Presented at the 2019 American Counseling Association, Veterans and clinical mental health professionals Duane France and Marco Bongioanni discuss how the Military and Government Counseling Association Competencies for working with military populations correlate with the American Counseling Association Code of Ethics

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“Beyond Basic Training: Ethical Considerations in
Developing Military and Veteran Cultural
Competence”
Duane K. L. France, MA, MBA, LPC
duane@veteranmentalhealth.com
Marco A. Bongioanni, MA, LMHC
marco.bongioanni@va.gov
(DVIDS, 2017) (DVIDS, 2017)
(DVIDS, 2017) (DVIDS, 2017)

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DUANE FRANCE, MA, MBA, LPC
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• MA (Adams State University, 2015); BS (Excelsior College, 2011)
• Director of Veteran Services, Family Care Center LLC and
Executive Director, Colorado Veterans Health and Wellness
Agency
• Outpatient mental health counseling for service members,
veterans and their families, justice involved veterans, and grant-
funded services to overcome barriers to care
• Retired from the United States Army in 2014 after twenty-two
years of service. Five combat and operational deployments (OIF,
OEFX2, North Africa, Bosnia). Served two tours of Germany, one
as a Recruiter, and the 82nd Airborne Division
• 2015 NBCC Foundation Military Scholarship Recipient, Member
of the MGCA Board of Directors, Member of the ACA Public
Policy and Legislation Committee
• Founder and host of Head Space and Timing, a blog and podcast
dedicated to changing the way we think and talk about veteran
mental health www.veteranmentalhealth.com

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MARCO A. BONGIOANNI, LMHC
(Personal Photo, 2015)
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• MSEd. (Fordham University, 2012); BS (Cornell University, 2001)
• Readjustment Counseling Therapist, Bronx Vet Center,
U.S. Department of Veterans Affairs
• Works in outpatient setting, primarily with combat veterans,
family members, and veterans who have experienced military
sexual trauma
• Served on active duty in the U.S. Army for nine years to include
two combat deployments to Iraq and service in the Republic of
Korea, Germany, and Egypt. Currently still serves part time as a
Civil Affairs Battalion Commander in the U.S. Army Reserve.
• Mr. Bongioanni’s Disclosure: The views expressed in this
presentation are those of the author and do not necessarily
reflect the official policy or position of the U.S. Department of
Veterans Affairs, the U.S. Department of Defense, nor the U.S.
Government. Mr. Bongioanni has no relevant financial
relationships to disclose relating to the content of this activity.
Commercial support was not received for this activity.

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In 2016, the Military and Government Counseling Association appointed a task force
to develop a set of competencies for professional counselors when working with
service members, veterans and their families. The appointed task force developed and
presented Competencies for Counseling Military Populations (Prosek, et al., 2018).
COMPETENCIES FOR COUNSELING
MILITARY POPULATIONS
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American Counseling Association. (2014). ACA code of ethics. American Counseling Association.
Prosek, E., Burgin, E., Atkins, K., Wehrman, J., Fenell, D., Carter, C., & Green, L. (2018). Competenceis for Counseling Miltiary Populations. Journal of Military and Government Counseling,
87-99.

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Advocacy represents counselors’ ability to understand and influence individual, system, and
public policy efforts to increase access to mental health resources for military-connected clients
and promote the role of counseling professionals working with military populations.
PROPOSED COMPETENCIES
Military Culture represents general information about the functioning and worldview of
military service members and their families.
Ethics represents counselors’ self-awareness and motivation to serve military-connected clients, as
well as ethical considerations working with military populations.
Systems Features represents general information about the nature and structure of the military
lifecycle including, but not limited to, deployment, family, spouses and children, health and
wellness, employment, and retirement.
Assessment of Presenting Concerns represents common areas of clinical concerns that service
members frequently present to mental health services to address.
Identity Development represents the whole person concept of military life including one’s
personal identity as a service member and connection to mission and core values of working in a
high-risk occupation across the lifespan.
Treatment represents general information about unique issues that may arise in the treatment of
military-affiliated clients and approaches supported by research for military populations, including
best practices of military care systems, as well as holistic, wellness-oriented services.

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LEARNING OBJECTIVES
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Ethics represents counselors’ self-awareness and motivation to serve military-connected clients, as
well as ethical considerations working with military populations.
Reference the MGCA Proposed Competencies for Counseling Military Populations (CCMP)
(Prosek, et al.) and how these proposed competencies align with the ACA Code of Ethics

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LEARNING OBJECTIVES
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Ethics represents counselors’ self-awareness and motivation to serve military-connected clients, as
well as ethical considerations working with military populations – 14 competencies
n. Considers community referrals when in the best interest of the client.
(ACA Code of Ethics Section A.11.a)
a. Maintains competence by completing formal training for working with military
personnel; and when possible, the training is experiential in nature.
(ACA Code of Ethics Section C.2.a.)
c. Brackets personal values and attitudes of war policies; addresses potential
prejudices about military service or war; and recognizes their own political opinions
of current and previous combat operations.
(ACA Code of Ethics Section A.4.b)
f. Actively adheres to a self-care routine to prevent burnout, depersonalization,
compassion fatigue, and impairment.
(ACA Code of Ethics Section C)

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PRACTICING WITHIN BOUNDARIES
OF COMPETENCE
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C.2.a. Boundaries of Competence Counselors practice only within the boundaries of their
competence, based on their education, training, supervised experience, state and national
professional credentials, and appropriate professional experience. Whereas multicultural
counseling competency is required across all counseling specialties, counselors gain knowledge,
personal awareness, sensitivity, dispositions, and skills pertinent to being a culturally competent
counselor in working with a diverse client population.
6. Ethics represents counselors’ self-awareness and motivation to serve military-connected
clients, as well as ethical considerations working with military populations.
The professional counselor:
a. Maintains competence by completing formal training for working with military personnel; and
when possible, the training is experiential in nature

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Developing
sensitivity and
understanding of
another ethnic
group…Cultural
awareness must be
supplemented with
cultural knowledge
Familiarization
with selected
cultural
characteristics,
history, values,
belief systems,
and behaviors of
the members of
another ethnic
group
Has the ability to be
appropriately
responsive to the
attitudes, feelings,
circumstances of
groups of people that
share a common and
distinct racial,
national, religious,
linguistic, or cultural
heritage
Can Function
effectively and
appropriately in
diverse cultural
interaction and
settings
Cultural
Awareness
Cultural
Knowledge
Cultural
Sensitivity
Cultural
Competence
Adams, D. L. (1995). Health issues for women of color: A cultural diversity perspective.
CONTINUUM OF CULTURAL
COMPETENCE

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DEFINING MILITARY CULTURE
• Military Culture: Collective
• ‘We’ Culture
• Fixed
• The group’s goals placed
ahead of personal goals
• Learn first to manage people,
then ideas
• Success is measured by group
achievement
• Work is life (Profession…some
might call it a vocation)
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• Civilian Culture: Individualistic
• ‘I’ Culture
• Fluid
• Emphasis is on individual
achievement and self-reliance
• Learn first to manage ideas,
then people
• Success is measured by
individual achievement
• Work is just a job (Occupation)
What is the difference?
Military/Civilian
Gap or Divide?
(PowerPoint Clip Art, 2017)

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DEFINING MILITARY CULTURAL
COMPETENCE
Multicultural Orientation Has Two Domains:
1. Cultural Humility - Ability to maintain a personal stance that is
nonjudgmental and other oriented.
2. Cultural Opportunity - Moments in session when a counselor can
address and focus on a client’s cultural identity.
ØMissed cultural opportunities are missed opportunities to improve
your clients outcome.
Three Main Areas of Multicultural Counseling Competency:
1. Counselor Knowledge About Different Cultures & Perspectives
2. Counselor Awareness About Their Own Heritage and How That May
Affect Their Own Attitudes, Beliefs, and Judgements
3. Counselor Skills to Utilize in Culturally Appropriate Approaches
ØMany Military Cultural Competence trainings for clinicians focus at the
first point and often also address the second. Few capture the third.
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(Sue and Sue, 1981)
Sue, D.W., & Sue, D. (2008) Counseling the Culturally Diverse, Fifth Edition. Hoboken, NJ: John Wiley & Sons, Inc.

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EXPLICIT COMPONENTS OF
MILITARY CULTURE
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• While important to understand these, it provides generally only
a surface level understanding of military culture.
• Explicit elements might include:
• Branch Cultural Differences
• Rank Structure
• Hierarchies
• Uniforms
• Missions
• Chain of Command
• Uniform Code of Military Justice
• Military and Veteran Specific
Terms, Jargon, and Acronyms
• Who makes up a military family
• What was their job in military
• Differences between active
duty and reserve
• Military demographics
• Length of Service
• Deployment History
• Unique Challenges to Female,
LGBTQA, minorities
• Life chapter of a service
member

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IMPLICIT COMPONENTS OF
MILITARY CULTURE
….”We review the elements of military culture that may be the most powerful and
enduring just because they are implicit and intangible, and cannot be shed along with
the uniform: the values and guiding ideas that the warrior ethos comprises.”
(Litz, Lebowitz, Gray, & Nash, 2016)
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• These Include Things Like:
• Ethos
• Values
• Socialization Process
• Reasons behind why somebody joined the military
• Parallels
Litz, B. T., Lebowitz, L., Gray, M. J., & Nash, W. P. (2017). Adaptive disclosure: A new treatment for military trauma, loss, and moral injury. Guilford Publications.

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MILITARY ETHOS
• Warrior Ethos
• “Leave no one behind” deep and enduring sense of loyalty and
commitment to fellow service members
• Emphasize the importance of teamwork
• Infuse in each Service member a moral focus including the ability
to make ethical decisions in situations that are morally ambiguous
• The basic tasks of a service member are fourfold: prepare to kill,
kill if ordered, prepare to die, and die if necessary
• Profession/Vocation vs. Occupation
• Instill a Bond of brotherhood/sisterhood lasts throughout their
military career and beyond. This bond is highly valued, nurtured,
and protected. This drives Unit Cohesion. After a service
member separates, this is lost and can often leave a veteran
searching for a substitute.
14Snider, D. M. (2005). The future of the army profession. L. J. Matthews (Ed.). Boston: McGraw-Hill.
Substance Abuse and Mental Health Services Administration. (2010). Understanding the Military: The Institution, the Culture, and the People.Washington, D.C.: SAMHSA

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MILITARY VALUES
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The attributes that soldiers, sailors, marines, airmen
and coast guardsmen gain during their military service
changes who they are as a person in a positive way.
Channeling their understanding of the military ethos &
values culture can be a key technique in therapy.
(SAMHSA Handbook, 2010)

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• Initial Entry Training- socialization process to military culture:
1. Anticipatory
2. Encounter
3. Acquisition
4. Individual internalizes values and norms in identity
• While Basic Training is a specific experience to enlisted service
members, officers also have a similar initial socialization process.
• Upon completing Basic Training, service members often attend
more advanced schools to learn their specific technical job and
then return to their assigned unit to train for potential future
missions. Readiness through training is a key aspect of day to day
military operations.
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SOCIALIZATION PROCESS
Andersen, R. & Rodriguez, A. (2015, August). Working with those who have Served? Learn Best Practices. Symposium conducted at the meeting of the Veterans
Mental Health Coalition, New York, NY

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• Family Tradition
• Transition to manhood/womanhood
• To serve country
• Drafted (Ended in 1973)
• Friends did it
• Do something noble with their life
• Give life (death) purpose
• Protect people, country and way of life
• Be part of a team – something bigger than self
• Inherent sense of selflessness
• College money, free medical care, travel
• Way out from challenging psyco-social childhood/home environment
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Understanding what an individuals motivation was to join the military can lead to a deeper
understanding of the implicit factors that may still influence their lives
REASONS CIVILIANS JOIN
THE MILITARY
Andersen, R. & Rodriguez, A. (2015, August). Working with those who have Served? Learn Best Practices. Symposium conducted at the meeting of the Veterans
Mental Health Coalition, New York, NY

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WHAT IS A PARALLEL?
Something that is similar in comparison
Possible Components of a good Parallel:
• Metaphor: A term or phrase that is used to make a comparison between two things that
aren't alike but have something in common.
• Analogy: A comparison between two like things, typically for the purpose of explanation
or clarification.
• Allegory: Using storytelling and narrative to express an idea or teach a lesson.
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• A parallel can be a way to reframe what the service member/veteran already knows in order to educate them
about a psychological model
• Most parallels are not unique to combat experiences and are frequently common implicit cultural experiences
• If can be a way to normalize therapy for client and show your military cultural competence at same time.
Ultimately, it can help build trust.
Before using a parallel…providers should ask themselves:
- Does the veteran/service member highlight their military experience as one based in positive or negative
thoughts/beliefs/emotions? Most of the time you will get the details needed for you to make this assessment
in the intake.
- Impact of ‘Time Effect’- recently separated vs. separated 50 years ago
NOTE: The methodology of using military parallels to achieve more positive therapeutic outcomes is mainly anecdotal and has not been
tested in research or empirically proven. However we can look to research that shows establishing a better therapeutic alliance leads to
improved outcomes and also research in the efficacy of using metaphors in therapy as likely guides for this model.

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• Breathing in Marksmanship
• Preventative Maintenance Checks and
Services (PMCS) on Equipment
• Negotiating a Military Obstacle Course
• Military Planning
• Importance of Physical and Health
Readiness in Military
• ‘Having their Shipmate/Battlebuddy
Wingman’s Back
• Vocational ‘Hard’ Skills
• Resilience Training Currently In Military
• Personal Protective Equipment
• Military Values
• After Action Reviews
• Securing Sensitive Items
• Heuristics
• Moral Justification for Killing in War
• Mindfulness Breathing
• Need to sometimes perform
maintenance on our minds
• Obstacles in civilian life
• Life/Goal Setting Models, Solution
Focused Therapy, Reality Therapy
• Whole of Health/Wellness
Therapeutic Lifestyle Change Models
• Helping them to find a new ‘unit’ in
their civilian life
• ‘Soft’ Skills for Civilian vocation
• Positive Psychology
• Dialectical Behavior Therapy (DBT)
• Values Work (DBT & ACT)
• Cognitive Behavioral A-B-C Worksheet
• EMDR Container Exercise
• Ways to Challenge Heuristic Thinking
• Moral Injury, Spirituality, Cleansing
Ritual, Community Healing

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• Philosophy
• Stoicism
• Psychology and War
• Michael Matthews: Headstrong How Psychology is Revolutionizing War
• Civil Military Divide/Gap
• Kori Schake & Jim Mattis: Warriors & Citizens American Views of Our
Military
• Karl Marlantes: What It Is Like to Got to War
• Importance of Community in Healing
• Sebastian Junger: Tribe On Homecoming and Belonging
• Joseph Bobrow: Waking up from War
• Moral Injury
• Jonathan Shay: Achilles in Vietnam: Combat Trauma and the Undoing of
Character
• Nancy Sherman: Afterwar Healing with Moral Wounds of Our Soldiers
• Brett Litz, Leslie Lebowitz, Matt Gray, and William Nash: Adaptive
Disclosure
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OTHER POINTS OF RESEARCH IN
IMPLICIT MILITARY CULTURE

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BOUNDARIES OF COMPETENCE
ETHICAL DILEMMA
You have been working with a client for three months on rebuilding his life and
leaving the military after eight years with three combat deployments. As you have
been building rapport and establishing a therapeutic relationship, he has gradually
started to open up to you.
During the most recent session, the client appeared more distracted than usual.
When you inquire about his mood, he says, “We’re coming up on Black Sunday.”
When you ask him to elaborate, he simply says, “Sadr City? April 4, 2004?”
After inquiring further, he changes the subject and says he doesn’t want to talk
about it.
On April 4th, 2004, a platoon of infantry who had
been escorting wastewater vehicles was attacked and
surrounded in an ambush. Eight soldiers were killed
in the initial ambush and subsequent rescue attempt,
and dozens more wounded.

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AVOIDING THE IMPOSING OF VALUES,
ETC. ON A CLIENT (A.4.B.)
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A.4.b. Personal Values
Counselors are aware of—and avoid imposing—their own values, attitudes, beliefs, and
behaviors. Counselors respect the diversity of clients, trainees, and research participants and
seek training in areas in which they are at risk of imposing their values onto clients, especially
when the counselor’s values are inconsistent with the client’s goals or are discriminatory in
nature.
6. Ethics represents counselors’ self-awareness and motivation to serve military-connected
clients, as well as ethical considerations working with military populations.
The professional counselor:
c. Brackets personal values and attitudes of war policies; addresses potential prejudices
about military service or war; and recognizes their own political opinions of current and
previous combat operations

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IMPOSING VALUES EXAMPLES
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Listen to the full
episode at
www.veteranm
entalhealth.com
/hst004
Adamec, J. (2017, July 25). Accessing Mental Health Services with Jeff Adamec.(D. K. France, Interviewer)

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DEVELOPING AWARENESS
War Attitude Scale is a 27 item assessment to
determine the respondent’s attitudes towards war.
• 6-point Likert format
• Higher scores indicate more accepting war
attitudes.
• Examples:
“Even if there is not any hard evidence against
another country (i.e. weapons of mass destruction), I
would support war”
“I believe that war is necessary to resolve conflicts”.
Moral Foundations Questionnaire is a 32 item
assessment to identify an individual’s attitudes
towards five different foundations of moral beliefs:
• Care/harm
• Fairness/Reciprocity
• Loyalty/betrayal
• Authority/Respect
• Purity/Sanctity
Dupuis, E. C., & Cohn, E. S. (2011). A new scale to measure war attitudes: Construction and predictors. Journal of
Psychological Arts and Sciences.
Graham, J., Nosek, B. A., Haidt, J., Iyer, R., Koleva, S., & Ditto, P. H. (2011). Mapping the moral domain. Journal of
personality and social psychology, 101(2), 366.

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CULTURAL AWARENESS, SELF
EFFICACY AND WAR ATTITUDE
Experience working with
veterans seemed to make a
difference in both cultural
awareness and self-efficacy
(as expected) but not in
attitudes about war
Coll, J. E., Weiss, E. L., Draves, P., & Dyer, D. (2012). The impact of military cultural awareness, experience, attitudes,
and education on clinician self-efficacy in the treatment of veterans. Journal of International Continuing Social Work
Education, 15(1), 39-48.

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Sayer et al. (2009) identified a number of barriers that keep service members and veterans from
seeking mental health treatment. One category of barriers included an Invalidating Post-Trauma
Socio-Cultural Environment
IMPOSING VALUES AS A BARRIER TO
TREATMENT
Social network discouragement of help-seeking
Societal rejection
Negative homecoming experiences
Withdrawal from social network
or society
Sayer, N. A., Friedemann-Sanchez, G., Spoont, M., Murdoch, M., Parker, L. E., Chiros, C., &
Rosenheck, R. (2009). A qualitative study of determinants of PTSD treatment initiation in
veterans. Psychiatry: Interpersonal and Biological Processes, 72(3), 238-255.

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IMPOSING VALUES ETHICAL DILEMMA
You have been working with a justice involved veteran as part of a court-ordered
rehabilitation program.
She pleaded guilty to assault with a deadly weapon after she cut her husband’s arm
with a knife during a mutually combative altercation. During the therapeutic
process, she reveals that her husband had previously been systematically physically
abusive and she decided that she had “had enough.”
The client also revealed that she had been sexually assaulted by her supervisor in
Afghanistan, after which she was marginalized by her Chain of Command; it was only
after the supervisor attempted to take his own life and admitted to the assault, and
was subsequently court martialed, that the command took her accusation seriously.
What personal values do you think would
impact your ability to support the veteran in
resolving the multiple traumas in this situation?

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PROFESSIONAL RESPONSIBILITY TO
ENGAGE IN SELF-CARE ACTIVITIES (C)
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Section C: Professional Responsibility
…In addition, counselors engage in self-care activities to maintain and promote their own
emotional, physical, mental, and spiritual well-being to best meet their professional
responsibilities.
6. Ethics represents counselors’ self-awareness and motivation to serve military-connected
clients, as well as ethical considerations working with military populations.
The professional counselor:
f. Actively adheres to a self-care routine to prevent burnout, depersonalization, compassion
fatigue, and impairment

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Scroggins, N. (Director). (2017). Heart of the Bull [Motion Picture].
http://veteranmentalhealth.com/heart-bull-short-film-nicolas-scroggins/

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SECONDARY TRAUMATIC STRESS IN
MILITARY AND VETERAN CAREGIVERS
Burnout
Countertransference ReactionVicarious Traumatization
Compassion Fatigue
Secondary Traumatic Stress
The natural and consequent behaviors and emotions resulting from knowing about a
traumatizing event experienced by a significant other – the stress resulting from helping
or wanting to help a traumatized or suffering person
Bride, B. E., & Figley, C. R. (2009). Secondary trauma and military veteran caregivers. Smith
College Studies in Social Work, 79(3-4), 314-329.

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Secondary Traumatic Stress Scale
MEASURING TRAUMATIC STRESS AND
COMPASSION FATIGUE
Compassion Fatigue Short Scale
Adams, R. E., Boscarino, J. A., & Figley, C. R. (2006). Compassion fatigue and psychological distress among social workers: A validation study. American Journal of
orthopsychiatry, 76(1), 103-108.
Bride, B. E., Robinson, M. M., Yegidis, B., & Figley, C. R. (2004). Development and validation of the secondary traumatic stress scale. Research on social work practice, 14(1),
27-35.

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Your weekly Vietnam Veterans Support Group has grown considerably for the past
two years. For many of these veterans, the emergence of a new generation of
combat veterans, combined with the natural consequences of aging, has led them to
seek treatment for the first time in their lives.
The group members are responding well to the group dynamic, and many of them
indicate that you are the first therapist that they felt like they’ve been able to trust.
Most of them also indicate that the group is the social highlight of their week.
You have had a long-planned family vacation scheduled for the first two weeks in
August; and you have been notified that you have been selected to attend a month-
long professional development course that is in your area of interest.
You will be unable to hold the group for six weeks, and none of your colleagues will
be able to take the group over on a temporary basis.
Do you cancel the professional development, vacation,
neither, or both? How do you handle this conversation?
SELF CARE ETHICAL DILEMMA

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CULTURALLY AND CLINICALLY
APPROPRIATE RESOURCES
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A.11.a. Competence Within Termination and Referral
If counselors lack the competence to be of professional assistance to clients, they avoid
entering or continuing counseling relationships. Counselors are knowledgeable about
culturally and clinically appropriate referral resources and suggest these alternatives. If clients
decline the suggested referrals, counselors discontinue the relationship.
6. Ethics represents counselors’ self-awareness and motivation to serve military-connected
clients, as well as ethical considerations working with military populations.
The professional counselor:
n. Considers community referrals when in the best interest of the client.

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PTSD Consultation Program
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Veterans Crisis Line
Vet Center Call CenterNational Resource Directory
FURTHER TOOLS FOR MILITARY
CULTURAL COMPETENCE TRAINING

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Make the Connection Coaching Into Care
About Face PTSD Decision Aid
Have You Served?
FURTHER TOOLS FOR MILITARY
CULTURAL COMPETENCE TRAINING

36. BEYOND BASIC
TRAINING
ACA 2019
WWW.VETERAN
MENTALHEALTH
.COM/ACA2019
36
Center for Deployment Psychology Defense Centers of Excellence for Psychological
Health & Traumatic Brain Injury
VA Community Provider Toolkit VA PTSD 101
FURTHER TOOLS FOR MILITARY
CULTURAL COMPETENCE TRAINING

37. BEYOND BASIC
TRAINING
ACA 2019
WWW.VETERAN
MENTALHEALTH
.COM/ACA2019
PsychArmor Institute
The Training Institute at Home Base
Task & Purpose
37
2 Good Ted Talks Head Space and Timing
The War Horse
FURTHER TOOLS FOR MILITARY
CULTURAL COMPETENCE TRAINING

38. BEYOND BASIC
TRAINING
ACA 2019
WWW.VETERAN
MENTALHEALTH
.COM/ACA2019
38
38
@veteranmentalhealth
@ThCounselingVet
www.linkedin.com/in/dklfrance
www.veteranmentalhealth.com
duane@veteranmentalhealth.com marco.bongioanni@va.gov
QUESTIONS AND COMMENTS