Veterans Mental Health

Christa Butler:

Welcome to the Voice of Counseling from the American Counseling Association. I'm Christa Butler from ACA, co-hosting with Emily St. Amant, and joining me today is Duane France, who is here to talk about veterans mental health. For more information about counseling veterans, check out the ACA book, Clinical Military Counseling Guidelines for Practice by Mark Stebnicki, which can be found on the ACA website counseling.org in the ACA store. Duane France is a retired army non-commissioned officer combat veteran of both Iraq and Afghanistan and a licensed professional counselor in Colorado. After retiring from the United States Army in 2014, Duane earned his master's degree in clinical mental health counseling and master's in business administration from Adams State University.

Christa Butler:

He is currently the co-director of SAMHSA's Service Member, Veteran, and Military Family Technical Assistant Center. Duane has been a member of ACA since 2014 and has been involved in various leadership roles, including a board member of the Military and Government Counseling Association and co-chair of ACA's Public Policy and Legislative Committee. He currently serves as MGCA's governing council representative. Duane, thank you so much for joining us today for this important discussion on veteran's mental health. Let's start with you sharing with us more about your background and your specialty in veteran mental health.

Duane France:

Yeah, I appreciate it. Thank you so much, Christa and Emily, for having me on the show. Really excited. So, like many of us in the counseling profession, I came at this sort of secondarily. I actually served in the Army for 22 years. So, I retired from the United States Army in 2014 after 22 years and five combat and operational deployments. And it wasn't until I was in Iraq in 2006 and I'd been in the army for 15 years before I really realized what I wanted to be when I grew up. I always thought after the military that I would be a high school English teacher or a history teacher where the kids would be able to start asking me war stories and derail me and not get homework, that kind of stuff. But then when I was in Iraq, I started to see... My father was a Vietnam veteran, three of his brothers are Vietnam veterans, and so I knew what the impacts of combat was.

Duane France:

And then when I was in Iraq, I started to see that the service members of this generation were going to need the same kind of support. So, sort of the idea, the interest in psychology was there. But then after that, immediately after that, we were doing our post-deployment briefing, and we had a counselor, a mental health professional from the vet center, actually, here in my community who was presenting us on how to be nice to each other. Don't throw things at the dog, don't yell at the neighbors, be good after you come... And so she stopped sort of in the middle of her presentation and she said, "Oh, by the way, if any of you are interested in mental health, consider a career in the mental health field because there are not enough combat veterans in the space." Again, this was December of 2007 probably.

Duane France:

And so that sort of dropped a stone in my mind and just said I wanted to start thinking about becoming a clinical mental health professional. At the same time, my community here in Colorado Springs was starting a veteran's court. I knew that those veterans would benefit from somebody who had lived experience. So, that's really what started me down my journey. I got my graduate degree in clinical mental health counseling from Adams State University in 2015, and then started working as a clinician here in my community for many years, very specifically supporting our local veterans court as a member of their team, but also developing programs that reduce barriers to care. I served as a director of veteran services for a large outpatient private practice for a while, doing a lot of work with the Department of Veterans Affairs, Department of Defense, large military installation community here in Colorado Springs, and then just recently started an administration position with a technical assistance center for SAMHSA.

Christa Butler:

Wow. Thank you so much for your service and for your dedication to veterans into mental health. And I think it's amazing how you've been able to blend your passion for mental health and your passion for veterans and have done so much to advocate and to contribute to the needed efforts and legislation and everything that you do for veterans. So, we appreciate everything that you've done as far as being a veteran yourself, as well as being such a strong advocate for veterans, for veteran mental health.

Duane France:

No, I appreciate that. Like many of us in the clinical field, lived experience is very critical. I always say the best preacher is a former sinner, right? And we see this in recovery, really. As people go through their own recovery space, and then they really become valuable recovery professionals. And I see the same thing with, again, not only my experience with my father... Two of my grandfather served in World War II. My younger brother was a combat veteran of Iraq and Afghanistan just after me. And so really the family service, but I think that lends a unique lived experienced aspect to the work that we do.

Christa Butler:

Absolutely, absolutely. And we want to get into that in a minute. We want to ask you about family members of veterans, family members of active military as well.

Emily St. Amant:

Yeah. So, speaking to your experience, you've probably seen a lot of this firsthand, but also in your work and heard this from others or just seen observing systems of care and such. So, speaking of barriers, when it comes to accessing services and treatment, what are some of the challenges that people that need support, what are some of the things that they encounter that counselors need to be aware of when it comes to accessing care for veterans?

Duane France:

Well, I think one of the most important things to consider for professional counselors, for the audience that's listening here, is how they can work with veterans. That's one of the things that I often hear is they know that that veterans may be experiencing some barriers to care, and how can they help? And how do we engage with veterans in the first place? And the ACA has worked very closely in the last several years to increase the hiring of professional counselors and Department of Veterans Affairs, because that's one of the things. That's where a lot of veterans get their care. And often, you'll hear our colleagues from the VA say, "If you've stepped in one VA, you've stepped in one VA." But there's a lot of differences between perhaps wait times and things like that. And one of the challenges is just the number of mental health professionals in the VA, in large caseloads.

Duane France:

And so I think that's one of the big things for professional counselors to know is the ACA has really tried to do a lot. And the VA calls them LPMHC, so licensed professional mental health counselors. Professional counselors in my experience, are very widely represented in vet centers. For those listeners who don't know, it's sort of a subset. It's basically a community counseling center for the VA. So, there's a lot of LPMHCs in the vet centers, and the ACA has been doing more to get them in the larger VA hospitals. Also, ensuring that professional counselors are paneled with TRICARE, which is sort of the DODs version of insurance. And like any other insurance, there's challenges both on the client side and accessing that insurance, but also on the professional side, managing that insurance. But then also, not all veterans are eligible for VA services or TRICARE, so learning how to integrate them into their practice, even if they're outside those areas.

Duane France:

You might be in a practice and you might find that you're serving veterans or military spouses that aren't using VA funding or TRICARE. They're using their own personal, maybe their work employer healthcare or things like that, but still understanding that there's some unique needs related to military and veteran mental health and their families.

Emily St. Amant:

Yeah. So, there's a lot of improvements that have been made in recent years, thankfully. Still a lot of work to be done, however, to expand counselors reach and to communities. And like you said, if you're not associated with one of those formal structures that serve this community, there's a learning curve probably that goes along with trying to serve that community.

Christa Butler:

Right. And it's important for counselors to be competent in those areas of expertise and in those areas of clientele that they're serving. And so what suggestions do you have as far as the best practices for counseling veterans that counselors might need to keep in mind?

Duane France:

Whenever I talk to any mental health professionals, and this is even outside the counseling field, but when I talk to psychologists and social workers, marriage and family therapists, anytime someone asks me that question, I always point them to the resource on the ACA website, the exemplary practices for military populations. This is a set of recommendations that was developed by a task force appointed by the Military and Government Counseling Association board of directors in 2016. It makes recommendations in a number of different areas, knowing about military culture that you just mentioned, Christa, understanding the identity development of a service member or veteran, the systems that the military affiliated clients interact with, whether it's active, guard, reserve, or even the veteran system in a lot of different areas. It's really the most comprehensive list of things that a mental health professional who's working with service members, veterans, and their families needs to know. It is the most comprehensive resource that I've been able to share, and it's widely available for anybody.

Christa Butler:

Thank you for bringing that up. We'll make sure to link that in our episode notes. You mentioned the division within ACA for those who are interested in working with the military. Could you tell us about the division that helped to put the exemplary practices together?

Duane France:

Yeah, so the Military and Government Counseling Association, as you mentioned, is a division of the ACA. And so I've formally served on their board of directors. After I retired, apparently I didn't stop volunteering for stuff. And so I still find myself involved in a lot of different things. And a very, very good mentor of mine, Dr. Dannette Berksteiner encouraged me to get involved in NGCA. And now I currently serve as the military and government Counseling Association governing council representative. So, still involved in the leadership of the organization, but really, like all of the divisions, it's based around those who have an interest in, a desire to support, those who maybe want to learn more about how to support service members, veterans, and their families. And like all divisions, we have adjacent activities that are related specifically to not just supporting service members and veterans, that's why we call ourselves the Military and Government Counseling Association, but also really a focus on first responders.

Duane France:

There's a lot of overlap between the military population and first responders. Again, my father, a combat veteran in Vietnam, left there and became a St. Louis City cop in the seventies. So, we don't know where PTSD from one ended and the other began. And so I think that there is a lot of support for anybody who is interested in working with clients in that sort of space. The Military and Government Counseling Association is really great place to connect with like-minded professionals.

Emily St. Amant:

Okay, yeah, that's a great resource for people to check out, and also to have a community that's also working to support this population. So when it comes to counselors who want to work with the military or veterans, like you said, they're oftentimes in recovery. It's been sort of a standard for people to been recovery themselves, but that's not necessary always. So when it comes to working with veterans, some people might think that maybe they can't because they're not a veteran themselves. So, what are your thoughts on that? And any thoughts about counselors who aren't veterans themselves serving veterans?

Duane France:

Yeah, no, that's a great point. And I think that limiting belief is something that both counselors and clients can have, so veterans who are clients. And sometimes clients can take it even farther. I mean, I've had clients that worked in our practice. I don't want to see a counselor unless they served in Vietnam between this time and this time and had this exact MOS for me and in five miles away from where I'm at. And so those kind of limitations really... Is that client ready to really engage in what we're trying to do? But yeah, so there's that idea of I can't see someone unless they were a combat veteran, or I can't see someone unless they were this particular thing. And whenever I have those conversations, it's like to being an oncologist. You don't have to have had cancer to be an oncologist. You don't have to have served in the military to be a counselor for veterans.

Duane France:

One, there's just not enough of us veterans, much less combat veterans like me in the clinical mental health space. The need is so great and the numbers are so few that it just wouldn't make sense. Like that oncologist though, you do have to learn your subject matter. You do have to start to understand the unique aspects of military culture. Anytime you find yourself working with a particular population, you need to be able to learn the culture of that population, learn the language of that population, learn how to appropriately responsibly interact with them. And I think that's the more important thing, is if a counselor is willing to take the time to learn and understand and develop knowledge, the clinical skills are there. So, treating PTSD for someone who is in a vehicle accident and treating somebody who has PTSD from combat, the techniques are still the same.

Duane France:

The contents of the bucket may be different, but how you actually deal with it is very similar. And I think it's really something that can be powerful, even for someone who wasn't a service member or veteran to be able to engage with veterans as a clinical mental health counselor.

Emily St. Amant:

Okay. So, it's important to not let that hold people back if they have an interest or a passion for supporting this community, that it is possible and that the need is there, right?

Duane France:

Absolutely. And the other piece though is desire is not enough. And sometimes you may say, "I want to work with veterans." And then you start to get in the room and you're going to start to hear some pretty heavy stuff, some of the most challenging things. And you may find that, wow, there's more to this than I thought, that this is a little bit heavier than I expected. And it's perfectly fine to go back and say, "You know what? I don't think that I want to work with veterans." I've actually had colleagues who are veterans that don't want to work with veterans. Conversely, and I had this early in my internship, was... My clinical supervisor said, "Hey, we have this 18 year old who would really like to see a male counselor. Can you engage?" It had nothing to do with the military. I've got two teenagers at home. I don't want to work with teen... Give me a three tour combat vet all day long. I would love to do it. Teens are way outside my comfort zone.

Duane France:

So, I think everybody needs to understand where their inclinations lie, where their strengths lie, and just work with the population that they feel they can work most strongly with.

Christa Butler:

All very important points, that you are able to work with populations that you may not have that direct experience in, but you have to practice counselor self-awareness and assessing where you are in, like you said, in your desire, in your ability to be able to best serve that community. And you brought up some really important points as far as being culturally responsive in serving veterans and the importance of being mindful of the specific culture, the language, and the things that make the culture that you're serving unique from others. And so I'm curious if you could share with us what are some things that counselors should know in terms of learning about the culture of the military and how the culture can impact mental health in both some of those positive ways as well as ways that might be harmful.

Duane France:

And so I think that's a whole podcast episode in and of itself. This idea of... For those who may not have served, the military is a separate culture. Yes, it's an occupation, and there are some occupations that can develop cultures, like we were just talking about, as far as law enforcement, first responders, things like that. I think teachers and educators is another occupation that can also develop a certain type of culture. But the military has its own culture, everything that defines a culture way of dressing, way of transmitting knowledge between generations. We have our own language. I speak both acronym and expletive fluently, right? The military has its own culture that has its own unique aspects and cultural touchpoints. And so I think just knowing that is necessary. But then just any other multicultural group that we may find in our practice, we, as clinicians, have a responsibility to learn about that culture.

Duane France:

And this is very critical. And I think people in the multicultural space know this. Not have the client teach us about the culture, right? So, we can't have the client, well, explain to me... I've actually had that experience. My wife and I, after Iraq and Afghanistan, actually went to marriage counseling. And in our counseling session, the counselor was asking me about military culture as it applies to another client he had, which was not why I was there and not really cool, right? And so I think we have a very important responsibility to learn about that culture on our own, and then to be able to... And even if you don't intend to work with military veterans, if you start to find that you have military veterans, maybe a military spouse, or even more specifically maybe a woman veteran or a veteran of color in your practice, to understand that there are subcultures within these cultures. There's diverse aspects within the military culture.

Duane France:

My experience as a senior non-commissioned officer in the United States Army and global on terror, very, very different than the experiences of a person of color who served in the mid eighties not in combat, right? And so I think that it's very important not just to understand the culture, but the diversity. But there are organizations. There's a group called Psych Armor. They provide free online training to individual learners, and they have a very good basic military culture course, but also there's an opportunity, I think, for people to really pick up knowledge from a lot of different places.

Emily St. Amant:

So, it's important to remember that the, because it is a one culture, it's not a monolith, and that every person is going to have their own cultural experience and bring... They're also bringing you to the table with their personal identities that are all intersecting, right? So, it's really important to remember that while we can never be an expert in a culture that we belong to, that doesn't mean we don't have a ethical responsibility to do our homework, because it's... I think expecting the clients to educate us on things we can actually seek out and learn ourself is... That's putting an undue burden on them. So, I think that's important to keep in mind. And when you comes to... Speaking of culture, even the spouses and families of military and veterans have experiences of culture as well. And they're not the only ones impacted by the service, the culture, and if their loved one is experiencing mental health concerns. So, can you speak briefly about the need to also take into account the veterans family and support system?

Duane France:

Sure. Our relationships impact our mental health and our mental health impacts our relationships, right? And so my wife and I have been married for almost 24 years. And the large portion of that, a significant portion of that was while we were in the military. We got married while I was in the military. When I started to deploy in Iraq in 2006, my children were in kindergarten and first grade. And when I stopped deploying, my last deployment to North Africa, they were approaching high school. So, those experiences, they had those experiences of... There was no year between 2006 and 2013 that I wasn't gone for part of or the entire year. And so I think that understanding that military families experience service along with that, they have their own stressors, as well as vicarious stressors that come from those who served. But then you have the other type of experience like me.

Duane France:

I never knew my father was a service member. I was born four years after his time in Vietnam. I never knew any of my... I think I had one uncle who had served in the Air Force. I didn't know him until the mid eighties because that's when he retired. And so I think there's that other aspect of you have families that develop around service members. We see this a lot with veteran spouses that didn't have connection to their partner when they were in the military that really don't understand military culture either and don't understand... They never knew their service member before these things happened, knew their veteran before these things happened to them. And so I think that's a very important aspect for counselors to understand that it's not just the service member of the veteran that experiences stresses related to military life, that it's really the families as well.

Christa Butler:

Yeah. So, it'll be important to not only have an understanding of the intersectionalities, but to have an understanding of the family and the children's needs when working with military and working with veterans. So for our listeners who would like to learn more or to specialize in counseling veterans, you've already shared so many helpful resources. Are there any additional resources or trainings that you would recommend?

Duane France:

So, I think that just other populations of clients, there's not really like a certification in this particular culture. There are some universities that have programs that are really developing these kind of things around service member and veteran mental health, and there are additional learning opportunities online, but it's really a self-paced learning kind of thing. Going back to the exemplary practices guideline that I talked about earlier, there's 10 or 15 different elements in seven different focus areas. That's a lot of information. And I think that really, it's a matter of understanding that as you start to engage with military and veteran clients, you're going to start to really understand, am I seeing more Vietnam or Cold War era veterans, and I need to do more research in that area? Or am I seeing more global war and terror veterans, post 9/11 veterans and I need to do more understanding about the wars in Iraq and Afghanistan? And so I think that really, it's a matter of, as you said, Emily, doing that homework on our own to be able to best meet the needs of our clients.

Emily St. Amant:

Yeah, absolutely. And that process never ends, right? We can't stop learning and growing and reflecting and seeking out ways to better understand our clients and where they're coming from. And also something that's exceptionally important for us to do as counselors is to advocate for our clients and to advocate for even systems level changes that are needed to better support their mental health and wellbeing. So, what are some of the things that counselors can do to advocate for military veterans, needed changes, resources, and support for this population?

Duane France:

No, I really like that question. I actually have a colleague, Josh [inaudible] who serves with me on the governing council who has said that our job as counselors sometimes is to wipe the mud off the pig, but then the pig just goes back in the pigsty and gets muddy again. We have to understand that there are systems in which service members and veterans operate that do need changes. And so we can address what's happening now and help them address what had been happening before, but how can we make those changes so that the pig doesn't keep getting muddy, so to speak? And I think the most important thing is to get involved. You can definitely engage with the government affairs and public policy team at ACA, the opportunities there around advocacy. We've been consistently advocating, for a number of years, different areas related to military and veteran mental health.

Duane France:

One of the things, especially with our years long effort to get Medicare, counselors approved for Medicare. Many people think about Medicare is an aging population concern, but a lot of veterans who are catastrophically disabled, even at a young age, find themselves on Medicare. So, veterans who may be seeing a mental health counselor through TRICARE, for example, now they are on Medicare. All of a sudden, TRICARE becomes a secondary [inaudible 00:27:1] and they have to disrupt their clinician, their clinical experience. And so I think that that's a great example of how ACA is really supporting the military and veteran population. But I also suggest making connections to state lawmakers and understanding how state resources can be provided for veterans in your community. I've found a lot of value in working with state lawmakers to enact state laws, because everything is really... Where counselors are licensed, that's really the work that you're doing, as well as reaching out to congressional representative staff and offer expertise as a resource. They're not clinicians, they're not experts in mental health, and they're especially not experts in veteran mental health.

Duane France:

But a lot of times when people reach out to congressional staff, either you're senator or your local congress person, not to say that there's a mental health component, but there's a mental health component probably to a lot of the distress they're experiencing. And being able to be available for your congressional staff to maybe just offer advice , if not to be a resource, is also something that can be really helpful.

Christa Butler:

Yes, thank you so much for all of those resources. So, it's getting involved at the state level, getting involved in your specific community, getting involved with the legislation that ACA is working so hard on. And Duane, you're a big help with many of those initiatives. And so for counselors, wishing to learn more how you can get involved in some of those things that Duane mentioned, you can check out our website and go to the advocacy tab where you can learn more. Duane, thank you so much for joining us today. This has been a excellent episode. And your wealth of knowledge has been really helpful for counselors, and we appreciate everything that you're doing for veterans and for the counseling community as well.

Duane France:

Oh, thank you for having me. I always say whenever it talks to veteran mental health, I'll talk to three ducks in a street corner. It doesn't matter, and really, because we don't have these conversations enough, I think, about the unique needs of service members and veterans. And so I just appreciate the opportunity to come have a conversation with you both.

Christa Butler:

Excellent. Thank you so much. And for our listeners who like to get in contact with you, how can they reach you?

Duane France:

I think the best way is to find me at veteranmentalhealth.com, all one word. I'm a big guy, both in real life and on social media. So as long as you spell my name correctly, it won't be too hard to find me. I do a number of different things outside of the work that I do for SAMHSA, but really, the website, veteranmentalhealth.com is probably the best place to sort of see all of those in one place.

Christa Butler:

Duane, thank you so much for joining us today. For additional information on topics and resources discussed and access to the ACA book, Clinical Military Counseling: Guidelines for Practice, check out the episode notes. Be sure to subscribe to the Voice of Counseling on Apple and Google Podcasts, and you can follow us on social media. To join ACA and to get exclusive access to all member benefits, check out counseling.org.

Outro Speaker:

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