Adrian Marquez, a retired Marine sergeant and marine raider, woke up one morning while serving in the Marine Corps and couldn't remember how to dress. He looked down at his pile of clothes and mumbled, "First pants, then shoes?"
Marquez also had physical pain all over his body, including radiating pain in his arms and legs. His left arm sometimes lost strength and became numb. So he went to his department's medical clinic – a team of family doctors, psychologists, psychiatrists, social workers, and physical therapists – and the medical staff told Marquez he was physically healthy compared to his peers in his age group in the United States. They found that everything was in his head. The psychiatrists made assumptions based on Marquez's extensive battle history and quickly diagnosed him with post-traumatic stress disorder (PTSD), anxiety disorder, and depressive disorder with severe somatic symptoms.
But the symptoms did not go away. Marquez later returned to the clinic with severe pain in the left fundus. This time the clinic performed an MRI and found that in addition to possible injuries to his brain, he had eye damage. Another MRI was scheduled and confirmed that Marquez had a traumatic brain injury (TBI) that caused lesions in his brain, including one in his orbital tract. The scan also picked up another issue: Marquez had four compressed discs, two of which were torn, so even a moderate impact would paralyze them.
Despite his injuries, the Marine Corps insisted that Marquez get ready for action again in a few weeks. When he found out, his sergeant pulled him aside and said to him, "There will be a time when you will have to take off your uniform and live with the person underneath. If you want to lead a normal life, you have to take care of yourself . "
The Sergeant Major sent Marquez 'records to the Wounded Warrior Regiment, which allowed medical personnel to examine him fully for a month. According to Marquez, the Sergeant of the Master Gunnery lost his position because of the decision, but Marquez took to heart what his "Master Gunns" were saying. During the evaluation, Marquez concluded that he must take care of his physical and mental health before returning to the field. When he told his new sergeant major that he wanted an operation before he was deployed, the Marine Corps forced him into medical retirement.
The decision shook Marquez to the core. He had given the Marines 17 years of his life and now, in addition to his physical injuries and TBI, he had issues related to abandonment, depression, and anxiety to deal with. When he started mental health therapy, he quickly found that the clinicians treating him knew about mental health issues, but they didn't seem to have much understanding of military culture.
Improvement of military cultural competence
Marquez is now a licensed mental health advisor himself. He created and serves as the program director for the Sheepdog Program, a mental health and substance abuse program for veterans and first responders in Melbourne, Florida. The fact that he has encountered so many psychiatric clinicians who were culturally incompetent in the military is not shocking, as many practitioners do not have specific training in the field and clients serving in the military do not necessarily have to be part of a specific one Consider culture
But as Marquez points out, the military indoctrinates people into a unique culture – one that is fast moving and has its own rules, guidelines and languages. Being in the military changes the way people think and feel, Marquez points out. He likens this new mentality to being a sheepdog because the members of the service are trained to stand outside and protect the herd by leaving the herd and staring into the wolf's eyes. You can't and don't want to hide from the ugliness of the world. Instead, they are often subjected to brute force. And once they're exposed, they can't see it anymore, says Marquez. It's imprinted on their minds and shapes the way they see the world.
Keith Myers, Dean of Clinical Affairs and Associate Professor of Counseling at Richmont Graduate University, interviewed veterans for his recently published book Counseling Veterans: A Practical Guide, co-authored with W. David Lane, Licensed Professional Consultant (LPC) and Professor of Consulting at Mercer University. During the interviews, Myers said that one topic kept coming up: the need for counselors to be culturally competent with this population.
As with any other cultural group, counselors need to learn the specific language and customs of military culture, says Taqueena Quintana, a member of the American Counseling Association and owner of Transformation Counseling Services, a private practice that works with the military. connected populations. The language is also specific between military branches, she emphasizes. For example, if you refer to someone in the Air Force as a "soldier", this means a misunderstanding and can lead to insults, as they are rightly called "aviators".
Counselors must also consider these clients' personal cultural factors – ethnicity, sexual orientation, spirituality, era of service, etc. – that further shape their experience both during and after military service.
"Veterans are not cut out of the same material," notes Tanya Workman, an LPC who serves as the trainer for the licensed professional training program for mental health counselors at the Veterans Health Care Systems Frank Tejeda Outpatient Unit in South Texas in San Antonio. “Your general life experiences, as well as your military experience, will potentially influence your perspective and response to treatment. So take the time to understand the impact veterans' service life has on their current mental health and function. "
Workman advises counselors to study military culture, the various branches of the service, the history of various eras, and veterans' perceptions of the role they played in the service. Showing interest in the veterans' experiences builds a relationship and helps unintentionally create obstacles by assuming they know what that experience was like for them, she continues. For example, when a veteran is grappling with moral harm, they may find it difficult to respond to a therapist's expectation that they would be proud of their service, she says. Therefore, Workman recommends that advisors ask clients, “Why did you join the military? What did your period of service mean to you? How do you feel about your time in the military? "
Whenever she has clients who have retired or left the service, she always asks about their transition from military to civilian life and whether they were ready to retire or part with the military. Some are ready to be done, but others may feel that their time has been reduced for administrative, disciplinary, or medical reasons (for example, failing to achieve a certain rank within a certain period of time and having a medical or mental health status that prohibits the service member from doing his or her job). Processing her feelings (like loss or sadness) related to the sudden end of her service can be an affirmation and help set the tone for future healthy disclosure, she adds.
Myers, an LPC with a private veteran's practice in Marietta, Georgia, recommends counselors first speak to relatives or friends who are veterans and ask them, “How was your experience? What do you advise me as a consultant who wants to work with this population? "
Relate advice
When counselors learn more about clients' professions and experiences in the military, they can better link counseling activities and concepts to things that are relevant to the clients, advises Workman, an Army veteran and ACA member, who focuses on Treatment for veterans has specialized in dealing with trauma (including military sexual trauma), substance use disorders, and difficulty transitioning from the military to the civilian setting. For example, she equates the importance of breathing techniques with running and cadence or being on a shooting range. All of these activities involve rhythmic or structured breathing that some military clients already understand well.
Marquez, owner of the private practice Calm in the Storms, changes the way he teaches mindfulness to his clients. He begins by calling it mindfulness training rather than mindfulness meditation. Then he compares mindfulness training with training or pistol exercises: Customers have to repeat the action over and over for it to work effectively. With meditation, clients do a repetitive act – like focusing on breathing or a certain sound or sensation – to control intrusive thoughts and to 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, fear, and avoidance. She often describes Hyperarousal as birthday candles that set off smoke alarms and sprinklers to explain how the body's response to the environment is sometimes more than necessary. Like alarms, the body only reacts to a perceived danger. This analogy helps clients understand that hyperarousal is a normal physical response that is meant to protect them. Workman then teaches clients how to become aware of this increased response and how to calm the body so that the response is appropriate to the level of danger.
Marquez also describes solution-oriented therapy as mission-oriented therapy when working with clients associated with the military. He describes the approach as a way to meet the 5, 10, and 25 meter goals in customers' lives. He explains that if the client is not faced with the 5 meter goal and takes action, they could be prevented from working on their longer term goals (his 10 and 25 meter goals).
Myers, an ACA member whose clinical specialties include veteran problems, trauma, and combat-related PTSD, sometimes makes subtle adjustments to counseling approaches when working with military-affiliated clients. For example, Myers often uses John and Julie Gottman's concept of “accepting influence from your partner” in couple counseling, which takes your partner's opinion into account and is open to using their input to make decisions together.
With couples who belong to the military, Myers brings in a third partner – the military – because the couple has to compromise not only with each other, but also with the military. If the military appoints the service member or reassigns the service member, the couple will have to readjust their plans and deal with these additional stressors together.
It's not all battle-related PTSD
Marquez says he worked with some therapists who did almost more harm than good for him because they believed that his fighting experience was the catalyst for his PTSD. They thought that the cause of his trauma must be to engage in military operations and pull the trigger on his gun so often. They did not seem to understand or accept that Marquez was satisfied with the measures he had taken during his military service.
But one therapist was different. He did not assume that Marquez 'PTSD was associated with his military service. Setting aside his own assumptions, he said to Marquez, "I can't pretend I understand what you've been through and I won't." I'll ask you questions, hear you talk, and connect the dots based on what you say. "
When Marquez went through this process with the therapist, he finally discovered that the real source of his PTSD was his experience of bringing his friend's body to Texas. As an escort, he had to look at the body and make sure the uniform was ready for presentation. When he saw his friend's face – which was almost unrecognizable and was wrapped in makeup and saran to preserve the body for the funeral – and faced the reality of death, it triggered his PTSD.
Therapists are good at understanding different types of trauma, but some have clouded the water by diagnosing what appears to be military-related as PTSD, adds Marquez.
Quintana, a Washington, DC LPC and assistant professor of counseling at Arkansas State University, agrees that PTSD and TBI are the two mental health problems that most closely associate people with the military. While large numbers of veterans and service members actually grapple with these issues, they also regularly deal with depression, anxiety, adjustment disorders, concomitant disorders, substance use disorders, family discord, and marital problems, to name a few, says Quintana. Sometimes people associate the military almost exclusively with war and combat, she says, forgetting or not realizing that chaplains, medics and lawyers also serve in the military.
Combat-related PTSD often makes the news, which is good because it raises awareness of mental health and military-related clients, but also creates the widespread misconception that the majority of veterans suffer from PTSD, Myers says . an MGCA member who previously served on the association's board of directors. Although PTSD is a common clinical problem, the majority of veterans do not have PTSD. According to the Department of Veterans Affairs, 11% to 30% of veterans have had PTSD during their lifetime.
On the flip side, clinicians and veterans may sometimes assume that certain members of the military might not suffer PTSD because they did not see a fight in the traditional sense, Workman adds. However, the trauma is not limited solely to fighting occupations. Therefore, doctors should screen all veterans for trauma exposure while on duty, as well as trauma that may have occurred elsewhere in life, she continues.
For example, she worked with veterans who served in military intelligence. Their jobs required the surveillance of a computer and as a result they were often exposed to the aversive details of violence and war. While it would be easy to dismiss their experience as simply sitting in a safe space without the fear of others shooting them, they were nonetheless exposed to combat in other ways, Workman says.
Treatment of disorders that occur simultaneously
Mental health work is not always neatly packaged when there is only one problem. Problems often overlap, and Quintana, a dedicated Navy resilience advisor, notes that concurrent disruptions are common with military-related customers.
According to the National Center for PTSD, substance use disorders and PTSD often occur together with veterans. In the past, clients in mental health and substance use institutions were often required to abstain from substance use before being treated for mental health problems. This happens less often, however, and an increasing number of agencies are taking an inclusive approach to care through double-diagnosis groups, relapse prevention education, and comprehensive treatment plans for concomitant disorders, says Quintana, a member of the MGCA and former Department of Defense activities school advisor.
Yet too often, health professionals focus only on high intake of substances rather than looking at the bigger picture or other concurrent problems, Marquez notes. He says he knows of clinics where military-related patients were quickly diagnosed with substance use disorder and made this the primary treatment plan or they refused to deal with trauma at all because they didn't have the time or resources to both substances treat disorder and trauma at the same time. This experience often results in these clients either leaving counseling or not speaking honestly about their substance use for fear that they will automatically be labeled with a substance use disorder, he says.
When clients come to Marquez with concurrent problems such as trauma and substance use, he is honest with them. He informs her that her drinking could technically be classified as a substance use disorder, but also admits that he knows that behavior is considered acceptable in military culture. He does not ask her to stop, but he does ask her to show him that substance use is not a factor in their present edition. Often they stop using substances with no problem. If they don't, the substance use disorder becomes another part of their treatment plan.
When working with veterans who may have had a history of alcohol or substance use, Workman recommends that counselors pay attention not only to how much those clients are drinking or using substances, but also to their history of trauma, Anxiety and other mental health problems. If a person's anxiety is high and not treated appropriately, it isn't shocking to find that they are drinking too much or having trouble with irritability, anger, or interpersonal interactions at home or at work, she says.
Consultants should also conduct a thorough assessment whenever a military affiliate is referred to them for a behavioral problem, since so often the problem is not the problem, Workman says. “Counselors should ask the veteran, 'When did this behavior begin? What makes it worse? What did you think and feel? What was going on when you engaged in this behavior? When wasn't it like that? "
It is easy to just focus on the negative behavior, but then the underlying mental health problems that contributed to that behavior are often overlooked and untreated, Workman adds.
Likewise, advisors should not focus only on the events that occurred during the clients' military service. Sometimes past trauma or mental health problems can go untreated, and military experience only exacerbate the problem. For example, someone who was previously reprimanded for violence could now be applauded and promoted for similarly violent acts during their military service. That person is receiving conflicting moral messages that can worsen the emotional wounds they had prior to entering the service, says Marquez.
Simultaneous disturbances can also become a problem if the symptoms overlap, emphasizes Myers. TBI and major depression can both cause attention difficulties, depressed mood, and insomnia. And irritability and restlessness are both symptoms of TBI and PTSD. That overlap can make treatment difficult, Myers says. Counselors can get stuck trying to figure out the diagnosis – is it TBI, depression, or both? "It's less about deciding what the diagnosis is than about treating that person holistically," says Myers.
Marquez says that if counselors focus on a client's trauma first and wait to address their grief until later, then all of the client's trauma could reappear if they focus on the grief. That's why Marquez addresses everything 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, as well as other specialized therapy sessions such as narrative therapy, desensitization and eye movement recovery (EMDR), and family therapy that deals with the specific Deals with problems they are dealing with.
Short-term therapies
Traditional, hour-long counseling sessions are not always an option for militarily connected clients, especially those who are active duty members, because they are always on the move, says Quintana. Depending on their duties, some service members may only have a short amount of time to meet with a psychologist, such as during lunch breaks.
For this reason, Quintana continues, solution-oriented therapy, which is a forward-looking and goal-oriented approach, can be effective for certain problems in the military environment (but not for more serious problems such as trauma and suicide). For example, if a service member has a relationship problem, the customer can use Quintana to identify their own solutions. She might say, “Tell me about a time when this problem didn't exist. What was different then? "This encourages the client to break away from all-or-nothing thinking and highlight strategies that were previously helpful.
Quintana also believes it is important to build on customers' strengths. For example, if the client said she was good at communication, she would work with the client to explore how she could use this skill to improve their relationship. After the customer sets goals (with assistance from Quintana), Quintana will continue to contact the customer to monitor success.
Workman fears that some veterans could be burned out by solution-oriented therapy because it is so widely used on service members in the military setting. In her work with veterans, she uses Extended Exposure for Primary Care (PE-PC), a type of short-term therapy specifically designed to treat trauma. It consists of at least six 30-minute sessions in the client's primary care clinic, which are usually more convenient and familiar for them. This therapy also helps veterans who are unable to devote much of their day to counseling and may remove potential barriers to treatment created by the stigma associated with referral to a mental hospital Workman.
In these sessions, clinicians teach veterans about common mental health problems such as PTSD. You will learn to identify distressing symptoms and to rate the intensity of those symptoms using the subjective units of distress scale, a self-assessment tool that measures the subjective intensity of any disorder or suffering a person experiences. Clients use this scale to track their plight before, during, and after writing their trauma narrative. In doing so, Workman finds that customers notice improvements in the way they respond to stressful thoughts and memories, and that their distress diminishes the more they read their story aloud. They are also more in control and not experience the same overwhelming symptoms of trauma-related anxiety, she adds.
Doctors also teach veterans how to safely manage mood issues by using safe grounding and relaxation techniques, Workman continues. Clients work through an extended exposure workbook and, with the assistance of the therapist, record their personal trauma event in a safe and systematic manner. The therapist ends each session with a relaxation exercise.
After this sequence of steps, customers can repeat this behavior themselves, she emphasizes. She found the treatment to be effective, with clients reporting a decrease in severity and, most importantly, an improvement in their quality of life.
Marquez notes that virtual reality exposure therapy helps military-affiliated clients relive and recall events associated with emotionally charged memories. Marquez once worked with a client who had dissociative amnesia related to an incident in which his comrade died in a car. The customer felt guilty for not pulling his colleague out of the car in time. Marquez put the customer in front of a black virtual reality screen and asked them to remember the events of that day. At one point, the client described hearing a roar, so Marquez played a few different noises. As he played a fire sound, the customer said, "Yes, that's the sound."
Marquez then turned on the virtual reality screen and the customer saw a vehicle that was on fire. When the customer saw this picture, he remembered that the car had been on fire so he couldn't go back to rescue his comrade. The interactive experience restored the client's lost memories and freed them from the guilt they had felt for years.
Marquez says this therapy helps clients reduce the triggers associated with traditional PTSD responses. It also helps them revisit memories, often suppressed by their military training, in order to respond rationally and emotionlessly. But if they relive the event, they can experience unrecognized emotions associated with it, Marquez points out. As a result, he uses EMDR to help clients manage the emotional memories that often re-emerge after exposure to virtual reality. "They allow themselves to finally feel the emotions that they never let themselves be felt because they only acted in the rational mind and only followed their training," he explains.
Building a Pipeline for Success
Some military families have confided in Quintana that they will not seek advice because they fear that they will simply be passed on to someone else or that they will be given a referral list. "Consultants need to take the time to invest in their clients and make sure they're part of the process," she says.
Quintana takes a collaborative approach with military-related customers. She believes partnership is key to facilitating change. In addition to meeting customers where they are, Quintana works with them to highlight their past achievements, set goals, and identify tools and resources that can help solve their problems.
Quintana provides an example: A military family is on their second deployment and the spouse is 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 could examine the family's past experiences and achievements. She might ask the spouse, "What helped your child when they faced mission-related challenges?" oder „Erzählen Sie mir von einer Zeit während der Bereitstellung, in der dieses Problem weniger auffiel. Wie haben Sie das möglich gemacht? “ Diese Art von Fragen hilft dabei, auf dem aufzubauen, was bereits funktioniert hat, die Stärken der Familie hervorzuheben und die Familie zu befähigen, Lösungen zu finden.
Durch dieses Gespräch erfährt Quintana, dass der Schulberater das Kind während des vorherigen Einsatzes in eine Gruppe mit anderen militärisch verbundenen Kindern stellte, die sich mit Einsatzproblemen befassten, und dass die Bibliotherapie für das Kind hilfreich war, um ihre Gefühle zu verarbeiten. Anstatt den Eltern eine Liste mit Ressourcen zu geben, schlägt Quintana vor, dass die Familie mit dem neuen Schulberater ihres Kindes an Strategien für die Bibliotherapie zusammenarbeitet, die sowohl in der Schule als auch zu Hause angewendet werden können. Sie würde auch mit dem Ehepartner zusammenarbeiten, um Zugang zu diesen Diensten innerhalb der Schule und, falls erforderlich, der Gemeinde zu erhalten. "Diese Beziehungen sind bedeutungsvoll und fördern das Vertrauen, was für die Unterstützung von Militärfamilien von entscheidender Bedeutung ist", sagt Quintana.
Myers versucht häufig, seine mit dem Militär verbundenen Kunden durch motivierende Interviews zu stärken. Dieser Ansatz ermutigt Kunden, ihre eigenen Gründe und Motivationen für Veränderungen zu diskutieren. In der Lage zu sein, ihre eigenen Ziele zu setzen, über Wege zu sprechen, um Veränderungen zu erreichen und ihre Motivationen zu erforschen, ehrt ihre Autonomie, sagt Myers.
Marquez lernte die Bedeutung des psychischen Wohlbefindens auf die harte Tour durch Fehldiagnosen und Kliniker, die in der Militärkultur nicht ausreichend ausgebildet waren. Um dieses Problem zu beheben, hat er Programme und Schulungen entwickelt, um Kliniker über die Arbeit mit dieser Bevölkerung aufzuklären. Er würde sich jedoch freuen, wenn mehr Fachkräfte für psychische Gesundheit daran beteiligt wären, eine Pipeline für Veteranen zu erstellen, die Berater werden möchten, und Peer-Support zu ermöglichen Fachgruppen unter der Leitung von Veteranen.
Marquez fand schließlich einen Kliniker, der sich die Zeit nahm, zuzuhören und ihm zu helfen, die Wurzel seiner PTBS herauszufinden. Psychiater können aus seinen Erfahrungen lernen, indem sie kulturell kompetenter werden und ihre Werkzeuge neu gestalten, damit sich militärisch verbundene Klienten nicht allein in den Schützengräben befinden.
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Handlungsschritte für weitere Informationen:
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Lesen Sie einen Begleitartikel zu diesem Artikel, "Ratschläge für Berater, die mit militärischen Kunden arbeiten möchten", bei CT Online.
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Lindsey Phillips ist Autorin von Counseling Today und UX-Content-Strategin. Kontaktieren Sie sie unter [email protected] oder über ihre Website unter lindseynphillips.com.
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