Ethical Considerations when Counseling Veterans and Military

Cynthia Ware

Please watch the following video

• http://nyti.ms/1q5dtFp

What does this mean to you?

• On July 17, 2014 the Department of Defense published a final rule to implement the TRICARE Certified Mental Health Counselor (TCMHC) as a qualified mental health provider authorized to diagnose and treat TRICARE beneficiaries and receive payment for services.

• This means that you will be able to diagnose and treat military service members, veterans, and their families.

• Good news, You will get paid for your services!

Why is this important to you?

• Veterans and military personnel are facing challenges that many people, including counselors, do not understand

• There is an expressed need for mental health professionals to work with veterans.

• Even though the need exists, counselors have to be aware that this population tends to have concerns that are not possessed by any other population.

Military Culture

• The ACA defines culture as “membership in a socially constructed way of living, which incorporates collective values, beliefs, norms, boundaries, and lifestyles…”

Military Culture

• From the way military personnel (past and present) carry themselves, to the use of jargon and acronyms, the military has its own culture.

• Counselors who wish to work with military personnel and veterans need to be aware of the differences between client with no military affiliation, and a client that has a military background.

• Elements Behavioral Health (n.d.) suggests that veterans are less likely to continue treatment if they have a counselor who has limited knowledge of the military.

Military Culture• It is helpful to know rank structure

• A Captain in the Navy has more rank than a Captain in the Army

• It is helpful to know common military jargon• MRE – meal ready to eat• AIT – Advanced Individual Training• ACU – Army Combat Uniform• Dress blues – Formal military uniform• PT – Physical Training• SOP – Standard Operating Procedure• FTX – Field Training Exercise

Being Culturally Aware• Counselors cannot assume that each veteran or military client fits the exaggerated

role typically portrayed in various television programs. • It is a common misconception by counselors that veteran and military clients will have

PTSD. • It is also common for counselors with no military knowledge to misunderstand a

veteran client. • A veteran client may describe having every symptom of bipolar disorder but due to the lack of affect

while in the office, the client may be misdiagnosed or not receive a diagnosis at all (Monroe, 2012).

• Do not automatically assume that a veteran or military client is coming to see you because they have PTSD. • Soldiers have the same issues (marital, body image, familial, etc.) as the average person in society.

They may just be seeking help for one of the things listed above.

What do the Studies Say?• PTSD is the most frequently diagnosed mental

health disorder among veterans that have served in the Iraq and Afghan campaigns.

• PTSD is associated with an increased probability of suicidal ideation in veterans.

• Veterans with PTSD and two or more comorbid mental health disorders are about six times more likely to have suicidal ideations than those with PTSD alone

• Suicidal ideations are the highest predictor of suicide (Jakupcak, 2009).

What Can be Done?

• Mental health screening for veterans that have served in the Iraq and Afghan wars.

• Access to care for veterans and returning service members with mental health concerns.

• Ensuring that we do not try to fit our clients into a diagnosis we want them to have, but that we mold our diagnosis based on the client.

What is in the Media?• VA personnel falsifying wait time records to meet “quota”• Department of Veterans Affairs Secretary steps down amid allegations of

falsifying and destroying records• More than two thirds of veterans that needed mental health care at a

Veterans Administration (VA) facility had extended delays in scheduling appointments.

• Department of Defense recognizes the TRICARE Certified Mental Health Counselor (TCMHC) as a qualified mental health provider authorized to diagnose and treat TRICARE beneficiaries and receive payment for services.

What Does it Mean?

• Although the VA has been humiliated recently due to all the negative press, it is a great time for mental health counselors seeking to get a great paying job with opportunities for paid travel.

• The returning men and women that have served our country are owed at the very least quality health care for the sacrifices they made. This is an opportunity for educated, culturally competent counselors to make their mark.

Case Study• Sgt. Leslie Wilson from Miami, Florida is a 28 year old single mother of two children Josh, 6 yrs. Old, and

Evan, 5 years old. Her job is an Air Traffic Controller. She has been a distinguished soldier receiving 5 Army Achievement Medals and One Army Commendation Medal. Leslie has always been top of her class on the commandants list. Leslie set very high expectations for herself and wants to achieve in a predominately male operated military. She has been on two major deployments to Afghanistan. She injured herself diving off a makeshift runway after a plane attempted to land with a damaged front landing gear and hurt her back severely. Her best friend from Advanced Individual Training (AIT) was killed in Afghanistan on her son Josh’s birthday. Sgt. Wilson has been prescribed hydrocodone in the past for her back injury. She has been honorably discharged from the Army on 02/15/2012 for medical purposes.

• For the past year Sgt. Wilson has been displaying some odd behavior noticed by her family and friends. She is fatigued, non-motivated, makes mistakes often, displays aggressive behavior and has mentioned frequent nightmares to her family and friends. She has become withdrawn from her family and a nuisance to her two boys. Her mother has to keep the boys three nights out of the week so she can rest since she has a hard time sleeping. Her kids has noticed a change in her behavior and her constant pain she speaks of throughout the day. Sgt. Wilson has been seeing a counselor Mrs. Hailey Withers who has been practicing for year now and working with the Department of Veterans Affairs (Behavioral Health Department) i.e. social worker (case management), substance abuse, acute care, and PTSD diagnosis.

Case Study• Counselor has no prior experience with active duty military or veterans who have

served in the military. Mrs. Withers has a Master’s degree in Psychology specializing in behavior disorders (behavioral health) is an honor grad student from the University of Miami Florida. Her passion is to assist veterans who are coming home that have behavior issues stemming from the military. Sgt. Wilson has never spoken of suicide, but has found herself increasingly dissatisfied with her life and the pain she endures constantly. She gets frustrated often with herself because she feels like she has every reason to be happy. The times she is not in bed sleeping and watching TV she is always finding a ways to cope with her pain. Mrs. Withers (counselor) believe the client has a prescription pill problem due to the excessive pain she talks about constantly.

• The counselor did think the client met the Post Traumatic Syndrome Disorder PTSD criteria based on the information received verbally from the client, but the client displayed little affect. The counselor also believes the client just has a problem sleeping due to her stressful job as an Air Traffic Controller. The counselor thinks the client does not want to interact with her kids because her demanding job and long hours contribute to her being tired. The counselor has written a few recommendations to her clinical supervisor stating that the client just wants medication to solve her problems that deal with pain.

Case Study

What are your thoughts?

Ethical Codes Related to Working with Veterans and Military Personnel• Standard A.1.a The primary responsibility of counselors is to respect the dignity

and promote the welfare of clients.• By a counselor taking the time to learn even a small amount of information about the military,

it shows the military client that you respected them enough to at least take the time to learn about their culture.

• Standard A.2.c Counselors communicate information in ways that are both developmentally and culturally appropriate. Counselors consider cultural implications of informed consent procedures and, where possible, counselors adjust their practices accordingly. • There are many in the military that do not have an advanced education, counselors to talk to

them using words they understand. Counselors need to be aware of military culture when discussing informed consent and other confidentiality matters with veteran or military clients.

Ethical Codes Related to Working with Veterans and Military Personnel

• Standard A.2.e Counselors discuss the required limitations to confidentiality when working with clients who have been mandated for counseling services. • Those in the military can be forced, or mandated (via orders by

Chain of Command), to attend counseling. It is important to let the military client know that information can be disclosed to the chain of command, which can affect the soldier’s position.

• Standards B.1.a, B.1.b, B.1.c, and B.1.d as they refer to respecting clients rights. • The military has its own culture, and by educating oneself to the

military culture, can truly assist the therapeutic relationship. It is also important to explain to military client the limitations of confidentiality and privacy, because military personnel are subject to a higher standard of rules and regulations.

Ethical Codes Related to Working with Veterans and Military Personnel

• Standard C.2.a Counselors practice only within the boundaries of their competence, based on their education, training, supervised experience, state and national professional credentials, and appropriate professional experience.• In order for non-military affiliated counselors to be competent when working

with veterans and military personnel, the need to ensure that they are remaining culturally sensitive

• Standard C.5 Counselors do not condone or engage in discrimination against prospective or current clients, based on age, culture, disability, ethnicity, race, religion/spirituality, gender, gender identity, sexual orientation, marital/partnership status, language preference, socioeconomic status, immigration status, or any basis proscribed by law.• Many veterans and returning service members may have disabilities such as

traumatic brain injury and amputations. Some counselors may need to ensure that they are willing and able to work with clients that have these, and other disabilities

Ethical Codes Related to Working with Veterans and Military Personnel

• Standard C.6.b Counselors are accurate, honest, and objective in reporting their professional activities and judgments to appropriate third parties, including courts, health insurance companies, those who are the recipients of evaluation reports, and others.• When working with military or veteran clients, while not

employed by the Veterans Health Administration or the Department of Defense, the aforementioned agencies will likely request records for the veterans or military personnel seen. It is also likely that a military or veteran may have their records subpoenaed for litigation, so this standard is applicable to all third party requests for reports.

Questions?Thank you for your attention.