Clinical care guideline: Working with service members, veterans, and their families

This care guideline offers a brief summary of the evidence-based, best practices for providing culturally competent and effective care for Service Members, Veterans, and their Families (SMVF) in an outpatient setting.

Cultural and clinical considerations

While the military experience itself isn’t inherently a clinical concern, it is helpful to understand how military training and culture shape a client's worldview, presentation, and help-seeking behaviors. Veterans’ identification with military culture will vary. Many view their service as an important period in their lives, whether positive, challenging, or both, which has contributed to who they are today. Trying to understand key aspects of a Veteran’s military experience may help clinicians to establish a connection, build trust, and help inform treatment planning.

When assessing SMVF clients, consider the following:

  • Military norms and stoicism: Does the client minimize emotional or physical pain due to a "mission-first" mentality? Are they hesitant to show vulnerability or concerned about the stigma of appearing "weak" or vulnerable?
  • Transition and reintegration: Is the client or their family currently navigating a return from deployment or the transition from active duty to civilian life? This period often involves a profound shift of identity, community, and purpose.
  • Moral injury: Has the client experienced events that transgressed their deeply held moral beliefs, leading to profound guilt, shame, or spiritual distress?
  • Common co-occurring presentations: Is the client presenting with symptoms related to trauma (PTSD), traumatic brain injury (TBI), substance use, or sleep disturbances?

Specific sub-population nuances

  • National Guard & Reservists: Often referred to as "citizen-soldiers," these individuals experience rapid transitions between civilian jobs and active duty deployments, frequently without the social buffer, community, or immediate resources of living on a military installation.
  • Female service members and veterans: Face unique challenges, including higher rates of Military Sexual Trauma (MST), feeling invisible in traditional veteran spaces, and navigating gender-specific health and career barriers.
  • Military children and youth: Experience distinct emotional deployment cycles (pre-deployment, sustainment, reintegration). Stress often manifests behaviorally and changes across developmental stages.

Practical intake & assessment questions

To gather a thorough military history without sounding overly clinical or interrogative, providers can utilize open-ended intake questions such as:

  • Branch and component: "Which branch did you serve in, and were you Active Duty, National Guard, or Reserve?" (Crucial for identifying citizen-soldier dynamics).
  • Role & specialty (MOS/AFSC): "What was your job or specialty in the military?" (MOS refers to Army/Marines Military Occupational Specialty, AFSC refers to Air Force Specialty Code, and Rating refers to Navy/Coast Guard jobs. Asking about specialty helps gauge exposure to combat, trauma, or administrative stress).
  • Discharge status & reintegration: "What type of discharge did you receive, and how has the shift to civilian life been for you?" (Identifies administrative stressors or eligibility for VA benefits).
  • Therapeutic alliance building: "Have you worked with a civilian therapist before? What’s most important for me to know as someone who hasn't walked in your shoes?"

Symptom screening and monitoring

Conducting routine screening of symptom severity is a critical component of measurement-informed care. If a client presents with symptoms related to their military service or transition, the following tools may be of clinical value, particularly in monitoring for increases in symptom severity and risk of suicidality:

  • PCL-5 (PTSD Checklist for DSM): Highly effective for monitoring the severity of trauma-related symptoms over time. You can use this with clients at Rula through our supplemental library of measures. 
  • PHQ-9 and GAD-7: Standard tools utilized at Rula for monitoring depressive and anxious symptom severity, particularly during stressful reintegration periods.
  • PC-PTSD-5: A brief 5-item screen that can be utilized during initial intake to identify potential trauma exposure.

Evidence-based approaches to treatment

Research demonstrates that the SMVF population responds well to structured, culturally informed psychotherapy. Evidence-based interventions include:

Psychotherapy

  • Cognitive Behavioral Therapy (CBT): Effective for addressing depression and anxiety by identifying negative thought patterns related to transition or trauma and increasing adaptive coping and problem-solving skills.
  • Trauma-focused therapies: Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) are the gold standards for treating PTSD in veteran populations. Eye Movement Desensitization and Reprocessing (EMDR) is also highly effective.
  • Acceptance and Commitment Therapy (ACT): Particularly useful for addressing moral injury and the loss of identity during the transition to civilian life by focusing on values clarification and behavioral activation.
  • Family therapy: Focuses on making needed changes within the family system, improving communication skills, modifying family interactions during reintegration, and increasing support among family members dealing with secondary traumatic stress.

Targeted interventions for sleep and chronic pain

  • Sleep disturbances: Sleep disturbance is one of the most common reasons SMVF clients seek care. Cognitive Behavioral Therapy for Insomnia (CBT-I) is highly effective. For recurring trauma-related nightmares, Imagery Rehearsal Therapy (IRT) is an evidence-based modality.
  • Chronic pain & somatization: Provide guidance on assessing the interplay between operational physical injuries, chronic pain, and PTSD/substance use. Behavioral pacing and pain-focused CBT can improve functioning.
noun-lightbulb-1262995.pngAs a reminder, it is beyond the scope of a psychotherapist to suggest specific medications, groups of medications, specific supplements, or advise on the frequency of taking or stopping medications. These discussions must only be carried out by a medical provider.

Assessing risk and higher level of care needs

Many stressors and clinical presentations within the SMVF population (e.g., loss of housing, transition stress, trauma) may increase clinical risk. Veterans have a statistically higher risk for suicide compared to the civilian population, and female veterans are nearly twice as likely (an 80% to 100%+ higher rate) to die by suicide compared to non-veteran adult women. Therapists should consider regularly:

  • Assessing for suicidal ideation, substance use, and self-harm.
  • Creating or revisiting a safety plan with the client.

Lethal means safety counseling

Firearm ownership is culturally prevalent among service members and veterans. Providers must discuss safe storage collaboratively without utilizing a confiscation mindset that may rupture the therapeutic alliance.

  • Conversational scripting: Try framing the discussion around safety and performance: "Just like locking up gear or putting on personal protective equipment (PPE) during training, putting a barrier between a moment of intense emotional pain and a firearm saves lives. What temporary storage option feels most comfortable for you right now?"
     
  • Collaborative storage options: Outline concrete options such as cable locks, lockboxes, temporary off-site storage with a trusted friend/family member, or local law enforcement/armories.

Higher Level of Care (HLOC) routing

If a non-active duty client's risk elevates beyond the scope of routine outpatient care, Rula's Care Coordination team is available to support your client in accessing these additional clinical services outside of Rula.

Active Duty Service Members (ADSM), however,  have an additional layer of care coordination, as care typically requires involvement of a Service Point of Contact, and for some conditions, coordination with the Military Treatment Facility commander. Reservists on active duty orders are treated similarly.

To help an active duty service member step up to a higher level of care, such as an Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), or inpatient hospitalization:

  1. Work through the Military Treatment Facility (MTF) and the appropriate regional contractor (Humana Military for the East region, or TriWest Healthcare Alliance for the West region).
  2. All referrals for ADSMs must go through their Primary Care Manager (PCM) at their installation. The provider will be required to submit clinical documentation explaining why outpatient care is no longer sufficient and why a higher level of care is medically necessary.
  3. Depending on the military branch and MTF, some referrals may also require unit or command notification/approval so that duty status can be monitored.

Emergency hospitalizations are the exception to this process. If the Active Duty Service Member is in active danger to themselves or others, send them to the nearest emergency room or call 911.

Regional HLOC Resources:

Documentation and medical necessity

When documenting care, be sure to include the specific symptoms and the cultural or environmental context experienced by the client. Be sure to clearly state how their symptoms are getting in the way of them living a satisfactory life. This ensures your note reflects an accurate clinical picture, honors the client's lived experience, and demonstrates medical necessity for the service. Consider utilizing applicable Z-codes (e.g., related to deployment, relocation, or discharge) to link military-specific operational stressors to functional impairment in the HPI without pathologizing the service experience itself.

Clinical resources to support treatment

For information on providing effective care and resources for Service Members, Veterans, and Their Families, check out the below resources:

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Publishing. https://doi.org/10.1176/appi.books.9780890425787

Blevins, C. A., Weathers, F. W., Davis, M. T., Witte, T. K., & Domino, J. L. (2015). The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): Development and initial psychometric evaluation. Journal of Traumatic Stress, 28(6), 489–498. https://doi.org/10.1002/jts.22059

Department of Veterans Affairs & Department of Defense. (2023). VA/DoD clinical practice guideline for the management of posttraumatic stress disorder and acute stress disorder. U.S. Department of Veterans Affairs. https://www.healthquality.va.gov/guidelines/MH/ptsd/

Department of Veterans Affairs & Department of Defense. (2024). VA/DoD clinical practice guideline for the assessment and management of patients at risk for suicide. U.S. Department of Veterans Affairs. https://www.healthquality.va.gov/guidelines/MH/srb/

Hall, L. K. (2011). The importance of understanding military culture. Social Work in Health Care, 50(1), 4–18. https://doi.org/10.1080/00981389.2010.513914

Hoyt, T., Holliday, R., Simonetti, J. A., & Monteith, L. L. (2021). Firearm lethal means safety with military personnel and veterans: Overcoming barriers using a collaborative approach. Professional Psychology: Research and Practice, 52(4), 387–395. https://doi.org/10.1037/pro0000372

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