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In 2012, I was asked to help create a PTSD treatment program for returning Iraq and Afghanistan combat veterans. Before seeing the first of what would be more than 2,000 veterans our program saw over the next ten years, I met with groups of veterans to better understand this population. Although my father had served in combat in WWII, he never talked about it. What I quickly learned is that combat veterans are a sub-culture, a minority population with their own language, code of conduct, values, and mores. Working with military service members and veterans requires more than knowledge of trauma treatment. It requires an understanding of the culture in which many of these clients learned to survive.
For many military personnel, asking for psychological help can feel fundamentally inconsistent with the values that helped them succeed in an operational environment. Strength, self-reliance, emotional control, loyalty to the team, and the ability to function under pressure are highly valued. These qualities can be tremendous assets, but they can also become barriers when a person is struggling with trauma, anxiety, anger, sleep problems, relationship difficulties, or other consequences of military service.
The challenge for clinicians is therefore not simply, "How do I treat trauma?" It is often, "How do I engage someone who may not initially believe they need treatment?"
Military members may approach therapy with considerable skepticism. Some may worry that seeking treatment will make them appear weak or negatively affect their careers. Others may have concerns about confidentiality, security clearances, hospitalization, or whether information may be shared with command.
Military culture can also encourage a strong form of self-reliance. Service members are often trained to push through discomfort, maintain control under pressure, and prioritize the mission over personal needs. In that context, acknowledging emotional distress may feel unnecessary, or even dangerous.
Other barriers can include distrust of civilian providers, previous negative experiences with healthcare systems, fear of vulnerability, and concern about being misunderstood by someone who has never experienced military life.
These concerns should not automatically be interpreted as resistance. What may look like resistance actually represents an adaptive strategy that developed in a very different environment.
Military culture has several characteristics that are particularly relevant to psychotherapy. Identity is often strongly connected to mission, purpose, and membership in a team. Group cohesion can be extraordinarily important, with the needs of the team sometimes placed above those of the individual.
Communication tends to be direct, blunt, and action-oriented. Emotional control is often viewed as a functional requirement, particularly in high-pressure environments. There may also be a strong distinction between insiders and outsiders.
For clinicians, this means that the therapeutic relationship must begin before trauma processing ever occurs. A military client may be asking themselves:
These questions are central to engagement.
One of the most important principles when working with reluctant military clients is simple: engagement comes before intervention.
The first session should prioritize psychological safety, credibility, collaboration, confidentiality, and autonomy. Clinicians need to demonstrate competence without becoming overly authoritative. They should clearly explain what they are doing and why. Avoiding vague or overly abstract language can be especially helpful. Psychoeducation on how the brain and nervous system react to combat de-stigmatizes and normalizes their experiences.
A client who is accustomed to structured environments may respond better when therapy has a clear rationale and identifiable goals.
The therapist should also avoid over-pathologizing adaptive military behaviors. Suppression and compartmentalization, for example, may have served important functions during deployment or other operational environments. Emotional control may have helped a service member remain focused when there was no opportunity to process what was happening.
The goal is not to tell the client that these strategies are "bad." Instead, therapy can explore whether strategies that were once useful are still working in the client's current environment. This distinction can significantly reduce shame. Rather than communicating, "Your coping mechanisms are dysfunctional," the clinician can communicate, "That strategy helped you function when you needed it. Let's determine whether it is still serving you now."
Credibility is a major component of therapeutic alliance with military populations. Clinicians should be structured, transparent, and practical. Explain what you are doing, what the client can expect, and how the intervention is intended to help. Avoid excessive abstraction when concrete language will work better.
For example, instead of beginning with a discussion about "processing emotions," a clinician might explain that the goal is to help the nervous system respond differently when the client encounters reminders of a traumatic event. This kind of language can make treatment feel more understandable and actionable.
It is also important to recognize that military clients may communicate differently than civilian clients. Bluntness does not necessarily indicate hostility. Minimal emotional expression does not necessarily mean disengagement. Humor may be a way of regulating distress rather than avoiding treatment. Even dark humor can serve a regulatory and social function within military culture.
The clinician's task is to understand these behaviors within their context rather than immediately interpreting them as symptoms or resistance.
Trust develops through reliability, not intensity.
Military clients may not need a therapist to demonstrate extraordinary emotional warmth during the first session. They may need evidence that the therapist is dependable. Being punctual, consistent, boundaried, and transparent can communicate more than excessive reassurance.
Following up after a missed appointment can also be important. A missed session should not automatically be interpreted as avoidance or lack of motivation. A simple, respectful follow-up can communicate concern without judgment.
Similarly, clinicians should avoid pushing emotional depth prematurely. Trust is built over time. When clients experience the therapist as predictable and respectful of their autonomy, they may become increasingly willing to disclose difficult material.
One effective way to engage military clients is to connect treatment to outcomes that matter to them. Rather than framing therapy exclusively around symptom reduction or emotional expression, clinicians can discuss goals such as:
The language matters. "Let's process your feelings" may not resonate with every military client. "Let's improve your response when you're under pressure" may feel more concrete and relevant.
This is not about avoiding emotional work. It is about presenting that work in a framework that connects with the client's values and experience.
Action-oriented approaches can resonate strongly with military populations. For some clients, experiential treatment may feel more natural than prolonged verbal exploration. EMDR, one of the evidence-supported treatments in the VA and DoD Clinical Practice Guidelines, may fit well because it provides a structured therapeutic procedure while reducing the need for extensive verbal processing.
The clinician can frame EMDR as a process of helping the nervous system update its response to experiences that are no longer occurring in the present. This approach can help move therapy away from the idea that the client must simply "talk about feelings."
Social and physical activities can also provide opportunities to strengthen connection. Running groups, CrossFit, climbing, kayaking, and other activities can recreate aspects of the structure, teamwork, and physical engagement that many service members experienced in military environments. These activities can help reduce isolation while providing opportunities for connection outside traditional therapy.
Reluctance can take many forms. A client may say, "I don't need therapy." Another may say, "I'm only here because command sent me." Some clients may provide minimal information. Others may rely heavily on humor, intellectualization, or deflection.
The clinician's response is critical. Arguing with the client about whether they need therapy is unlikely to build alliance. Instead, the clinician can begin by identifying what the client would like to change.
Perhaps sleep is the problem. Perhaps anger is affecting a relationship. Perhaps the client is tired of being constantly on edge. Perhaps they want to feel more in control.
The treatment conversation can begin with the problem the client actually wants to solve. This creates collaboration rather than confrontation.
Reluctance to disclose can be driven by very real fears. Clients may worry about career repercussions, loss of security clearance, hospitalization, appearing weak, burdening others, or simply being misunderstood.
These concerns should be addressed directly rather than dismissed. Clarifying confidentiality and its limits is particularly important early in treatment. Clients should understand what information remains private, what circumstances might require disclosure, and what they can expect from the therapeutic process. Transparency can reduce uncertainty and help establish credibility.
Even with a strong therapeutic approach, ruptures will occur. A military client may miss appointments, withdraw, become irritable, become more defensive, suddenly become silent, or challenge the therapist intellectually. These behaviors can signal that something has happened in the therapeutic relationship.
Rather than responding defensively, clinicians can become curious. What changed? Did the client feel misunderstood? Did the therapist move too quickly? Was a question experienced as intrusive? Did the client perceive judgment? Was confidentiality misunderstood?
A rupture does not necessarily mean the therapeutic relationship has failed. In many cases, addressing the rupture directly can strengthen the alliance.
Effective treatment with military populations does not require clinicians to dismantle the characteristics that helped clients survive and function. Strength, discipline, loyalty, emotional control, independence, and the ability to compartmentalize can all be valuable.
The clinical goal is to help clients develop flexibility. A strategy can be adaptive in one environment and limiting in another. The ability to suppress emotion during a dangerous mission may be essential. The inability to access emotion with a spouse or child after returning home may create problems. The ability to remain hypervigilant in a combat environment may promote survival. Remaining hypervigilant while sitting in a living room may interfere with sleep and relationships.
Therapy can help clients determine when a strategy is useful, and when it is time to shift gears.
Ultimately, effective engagement can be summarized in five principles:
For clinicians treating trauma in military populations, therapeutic alliance is not a preliminary step before the "real" work begins. It is the real work.
When therapists understand military culture, communicate with credibility, respect autonomy, and connect treatment to meaningful outcomes, reluctant clients may become more willing to engage. The objective is not to convince service members that their strengths are problems. It is to help them use those strengths more effectively, while developing new ways of responding when the mission has changed.
This series continues with related posts from the Trauma Therapist Institute:
What looks like resistance is usually an adaptive strategy developed in a very different environment. Self-reliance, emotional control, and skepticism of outsiders served real functions in military life. Reading these behaviors within their cultural context, rather than as symptoms, is the foundation of engagement.
Psychological safety, credibility, collaboration, confidentiality, and autonomy. Explain what you are doing and why, use concrete language, clarify confidentiality and its limits, and avoid pushing emotional depth prematurely. Engagement comes before intervention.
Do not argue the point. Begin with the problem the client actually wants to solve, whether that is sleep, anger, concentration, or feeling constantly on edge. Starting from their goals creates collaboration rather than confrontation, and the deeper work follows from there.
Often, yes. EMDR is one of the evidence-supported treatments in the VA and DoD Clinical Practice Guidelines for PTSD, and its structured, action-oriented format can suit clients who find prolonged verbal exploration unnatural. Framing it as helping the nervous system update its responses tends to resonate.
Get curious rather than defensive. Ruptures often signal that something happened in the relationship: a question felt intrusive, the pace was too fast, or judgment was perceived. A respectful follow-up and a direct, non-defensive conversation about what changed can strengthen the alliance rather than end it.
With respect,
Gerard
Gerard Ilaria, LCSW-R, EMDR-C
Founder, Bilateral Health · Former Clinical Director, Weill Cornell Center for Trauma and Addiction · Co-creator, Treating Military Trauma Practitioner Program
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Everything in this post comes from the decade I spent building and running a veterans trauma program, and it is the foundation of what Dr. Arielle Jordan and I teach in this program. Eight on-demand modules covering military culture, the neurobiology of operational trauma, engagement, risk assessment, and moral injury. 8 CEs, no EMDR training required.
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VA/DoD Clinical Practice Guideline Working Group. (2023). VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. Department of Veterans Affairs and Department of Defense. https://www.healthquality.va.gov/guidelines/MH/ptsd/