____________________________________ Substance Use Disorders: Assessment and Treatment, 2nd Edition
context of mental health consumers is a core professional com- petency across the mental health disciplines, but professionals typically limit their conceptualization of “multicultural” to demographic variables such as gender, race, ethnicity, religious beliefs, and sexual orientation. Viewing the military as a dis- tinct culture relative to the general population is increasingly being recognized as an essential competency for working with military and veteran patients (Bryan & Morrow, 2011). From this multicultural perspective, mental health stigma is viewed as a disconnection between the rules, norms, and identities of the military and veteran populations and those of the mental healthcare system. Many in the field of veteran and military personnel mental health believe that further attempts to change identity-based cultural norms within the military are unlikely to be successful. However, adapting mental health services approaches to better align with military cultural norms is much more likely to result in improved access to care and service engagement. A number of relatively simple strategies can improve access to care and lead to greater acceptability of mental health interventions for military and veteran clients. The following approaches have been suggested: • Incorporating strengths-based conceptualizations consistent with the positive psychology movement fits better with the military identity. For example, common mental health interventions (e.g., relaxation, mindfulness, cognitive restructuring) are more readily accepted when they are presented and described as occupational skills or life skills for bolstering mental toughness, hardiness, or mental agility, as opposed to being presented as clinical techniques for reducing illness or correcting a deficiency. • Adopting a “skills training” approach that emphasizes action-oriented interventions that show service members and veterans what to do, how to do it, and when to do it aligns with the action-oriented military culture. It is recommended that clinicians practice these skills with clients during sessions, as opposed to relying primarily on discussion-based interventions (i.e., “talk therapy”) without skills training. • Learning about the service member’s training background can help mental health professionals to identify pre-existing skill sets and improve learning by drawing parallels with military skills and training (e.g., marksmanship, physical conditioning, survival training). The clinician needs to translate mental health concepts into culturally relevant ideas based on the individual’s language and knowledge sets. • Recognizing the potential for personal growth associated with adverse life experiences (e.g., combat exposure), rather than perceiving such
events solely as “bad” life experiences, aligns with the military cultural norm of strength and mental toughness. The clinician should ask service members what they have learned about life or themselves, what new skills they have acquired or mastered, or how they have become better people as a result of adverse experiences, and frame adversity as a necessary condition for growth and development. • Adopting a more functionally oriented perspective toward treatment goal setting, as opposed to a diagnosis-based perspective, increases the perceived value and relevance of mental health treatment. Military personnel and veterans tend to be motivated more by goals such as “being able to get a good night’s sleep,” “being able to go to a restaurant again with my wife,” or “being able to go to an amusement park with my family,” as opposed to goals such as “reducing symptoms of anxiety.” The clinician should frame treatment as the method for accomplishing these functional outcomes. (Bryan & Morrow, 2011) McDevitt-Murphy, Fields, Monahan, and Bracken (2015) examined two samples of heavy-drinking veterans of Operation Iraqi Freedom and Operation Enduring Freedom. One group met the criteria for PTSD, and one group did not. They found that the PTSD group scored higher than the non-PTSD group on measures of drinking to cope with anxiety and depression and similarly to the non-PTSD group on scales measuring social, enhancement, and conformity motives. Measures of coping and social motives were significantly correlated with adverse drinking consequences. The PTSD group showed a stronger relationship between coping scales and aspects of alcohol misuse relative to the non-PTSD group. This finding is not surprising because anxiety and depression are common features of PTSD and use of alcohol is not an uncommon means of coping with painful internal experiences. In this particular study, it was also found that the negative affect and cognition that accompanies PTSD was a significant motive for using alcohol to cope. Consequently, treatment of veterans with PTSD and SUDs requires considerable sensitivity to the traumatic experience of individuals. Treatment protocols such as Seeking Safety might be especially helpful. Seeking Safety is a manual-based, symptom-focused form of treatment developed to address the special needs of individuals with co-occurring SUDs and PTSD. As previously discussed, Seeking Safety consists of 25 sessions that cover a variety of topics of importance to individuals with comorbid conditions. This treatment allows for considerable latitude so that clinicians can order the sessions and modify them based on the needs of clients. Seeking Safety has been tested with a wide range of individuals, including both male and female veterans (SAMHSA, 2020). The treatment protocol is equally
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