Veterans seek mental health services for a variety of reasons, and a substantial percentage of them are diagnosed with PTSD. The U.S. Department of Veterans Affairs (VA) reports that over 1.7 million veterans received mental health treatment within the VA clinic system in 2019 alone.
For those who served in Iraq or Afghanistan, the prevalence of post-traumatic stress disorder (PTSD) is 11% to 20%. Combat experiences are not the only causes of PTSD in veterans. Others might be experiencing terrorist attacks, serious car accidents, or natural disasters.
Military sexual trauma is another factor, and it can occur in varied settings from offices to combat deployment. The VA reports that among veterans using its healthcare system, 23% of women have reported sexual assault when in the military. Further, VA figures indicate that the incidence of sexual harassment for service members is 55% for women and 38% for men during their service.
Clinicians may be called on to treat veterans through VA programs or from independent referral sources. To aid in understanding best practices in treating veterans experiencing PTSD and associated symptoms of trauma, we sat down with Reverend Wiley Hughes, D.Min., Psy.D., FBPPC, LCMHC, NCC, of Southeast Counseling Services. Based on that conversation, we have included important strategies for working with the veteran population.
1. Acknowledge the far-reaching repercussions of untreated PTSD
Recognize that PTSD can have a severe impact on a client’s physical health, functioning, and family life. Although symptoms of PTSD are not limited to veteran clients, they can be more acute. Veterans may exhibit symptoms in a different way from the rest of the population, Hughes noted.
Many veterans report that they feel no one can possibly understand what they have experienced. The violence and death surrounding them and the expectation to always be in control can be powerful forces that silence those struggling with a painful trauma history.
On top of these challenges are fears of traumatizing those close to them when discussing their past. When an everyday event or sound triggers flashback memories, the person experiencing PTSD may respond with fear or anger. They may resist discussing those vivid memories with family members for fear of plaguing them with nightmares, intrusive thoughts, or panic attacks as well.
The repercussions of the past trauma on a client’s health, relationships, and daily functioning can lead to an acute increase in symptoms.
2. Acknowledge that symptoms may temporarily worsen before improving
Although millions of people have served in the military, being part of this community does not guarantee a person is receiving the support they need. Other service members or even family members may reject a person who experienced trauma for reaching out or telling their story. But many veterans can empathize and attest to the positive results of treatment.
When a veteran begins therapy sessions, their fear and anxiety may intensify initially. Trauma survivors may find that their loved ones get overwhelmed and lose patience with them because they can’t let go of their experience and move forward now that they have returned home.
In response to this fear of rejection, trauma victims develop a story that offers an explanation for visible symptoms yet does not truly encompass the pain and suffering experienced inside.
3. Encourage a shift in perspective among trauma survivors
Instead of thinking of PTSD as a mental illness, what if we could challenge clients to see it as a mental injury?
An injury is something we can externalize and view as something that happened to us, not something that is wrong with us. Hughes mentioned that families are often better able to accommodate a physical injury like an amputation by changing things around the house, installing a wheelchair ramp, or reassigning certain household chores.
What if you were able to help clients see PTSD as an injury that can be accommodated in the same ways? This is the basis of being trauma-informed: ask individuals “what happened to you?” versus “what’s wrong with you?”
4. Remember that empathetic support is built over time
The basis of all therapeutic efforts should be empathy. But, as Hughes explained, to get to empathy we have to get through the defenses guarding our client.
Military service members have been trained to embrace only one trauma response: fight. While this is necessary for obvious reasons, it goes against human instinct. Most people have the option to freeze or flee from danger as well.
Many veterans are left with the feeling that they must engage with the enemy at all costs. When the enemy becomes your own mind, the first thing you need is a new source of support.
Hughes stressed that clinicians must hold off on inviting any clients, but most especially veterans, to share their trauma history in the initial sessions. Veterans must be given the time and space to build trust with the clinician.
5. Know your own limits as well as your strengths
Clinicians must also be willing and able to analyze their own countertransference or preexisting beliefs about veterans. Our society worships heroes. Naturally, we tend to idolize those we see as demonstrating certain strengths we desire for ourselves. We must recognize our own beliefs without imposing them on the client in front of us.
Hughes further explains that we must be able not only to hold space for the client but also to challenge them on their narrative or perception of events. These clients need and deserve for the clinician to be genuine in their responses and efforts to be empathetic while also pushing the client when necessary.
6. Acknowledge your client’s moral injury
Service members are called on not only to endure, but also to employ, violence in the name of war. Hughes said the issue of morality and moral injury comes up often in his sessions with veterans. He says that many of his clients seek him out specifically due to his specialization in pastoral counseling and presumed authority on morality.
Military service may require actions in direct opposition to a service member’s own moral values. We discussed the haunting images that may accompany veterans returning home from active duty. Many report being unable to reconcile their memories with their own humanity.
Clinicians need to be able to assist veterans with reconciling their traumatic experiences with their feelings and behaviors going forward. Moral injury is an important aspect of trauma. Effective treatment efforts will support clients as they recall experiences that were in direct conflict with their moral or core beliefs.
7. Face down myths with accurate information
Trauma recovery is a process and a journey. Help your client understand myths related to PTSD and counteract them with treatment resources. You should always be willing to refer a client out for a modality that is outside your scope of practice.
If the client declines a referral, don’t be afraid to ask why. Then you can address the fear that may be preventing them from moving forward.
8. Employ shared decision-making techniques
Your client’s experiences likely are tied to feelings of powerlessness and lack of choice that accompany moral injury and trauma. Your approach should help them feel a sense of control in their own recovery. Honor their ability to make informed choices. Empower them by providing information and resources and promoting collaboration as you discuss treatment options.
With ever-increasing numbers of service members seeking mental health assistance, the work of well-trained, genuine, and empathetic helping professionals is critical. If you’d like to get involved with helping veterans or their families, contact your local Veterans Administration office to ask how you can become a referral source in your area. You can also connect with other providers in your area who specialize in helping veterans.
Note: Our thanks to Wiley Hughes, D.Min., Psy.D., FBPPC, LCMHC, NCC, of Southeast Counseling Services. Hughes is a licensed clinical mental health counselor, a state certified pastoral counselor, and a national certified counselor.