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Paula Domenici, PhD, Matthew Sacks, PhD, and Debra Nofziger, PsyD

Center for Deployment Psychology

Continuing Education Information

The American Psychological Association (APA) Ethics Code calls for psychologists to be competent in regards to the diverse cultures of our patients. This article focuses on the members of the United States military as a distinct cultural group that psychologists should be knowledgeable about and prepared to serve. Whether you are a psychologist or doctoral student of psychology working in a Department of Defense (DoD) treatment facility, Department of Veterans Affairs (VA) hospital, community clinic or some other clinical setting, it is only a matter of time before you will encounter a patient who is connected to the military in some way.

What should you learn about military culture and treating military patients to develop competence in meeting this population’s unique needs? We will address this question by first exploring some commonly held misconceptions about the military and describing experiences unique to military life. Next we will highlight distinct organizational aspects of the military that psychologists should consider when providing therapy. Then clinical presentations common to military patients and evidence-based psychotherapies (EBPs) will be reviewed, followed by a thorough list of resources we recommend for advancing your military competence (see online appendices). Throughout this article the term ‘Service Members’ will be used to refer to all patients who are currently or have been in any branch of the Armed Services including the National Guard and Reserves.

Assumptions about the Military

A number of stereotypes exist regarding the military, including the belief that war Veterans are “emotionally broken.” While nearly 2.8 million Service Members have been deployed in Afghanistan and Iraq (Meadows et al., 2016), the vast majority returning from these operations have demonstrated resilience and readjusted to home and work without significant problems. Indeed, the military culture can offer protective factors that promote resilience (e.g., camaraderie, structure, oversight, a clear sense of purpose and security) that are not always provided in the civilian community. In actuality, only a minority (albeit a significant one) of troops struggle with persistent psychological diagnoses. Nonetheless, there are deployment experiences that put Service Members at risk that civilians are unlikely to encounter. Four unique types of combat and operational stress injuries include:

(1) trauma from events provoking terror, horror or helplessness,

(2) wear and tear injuries from fatigue and the hardship of deployment,

(3) loss injuries from deaths of comrades, and 4) moral injuries from inner conflict about transgressed beliefs (Hammer, 2010). In combat, such stressors can co-occur, thus compounding their effects. Psychologists should be open to hearing about these different experiences and how they may affect patients.

Another misconception about military personnel is that psychological problems stem only from combat experiences. While greater combat exposure has indeed been associated with increased mental health concerns, Service Members are also impacted by non-combat deployments and experiences, such as entering boot camp, unexpected temporary duties, or participation in disaster relief/humanitarian missions. Other military-specific stressors include long hours, high work demands, repeated moves and separation from loved ones, and high standards and calls for discipline. Moreover, some individuals join the military with pre-existing problems that are exacerbated by military life, or backgrounds that predispose them to developing psychological conditions. Research has found that males with military service had significantly higher rates of adverse childhood experiences as compared to non-military males, suggesting that enlistment may be an escape for some Service Members who are at greater risk for developing physical and mental health problems (Blosnich, et al., 2014).

At the same time, the military promotes values such as strength, emotional control, self-reliance, discipline, teamwork, loyalty, and self-sacrifice that may be at odds with seeking help for mental health problems. Recognizing that a warrior mindset may conflict with help-seeking is valuable when serving military patients. Service Members may believe that if they disclose problems, their military career will be ruined, their duties limited, or they will appear weak. These beliefs can lead to underreporting and a tendency to mask potential mental health problems to leadership and other healthcare providers. Logistical barriers may interfere with seeking care as well, such as difficulty getting time off, being short staffed, or duties requiring travel. Therefore, it is especially important for psychologists to appreciate the effort it takes for military patients to not only seek treatment but also stick with it given these obstacles.

Awareness of the culture and operational system that a Service Member comes from is also crucial. Military patients’ expectations about mental health providers may be different from those of civilians. They may be more guarded about their problems and concerned about confidentiality. Psychologists should be clear about the limits of confidentiality and discuss potential stigma and concerns with military patients. Some Service Members may hold preconceived notions that civilian providers are overly sensitive, judgmental, or naïve about the military, all of which can have an impact on the therapy dynamic. Yet others may actually prefer to see civilian providers because they are not part of the military structure and feel less threatening. Either way, military patients are more likely to lower their defenses, engage well with treatment and develop trust when psychologists are educated about military culture and genuinely open to learning about their experiences.

Distinct Structural Aspects of the Military

The beliefs and practices encompassing the warrior ethos can be incongruent with an individualistic approach to therapy. While most psychologists learn a traditional model of therapy that relies upon patients learning to become emotionally vulnerable, this approach does not always fit with military culture, which is essentially collectivistic. With a focus on the larger groups needs and bias toward emotional “toughness,” many military patients will not feel a psychologist understands their world if they are viewed from an individualistic lens. At the same time, psychologists should not assume that all military members have the same connection to military values. Clinicians are advised to determine how much military patients have integrated into the collective culture during initial sessions by:

  • querying about their overall military experience,
  • inquiring how Service Members see themselves connecting with the military culture, and
  • listening for language indicating strong beliefs and ties to their military cohort.

Insights gained will help therapists balance the traditional mental health culture with that of the military to fit a particular patient. Strengths that a patient possesses and serve the collective group can be recognized while comparative vulnerability and individual needs are addressed in treatment.

When it comes to therapy, short-term Cognitive-Behavioral Therapy (CBT) models and brief interventions tend to work best when treating Service Members because they align well with the military goal of returning troops to a full duty status. Patients receiving medical care might be involved in long-term therapy, but this tends to be the exception. DoD medical retention regulations state that behavioral health patients must be treatable within a year, and thereafter must be fully capable of performing military duties to include deployment. If this is not possible, these patients are considered for medical separation or retirement. Service Members who have separated from the military or are treated outside of the military structure are not subject to the same constraints and may be more appropriate for longer-term therapies.

In addition to CBT treatments, crisis management skills are very important, for both short- and long-term patients. These skills are critical for managing suicidal and self-harming behaviors as well as issues surrounding grief, loss, and family and/or interpersonal crises. Given increased suicide rates across the DoD since the wars in Iraq and Afghanistan and greater suicide risk for Veterans compared to civilians, it is essential that psychologists develop strong suicide risk assessment and management skills. We strongly encourage clinicians to undertake an intensive training on suicide prevention, such as the 2-day EBP workshop offered by the Center for Deployment Psychology (CDP) (see resources). Additionally, it is recommended that clinicians become familiar with the VA/DoD Clinical Practice Guideline for the Assessment and Management of Patients at Risk for Suicide (see resources).

While all psychologists are beholden to the APA ethical guidelines, those working as DoD employees must also follow government policies. Such clinicians are employed in an organizational psychology environment in its truest form: their patient is the Service Member but the DoD is concurrently present in all treatment considerations as a third party that is requesting services for its members (see APA Ethics Code 3.07). Thus, when joining the military system, psychologists not only need an understanding of military culture but also of the organizational structure, which can be a steep learning curve. What should they do when confronted by competing demands from these separate bodies? For example, a key ethical principle is to “do no harm.” However, a psychologist’s patient may wish to leave the military for his or her emotional well-being, while the DoD may determine that he or she remains fit for duty and is required to continue military service. Traditional ethical guidance for psychotherapy in such situations may be incomplete, making it essential that dual agency and potential conflicts of interest are considered carefully by the therapist and discussed thoroughly with the patient.

Working in a military context also presents psychologists with confidentiality challenges. DoD regulations often put providers in situations where they must be less confidential with patient information because the safety needs of the larger military and other Service Members trump the needs of an individual patient. For example, a psychologist may have to recommend to command whether or not a Service member can have access to loaded weapons due to his or her mental health status. Additionally, psychologists are mandated to share information with a patient’s command when he or she is abusing substances. While this is a common treatment issue, the military services require providers to refer these patients to specific treatment programs that are not confidential (i.e., the command is notified). This may anger patients, increase their ongoing distress, or potentially harm the therapeutic relationship. Nonetheless, psychologists must consider the risk these patients may pose not only to themselves but also to the military unit. But even in situations where confidentiality must be broken for the larger good, a military patient’s privacy is still protected. Certain patient information simply does not need to be shared with the command. Shared information typically is limited to diagnosis, mental status, fitness for duty and/or deployment status, and specific recommendations requiring command involvement. Prior to communication with a patient’s command, there are ample opportunities for a psychologist to consult with colleagues on how to balance duty between the patient and the DoD and to exercise clinical judgment. Balancing ethical and moral considerations is a difficult but necessary duty that all psychologists, not just military providers, face. We do, however, recommend that psychologists receive additional military specific ethics training prior to working with DoD clientele (see resources).

The Military Landscape of Clinical Conditions

This section will review clinical presentations that may require special considerations when working with the military population. Cultural issues will be highlighted as well as treatment recommendations. The Veterans Health Administration and DoD have developed Clinical Practice Guidelines (CPGs) that recommend EBPs with the strongest empirical evidence in the treatment of several mental health problems, including posttraumatic stress disorder (PTSD), mild traumatic brain injury (mTBI), depression, patients at risk for suicide (noted earlier) and substance use disorders (SUDs; see VA/DoD CPGs under resources). We advise psychologists who treat military patients to become familiar with these CPGs and be trained in the EBPs that are mentioned. When CPGs are not available, we recommend evidence-based practices, some of which are highlighted below.

Posttraumatic Stress Disorder

While trauma exposure is fairly common in any person’s lifetime, individuals who have served in the military may face a greater number of traumas given that the mission, often requires confronting life or death situations. Combat trauma and sexual victimization (described below) are more likely to result in PTSD than other types of traumas (e.g., disasters and accidents). Psychologists, however, should not assume that military patients have PTSD merely because they have served in combat or experienced military sexual trauma. To avoid this trap, clinicians should gather a thorough history about what is causing a patient’s current distress, including trauma exposure. Furthermore, be mindful that a variety of problems may occur following trauma including depression, substance abuse, and increased reactivity as well as more functionally adaptive responses. Thus, a diagnosis of PTSD following a traumatic experience may neither be accurate nor may it be the most pressing clinical issue. A hallmark feature of PTSD that psychologists can look for to differentiate it from other conditions is the avoidance of internal and external trauma cues. Is your patient not leaving the house because he or she has no energy, or because they feel anxious or unsafe in crowds and wants to avoid these emotions and trauma reminders?

It is important to emphasize to Service Members and others that PTSD is a treatable disorder and to convey a message of hope. While trauma will impact a person’s life, the distress and dysfunction tied to it can be diminished. The VA/DoD CPG for Management of Post-Traumatic Stress currently lists the following EBP’s as top tier treatments: Cognitive Processing Therapy (CPT), Prolonged Exposure Therapy (PE), Stress Inoculation Therapy (SIT), and Eye-Movement Desensitization and Reprocessing (EMDR). We strongly encourage training in one or more of these EBPs and using them with military patients.

Sexual Victimization

Sexual victimization” (SV)—the term we will use to encompass sexual assault and other acts of sexual violence—is unfortunately a problem in both the military and the culture at large. While the military has made recent changes to its SV policies, systemic and cultural problems persist that often exacerbate what is already an incredibly difficult experience for Service Members. For example, commanders still oversee SV investigations and victims may be reluctant to report the event, fearing reprisal or that they will not be believed. Victims also report apprehension due to power differentials or concerns that peers will ostracize them. When military values such as unit cohesion and loyalty are violated by an act of SV, feelings of disillusionment, betrayal, and isolation may result. Some victims may feel their military world has been shattered—a safe and secure environment has become dangerous and untrustworthy. For victims with a strong connection to this collectivistic culture, these experiences can be devastating.


...be mindful that a variety of problems may occur following trauma including depression, substance abuse, and increased reactivity as well as more functionally adaptive responses.


We recommend that psychologists always ask questions about SV when initially meeting with military patients, which may be included as part of the trauma history discussed above. A careful assessment of current symptoms will help determine if PTSD or other post-assault diagnoses are present and will identify which are the most pressing clinical concerns, including suicidal thoughts and behaviors. When appropriate, EBPs can then be utilized. We further recommend that psychologists complete more formalized and in-depth training on the current landscape of SV for the particular military patients seen in their practice. For example, psychologists working in military clinics should be familiar with restricted and non-restricted reporting procedures. These separate procedures were instituted in an attempt to increase the historically low rate at which military sexual assault was being reported and to offer treatment to victims reluctant to fully disclose the circumstances of the assault; for details refer to Department of Defense Directive 6495.01. Restricted reporting offers victims the option of choosing to receive treatment without the assault being reported to authorities. This option is not available in all circumstances, e.g., if violence other than sexual assault also occurred. With non-restricted reporting the victim chooses to have the assault reported to law enforcement and command authorities (this option is mandated in certain jurisdictions and in cases that involve crimes other than sexual assault). Clinicians at VA hospitals should be aware of the mandatory military sexual trauma (MST) screen as well as the required MST training (see VA MST website under resources). Furthermore, sexual violence against male Service Members appears to be a vastly underreported phenomenon that requires additional clinical attention and investigation, given the often high levels of shame or guilt associated with disclosure. Clinicians are advised to seek more specialized education regarding the experience of SV for all gender identities.

Traumatic Brain Injury (TBI)

Along with PTSD, mild TBI (mTBI) is regarded as one of the ‘signature injuries’ of the recent conflicts in Iraq and Afghanistan, where improvised explosive devices (IEDs) have injured thousands of Service Members. Outside of the combat environment, military members are also at risk for mTBIs due to training accidents, falls, motor-vehicle accidents, and other activities of daily living associated with a youthful, highly active population. Psychologists who do not work in specialized TBI settings are most likely to encounter patients with mild to moderate deficits related to TBI, given that 80% of TBIs fall within the “mild” category. A comprehensive assessment of TBI-related symptoms should include a multimodal approach encompassing multiple sources of information such as symptom checklists, cognitive assessment, reports from the patient’s family and friends, and a medical records review. It is important to look for differences between the patient’s functioning before and after the TBI to help determine his or her current level of adjustment.


...depressive symptoms may manifest more as complaints of anger, irritability, apathy, physical aches and pain, sleep trouble, withdrawal behaviors or acting out.


The majority of patients with mTBI will recover over time with the support of family, friends, and providers. During recovery, it is helpful to engage the patient and family in education to reduce anxiety, instill hope, prevent the patient from having further injuries, and facilitate specialized referrals when appropriate. The CPG for the Management of Concussion-mild TBI offers recommendations for those who continue to be negatively affected by mTBI, although there currently is no clear consensus on a specific clinical intervention. The risk of comorbid psychiatric conditions increases with the presence of mTBI including PTSD, depression, and problems with sleep and pain. We recommend that psychologists use EBPs for any of these co-occurring problems. For clinical tools and patient resources, the Defense and Veterans Brain Injury Center (DVBIC) website (see resources) is useful. Regarding blast-related TBIs, current research suggests that this specific injury does not differ significantly from other TBIs caused by blunt injuries, although recent MRI imaging studies have shown some mixed findings. Thus, at this time, Service Members who have sustained blast-related TBIs do not need to be assessed or treated differently by clinicians.

Adjustment Issues and Depression

Depression is another noteworthy clinical concern that requires psychologists’ attention when working with the military population. In fact, some findings demonstrate rates of depression commensurate with or even higher than those of PTSD (Blakely & Jansen, 2013; Tanielian & Jaycox, 2008). Service Members’ military bearing, which may include stoicism and emotional control, can easily mask depressive symptoms and make it difficult to detect. Instead, depressive symptoms may manifest more as complaints of anger, irritability, apathy, physical aches and pain, sleep trouble, withdrawal behaviors or acting out.

Additionally, times of adjustment—a common occurrence in military life—may lead to symptoms of depression and anxiety. Examples include readjusting home after deployment, moving, transitioning to civilian life upon retirement, or being assigned to vastly different duties. Taking the time to build close rapport and understanding during these transitional struggles is worthwhile. At the same time, remember that every Service Member is different, and your patient may actually be adjusting very well and embracing the change. Times of transition, especially transitioning out of the military, can also reveal problems related to losses. As patients reflect back on their service, they may begin processing earlier events such as the death of comrades, loss of physical capabilities, a crisis of spirituality and/or loss of a sense of purpose.

Symptoms associated with depression, such as guilt, self-blame, self-loathing, or suicidal thoughts and/or behaviors, may also emerge from shame-based situations when a Service Member feels his or her honor has been disgraced like failing a promotions board or being reprimanded by command for a violation (e.g., a DUI). They also may spring from morally injurious events when military members feel their own actions or inactions have transgressed cherished moral beliefs or expectations (Litz, et al, 2009) or an authority figure has betrayed what they believe is right (Shay, 2014).  For example, if a Service Member were to shoot and kill a woman and child in the belief they were planting an IED that would kill fellow Service Members, they may subsequently experience persistent anguish over this decision leading to functional impairment. Most Service Members are indeed able to resolve such moral quandaries, but a subset cannot. Psychologists are encouraged to have open and empathetic conversations with military patients about possible moral and spiritual struggles and ensuing symptoms of depression, PTSD, or other reactions.

The VA/DoD CPG for Management of Major Depressive Disorder currently lists the following EBPs as best recommended for depression: Acceptance and Commitment Therapy (ACT), Behavioral Therapy/Behavioral Activation (BT/BA), Cognitive Behavioral Therapy for Depression (CBT-D), Interpersonal Therapy (IPT), Mindfulness-Based Cognitive Therapy (MBCT), and Problem Solving Therapy (PST).

Sleep Problems

Over the past several years, there has been an increase in the rates of sleep disorders within the military population including insomnia, obstructive sleep apnea (OSA), circadian rhythm sleep disorders and nightmares. These sleep conditions may originate from specific military stressors such as shift or rotating schedules, around the clock operations, injuries and chronic pain, as well as deployments and trauma exposure. Psychologists should be aware that many Service Members do not routinely engage in healthy sleep behaviors because of the military’s emphasis on endurance and task completion. There exists an implicit cultural pressure to limit either sleep time or personal time in the service of the mission. Also, sleep problems are often comorbid with other conditions like PTSD, TBI and depression or medical problems and the symptoms of one disorder can be confused with another. Thus, it is vital to have strong training in the assessment and treatment of sleep disorders including how to make a good differential diagnosis and when to refer to a medical provider. Start with a good sleep interview, inquiring about your patient’s sleep-wake schedule, symptoms of sleep problems, medication use, diet, exercise, and bedroom environment, and have him/her keep a sleep diary (see Sleep Interview and Diary under resources). Evidence-based treatments like Cognitive Behavioral Therapy for Insomnia (CBTi) and nightmare rescripting treatments such as Imagery Rehearsal Therapy (IRT) for trauma nightmares are highly recommended and have shown effectiveness with the military population.

Chronic Pain


Cognitive Behavioral Therapy for Chronic Pain (CBTCP) has been found to be effective in the management of pain symptoms.


Chronic pain is a serious and common problem among Service Members. A review of medical records revealed that nearly 82% of OIF/OEF Veterans were suffering from chronic pain (Lew et al., 2009). In another study, chronic pain conditions were identified as one of the major reasons why Service Members were evacuated from Iraq (Harman et al., 2005). Similar to sleep problems, unique military circumstances put Service Members at risk for developing pain, especially back pain. Such circumstances include carrying heavy packs, riding in operational/all-terrain vehicles or rotary wing aircraft, rigorous training requirements and the psychological hazards of combat. While military slogans like “pain is weakness leaving the body” or “no pain, no gain” may help individuals survive extreme situations, these types of beliefs can deter Service Members who are experiencing pain from seeking treatment because they may feel they need to ‘tough it out’ or not appear ‘weak.’ It is important to have tools in your practice for normalizing and addressing pain when working with military patients such as a simple 0 to 10 pain scale or the Defense and Veteran Pain Rating Scale (Buckenmaier et al., 2013; see DVPRS under resources). Ask questions specific to their pain experience including the history and quality of their pain, what they or others think is causing their pain, and how they and their family are coping/responding to the pain (see Pain Interview under resources). Cognitive Behavioral Therapy for Chronic Pain (CBTCP) has been found to be effective in the management of pain symptoms. Widely recognized components of CBTCP include psychoeducation, relaxation, activity modification (e.g., activity pacing), behavioral activation (e.g., scheduling pleasant activities), sleep hygiene, and cognitive restructuring. Since patients often have more than one site and type of pain, treating chronic pain only with medications may not be as effective as offering combined treatment within a multidisciplinary team.

Substance Use Disorders

Psychologists should be prepared to address alcohol and drug use problems in Service Members as well. These issues often co-occur with other problems including depression, PTSD, TBI, chronic pain, and disrupted sleep, as reviewed above. A recent meta-analysis found that Gulf War, Iraq and Afghanistan Veterans were at increased risk of alcohol use disorders compared to those who didn’t deploy to these wars (Kelsall et al, 2015). In fact, alcohol is more widely used in the military than other illicit substances because it is legal, easy to access, and has been a traditionally accepted part of military life for decades. Similarly, there is a longstanding history of tobacco use, with Service Members reporting their first or increased use within the operational or work setting. Unhealthy alcohol use may contribute to behaviors that endanger both the individual Service Member and those working or living with that member. The use of illicit substances is strictly forbidden within the DoD. Service Members can be discharged from the military and in some cases may even face criminal prosecution if caught using illicit substances. Military members with substance use problems are also mandated to attend treatment, which is closely monitored by their command.

Over the last several years, significant concern has been raised about prescription drug misuse among Service Members especially with regards to opioids or pain relievers (e.g., Oxycodone, Percocet, and Vicodin). While prescription drug misuse is also a

concern in the civilian community, some military-related factors may put Service Members at risk for increased misuse of opioids including chronic pain and extensive injuries from the physical toll of more than a decade of war. Availability is also an issue, with individuals who are prescribed painkillers three times more likely to misuse them (Bray et al., 2009). Studies have shown that VA-enrolled male and female Veterans with any substance use disorder history were two or more times more likely to die by suicide than those without a substance use problem (Ilgen et al, 2010); thus, it is an important factor to explore closely with such patients.

The VA/DoD CPG for Management of Substance Use Disorders recommends using evidence-based screening tools for the assessment of substance use and motivational interviewing, evidence-based psychotherapies (e.g., CBT and Behavioral Couples Therapy), and concurrent (not sequential) treatment of comorbid conditions for the treatment of substance use disorders. For example, Allen et al. (2016) recommend that comorbid alcohol use disorders and PTSD in Service Members should usually be treated at the same time through carefully coordinated or integrated care. Contrary to the traditional belief that PTSD treatment should not be introduced until after a patient’s substance abuse has been addressed, the latest research suggests that providing the treatments simultaneously can have positive results. In fact, concurrent treatment may help some patients better maintain their substance use gains. The CPG also endorses the initial use of brief interventions and psychoeducation followed by more specific treatments (provided in the least restrictive setting), with an increasing or stepped level of care. When appropriate, psychotherapy should be supplemented with pharmacologic treatments for addictions.

Family and Couples Issues

No discussion of Service Members would be complete without addressing their family and marital situations. Today’s military members are more likely to marry younger and have children earlier than nonmilitary families. Indeed, spouses and children are a significant percentage of the military community, outnumbering Service Members by a ratio of 1.4 to 1 (Clever & Segal, 2013). Compared to civilians, these families experience more frequent relocations, separations and deployments, all of which can create stress, fear, uncertainty, and financial hardship. As a result, when military couples seek treatment some of the common presenting issues include difficulty communicating and resolving conflicts during deployment, difficulty reestablishing family roles post deployment and struggles around caring for a partner who has sustained a physical or mental health injury from service.

Since there is not a single gold standard evidence-based treatment approach for working with military couples, we encourage psychologists to complete a comprehensive assessment and case conceptualization to determine the most appropriate intervention based on each couple’s identified needs. For couples seeking therapy following a deployment, we advise assessing not only the presenting problem and level of distress, but also trauma histories, previous deployment experiences, the “meaning” of the most recent deployment, attachment style, the couple’s strengths and level of identity with the military.

When clinical interventions are used, they should incorporate both skill development as well as relationship building. We recommend that providers build on military couples’ strengths such as being adaptable, resourceful and deriving support from the larger military community. Psychoeducation about what can be expected with different military stressors, especially pre- and post-deployment, can be very helpful to couples. Some evidence-based couples’ interventions to consider when working with this population include: Integrative Behavioral Couples Therapy (IBCT), Cognitive Behavioral Conjoint Therapy for PTSD (CBCT for PTSD) and Emotionally Focused Therapy (EFT).

Conclusion

Like all patients, Service Members bring their own cultural experiences to therapy, which have shaped who they are including their presenting problems and treatment expectations. While no psychologist is expected to learn every aspect of a person’s culture, it is important to be considerate of basic cultural differences that may impact a military patient. A key to cultivating a strong therapeutic alliance is exploring how their military experience may be contributing to their personal and professional struggles. Also, it can be useful to incorporate resilience and other military assets into the therapy, particularly if a patient feels a strong connection to military values and a collectivistic culture. At the same time, distinct organizational and ethical challenges can complicate the therapeutic alliance especially when working in DoD settings. To be effective, we recommend that psychologists find ways to expand their knowledge of military culture, policies and operations and receive training in the EBPs mentioned to treat the variety and co-occurrence of problems that Service Members and their families face (see CDP’s online and in-person training seminars under resources). We also encourage seeking supervision or consultation from professionals with expertise in military psychology and EBPs. Remember that you are not alone in this journey—there is a community of providers dedicated to serving this amazing population. As you embark on this meaningful and rewarding path, a multitude of resources and training opportunities are available for advancing your military competence and clinical skills.

Authors

paula-domeniciPaula Domenici, PhD is a licensed counseling psychologist and the Director of Civilian Training Programs at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences (USU) in Bethesda, Maryland. Earlier in her career, she worked as a Deployment Behavioral Health Psychologist at the National Naval Medical Center and Staff Psychologist at the San Francisco VA Medical Center. Dr. Domenici also was an APA Congressional Fellow at the Office of Senator Hillary Clinton. She specializes in military behavioral health, combat trauma, and the treatment of PTSD using Prolonged Exposure Therapy.


matthew-sacksMatthew Sacks, Ph.D. is a licensed clinical psychologist and the Assistant Director of Online Programs at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences (USU). He has worked in multiple VA settings and as a Staff Psychologist at Joint Base Andrews. Dr. Sacks maintains interests in depression, mindfulness, and improving mental health outcomes via the use of technology.


deb-nofzigerDebra Nofziger, PsyD is a Deployment Behavioral Health Psychologist with the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences (USU) in Bethesda, Maryland. Located at the Brooke Army Medical Center, she trains and supervises pre-doctoral interns and postdoctoral fellows in providing evidence-based treatment to active duty Service Members and their families. Prior to joining the CDP, she was an active duty Army psychologist with assignments at Brooke Army Medical Center and the U.S. Army School of Aviation Medicine. Dr. Nofziger deployed for a year in Iraq with the 4th Infantry Division. She continues to have interest in serving military personnel and their families through direct care and training of military and civilian medical and mental health providers. She has been credentialed by the National Register since 2011.

 

References

Allen, J. P., Crawford, E. F., & Kudler, H. (2016). Nature and treatment of comorbid alcohol problems and post-traumatic stress disorder among American military personnel and veterans. Alcohol Research, 38(1), 133-140.

Blakeley, K., & Janson, D. J. (2013, August). Post-Traumatic Stress Disorder and Other Mental Health Problems in the Military: Oversight Issues for Congress. Congressional Research Service Report No. R43175.

Blosnich, J. R., Dichter, M. E., Cerulli, C., Batten, S. V. & Bossarte, R. M. (2014).

Disparities in adverse childhood experiences among individuals with a history of military service. Journal of the American Medical Association Psychiatry, 71(9), 1041-1048.

Bray, R. M., Pemberton, M. R., Hourani, L.L., Witt, M., Olmsted, K. L., Brown, J. M.,...& Scheffler, S. (2009). 2008 Department of Defense survey of health related behaviors among active duty military personnel. Prepared by RTI International.

Buckenmaier, C. C., Galloway, K. T., Polomano, R. C., McDuffie, M., Kwon, N., & Gallagher, R. M. (2013). Preliminary validation of the Defense and Veterans Pain Rating Scale (DVPRS) in a military population. Pain Medicine (14), 110-123.

Clever, M. & Segal, D (2013). The demographics of military children and families. The Future of Children, 23(2), 13-39.

Hammer, Paul (S.) 2010. Navy Operational Stress Control [Powerpoint Slides]. Presented

at the Navy and Marine Corps Combat and Operational Stress Conference 2010: “Taking Action, Measuring Results." Retrieved  from  http://www.slideserve.com/enye/navy-operational-stress control

Harman, D. R., Hooper, T. L., & Gackstetter, G. D. (2005). Aeromedical evacuations from Operation Iraqi Freedom: A descriptive study. Military Medicine, 170, 521-527.

Ilgen, M. A., Bohnert, A. S. B., Ignacio, R. V., McCarthy, J. F., Valenstein, M. M., Kim, M., & Blow, F. C. (2010). Psychiatric diagnoses and rise of suicide in veterans, Archives of General Psychiatry, 67(11), 1152-1158.

Kelsall, H. L., Wijesinghe, M. S. D., Creamer, M. C., McKenzie, D. P., Forbes, A. B., Page, M. J., & Sim, M. R. (2015). Alcohol use and substance use disorders in Gulf War, Afghanistan and Iraq war veterans compared with nondeployed military personnel. Epidemiologic Reviews, 37, 38-54.

Lew, H. L., Otis, J. D., Tun, C., Kerns, R. D., Clark, M. E., & Cifu, D. X. (2009). Prevalence of chronic pain, posttraumatic stress disorder and persistent postconcussive syndrome in OIR/OEF veterans: Polytrauma clinical triad. Journal of Rehabilitation Research and Development, 46, 697-702.

Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29, 695-706.

Meadows, S., Tanielian, T., & Karney, B. R. (2016). The deployment life study:

Longitudinal analysis of military families across the deployment cycle. Santa Monica, CA: RAND Corporation. Retrieved from: http://www.rand.org/pubs/research_reports/RR1388.html.

Shay, J. (2014). Moral injury. Psychoanalytic Psychology, 31(2), 182-191.

Tanielian, T., & Jaycox, L. (2008). Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. Santa Monica, CA: RAND Corporation. Retrieved from: http://www.rand.org/pubs/monographs/MG720.html.

Resources

Treating Service Members

Defense and Veterans Brain Injury Center (DVBIC): To promote effective services for military members with TBI and their families, DVBIC - in collaboration with DCOE - provides a breath of resources including clinical tools, fact sheets, and free continuing education training on the causes, symptoms and treatment of TBI. http://dvbic.dcoe.mil/resources

Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE): This website provides many resources ranging from the latest research to monthly webinars to help improve the lives of Service Members and their families. http://www.dcoe.mil

DoD Safe Helpline: This website provides sexual assault support for the DoD community via online and live telephone contacts. It offers information on sexual assault for individuals and clinicians, as well as assists transitioning Service Members in accessing local resources. https://www.safehelpline.org

inTransition: This free program assists Service Members and their mental health care providers during times of transition via live telephone contacts and multimedia materials.  http://intransition.dcoe.mil/

Military Family Research Institute (MFRI) at Purdue University: Focused on research, outreach and programming to improve the lives of military families, MFRI offers a wealth of resources including presentations, publications and articles.
https://www.mfri.purdue.edu/publications/presentations.aspx

Military OneSource: This highly-used resource provides a wide range of support services for the military population including mental health, legal, financial, deployment and transition assistance. Exploring this site can help providers understand military life concerns and resources available to patients. http://www.militaryonesource.mil

National Sexual Violence Resource Center (NSVRC): This website offers a variety of information on current news, practices, resources, and free online training courses related to the prevention and response to sexual violence.  http://www.nsvrc.org/

PsychArmor Institute: Developed to help individuals who support or interact with Veterans, this organization offers a menu of free online courses and other resources to healthcare providers, employers, educators, caregivers, family members, and volunteers. http://www.psycharmor.org

Substance Abuse and Mental Health Services Administration (SAMHSA): This agency has a section dedicated to advancing behavioral health care in the military population that includes publications, webcasts and other resources to improve access to services and treatment. http://www.samhsa.gov/veterans-military-families

The Military Families Learning Network: Offering free online webinars specific to military families, this network provides information on topics such as military caregiving, personal finance, and family transitions.
http://articles.extension.org/pages/62581/military-families-learning-network-webinars

The National Child Traumatic Stress Network (NCTSN) Learning Center: This resource center provides free online education include a series of presentations on Military and Veteran Families. http://learn.nctsn.org/course/index.php?categoryid=10

Transition Assistance Program (TAP): Designed to assist Service Members as they transition from military to civilian life, this DoD program provides employment and education assistance. This is a useful resource for clinicians working with separating Service Members. https://www.dodtap.mil/

TriCare: Mental health clinicians can become TriCare providers for this health care program that insures DoD beneficiaries and offers mental health services to them. http://www.tricare.mil/Providers/Resources

USC Social Work Center for Innovation and Research on Veterans and Military Families: This program offers open enrollment, self-paced continuing education courses such as Military Culture and Motivational Interviewing with Military Populations. http://cir.usc.edu/cirlearn/current-course-offerings

US Department of Veterans Affairs Military Sexual Assault Webpage: This webpage provides a wealth of information on military sexual trauma (MST) including treatment services offered by the VA, staff education and training, articles, fact sheets and other resources. http://www.mentalhealth.va.gov/msthome.asp

US Department of Veterans Affairs National Center for PTSD: This well-established website has a myriad of PTSD resources available to anyone interested in PTSD including Veterans, family members, providers, and the general public. In the professional section, providers can find links to PTSD assessments, publications, continuing education courses and consultation services. http://www.ptsd.va.gov

VA/DoD Clinical Practice Guidelines:  The Veterans Health Administration and DoD in collaboration with other organizations have developed a set of evidence-based best practice guidelines on topics including PTSD, SUDs, MDD, mild TBI and suicide risk. These guidelines are used to systematize and improve care provided to Service Members and Veterans. http://www.healthquality.va.gov/

Tools and Trainings Offered by the Center for Deployment Psychology (CDP)

Addressing the Psychological Health of Warriors and their Families: This one-week course is delivered 4 to 6 times per year in different regions of the country to civilian licensed mental health providers. Topics covered range from military culture and the deployment cycle to TBI, PTSD, sleep problems and ethical challenges when working with military patients. A 2-day training in an EBP such as PE, CPT, CBTi, CBT-D, or Suicide Prevention concludes the week. For a nominal fee, over 30 CE credits are provided depending on which sessions are taken.
http://deploymentpsych.org/regional-civilian-1-week-training

Blog Series:  CDP posts weekly blogs to share innovative perspectives on military topics written by CDP personnel and external subject matter experts. Recent topics include LGB History in Psychology and the Military and New VA Suicide Prevention Efforts. http://deploymentpsych.org/blog

CDP Presents: This free monthly webinar, offering 1 CE credit, provides timely discussion of content relevant to providers working with military-connected populations and is hosted by CDP subject matter experts or guest speakers. Recent topics covered include Mindfulness-based Interventions for Service Members and Veterans; Reconceptualizing Resilience and Growth in the Wake of Trauma and Helping Military Couples Enhance Connection After Deployment. http://deploymentpsych.org/webinars

Evidence-Based Psychotherapy (EBP) Workshops: CDP offers in-person and online 2-day EBP workshops including topics on PE, CPT, CBTi, CBT-D and Suicide Prevention. In-person EBP workshops are offered at different military treatment facilities across the country for DoD providers. For information, contact khannah@deploymentpsych.org. For online EBP workshops offered to all providers in platforms such as Zoom and Second Life, visit http://deploymentpsych.org/workshops.

Military Culture – Core Competencies for Healthcare Professionals: Developed by CDP and the VA, this nationally-recognized self-paced online course consists of four in-depth modules for increasing healthcare professionals’ competence in military culture. Two free CE credits are provided for each completed module. http://deploymentpsych.org/military-culture

Star Behavioral Health Providers (SBHP): Established by CDP with the Military Family Research Institute at Purdue University, this program collaborates with the National Guard to offer civilian providers a series of three continuing education trainings in select states including IN, OH, MI, GA, NY, and SC. SBHP-trained providers are able to join a registry for military-connected individuals to search for behavioral health services. http://deploymentpsych.org/training/star-training-program

The Summer Institute - Preparing for a Military-Focused Career: This unique 5-day training program is designed for psychology doctoral students contemplating a career in military psychology.  Hosted annually at the Uniformed Services University of the Health Sciences (USU) in Bethesda, MD, students gain firsthand knowledge of military culture, the work of military psychologists, and EBP strategies to treat military members. http//:deploymentpsych.org/the-summer-career

Tools & Resources: CDP’s ever-expanding collection of online training resources encompasses tools for military competence and EBP delivery including those listed below. http://deploymentpsych.org/content/resources-and-tools

Defense and Veterans Pain Rating Scale: http://ww.dvcipm.org/clinical-resources/pain-rating-scale

Pain Interview: http://deploymentpsych.org/sites/default/files/Pain_Interview.pdf

Sleep Diary:
http://deploymentpsych.org/system/files/member_resource/New_CDP_Sleep_Diary.pdf

Sleep Interview:
http://deploymentpsych.org/system/files/member_resource/New_Sleep_Disorders_Interview.docx