Staff Perspective: In Their Own Words - The Voices of the Military Culture Training
The goal was to gather as many real-world examples as we could. To get at the stories behind the Service member, Veteran or family member’s lived experience of military culture. Why did the individual choose to serve? Why did they pick a particular branch? What were some high and low points of service? How would they explain the military culture to a civilian and most importantly, a civilian healthcare provider? We wanted to give healthcare providers concrete examples of things they could do to help Service members, Veterans and family members feel understood, respected and cared for in a culturally-informed manner.
“I think doctors in general just need to realize that we all paid a price when we decided to do whatever we decided to do with our lives. We're all equals. We're all human beings, and we all need to be treated like such. We don't need to be treated like heroes; you don't need to glorify us. But at the same time you don't need to look down on us and pity us either. Just treat us like a human being. Treat us like you would want to be treated if you were in our shoes. So, take a step back, look at it, read somebody's story and realize what kind of doctor you need to become. “ Ronald Barnes, Lance Corporal, U.S. Marine Corps
The interviews and stories told were powerful, captivating, colorful, emotional – in short, everything we’d hoped they would be. As part of the joint DoD/VA Strategic Action #25 – Military Culture Training for Healthcare Providers development team, we now had 90 plus hours of footage to give life to the didactic online course on “military culture”. More importantly, we now had practical advice from military-connected patients on how to provide culturally-informed healthcare. The advice extracted from the interviews came mostly in the form of what-not-to-do, examples that we came to call “missteps”. As we combed through each interview noting any “missteps” described, we ended up with a collection of errors that essentially fell into 4 categories: making assumptions, customer service, attitude and inflexibility. As you review each, think about how this may apply to your practice.
1. Making Assumptions – As much as we providers strive to keep our own biases and beliefs out of the clinic sometimes they creep in especially if we are not vigilant about taking time to examine them. Military-connected patients expressed frustration when providers:
- Made assumptions about their unique experiences in the military without asking them their experiences and views
- Compared any military experience to a movie
- Said they “completely” understood an experience
- Tried to impose their values on military experiences or acculturation (i.e., it’s more important for the patient to take care of themselves than it is to serve others)
- Assumed they had PTSD because of their exposure to trauma, or had trouble sleeping, were angry, etc.
“Honestly, don't ever tell anybody that you understand what they've gone through. That's the biggest thing. That was my biggest pet peeve anyways. Going through the VA, someone told me that they had a perfect understanding of it and never spent a day in the military or anything and it just really irked me because I knew. Because it's one of those things where like I said it's you know, it's a brotherhood. It's you know unless you've been there.” Michael Proia, Veteran, U.S. Army (module 4)
2. Customer Service – The military is a highly structured organization with clear expectations that its members are prepared and punctual at all times. Military courtesies are instilled at boot camp and reinforced throughout a military career. The core values of every service branch include words like integrity, commitment, honor, and excellence. Healthcare experiences that did not reflect these types of values made military-connected patients feel disrespected disappointed and uncared for. Examples cited were providers who:
- Were not organized
- Were not punctual
- Seemed like they didn’t care
- Used the wrong title (e.g., calling a Marine a Soldier)
- Didn’t know the basics: title, rank, service, mission
- Had not reviewed records prior to appointment
- Had a long wait list or extended time between appointments
I think if there was one thing that I could tell a colleague, a fellow student, professional, civilian, whatever, as to how to deal with a military member, I would say the number one thing is respect. The value of respect is at the core of military service ”whether it is respect for the mission, respect for an officer and an officer's respect for the enlisted and what they're trying to do. I think if you approach that client with the respect for what they have done, how they've lived their life and the choices they have made, because it is a voluntary choice to do what we do, I think that will start you off on the right foot. Mark Stonger, Captain, Clinical Psychologist, U.S. Air Force (module 4)
3. Attitude - It has been said that “Attitude is a little thing that makes a big difference”, a message that certainly applies when providing healthcare to military-connected patients. In the military, attitude can often make or break leaders and significantly impact unit cohesion. Service members become very adept at quickly assessing attitude based both on what a leader/unit member says and more importantly what they do. You will most likely be viewed as a leader in a military-connected patient’s healthcare. Be aware of how your attitude might be interpreted and be sure to have patients reflect back what they heard to check for possible misperceptions and opportunities for clarification. Missteps reported in this category included providers who:
- Acted like an expert on PTSD without personalizing it to the patients’ context
- Represented an understanding of military culture without personalizing it to the patients’ context
- Acted judgmental about killing/combat, etc.
- Looked uncomfortable or disgusted when patients talk about their experiences
- Appeared paternalistic, arrogant, or condescending
- Tried to get patients to open up too soon, or told them they have to open up their feelings in order to get better
- Acted like any one component of treatment is critical for success (i.e., mindfulness, homework, breathing)
- Proceeded as if the patient was faking PTSD to get compensation.
“I think just pretty much just coming across and just having the attitude of being open, a point of listening because if we know that you're willing to listen, a lot of times we feel a little more relaxed and a little calm because when you try to force a different perspective on us, which is totally different to what we're used to, we put up that barrier again, and it's to the point where if we know your just, "Hi, I'm here, I'm not very aware of military culture but tell me a little about how it goes in your world." So we're like, okay, they're willing to listen to what we have to say and listen to our lives and what's going on with us.” Eldria Burkett, Staff Sergeant, U.S. Army
4. Inflexibility - While Service members are often labeled as rigid, in truth, the military culture demands that its members exercise extreme flexibility in most areas of their life from where they live to what hours they work to when they deploy and come home. Sayings like “adapt and overcome”, “hurry up and wait”, “flexibility is the key to air power” are prominent in the culture because Service members are used to changing requirements. When healthcare providers present with rigidity or demands that are inconsistent with a Service members priorities (e.g., frequent appointments that disrupt work schedule) or appear to have questionable value (e.g., open-ended treatment with unclear goals), military connected patients are unlikely to engage and adhere. Examples provided include providers who:
- Are not flexible with regards to the type of treatment offered
- Are not flexible about appointment times
- Tell patients they can’t be helped if they don’t take medications or “open up”
- Exclude spouses in treatment
- Are too rigid with a treatment protocol
“Well, for the most part, at first don't be surprised that the answer you're going to get from a Soldier is everything is fine. And so, don't regard that as anything personal that they're not opening up to you when you can clearly see in their record that perhaps not everything is fine. You just need to allow some time, be empathetic. But once again be respectful. It's a fine line between wanting to truly indicate that you're supportive and empathetic, but on the other hand you don't necessarily want in most cases to sort of imply that they're helpless without your care. Try to view your role as enabling them to achieve the next higher level as opposed to just like a long-term permanent support role. “ Rochelle Wasserman, Colonel, Warrior Transition Battle Surgeon, Director of the Warrior Care Clinic, Ft. Campbell, U.S. Army (module 4)
I have often argued that these interviews could stand alone as a powerful documentary on the interface of military culture and healthcare. The Service members, Veterans, family members and healthcare providers, who volunteered to be interviewed for this project, spoke with conviction and passion on the topic because it mattered to them. Healthcare providers gaining cultural competence and improving the quality of care for past, current and future military-connected patients mattered to all the individuals we interviewed. So set some time aside and listen to what they have to say. Whether it is taking the time to ponder how the above mentioned missteps might play out for your practice or a more intensive review of these interviews housed on our website, get inspired.
“The only advice I have to give, it's coming from the bottom of my heart, is just to appreciate the Service members. We're very grateful for doctors and nurses, anybody who's there, physical therapists, whatever the case may be because there are many jobs out there that provide you the opportunity to help others, and if you have the opportunity to help others put your hand out there. I'm pretty sure somebody will grab it. So, just look forward to learning and getting to know different patients. Do anything you can to help them out, and at the end of the day know that you really did touch somebody's life because, like I said, I can almost picture and remind you of everybody who's been there in my life to help me for mine.” Matias Ferreira, Lance Corporal, U.S. Marine Corps (module 4)
To view these videos and more, please visit the Military Culture section of the CDP website.
Jenna Ermold, Ph.D., is a clinical psychologist working as the Lead, e-Learning Strategies for the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
The goal was to gather as many real-world examples as we could. To get at the stories behind the Service member, Veteran or family member’s lived experience of military culture. Why did the individual choose to serve? Why did they pick a particular branch? What were some high and low points of service? How would they explain the military culture to a civilian and most importantly, a civilian healthcare provider? We wanted to give healthcare providers concrete examples of things they could do to help Service members, Veterans and family members feel understood, respected and cared for in a culturally-informed manner.
“I think doctors in general just need to realize that we all paid a price when we decided to do whatever we decided to do with our lives. We're all equals. We're all human beings, and we all need to be treated like such. We don't need to be treated like heroes; you don't need to glorify us. But at the same time you don't need to look down on us and pity us either. Just treat us like a human being. Treat us like you would want to be treated if you were in our shoes. So, take a step back, look at it, read somebody's story and realize what kind of doctor you need to become. “ Ronald Barnes, Lance Corporal, U.S. Marine Corps
The interviews and stories told were powerful, captivating, colorful, emotional – in short, everything we’d hoped they would be. As part of the joint DoD/VA Strategic Action #25 – Military Culture Training for Healthcare Providers development team, we now had 90 plus hours of footage to give life to the didactic online course on “military culture”. More importantly, we now had practical advice from military-connected patients on how to provide culturally-informed healthcare. The advice extracted from the interviews came mostly in the form of what-not-to-do, examples that we came to call “missteps”. As we combed through each interview noting any “missteps” described, we ended up with a collection of errors that essentially fell into 4 categories: making assumptions, customer service, attitude and inflexibility. As you review each, think about how this may apply to your practice.
1. Making Assumptions – As much as we providers strive to keep our own biases and beliefs out of the clinic sometimes they creep in especially if we are not vigilant about taking time to examine them. Military-connected patients expressed frustration when providers:
- Made assumptions about their unique experiences in the military without asking them their experiences and views
- Compared any military experience to a movie
- Said they “completely” understood an experience
- Tried to impose their values on military experiences or acculturation (i.e., it’s more important for the patient to take care of themselves than it is to serve others)
- Assumed they had PTSD because of their exposure to trauma, or had trouble sleeping, were angry, etc.
“Honestly, don't ever tell anybody that you understand what they've gone through. That's the biggest thing. That was my biggest pet peeve anyways. Going through the VA, someone told me that they had a perfect understanding of it and never spent a day in the military or anything and it just really irked me because I knew. Because it's one of those things where like I said it's you know, it's a brotherhood. It's you know unless you've been there.” Michael Proia, Veteran, U.S. Army (module 4)
2. Customer Service – The military is a highly structured organization with clear expectations that its members are prepared and punctual at all times. Military courtesies are instilled at boot camp and reinforced throughout a military career. The core values of every service branch include words like integrity, commitment, honor, and excellence. Healthcare experiences that did not reflect these types of values made military-connected patients feel disrespected disappointed and uncared for. Examples cited were providers who:
- Were not organized
- Were not punctual
- Seemed like they didn’t care
- Used the wrong title (e.g., calling a Marine a Soldier)
- Didn’t know the basics: title, rank, service, mission
- Had not reviewed records prior to appointment
- Had a long wait list or extended time between appointments
I think if there was one thing that I could tell a colleague, a fellow student, professional, civilian, whatever, as to how to deal with a military member, I would say the number one thing is respect. The value of respect is at the core of military service ”whether it is respect for the mission, respect for an officer and an officer's respect for the enlisted and what they're trying to do. I think if you approach that client with the respect for what they have done, how they've lived their life and the choices they have made, because it is a voluntary choice to do what we do, I think that will start you off on the right foot. Mark Stonger, Captain, Clinical Psychologist, U.S. Air Force (module 4)
3. Attitude - It has been said that “Attitude is a little thing that makes a big difference”, a message that certainly applies when providing healthcare to military-connected patients. In the military, attitude can often make or break leaders and significantly impact unit cohesion. Service members become very adept at quickly assessing attitude based both on what a leader/unit member says and more importantly what they do. You will most likely be viewed as a leader in a military-connected patient’s healthcare. Be aware of how your attitude might be interpreted and be sure to have patients reflect back what they heard to check for possible misperceptions and opportunities for clarification. Missteps reported in this category included providers who:
- Acted like an expert on PTSD without personalizing it to the patients’ context
- Represented an understanding of military culture without personalizing it to the patients’ context
- Acted judgmental about killing/combat, etc.
- Looked uncomfortable or disgusted when patients talk about their experiences
- Appeared paternalistic, arrogant, or condescending
- Tried to get patients to open up too soon, or told them they have to open up their feelings in order to get better
- Acted like any one component of treatment is critical for success (i.e., mindfulness, homework, breathing)
- Proceeded as if the patient was faking PTSD to get compensation.
“I think just pretty much just coming across and just having the attitude of being open, a point of listening because if we know that you're willing to listen, a lot of times we feel a little more relaxed and a little calm because when you try to force a different perspective on us, which is totally different to what we're used to, we put up that barrier again, and it's to the point where if we know your just, "Hi, I'm here, I'm not very aware of military culture but tell me a little about how it goes in your world." So we're like, okay, they're willing to listen to what we have to say and listen to our lives and what's going on with us.” Eldria Burkett, Staff Sergeant, U.S. Army
4. Inflexibility - While Service members are often labeled as rigid, in truth, the military culture demands that its members exercise extreme flexibility in most areas of their life from where they live to what hours they work to when they deploy and come home. Sayings like “adapt and overcome”, “hurry up and wait”, “flexibility is the key to air power” are prominent in the culture because Service members are used to changing requirements. When healthcare providers present with rigidity or demands that are inconsistent with a Service members priorities (e.g., frequent appointments that disrupt work schedule) or appear to have questionable value (e.g., open-ended treatment with unclear goals), military connected patients are unlikely to engage and adhere. Examples provided include providers who:
- Are not flexible with regards to the type of treatment offered
- Are not flexible about appointment times
- Tell patients they can’t be helped if they don’t take medications or “open up”
- Exclude spouses in treatment
- Are too rigid with a treatment protocol
“Well, for the most part, at first don't be surprised that the answer you're going to get from a Soldier is everything is fine. And so, don't regard that as anything personal that they're not opening up to you when you can clearly see in their record that perhaps not everything is fine. You just need to allow some time, be empathetic. But once again be respectful. It's a fine line between wanting to truly indicate that you're supportive and empathetic, but on the other hand you don't necessarily want in most cases to sort of imply that they're helpless without your care. Try to view your role as enabling them to achieve the next higher level as opposed to just like a long-term permanent support role. “ Rochelle Wasserman, Colonel, Warrior Transition Battle Surgeon, Director of the Warrior Care Clinic, Ft. Campbell, U.S. Army (module 4)
I have often argued that these interviews could stand alone as a powerful documentary on the interface of military culture and healthcare. The Service members, Veterans, family members and healthcare providers, who volunteered to be interviewed for this project, spoke with conviction and passion on the topic because it mattered to them. Healthcare providers gaining cultural competence and improving the quality of care for past, current and future military-connected patients mattered to all the individuals we interviewed. So set some time aside and listen to what they have to say. Whether it is taking the time to ponder how the above mentioned missteps might play out for your practice or a more intensive review of these interviews housed on our website, get inspired.
“The only advice I have to give, it's coming from the bottom of my heart, is just to appreciate the Service members. We're very grateful for doctors and nurses, anybody who's there, physical therapists, whatever the case may be because there are many jobs out there that provide you the opportunity to help others, and if you have the opportunity to help others put your hand out there. I'm pretty sure somebody will grab it. So, just look forward to learning and getting to know different patients. Do anything you can to help them out, and at the end of the day know that you really did touch somebody's life because, like I said, I can almost picture and remind you of everybody who's been there in my life to help me for mine.” Matias Ferreira, Lance Corporal, U.S. Marine Corps (module 4)
To view these videos and more, please visit the Military Culture section of the CDP website.
Jenna Ermold, Ph.D., is a clinical psychologist working as the Lead, e-Learning Strategies for the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.