10 Working with Veterans, Social Class, and Counseling: Understanding the Veteran Population and Implications for Treatment Purchased

In preparation for writing this chapter, the authors held many conversations and conducted numerous searches to figure out how to approach thinking and writing about social class within the veteran population. It was through one of those searches that we came across a New York Times series exploring how class influences one’s course in America. One of the articles in the Class Matters series focused on a National Guard unit from Tennessee that was called up for deployment to Iraq. Though brief, the article follows several Guardsmen to sample their views on military service. One of those interviewed was Sergeant Daryell H. Ledford:

Sgt. Daryell H. Ledford, 39, a crane operator who lives in Clyde, NC, spent four years on active duty and joined the Guard in 1989. He was surprised when he visited a bar outside Camp Shelby near Hattiesburg, MS, and saw college students spending $80 and $90 on drinks. “Where’s the money come from?” he wondered. As he sees it, there are three types of people: “There are rich people, who are thinkers. There are blue-collar people like us, who are the doers. And there are the poor people, who don’t do anything but will follow.” He favors a draft.

In his brief statement, Sergeant Ledford provided a clear snapshot of who is serving in today’s all-volunteer military. Since the dissolution of the draft in 1973, the National Guard, like the US Army, has drawn heavily from the working class. Research suggests that an important predictor of military service in the general population is family income, such that those with lower family income are more likely to join the military than those with higher family income (Lutz, 2008), suggesting that the military may be a career option or provide opportunities that might not otherwise be available (Lutz, 2008). The opportunity for career mobility is captured by National Guardsman Specialist Vinson L. Elliott, also interviewed for the New York Times series:

Specialist Vinson L. Elliott, 28, was a supervisor at a youth correctional facility in Dandridge, TN. He wanted to play football in college and turn pro but was forced to drop out his freshman year, he said, because he was late turning in financial aid papers. He immediately enlisted to get out of Newport. “There are really no jobs or anything there,” he recalled. “I wanted to see something else.” After Iraq, he wants to become a state trooper. “People look up to state troopers,” he said.

Although discussing the relevance of social class within the veteran population, much less American society as a whole, can been tricky, in part because of the tendency of some to ascribe to a belief that America is a classless society, common terminology, like “middle-class values,” “elitist,” and “working poor,” suggests not only an acknowledgment of the stratification along economic lines, but also of a set of group-level rules, expectations, and values that may accompany group membership.

There is no other group with a stronger set of values, expectations, and customs than the US Armed Forces. Those who are active duty and veterans of the US Armed Forces undoubtedly share common values and beliefs and a sense of shared group identity, despite the diversity and heterogeneity of the individuals who serve. To begin working toward a better understanding of how social class, socioeconomic status, and shared group experience may function in the population of veterans, it is important to first understand the economic diversity in this country.

The United States is an economically diverse country. Statistics compiled from information collected in the Current Population Survey (CPS) 2011 Annual Social and Economic Supplement (US Census Bureau, 2010b) estimates that there were approximately 46.2 million (15.1%) people living in poverty in 2010. This represents the highest poverty rate since 1993. Additionally, data on health insurance coverage indicated that approximately 46 million Americans were uninsured.

Geographically, median incomes in 2011 were higher in certain parts of the country. The South continued to have the lowest median household income ($46,899), followed by the Midwest at $48,722, the West at $52,376, and the Northeast at $53,864. Consistent with previous years’ reports of poverty within different ethnic and racial groups, African Americans were more likely to be living in poverty than any other racial/ethnic group. The 2008 poverty rate for African Americans was 24% (unchanged from 2007; median household income = $34,218). Hispanics had the next highest rates of poverty at 23.2% (up from 21.5% in 2007; median household income = $37,913), with significantly lower poverty rates for Asians at 11.8% (up from 10.2% in 2007; median household income = $65,637) and Whites at 8.6% (up from 8.2% in 2007; median household income = $55, 530). Gender inequities in income continued to be noted in 2008, with women earning approximately 77 cents for every dollar men made. This represents a decrease from the 78 cents per dollar women earned in 2007.

As Liu, Ali, Soleck, Dunston, and Pickett (2004) argue, such economic diversity would likely result in people having different social class experiences and different worldviews. As such, it would only stand to reason that psychologists would also benefit from having greater understanding of how social class may influence one’s individual and group-level functioning. Among veterans in particular, those who have served in the all-volunteer force since 1973 are drawn from certain segments of the US population such as from families with strong military service histories and the working class, contributing to and reinforcing a particular sense by veterans as being part of a special and separate group of Americans.

Although still limited, the growing body of research looking at social class suggests that it is an important variable with implications for both psychological and physical health (Pope & Arthur, 2009; Lynch & Kaplan, 1997). Despite the reliance of existing research on economic indicators of social class group membership (i.e., income level), such indicators still provide some useful information and illustrate the strong association between social class and psychological functioning (Anderson & Armstead, 1995; Chen, Matthews, & Boyce, 2002; Lorant et al., 2003). Specifically, as one moves down the socioeconomic status ladder, the risks of depression (Lorant et al., 2003), anxiety (Lynch, Kaplan, & Salonen, 1997), intellectual disability, learning disabilities (Blair & Scott, 2002; Fujiura, 2003), and substance abuse/dependence increase (Diala, Muntaner, & Walrath, 2004).

In addition to its association with psychological phenomena, social class has been shown to have other health-related consequences as well. For example, lower-class men and women tend to have higher rates of obesity (El-Sayed, Scarborough, & Galea, 2012), chronic illness (e.g. diabetes mellitus, heart disease, high blood pressure)(Kaplan & Keil, 1993), experience work-related stress and workplace accidents, and participate in risky sexual behavior. Explanations for the relationship between social class and one’s psychological and physical well-being have gone beyond a simplistic view that poor health is a natural consequence of lower class status and have begun to recognize the more complex sociocultural and political influences. Specifically, Lorant et al. (2003) postulated that, “personal resources, such as self esteem, coping style, mastery, and locus of control, protect individuals from the impact of stress.” In comparison to those of higher socioeconomic status, individuals of lower socioeconomic status may have fewer individual resources to draw on as a result of chronic economic constraints and stressors (Pope & Arthur, 2009). Theories focusing on the chronic strain experienced by those in low socioeconomic status groups also identify community and individual factors such as workplace discrimination, family fragmentation, and less-than-ideal public health policies as contributing to increased symptomatology (Lorant et al., 2003).

In thinking about how this general research applies to the veteran population, it would seem to be mixed. Veterans make up approximately 10% of the US adult population (US Census Bureau, 2010a). They have unique health care needs, resulting in part from the significant physical and psychological challenges they faced during their military service (Hausmann, Jeong, Bost, Kressin, & Ibrahim, 2009). Additional stressors such as multiple deployments, higher divorce rates, separation from support networks, and financial stress may also tax veteran resources and lessen their ability to employ adaptive coping strategies (Kelty, Kleykamp, & Segal, 2010), thereby placing them at increased risk for psychological and physical health consequences. On the other hand, the military selects for individuals who possess a baseline level of physical and mental health and provides free medical and mental health treatment to active duty service members. Further, for those who are eligible, free or low-cost medical and mental health care through the Veterans Health Administration may serve as a protective factor against the physical and psychological risks associated with lower social class status.

Although research demonstrating the impact of objective indicators of one’s social class status on psychological distress, health, and well-being is available, guidance on how to integrate these findings into clinical practice has been lacking. The goal of this chapter is to provide one way of understanding social class and begin to make practical recommendations for how this understanding can be applied to clinical practice when working with the veteran population. The following section will provide a working definition of social class that will be used throughout the remainder of this chapter.

As previously stated, traditional definitions of social class have primarily relied on demographic indicators of one’s social position as a way to stratify people into groups with the goal of then interpreting individual’s experiences within those groups. This strategy, though useful to some degree, relies on the assumption that people within similar economic groups share similar experiences and preferences. Existing research does not support this assumption and instead indicates that the worldview of those within a specific social class group may differ depending on the region of the country, workplace autonomy, and property ownership (Liu et al., 2004). Later in this chapter, the authors will argue that veterans as a social group also differ among numerous social and economic factors, but share the common experience of service in the US military and the shared values of that service.

Thus, although a social stratification paradigm is useful in understanding one’s relative position as compared to others, sole reliance on objective indicators does not increase understanding of what one’s relative social position means to the individual. Nor does it aid in the understanding of the values, beliefs, or pressures that accompany one’s relative social position. Additional limitations of relying on a social stratification paradigm were identified by Liu (2002) as the following: (1) inability to explain affect associated with social class experiences; (2) inability to explain social class relationships; and (3) inability to explain people who choose to move “downward” in social class or the individual who chooses to change from a fast-paced lifestyle to a slower lifestyle.

In an attempt to move away from models that use occupation, education, and income to operationalize social class, Liu et al. (2004) have introduced the social class worldview model (SCWM), which works from the premise that all people live within an economic context. In other words, the definition of social class revolves around a worldview approach and that social class worldview is defined as, “the beliefs and attitudes that help the individual understand the demands of one’s economic culture, develop the behaviors necessary to meet the economic culture demands, and recognize how classism functions in one’s life.” The assumptions of the SCWM are (1) that people’s perceptions shape their reality, (2) that social class can operate on an individual level, and (3) that people oscillate between feelings of satisfaction and failure when it comes to needs and work toward homeostasis in their social class worldview. In sum, the SCWM represents a shift away from understanding social class within a sociological and demographic realm and broadens the conceptualization to include more subjective considerations of this cultural construct.

Although the body of research is relatively small, there is growing support for the use of subjective measures that allow people to determine their own social class position versus being placed into a category and position. Within this existing small body of research, subjective measures of social class (e.g., personal perception of available resources and opportunities) have been found to be a stronger predictor of health outcomes (Adler, Epel, Castellazzo, & Ickovics, 2000) and health behaviors than objective measures (Ostrove, Adler, Kuppermann, & Washington, 2000). Data also suggested that subjective measures of social class may be linked to how an individual copes with life stress, sense of control, pessimism, and other health indicators (e.g., sleep and body fat; Adler et al., 2000).

In the current chapter, the authors will attempt to provide a clearer picture of veterans along both objective indicators of social class (i.e., income, occupation, and education) as well as from the broader subjective worldview perspective (i.e., values, beliefs, expectations), including how veterans interact with the health care system designed for veterans (Veterans Health Administration) and within the therapeutic context. The authors assume an audience of mental health professionals and researchers who do not currently work within veteran-only settings, but want to understand the experience of veterans while taking into account socioeconomic status and social class factors. Taking into account both objective data and the subjective experience of veterans can improve the development of therapeutic rapport and, hopefully, the outcomes of treatment for veterans.

Within the US Department of Veterans Affairs (DVA), the Veterans Health Administration (VHA) seeks to provide comprehensive health care to veterans, especially those who are unable to obtain adequate health care from other sources due to low income. VHA operates the nation’s largest integrated health care system, consisting of 152 medical centers, as well as hundreds of additional community-based outpatient clinics, vet centers, community living centers, and domiciliaries (National Center for Veterans Analysis and Statistics, n.d.). The veteran population is large and diverse, consisting of a total of over 22 million individuals who are potentially able to receive health care services within in the VA health care system (National Center for Veterans Analysis and Statistics, n.d.). Over 8 million veterans were enrolled in the VA health care system in fiscal year 2010 (National Center for Veterans Analysis and Statistics, n.d.), with over 6 million veterans treated yearly in fiscal year 2011 (“fiscal year” refers to the 1-year period from October 1st through September 31st of the indicated year; US Department of Veterans Affairs, 2012).

The VA health care system provides preventive outpatient services and inpatient treatment to all eligible veterans, regardless of race, gender, ethnicity, or sexual orientation. Low income is one factor taken into account when determining VA enrollment priority, meaning that low-income veterans have higher priority for receiving some VA health care services than some others. Low income is determined geographically and is defined as 80% (or lower) of median income for the veteran’s location and family size. VA currently provides services to 75% of all disabled and low-income veterans (Veterans Today, 2009). Since low-income individuals tend to have less access to health care and health insurance, and experience higher levels of morbidity and mortality, one of the goals of VHA is to provide health care for veterans who have difficulty obtaining quality health care elsewhere, and therefore to reduce the expected health disparities in veterans due to socioeconomic status.

However, according to the VA Center for Health Equity Research and Promotion (CHERP, n.d.), equal access to health care does not guarantee equalities in health care or health outcomes, since these latter outcomes can be affected by many other factors, such as individual behavioral differences, provider attitudes, patient-provider communication, or the social or physical environment. In addressing the role of socioeconomic differences in disparities, CHERP summarizes the literature:

There is evidence to suggest that poor living and working situations, social isolation and segregation, economic vulnerability, and other complex social forces conspire to reduce the health and health care of poor populations. But if these complex social forces are the cause of observed disparities in health and health care, then we must reveal the underlying mechanisms and work to address them.

To understand how socioeconomic variables may affect the veteran population and health outcomes, the following section provides a description of the current veteran population along objective measures of socioeconomic status and, by extension, social class.

Men currently make up 92% of the US veteran population. There are presently 1.8 million women veterans, although the proportion of female veterans is expected to increase in the future as the military includes increasing numbers of women in its ranks. For example, among the veterans serving in the OEF/OIF (Operation Enduring Freedom in Afghanistan; Operation Iraqi Freedom in Iraq) operations since 2001, 11% were women. Moreover, in 2009, 18% of veterans were women, compared to 3% of veterans from World War II, the Korean War, and the Vietnam War (Bureau of Labor Statistics [BLS], 2011). However, most of the available information and data about the veteran population, as will be reported in this chapter, often refers only to men.

Veterans 65 years of age and older make up 39.9% of the current veteran population, significantly higher than in the general population (12.8%). In 2009 the average age of male veterans was 63 years, while the average age of female veterans was 48 years (US Department of Veterans Affairs, n.d.). In the US veteran population, 79.3% are White non-Hispanic (National Center for Veterans Analysis and Statistics, n.d.), compared to 65.6% of the general population. An additional 11.3% are African American, close to the general population percentage of 12.6% (US Census Bureau, 2010a). Hispanics of any race are underrepresented in the veteran population (5.8%) compared to the general population (16.3%), as are Asian/Pacific Islanders (1.5% vs. 4.8%) and Native Americans (0.8% vs. 9%). The differences in race/ethnicity may be explained partly by a cohort effect such that the overall older age of veterans, reflecting the diversity of the US population in times of increased recruitment into the armed services (e.g., World War II, Vietnam War). Also likely related to greater numbers of women in more recent, more ethnically diverse cohorts of veterans, 28% of women veterans in 2000 identified themselves as a member of an ethnic minority group, compared to 17% of male veterans (US Department of Veterans Affairs, 2007).

Socioeconomic status is typically defined by a combination of income, educational attainment, and employment status. Data from the 1999 Current Population Survey (Klein & Stockford, 2001) indicate that many indices of socioeconomic status are higher for male veterans as a group compared to their nonveteran counterparts. Data summarized by Klein and Stockford are supported by data from the American Community Survey (US Census Bureau, 2010a) reported below.

The selection preferences in joining the armed services (i.e., high school diploma or alternative credential), as well as financial support to enroll in college courses through the GI Bill, resulted in veterans overall having higher educational attainment than the general population. In 1999, 12% of male veterans had not graduated from high school, compared to 18% of their nonveteran counterparts. In 2010 the difference between all veterans compared to all nonveterans who had less than a high school diploma was maintained, at 8% versus 15.2% (US Census Bureau, 2010a). Some of these veterans without a high school diploma were assisted while in the military to pass the tests to attain a GED (General Equivalency Diploma). More male veterans had graduated from high school or had 1–3 years of college (65%), compared to 56% of male nonveterans. Among all veterans in 2010, 66% had graduated from high school or had some college, compared to 56.4% of all nonveterans. Finally, male veterans were more likely to have completed 4 or more years of college (26%) compared to male nonveterans (23%) in 1999. In 2010 the college graduation rate of all nonveterans had surpassed that of all veterans (28.4% vs. 25.9%).

According to the 2006 American Community Survey as reported by the US Department of Veterans Affairs (2007), among female veterans, 24% had a high school diploma as their highest level of education, while an additional 72% had some years of college. Of those who had some college experience, 40% had attained a bachelor’s degree. Only 4% had no high school diploma.

Given this educational data, it appears that many veterans, particularly those from older cohorts, may see themselves as more highly educated and skilled compared to the general population, and may experience or have experienced greater social mobility and employment opportunities when they returned to the civilian society and workforce. While the experiences of individual veterans may vary widely, veterans as a group may have significant advantages relative to nonveterans that may contribute to both greater social and psychological functioning.

The higher educational attainment of veterans as a group, in addition to specialized job training and skills while in the armed services, likely contribute to higher employment rates and personal income levels of veterans compared to nonveterans. In 1999 the data show that the average unemployment rate for veterans was somewhat lower than that of nonveterans (3.2% vs. 3.7%). However, this difference was only true for male veterans (3.1% vs. 3.6%); the unemployment rate for female veterans was higher than for female nonveterans (4.6% vs. 3.7%). Notably, in 1999 the personal income of male veterans in every age category was higher than that of their male nonveteran counterparts. Overall, the median income of male veterans was 9% higher than the median income of male nonveterans. According to the 1990 US Census, significantly fewer male veterans (5.7%) were at or below the poverty level, compared to 9.1% of all adult US men (Klein & Stockford, 2001).

According to the 2000 Census, the employment rates for women veterans did not differ significantly from their nonveteran counterparts of the same age (71% vs. 70%). In addition, the 2007 Census Population Survey showed that the overall family income of female veterans did not differ significantly from the family income of their nonveteran counterparts, though female veterans were less likely to be represented at the lower end of the family income distribution (US Department of Veterans Affairs, 2007). Following the major recession of 2008, the median income of women veterans in 2010 appears to be significantly higher than the women who are not veterans ($30,540 vs. $20,634) (US Census Bureau, 2010d).

Updated information from the Bureau of Labor Statistics (BLS, 2010) on the group of veterans serving in the military since September 2001 show that the unemployment rate for this newest group was 10.9% in 2009, while the overall unemployment rate for all groups of veterans was 8.1%. According to this report, the unemployment rates of this group were not statistically different from those of their nonveteran counterparts of the same age and gender. These statistics remained unchanged in 2010, such that the unemployment rates for all veterans was 8.7% compared with 9.4% for nonveterans (BLS, 2010). Notably, younger veterans (ages 18–24) in this group had an unemployment rate twice that of older veterans ages 25–34 (21.1% vs.10.6%) in 2009. In 2010 young male veterans had markedly high unemployment rates (21.9%), though this jobless rate was not statistically different from that of nonveterans of the same age group and gender (19.7%) (BLS, 2010). These data suggest that younger members of the veteran and general population currently face significantly greater unemployment compared to older individuals.

These occupational data support the general conclusion that veterans as a group are able to maintain higher levels of employment relative to nonveterans of the same age and gender. It appears that veterans as a group experience successful occupational functioning following their service in the armed forces, likely contributing to greater social and psychological functioning and positive self-images as productive members of society and providers for their family. It appears that the promise of better future prospects for those veterans who enlisted from working-class backgrounds have typically been achieved. However, the data from 2009 and 2010 on the higher unemployment rates for the youngest veterans (ages 18–24) suggest that, similar to that of other young Americans, the impact of the Great Recession of 2007–2009 continues to take its toll disproportionately on the younger population. The effects of early unemployment may include lower lifelong economic and occupational attainment, as well as a poorer subjective sense of well-being, sense of control, and self-image. How the VA responds to the emerging needs of this younger cohort of veterans may influence the eventual outcomes experienced by this group.

In the general population and among veterans, incarceration represents one end-point in a series of psychosocial problems and illegal actions by an individual. Objectively, participation in illegal activities can limit one’s participation in legitimate economic enterprise, and incarceration can limit future social and economic functioning following release, while one’s subjective sense of being a “felon” can strongly inform one’s self-image, choice of peers, and sense of belonging to a particular group of individuals. According to both the 1990 Census data and the 1997 data from the Bureau of Justice Statistics (2000), male veterans were incarcerated at less than half the rate of adult male nonveterans. Since veterans as a group are older than the general adult male population, these differences in incarceration rates are partially explained by the smaller proportion of veterans in the younger age groups that constitute the majority of the prison population. According to the most recent data from the Bureau of Justice Statistics (2002), 9.3% of incarcerated individuals in the United States are veterans.

Homelessness is a special problem among veterans, and the multiple and complex reasons for this situation are not yet completely understood by the VA. Veterans constitute only 9% of the general population but make up almost one-fifth of the total homeless population (National Coalition for Homeless Veterans, n.d.). Homeless veterans are overwhelmingly male (98%) and make up 33% of the homeless male population. Many homeless veterans have sought medical care at VA medical facilities (57%), and 25% have used other veteran-specific services such as at domiciliaries, compensated work therapy, and homeless shelters. Compared to their nonveteran counterparts, more homeless male veterans are non-Hispanic White (46% vs. 34%), more likely to have completed high school or attained a GED (85% vs. 56%), and more likely to be of older age. Due to their older average age, homeless veterans are more likely to report chronic medical conditions (52% vs. 44%), the most common of which are arthritis, rheumatism, or other joint problems, as well as high blood pressure (US Department of Housing and Urban Development, 2010). Given the disproportionate representation of veterans in the homeless population and the obvious and significant needs of this population, VA has developed numerous special programs to understand the needs of homeless veterans and to provide assistance to this population. Some of these programs will be described in greater detail in a later section of this chapter.

In summary, US veterans are a large and heterogeneous population who, as a group, are typically functioning as well or better on objective indices of socioeconomic status compared to their nonveteran counterparts in US society. Stereotypes about veterans as poorly functioning and mentally unstable have been fueled by dramatic depictions in popular culture and the media, and by lack of knowledge about veterans more generally. Such stereotypes mask the accomplishments of the majority of veterans who are gainfully employed, well adjusted, and continue to contribute in positive ways to society following their military service. However, there are unique challenges faced by veterans who are low-income, disabled, and/or homeless. The VA, which serves as the primary health care provider for low-income and disabled veterans, has allocated significant resources to address the needs of these veterans.

As noted earlier in this chapter, veterans are slightly overrepresented in the adult homeless population, especially among those who served during the implementation of the all-volunteer force after the Vietnam era (Gamache, Rosenheck, & Tessler, 2001; Rosenheck & Fontana, 1994). On average, veterans experience their first episode of homelessness approximately 8 years after separating from the military (Mares & Rosenheck, 2004). Given the lag time between separation from the military and first episode of homelessness, the factors contributing to homelessness among the US veteran population are likely multiple. When veterans were asked about whether they viewed their military service as contributing to their homelessness, only 31% attributed their homelessness to their military service. Of those, 75% attributed the increased risk to drug and alcohol problems that began in the military, 68% to inadequate preparation for civilian employment, 60% to loss of structured lifestyle, 43% to weakened social connections w/ family and friends, 42% to health problems that began in the military, and 29% to interrupted educational pursuits while in the military (Mares & Rosenheck, 2004). Additionally, many veterans experience symptoms of post-traumatic stress disorder (PTSD), traumatic brain injury (TBI), substance use disorders, and other mental health problems that may contribute to difficulty maintaining relationships or performing in the workplace (McMurray-Avila, 2001).

Regardless of veteran status, homelessness places individuals in a particularly vulnerable position with respect to access to resources to manage health and well-being. Compared to housed individuals, homeless persons have higher prevalence rates and incidences of medical and psychiatric problems (Gordon, Haas, Luther, Hilton, & Goldsein, 2010; Barrow, Herman, Cordova, & Struening, 1999) and the poorest prognoses (Liu, Hernandez, Mahmood, & Stinson, 2006). Approximately half of homeless veterans carry a serious mental illness diagnosis and 70% carry a substance use diagnosis (US Interagency Council on Homelessness, 2011; see O’Toole, Gibbon, Hanusa, & Fine, 1999). In addition, homelessness increases risk of contact with the legal system, such that approximately half of homeless veterans had contact with the legal system after discharge from the service (National Coalition for Homeless Veterans, n.d.).

Since the late 1980s and 1990s, the US Department of Veterans Affairs has applied a range of rehabilitation models to the development and provision of housing resources to homeless veterans, including identification and outreach to underserved veterans (e.g., mobile medicine, jail/prison outreach; Lam & Rosenheck, 1999); drop-in services for basic needs (e.g. showering, laundry, telephone access), medical care, and mental health services (Morse, 1999; Lehman et al., 1997); time-limited residential treatment offering medical and psychiatric services including substance abuse treatment as well as social-vocational rehabilitation; linkage with health and benefits programs; and transitional/permanent housing (Conrad et al., 1998; Goldfinger et al., 1999). The VA’s focus on time-limited residential treatment, instead of permanent housing, stemmed both from the agency’s statutory authority to provide health care but not housing and from the fact that transitional residential treatment allows for a greater number of veterans to be served over a period of time. The three forms of VA-funded residential care services for homeless veterans are the following:

Collectively HCHV, G&PD, and DCHV support almost 15,000 residential treatment beds.

Recent program evaluation studies estimated that all three programs serve to reduce homelessness among US veterans. Specifically, 78% of veterans housed through HCHV community-contracted housing were no longer homeless at 12 months after program discharge. DCHV programs reported housing stability of 77% and 76% at 6 months and 1 year after program discharge, respectively. G&PD programs reported similar findings with 81% of veterans being housed 13 months after program discharge (McGuire, Rosenheck, & Kasprow, 2010).

In 2009 the secretary of Veterans Affairs, General Shinseki, made the following pronouncement when introducing the Five Year Plan to End Homelessness among Veterans: “Those who have served this nation as Veterans should never find themselves on the streets, living without care and without hope.” The plan represents the Obama administration’s recommitment to address the myriad issues that contribute to a veteran’s becoming and remaining homeless. In addition to increasing resources available to existing programs aimed at intervening with currently homeless veterans, the Five Year Plan also aims to prevent veterans from experiencing their first episode of homelessness. Specific prevention efforts include resources provided to the general veteran population (e.g., Post 9/11 GI Bill) as well as interventions targeted toward those veterans identified as most at risk for homelessness (e.g., veterans discharging from incarceration, low-income families at risk of losing housing). Other initiatives aimed at providing employment support and financial assistance include employment assistance (supportive employment [SE]/compensated work therapy [CWT] programs targeted at veterans with significant health problems, mental health problems, and/or legal histories), entitlement assistance (decreasing barriers for veterans to access social security benefits and VA compensation and pension), financial assistance (e.g., general assistance, Temporary Assistance to Needy Families), and vocational rehabilitation.

A prominent element of the Five Year Plan is the VA’s partnership with the Department of Housing and Urban Development (HUD), the VA’s only permanent housing program. Developed in 1992, HUD-VA Supported Housing (HUD-VASH) combines Section 8 vouchers with intensive case management provided by VA clinicians. The mission of the HUD-VASH program is to exit veterans from homelessness with the case managers serving to support the veterans’ independence, physical health, and recovery from mental health/substance abuse diagnoses. Although recovery is supported, veterans are not required to be abstinent from substances prior to admission to the HUD-VASH program if they are otherwise eligible. Priority groups identified for admission to the HUD-VASH program include chronically homeless veterans with mental health and substance use disorders, homeless veterans with children and an identified disability, homeless veterans with children, veterans from Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF), and female homeless veterans. Since the emergence of the Five Year Plan, the HUD-VASH program has grown immensely. Between fiscal year (FY) 2008 and FY 2009 (October 1, 2007–September 30, 2009), over 20,000 vouchers were distributed, with additional vouchers approved each fiscal year to date. Recent data suggest that from 2010 to 2011, there has been a 12% decrease in homelessness among veterans nationally. In some places the reduction was as high as 20% (US Interagency Council on Homelessness, 2011).

As mentioned above, eligible veterans have access to both VA and non-VA care, while nonveterans do not have access to VA care and rely on private health insurance, Medicaid/Medicare, or public health services. Thus, the VA health care system serves as a health care “safety net” for low-income veterans and veterans without other forms of health insurance. The periodic National Survey of Veterans collects data on a heterogeneous and nationally representative sample of veterans about the use of health care services at VA and non-VA facilities. According to the 1992 National Survey of Veterans (Long, Polsky, & Asch, 2003), a large percentage of low-income veterans (47.2%) did not utilize any health care services in 1992. Of the low-income veterans served by the VA, more had multiple chronic conditions and/or disabilities compared to low-income veterans not treated at VA. Importantly, “even after adjusting for demographic, social, and clinical factors, low-income veterans remain less likely than high-income veterans to receive outpatient and preventive care and are more likely to have an unmet medical need” (p. 310). These disparities persisted even among veterans receiving VA services, although veterans receiving VA services were more likely to receive preventive care relative to veterans utilizing non-VA services. This study supported previous research showing that the availability of VA care did not eliminate health disparities between lower income and higher income veterans.

In the late 1990s, the VA streamlined and expanded eligibility for VA care, reorganized its delivery of health care services to emphasize more outpatient and preventive care, developed outreach programs to underserved veteran groups, and provided greater access to care by developing community-based outpatient clinics. Elhai, Richardson, and Pedlar (2007) analyzed data from the 2001 National Survey of Veterans, and the results suggested that physical health and disability (i.e., health care need) were the primary factors in determining health and mental health care utilization among veterans. Importantly, demographic and socioeconomic factors such as race/ethnicity, gender, employment status, and lack of health insurance were not associated with disparities in obtaining treatment. These findings are also consistent with a recent study by Duggal et al. (2010) comparing outpatient health care utilization among female and male veterans returning from service in Afghanistan and Iraq (OEF/OIF). Duggal et al. found that, unlike in previous eras of military service when women were much less likely to utilize VA services compared to their male counterparts, OEF/OIF female veterans sought VA health care at higher rates than male veterans. This finding suggests that VA’s efforts to provide quality health care to women, including gender-specific health care services, have shown some effectiveness in reducing barriers to treatment for female veterans. Moreover, another recent study by Fasoli, Glickman, and Eisen (2010) found that need (e.g., number of comorbidities) was the strongest predictor of mental health care utilization. Notably, socioeconomic factors such as homelessness and unemployment predicted greater utilization, further suggesting that these factors do not pose a significant barrier to veterans seeking VA mental health care.

Elhai et al. (2007) also found that veterans without private health insurance generally continue to utilize VA services, and that veterans with higher socioeconomic status more often opt to utilize non-VA mental health services. These authors argue that “the existence of VAs themselves probably accounts for why socioeconomically disadvantaged veterans do not face the same level of healthcare shortages that non-veterans face” (p. 866). It appears that access to VA health care provides individuals an additional resource important to quality of life and well-being related to their status as veterans of the US Armed Forces.

Veterans share the experience of having served in the US Armed Forces, but what does this shared experience mean for their sense of identity as veterans, both individually and as a group? As discussed earlier, veterans are a heterogeneous group reflecting the ethnic and racial diversity within the United States, dispersed geographically, and inhabiting a wide range of income levels from the highest levels of government and corporate positions, the professional and working classes, and the disabled and homeless. Yet, veterans have shared an experience of service within a military culture with a common set of values, traditions, and expectations for behavior. Thus, understanding the shared values of the military will be helpful in increasing the effectiveness of clinicians working with veterans, particularly for veterans in low-income situations and homeless veterans.

The US Armed Forces consists of the Army, Navy, Air Force, Marines, and Coast Guard. All of the branches of the military are under the direction of the Department of Defense with the exception of the Coast Guard, which is under the umbrella of the Department of Homeland Security. As of March 2012 the US military boasts approximately 1.5 million active duty service members and an additional 1.2 million reservists (US Department of Defense, 2012). The US military is the second largest in the world, second only to the People’s Liberation Army of China (PLA).

The average US soldier is 22 years of age, has served 4 years in the military, has earned a high school diploma, earns $1,978.50/mo, and is married with two children. The majority of military personnel are enlisted (approximately 84%), with 2% holding the rank of warrant officer (an individual ranked as an officer above the senior-most enlisted ranks; highly skilled, single track specialty officers, e.g., pilots), and 14% holding the rank of commissioned officer (highest ranks; requires a bachelor’s degree or higher).

Since the establishment of the Army, Navy, and Marines in 1775 to meet the demands of the Revolutionary War, the preparation for and conduct of war has been the military’s central purpose. The armed forces train themselves and are organized around their combat roles, distinguishing between combat arms and other support activities (e.g., disaster, peacekeeping missions, and humanitarian relief efforts; Dunivin, 1994). Beginning with basic training (a.k.a. Boot Camp), new recruits are put through 6–12 weeks (depending on the branch of service) of rigorous training to prepare them for the physical, mental, and emotional elements of military service. New recruits are pushed to, and beyond, their physical limitations and are rewarded for persisting in the face of discomfort and/or pain.

As an institution, the military has historically been, and continues to be primarily male-centric with soldiering being viewed as men’s work; a paradigm that has been dubbed the combat, masculine-warrior (CMW) paradigm (Dunivin, 1994, 1997). Within this paradigm, masculinity and traditional gender roles continue to hold a highly valued role within the armed forces. This is no more clearly stated than by Lieutenant Colonel Karen O. Dunivin, in her article “Military Culture: A Paradigm Shift?”

The US military defines itself as a combat, masculine-warrior organization—a characterization that, by definition, excludes members who do not perform combat roles (i.e., many women) or who are not perceived as masculine (gay men). From its CMW paradigm, military culture fosters traditional gender roles (i.e., distinct masculine and feminine roles) and embraces heterosexuality.

Characteristics such as emotional control, autonomy in coping with problems, aggression, sexual prowess, and bravado are all associated with a recruit’s ability to perform his duty and fit in with his fellow service members. On the one hand, the CMW paradigm has served the military and nation well, producing well-trained soldiers who win wars. On the other hand, the CMW continues to marginalize of any service member, male or female, who does not adhere to these traditional roles.

In 2009, women made up 14% of active duty enlisted personnel, 16% of active duty officers, and 21% of reservists (National Center for Veterans Analysis and Statistics, 2011). Although the role of women in the armed forces has evolved from serving primarily as nurses, operators, and clerks in World War I and World War II (Women in Military Service for America, n.d.) to being permitted to serve aboard combat vessels and pilot aircraft engaged in combat missions in the early 1990s (Women in Military Service for America, n.d.), the Department of Defense continues to bar women from direct ground combat (National Center for Veterans Analysis and Statistics, 2011). It should be noted, however, that this regulation means little as the reality of the fuzzy frontlines and tactics common to Desert Storm/Desert Shield and the Wars in Afghanistan and Iraq places female soldiers in the line of fire more than any past conflict (Lee, 2008). This reality has been captured by the documentary Lioness, which follows several female soldiers who were attached to all-male combat units with the aim of reducing cultural tensions resulting from men interacting with Muslim women. As stated by former Lioness, Staff Sergeant Ranie Ruthig, “We’ve had grenades thrown at us, shooting at us with AK-47’s. It’s a fight-or-flight thing. When someone is shooting at you, you don’t say, ‘Stop the war, I’m a girl’” (quoted in Lee, 2008).

Despite the restrictions placed on women in the military, the expansion of their role over the 20th and 21st centuries illustrate the slow, but present cultural shifts in the US military. The recent repeal of “Don’t Ask, Don’t Tell” (the military’s policy of removing military personnel for their sexual orientation) in December 2010 became effective September 2011, and represents another, current example of the military’s shift away from the conservative, hypermasculine ideal toward a more inclusive and accepting culture. The current tension between the traditional and the modern can be heard in the arguments that inclusion will lead to the reduced effectiveness and cohesion of combat units. Although specifically speaking of the introduction of women into combat zones, the words of retired Brigadier General Samuel G. Cockerham capture the fears associated with the evolving military culture: “the introduction of female personnel into the direct combat environment … is a giant distraction that would reduce the effectiveness of combat units across the board. I believe an all-male combat force is the most effective.”

Though each branch of the military carries its own set of core values, when talking more broadly about military culture, much of the literature has relied on James Burk’s assertion that military culture contains four elements: discipline, professional ethos, ceremony and etiquette, and cohesion (Burk, 1998). Each of these elements contributes to the shared experiences and camaraderie that provide order and continuity to what can be unpredictable circumstances of military life. Although all the other terms are straightforward, the element of professional ethos captures the set of normative beliefs that define an organization’s identity, code of conduct, and worth to the larger society (Snider, 1999). It encapsulates the soldier’s loyalty to his comrades, unit, and nation; his physical and moral courage; and his willingness to sacrifice himself to accomplish the mission. In the words of General Douglas MacArthur, “Yours is the profession of arms, the will to win, the sure knowledge that in war there is no substitute for victory; that if you lose the nation will be destroyed, that the very obsession of your public service must be Duty, Honor, and Country” (Snider, 1999).

As our service members transition from active duty status to veteran status, it will be important to examine how the military values they have strongly held help or hinder them in receiving much needed medical and mental health care. A growing body of research articulates the adverse consequences of men’s adherence to the traditional masculine ideal on health and mental health outcomes. Specifically, men who adhere to traditional gender roles are more likely to delay seeking treatment for cardiac problems (Helgeson, 1999). Additionally, traditionally masculine men have higher incidence of substance abuse (Blazina & Watkins, 1996; Mahalik, Lagan, & Morrison, 2006) and tobacco use (Mahalik et al., 2006). With respect to mental health, men who adhere to traditional gender roles report greater post-traumatic stress disorder (PTSD) symptom severity and anxiety sensitivity (McDermott, Tull, Soenke, Jakupcak, & Gratz, 2010), greater overt hostility (Jakupcak, Tull, & Roemer, 2005), and decreased willingness to seek psychological help (Smith, Tran, & Thompson, 2008).

The troops deployed to Iraq and Afghanistan face a variety of deployment and combat stressors. Of those deployed to a combat zone, 15% of soldiers and Marines returning from combat duty met criteria for PTSD. Increased rates of depression and anxiety were also observed 12 months postdeployment; however, only 40% of those who identified an interest in seeing someone for alcohol, stress, family, or an emotional problem actually sought help. In a study exploring the reasons veterans do not seek help, 65% identified fear of being perceived as weak, 59% feared that their unit would have less confidence in them, and 63% said that their leadership might treat them differently or blame them for the problem (Castro, Hoge, & Cox, 2006). Although not overtly stated, the values of physical and emotional strength, courage, self-reliance, and emotional control can be seen in the veterans’ hesitance to seek help.

In response to the needs of returning veterans, one way that the military has attempted to normalize help-seeking is through the concept of battlemind (Castro et al., 2006). Battlemind training was designed by the US Army to build soldier resiliency, increase self-confidence, and normalize help-seeking for the myriad mental health issues that can arise from exposure to the atrocities of war. Training consists of both predeployment and postdeployment classes to help soldiers meet the challenges of combat and returning home. Postdeployment training in particular seeks to normalize the common reactions to, and symptoms resulting from, combat; encourages soldiers to monitor their own and their peers’ mood; and encourages them to seek help when needed. It seeks to reframe the image of strength, courage, and leadership to decrease potential stigma and increase the likelihood that returning troops will seek mental health assistance when needed. The key message of this training is that, “It takes courage for a soldier to ask for help, and it takes leadership to help a fellow soldier get help.”

In addition to familiarity with the concept of battlemind, other tools for engagement include the clinician’s developing some knowledge of the basic aspects of military values and culture discussed here. In addition to the information provided here, there are several good online resources available for more information about branches of the military, the rank system, and military code of conduct. A nonexhaustive list of those resources will be provided at the end of this chapter. The next section of this chapter begins the transition from information provision to clinical application and seeks to provide mental health clinicians and researchers with specific guidance in the assessment of military veterans. In approaching the final sections of this chapter, clinicians should keep in mind that the social class and the socioeconomic status of veterans vary widely in this heterogeneous population, and that an individual’s experience in the armed forces and as a veteran appears to lend both protective as well as risk factors for social and psychological functioning. Moreover, the subjective sense of veterans of belonging to a separate and special class of Americans (those who have served in the armed forces) can be an important factor in a veteran’s self-image, deeply held values, health behaviors, and style of coping.

The authors of this chapter have assumed an audience of mental health professionals and researchers who are not veterans and who do not currently work within veteran-only settings, but want more guidance about how to understand and work with veterans or are seeking to increase their clinical or research work with veterans. Other chapters in this volume will present in greater detail more general issues related to social class and assessment, diagnosis, treatment, psychotherapy process, and men’s issues, all of which are relevant to working with a veteran population. In this section, the authors will outline important assessment issues specific to veterans, particularly those related to their service, readjustment to civilian life, and at-risk conditions.

The VA Office of Academic Affiliations developed the Military Health History Pocket Card as a resource to front-line health and mental health providers, particularly those in training at VA medical facilities. This resource guides clinicians in developing rapport with veterans and assessing and understanding veteran-specific problems and complaints (US Department of Veterans Affairs, 2012). In addition this baseline assessment can guide further treatment planning and referrals. The following are the initial open-ended questions all clinicians should ask of veterans, followed by suggestions of additional information to obtain:

Conveying an understanding of the veteran’s military experience contributes to the establishment of initial rapport. In addition, the veteran’s responses to the above questions provide clues to possible exposures to combat, trauma, and environmental contaminants, for example, as well as to their experience in the military based on occupation, rank, and status. The clinician can then proceed with asking more sensitive questions, such as those below:

If the veteran answers “Yes” to any of these questions, follow up with an open-ended query: “Can you tell me more about that?” and “Is this causing you any problems now?” For mental health providers, this initial assessment can segue into a more general assessment of symptoms of stress-related conditions, such as acute stress reaction or PTSD, symptoms of anxiety and depression, adjustment to civilian life, quality of relationships, and presence of social support. Given the high risk of homelessness among veterans and the likelihood of veterans’ having come from working-class backgrounds with fewer individual and family resources, clinicians should also assess the veteran’s economic resources and stability of living situation.

Since many readers of this chapter may not be working within exclusively veteran-focused treatment settings but may be working with veterans in other settings such as community clinics or college counseling centers, two case examples are provided in this section that illustrate common pathways of social disconnection, poverty, unemployment, and homelessness that some of the most at-risk veterans face. The case examples are composites of patients treated by the VA Palo Alto Health Care System Domiciliary Service. The challenges in providing effective interventions are discussed and the treatment strategies used to address the multiple psychosocial problems presented by these veterans are described.

Both Martin and Gerald entered the military as the better of the other life choices available to them at the time of enlistment. They both benefited in treatment from increased awareness and exploration of the social class values of their families of origin. For Martin, articulation of the expectations of his working-class family allowed him to understand both his family’s disappointment in him and his sense of having failed to reach important life goals. At the same time, he became more aware and occasionally even accepting of his ambivalence to live “a normal life” as defined by the social class values of his family. For Gerald, exploration of the social class values of his African American working-class family allowed him to rediscover and internalize the positive aspects of family, faith, and hard work that were exemplified by his mother prior to her downward spiral into substance abuse and sex work. These values became a prosocial alternative to the values and behaviors learned from living in the dangerous environment of the streets, illegal activity, and prison. The therapeutic work with both these cases suggests that an examination of, and self-reflection by, veterans of their past and present social class experiences can illuminate the values by which they can choose to guide their future behaviors and life paths.

In working with veterans who come from all backgrounds and socioeconomic levels, but whose formative years were often spent within the intensely masculine environment of the military, clinicians should view veterans as a distinctive yet heterogeneous cultural group, while being cautious in responding to stereotypes about veterans. Both male and female veterans often derive a strong sense of identity from military culture, particularly the military’s emphasis on strength and stoicism, which can present barriers for veterans in seeking both health and mental health care.

In addition, the review of veterans’ socioeconomic status and educational and income attainment presented earlier in this chapter suggests that, while many veterans are doing as well or sometimes better than their nonveteran peers on objective measures of socioeconomic status, there are subgroups of veterans who are at high risk of underemployment, homelessness, social isolation, and poor health and mental health outcomes. These veterans may include those coming from disadvantaged social backgrounds as well as the youngest cohorts of veterans facing one of the most challenging economic and employment climates in decades. Often, veterans are at their most vulnerable to the above risks during the transition from active duty to civilian life. The Department of Veterans Affairs has developed special programs to address issues of readjustment, as well as longer-term problems faced by low-income, disabled, and/or homeless veterans, and veterans with multiple legal problems or lack of employment.

Clinicians encountering veterans in non-VA health and mental health settings can educate themselves on basic information about the military, military life, and military values, so as to develop rapport with veterans during initial assessment. Included in the nonexhaustive list of resources presented at the end of this chapter, the Department of Veterans Affairs provides online resources (www.mentalhealth.va.gov/providers/index.asp) to disseminate the VA’s knowledge in behavioral health care for mental health professionals working with veterans. The Center for Deployment Psychology (CDP) also maintains a website (www.deploymentpsych.org) which offers online courses such as “Military Cultural Competence,” which provides an overview of military culture. The CDP also offers in-person behavioral health training for civilian providers at various US locations throughout the year, including workshops on evidence-based treatments to address psychological issues of active duty service members and veterans.

In addition, consistent with the literature on working with men in therapy, examining the consequences of a rigid adherence to masculine gender norms in their lives and relationships, as well as giving veterans permission to be vulnerable and express their emotions, is crucial to effective treatment. Often, reframing a veteran’s emotional expression and vulnerability as “having the strength to face your fears” or “having the courage to cry” can allow the veteran to derive benefit from therapy while holding on to positive aspects of their identity. The VA’s current Suicide Prevention Program illustrates such an approach through their public message of “It takes the courage and strength of a warrior to ask for help” when encouraging veterans to seek assistance for suicidal ideation before acting, often fatally, on such thoughts. Similarly, the VA developed a recent public health campaign including posters and brochures showing a veteran with two medals and a hand over his heart, with the message “Be courageous again. Get tested for HIV.”

Non-VA clinicians should also have basic information about VA services, which are typically more comprehensive and targeted than those offered by community health or mental health settings. After an initial assessment and brief treatment of a veteran’s presenting problem, clinicians should educate veterans about how to access VA services, allowing the veteran a choice between public, private, and VA treatment. For low-income and homeless veterans in particular, VA services specially designed for these individuals are likely to be of significant assistance to them. The Department of Veterans Affairs maintains a useful website (www.va.gov) that provides clinicians and veterans information about VA services by type of service and geographical region.

Veterans adhering to a strong masculine gender identity and/or strong internalization of military values would benefit from therapy that assists them to understand their own cultural/subgroup norms and values, and then encourages them to more flexibly apply or enact these values (e.g., Burns & Mahalik, 2008; Mahalik, Good, & Englar-Carlson, 2003). For example, veterans whose physical strength and abilities may be limited by chronic illness, pain, or disability may be encouraged to seek alternative ways to live their values, such as emphasizing success or performance in other areas of life. Veterans would also benefit from an examination of maladaptive behavior patterns related to masculine gender norms, including health risk behaviors (e.g., poorer diet, decreased exercise, alcohol misuse) and lower adherence to medical recommendations (e.g., not seeking health or mental health care, not following through with treatment plans). Techniques such as motivational interviewing are helpful in reframing self-care in terms of gaining strength and functionality. For example, “on one hand, you like eating prime rib; on the other hand, you want to lose weight so that you can get stronger and do things you used to enjoy, like camping and hunting.”

Moreover, veterans would also benefit from ways to provide help to others as they did while in the military. Such activities are consistent with a culture of service and could both validate their identity as a military veteran and provide opportunities for reengaging in the camaraderie and connection with other veterans that they experienced in the military. Examples include volunteering with Disabled Veterans of America (DVA) or the local VA medical center, getting involved with the local chapter of Veterans of Foreign Wars (VFW) or the Wounded Warrior Project, or helping other veterans struggling with substance abuse, PTSD, or transitioning from military to civilian life.

Finally, when working with veterans on an individual level, it is vitally important for clinicians to communicate an understanding and appreciation of their service and their invaluable contributions to American society.

The Department of Veterans Affairs continues to study the veteran population closely, in order to better understand the changing needs among this highly diverse group and to develop and implement intervention programs to prevent and ameliorate health and psychosocial problems faced by veterans. In this chapter, the authors attempted to examine and discuss some of the intersections among social class, social group membership, and socioeconomic status in the veteran population, as well as present information about veterans and veteran-specific services provided by VA that may not be known by non-VA providers.

It is clear that, within the veteran population, there are many highly functioning individuals who have contributed, and continue to contribute, positively to American society, as well as those who are represented among the most vulnerable and needy. When viewed across all cohorts, veterans as a group experience relatively successful occupational functioning following their service in the armed forces, likely contributing to greater social and psychological functioning, social mobility and employment opportunities, and positive self-images as productive members of society and providers for their family. However, some veterans, especially those targeted by the Veterans Health Administration, also face risks of poorer health and well-being related to disability, homelessness, legal problems, and poverty. Younger cohorts of veterans serving since 2001 may also be facing special challenges in today’s difficult economic and employment climate and may be at higher risk for psychosocial problems and poorer social, psychological, and economic functioning.

In addition, different cohorts of veterans have represented different segments of the US population, with the most dramatic change resulting from the end of the draft in 1973. Since then, it appears that a significant number of volunteer enlistees in the armed forces are drawn from lower-income and working-class groups. However, there is limited information about the subjective experience of social class among all enlistees. One goal of basic training and assimilation into the military is to erase individual and social class differences among recruits; therefore, the common experience of having been part of the military can lead to the subjective sense of being part of a special social group (i.e., veterans) with strongly held beliefs and values, and a unique worldview.

Since recommendations for clinicians have been presented and discussed above, recommendations for future directions in research with veterans are presented here. Research with veterans should pose and answer some of these questions: Can aspects of military service serve as protective factors for veterans’ health and mental health outcomes? Which factors lead to subjective well-being as well as objective measures of social, occupational, and economic success or failure? What are individual veterans’ subjective sense of their social class and accompanying values, beliefs, and worldview? How might an enlistee’s social class worldview contribute to, or interact with, military culture? Also, while some research has addressed how some aspects of social class and military culture relate to help-seeking, coping, and health and mental health outcomes, more work is needed in these areas, particularly when social class and military culture interact in the lives of individual veterans. Results of such research can lead to more informed service delivery systems and intervention programs to better improve the health and well-being of our nation’s veterans.