Developing military cultural competence in civilian clinicians: Working with returning U.S. military populations with combat-related PTSD

An integrative literature review and online survey examined the significance of military cultural competence in civilian clinicians treating U.S. combat veterans diagnosed with posttraumatic stress disorder (PTSD), where the U.S. military was understood as an unrecognized "cultural minority." Combat trauma's development as a diagnostic construct since the American Civil War was reviewed in the clinical literature, and cultural factors distinguishing combat PTSD from civilian trauma were identified. These factors include: (a) parallels between disseminated military values and behaviors inculcated into military personnel and the DSM-IV-TR criteria for PTSD; (b) the multi-faceted nature of trauma occurring in combat; and (c) retraumatization upon civilian reentry.;An online survey of 33 combat veterans corroborated themes in the literature related to military cultural values, homecoming, reentry, and treatment-seeking behaviors. Only 44% of participants reported feeling comfortable receiving mental health services from a civilian provider, and 72% preferred a military provider. Additionally, 88% agreed that civilian clinicians should be familiar with military culture, and 37% were concerned that clinicians could not understand their experience. Results suggest that military cultural competence in civilian psychologists is important in delivering effective mental health care to returning troops with combat-related PTSD.;Six practice guidelines modeled on APA Multicultural Guidelines from 2003 are proposed for civilian psychologists working with military clients. Practitioners should (a) recognize certain attitudes and beliefs that can influence their interactions with military individuals who have different histories, norms, behaviors, and values than themselves; (b) recognize the importance of sensitivity, responsiveness, knowledge, and understanding about military personnel, particularly those with combat histories; (c) learn about unique aspects and risk factors for PTSD and suicide in service members; (d) learn about U.S. military history from all combat eras, including the development of the construct of combat trauma; (e) acquire culturally-appropriate skills in clinical practice with military individuals, i.e. an understanding of rank, terminology/language as it pertains to the therapy relationship, and military distrust of civilian providers; and (f) learn to differentiate between abnormal or maladaptive posttraumatic symptoms as compared to behaviors comprising the military skill set.