioral problem because, so often, the problem is not the problem, Workman says. “Counselors should ask the veteran, ‘When did this behavior start? What makes it worse? What were you thinking and feeling? What else was going on when you were engaging in this behavior? When was it not like this?’”

It is easy to focus only on the negative behavior, but then the underlying mental health issues that contributed to that behavior often go overlooked and untreated, Workman adds.

Likewise, counselors shouldn’t focus only on the events that happened during clients’ time in the military. Sometimes, past traumas or mental health issues can go untreated, and military experiences only compound the issue. For example, someone who was previously reprimanded for violence might now be applauded and promoted for similarly violent actions performed during their military service. This person is receiving conflicting moral messages, which may compound the emotional wounds they had before entering service, Marquez says.

Co-occurring disorders can also become an issue when symptoms overlap, Myers points out. TBI and major depression can both involve difficulties with attention, depressed mood and trouble sleeping. And irritability and agitation are both symptoms of TBI and PTSD. This overlap can make it challenging to treat, Myers says. Counselors may get stuck trying to figure out the diagnosis — is it TBI, depression or both? “It’s less about deciding what the diagnosis is and more about treating this person holistically,” Myers says.

Marquez says that if counselors focus on a client’s trauma first and wait to address their grief until later, then when they do get around to focusing on the grief, all of the client’s trauma could resurface. That’s why Marquez addresses it all at once. In the Sheepdog Program, which offers a partial hospitalization program and an intensive outpatient program, clients have two to five individual therapy sessions per week, along with other special therapy sessions such as narrative therapy, eye movement desensitization and reprocessing (EMDR), and family therapy that address the specific issues with which they are dealing.

Short-term therapies

Traditional, hourlong counseling sessions aren’t always a possibility for military-connected clients, especially those who are active-duty service members, because they are always in motion, Quintana says. Depending on their duties, some service members may have only a short span of time to meet with a mental health professional, such as during lunch breaks, she points out.

For this reason, Quintana continues, solution-focused therapy, which is a future-focused and goal-oriented approach, can be effective for certain issues within military settings (although not for more serious issues such as trauma and suicidality). If a service member presents with a relationship issue, for example, Quintana empowers the client to identify their own solutions. She may say, “Tell me a time when this issue did not exist. What was different then?” This encourages the client to get away from all-or-nothing thinking and highlight strategies that were helpful previously.

Quintana also believes it is important to build on clients’ strengths. For example, if the client says they are good at communication, she would explore with the client how they could use this skill to improve their relationship. After the client sets goals (with Quintana’s support), Quintana would continue to follow up with the client to monitor success.

Workman fears some veterans may be burned out by solution-focused therapy because it is used so often with service members while in the military setting. In her work with veterans, she uses prolonged exposure for primary care (PE-PC), a type of abbreviated therapy specially designed for the treatment of trauma. It consists of a minimum of six 30-minute sessions provided at the client’s primary care clinic, which tends to be a more convenient and familiar setting for them. This therapy also helps veterans who are not able to dedicate a large portion of their day to counseling and may remove potential barriers to treatment posed by the stigma associated with referral to a mental health clinic, Workman notes.

In these sessions, clinicians teach veterans about common mental health issues such as PTSD. They learn to recognize distressing symptoms and evaluate the intensity of these symptoms by using the Subjective Units of Distress Scale, a self-assessment tool that measures the subjective intensity of disturbances or distress experienced by an individual. Clients track their distress level using this scale before, during and after writing their trauma narrative. By doing this, Workman finds that clients begin to notice improvements in the way they respond to distressing thoughts and memories and that their distress decreases the more they read their narrative out loud. They also have more control and do not experience the same overwhelming symptoms of trauma-related anxiety, she adds.

Clinicians also teach veterans to safely cope with mood distress by using safe grounding and relaxation techniques, Workman continues. The clients work through a prolonged exposure workbook, recording and processing their personal trauma event in a safe and systematic manner with the therapist’s support. The therapist ends each session with a relaxation exercise.

Following this sequence of steps empowers clients to repeat this behavior on their own, she points out. She has found the treatment to be effective, with clients reporting a decrease in severity levels and, more importantly, an improvement in their quality of life.

Marquez finds that virtual reality exposure therapy helps military-connected clients reexperience and remember events connected to emotionally charged memories. Marquez once worked with a client who had dissociative amnesia surrounding an event in which his comrade died in a car. The client felt guilty for not pulling his fellow service member out of the car in time. Marquez positioned the client in front of a black virtual reality screen and asked him to recall the events of that day. At one point, the client described hearing a roar, so Marquez played a few different sounds. When he played a fire sound, the client said, “Yeah, that’s the sound.”

Marquez then turned on the virtual reality screen, and the client saw a vehicle that was on fire. Seeing this image made the client recall that the car had been on fire, so he couldn’t have gone back to save his comrade. The interactive experience restored the client’s lost memories and freed him from the guilt he had felt for years.

Marquez says this therapy helps clients reduce the triggers associated with traditional PTSD responses. It also helps them revisit memories that are often repressed by their military training to react in a rational, nonemotional way. But when they relive the event, they may experience unrecognized emotions associated with it, Marquez points out. So, he uses EMDR to help clients manage the emotional memories that often resurface after virtual reality exposure. “They’re allowing themselves to finally feel the emotions that they never let themselves feel because they were just operating in the rational mind, just following their training,” he explains.

Creating a pipeline for success

Some military families have confided to Quintana that they don’t seek out counseling because they fear they will simply be passed off to someone else or handed a referral list. “Counselors must take time to invest in their clients and ensure they are part of the process,” she stresses.

Quintana takes a collaborative approach with military-connected clients. She believes that partnership is key to facilitating change. In addition to meeting clients where they are, Quintana works with them to highlight their past successes, set goals, and identify tools and resources that can help to address their issues.

Quintana provides an example: A military family is experiencing their second deployment, and the spouse comes to counseling concerned about their child’s social, emotional and behavioral responses to the transition. To better understand this family and their particular needs and strengths, Quintana might explore the family’s past experiences and successes. She might ask the spouse, “What helped your child when they previously navigated challenges related to deployment?” or “Tell me about a time during deployment when this issue was less noticeable. How did you make that happen?” These types of questions help build on what has already worked, highlight the family’s strengths and empower the family to identify solutions.

Through this conversation, Quintana learns that during the previous deployment, the school counselor placed the child in a group with other military-connected children dealing with deployment challenges, and the child found bibliotherapy to be helpful in processing their feelings. Rather than handing the parent a list of resources, Quintana would suggest that the family collaborate with their child’s new school counselor on bibliotherapy strategies that could be used both at school and at home. She would also work with the spouse to access these services within the school and, if needed, the community. “These relationships are meaningful and foster trust, which is critical when supporting military families,” Quintana says.

Myers often seeks to empower his military-connected clients through the use of motivational interviewing. This approach encourages clients to discuss their own reasons and motivations for change. Being able to set their own goals, talk about ways to achieve change and explore their motivations honors their autonomy, Myers says.

Marquez learned the importance of mental wellness the hard way through misdiagnosis and clinicians who were insufficiently trained in the military culture. To correct this issue, he has developed programs and trainings to educate clinicians on working with this population, but he says he would love to see more mental health professionals get involved in creating a pipeline for veterans who want to become counselors and in facilitating peer support specialist groups led by veterans.

Marquez finally found a clinician who took the time to listen and help him figure out the root of his PTSD. Mental health professionals can learn from his experience by becoming more culturally competent and reframing their tools so that military-connected clients do not find themselves alone in the trenches.

 

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Action steps for more information:

• Read Duane France’s series of “From Combat to Counseling” columns at CT Online (ct.counseling.org).
• Purchase Clinical Military Counseling: Guidelines for Practice by Mark A. Stebnicki, newly published by ACA (imis.counseling.org/store).
• Visit the website of the Military and Government Counseling Association (mgcaonline.org).
• Join the ACA Veterans Interest Network (counseling.org/aca-community/aca-connect/interest-networks).

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Read a companion article to this piece, “Advice for counselors who want to work with military clients,” at CT Online.

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.com.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.