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COUNSELORS AND THE MILITARY: WHEN PROTOCOL AND ETHICS CONFLICT

Article, Volume 4 - Issue 2

Elizabeth A. Prosek, Jessica M. Holm

The U.S. Department of Veterans Affairs (VA) and TRICARE have approved
professional counselors to work within the military system. Counselors need to
be aware of potential ethical conflicts between counselor ethical guidelines and
military protocol. This article examines confidentiality, multiple relationships
and cultural competency, as well as ethical models to navigate potential
dilemmas with veterans. The first model describes three approaches for
navigating the ethical quandaries: military manual approach, stealth approach,
and best interest approach. The second model describes 10-stages to follow when
navigating ethical dilemmas. A case study is used for analysis. 

Keywords: military, ethics, veterans, counselors, competency, confidentiality

The American Community Survey (ACS; U.S. Census Bureau, 2011) estimated that
21.5 million veterans live in the United States. A reported 1.6 million veterans
served in the Gulf War operations that began post-9/11 in 2001 (U.S. Census
Bureau, 2011). Gulf War post-9/11 veterans served mainly in Iraq and
Afghanistan, in operations including but not limited to Operations Enduring
Freedom (OEF), Iraqi Freedom (OIF), and New Dawn (OND) (M. E. Otey, personal
communication, October 23, 2012). Holder (2007) estimated that veterans
represent 10% of the total U.S. population ages 17 years and older. Pre-9/11
data suggested that 11% of military service members utilized mental health
services in the year 2000 (Garvey Wilson, Messer, & Hoge, 2009). In 2003,
post-9/11 comparative data reported that 19% of veterans deployed to Iraq
accessed mental health services within one year of return (Hoge, Auchterlonie, &
Milliken, 2006). Recognizing the increased need for mental health assessment,
the U.S. Department of Defense (DOD) mandated the Post-Deployment Health
Assessment (PDHA) for all returning service members (Hoge et al., 2006). The
PDHA is a brief three-page self-report screening of symptoms to include
post-traumatic stress, depression, suicidal ideation and aggression (U.S. DOD,
n.d.). The assessment also indicates service member self-report interest in
accessing mental health services.

Military service members access mental health services for a variety of reasons.
In a qualitative study of veterans who accessed services at a Veterans Affairs
(VA) mental health clinic, 48% of participants reported seeking treatment
because of relational problems, and 44% sought treatment because of anger and/or
irritable mood (Snell & Tusaie, 2008). Veterans may also present with mental
health symptoms related to post-traumatic stress disorder (PTSD), depression,
and suicidal ideation (Hoge et al., 2006). Depression is considered a common
risk factor of suicide among the general population, and veterans are
additionally at risk due to combat exposure (Martin, Ghahramanlou-Holloway, Lou,
& Tucciarone, 2009). The DOD (2012) confirmed that 165 active-duty Army service
members committed suicide in 2011. Furthermore, researchers asserted that
suicide caused service member deaths more often than combat (O’Gorman, 2012).
Hoge et al. (2004) reported that veterans were most likely to access mental
health services 3–4 months post-deployment. Unfortunately, researchers suggested
that service members were hesitant to access mental health treatment, citing the
stigma of labels (Kim, Britt, Klocko, Riviere, & Adler, 2011). Studies indicated
that mental health service needs are underestimated among the military
population and are therefore a potential burden to an understaffed helping
profession (Garvey Wilson et al., 2009; Hoge et al., 2006). In May of 2013, the
DOD and VA created 1,400 new positions for mental health providers to serve
military personnel (DOD, 2013). Moreover, as of March 2013, the DOD-sponsored
veterans crisis line reported more than 800,000 calls (DOD, 2013). It is evident
that the veteran population remains at risk for problems related to optimal
mental health functioning and therefore requires assistance from trained helping
professionals.

Historically, the DOD employed social workers and psychologists almost
exclusively to provide mental health services in the military setting. Recently,
the DOD and VA expanded services and created more positions for mental health
clinicians (U.S. VA, 2012). Because licensed professional counselors (LPCs) are
now employable by VA service providers (e.g., VA hospitals) and approved TRICARE
providers (Barstow & Terrazas, 2012), it is imperative to develop an
understanding of the military system, especially of the potential conflict that
may exist between military protocol and counselor ethical guidelines. The
military health system requires mental health professionals to be appropriately
credentialed (e.g., licensed), and credentialing results in the mandatory
adherence to a set of professional ethical standards (Johnson, Grasso, &
Maslowski, 2010). However, there may be times when professional ethical
standards do not align with military regulations. Thus, an analysis of the
counselor ethical codes relevant to the military population is presented. At
times, discrepancies between military protocol and counselor ethical codes may
emerge; therefore, recommendations for navigating such ethical dilemmas are
provided. A case study and analysis from the perspective of two ethical
decision-making models are presented.

 

Ethical Considerations for Counselors

 

The mission of the American Counseling Association (ACA) Code of Ethics (2005)
is to establish a set of standards for professional counselors, which ensure
that the counseling profession continues to enhance the profession and quality
of care with regard to diversity. As professional counselors become employed by
various VA mental health agencies or apply for TRICARE provider status, it is
important to identify specific ethical codes relevant to the military
population. Therefore, three categories of ethical considerations pertinent to
working with military service members are presented: confidentiality, multiple
relationships, and cultural competence.

 

Confidentiality

The ACA Code of Ethics (2005) suggests that informed consent (A.2.a., p. 4) be a
written and verbal discussion of rights and responsibilities in the counseling
relationship. This document includes the client right for confidentiality
(B.1.c., p. 7) with explanation of limitations (B.1.d., p. 7). The limitations,
or exceptions, to confidentiality include harm to self, harm to others and
illegal substance use. In the military setting, counselors may need to consider
other exceptions to confidentiality including domestic violence (Reger,
Etherage, Reger, & Gahm, 2008), harassment, criminal activity and areas
associated with fitness for duty (Kennedy & Johnson, 2009). Also, military
administrators may require mandated reporting when service members are referred
for substance abuse treatment (Reger et al., 2008). When these conditions arise
in counseling, the military may require reporting beyond the standard ethical
protocol to which counselors are accustomed.

Counselors working in the VA mental health system or within TRICARE may need to
be flexible with informed consent documents, depending on the purpose of
services sought. Historically, veterans represented those who returned from
deployment and stayed home. Currently, military members may serve multiple tours
of combat duty; therefore, the definition of veterans now includes active-duty
personnel. This modern definition of veteran speaks to issues of fitness for
duty, where the goal is to return service members ready for combat. Informed
consent documents may need to outline disclosures to commanding officers. For
example, if a service member is in need of a Command-Directed Evaluation (CDE),
then the commander is authorized to see the results of the assessment (Reger et
al., 2008). Fitness for duty is also relevant when service members are mandated
to the Soldier Readiness Program (SRP) to determine their readiness for
deployment. In these situations, counselors need to clearly explain the
exception to confidentiality before conducting the assessment. Depending on the
type of agency and its connection to the DOD, active-duty veterans’ health
records may be considered government property, not the property of the service
provider (McCauley, Hacker Hughes, & Liebling-Kalifani, 2008). It is imperative
that counselors are educated on the protocols of the setting or assessments,
because “providing feedback to a commander in the wrong situation can be an
ethical violation that is reviewable by a state licensing authority” (Reger et
al., 2008, p. 30). Thus, in order to protect the client and the counselor,
limitations to confidentiality within the military setting must be accurately
observed at all times. Knowledge of appropriate communication between the
counselor and military system also speaks to the issue of multiple
relationships.

 

Multiple Relationships

Kennedy and Johnson (2009) suggested creating collaborative relationships with
interdisciplinary teams in a military setting in order to create a network of
consultants (e.g., lawyers, psychologists, psychiatrists), which is consistent
with ACA ethical code D.1.b to develop interdisciplinary relationships (2005, p.
11). However, when interdisciplinary teams are formed, there are ACA (2005)
ethical guidelines that must be considered. These guidelines state that
interdisciplinary teams must focus on collaboratively helping the client by
utilizing the knowledge of each professional on the team (D.1.c., p. 11).
Counselors also must make the other members of the team aware of the constraints
of confidentiality that may arise (D.1.d., p. 11). In addition, counselors
should adhere to employer policies (D.1.g., p. 11), openly communicating with VA
superiors to navigate potential discrepancies between employers’ expectations
and counselors’ roles in best helping the client.

In the military environment, case transfers are common because of  the high
incidence of client relocation, which increases the need for the
interdisciplinary teams to develop time-sensitive treatment plans (Reger et al.,
2008). Therefore, treatment plans not only need to follow the guidelines of
A.1.c., in which counseling plans “offer reasonable promise of success and are
consistent with abilities and circumstances of clients” (ACA, 2005, p. 4), but
they also need to reflect brief interventions or treatment modalities that can
be easily transferred to a new professional. Mental health professionals may
work together to best utilize their specialized services in order to meet the
needs of military service members in a minimal time allowance.

For those working with military service members, consideration of multiple
relationships in terms of client caseload also is important. Service members who
work together within the same unit may seek mental health services at the same
agency. Members of a military unit may be considered a support network which,
according to ethical code A.1.d., may be used as a resource for the client
and/or counselor (ACA, 2005, p. 4). However, learning about a military unit as a
network from multiple member perspectives may also create a dilemma. Service
members within a unit may be tempted to probe the counselor for information
about other service members, or tempt the counselor to become involved in the
unit dynamic. McCauley et al. (2008) recommended that mental health
professionals avoid mediating conflicts between service members in order to
remain neutral in the agency setting.

However, there are times when the unit cohesion may be used to support the
therapeutic relationship. Basic military training for service members emphasizes
the value of teamwork and the collective mind as essential to success (Strom et
al., 2012). It is important for counselors to approach military service member
clients from this perspective, not from a traditional Western individualistic
lens. Mental health professionals also are warned not to be discouraged if
rapport is more challenging to build than expected. Hall (2011) suggested that
the importance of secrecy in the military setting might make it more difficult
for service members to readily share in the therapeutic relationship.
Researchers noted that military service members easily built rapport with each
other in a group therapy session, often leaving out the civilian group leader
(Strom et al., 2012). It might behoove counselors to build upon the framework of
collectivism in order to earn the trust of members of the military population.
Navigating the dynamic of a unit or the population of service members accessing
care at the agency may be a challenge; however, counselors are able to alleviate
this challenge with increased knowledge of the military culture in general.

 

Cultural Competence

The military population represents a group of people with a unique “language, a
code of manners, norms of behavior, belief systems, dress, and rituals” and
therefore can be considered a cultural group (Reger et al., 2008, p. 22). Reger
et al. (2008) suggested that many clinical psychologists learned about military
culture as active service members themselves. While there may be many veterans
currently working as professional counselors, civilian counselors also serve the
mental health needs of the military population; and as civilians, they require
further training. The ACA Code of Ethics (2005) suggests that counselors
communicate with their clients in ways that are culturally appropriate to ensure
understanding (A.2.c., p. 4). This can be achieved by prolonged exposure to
military culture or by seeking supervision from a professional involved with the
military mental health system (Reger et al., 2008). Strom et al. (2012) outlined
examples of military-specific cultural components for professionals to learn:
importance of rank, unique terminology and value of teamwork. It behooves
counselors intending to work with the military population to learn terminology
in order to understand service members. For example, R&R refers to vacation
leave and MOS or rate refers to a job category (Strom et al., 2012).

Personal values may cause dilemmas for a mental health professional working
within the VA system. This can be especially true during times of war. Stone
(2008) suggested that treating veterans of past wars may be easier than working
with military service members during current combat because politics may be
intensified. A counselor who does not support the current wartime mission may be
conflicted when clients are mandated to return to active-duty assignments
(Stone, 2008). The ACA Code of Ethics (2005) addresses the impact of counselors’
personal values (A.4.b., pp. 4–5) on the therapeutic relationship. It is
recommended that counselors be aware of their own values and beliefs and respect
the diversity of their clients. Counselors need to find a way to value the
contributions of their client when personal or political opinion conflicts with
the DOD’s plans or efforts overseas. If one wants to be successful with this
population, Johnson (2008) suggested the foundational importance of accepting
the military mission. If this is in direct conflict with the counselor’s values,
it may be recommended for the counselor to consider the client’s value of the
mission.

The ACA ethical code stresses the importance of mental health professionals
practicing within the boundaries of their competence and continuing to broaden
their knowledge to work with diverse clients (ACA, 2005, C.2.a., p. 9).
Counselors should only develop new specialty areas after appropriate training
and supervised experience (ACA, 2005, C.2.b., p. 9). Working within the VA
mental health system, mental health professionals may be asked to provide a
service in which they are not competent (Kennedy & Johnson, 2009). Such a
request may occur more frequently here than in other settings, due to the high
demand of mental health services and low availability of trained professionals
(Garvey Wilson et al., 2009; Hoge et al., 2006). Counselors must determine if
their experience and training can be generalized to working with military
service members (Kennedy & Johnson, 2009), and may be their own best advocate
for receiving appropriate training.

Awareness of when and how military service members access mental health services
also might be important to consider. Reger et al. (2008) reported that military
personnel were more likely to access services before and after a deployment.
Researchers specified a higher prevalence rate of access 3–4 months after a
deployment (Hoge et al., 2004). The relationship of time between deployment and
help-seeking behaviors suggests that counselors should be prepared for issues
related to trauma. For women, combat-related trauma is compounded with increased
rates of reported military sexual trauma (Kelly et al., 2008). Counselors would
benefit from additional trainings in trauma intervention strategies. The VA and
related military organizations offer many resources online to educate
professionals working with military members with identified trauma symptoms
(U.S. VA., n.d.).

Advocating for appropriate training in areas of incompetence is the
responsibility of the professional, who should pursue such training in order to
best meet the needs of the military population. It is best practice for mental
health professionals to be engaged in ongoing trainings to ensure utilization of
the latest protocols and treatment modalities (McCauley et al., 2008). Trainings
may need to extend beyond general military culture, because each branch of
service (e.g., Army, Marines, Navy) could be considered a cultural subgroup with
unique language and standards. For example, service members in the Army are
soldiers, whereas members of the Navy are sailors (Strom et al., 2012).

This article has outlined many ACA (2005) ethical guidelines pertinent to
working with the military population. However, as presented, there are times
when counselor ethical codes conflict with military regulations. Counselors
interested in working in the military setting or with military personnel may
consider decision-making models to address ethical dilemmas.

 

Recommendations for Counselors

 

The military mental health system has almost exclusively employed psychologists
and social workers. Counselors interested in employment within VA agencies or as
TRICARE providers may utilize the resources created by these practitioners to
better serve the military population. Two ethical decision-making models are
presented, and a case study is provided to demonstrate how to implement the
models.

 

Ethical Models

The ACA Code of Ethics (2005) advises counselors to adhere to the code of ethics
whenever possible, working towards a resolution of the conflict (H.1.b., p. 19).
If a favorable resolution cannot be formed, counselors have the choice to act in
accordance with the law or regulation. Psychology researchers have suggested
ethical models for professionals to use during times of dilemma within the
military setting. The first model presented considers three overarching
approaches to address ethical dilemmas; and the second model presented is a more
specific stage model with which to approach dilemmas. These models may serve to
assist counselors as the counseling profession gains more experience in the VA
system and eventually develops counselor-specific decision-making models.

Approach model. Johnson and Wilson (1993) identified three approaches for
psychologists to consider when navigating the ethical quandaries of the military
mental health system. The first, the military manual approach, occurs when
professionals adhere strictly to military regulations without consideration for
the specific client’s needs. The second, the stealth approach, occurs when there
is strict adherence to the mental health professionals’ code of ethics,
regardless of the legalities surrounding the circumstances. While the client’s
best interests may be at the forefront in this approach, the counselor must also
take into account the possibility of being the subject of legal action for not
adhering to the standards set by the military. For example, the counselor may
use ambiguous wording within the client file or leave some information out
altogether, so that if the files were requested, the client’s information would
be protected (Johnson & Wilson, 1993). The third, the best interest approach,
occurs when the counselor maintains focus on the client’s best interest while
also adhering to the standards of the military. This may require professionals
to adhere to the minimum professional standards in order to accommodate the
client’s best interest. Although most professionals have deemed this approach
the best option, it also leads to the most ambiguity. Under certain
circumstances, the counselor also must take into account what is in the best
interest for society as a whole, while also navigating a responsibility to the
client and the military mental health system. Researchers in psychology
responded to the ambiguity of this model by developing a more specific stage
model to assist professionals with ethical dilemmas.

Stage model. Barnett and Johnson (2008) proposed a 10-stage model to follow when
navigating an ethical dilemma. They advise that professionals must do the
following:

1.   Clearly define the situation.

2.   Determine what parties could be affected.

3.   Reference the pertinent ethical codes.

4.   Reference the pertinent laws and regulations.

5.   Reflect on personal thoughts and competencies on the issue.

6.   Select knowledgeable colleagues with whom to consult.

7.   Develop alternate courses of action.

8.   Evaluate the impact on all parties involved.

9.   Consult with professional organizations, ethics committees and colleagues.

10. Decide on a course of action.

Barnett and Johnson (2008) also noted that once a decision is made, the process
does not end. It is best practice to monitor the implications and, if necessary,
modify the plan. Documentation throughout this entire process is necessary for
the protection of the counselor, the client and other involved stakeholders.
Counselors working in the military mental health system may find this 10-stage
model helpful when navigating ethical dilemmas.

To better understand the implementation of the two presented ethical
decision-making models, a case study was developed. The case is then
conceptualized from both the approach model and stage model, and the ethical
dilemmas associated with the case are discussed.

 

Case Study

Megan is a licensed professional counselor employed at a clinic that serves
military service members. She provides individual outpatient counseling to
veterans and family members, as well as facilitates veteran support groups.
Megan’s client, Robert, is a Petty Officer First Class in the Navy. Robert is
married with two children. In recent sessions, Megan became concerned with
Robert’s increased alcohol use. Recently, Robert described a weekend of heavy
drinking at the local bar. Although Robert drove after leaving the bar both
nights, Megan suspected that he was not sober enough to drive. In a follow-up
session, Robert reported that his binge-drinking weekend caused friction at home
with his wife, and that he missed his children’s soccer games. During his most
recent session, Robert was visibly distressed as he disclosed to Megan that he
received orders for a deployment in 3 months. Robert is anxious about informing
his wife and children of the pending 6-month deployment, as he knows it will
only increase conflict at home. Robert reported that his family could use the
increase in pay associated with family separation and tax-free wages during
deployment. However, he also knows that deployments cause tension with his wife,
which has already increased due to Robert’s recent drinking binges. While
leaving the session, he mentioned with a laugh that he would rather go to the
bar than go home.

 

Analysis from approach model. Megan may consider using Johnson and Wilson’s
(1993) ethical approach model as she conceptualizes the potential ethical
dilemma presented in Robert’s case. From a military manual approach, Megan may
need to report Robert’s recent alcohol abuse behavior to his superior, as it may
impact his fitness for duty on his next deployment. And although Robert has not
been caught drinking and driving or charged with a crime, his behavior also puts
him at risk of military conduct violations. However, when Robert originally came
to the clinic, he did so of his own accord, not under orders, which could mean
that notifying a commanding officer is an ethical violation. In consideration of
the stealth approach, Megan may review the ACA (2005) ethical guidelines and
conclude that there are no violations at risk if she chooses not to report
Robert’s drinking habits. However, Megan contemplates whether addressing
Robert’s drinking binges is in his best interest overall. She understands that
the money associated with deployment is important to Robert’s family at this
time; however, his drinking may put him at increased risk during deployment.
Finally, Megan applies the best-interest approach to Robert’s situation. Megan
may refer Robert to the center’s substance use support group. This referral will
be reflected in Robert’s records, but if he begins receiving treatment for his
alcohol abuse now (3 months before deployment), there may be time for Robert to
demonstrate significant progress before his fitness for duty assessment.

 

Analysis from stage model. Megan may consider her ethical dilemma from Barnett
and Johnson’s (2008) 10-stage model. In stage 1, she clearly defines the
situation as Robert’s alcohol abuse and pending deployment. In stage 2, Megan
considers who may be affected in this situation. She understands that Robert’s
family would benefit from the extra money associated with the deployment, and
therefore the family may be impacted if Robert is not deployed. Megan also notes
that the family is already negatively impacted by his recent drinking binge
(e.g., conflict with his wife, missed soccer games). If Robert’s problematic
drinking continues, he is at risk for evaluation and promotion issues. In stage
3, Megan reflects upon the ACA (2005) ethical codes in order to better
understand her dilemma from a counselor’s view. Robert has a right to
confidentiality (B.1.c., p. 7) with limitations including illegal substance use
(B.1.d., p. 7). However, Robert’s current substance is alcohol, which is a legal
substance. Megan considers the importance of his support network (A.1.d., p. 4)
including his family and unit, but she does not have the ethical right to
disclose her concerns about his substance abuse. In stage 4, Megan considers the
pertinent laws and regulations of the dilemma. As per the clinic regulations,
she is aware that if she makes a substance use program referral, it will be
reflected in Robert’s record, which is the property of the military. Megan also
is aware that Robert has not committed a documented crime of driving under the
influence.

In stage 5 of the 10-stage ethical decision-making model, Megan must reflect on
her personal thoughts and competencies. She is very concerned about Robert’s
increased use of alcohol and is worried for his safety if deployed. Megan feels
less confident in her ability to accurately assess for substance use problems.
She facilitates the PTSD support group for the clinic, which is her specialty
area. Megan recognizes that she is fond of Robert as a client and is
disappointed that he could be jeopardizing his family and career with his
alcohol abuse. She considers whether she is overreacting to his binge-drinking
incident because of her higher expectations of him. In stage 6, Megan consults
with her colleague who leads the substance use support groups at the clinic. She
describes Robert’s recent abuse of alcohol and inquires as to whether he is a
good candidate for the substance use group, needs more intense treatment, or
needs no treatment at all. The colleague suggests that the group would be a very
appropriate fit for someone with Robert’s symptoms.

In stage 7, Megan develops her course of action to refer Robert to the substance
use group. Then, in stage 8, she evaluates the plan for potential impact on
parties involved. Megan conceptualizes that Robert may be at risk for losing his
deployment orders if he is accessing substance use treatment. Megan believes she
has reduced this potential impact by referring to the substance support group,
rather than an inpatient treatment facility, which may be more appropriate for a
dependence issue. Megan recognizes that attending a 90-minute group each week
will take Robert away from his family, but she also realizes that the 90-minute
commitment is less than his current time spent away from the family when binge
drinking. Megan reflects upon how her therapeutic relationship with Robert may
be strained at the time of referral, and is prepared for a potential negative
response from her client. She trusts in their therapeutic relationship and moves
forward. In stage 9, Megan presents her planned course of action to her
supervisor at the clinic. The supervisor approves the referral for the support
group, but also suggests that Megan consider a referral to couples counseling
for Robert and his wife, which may assist with resolving conflicts before the
deployment.

In the final stage, Megan proposes the treatment plan of action to Robert in
their next session. Megan explains that she feels ethically obligated to refer
Robert to the substance use support group, and that as of now, Robert may make
this choice for himself. Megan and Robert discuss the potential that substance
use treatment may no longer be a choice in the future if his current drinking
behavior continues. There is more discussion of fitness for duty and how
participation in the support group will positively reflect upon the assessment
in the future. Megan also presents Robert with the recommendation of couples
counseling to help mediate relationship conflicts before deployment. She reports
that if Robert and his wife decide to receive couples counseling, she can
provide a referral for them at that time.

With the ethical decision-making models presented, the counselor is able to
successfully navigate the military mental health system, while still maintaining
the professional standards of the counseling profession. In each model, the
situation is resolved with considerable attention to the client’s best interest,
while maintaining the expectations of the military clinic. Psychologists
developed the two ethical models presented, and counselors may choose to utilize
these approaches until more counselor-specific ethical processes are created. As
counselors become more permanent fixtures in the VA mental health system and as
TRICARE providers, opportunities to develop an ethical decision-making model
will likely arise.

 

Conclusion

 

The recent inclusion of counselors as mental health professionals within the VA
system and as TRICARE providers allows for new employment opportunities with the
military population. However, these new opportunities are not without potential
dilemmas. Counselors interested in working with service members need to be
educated on the potential conflict between counselor professional ethical
guidelines and military protocols. Future research in the counseling field may
develop a counselor-specific ethical decision-making model. In the meantime,
counselors may utilize or adapt the ethical decision-making models created by
other mental health professionals, who have a longer history working with the
military population.

 

References

American Counseling Association. (2005). ACA code of ethics. Retrieved from
http://www.counseling.org/Resources/aca-code-of-ethics.pdf

Barnett, J. E., & Johnson, W. B. (2008). The ethics desk reference for
psychologists. Washington DC: American Psychological Association.

Barstow, S., & Terrazas, A. (2012, February). DoD releases TRICARE rule on
independent practice for counselors. Counseling Today, 54(8), 10. Retrieved from

http://ct.counseling.org/2012/02/dod-releases-tricare-rule-on-independent-practice-for-counselors/

Garvey Wilson, A. L., Messer, S. C., & Hoge, C. W. (2009). U.S. military mental
health care utilization and attrition prior to the wars in Iraq and Afghanistan.
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Hall, L. (2011). The importance of understanding military culture. Social Work
in Health Care, 50, 4–18. doi:10.1080/00981389.2010.513914

Hoge, C. W., Auchterlonie, J. L., & Milliken, C. S. (2006). Mental health
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Elizabeth A. Prosek, NCC, is an Assistant Professor at the University of North
Texas. Jessica M. Holm is a doctoral student at the University of North Texas.
Correspondence can be addressed to Elizabeth A. Prosek, University of North
Texas, 1155 Union Circle #310829, Denton, TX 76203-5017,
elizabeth.prosek@unt.edu.



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