Captain Ross Maher speaking to a group of health care providers with Operation Immersion. Photo courtesy of Army Sergeant Peter Ramaglia

What Military Patients Want Civilian Providers to Know

By Sandy D. Cogan

Staff Sergeant David Hollinrake (left) instructs trainee Leland Wilcox about the military way of life during Operation Immersion in Warwick, RI. Photo courtesy of Army Sergeant Peter Ramaglia

"My memories are full of jargon," Senior Master Sergeant Leonard Macari says. "If I finally open up to a counselor, I don't want to have to stop and explain acronyms like MRE or terms like 'I did a 5 and 25.' I want my therapist to know what I'm talking about. Otherwise, there's a disconnect that's hard to get past," the Rhode Island National Guardsman explains.

Other servicemembers agree that civilian providers, while professionally competent, often lack an understanding of the warrior's way of life as well as their experiences, challenges and language. That lack of knowledge and appreciation is often the reason military patients discontinue treatment with a community-based behavioral health service provider after only one visit, say experts.

Fear of Repercussions

"Some of our military personnel who are suffering from post-traumatic stress disorder, major depression, a traumatic brain injury, and/or substance abuse are choosing private-sector providers over military therapists for fear of discrimination or jeopardizing their career or their spouse's career," says A. Kathryn Power, M.Ed., Director of the Center for Mental Health Services (CMHS) at SAMHSA and lead for the Agency's Military Families Strategic Initiative. "Finding a community-based provider who understands the military culture and language is hit or miss; and that understanding can be the difference between receiving ongoing, effective treatment and not returning for a second appointment."

An active duty servicemember, who asked to remain anonymous, concurs. After months of heavy drinking and misuse of prescription drugs, he turned to a community-based provider for help because he didn't want to risk being "kicked out of the Army after 20 years of service." He recounts that while sharing his combat experiences about - how he lost both legs and came home to find his wife and kids gone, "the therapist started crying. On top of that, he kept interrupting me, asking what I mean by this term and that." The sergeant shakes his head. "I never went back to him, and I never went to another civilian provider, and yes, I'm still using."

SAMHSA's Role

Ms. Power emphasizes that "most servicemembers have strong resiliency that enables them to deal successfully with isolation, multiple relocations, and new environments, in addition to combat-related stressors and trauma. For those who do not, it is our responsibility and our duty to help them heal and re-integrate into society."

SAMHSA works in partnership with the Department of Veterans Affairs and the Department of Defense in providing information and assistance, and by enhancing the understanding of behavioral health service providers in the civilian community. In support of this effort, SAMHSA has introduced the Military Families' Strategic Initiative as part of Leading Change: A Plan for SAMHSA's Roles and Actions 2011-2014. In addition, the National Action Alliance for Suicide Prevention, of which SAMHSA is a member, established the Military/Veterans Task Force to strengthen suicide prevention efforts among this high-risk population.

Lessons in the Warrior Culture

Insight into the military culture is often just a click away. For example, civilian providers can learn about the warrior culture, the issues around deployment and the stress and trauma of combat through online webinars, speaker series, and online interactive courses – both for credit and non-credit. Private-sector therapists can also participate in in-person trainings held year round across the country.

Lisa Peterson, LMHC, LCDP, a civilian treatment provider, recently participated in one such training -- Operation Immersion (OI), a two-day experiential program in which civilian therapists were plunged into the military way of life. The experience, she says, has won her "credibility" among her military clients. It also created a noticeable shift in the client-therapist dynamics in the psycho-educational classes she manages for veterans suffering trauma, addictions, and mental health issues at a community behavioral healthcare center in Warwick, RI.

"Before I went through OI – where we slept in bunk beds in open bays, shared showers, ate MREs (Meals, Ready-to-Eat), and pushed through a high cardio workout—some of my military clients were guarded and unsure if I would understand their issues or experiences," Ms. Peterson says. "When they saw a MRE on my desk, they began sharing their personal stories more spontaneously with me and expressed appreciation for my efforts to learn their culture."

Jill Legault, LCDP, a community-based substance abuse counselor, says that her military patients are more "forthcoming" now that she has participated in OI. "Before learning about the military culture, I couldn't fully appreciate my military clients' problems. I didn't understand words like 'convoy' or acronyms like 'IED.'" Now Ms. Legault says she has a new appreciation of their experiences and is changing the goals of treatment to be more family-centric.

Another civilian therapist, who asked not to be named, said she used to be "intimidated by servicemembers who would ask her how she could help if she had never been where they had been." After having taken several online courses about the military culture and experience, she feels more confident in asking her military patients questions about their experiences—questions that helped build rapport, such as "How many times have you been deployed" or "Where and when were you deployed?" This, she says, shows she understands that different places at different times have different stressors.

Military Members Access to Care

Master Sergeant (MSG) Stephanie Weaver, liaison to SAMHSA from the National Guard Bureau, emphasizes that military culture and treatment implications vary among the various branches of the service as well as the National Guard and the Reserves.

"Most members of the military and their families are covered by TRICARE," she says, "which covers behavioral health care provided on military bases and also sometimes among private providers who get TRICARE certification. But the status of National Guard and Reservists as 'citizen soldiers' means that their health care benefits differ from those of other soldiers. Many of those deployed to Iraq or Afghanistan find their benefits for substance abuse and mental health services are very limited upon their return. Most of them receive these services from community providers.

"It's important that needs of the National Guard and Reservists be understood and addressed," says MSG Weaver. For more information on SAMHSA's work with the National Guard, see SAMHSA News, September/October 2010.

How Community-Based Providers Can Serve

Ms. Power encourages private-sector providers to become TRICARE-authorized (certified) practitioners to ensure they are eligible for reimbursement for their services to military members and their families.

She adds, "We encourage private-sector mental health professionals to serve our men and women in uniform. Their help can ensure our military consumers continue treatment and therapy and have a greater opportunity to recover. Supporting and strengthening our military families is not only critical to our national security, it is a national moral obligation."

For more information on SAMHSA's Military Families' Strategic Initiative, visit http://www.samhsa.gov/MilitaryFamilies/.