Military Cultural Competency for Veteran Mental Health Counseling in Civilian Settings ()
1. Background
1.1. Introduction
As a vulnerable cultural group, veterans present unique challenges to mental healthcare providers as a result of their experiences in the military (Meyer & Wynn, 2016) . Veterans are vulnerable to mental health disparities related to post-traumatic stress disorder (PTSD), military sexual trauma (MST), depression, and substance use that must be thoroughly understood by mental health professionals in order to ensure best practices are being implemented while treating this population (Meyer & Wynn, 2016) . This study aimed to address the need for mental health counselors in civilian/non-governmental mental health settings to better understand the unique cultural experiences within this community as a result of military service (USDVA, 2021) .
The topic of this research study informed the development of an action research monograph summarizing best practices for military cultural competency in counseling in order to understand how to provide better mental health services to veterans in civilian mental health counseling settings (Carrola & Cordin-Burdick, 2015) . The research monograph describes how to integrate a multicultural and integrated interorganizational theoretical framework to best address the research question targeting stakeholders identified as local civilian mental health leaders and clinicians.
1.2. Problem Statement and Purpose of Research Study
The problem is related to the growing demand for community mental health providers to meet the needs of post 9/11 veterans. Over the last 10 years, the Department of Veterans Affairs (VA) has reported a 32% increase in veterans seeking outpatient mental health care (USDVA, 2021) . There has been an increase in veterans seeking care across private sector and non-governmental public sector organizations (Richards et al., 2017) . Due to this demand, veterans being treated by civilian mental health professionals need informed treatment for their mental health issues (De Luca et al., 2016) . There is a need for mental health counselors working with this population to be able to access information about military culture and its unique experiences in order to provide veterans with culturally sensitive counseling treatment and interventions (Navjit Sanghera, 2017) . Mental health counselors working with this population who seek to better understand the military cultural backgrounds of their veteran consumers are better equipped to provide the most effective care (Navjit Sanghera, 2017) . Most recent conflicts presented in the Operation Iraqi Freedom (OIF) war lasted from 2003-2011 (USDVA, 2021) . Operation Enduring Freedom (OEF) continued with the global war on terrorism also spanning from 2001-2014. The lingering effects of these deployments are still relevant and the factors pertaining to the mental health of affected veterans still need to be addressed years later (USDVA, 2021) . The mental health consequences of the Iraq and Afghanistan conflicts among the post 9/11 veteran population are well documented as a result of multiple deployments, traumatic injuries, military sexual trauma, and exposure to chronic stressors for long periods of time (NASEM, 2018) . These factors are known to increase the risk of mental health problems among this population (NASEM, 2018) . It is estimated that 20% of all OIF/OEF veterans face a diagnosis of PTSD compared to 7% of the civilian population (NASEM, 2018) . Gender disparities also depict that 70% of all female service members who serve have a diagnosis of PTSD (NASEM, 2018) . Since the start of the Covid-19 pandemic, it is estimated that military suicides have now risen 30% (Debeer et al., 2020) . This news comes as an added stressor to the dire mental health needs of the veteran population (Debeer et al., 2020) .
The purpose of this research is to investigate current and upcoming military cultural competence best practices for counseling veterans in civilian and/or non-governmental outpatient mental health settings. This study aims to deliver an action research monograph which will outline novel approaches that encompasses best practices of military cultural competency in order to better address the counseling needs across mental health agencies in civilian/non-governmental settings (Plano et al., 2016) . The intended outcomes of this study are to support upcoming and already existing literature on best practices for providing veterans with culturally competent mental health care. It is the researcher’s intent to summarize studies investigating the significant benefits of implementing military cultural competency for the treatment of PTSD and other mental health symptoms for future implications for the sustainment of veteran counseling best practices and mental health literature (Atuel & Castro, 2018) .
This action research will extend best practice research and intervention efforts that incorporate effective treatment methods (Carrola & Cordin-Burdick, 2015) . These treatment methods ensure best practices are implemented across civilian mental health treatment settings (Carrola & Cordin-Burdick, 2015) . This will help to empower both mental health counselors as well as the veteran community. Providing solutions with partnering agencies to implement culturally sensitive interventions can aim to better treat the mental health needs of veterans (Carrola & Cordin-Burdick, 2015) . The recommendations presented in this studies’ monograph can help train private civilian and non-governmental counseling clinicians to better understand and help meet the mental health treatment needs of the population of veterans of the US armed forces.
1.3. Research Design/Method
The purpose of this research was to review the mental health needs of veterans, challenges in provision of care, and best practices for military cultural competency in order to understand how to provide better clinical counseling services to veterans in civilian and/or non-governmental mental health settings (Carrola & Cordin-Burdick, 2015) . The design and method for this study is a qualitative review and thematic analysis of the literature using purposive sampling focused on key words and phrases related to the purpose of the study. A review and analysis of 2019 datasets provided by the USDVA is integrated within the literature review to support major themes that arose through thematic analysis.
The qualitative data sources consist of a best practices style literature review and the analysis of continuing education/professional development opportunities for developing military cultural competency as well as other related topic in working with veterans (Plano et al., 2016) . A traditional qualitative design has informed the literature review used to assess various best practices of larger health care organizations, current best practices in treating this population, as well as the barriers to treatment (Plano et al., 2016) .
1.4. Evidence/Data Used to Establish Rationale for Research Study
Data findings demonstrate that veterans seeking behavioral health services for issues related to post-traumatic stress disorder and other mental health disparities are diverse in nature (Carrola & Corbin-Burdick, 2015) . Data from organizational studies and evaluations were collected by resources released by the Department of Defense (DOD) and the Department of Veterans Affairs (VA) in an effort to evaluate mental health and outreach intervention strategies delivered to the veteran target population that can later be used to report findings that encourage a substantial basis for solving these complex issues (USDVA, 2021) . Data types include qualitative outcome data highlighting recommendations for client treatment outcomes that should be frequently generated in order to ensure the needs of the target population are being met (USDVA, 2021) . Quantitative data types pertaining to accountability, such as surveys and standards for performance, are also highlighted within the data in order to inform the measurement for consistent improvements to be made within the delivery of mental health services to veterans (USDVA, 2021) .
1.5. Historical Background of the Problem
Although government sector organizations, such as the Department of Veterans Affairs, remain the largest organization that serves the mental healthcare needs of this population, only about 1/3 of veterans are in the care of the VA (Hester, 2017) . Rather than using the VA healthcare system, veterans who are employed often choose to utilize their own private health insurance benefits (Hester, 2017) . Mental health resources, such as clinical outpatient counseling services, are not always readily available at all VA Health Systems due to the shortage of clinical mental health personnel and the growing needs to treat this population (Hester, 2017) . Moreover, veterans have historically faced stigma for receiving mental health care. The social culture that surrounds the veteran and military community may reinforce apprehensions for veterans to accept mental health diagnostic information on their permanent VA medical records (Carrola & Corbin-Burdick, 2015) . A combination of these barriers to treatment and exponentially growing needs for treatment have resulted in trends to outsource mental health services for this population to civilian private and nonprofit organizations (Tricare, 2020) .
There is a great need to provide qualified mental health treatment to the veteran population in the civilian private sector is growing. Veterans who do not rely primarily on the VA health care delivery systems to address their mental health needs must locate treatment utilizing smaller private, non-government sources (Hester, 2017) . Findings within the literature cited by Atuel & Castro (2018) suggest that it would be difficult for civilian providers to provide effective mental health care to veterans without an understanding of how the military may impact the wellbeing of those who have served. Citing the work from Nedegaard and Zwilling (2017) , Meyer and Wynn also found that clinicians not familiar with military lifestyle with at least one or more continuing education courses in military counseling scored significantly higher in military cultural awareness than those without (Meyer & Wynn, 2016) . Cultural competence, training, and knowledge among mental health practitioners who serve this population in the private sector play an important role in facilitating the psychological and social adjustments among veterans reintegrating back into their communities returning from their service (Meyer & Wynn, 2016) . It is imperative that mental health care providers working within these private sectors, human services organizations have the resources and training to provide competent mental health services for veterans within local communities seeking mental health services from a variety of different agencies (Tricare, 2020) .
1.6. Organizational Context
The context is significant because it will help to address counseling needs for mental health organizations providing treatment for veterans who are utilizing public and private sector mental health services (Atuel & Castro, 2018) . A significant challenge for private and public sector organizations serving the veteran population lies in adhering to military competency that informs evidenced-based mental health practices administered to this population (Mac Donald et al., 2017) . The goals of this study may help to implement and conduct research to learn how to better improve military cultural competency for mental health counselors in agencies that span from for-profit private counseling clinics to nonprofit organizations [Carry the Load (CTL, 2019) ]. For example, non-profit organizations, such as The Carry the Load foundation, are providing military, first responders, and their families with access to psychological services throughout local communities (CTL, 2019) . This organization has specifically relied on the latest data released by the Department of Veterans Affairs (VA) depicting the shortage of government resources as a foundation for their work to provide culturally informed mental healthcare and educational outreach programs that emphasize the prevention and rehabilitation of mental health related issues common within the military and veteran populations (CTL, 2019) . This substantiates and addresses the need for local and national organizations to provide veterans with health care and mental health services (CTL, 2019) . Agencies across local communities who do not specialize in working with veterans may not be aware of best practice standards for treating this population (Atuel & Castro, 2018) . However, the growing need to service veterans in civilian mental health settings asserts the importance of the expansion of research and outreach efforts to ensure clinicians across the civilian sector are culturally competent in the unique experiences of those who have served in the military (Atuel & Castro, 2018) .
The practical implications of this research also aim to address organizational needs spanning across several different agencies within the local community. This study will serve organizations across the broader community addressing the problems described that relate to serving the veteran population with the common mission to provide culturally competent mental health services and service coordination to veterans (USDVA, 2019) . The results of this action research monograph are intended to be shared to benefit local civilian mental health organizations and program leaders to use this material to better serve the veteran community. The deliverable summary information can help train private civilian and non-governmental counseling clinicians to better understand and help meet the mental health treatment needs of the population of veterans of the armed forces.
1.7. Theoretical Framework
According to Kivunja (2018) , a theory is described as a set of concepts that present a systematic viewpoint of a particular phenomenon by defining the relationships between variables in order to explain or predict the phenomenon. For purposes of framing this research topic, several theories have informed the planning for this research study. One in particular is called a “multicultural theoretical framework” that was originally developed to lay a particular emphasis on integrating multicultural competencies into the psychotherapy process in mental health (Davis et al., 2018) . Multicultural theoretical framework is an emerging psychotherapy discipline that aims to inform mental health practitioners of cultural considerations that are relevant to presenting mental health issues (Davis et al., 2018) . This approach honors the ethical obligations that mental health professionals hold in their duty to consider the implications that current diagnostic practices and utilization of best practice interventions may have (Carrola & Cordin-Burdick, 2015) . This is especially true for veteran clients who have served in the military. Like many client groups that require special needs for treatment, the veteran population is considered a vulnerable group (Meyer & Wynn, 2016) . As a result of their experiences unique to the military environment, there is a challenge for mental health workers to provide adequate mental health services (Meyer & Wynn, 2016) . Employing multicultural theory allows professionals to look at the veteran population as a special group and acknowledges that the veteran’s experience and worldview may be different from the professional (Carrola & Cordin-Burdick, 2015) . This allows mental health professionals and organizations to develop competencies and best practices to incorporate differences in the therapeutic relationship using a multicultural lens (Carrola & Cordin-Burdick, 2015) .
In conjunction to multicultural framework, an interorganizational collaboration framework also ensures social justice to continue improving the welfare of veterans through the collaboration of human service professionals across the fields within the community (Carrola & Cordin-Burdick, 2015) . As cited by (Mac Donald et al., 2017) , an “interorganizational collaboration” framework is defined by the identification and integration of community resources for the consumers of mental health services. The organizations that are identified for integrated interorganizational collaboration include government as well as civilian non-profit and private for-profit mental health settings. Further research supports an action research topic concerned with mental health professionals and organizations in ensuring teamwork initiatives are being met in order to serve these veterans (Sridharan & Nakaima, 2011) . This theory can be used to inform multiple human service professionals in order to compare and substantiate program components in order to make necessary adjustments (Sridharan & Nakaima, 2011) . The issues that this action research aims to improve should be addressed with a multitude of professionals and organizations that are involved in the process of treating this population (Sridharan & Nakaima, 2011) .
The study investigated best practices for military cultural competency among larger outpatient mental health settings in order to understand how to provide mental health services to veterans of the armed forces in smaller, private mental health settings (Carrola & Cordin-Burdick, 2015) . Multicultural and interorganizational collaborative theoretical frameworks are identified for application towards this action research. Interorganizational collaboration concepts help to emphasize multicultural theoretical frameworks and considerations for the identification of the proper community resources for the consumers of mental health services (Mac Donald et al., 2017) . The issues commonly faced in improving the mental health treatment outcomes of Veterans also relates to other issues, such as cultural issues that are not addressed within all organizations (Mac Donald et al., 2017) . A significant challenge for serving this community of veterans lies in adhering to cultural diversity among collected data informing evidenced-based mental health practices administered to this population across all agencies large and small (Mac Donald et al., 2017) .
1.8. Literature Review
This literature review was conducted in order to find the relevant information related to the topic of this research. The review below is organized by sections, specifically 1) Mental health needs of the military population; 2) Recognition of the population and need for culturally competent care; 3) Limitations and barriers to treatment; 4) Oppression, hierarchy, sexism and stereotypes in the military and mental health; 5) PTSD, MST and related mental health disparities; 6) Resilience and posttraumatic growth; 7) Holistic wellness approaches to veteran treatment; 8) Evidenced-based best practices.
The sections reflect major organizational categories of literature supporting the topic of the research findings. An extensive list of key themes will be later identified in Section II: Process of this research study as well as a detailed account of the search strategies conducted within the methods section of this study. The process is expanded upon in the following section of this study and highlights the criteria used for the identification and the review of evidence directly related to the selected research question focusing on United States military mental health and military cultural competency.
1.8.1. Mental Health Needs of the Military Population
As a vulnerable cultural group, veterans present unique challenges to mental healthcare providers as a result of their experiences in the military (Carrola & Corbin-Burdick, 2015; Meyer & Wynn, 2016) . Veterans need treatment for their mental health issues from qualified mental health professionals who are trained and informed about the specific and unique needs of this population (De Luca et al., 2016) . Veterans are vulnerable to mental health disparities related to post-traumatic stress disorder (PTSD), military sexual trauma (MST), depression, and substance use that must be thoroughly understood by mental health professionals in order to ensure best practices are implemented (Meyer & Wynn, 2016) .
According to a study assessing strength-based treatment models and interventions for veteran mental health, researchers Carrola & Corbin-Burdick (2015) suggest that veterans that constitute a population of those who have served in the armed forces and who are seeking behavioral health services for issues related to post-traumatic stress disorder (PTSD) are diverse in nature. These findings are further substantiated by data sets released by the VA in 2019 stating that ethnicity demographics of post 9/11 veterans utilizing VA benefits seeking care for PTSD depicted a diverse demographic in frequency of diagnoses depicted (Byrd, 2019; USDVA, 2021) . Research supports that not only is there diversity in the backgrounds of individual members of the US military, but there are more women joining the military as well as a newer generation of service members (Byrd, 2019) . Demographic data also suggests shifts and a large minority population that is growing among the armed forces (USDVA, 2021) . It is estimated that 40% of post 9/11 service members makeup minority demographics (USDVA, 2021) . This includes the largest growing minority populations including the Black and Latino/a cultural demographic makeup as well as the growing number of female populations in the service that is estimated to continue rising (USDVA, 2021) . The evidence depicts the increasing diversity is a transition that the military is currently experiencing (Byrd, 2019) .
A VA treatment meta-analysis of the effectiveness of large scale culturally relevant psychotherapy and mental health intervention strategies showed that among those diagnosed with PTSD, outcomes proved promising (USDVA, 2021) . In relation to needs, it is essential to advocate for best practices and procedures that helps to ensure that community mental health treatment centers are aware and culturally informed of the needs presented within the community that can be translated into assuring culturally competent mental health intervention strategies that can benefit the diverse consumers of mental health within the military veteran population (Guenole et al., 2017) .
1.8.2. Recognition of the Population and Need for Culturally Competent Care
Veterans face enormous challenges as they transition out of the military and into the civilian world (Stevenson, 2020) . This period of transition can be characterized by a loss of identity and loss of community (Stevenson, 2020) . Research and cited works have thoroughly defined the military culture and this period of transition for the purpose of informing best practice standards in the fields of psychotherapy (Atuel & Castro, 2018; Stevenson, 2020) . Researchers Atuel and Castro published an article in 2018 offering newer and more contemporary definitions of military cultural competence based on a review of prior literature. Their review suggests that the military as an organization, cultural group, and social group is different from any other groups and depicts the need to develop military cultural competency training for mental health professionals across all sectors (Atuel & Castro, 2018; Carrola & Corbin-Burdick, 2015) . This information continues to reinforce prior literature depicting the military population as diverse in nature with complex and severe mental health disorders that are related to their shared cultural experiences of serving in the armed forces (Atuel & Castro, 2018; Carrola & Corbin-Burdick, 2015) .
One study conducted by researchers Meyer & Wynn (2016) assessed a meta-analysis of a multitude of national surveys administered to mental health professionals related to providing mental health services to the veteran population demonstrated evidence of the importance of clinicians gaining experience and pursuing continuing education in working with this population. According to Meyer & Wynn (2016) the variety of national surveys assessed have indicated low military cultural competence among healthcare professionals as well as limited efforts of education on military culture by higher level healthcare educational institutions. For example, their study found that the Association of American Medical Colleges deployed surveys demonstrating how few healthcare educational programs were discussing culture or PTSD within the context of the military (Meyer & Wynn, 2016) . Data findings provided a context for understanding the veteran identity that caries implications for mental health providers that presents the continued importance of healthcare providers responses to the unique health needs of veterans as a result of the military experience (Meyer & Wynn, 2016) .
In the same study, surveys conducted by the PEW Research Center also measured social and demographic trends of military and civilian gaps conducted across the nation found that civilian understanding of the military culture continues to decline as fewer Americans serve in the military (Meyer & Wynn, 2016) . Although the current era has depicted the longest period of war in US history, only less than 0.5% of the American population has served in the military within the last 10 years (Meyer & Wynn, 2016) . This same study reported that only 20% of veterans believe the civilian population has a general understanding of the unique problems that military members face (Meyer & Wynn, 2016) . This is a cautioning statistic in light of the reflection that those among civilian mental health professionals that may find themselves treating the veteran population, it is estimated over 70% of modern war era veterans receive their care completely outside of the VA (Meyer & Wynn, 2016) .
It is paramount, then, that more contemporary definitions of military cultural competency in the mental health sector should not only take into account unique military experiences within this population, but should also take into account the diversity found within the military such as race/ethnicity, gender, sexual orientation, and religious affiliation (Atuel & Castro, 2018; Stevenson, 2020) . This is vital to the understanding of the military experience across different cultural groups (Atuel & Castro, 2018; Stevenson, 2020) .
1.8.3. Limitations and Barriers to Treatment
Researchers (Kimerling et al., 2015) deployed a nationally representative survey of veteran primary care utilizing a sample of over 6200 veterans. In their study, mental health care experiences were assessed in relation to VA mental health services received (Kimerling et al., 2015) . Survey results found that veterans transitioning from being overseas in combat, frequent moves, and also exiting the military are often made to wait extensive periods of time in order to receive mental health care services (Kimerling et al., 2015) . More recent research conducted by Stevenson (2020) concluded that leaving the military can lead to tremendous levels of stress and loss of resources and social connectedness navigating civilian life. Often times, the burden is placed on the military members within the community to find services themselves without the help of community resources (Kimerling et al., 2015; Stevenson, 2020) . These dynamics often result in crisis and isolation from a supportive community network (Kimerling et al., 2015; Stevenson, 2020) .
These demands depict a growing need for community mental health providers to meet the needs of post 9/11 veterans as there has been an increase to seek care in the public sector (Richards et al., 2017) . Although government sector organizations, such as the Department of Veterans Affairs, remain the largest organization that serves the mental healthcare needs of this population, only about 1/3 of veterans are in the care of the VA (Hester, 2017) . Veterans who are employed often choose to utilize their own private health insurance benefits rather than using the VA healthcare system (Hester, 2017) . Mental health resources, such as clinical outpatient counseling services, are not always readily available at all VA Health Systems due to the shortage of clinical mental health personnel and the growing needs to treat this population (Hester, 2017) . Likewise, growing trends depict collaborating entities, such as Tricare health coverage and VA Choice programming, are frequently outsourcing services such as psychotherapy, psychological testing, and medication management to private sector mental healthcare providers (Richards et al., 2017) .
The Department of Veterans Affairs also remains one of the largest legal and economic barriers that affects service delivery implementation and prevents access to this community to adequately seek out mental health services (APA, 2017) . For example, past and current legislation efforts have consistently provided the VA with the task to implement qualified mental health workers by creating initiatives and raising budget costs to do so (APA, 2017) . Despite this legislation, the VA continues to utilize loopholes making it increasingly difficult for qualified mental health staff to seek employment within VA mental health agencies (APA, 2017) . The Veteran community continues to be exposed to professionals who are not qualified (APA, 2017) .
These aspects affect multi-agency collaboration as the VA has remained impenetrable and unresponsive to other collaborating entities (APA, 2017; Bovin et al., 2019) . Research has revealed a variety of barriers associated with initiating care by the VA for qualifying veterans, including care specific to accessing mental health care (Bovin et al., 2019) . Professional organizations, such as the American Psychological Association, have continued to advocate for the critical need of establishing a variety of qualified mental health professionals within the VA mental health workforce (APA, 2017) .
The military demographic has also been historically noted for having a strong male presence and a majority of males serving within the ranks (Kimerling et al., 2015) . For these reasons, services available to female veterans remains one of the largest gaps within this community (Kimerling et al., 2015) . Mental health treatment within this community has been mostly geared towards the male population (Kimerling et al., 2015) . Moreover, female veterans lack proper identification of adequate needs (Kimerling et al., 2015) . More women are serving within the military and in combat roles (Kimerling et al., 2015) . Treatment for the veteran population is changing and should continue to address gaps in funding initiatives for women serving in the military within this community (Kimerling et al., 2015) .
In historical contexts, mental health clinicians and institutions alike have used classifications of mental health disorders in order to pathologize populations that may be considered vulnerable (Carrola & Corbin-Burdick, 2015) . This same story can be portrayed among vulnerable military populations concerning the negative impacts that a diagnosis, such as PTSD, holds for those returning from war or those exposed to other military-related traumas (Carrola & Corbin-Burdick, 2015) . The social culture that surrounds the military populations can have grave effects on such diagnoses (Carrola & Corbin-Burdick, 2015) . Those effects embody the oppressive stain that is often related to the stigmatization of mental health that prevent those affected from actively seeking help (Carrola & Corbin-Burdick, 2015) .
1.8.4. Oppression, Hierarchy, Sexism and Stereotypes in the Military and Mental Health
For decades, mental health professions have been derived of a Eurocentric approach to psychotherapy, counseling, and psychology conceptualizing an individual’s mental illness as a pathology of the person alone (Keeler, 2021; Olukemi, 2012) . This framework suggests that people are ill mentally because they themselves are not well and need psychological treatment ranging from a variety of different voluntary means of psychotherapy, counseling, or prescribed medication (Olukemi, 2012) . Historically, forcible detainment under sections and codes of mental health were harmful practices derived of this method of treatment (Keeler, 2021; Olukemi, 2012) . These treatments have been historically prescribed within oppressive environments supporting mental health phobic institutions, such as the military (Olukemi, 2012) .
Within society, hierarchies exist that suggest each individual is compartmentalized based on their worth on the scale of hierarchy (Olukemi, 2012) . Therefore, people exist within positions of status ranging from high to low based on characteristics such as age, ability, class, race, gender, or sexual orientation (Olukemi, 2012) . Because these hierarchies exist, people can be oppressed within a system. People can also exist in groups and work together while also living with multiple levels of oppression (Olukemi, 2012) . In her analysis Olukemi (2012) and later cited work by Keeler (2021) , found these approaches to psychotherapy were significant because they demonstrated the oppressive stain of mental health stigma and discriminatory attitudes found in the military culture surrounding mental health.
For some hierarchal structures, such as those in place within the military system, there is a possibility of up or down movement related to one’s ability, age, rank, etc. Within the same system, however, factors such as gender, race, or sexual orientation, make it much more difficult to move (Olukemi, 2012) . This results in social derived hierarchies, such as those found within the military, that directly contributes to the individuals deflated or inflated send of self-identity and worth within the system (Olukemi, 2012) . These findings are significant because they represent those viewed within the hierarchy as having qualities that are less valued may struggle to find value in themselves and succeed within the institution itself (Olukemi, 2012) .
In relation to Olukemi (2012) ’s findings, Keeler (2021) then redefined the elements of military hierarchy, and in doing so, defined significant concepts related to US military service members and their adherence to strict regulations. The hierarchy in the military refers to an unquestioned concept of the “chain of command” where each individual must know and act in accordance to their place (Keeler, 2021) . Organizational hierarchy is reflected in one’s rank. The hierarchy structure is divided between enlisted personnel that makeup the largest amount of service members and commissioned officers that hold the higher ranks. Order stands as the main goal of this hierarchal arrangement (Keeler, 2021) . Within this hierarchy, those who find themselves disadvantaged also reflect those disadvantaged in greater society (Keeler, 2021) . This largely includes differences in gender, race, sexual orientation, cultural background, and class (Keeler, 2021) . Keeler (2021) argues these concepts are crucial to understanding the military culture itself. Humiliating stereotypes persist and proliferate to exclude and justify the treatment of racial/cultural minorities, women, sexual minorities, and lower classes (Keeler, 2021) .
Schaefer and associates expanded these arguments in order to assess the discrimination reflected in US culture. Within military ranks there is also an unequal distribution of class, race, and gender (Schaefer et al., 2021) . For example, in order to become an officer, one most hold at least an undergraduate college degree (Schaefer et al., 2021) . Officers earn more than enlisted personnel even with similar number of years in service (Schaefer et al., 2021) . These policies provide those who have access to more resources, such as money and education, with the reward of higher ranks (Schaefer et al., 2021) . Race, gender, and socio-economic disparities among minorities in the US may have less access to those resources (Schaefer et al., 2021) . Therefore, they are less likely to fulfill officer ranks and are more likely to be enlisted personnel (Schaefer et al., 2021) . As a result, those of higher status may be protected from negative military encounters in comparison to lower status servicemembers (Schaefer et al., 2021) . For example, it is reinforced by the literature with consistent reports of female enlisted personnel that reveal higher levels of sexual harassment in comparison to female officers that are least likely to report those circumstances (Schaefer et al., 2021) . In comparison, military personnel of lower organizational status are at a heightened risk for being harassed and having more negative psychological experiences compared to higher-ranking service members (Keeler, 2021; Olukemi, 2012; Schaefer et al., 2021) .
In the military itself, women in particular are at an increased risk of experiencing sexist acts and discrimination (Keeler, 2021; Olukemi, 2012; Schaefer et al., 2021) . The unique hierarchy and intersectionality of race and gender in a male-dominated military culture often leads to more harmful forms of sexism and racism, particularly against women of color (Schaefer et al., 2021) . For example, the presence of African-American women in the military has increased larger than any other racial minority in the military (Schaefer et al., 2021) . However, little is still known about how military work experiences for African-American women affect daily work stress coupled with higher exposure to sexism and discrimination within the ranks (Schaefer et al., 2021) .
Research indicates that sexism is still a major stressor in women’s lives. About one half of civilian working women experience sexual harassment before their retirement (Schaefer et al., 2021) . Rates among military service women are much higher estimating over 80% experiencing sexual harassment within one year of military service (Schaefer et al., 2021) . Empirical research has ascertained the increased rates of severity of sexual harassment among women of cultural minorities (Schaefer et al., 2021) . These differences may influence the types and frequency of harassment faced by minority women in the military (Schaefer et al., 2021) .
Glick & Fiske (1996) originally proposed the term hostile sexism that describes a blatant type of sexism that depicts apathy and hostility towards women. This type of sexism is formed within hierarchal structures where men are considered dominant and superior to women, thus forming resentment towards them and are challenged to gain power over them (Salmen & Dhont, 2021) . In order to maintain control over women in their prospective role, those acts of hostile sexism are understood as the negative factors driving prejudice as the justification for derogatory behavior against women (Salmen & Dhont, 2021) . For example, hostile sexism is demonstrated as historically women were banned from entering combat roles because women were viewed as incapable and only the men were more qualified of those positions of leadership and power. Benevolent sexism, or sexism that views women positively in their stereotypical roles can be characterized by viewing women as fragile, in need of protection, and nurturing (Salmen & Dhont, 2021) . Although this type of sexism is expressed as positive, it categorizes women limiting them to stereotypical roles and undermines a military women’s perceptions of competency in their leadership roles (Salmen & Dhont, 2021) .
The application of theoretical frameworks of epistemology can be helpful to understand the functions of racism and sexism and their intersectionality within the military system. They are also helpful in defining how ideologies of larger societies were created and flourished within the military culture largely influencing cultural minority servicemembers (Schaefer et al., 2021) . According to social constructivism, people come to describe or explain the world around them by developing their reality and meanings through social interactions (Schaefer et al., 2021) . Similarly, Michael Foucault’s theory of power focuses on how social interactions can lead to hierarchies of acceptance of rationality from individuals in a society deemed more rational and therefore worthy of more leadership and power (Schaefer et al., 2021) . These theories help to produce a context of understanding of social, political, and cultural agendas behind the dominant factors of gender, culture, race, and sexuality as they exist today in US military culture (Schaefer et al., 2021) .
Outside of the military, the mental health profession in itself has historically viewed oppressed and lower hierarchal groups as inherently pathological rather than acknowledging how an oppressive system can affect the relevance of personalities and overall mental health within groups (Olukemi, 2012) . This is exceptionally true in consideration to the relation of common mental health stereotypes of military veterans among the mental health and civilian sectors (Olukemi, 2012) . There are many stereotypes that confront this population within the public, and even within the veteran community itself, that provide rationale towards discrimination that are worth further exploration (Netting et al., 2017) . It is vital within the mental health fields and across all fields that a new approach adopts the importance of firstly acknowledging oppression in a societal system and understanding it as a central factor to mental health functioning in order to inform successful treatment practices (Keeler, 2021; Olukemi, 2012; Schaefer, 2021; Netting et al., 2017) .
1.8.5. PTSD, MST and Related Mental Health Disparities
There are many areas in which military members and their family members face significant mental health status disparities compared to the civilian population. These include symptoms related to combat exposure, military sexual trauma, post-traumatic stress disorder (PTSD), depression, substance use, etc. (Carrola & Corbin-Burdick, 2015) . According to the APA (2017) , from the years of 2006-2013, there was a substantial 63% increase in veterans of the US armed forces requiring mental health treatment, and the number continues to grow (APA, 2017) . This includes the 1 in 4 post 9/11 veterans seeking mental health care by the Department of Veterans Affairs (APA, 2017) . The Department of Veterans Affairs also supports the need to service veterans where demand has since grown exponentially (USDVA, 2021) .
Currently, the military population faces mental health disparities associated with the stressors that accompany the military lifestyle (Carrola & Corbin-Burdick, 2015) . In a 2017 study conducted to evaluate demographics related to incidents of mental health diagnoses found that across all demographics, PTSD is the most widely diagnosed mental health condition among US veterans of the most recent war era including Operation Iraqi Freedom, Enduring Freedom, and New Dawn (Ramsey et al., 2017) . The findings of this study were significant because the authors report the incident rates of all mental health diagnoses were highest among the ages of 18 - 29 years old (Ramsey et al., 2017) . Major Depressive Disorder (MDD) was the second largest mental health diagnoses for both men and women veterans peaking most commonly in midlife from ages 30 - 44 years (Ramsey et al., 2017) . Military members seeking care within military behavioral health facilities are often diagnosed with post-traumatic stress disorder (Carrola & Corbin-Burdick, 2015; Ramsey et al., 2017) . In relation to these findings, Carrola & Corbin-Burdick (2015) previously noted the large frequency of mental health diagnoses, including PTSD, among the post 9/11 veteran population.
In relation to past definitions, Angel (2016) describes post-traumatic stress disorder (PTSD) as a disorder that is trauma-related and results in psychological distress after the exposure of a traumatic event. In the military culture, this phenomenon is often referred to as an invisible wound (Angel, 2016) . Angel presents a perspective that chronic PTSD is significantly impacting veteran mortality rates (Angel, 2016) . As depicted by supporting research, these mortality rates are affected by mental health disparities such as the growing number of suicides among post 9/11 veterans, higher rates of depression, substance use, and overall decline in health (Angel, 2016; Carrola & Corbin-Burdick, 2015; Ramsey et al., 2017) . PTSD also causes significant distress in the areas pertaining to an individual’s ability to work, socially interact, and to function properly (Angel, 2016) .
Results of data evaluation inform multicultural and best practice elements of this study to encourage an increase in professional development so that positive changes can occur among the administration of veteran mental health services (Kettner, 2017) . For example, according to data sets released by the VA in 2019, ethnicity demographics of post 9/11 veterans utilizing VA benefits seeking care for PTSD depicted a diverse demographic in frequency of diagnoses depicted below in Figure 1 (Meyer & Wynn, 2016; USDVA, 2019) .
Figure 1 highlights the frequency of PTSD diagnosed across race/ethnicity demographics represented within the population of veterans receiving services at the VA in 2019 (USDVA, 2019) . Most notably the highest frequency at 30.7% belonging to Native American groups followed by Pacific Islander, Mixed race/ethnicity, and the Hispanic population that had the highest rates of a formal diagnoses of PTSD listed by the VA (USDVA, 2019) . This sample does not include the population of veterans receiving mental health care outside of the VA. This sample is crucial because is supports Carrola & Corbin-Burdick (2015) ’s previous argument suggesting military minority populations are at risk for developing PTSD and also represent a shift in military cultural demographics. All this data supports the initiative to put together an action research monograph establishing the importance of multicultural principles when treating this population.
Data sets released by the Department of Veterans Affairs in 2021 also highlight the frequency of those diagnoses differentiated by gender demographics (USDVA, 2021) . Furthermore, these gender demographics also depicted a growing number of female veterans estimated to continue growing as the largest minority in the armed services that warrants effective mental health care interventions across genders as noted in the following tables (USDVA, 2021) . In 2021, an estimated 757,922 female service members were accounted for in total in comparison
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Figure 1. Race/ethnicity of PTSD among post 9/11 veterans (ages 18 - 44). Note. Adapted from https://www.va.gov/vetdata/docs/Demographics/New_Vetpop_Model/3L_VetPop2018_Race_Ethnicity_National.xlsx. Copyright 2019 by U.S. Department of Veterans Affairs.
to 167,000 in 2010. It was also estimated in 2021 that 3,234,284 men served in total. This ratio estimates 22.71% of the armed forces in 2021 consisted of women. Although the overall female population is growing, this data supports the evidence that a smaller number of women than men serve overall.
Military sexual trauma (MST) is defined by behaviors such as sexual harassment or sexual assault that occurs during one’s military service (Barth et al., 2016; Holliday & Monteith, 2019) . MST is rising as an increase to public health concerns among service members (Barth et al., 2016; Holliday & Monteith, 2019) . According to reports in the VA Healthcare system assessed in a 2016 study, MST as a public health concern within the military (Barth et al., 2016) . One in 4 female veterans and 1 in 100 male veterans report experiencing MST (Barth et al., 2016) . (Barth et al., 2016) argue that MST during military service is a preventable hazard to service members associated with pervasive health-related consequences (Barth et al., 2016) . Service members, largely female, who have experienced MST experience higher rates of PSTD, anxiety, depression, substance, suicidal ideation, and suicide (Barth et al., 2016; Holliday & Monteith, 2019) .
Later cited work by Holliday & Monteith (2019) concluded that MST is associated with an increased likelihood of physical and mental diagnoses and suicide. Unlike combat experiences, MST is preventable within the military occupational force and has affected many generations of veterans (Barth et al., 2016) . Coping with sexual trauma is a large component of adjustment for military servicemembers throughout their transition to civilian life and their homecoming (Barth et al., 2016) . In relation to Barth and associate findings (Barth et al., 2016) , Holliday & Monteith (2019) found a revealing phenomenon that suggests MST survivors feel betrayed by the military institution. These findings are significant because these perceptions of betrayal may prevent MST survivors from disclosing MST and utilizing mental health treatment Holliday & Monteith (2019) . Mental health professionals and all healthcare providers should be informed and sensitized to the prevalence of MST and the relation to the physical and mental health care of veterans (Barth et al., 2016; Holliday & Monteith, 2019) .
A complex problem within the military servicemember community serviced is in regards to the history of mental health care that has been affected by the stigma for seeking services (Kim et al., 2011) . The utilization of mental health facilities is affected by this social problem (Kim et al., 2011) . Military culture has been affected by viewpoints conceptualizing mental health as weakness (Kim et al., 2011) . This mental health stigma and other institutional barriers within the military community continue to contribute to the small amounts of military members that are willing to seek help (Kim et al., 2011) . This stigma facilitates a culture that harbors negative views towards receiving mental health treatment (Kim et al., 2011) . These views act as a barrier to the military community to willingly seek treatment for mental health related issues (Kim et al., 2011) . Negative attitudes towards mental health treatment actually contribute to the willingness of military members to seek out treatment for mental health (Kim et al., 2011) .
These findings highlight the need for community outreach services, education for prevention, and policy changes that can help promote more positive attitudes towards mental health treatment within the veteran and military communities (Kim et al., 2011) . Similarly, disparities can be reduced by providing access to evidenced-based and culturally competent mental health treatment and placing a focus in consideration to lessoning the stigma surrounding seeking mental health care (Carrola & Corbin-Burdick, 2015) .
1.8.6. Resilience and Posttraumatic Growth
Nearly three fourths of veterans who have experienced moderate PTSD will also experience posttraumatic growth (Tsai et al., 2015) . Posttraumatic growth (PTG) can be described as a positive change that occurs as a result of successfully coping after the exposure to trauma (Jayawickreme et al., 2021; Tsai et al., 2015) . Several positive characteristics associated with PTG include having a life purpose, social support, and optimism (Tsai et al., 2015) . In a study of over 3000 veterans that deployed to Iraq, nearly 75% of them screened positive for PTSD (Tsai et al., 2015) . Fifty percent of those veterans also screened positive for moderate PTG as it related to the worst traumatic event they had ever experienced (Tsai et al., 2015) . These results indicate that a legacy of positivity in light of military trauma may hold functional significance for the veteran population, and for the mental health professionals treating them (Tsai et al., 2015)
Previous years of research analyzing five PTSD clusters among trauma exposed veterans, conducted by Tedeschi & McNally (2011) , concluded that the re-experiencing of symptoms were those largely associated with the PTG phenomenon. The re-experiencing symptoms are often correlated with emotional outcomes negative in nature that include flashback memories or nightmares (Stockton, Hunt, & Joseph, 2011) . A more recent study found a correlation that these symptoms may go on to hold the keys for further exploration that provide the opportunities for individuals to reflect on their trauma and other symptom clusters (Jayawickreme et al., 2021) . In the original study, Tedeschi & McNally (2011) found the symptom clusters that most strongly related to PTG included other related re-experiencing symptoms such as flashbacks, nightmares, and physiological reactions. Once those re-experiencing symptoms subsided, PTG was more likely to develop among participants (Tedeschi & McNally, 2011) . In relation to efficacy of method, Jayawickerme and associates expanded these characteristics, and in doing so, found a set of considerations for examining the resilience and growth through the context of adversity. Jayawickerme and associates argue the PTG can be more accurately captured in terms of one’s development, health, social psychology, and personality changes (Jayawickreme et al., 2021) .
Although post-traumatic stress disorder (PTSD) is a topic widely covered in psychological literature of veteran mental health, the adaptations to overcoming trauma such as resilience and posttraumatic growth (PTG) are far less studied and defined in community treatment efforts (Angel, 2016) . The significance of the PTG phenomenon recognizes a stable trajectory of health functioning following traumatic events (Angel, 2016) . It is recommended that professionals who have frontline contact with this population at the VA work alongside veterans to educate about these coping trajectories (Angel, 2016) . This approach can be adopted in public sector civilian community mental health settings to help refute traditional negative biases suggesting that PTSD and all veteran mental health diagnoses require acceptance solely of limitations and negative characteristics (Tsai et al., 2015) .
In a relevant historical article, Bonanno (2004) highlighted the factors pertaining to loss, trauma, and the positive emotional growth experiences that stem from the capacity of human resilience. Historical findings suggest that resilience is common and can be reached through a variety of pathways (Bonanno, 2004) . The author’s findings presented an evaluation of many studies that have been investigated. This type of research is useful for future practice implications when working with veterans experiencing PTSD. It may be just as imperative that future investigations in the field of trauma include more detailed studies of the range of possible outcomes for the individuals dealing with the difficulties of such a diagnosis (Bonanno, 2004) . Implications for diagnosis and treatment planning can be facilitated with guidance that adheres to an individual’s unique strengths and coping advantages (Bonanno, 2004) .
The effects of PTSD on this population and the entire military community are vast and they influence many other mental health struggles, such as, problems with sleep, suicide, depression, anxiety, and substance use (Carrola & Corbin-Burdick, 2015) . Fortunately, data findings have produced favorable results towards positive treatment outcomes for veterans when providing adequate access to evidenced-based and culturally competent mental health treatment that places a focus in lessoning the barriers to seeking quality mental health care (Carrola & Corbin-Burdick, 2015) .
1.8.7. Holistic Wellness Approaches to Veteran Treatment
When working within the target population of these veterans, the mental health professional plays a vital role that promotes several aspects related to resilience. They include wellness, development, and optimum levels of mental health through educational activities as well as preventative means (Finley et al., 2018) . Promoting health and wellness throughout all of their interventions is a main goal among mental health professionals working with this population (Finley et al., 2018; Purcell et al., 2021) . Through the foundations of holistic psychotherapeutic theories, several wellness models have been created (Finley et al., 2018) . They focus on holistic approaches that take into consideration the person as a whole (Finley et al., 2018) . In their analysis of VA healthcare impact on wellness and quality of life, Purcell and associates (Purcell et al., 2021) elaborated on the holistic wellness model role and the emphasis in integrating this approach in veteran patient care planning. With the use of this theoretical output, it applies to the clinician’s role within the population of veterans whose outcomes should revolve around seeking connectedness within their communities and reaching levels of personal growth (Finley et al., 2018) . The integration of mind, body, and spirit would be enhanced by a counselor’s integration of holistic approaches in order to help these veterans reach higher levels of fulfillment within their treatment and overall quality of life (Finley et al., 2018; Purcell et al., 2021) .
Purcell and associates (Purcell et al., 2021) argue the importance that mental health professionals play in developing intervention activities that promote optimal wellness, reduce stress, and improve overall quality of life. In their findings, Finley and associates (Finley et al., 2018) notated that within the Veteran target population stood the common issue of depression. These findings are crucial in supporting future research and the importance of the clinician’s efforts to incorporate and promote activities within their lives that can connect them to relaxing and natural experiences, such as hiking or gardening, could greatly benefit these veterans (Finley et al., 2018) . This could result in a positive spiritual connection based on natural experiences (Finley et al., 2018) . Utilizing intervention and prevention techniques early on will allow the clinician to help their clients reach optimum levels of wellness (Finley et al., 2018) . The goal of these intervention activities will eventually empower and educate the individuals to allow them to advocate for themselves in the future (Finley et al., 2018) .
There are several approaches that a mental health professional can use in order to incorporate prevention and educational activities that are designed to promote optimum human development, wellness, and mental health within this Veteran population. In this culturally diverse population, preventative measures before and after certain military exposures that emphasize in psychoeducational approaches could be beneficial to help these veterans learn important coping skills (Carrola & Corbin-Burdick, 2015) . A clinician working with this population should also promote reintegration techniques and services offered to veterans returning from combat or other forms of military training (Carrola & Corbin-Burdick, 2015) . These activities could help ensure that these veterans will be reconnected with their communities and families (Carrola & Corbin-Burdick, 2015) . The very meaning of wellness incorporates the healthy integration of the individual to live fully through the connectedness of their communities (Carrola & Corbin-Burdick, 2015) . The clinician’s role in advocating for programs that may adhere to community connectedness within this Veteran population could also help many of the individuals to connect with others experiencing many of the same issues (Carrola & Corbin-Burdick, 2015) .
Family involvement is another aspect of a holistic wellness approach that may be particularly beneficial to the veteran population. Healthy relationships with family can aid in the recovery process of PSTD (Laws et al., 2018) . Most recently noted, one study published findings associated with the improvement of PTSD symptoms after family involvement in mental health treatment (Laws et al., 2018) . Research has indicated that veterans actually prefer their families to be more involved in their mental health care (Laws et al., 2018) . Results depicted that on average, there were statistically lower symptoms of PTSD after just one family session (Laws et al., 2018) . Women veterans as well as those who depicted comorbid depression and engaged in eight or more family sessions actually showed stronger reductions of symptoms that other groups (Laws et al., 2018) . This study depicts the importance of evidence that family involvement is associated with higher PTSD treatment success outcome (Laws et al., 2018) .
1.8.8. Evidenced-Based Best Practices
Trends of military mental health utilization suggest that veterans with mental health problems often choose not to seek treatment (Bovin et al., 2019; Johnson et al., 2018) . Studies have also depicted military personnel will have a higher willingness to seek mental health treatment from a psychotherapist who is also a veteran (Johnson et al., 2018) . Other proposed recommendations to lesson these barriers to treatment examine community efforts to employ military culture certification programs in order to meet the need for mental health professionals to acquire military cultural competence in order to serve this population more effectively (Atuel & Castro, 2018; Meyer & Wynn, 2016; Nedegaard & Zwilling, 2017) . Recommendations also suggested that civilian mental health professionals in the public sector supplement using other convenient methods of obtaining training to better enhance military cultural competence (Botero et al., 2020; Meyer & Wynn, 2016; Nedegaard & Zwilling, 2017) .
Extensive studies measuring community-based healthcare provider capacity to deliver care that is culturally competent to veterans and their families demonstrated overall improved experiences might hold the key factor in improving mental health care for veterans (Meyer & Wynn, 2016) . The findings of such studies demonstrate that military cultural competence declined with a decrease of exposure to military patients (Meyer & Wynn, 2016) . Thus, promoting the recommendation of incorporating cultural competence trainings, increased military exposure, and further use of evidence-based treatments to better serve the veteran community (Meyer & Wynn, 2016) . Other studies conducted by the Institute of Medicine also concluded best practice recommendations that improved outcomes for this population requires an improved understanding of military culture (Meyer & Wynn, 2016) . The effectiveness of large scale culturally relevant psychotherapy and mental health intervention strategies collected from VA treatment meta-analysis conducted by the National Center for PTSD listed among those diagnosed with PTSD have proved promising (USDVA, 2021) . In a sample of 28,663 participants, 26,301 achieved a clinically meaningful response to psychotherapy efforts within that same study (USDVA, 2021) . This data supports the initiative to continue the expansion of best practice psychotherapeutic standards when treating this population.
In the United States, many mental health treatment programs have been designed to adhere to treating the Caucasian, English speaking demographic (Mac Donald et al., 2017) . This also applies to the data compiled from the Veteran population and what is known from PTSD treatment research that is focused mainly on middle aged, Caucasian males (Mac Donald et al., 2017) . These constructs ignore the differential data sets adhering to the remainder of the military community and warrant modifications in order to accurately represent diversity among this group (Mac Donald et al., 2017) . Best practices, on the contrary, encourage multicultural sensitivity extended in research and treatment efforts that incorporate all groups within this community to include characteristics such as different cultural backgrounds, genders, and ages among this population of military veterans (Mac Donald et al., 2017) .
The constructs of multicultural theoretical framework help to emphasize the considerations for the identification of the proper community resources for the consumers of mental health services (Mac Donald et al., 2017) . The issues commonly faced in improving the mental health treatment outcomes of veterans relates to the significant challenges for servicing this community of veterans as a result of their cultural diversity as well as unique military experiences informing evidenced-based mental health practices administered to this population (Mac Donald et al., 2017) .
Theories supporting integrated community care provide a context of understanding for the growing amount of research that indicates the importance of collaboration among professionals of different disciplines and organizations in order to prepare professionals for collaborative practice (Clarkson-Hendrix & Carroll-Barbuto, 2019) . Examinations of surveys conducted of Texas mental health professionals providing treatment to veterans outside the VA depicted that community-based mental health providers in Texas do not consistently use the recommended evidence-based treatment for PTSD for veterans (Finley et al., 2018) . Recommendations suggested an opportunity for the VA to partner with outside community providers in order to achieve high quality care for veterans seeking outside treatment (Finley et al., 2018) . Best practice standards highlight the importance of a collaborative approach among public and non-profit mental health providers at the state and local levels to work together to increase the availability of mental health training services for professionals treating veterans (Clarkson-Hendrix & Carroll-Barbuto, 2019; Hester, 2017) .
Since the very foundations of multicultural care were established, this approach has espoused the understanding that it should be considered unethical for an individual who is culturally incompetent to provide care for patients that are culturally diverse (Meyer & Wynn, 2016) . This is especially prevalent for the military community that presents a unique culture as a result of shared military experiences and intersecting identities as individuals living within the military culture that are also diverse in nature (Meyer & Wynn, 2016) . Addressing military cultural competence and how cultural competence is taught in mental health, psychology, counseling, and all healthcare education is notably one of the first steps towards preparing professionals to work with US military and veteran populations (Mathewson-Chapman & Chapman, 2017) . In partnership with the VA Healthcare systems, a variety of curricula has been developed that can be implemented in various healthcare settings and available to the public. Such courses provide the learner with opportunities to engage in better understanding of military history, how to recognize and manage personal bias, class, and power within the clinical encounter between the clinician and veteran (Mathewson-Chapman & Chapman, 2017) . These educational efforts work to address numerous gaps within healthcare education that are necessary to develop veteran-centered care (Mathewson-Chapman & Chapman, 2017) .
The consequences of the military experience and combat cause veterans to struggle with mental health and readjustment back into civilian life (Botero et al., 2020) . Currently, there are more resources than ever providing insights onto education and the best treatment options for veterans (Botero et al., 2020) . For mental health providers and other professionals working with veterans, it is vital that they learn and remain informed about programs that are most successful in treating the veteran population (Botero et al., 2020) . The US Department of Veterans Affairs provides nationwide programs such as the Readjustment Counseling Service/Vet Center and Veteran Cultural Competence Training that are designed specifically to decrease mental health stigma for veterans as well as to increase veteran engagement in receiving mental health services (Botero et al., 2020) . These programs can provide insight for private civilian sector mental health organizations that highlight the importance of awareness of the culture within military systems as well as bringing light to the personal biases that may limit mental health professional practice (Botero et al., 2020) .
Sources show that mental health providers who seek to better understand the cultural backgrounds of their consumers are better equipped to provide the most effective care (Atuel & Castro, 2018; Navjit Sanghera, 2017) . It is essential that mental health counselors working with this population are thoroughly informed about military culture and its unique experiences in order to provide veterans with culturally sensitive counseling treatment and interventions (Navjit Sanghera, 2017) . Future improvements and recommendations for obtaining military cultural competency can also be further highlighted in this research. Military cultural competency should first identify its premise in curriculum taught in schools (Navjit Sanghera, 2017) . Military history and experiences should be taught as a routine part of counseling treatment as well as proper assessment and screening for this population (Navjit Sanghera, 2017) . Recommendations for counselors who already practice should consider continuing avenues of education such as attending military conferences, public events on military installations, online resources, and the Department of Veterans Affairs which includes training and resources for specific veteran groups (Navjit Sanghera, 2017) .
1.9. Synthesis of the Research Findings
The conceptual map outlined in Figure 2 below shows major themes from a synthesis of the literature, which point to the need to focus on multicultural and
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Figure 2. Conceptual map of main themes in literature review.
integrated inter-organizational approaches to meet the mental health needs of the military.
Several studies addressed factors that were found to contribute to disparities related to mental health within the military population, including: 1) combat and military stress experiences; 2) social oppression; 3) sexual assault; and 4) gender disparities. The studies also addressed the growing prevalence of psychological conditions such as PTSD, depression, substance use, and other mental health related problems (Carrola & Corbin-Burdick, 2015; Meyer & Wynn, 2016; Ramsey et al., 2017) . Importantly, barriers and limitations to accessing culturally component providers that are familiar with the military experience, military mental health, and the historical context of systemic oppression in the military also contribute to mental health disparities of this population (De Luca et al., 2016) . Of note, from the provider perspective, barriers are also present for counselors and other mental health professionals who are in practice related to the limited access of training and resources for continuing avenues of education to better treat this population (Navjit Sanghera, 2017) .
Several sources in the literature addressed need for veteran mental health cultural competency training for mental health professionals demonstrated across private and public community mental health treatment agencies (Atuel & Castro, 2018; Hester, 2017; Kimerling et al., 2015) . Military cultural competence and best practice standards for civilian mental health professionals may help ensure culturally competent mental health care is provided to this population (Atuel & Castro, 2018; Guenole et al., 2017) . Findings also depict that mental health professionals’ benefit through their capacity to maintain a knowledge base from credible training resources in order to identify concepts and to explore issues of growth and development when treating this population (Hester, 2017; Kimerling et al., 2015; Netting et al., 2017) .
Sources reflect key recommendations found within the literature to incorporate approaches central to multicultural theoretical framework, such as military cultural competency involved in treatment implementation that should go on to address the unique mental health dynamics of the veteran community as a whole and diverse community (Carrola & Corbin-Burdick, 2015; Hester, 2017; Meyer & Wynn, 2016; Ramsey et al., 2017) . Recurring themes suggesting best practices among treating this population highlighted an interorganizational collaborative approach that encourages the importance of community collaboration among public, private, and government mental health providers to work together in treating the veteran population (Hester, 2017; Mac Donald et al., 2017) .
1.10. Critique of the Previous Research Methods
In light of producing the most accurate data of the overall diverse general veteran population, findings suggest critiques of previous research methods as considerations for this research study. Data depicted within the literature presents concerns in specific measures of the population samples that include different traumas, cultural demographics, and histories that are diverse in nature (Carrola & Corbin-Burdick, 2015) . The specific concern highlighted in Carrola & Corbin-Burdick (2015) ’s study is in regards to the threats to external validity referring to the generalization of treatment outcomes to the population sample. Despite these limitations, data findings have produced favorable results towards positive treatment outcomes for veterans when providing adequate access to evidenced-based and culturally competent mental health treatment (Carrola & Corbin-Burdick, 2015) .
The shortcomings noted within data collection measures of previous studies also extends towards the lack of data representing the population of post 9/11 veterans of the armed forces. Specifically in Mac Donald (2017) ’s study, data sets that were depicted were noted as outdated and further elaborated the many mental health treatment programs that have been designed to adhere to treating a limited representation of cultural demographics within the military population (Mac Donald et al., 2017) . These specific data sets referenced population samples that were compiled mostly of Caucasian males diagnosed with PTSD and does not accurately reflect the current diversity demographics of those diagnosed with PTSD in the military (Mac Donald et al., 2017) . These constructs ignore the differential data sets adhering to the remainder of the military community and warrant modifications in order to accurately represent diversity among this group to implement culturally sensitive mental health treatment to the entire veteran population (Mac Donald et al., 2017) .
Demographic data suggests shift and a large minority population that is growing among the armed forces (USDVA, 2021) . It is estimated that 40% of post 9/11 service members makeup minority demographics (USDVA, 2021) . This includes the largest growing minority populations including the Black and Latino/a cultural demographic makeup as well as the growing number of female populations in the service that is estimated to continue rising (USDVA, 2021) . Schaefer and associates (Schaefer et al., 2021) cited important considerations within the literature review highlighting the importance of understanding how mental health agencies are serving veterans from different minorities, genders, and ethnic groups as well as how the intersection of such identities reflects the experiences of minority veterans. Also, to consider how effective these mental health services are for these diverse populations and what can be done to modify programs for improvement to treat diverse populations and minority veterans (Schaefer et al., 2021) .
1.11. Ethical Considerations
The Belmont Report, originally published in 1979, makes reference to the ethical principle of beneficence (USDHHS, 1979) . This refers to the concept of creating benefit and minimizing harm (USDHHS, 1979) . The researcher must consider all possible consequences of the research in order to balance the risks against the proportional benefits (USDHHS, 1979) . Historically speaking, mental health professionals and institutions alike have used classifications of mental health disorders in order to pathologize populations that may be considered vulnerable (Carrola & Corbin-Burdick, 2015) . Important ethical standpoints of this study consider vulnerable populations such as military veterans and the negative impacts that a diagnosis, such as PTSD, holds for those returning from war or those exposed to other military-related traumas (Carrola & Corbin-Burdick, 2015) . In considering this ethical standpoint, the benefits of such a study may outweigh the potential risks to further stigmatize this population and is intended to target and expand the competency of mental health professionals working with veterans (The CITI Program, 2021) .
The competency of the researcher is another important ethical consideration that encompasses careful design for the purpose of a worthwhile expected outcome (Bayley & Phipps, 2019) . Any lack of expertise or knowledge on behalf of the researcher is mitigated through work under a qualified supervisor and mentor as well as with the approval of the school’s academic committee (Bayley & Phipps, 2019) . Further ethical considerations for the researcher include careful choice of data collection and methodology as well as the assurance to provide validity and reliability that must be met in all research (Bayley & Phipps, 2019) . Although human research participants are not directly involved in this study, the essence of this study reflects real human beings and challenges related to veteran mental healthcare (Bayley & Phipps, 2019) .
1.12. Theoretical Assumptions
The constructs of the multicultural theoretical framework cited by Davis and associates (Davis et al., 2018) help to emphasize the considerations for the identification of the proper community resources for the consumers of mental health services (Mac Donald et al., 2017) . The issues commonly faced in improving the mental health treatment outcomes of veterans relates to the significant challenges for servicing this community of veterans as a result of their cultural diversity as well as unique military experiences informing evidenced-based mental health practices administered to this population (Mac Donald et al., 2017) . A key assumption is that military cultural competency involved in treatment implementation should go on to address the unique mental health dynamics of the veteran community as a whole (Hester, 2017) . Research also indicates the importance of collaboration among professionals of different disciplines and organizations in order to prepare professionals for collaborative practice (Clarkson-Hendrix & Carroll-Barbuto, 2019) . This helps to outline an interorganizational collaborative approach highlighting the importance of community collaboration among public, private, and government mental health providers to work together (Hester, 2017) . This construct leads to the assumption is that all collaborating professionals can play a significant role in facilitating posttraumatic growth (PTG) among the veteran populations diagnosed with PTSD.
1.13. Topic-Specific Assumptions
The research literature provides several topical assumptions that are applicable to this study and its deliverable application. An assumption is that the military as an organization, cultural group, and social group is different from any other groups and depicts the need to develop military cultural competency training for mental health professionals across all sectors (Atuel & Castro, 2018) . Another assumption is that mental health providers who seek to better understand the cultural backgrounds of their consumers are better equipped to provide the most effective care (Navjit Sanghera, 2017) . Barriers exist for counselors who already practice in accessing resources for continuing avenues of education to better treat this population (Navjit Sanghera, 2017) . This assumption supports an integrative collaborative approach among public, government, and private mental health providers at the state and local levels to work together to increase the availability of mental health training services for professionals treating veterans (Hester, 2017) .
This study and the deliverable stemming from this study are also based on several methodological assumptions. According to Yilmaz (2013) , the epistemological position deals with how knowledge is collected and from which sources. An epistemological assumption is based on evidence that is subjective to individual views (Yilmaz, 2013) . An ontological assumption is that mental health counselors perceive barriers to veteran mental health treatment as a result their experiences working with members of the military and mental health organizations. Axiological assumptions suggest the importance of the values and biases of the researcher (Yilmaz, 2013) . An axiological assumption is the researcher’s values of military multicultural competence that can influence the orienting research topics. This could include any preconceived notions that the researcher holds about the population or the orienting subject matter (Yilmaz, 2013) . The researcher considered what could mitigate the researcher’s own biases and values through bracketing by setting aside personal pre-conceived notions and acting in a manner that is non-judgmental (Yilmaz, 2013) .
1.14. Limitations
A purposive sampling approach to selecting journal articles for literature review might yield many articles. Limitations in the qualitative research process highlight a labor-intensive approach necessary to categorize and record the number of studies yielded in the search results (Smith & Zajda, 2018) . An implemented area of improvement of study weaknesses, including a large number of articles yielded, worked to limit searches and sampling to a limited group of journals published within the date of relevance in order to complete the study with conclusive results (Parker et al., 2019) . Relevant topics solely within field of counseling and the exclusion of professional literature and continuing education materials from related fields has also been implemented to address this implementation (Parker et al., 2019) . This study also presents limitations based on the scope of article samples generated over a five-year time span. To mitigate this limitation, collections include a wide-array of samples through the present year in order to create a larger sample size to ensure an accurate representation of the phenomenon that can depict significant relationships representative of the veteran population throughout the years.
When limiting specific journals, publication dates, and search terms, it is possible that results may be skewed or provided gaps in the literature. This will not generalize to the entire population of mental health counselors actively treating veterans. Selection bias is a related issue known in qualitative research that may make it difficult for the researcher to completely detach from the data at hand (Smith & Zajda, 2018) . It can be noted this approach has been scrutinized for being a compilation of impressions subject to the researcher’s interests (Smith & Zajda, 2018) . However, these issues may not need to be expanded upon as the selected sample of literature and professional trainings can be acceptable for proposing solutions at the local community level (Dennis, 2014) . Despite these limitations, collecting qualitative data through action research designs provides an ongoing and systematic inquiry into participants’ unique experiences (Dennis, 2014) . The research monograph and information gathered from descriptions of continuing education and training sources will offer triangulation of the data.
2. Research Process
2.1. Introduction
The purpose of this section of this study is to provide a basis of the process of methodology used to assess a systematic style literature review. Content identified in the literature informed the action research monograph, outlining best practices for military cultural competency to provide better clinical counseling services to veterans in civilian and/or non-governmental mental health settings (Carrola & Cordin-Burdick, 2015) . A thematic analysis of emerging topics in training content categorizes the basic themes that suggest patterns relevant to the research questions (Pokorny et al., 2018) . Categorizations and outlines of the differences and similarities found in the data have been used to better understand best practices through recommendations of continuing education and professional training resources. Data analysis findings also address how researchers have described mental health counselors’ perceptions of barriers to treatment (Kimerling et al., 2015) . These barriers are specific to treatment for the veteran population and their own understanding of military cultural competency (Kimerling et al., 2015) . This research design informs the analysis of training recommendations for mental health counselors on how they may acquire proper training and resources to better modify treatment to be more effective for veterans seeking mental healthcare.
2.1.1. Protocol and Search Procedure
This literature review was conducted to find relevant information on the topic of this study, which is the content used to develop the action research monograph deliverable. Criteria for the identification, review and synthesis of evidence directly related to the selected research question focused on United States military mental health and military cultural competency in the English language. For purposes of this study, research literature informed thematic analysis to focus on themes within orienting topics to identify, analyze, and report patterns within the research topic (Belotto, 2018) . In addition, the search criteria and thematic analysis aligned with the study’s theoretical framework. A flow chart of the literature search and identification process is presented below in Figure 3, highlighting the results for criteria, screening, identification, and publications included.
The search criteria associated with the phrases such as “best practices for veteran mental health” and “military cultural competency” within the identified databases, with key words produced 469 possible publications. Studies between 2011 through 2021 were scrutinized to determine that the content of the studies have been addressed in more recently published work. Any works conducted prior to the year of 2011 were presented as information to depict a historical context related to the thematic content. Of those, 210 publications were screened. A large proportion of the studies excluded in this screening were related to the outcomes of veteran mental health rather than an investigation into best practices for treating this population. The samples of these studies were not specifically related to treating the population, instead most studies characterized the participants with severe forms of mental health concerns that excluded a successful mental health outcome for the participants. Fifty articles were then assessed for eligibility whereas only a subset of these studies contained implications
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Figure 3. The systematic review process.
for the target audience. Specifically, 17 articles were excluded because they did not meet the eligibility criteria. Five studies were excluded because they were not published in the English language. Three were found to not be related to evidenced-based healthcare practices. Five were conducted outside of the United States not affiliated with the US military. Two studies were excluded because they did not include the target population of military veterans and two more studies were excluded because they had no relation to military mental health care.
Overall, 33 studies were identified that fit all criteria related to the research question addressing best practices for military cultural competency for counselors providing mental health services to veterans in civilian settings. Journal articles were located using the Capella University Library listed electronic databases. The ProQuest database provided resources (15 studies) available compiling complete databases across all major subject areas for this study. The remaining databases used for search criteria included Academic Search Premier (14 studies), Science Direct (2 studies), Ovid (1 study), and the Directory of Open Access Journals (1 study).
2.1.2. Qualitative Design
An analysis of selected training resources offered nationally by continuing education training providers, and professional organizational trainings that are currently available provide a basis for recommendations of best practice standards for this critical action research. An important point is that it is not the aim of this action research monograph to develop training, but rather to provide research-based information and to encourage agencies to utilize training currently being offered. A traditional qualitative approach was suitable for exploring the literature that highlights experiences and interpretations of mental health counselors treating veteran clients. Qualitative research works to understand the perspectives, opinions, beliefs, and observed experiences of the participant’s narratives while offering an opportunity to explore emerging themes and problems encountered (Korstjens & Moser, 2017) . Rather than creating objectivity that is specifically free of any value, the goal of this relationship strives towards creating neutrality that is empathetic towards emerging issues relevant to the veteran population (Roger et al., 2018) .
Data from the literature analyzed through the lens of a multicultural theory framework in order to depict military cultural competency. Detailed descriptions of factors that pertain to the importance of military cultural competency and barriers to treatment of this population are depicted within the qualitative constructs. Differences and similarities in data measured against the literature review drive meaning of vital emerging themes and concepts (Pokorny et al., 2018) . A second type of data collected is the content offered by organizations and consultants in the field who offer training and resources to support counselors working with veterans. The criteria utilized for selecting a variety of sources include the assessment of trainings materials that derive from the Department of Veterans Affairs, Mental Health Continuing Education, and The National Center for PTSD (USDVA, 2021) .
2.1.3. Thematic Analysis
Research literature was reviewed and analyzed for emerging themes within orienting topics. This review aimed to identify, analyze, and report patterns related to the research topic and question (Belotto, 2018) . Thematic analysis also served as the qualitative analysis approach used to review the data samples and the emerging themes found that were relevant to the research question: “What are the best practices for military cultural competency for counselors providing mental health services to veterans in civilian settings?” A thematic analysis of emerging topics in training content categorizes the basic themes that suggest patterns relevant to the research question (Pokorny et al., 2018) , as will be described further in the Data Analysis section. Categorizations and outlines of the differences and similarities found in the data have been used to better understand best practices through recommendations of continuing education and professional training resources. Data analysis findings also address how researchers have described how mental health counselors perceive barriers to treatment for this population and their understanding of military cultural competency.
2.1.4. Alignment to Proposed Methodology
The methodology of this study informs the actions that assess qualitative data sources that consist of a best practices style literature review. The qualitative data sources inform the thematic analysis for evidence-based academic content in order to investigate best practices for training for mental health professionals (Belotto, 2018) . The sampling plan was purposive where the research questions will guide the data gathering and analysis (Plano et al., 2016) . For this method, the researcher used an iterative process that was selective to include primary studies and trainings related to the orienting topics (Plano et al., 2016) . The literature review is used to assess various best practices of larger health care organizations, mental health and community-based organizations, current best practices and recommendations in treating this population, as well as the barriers to treatment (Plano et al., 2016) . This informs the qualitative data analysis method in order to provide recommendations for continuing education and professional training for data relevant to the research question (Plano et al., 2016) . The methods were approved by the learner’s Institutional Review Board. The study met the standards outlined in the IRB review for an action research monograph. This study solely uses secondary or archival data. This study does not meet the federal regulations definition of human subject research. The study is based on literature and other scholarly sources, and no people or personal data were involved.
2.1.5. Data Analysis Procedures
The qualitative data sources consisted of 1) best practices-style literature for developing military cultural competency in mental health settings and 2) other related topics in working with and treating veteran mental health. The literature review is used to assess various best practices of larger health care organizations, current best practices and recommendations in treating this population, as well as the barriers to treatment (Plano et al., 2016) . The content of the literature review was analyzed using thematic content analysis with an underlying theoretical relationship depicted in the diagram for the literature review highlighting major categories located in the outcomes following this section. This informs the qualitative data analysis method in order to provide recommendations best practices and the data relevant to the research question (Plano et al., 2016) .
The qualitative data sources also inform the content analysis for methods utilized in continuing education efforts across organizations in order to investigate best practices for training for mental health professionals to work with this population. The traditional qualitative design provided a strong basis for the literature review used to assess 1) best practices of larger health care organizations, 2) current best practices in treating this population, and 3) the barriers to treatment (Plano et al., 2016) . Qualitative analysis is also appropriate to assess the content of materials currently available to assist in training and continuing education efforts for mental health professionals. This analysis of training materials and literature content are most likely to produce data regarding narratives that helped to generate the common themes used to help answer the orienting research question (Korstjens & Moser, 2017) . Attempts made to compare past data sources also allowed data to be leveraged to the present data collected in this study related to best practice initiatives. The results of this data leveraging technique can aim to depict any evidence that supports the most beneficial treatment applications for those receiving mental health services (Mac Donald et al., 2017) .
2.2. Outcomes
Given the variety of different assessment measures identified in the literature, key outcomes have been categorized into separate major and sub-thematic groups based on the reports of their frequency among the 33 different studies. A list of the results of these studies is compiled in Figure 4 below demonstrating the theoretical relationship between multicultural and collaborative integration for best practice standards in the fields of veteran mental health counselling. Due to the methodological limitations presented in the prior section of this report, the following outcomes should be interpreted as initial preliminary themes that warrant further investigation.
Figure 4 above highlights a comprehensive conceptual map of the synthesis of research findings. This figure shows an expansion of the original findings which point to the need to focus on multicultural and integrated inter-organizational approaches to meet the mental health needs of the military. The literature review findings related to theoretical findings were extracted from the 33 studies that were identified for this study related to the research question: “What are the best practices for military cultural competency for counselors providing mental health services to veterans in civilian settings?” Depicted in this figure in ovals are the main themes emerging from each of the theoretical findings; specifically, the multicultural theoretical framework located on the left-hand side of this diagram and interorganizational collaboration located on the right-hand side of the diagram. Further thematic analysis identified the related subthemes depicted in the grey squares. 2 - 3 subthemes were identified for each of the major themes. The following figures provide a report of each theoretical framework and themes and subthemes separately.
The breakdown of the conceptual map outlined above in Figure 5 shows three main themes from a synthesis of the literature, which related to the need to integrate multicultural theoretical framework. The main themes highlighted in the literature included 1) Military cultural competence; 2) History of social oppression in the military; 3) PTSD and related mental health disparities. Sources in the literature pointed to subthemes of “military cultural competence” that highlighted the importance of understanding the veteran identity and the need for culturally competent clinicians across all sectors to include private, public, and government sectors (Atuel & Castro, 2018; Hester, 2017; Kimerling et al., 2015) .
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Figure 4. Conceptual map of literature review related to theoretical findings.
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Figure 5. Conceptual map: multicultural framework.
“The history of social oppression in the military” highlighted the historical tone for mental health treatment in the military paired with a long-standing history of racism, classism, and sexism in the military (Keeler, 2021; Olukemi, 2012; Schaefer et al., 2021) . Veteran mental health issues and mental health stigma were supported in the literature in relation to the main theme “PTSD and related mental health disparities” (Carrola & Cordin-Burdick, 2015; Hester, 2017; Kim et al., 2011) .
The continuation of the breakdown of the conceptual map outlined above in Figure 6 shows four main themes from a synthesis of the literature, which point to the need to focus on an integrated interorganizational collaboration theoretical framework. The main themes highlighted in the literature included 1) Organizational limitations and barriers; 2) Facilitating posttraumatic growth; 3) Holistic wellness approaches; 4) Best practice recommendations. Sources in the literature pointed to subthemes of “organizational limitations and barriers” that highlighted the need for civilian providers to provide mental health services to veterans (Hester, 2017) . “Facilitating posttraumatic growth” highlighted the understanding of the PTG phenomenon and the positive treatment outcomes for veterans diagnosed with PTSD (Jayawickreme et al., 2021; Tsai et al., 2015) . The need for providers to integrate holistic wellness models and integrated care were supported by the literature relating to the main theme “holistic wellness approaches” (Finley et al., 2018; Purcell et al., 2021) . The main theme “best practice recommendations” yielded key results in the literature addressing the need for organizations to develop culturally responsive veteran care, implement graduate
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Figure 6. Conceptual map: interorganizational collaboration framework.
and post-graduate level military competency education, and the importance of interorganizational collaboration among the VA and civilian mental health sectors (Meyer & Wynn, 2016; Hester, 2017; Navjit Sanghera, 2017) .
2.3. Development Process
The major themes found within the literature integrate the theoretical approaches that are central the development of this research study. These themes carried the concepts central to a multicultural theoretical framework. This would include the concept of military cultural competency involved in treatment implementation that addresses the unique mental health dynamics of the veteran community as a whole and diverse community (Hester, 2017) . Other emerging themes provided a foundation for the sub-thematic analysis suggesting best practices among treating this population. These subthemes integrated an interorganizational collaborative approach that encourages the importance of community collaboration among public, private, and government mental health providers to work together in treating the veteran population (Hester, 2017) .
2.3.1. Military Cultural Competence
The results for Military Cultural Competence emerged two subthemes specifically highlighting the importance of understanding the veteran identity and the need for culturally competent clinicians across all sectors to include private, public, and government sectors (Atuel & Castro, 2018; Hester, 2017; Kimerling et al., 2015) . Out of 33 studies, 17 studies specifically made reference and matched key words for the theme of “military cultural competence”. This shows a large majority of the studies assessed. More specifically, 8 of those studies matched the search criteria and phrasing for “cultural competency of mental health providers across government and civilian sectors”.
2.3.2. History of Social Oppression in the Military
The results for the History of Social Oppression highlighted two subthemes including the historical tone for mental health treatment in the military as well as the long-standing history of racism, classism, and sexism in the military (Keeler, 2021; Olukemi, 2012; Schaefer et al., 2021) . Five different studies depicted search terms related to “racism, classism, and sexism in the military” and 3 of those studies specifically aligned with key terms such as the “history of psychotherapy approaches in the military” and “historic treatment of veteran mental health”.
2.3.3. PTSD and Related Mental Health Disparities
The results for the PTSD and Related Mental Health Disparities also forged two subthemes; specifically, veteran mental health issues and the stigma of mental health in the military. Veteran mental health issues and mental health stigma were supported in the literature in relation to the main theme “PTSD and related mental health disparities” (Carrola & Cordin-Burdick, 2015; Hester, 2017; Kim et al., 2011) . Out of 33 studies, 25 studies made reference to search criteria for “PTSD” and “mental health” and 6 of those studies referenced the key search terms specific for “military sexual trauma”. Specifically referring to and aligning the key terms including “mental health stigma”, 3 of those were identified in the sample of studies assessed.
2.3.4. Organizational Limitations and Barriers
Sources in the literature pointed to subthemes of “organizational limitations and barriers” that highlighted the need for civilian providers to provide mental health services to veterans (Hester, 2017) . The results for Organizational and Limitations and Barriers emerged three subthemes; specifically, the VA outsourcing services to civilian facilities, the need for civilian providers to service veterans, and the VA’s legal and economic barriers to providing services (Carrola & Corbin-Burdick, 2015; Hester, 2017; Richards et al., 2017) . The emergence of this theme is shown depicted through the key search phrases including “VA mental health outsourcing”. Within the sample, 2 studies specifically highlighted these key terms. In total 5 studies showed key terms referencing the need for civilian providers to service veterans. Three different studies also highlighted the legal and economic barriers for veterans seeking VA healthcare.
2.3.5. Facilitating Posttraumatic Growth
The results for Facilitating posttraumatic growth (PTG) emerged two subthemes; specifically, the importance of the understanding of the PTG phenomenon among professionals across all sectors as well as the data findings that produce positive outcomes for PTSD treatment of veterans (Jayawickreme et al., 2021; Tsai et al., 2015) . Out of 33 studies, 3 studies specifically noted the key term for “posttraumatic growth”. Seven different studies also aligned with search phrasing that was positive for the effectiveness of PTSD treatment for the veteran population.
2.3.6. Holistic Wellness Approaches
The results for Holistic Wellness Approaches emerged three subthemes; specifically, the need for mental health professionals to integrate holistic intervention models in their treatment plans, implementing psychoeducational and prevention efforts in mental health, and reintegrating veterans to their communities and families. The need for providers to integrate holistic wellness models and integrated care were supported by the literature relating to the main theme “holistic wellness approaches” (Finley et al., 2018; Purcell et al., 2021) . Out of 33 studies, 4 different studies highlighted the key search terms for “holistic wellness approach” specific to the content of each article that referenced treating the veteran population. The key themes of “psychoeducation and prevention” as well as “community reintegration” was highlighted in 3 of those studies.
2.3.7. Best Practice Recommendations
The results for Best Practice Recommendations also emerged three subthemes; specifically, the need to develop and integrate military cultural competency in graduate level education programs, implementing post-graduate military certification programs for professionals, and interorganizational collaboration between VA government and civilian mental health sector organizations (Meyer & Wynn, 2016; Hester, 2017; Navjit Sanghera, 2017) . In total “best practices” were referenced in 14 studies within the sample of 33 studies. The subthemes aligning integrating in graduate level programs were referenced in 3 of those studies. Five of the studies also referenced the importance of post-graduate continuing education for mental health providers treating the veteran population. The key phrasing specifically highlighted “interorganizational collaboration was included in 4 of the studies sampled and specifically 2 studies highlighted VA collaboration with civilian providers.
2.4. Evaluation Plan
The evaluation plan highlights the approaches and practices professionals can use to evaluate their own level of care in order to determine what aspects are missing based on findings and recommendations conducted in the synthesis of research findings. Findings informed the evaluation plan related to the research question aimed at evaluating best practice standards for implementing cultural competency in civilian counseling settings treating veterans. The following sections will compile a description for the chosen evaluation approaches, needs, and standards for the purposes of facilitating the most effective treatment outcomes for veteran clients receiving mental health care.
2.4.1. Program Evaluation Approaches
A program evaluation model that will inform the deliverable is compiled of a systematic collection and analysis of the information gathered during the process and the outcomes of the research findings in order to draw conclusions and make improvements to civilian mental health programs treating the veteran population (Royse et al., 2016) . For purposes of proposing an evaluation design, a social agency and evaluation approach will be utilized in order to measure accountability practices within mental health settings. Rationale for this chosen model lies in the foundation for a client-centered evaluation model where evaluators work closely with clients and stakeholders to support, develop, and then implement programs for responsiveness of changing needs (Royse et al., 2016) . The opportunities for investigation into problem areas as well as strategies for improvement can be implemented in order to enhance the capacity for quality services administered to this population (Royse et al., 2016) .
There are many different theoretical approaches that have given light to effective wellness models and evidence-based interventions within the mental health field. For example, the foundations of holistic approaches as best practices during mental health treatment place great emphasis on considering the individual as a whole entity (Finley et al., 2018) . Clinical staff members can enhance the influence of integrating the mind, body, and spirit in order to work closely with the veteran community to reach higher levels of fulfillment within their lives (Finley et al., 2018) . Interorganizational collaboration among partnering agencies, such as the VA, also bring forth important collaborative efforts of bringing integrative therapeutic care to this community (Heath & Isbell, 2017) . Established agencies within local communities can help to influence the outcome of collaborations between stakeholder organizations (Heath & Isbell, 2017) . These agencies are interdependent on each other based on the added benefits to evaluating mental health programs provided by community collaboration (Heath & Isbell, 2017) .
2.4.2. Needs Assessment
Several approaches to needs assessment are appropriate to address this within the evaluation design (Royse et al., 2016) . A combination of survey approaches, interviews, focus groups, and secondary data analysis can help to provide thorough and in-depth information in order to identify the particular needs for servicing this population (Royse et al., 2016) . With awareness and sensitivity to the unique culture surrounding the veteran population, veterans that are serviced for issues related to PTSD are also made up of a diverse population (Carrola & Corbin-Burdick, 2015) .
Current needs for this particular population can help to identify problems that may exist, obstacles, as well as the barriers that may prevent this population from seeking out services and being satisfied with care (Carrola & Cordin-Burdick, 2015) . Such needs would extend into implementation for mental health prevention, intervention programs, clinical staff continuing educational efforts, clinical roles, as well as advocacy efforts that can help to address the social justice and public policy issues that are relevant to the veteran population (Carrola & Corbin-Burdick, 2015) . Advocacy planning in relation to needs assessment helps to ensure that civilian mental health providers work to make the public aware of treatment needs that this program will address for this particular population (Carrola & Cordin-Burdick, 2015) .
Within the context of such applicable needs lies specific information that must be acquired. The first step in narrowing down a needs assessment can allow each local agency to define the parameters for the needs, which includes its purpose as well as if the focus of needs will be narrow or broad (Royse et al., 2016) . In the case of assessing needs for this chosen population and answering the research question of this report, it could aim to define the purpose involving how to better serve the veteran population with PTSD within civilian counseling settings.
In utilizing the experiences of service users and their family members, service needs can be identified by targeting those questions concerning felt and expressed needs among this population (Royse et al., 2016) . Information from client surveys and interviews can help to identify these felt needs as well as to identify the expressed need for members of this population who have applied and are waiting for services from local counseling clinics (Royse et al., 2016) . Information for this needs assessment can also be acquired from other sources to include family members, clinical staff, and other community stakeholders (Royse et al., 2016) .
2.4.3. Evaluation Standards
During the implementation of program evaluation, there are several standards that are relevant to the intended mental health services being delivered to the veteran population with PTSD. For instance, clients and family members who participate in data collection measures and clinical services within local agencies should be made of aware of informed consent procedures for their voluntary participation in services received (APA, 2017) . Informed consent is to be obtained from mental health consumers in adherence to the ethical and legal guidelines set forth by professional mental health associations (APA, 2017) .
In alignment to theoretical orientation for this report, culturally relevant strategies are also important evaluation considerations. When collaborating with clients, family members, and clinicians, cultural implications unique to the military population should be applied to every procedure and adjusted when necessary in order to ensure that all members have a clear understanding of their directives (APA, 2017) . It is important that all staff and community members make an individual effort to form a thorough understanding of their own cultural dynamics that may interfere or affect their professional practices when servicing this population (APA, 2017) .
In relation to evaluation practices that are culturally sensitive, most treatment programs in the United States were designed mostly with the White, English speaking demographic in mind (Royse et al., 2016) . This also applies to the data compiled from the veteran population and what is known from PTSD treatment research that is focused mainly on middle aged, Caucasian males (Mac Donald et al., 2017) . The differential needs that adhere to the remainder of the veteran population call for large modifications to be made (Carrola & Cordin-Burdick, 2015) . These efforts should extend to the inclusion of all groups, cultural backgrounds, ranks, ages, and genders among this population (Mac Donald et al., 2017) . The results of these modifications will aim to address this diverse population in order to further explore issues that are related to the multicultural characteristics within the veteran population (Carrola & Cordin-Burdick, 2015) . Multicultural implementations during evaluation procedures should go on to address the unique cultural dynamics of the veteran community as a whole (Carrola & Cordin-Burdick, 2015) .
3. Application
3.1. Introduction
This section of the study will present the results of this study in relation to the development of the action research monograph deliverables to stakeholders. This includes outcomes derivative of the synthesis of the literature outlining what is known about treating the veteran population, feedback, and conclusions of the study used in action research monograph. The deliverable provides an overview of the literature, as well as an analysis that relates to the research problem and the recommended course of action to inform best practices when treating this population (Kettner, 2017) . A thematic analysis would depict tables of emerging themes and subthemes that have emerged from the content analysis of the descriptions of military cultural competency best practices in mental health (Rubinson, 2019) .
Key stakeholders for the action research monograph deliverable would be local civilian and/or non-governmental private sector mental health counseling centers that need to provide better informed culturally competent mental health services for veterans. The results of the data collection strategies used in this study were applied to the deliverable and can be used to inform clinical and program staff members to increase their level of professional development so that positive changes can occur among the administration of veteran mental health services across civilian private sector as well non-governmental public sector organizations (Kettner, 2017) .
3.2. Relevant Outcomes and Findings
The need for this study and the implications for the relevant outcomes and findings presented are highlighted in the research problem that the deliverable aims to address. That is, that there is a growing demand for civilian mental health clinicians to provide services to the post 9/11 veteran community (De Luca et al., 2016) . That demand in itself has presented the urgency for clinicians to be informed about the unique cultural attributes surrounding the military veteran community in order to adhere to multicultural best practice standards across the mental health professions (De Luca et al., 2016) . The emergence of main themes and their relating subthemes provided the rationale for a multicultural theoretical framework and understanding for the unique veteran identity and the need for culturally competent mental health providers across all sectors.
Relevant outcomes and findings depicted in the deliverable point to the disparities related to mental health within the military population. Such disparities include combat and military stress experiences; social oppression; sexual assault; gender disparities; as well as, the growing prevalence of psychological conditions such as PTSD, depression, substance use, and other mental health related problems (Meyer & Wynn, 2016) . Findings also pointed towards the barriers and limitations that prevent veterans from accessing culturally component providers that are familiar with the military experience, military mental health, and the historical context of systemic oppression in the military (De Luca et al., 2016) . Barriers were also present the mental health professionals treating this population such as the limited access of training and resources for continuing avenues of education to better treat the veterans (Navjit Sanghera, 2017) .
The literature made reference to other main merging themes of this study to include the need for veteran mental health cultural competency training for mental health professionals (Atuel & Castro, 2018) . This need is demonstrated across private and public community mental health treatment agencies (Atuel & Castro, 2018) . Findings relevant to this study also show that mental health professionals’ benefit through their capacity to maintain a knowledge base from credible training resources in order to identify concepts and to explore issues of growth and development when treating this population (Netting et al., 2017) .
The literature used to formulate the deliverable also highlighted key recommendations for best practices that incorporate approaches in alignment to a multicultural theoretical framework, such as military cultural competency involved in treatment implementation. Recommendations such that multicultural sensitivity towards this population should go on to address the unique mental health dynamics of the veteran community as a whole and diverse community (Hester, 2017) . An interorganizational collaborative approach was also present in recurring themes found in the literature that encourages the importance of community collaboration among public, private, and government mental health providers to work together in treating the veteran population (Hester, 2017) .
3.3. Application and Benefits
The results of this study informed an action research monograph deliverable. Its implications are expected to improve veteran mental health service delivery within the private and public sector civilian counseling practices (Carrola & Cordin-Burdick, 2015) . The themes that arose in this study may be used to empower mental health counselors with better solutions for implementing culturally sensitive interventions for the military population to better understand and treat the mental health needs of veterans (Carrola & Cordin-Burdick, 2015) . An added benefit may contribute to best practices in counseling interventions as well as counselor education and training recommended practices (Meyer & Wynn, 2016) . These applications could suggest that mental health professionals may benefit from continuing education, professional workshops, as well as additional support through larger government mental health outreach programs providing military cultural competency training when working with this population (Meyer & Wynn, 2016) . The action research deliverable will also extend best practice research and intervention efforts that incorporate the most relative and effective mental health treatment methods for the veteran population (Carrola & Cordin-Burdick, 2015) .
3.3.1. Target Audience
This study is aimed to educate the target audience of mental health counselors and relevant healthcare leaders in civilian/non-governmental mental health settings with the goal to help this audience better understand the unique cultural experiences within the veteran community as a result of their military service (USDVA, 2021) . The deliverable can inform leaders in these mental health settings about what is known in the research about best practices for working with this population. The sample used for this study drew from existing literature of the target population and best practices currently available to mental health counselors in public and private outpatient counseling facilities who provide direct services to veteran clients. The treatment approaches most relevant to modern best practice methods ensure those best practices are delivered to the veterans across these civilian mental health treatment settings with the ultimate goals to empower both mental health counselors as well as the veteran community (Carrola & Cordin-Burdick, 2015) . In doing, this can provide solutions with partnering agencies to implement culturally sensitive interventions to better treat the mental health needs of veterans (Carrola & Cordin-Burdick, 2015) .
There are several stakeholders identified as beneficiaries of the research that can be called upon to continue furthering the research cycle to include mental health professionals and veteran consumers of mental health treatment (Carrola & Corbin-Burdick, 2015) . These stakeholders include the veteran consumers of mental health services and also family members, clinical staff, partnering agencies, and other community members that will help to promote accountability factors for effective mental health treatment (Carrola & Corbin-Burdick, 2015) . Highlighted areas of importance should be depicted in communication to stakeholders and their involvement. Action planning to further this research should clearly communicate the benefits and services that are significant to improving the well-being of the veteran clients and their families by this organization in order to better meet the needs within this population (Carrola & Corbin-Burdick, 2015) .
3.3.2. Institution/Setting
The practical implications of this study also aim to address organizational needs spanning across several different mental health settings in the local community. The impact of this study can help to address counseling best practices for the growing mental health needs of veterans who are utilizing these civilian mental health services (Tricare, 2020) . The deliverable action research monograph shows the outcomes of this study highlighting best practices of military cultural competency in order to better address the counseling needs across mental health agencies and settings in civilian/non-governmental settings (Plano et al., 2016) . Currently, several identified agencies would benefit from the completed deliverable addressing the problems described that serve the veteran population with the common mission to provide culturally competent mental health services and service coordination to veterans in the local Dallas, Texas community where the researcher resides (USDVA, 2019) . This study used to develop the deliverable can ultimately help train private civilian and non-governmental counseling clinicians to better understand and help meet the mental health treatment needs of the population of veterans of the armed forces.
3.3.3. Beyond the Local Setting
The results of this study and its deliverable may prove beneficial, not only to the local mental health community, but to the entire mental health community services this population at large. While the deliverable was developed to assist the local mental health community, the need for military cultural competency for veteran mental health counseling are demonstrated in the literature across private and public community mental health treatment agencies beyond the local setting (Atuel & Castro, 2018) . It can further be noted that this study may effectively contribute to the evolution of veteran mental health best practices nationally and internationally as well as towards the growing body of research describing the effective components of service delivery to this population in mental health settings supporting the need for this study.
3.3.4. Implications for the Professional Specialization
As previously states, the implications of this study aim to address organizational needs spanning across several different agencies within the local community providing mental health counseling services to veterans. Learnings from this study imply the need to serve the best interests of diverse veteran populations. Culturally competent staff members and stakeholders should work to adhere to the unique cultural characteristics of veterans of the armed forces whose interests are served by this research. Needs within this population extend into the implementation for multicultural mental health framework and integrated community care by a variety of professionals with different clinical roles within mental health organizations (Carrola & Cordin-Burdick, 2015) . The needs within the serviced target population extend into the consideration for a program that embodies integrated clinical care that includes different professionals (Carrola & Cordin-Burdick, 2015) . This would aim to facilitate the different roles that are necessary to carry out the mission of human service organizational programs for improving the lives of the beneficiaries of this research including veterans and their family members seeking mental health care (Carrola & Cordin-Burdick, 2015) . Professionals within a behavioral health organization treating veterans with PTSD have varying roles in resolving many of the issues that may arise when treating this population (Carrola & Cordin-Burdick, 2015) .
3.3.5. Addressing New Questions and Furthering Research
The results of the data collection analysis in this research study have presented new and emerging questions related to veteran mental healthcare. The emerging questions pertain to clinical program staff members and how to increase their level of cultural sensitivity and professional development (Kettner, 2017) . These questions can lead to further research substantiating the positive changes that can occur among the administration of veteran mental health services by practitioners that are culturally component and qualified to work with this population (Kettner, 2017) . The purpose of this study can also lead towards a better understanding of how mental health professionals can best facilitate posttraumatic growth (PTG) among the veteran populations diagnosed with PTSD. Addressing a purpose statement in the realms of the PTG phenomenon can help to drive a very important research question within the counseling profession: What variables influences positive treatment outcomes for veterans seeking mental health treatment?
3.3.6. Action Planning
The results of study and the implications for the action research monograph deliverable may likely lead to a community action plan addressing the problem related to the growing demand for community mental health professionals to meet the needs of post 9/11 veterans of US armed forces as highlighted in the literature. The researcher along with local community stakeholders may work together to develop a task force that includes professionals within private, public, and government sector mental health facilities (Hasenfeld, 2015) . This collaborative approach to task force formulation may aid to strengthen stakeholder relationships to promote sustainable solutions (Hasenfeld, 2015) . These action planning steps may lead to solutions that can be derived from the results of this action research study to improve the mental health services and programs for veterans seeking services from civilian counseling centers within the public and private sector. Solutions can also create further awareness within the mental health community of the importance of providing veterans with access to evidenced-based and culturally competent mental health treatment while placing a focus on the benefits of providing access to educational resources for civilian counselors (Carrola & Corbin-Burdick, 2015) .
3.3.7. What the Research Addressed
Research helped further substantiate the deliverable and evidence-based mental health service best practices for the veteran population dealing with PTSD and other mental health related concerns in order to promote posttraumatic growth among this population. The research questions sought to address best practices for military cultural competency for counselors and other mental health staff providing mental health services to veterans in civilian settings. The strengths of the veteran community that mental health providers can facilitate pertain to each individual’s capacity to overcome trauma and the resilience that can be acquired after struggling with mental health issues, such as PTSD (Angel, 2016) . Research indicated the significance of culturally sensitive treatment programs that aim to promote positive outcomes among the veteran population (Angel, 2016) . This evidence suggests that recovery is an attribute that can be acquired after trauma and can be commonly reached through several different treatment pathways (Angel, 2016) . The identified strengths within local civilian mental health settings are also substantiated by the benefit of a strong collaborative relationship associated with VA government centers and the veteran community (USDVA, 2019) . Organizational strengths continue to suggest that there is a growing population of diverse veterans that require mental health care (USDVA, 2021) .
3.3.8. Serving Best Interests
These research efforts should extend to the inclusion of all groups, cultural backgrounds, ranks, ages, and genders among the population being served (Mac Donald et al., 2017) . These actions are supported by findings of this study and are also in alignment with mental health professional organizational standards that underlie a responsibility in respecting diversity when implementing and designing research practices (APA, 2017) . The results informing the deliverable addressed this diverse population in order to further explore issues that are related to the multicultural characteristics within the veteran population (Calley, 2009) . Multicultural implementations during mental health treatment implementation should continue to address the unique cultural dynamics of the veteran community as a whole and the unique challenges they face (Calley, 2009) .
Learnings from this study imply the need to serve the best interests of this diverse population. Culturally competent staff members and stakeholders should work to adhere to the unique cultural characteristics of veterans of the armed forces whose interests are best served by this research. Needs within this population extend into the implementation for interorganizational collaborative care by a variety of professionals with different clinical roles within civilian mental health organizations (Carrola & Cordin-Burdick, 2015) . The needs within the serviced target population extend into the consideration for veteran mental health treatments program that embodies integrated clinical care that includes different professionals (Carrola & Cordin-Burdick, 2015) . This would aim to facilitate the different roles that are necessary to carry out the mission of mental health organizational programs for improving the lives of the beneficiaries of this research including veterans and their family members seeking mental health care (Carrola & Cordin-Burdick, 2015) . Professionals across civilian mental health organizations treating veterans with PTSD have varying roles in resolving many of the issues that may arise when treating this population (Carrola & Cordin-Burdick, 2015) .
3.4. Recommendations
3.4.1. Developing Military Cultural Competency
Civilian mental health organizations should work to hire and train culturally competent staff members and stakeholders in order to adhere to the unique cultural characteristics of veterans of the armed forces whose interests are best served by this research (Carrola & Corbin-Burdick, 2015) . The results of this study and its recommendations are increasingly important in regard to informing healthcare services and mental health professionals who are working with military veterans. The results of this study show that mental health providers who seek to better understand the cultural backgrounds of their consumers are better equipped to provide the most effective care (Navjit Sanghera, 2017) . Mental health counselors working with this population must be thoroughly informed about military culture and its unique experiences in order to provide veterans with culturally sensitive counseling treatment and interventions (Navjit Sanghera, 2017) . Future improvements and recommendations for obtaining military cultural competency are further highlighted in the outcomes of this research and depicted in the deliverable. In addition, military history and experiences should be taught as part of an integration of counseling treatment and proper assessment and screening for this population (Navjit Sanghera, 2017) . Recommendations for counselors who already practice should consider continuing avenues of education such as attending military conferences, public events on military installations, online resources, and the Department of Veterans Affairs which includes training and resources for specific veteran groups (Navjit Sanghera, 2017) .
3.4.2. Integrating Military Education in Graduate Programs
Highlighted recommendations that arose in the literature found that military cultural competency should identify a premise in curriculum taught in schools and graduate level programs (Navjit Sanghera, 2017) . There should be such consideration given to presenting military mental health problems from a current and historical standpoint, specifically those problems related to PTSD and other mental health disparities (Navjit Sanghera, 2017) . These prevalent topics should be incorporated into the curricula of mental health graduate programs. As an example, The University of Southern California has established a specialization in Military Social Work in their graduate-level Master of Social Work Program (USC, 2022) . This program has created a strong emphasis that even includes placements in military social work settings for graduate level field placements (USC, 2022) . This specialized track helps future professionals to understand military culture and addresses the needs of military veterans in clinical practice (USC, 2022) . Military mental health curricula, such as this one, should be taught routinely as protocol and part of clinical internships and examinations in all universities offering degree in mental health (Navjit Sanghera, 2017) . Recommendations of providing graduate students with access to more military mental health treatment facilities for internship opportunities or short-term clinical exposure may prove very beneficial for future clinicians (Navjit Sanghera, 2017) .
3.4.3. Implementing Post-Graduate Military Certification Programs
Military mental health certificates, courses, and continuing education specializations have emerged throughout the years to help address the need for competent and culturally aware clinicians serving the military population (Whitworth et al., 2019) . Findings in the literature presented favorable outcomes for mental health clinical staff who have endorsed these post-graduate educational means as viable in order to prepare for clinical practice with the veteran community (Whitworth et al., 2019) . These findings support the best practice recommendations to implement post-graduate continuing education and miliary certification programs that help train clinicians to better understand the importance of professionals understanding the military culture and relevant mental health and psychological conditions most notable treated in this population (Whitworth et al., 2019) . Recommendations of providing civilian clinicians not affiliated with the military with access to acquire training and certifications working directly with the military population through partnering government agencies, such as the VA, may prove very beneficial for preparing clinicians to treat veterans (Navjit Sanghera, 2017) .
The recommendations depicted in the deliverable also point out a need to expand continuing education courses course and military specializations to addressing how mental health clinical staff can prepare for face the ethical challenges that they can expect to encounter when working with the military population in the treatment of their mental health (Whitworth et al., 2019) . Clinicians often face vast ethical challenges when working with this population and would benefit from understanding systematic approaches for addressing them (Whitworth et al., 2019)
3.4.4. Interorganizational Collaboration
These results of this study indicate the importance of collaboration among professionals across varying mental health disciplines and organizations in order to prepare professionals for collaborative practice (Clarkson-Hendrix & Carroll-Barbuto, 2019) . Examinations of surveys conducted by Finley and associates (Finley et al., 2018) of local Texas mental health professionals providing treatment to veterans outside the VA depicted that community-based mental health providers in Texas do not consistently use the recommended evidence-based treatment for PTSD for veterans. Recommendations found in the same study suggest an opportunity for the VA to partner with outside community providers in order to achieve high quality care for veterans seeking outside treatment (Finley et al., 2018) . Interorganizational collaboration is a best practice standard that considers the importance of a collaborative approach among public and non-profit mental health providers at the state and local levels to work together to increase the availability of mental health training services for professionals treating veterans (Hester, 2017) . Collaborating organizations servicing this target population must demonstrate that their internal programs adhere to cultural sensitivity as well as their external outreach and collaborating efforts with other organizations (Netting et al., 2017) . Recommendations to implement an improvement within the environmental relationship of the collaborating organizations for application to the veterans will be to first specify and understand this diverse population and to understand their characteristics (Netting et al., 2017) .
Organizational collaboration between civilian non-government organizations and the Department of Defense that includes the United States military and all branches Army, Navy, Airforce, Marine, and Coastguard holds the greatest interest in collaboration towards treating the veteran population (USDVA, 2019) . The DOD is the authority branch governing over the Department of Veterans Affairs (VA), Tricare, and local mental health veteran center clinics (USDVA, 2019) . All of these agencies are interdependent on each other recommended collaboration with the civilian sector can establish the initiative to share resources to provide mental healthcare benefits through community collaboration (Heath & Isbell, 2017) .
3.5. Conclusion
This action research study has formatted the foundation for an action research monograph that presents the analyzed the elements of a qualitative design conducted by the researcher in order to conduct a thematic analysis deriving themes to contribute to the body of research to better examine the effectiveness of mental health services for veterans seeking mental healthcare in the civilian sector. The findings of this study substantiated the original research questions and analysis of data. The results of this study concluded that there is a clear indication of the elements addressed in the original research question to better understand best practices of mental health services for this population and what can be done to improve clinical programs for improvement to treat this population. The research question addressed best practices for military cultural competency for counselors providing mental health services to veterans in civilian settings. The key points of the findings of this research suggest several new and emerging questions pertaining to clinical program staff members and how to increase their level of cultural sensitivity and professional development when working with the veteran population (Kettner, 2017) .
Several recommendations have been derived from the results of this action research study to improve the mental health services and programs for veterans within civilian mental health organizations. Providing veterans with access to evidenced-based and culturally competent mental health treatment staff and placing a focus on the consideration to lessen the stigma surrounding seeking mental health care is one area of proposed solutions (Carrola & Corbin-Burdick, 2015) . Organizations should work to hire and train culturally competent staff members and stakeholders in order to adhere to the unique cultural characteristics of veterans of the armed forces whose interests are best served by this research (Carrola & Corbin-Burdick, 2015) .
Overall, this study produced substantial evidence of the importance of providing access to mental health prevention programs to decrease the negative effects of PTSD and other mental health issues among the veteran community (USDVA, 2019) . These findings are increasingly important in regards to informing mental healthcare services and professional clinical staff that will be working with military veterans with PTSD as well as for many of the fields concerning trauma. It can further be noted that this study effectively contributed to the evolution of veteran mental health best practices as well as the growing body of research describing the effective components of service delivery to this population. This study can provide future implications for veteran mental health best practices in the civilian public sector as the research implies the promising results in the effectiveness of large scale culturally relevant psychotherapy and mental health intervention strategies (USDVA, 2021) .
Dedication
In dedication to the thousands of veterans who have fallen by suicide.
We honor you. We remember you.