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April 10, 2013

StrongVeterans.com Blog Military Cultural Knowledge: Request for Input

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Eric G. Meyer, MD

US Air Force, San Antonio, Texas

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Less than one-third of veterans receive their health care from military or VA hospitals.1 If civilian providers do not ask patients about military service and do not know much about military culture, then important context might be missed, common pathology might not be screened for, and care may be impacted.

I am a psychiatry resident working on a survey that assesses civilian providers’ military cultural knowledge. I am trying to figure out what questions best represent a reasonable foundation in military culture. I’d love to get your input: Are you familiar with all of the following information? Is some of it too esoteric? I appreciate your help!

  • The US military has 5 branches: Army, Navy, Air Force, Marines, and Coast Guard. Each branch has Reserve units, and the Army and Air Force also have National Guard units.
  • Nine percent of the current adult US population has served in the military.1
  • The military uses a rank structure, and knowing the basics (officer vs enlisted, low vs high rank) can tell you what type of work was done and how successful a service member may have been. For example, a member with 15 years of service who only made Corporal may have had some difficulties.
  • OEF stands for Operation Enduring Freedom and is the name for the current US operation in Afghanistan. The Iraq war was called Operation Iraqi Freedom (OIF). A member of the US Army who served in Iraq is called a US soldier or veteran, not an Iraqi soldier. About 2.5 million service members have deployed in OIF and OEF, and more than one-third have deployed more than once.2 Over 250,000 National Guard members have been deployed to Iraq and Afghanistan.3
  • TBI stands for traumatic brain injury, one of the most common types of injuries sustained in the wars in Iraq and Afghanistan.4 The primary mechanism of US combat injuries sustained in OIF and OEF is blasts4 (not gunshots or helicopter crashes).
  • Another important military diagnosis is PTSD. Among recently deployed soldiers, 11% to 20% develop PTSD due their combat exposure.5
  • Sexual trauma has been reported by 20% of women who have served in the US military.
  • A military patient’s commanders have a right to know about the patient’s medical ability to do his or her job without consent of the patient, according to Department of Defense Regulation 6025.18-R, Section C7.11.1.1.
  • Members of the military often state that protecting a friend was their main reason for attacking the enemy, rather than self-defense, following orders, or moral sensibility.6
  • The shared core values of Air Force members are Integrity First, Service Before Self, and Excellence In All We Do. Killing and destruction are NOT core values of a military branch.
  • More than 40% of military members who deployed in OIF and OEF have children.7 Children of a deployed parent have increased rates of behavioral problems.
  • The suicide rate among US veterans is estimated to be 22 deaths per day; veterans aged 50 years and older comprise 69% of these deaths. Suicidal ideation is an important part of the clinical assessment of patients with a military history.

Financial disclosure:Dr Meyer had no relevant personal financial relationships to report.

References

1. National Center for Veterans Analysis and Statistics. Profile of Veterans: 2011. Washington, DC: Department of Veterans Affairs; 2013. http://www.va.gov/VETDATA/docs/SpecialReports/Profile_of_Veterans_2011.pdf. Accessed March 18, 2013.

2. Adams C. Millions went to war in Iraq, Afghanistan, leaving many with lifelong scars. McClatchy. March 14, 2013. http://www.mcclatchydc.com/2013/03/14/185880/millions-went-to-war-in-iraq-afghanistan.html. Accessed March 19, 2013.

3. Congressional Research Service. CRS Report for Congress: National Guard Personnel and Deployments. RS22451. Washington, DC: The Library of Congress; 2008. http://www.fas.org/sgp/crs/natsec/RS22451.pdf. Accessed March 18, 2013.

4. Warden D. Military TBI during the Iraq and Afghanistan wars. J Head Trauma Rehabil. 2006;21(5):398–402. PubMed

5. National Institutes of Health. Post traumatic stress disorder (PTSD): a growing epidemic. NIH MedlinePlus. 2009;4(1):10–14. http://www.nlm.nih.gov/medlineplus/magazine/issues/winter09/articles/winter09pg10-14.html. Accessed March 19, 2013.

6. Grossman, D. On Killing: The Psychological Cost of Learning to Kill in War and Society. Revised edition. New York, NY: Little, Brown and Company; 2009.

7. Department of Defense. Report on the Impact of Deployment of Members of the Armed Forces on Their Dependent Children. Washington, DC: Department of Defense; 2010.
http://www.militaryonesource.mil/12038/MOS/Reports/Report_to_Congress_on_Impact_
of_Deployment_on_Military_Children.pdf
. Accessed March 18, 2013.

Category: PTSD , Veteran
Link to this post: https://www.psychiatrist.com/blog/strongveterans-com-blog-military-cultural-knowledge-request-for-input/
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22 thoughts on “StrongVeterans.com Blog Military Cultural Knowledge: Request for Input”

  1. This is useful information to get out to civilian psychiatrists. I am aware of most of it because my husband was Navy and most of my residency was at
    a big VA facility. Would love to go back to work with veterans.
  2. I am an active duty Army psychiatrist and just came back from Afghanistan.
    Btw, the quoted suicide rate amongst Veterans per day seems too high and would amount to over 8,000 suicide related deaths per year…hard to believe, but, I suppose, a possibility. I will share this data with my colleagues. Please let me know if I can be of any help.
  3. I work as a Forensic psychiatrist. I am also a now retired State Air Surgeon / Flight Surgeon (Colonel) with 28 years of military service including 4 years active in U.S. Army Special Warfare / Special Operaions.

    The most important questions to ask non-deployed Service Members:
    What are your dates of Service?
    Are you connected with the VA?
    What was your highest rank?
    What was the type of discharge: Honorable, General, Medical, other?
    What was your MOS (Military Occupational Specialty): Special ops, Demolition/Explosives, warrants especially close attention relative to a translator
    Did you receive Article XVs (non-judicial form of punishment, like extra guard duty): ask how many, reaason, etc.
    If the person is on active-duty, you need to ask about whether your will be asked to produce a report or sign-off on their fitness for duty. This is especially im[portant for those with Security Clearances.

    For those who were deployed to a combat area, ask:
    What and when were your deployments?
    Did you experience combat? Describe?
    Were you wounded? Diagnosed with a Traumatic Brain injury or were you close enough to an IED or other explosive device for your hearing to be effected, even temporarily (correlated with TBI)?
    Did you witness anyone’s death in combat? Describe what you saw.
    Have you sought or received any kind of care for a combat-related wound or injury?
    Have you or anyone in your family or unit told you that they have seen changes in your emotions, mood, thinking, or behavior following your return from overseas?
    has your commander ever ordered you to see a psychologist or other mental health professional?
    Have you ever received psychiatric medications? Ask the Service member to explain what meds, when, who prescribed, course of use, effects?
    Ask about whether the Service Member sought medical help for any reason following their return from a combat deployment (hunting for somatic symptoms associated with PTSD; these are much more likely to propel the patient to request care than formal PTSD symptoms)
    Consider using a PTSD structured screen (widely available on the web).
    Ask about whether the Service Member was treated for any illness while deployed (some infectious agents can penetrate the CNS)? Or whether they were exposed to any toxic agent.
    Is the Service member currently receiving VA Disability? What percentage?
    Have they applied for a Service-Connected Disability?

  4. I have been in the army reserve for 24 years in the Nurse Corps & have completed several tours. very useful information for civilians who have no knowledge of the military system. Our military health care system is broken. To quote a general in the recent past ” Our military health care system is fragmented, complex, & confusing. The stigma is still out there esp with commands in spite of all the funds spent on health care to include TBI & PTSD. I don’t foresee any future improvements. I have witnessed first hand abuse, suicides, & threatened homocides from military people. You do the best with what resources are given to you.
  5. I am a Clinical Specialist/Nurse Practitioner in Psych at the VA. It takes a special kind of provider to work with veteran’s who have mental health issues. Many of my patients have TBI, PTSD and I think the number of sexual assaults in the military is higher than 20%, you need to count the guys as well!
  6. Military Cultural Knowledge:
    I served in the USMC during the Vietnam era.
    I recently (2012) wrote a book with a Serbian colleague -“War Trauma and its Aftermath: An International Perspective on the Balkan and Gulf Wars” (University Press of America – Laurence Armand French & LdijaNikolic-Novakovic : ISBN 978-0-7618-5801-0) It addresses military culture….
  7. I am currently pursuing a Master’s in Counseling. I also have a daughter and son-in-law currently serving in the Air Force for almost 25 years each. I have been called on to keep their children while they were both deployed at the same time. I had to utilize military services for their children. It is my understanding that all soldiers have “security clearance” which is why the DoD has access to their medical records – to see if that security clearance needs to be revoked. If what you put in that record indicates a necessary revocation of the security clearance then you have cost that soldier his/her job. Watch what you write and be mindful that the soldier is watching what he/she is saying. They don’t want to lose their jobs which makes seeking treatment or help that much harder.
  8. I see veterans in both VA and private settings. I’d strongly emphasize asking about a service member’s MOS as it gives a good idea of premorbid skills and level of function. Another good question is whether the patient’s symptoms or complaints have been documented in their service medical record (SMR). This information is relevant to “service-connection” for certain conditions or traumas, and often is left out, records lost, etc., especially in older veterans. Asking about the DD-214 (discharge) form is often quite important.

    For patients with combat experience, it often means quite a lot if the practitioner knows, or takes the time to learn, something about the battles the patient faced, and their context. For instance, knowing a little about Guadalcanal, Anzio, Normandy, the Battle of the Bulge, Okinawa, or Iwo Jima may provide a point of contact and give a WWII veteran a sense that one is interested. Additionally, Vietnam veterans were often subjected to social opprobrium when they returned, and in my experience many of them appreciate the practitioner’s acknowledgement of their feelings about that.

  9. Combat vets (veterans who actually shot and were shot at, which lets out most Navy and Air Force vets) have had experiences which most civilians don’t understand. Combat vets tend to stick together or be loners.
    When I first got back I chatted in a hospital call room with a surgical resident and a P.A. student one afternoon. They seemed very interested in hearing my experiences, which I was reluctant to describe, esprcially details of torture which some members of my unit had suffered while prisoners of war. They kept drawing me out and I kept answering more questions. However I gradually realized that the more I answered them, the more they withdrew from me. I felt like a bug under a microscope. Their curiosity was morbid, like watching a TV movie about some wierdo. After that I learned to keep my mouth shut (which in retrospect probably contributed to my PTSD.)
  10. Robert, Your comments and suggestions are very good. However would you be kind enough to read and comment on my comment “Don’t push for information unless you can help”?
  11. One of the largest hurdles facing military members and veterans are gaining access to mental health professionals who can actually treat them. On most military installations you can find a host of “counselors” who are really nothing more than life coaches. To seek treatment, most must find help off the installation. The VA system is clogged with endless paperwork that causes clinicians to be far less effective in the overall treatment of veterans. So, for many vets, they, too, reach out to civilian providers. I agree that providers will see better results if they familiarize themselves with military culture and customs as more and more of their patients have served or been family members of those who have served.
  13. I am finishing up my Master of Social Work degree at USC and have completed the Military Social Work and Veteran Services Subconcentration. Prior to beginning the subconcentration work, I was unaware of most of the military points made in this posting. However, now that I have finished my degree, I feel competent in this area and confident in my ability to work with military servicemembers and veterans as a civilian provider.
  14. Certain aspects are available to the DoD, however confidentiality covers most of the information, especially if working as a civilian provider. Unless you are working IN the military, there is no reason to report to the commandant or otherwise, unless there are reportable issues. No servicemember can be required to receive treatment, only to be assessed.
  17. medics should stay away from torture and hold high our hippocratic oath. To support it only endangers soldiers by making life seem meaningless and thus for them, the values of loyalty, patriotism, only talk. For the enemy uses that as a reason to retaliate. Just like our soldiers respond as per your entry to protect a colleague, the enemy may do that. were doe this end? another death? The family of a soldier who we loose on the battle field is scared. The one who returns ‘a shell of what he was’, due to what he was asked to to and didnt agree with is a greater risk. suicide is a wasted life. Such surveys often serve as a convenient paper for the author and unless it is sincere in its attempt to help the veterans, it unsults their memory/service
  18. Correct. Which is why when a service member seeks treatment they often seek treatment off base, but if you are an on base provider records can be made available if treatment is sought for specific mental illnesses.
  19. I think you highlighted many of the topics that are discussed with veterans in the VA. The culture is esoteric, but if being seen outside the VA knowing commom themes, terms, lingo i.e. structure, branches, ranks, conflicts can only be helpful. It is a shame that only a 1/3 of veterans receive care from the VA. Trust is a huge concern for many veterans. The VA’s primary mission is to be a vibrant part of the veterans in partnership integrated healthcare network delivery system that improves the health of the Veteran population. Also the Department of Defence provides services in support ot the Veteran.
  20. I also am a Clinical Specialist in Psych and a LPC at the VA. Many veterans had the best times and the worst times of their lives in the service. The incidence of sexual harassment or MST is high in men and higher in women. Many vets did not seek help for Mental Health while in the service, because they were afraid of bias from higher ups.
  21. Thank you all for your thoughtful comments. We are currently working to validate our assessment and will hopefully be working to assess online curricula on military culture soon.
  22. I am a active duty psychiatrist with more than 24 years on AD. Doubtful that the suicide rate is as high as described, but I would like to reiterate that Vets of combat do tend to be loners or segregate themselves with other vets, usually even of the same campaigns. Our “disability system” hurts those that really have incredible resiliency and function and unfortunately solidify “projective identification.”
    The stigma of MH exists but is leagues apart from its barrier of yore. The main stigma now exists in personal / societal vs. military and the plea of those undergoing criminal or UCMJ process. Odd how it is mental illness after a felony charge…

    Our military is doing a great job, but the system does weigh down by the incredible sense of entitlement that exists now…

    just my 2 cents.

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