Military Culture: Working With Veterans

According to the U.S. Department of Veterans Affairs (VA), around 70% of physicians in the United States have received some of their training with the VA. A total of 178 of 183 U.S. medical schools are affiliated with the VA, and 43,565 medical residents, 24,683 medical students, and 463 advanced fellows received some or all of their clinical training within the VA system in 2017 (1). Despite this training, most clinicians do not feel adequately prepared to provide high-quality care for veterans. In a recent study, only 13% of mental health providers met readiness criteria for culture competency in treating veterans (2).

To better serve this population, it is imperative that clinicians understand military culture. The present article provides clinicians with useful information to consider when treating active-duty service members and veterans.

Ironically, service members forfeit many of the freedoms that they fight to protect. They give up a piece of their individuality to become a part of something larger than themselves. While serving in active duty, uniformity is the rule: dressing the same, speaking the same, and behaving the same. The right to free speech, the right to bear arms, protection from illegal search and seizure, and the right to a trial by jury are all relinquished. Additionally, unlike in civilian jobs, once a contract to join the military is signed, it cannot be freely withdrawn by the signee. Without a proper discharge, a service member can be criminally charged with desertion.

Despite all of the privileges that veterans give up, working as part of a team and being able to rely on those around them inspires a sense of pride, belonging, loyalty, and brotherhood known as esprit de corps. This is why many veterans feel a sense of comfort and connection with other veterans, even with those from different branches of service or from different eras. "I got your six" is a way of saying "I’ve got your back," which embodies this idea.

In the civilian world, an individual’s beliefs and values can be ambiguous and may change over time. In the military, values are spelled out and explicitly taught from the beginning. Each branch of service holds its own core values (Figure 1). However, despite differences in verbiage, honor, courage, duty, and service above self are common values shared by all service members. These traits and ethics epitomize holding oneself to a higher standard and remain with the veteran over the course of a lifetime.

At some point in most veterans’ experiences, they are confronted with their own mortality. By joining the military, they put themselves in harm’s way. They may have considered it when they signed the contract, or they may not have appreciated it until they were "down range" with rounds screaming past. Dark humor, with morbid jokes about death, are ubiquitous in the military. Whether serving during a time of war or peace, killing and dying in service to one’s country are common themes. Speaking flippantly about death is not a morbid preoccupation, it is a way of coping with this overwhelming burden. Thus, it is important for clinicians to note that a veteran admitting to thoughts about his or her own death may not necessarily be suicidal ideation, it is often a continuation of this mentality. These thoughts are often hidden from family and friends as well as from clinicians due to fear of judgment. This fear of judgment is what may prevent veterans from talking openly with civilians and from seeking professional help. Discussing the veteran’s thoughts about death, if approached from an empathetic and nonjudgmental stance, can bolster trust and expose possible internal conflicts, including moral injury.