I had the unique opportunity to attend a civilian medical school followed by residency and fellowship training along civilian providers, and I often was asked about my military experience. The more time I spent with civilian providers, the more I realized how unaware they are about the intricacies of military lifestyle and culture.
Of course, this makes sense. During the draft era, almost every family had a member who served, and more people were exposed to the uniqueness of military culture.1 However, with the shift to an all-volunteer military came a decrease in the number of both active duty members and veterans.2 Consequently, today’s society is generally less aware of the realities of the military lifestyle. This is especially true among people born after the Vietnam War, whose knowledge about military life is frequently limited to movies and video games. These movies and games are as accurate a reflection of military life as watching TV series such as ER or The Resident are for learning what it’s like to be a physician. To add to the problem, most medical schools and residency training curricula include little information about military culture.3 As a result, psychiatrists, like many other physicians, often feel unequipped to provide care for veterans, current military personnel, and their loved ones.4 At the very least, most psychiatrists are unaware of the differences between military and civilian cultures.
Veterans, current military members, and their families who seek mental health services outside the Veterans Affairs (VA) and military treatment facilities are more likely to encounter a clinician who does not feel comfortable with the nuances of the military lifestyle and its challenges.3 Facing a physician with limited familiarity with their experiences, and out of fear of being misunderstood, patients may not feel comfortable disclosing pertinent details.
The US military has its own culture, lingo, customs, rules, and regulations. Its structure is hierarchical and mission-oriented. The moment a person joins the military, he or she falls under a set of legal guidelines of the Uniform Code of Military Justice (UCMJ).5 For example, extra-marital sexual conduct, fistfighting (not in combat), disrespecting superior officers, and insubordination are all punishable under UCMJ.5,6 Active duty military members are also prohibited from suing the federal government for injuries.7 The Health Insurance Portability and Accountability Act (HIPAA) permits protected health information of Armed Forces personnel to be disclosed under special circumstances. These include fitness for duty determinations, fitness to perform a particular assignment, or other activities necessary for the military mission.8 A mental health provider’s understanding of the unique aspects of military culture can positively influence the patient-provider relationship whether the patient is still serving, has left the military, or is a family member of a current or former military member.
Not all military veterans qualify for VA health care. For example, those who didn’t serve the required time on active duty, those whose injury existed prior to joining the military and was not worsened by their military service, and those discharged under other-than-honorable, bad conduct, or dishonorable conditions are unlikely to qualify.9 Other veterans simply prefer to be privately treated outside the VA. However, despite where a veteran receives treatment, the clinician’s knowledge of important military concepts can facilitate rapport-building and providing a safe space for disclosure of pertinent history. Obtaining a military history that includes (for example) years of service, number and location of deployments, combat experience, and number of transfers can help with understanding the biopsychosocial factors contributing to the diagnosis and important treatment needs.
While military dependents (spouses and children) don’t wear uniforms, they are also affected by the service and sacrifices of the military member. Spouses have to deal with adjusting to the military lifestyle, searching for new housing and jobs, finding schools for children, and separation and reconnection with a military member. Military children are not spared, either. They, too, have to leave their friends and find new ones, and adjust to new places, routines, and schools, knowing that in 2 to 3 years they likely will have to move again.
As a military member, mother, and spouse of a former military member, I know how life-changing military service can be for the entire family. I encourage all physicians to start routinely asking if their patient or his or her loved ones have ever been in the military, because a positive answer could help you to better understand the patient and provide the most appropriate, person-centered, culturally-informed treatment.