Military Culture and Post-Military Transitioning Among Veterans: A Qualitative Analysis

Wesley H. McCormick, Joseph M. Currier, Steve L. Isaak, Brook M. Sims, Brett A. Slagel, Timothy D. Carroll, Karl Hamner, & David L. Albright Abstract While a considerable amount of theoretical literature has explored core values and characteristics of the US Armed Forces, limited empirical research has examined veterans’ accounts of military culture. To elucidate military culture and help inform ongoing efforts to incorporate military culture into the provision of healthcare services for veterans, seven focus groups (n = 44) were conducted with diverse groups of veterans to provide their first-hand accounts on these topics. Content analysis of their responses yielded four broad clusters: (1) descriptions of military culture and values (e.g., patriotism, camaraderie, discipline); (2) conflict with values during military service (e.g., betrayed by politicians and/or bureaucracy, internal conflict of killing); (3) cultural changes post-military service (e.g., continuity of military culture, disparate from civilian culture, interpersonal difficulties); and (4) communication with non-military connected persons (e.g., I do not talk about military experiences, I only talk with other veterans). The results expand upon prior conceptualizations of military culture and provide preliminary implications for integrating military culture into healthcare service provisions for veterans. Furthermore, this study highlights the need for further empirical research on the internalization and longer-term impact of military culture to better address the needs of US military veterans.


Introduction
The importance and troubling nature of the cultural gap between American civilian society and its military are longstanding (Feaver & Kohn, 2000). Despite the longstanding recognition of the gap as a problem and calls for action to reduce it, the gap has, if anything, increased over time. A large percentage of veterans returning from Operation Enduring Freedom/Operation Iraqi Freedom (OIF/OEF) report serious struggles with their transition to civilian life, and the culture gap plays a significant role in creating those struggles (Pease, Billera & Gerard, 2016). Developing clear understandings of military culture is crucial for honoring veterans' core values and beliefs in the delivery of healthcare services. Military culture represents the value structure that guides conduct in the military and promotes expressions of collective identity (Brim, 2013;Wilson, 2008). However, the intersection of this encompassing value structure with individual veterans' values is much more complex. Indeed, military culture exists both in the tenets espoused at the group level as well as the distinctive, idiosyncratic level of the individual veteran. To help enhance current theoretical conceptualizations of military culture, the current investigation utilized veterans as cultural informants to elucidate military culture and the role it plays in military-to-civilian transitions.
Consisting of both explicit (e.g., organization, roles, rituals, creeds, and symbols) and implicit (e.g., values, ideals, discipline, and etiquette) elements (Brim, 2013), military culture is characterized by unique norms, philosophies, customs, and traditions that differentiate the United States (US) Armed Forces from other organizations (Collins, 1998). Being inculcated through a hierarchical, authoritarian structure with clear order and repetitious responsibilities, military culture promotes cohesive identity among service members (SMs) and ensures mission readiness (Hall, 2013;Soeters, Poponete, & Page, 2006;Wilson, 2008). Furthermore, to fulfill its unique role of serving national interests through the enactment of war (Dunivin, 1994), the military strives to immerse SMs into its particular way of life by having SMs train, work, and often live in isolation from civilian culture (Collins, 1998;Hall, 2011;Redmond et al., 2015;Soeters, Winslow, & Weibull, 2003). Nevertheless, the military must execute its mission while remaining consistent with the beliefs and values of the larger society it is entrusted to serve (Riccio, Sullivan, Klein, Salter, & Kinnison, 2004;Soeters et al., 2003). Considering the potentially arduous task of balancing military and civilian cultures, further research is needed to delineate the characteristics of military culture while exploring veterans' experiences with military culture during and after service in the US Armed Forces.
Efforts exist to increase awareness and sensitivity toward military culture in healthcare and mental health professions (e.g., Canfield & Weiss, 2015;Kuehner, 2013). For example, the Department of Veterans Affairs (2018) and Center for Deployment Psychology (2018) have each developed training programs to promote competence regarding military culture and encourage healthcare providers to assess for military cultural factors that may impact receptivity to and engagement with healthcare services. Notwithstanding these efforts, empirical research is needed to advance conceptualization of military culture from veterans' perspectives. Such empirical research could augment the growing literature (e.g., Lancaster, Kintzle, & Castro, 2018) by promulgating the firsthand perspective of key stakeholders in military culture.
Possessing distinct attributes from civilian culture, military culture requires special consideration to facilitate cultural competence during the provision of healthcare services for veterans. However, current understandings of military culture are primarily theoretical and limited information is available regarding how military culture may affect veterans, over time. Thus, two research questions were developed for the current study: 1) How do veterans, as primary stakeholders, define military culture, and 2) how might military culture affect individuals over time?
In striving to answer these questions empirically, the current study uses veterans' self-reports of intra-and inter-subjective experiences to describe military culture and explore veterans' perceived continuity with military culture during and after their military service.

Participants and procedures
Data for this phenomenological study were collected as part of a needs assessment project conducted to determine perceived gaps in services and unmet needs among veterans and their families in an eight-county region in Southwest Alabama. (See  for a detailed account of project.) Following approval by an institutional review board, focus group interviews were conducted with distinct cross-sections of the overall veteran population in this region. Participants for the focus groups were recruited from veteran organizations (e.g., Veterans of Foreign Wars, Student Veterans of America) in the study region. In total, seven focus groups (ranging from three to 13 participants) were conducted with 44 veterans. These veterans were predominantly men (81.4%), Caucasian (57.1%), and ranged from 25 to 72 years of age with a mean age of 50.57 years (SD = 14.54). The largest proportion served in the Army (42.5%) with representation from the Navy (27.5%), Air Force (17.5%), and Marine Corps (12.5%).

Qualitative interview
Each focus group was conducted by one or two members of the research team and lasted 45 to 120 minutes. The research team was intentional about developing rapport and collaborative relationships with the local veteran organizations prior to the interviews, including discussions of personal (e.g., veteran status of some research team members) and professional (e.g., specialization of research team members in veteran health) motives in developing the project. The interview format was semi-structured, consisting of open-ended questions with prompts to encourage elaboration and/or clarify responses (e.g., "Please say more about that."). When requested, explanations of terminology used in the questions were provided to the focus groups. The current study examined the focus groups' responses to seven items: • What does "military culture" mean to you?
• What are the values or beliefs that you associate with the military/military service? • How did the most difficult aspects of your military service conflict with these values and beliefs? • How do you experience daily personal life since exiting the military? • How has your sense of cultural identity changed since exiting the military?
• When considering the most difficult aspects of your military service, how have your relationships and well-being been affected? • Military service may entail witnessing or doing things that might be misunderstood or viewed as wrong. In reflecting on your own experiences, how have you addressed these possible conflicts with persons outside the military?

Data analytic plan
The focus groups were audio recorded and transcribed by a professional transcription service. Content analysis (Creswell, 2007) was conducted to derive a comprehensive list of themes discussed across the focus groups. A formal code was developed by condensing similar themes into parsimonious categories. The transcripts were then independently coded (k = 0.76) in NVivo 11 by two psychology graduate students, and discrepancies were resolved via consensus method.
Results In total, 10 superordinate categories and 41 themes were nested into four broad clusters: a) descriptions of military culture and values, b) conflicts with values and beliefs that occurred during military service, c) changes or difficulties that were encountered after military service, and d) communication of military experiences with non-military persons. Descriptions of themes within each superordinate category are provided below, and a comprehensive list of qualitative themes with their respective extensiveness (E) statistics can be found in Table 1 (see appendix).

Descriptions of military culture and values
Individual character. Nine themes were identified that described what military service meant to the participants. The most common theme, Patriotism/Service to Country, was used 15 times across the focus groups. Responses were often succinct, such as "patriotism" or "honor, duty, country." One Army veteran stated, "Being a soldier, the patriotism is there. The love for our country is there. Like I said, the discipline that you have to be a good citizen." Other prominent themes included Honor/Integrity (E = 10), Discipline/Hard Work (E = 17), and Pride (E = 9). Responses often included various combinations of the three. For example, a veteran in her late 20s stated, "Honor. Pride. A team, a unit, working together, having pride in your work. Always working hard." Participants also discussed the themes of Courage/Confront Mortality (E = 10; e.g., acceptance of potential death in the line of duty and/or willingness to face exceptionally difficult, often lifethreatening situations) and Mission First/Overcome Adversity (E = 6; e.g., persevering in the midst of suffering; prioritizing the mission over self).
Relational character. A single theme, Camaraderie, captured the essence of relational character within the military. This theme was identified 75 times across the focus groups, capturing an appreciation for mutual trust, friendship, and individual differences between members of the US Armed Forces. Within this theme, there was also an emphasis on developing camaraderie, trust, and respect. For example, an Army veteran in his late 40s stated, "I was taught there is no race; everybody is related. Everybody's your brother, because at that time, you don't know who's gonna save your life, so we are all the same." Systemic character. Four themes described organizational facets within military culture. Order, Structure, and Training was a common theme within this category, being used 19 times across the focus groups. A response from an Air Force veteran in her 30s particularly captured this theme: "Just the military way of doing things, from the uniform to the core values that each service has, their own traditions, the language, the heritage, and ways of doing things." The theme of Generational Differences was used 32 times but was only discussed in two of the focus groups, which were composed mostly of older veterans. This theme captured the difference between being drafted and volunteering for military service, in addition to divergence of values and training between service eras. Two focus groups also discussed systemic issues regarding sexism in the US Armed Forces (E = 7), describing how women were treated differently from men and/or experienced hostile work environments without institutional support.

Conflict with values during military service
Betrayals. Three themes were identified that described how veterans might feel betrayed by their government, military leadership, and society during their military service. The most common theme, Betrayed by Leadership/Superior Officers, was used 19 times across the focus groups. An Air Force veteran in her 50s stated, "Our site commander wanted us to do something that was not according to our regulation. Because four or five of us chose not to participate, we were disciplined. We knew it was wrong and were not going to participate." Another common theme, Betrayed by Politicians/Bureaucracy, was used 17 times across the focus groups. One Marine veteran in his 70s stated, "The man in combat hates war worse than anybody.… They're fighting for Chevron. They're not fighting for any other purpose. If they grew carrots over there, we wouldn't be going." No conflict. Three themes were identified that captured how veterans might not perceive any betrayals or transgressions from their military service. The most common theme, Denial of Conflict, was used 10 times across the focus groups. Examples of this theme were typically succinct with participants stating they did not experience any conflicts of values or beliefs while in the military. Others described not experiencing conflicts with their values or beliefs because they were doing what was necessary to accomplish the mission. An Army veteran in his 70s stated, "I never had any conflicts whatsoever. You fight a war to win, and in Vietnam, we never had a mission that was not complete, and we never lost a battle." Transgressions. The two themes of Internal Conflict of Killing and Incongruent Behavior with Values captured how veterans might perceive violations of values or beliefs while in the military. Both themes were equal in prevalence, each being used six times across the focus groups. A veteran in his 70s described the conflict of killing by stating, "It took me 20 minutes to squeeze the trigger on the very first person I shot, because those thoughts are going through your mind. This is somebody's son. This is somebody's father, brother. I mean, all this and, 'Thou shalt not kill.'" Some of the focus group members also noted perceived transgressions of/or lackadaisical adherence to military standards for behavior. For example, an Air Force veteran in her 30s recounted difficulties addressing behavioral issues with servicemembers under her command: "As a leader, it kind of ties your hands because, this airman or sergeant or whatever it is, has been disrespectful, has no honor for the uniform that they're wearing." Perceived changes post-military service Personal struggles. Nine themes captured how veterans can experience struggles as they reintegrate into society. The most prolific theme, Disparate from Civilian Culture, captured how civilian society possesses different values, character, and ways of living from the military. This theme was identified 76 times across the focus groups. One Army veteran in his 50s stated, "The civilian world, it's getting away with what you can. In the military, it's perform because you have other people counting on you. It's some kind of gap when you get out." Other themes included Interpersonal Difficulties (E = 38) and Divorce (E = 10). These themes captured how veterans can struggle to reintegrate into their families and communities after military service, becoming socially isolated and struggling without the camaraderie they enjoyed in the military. Mental Health Issues were also common, being identified 31 times across the groups. A Marine veteran in his 70s illustrated the themes of Interpersonal Difficulties and Mental Health Issues by stating, "A person close to you dies, and you can't grieve because you've got all this grief. Then all of a sudden, you get smacked between the eyes with PTSD and it about destroys your family. Like I said, I nearly lost my wife." Personal growth or continuity of military culture. Six themes captured veterans' perceived continuity of cultural identity or increased well-being after military service. The most common theme, Continuity of Military Culture, was used 34 times across the groups. A veteran in her late 20s emphatically stated, "I'll always be a veteran. I'll always live by their standards as much as I possibly can. It will never change." Additional themes included Appreciation of Cultural Support for the Military (e.g., "The people are behind us. That's making us feel better."), Altered Existential Values (e.g., "I think once you face death, your whole value of life changes."), and Improved Interpersonal Relationships (e.g., "I think that my military experience has strengthened my relationship with all of my family.").

Communication with non-military connected persons
Limited communications. Two themes described how veterans struggle to talk about their time in the military with civilians. The most prominent theme from this category, Civilians Do Not Understand, occurred 36 times across the focus groups. One veteran stated, "It's hard to adjust to civilian life after you get out. Your family, even though they are a military family, don't go through what you've been through. They don't know how to ask you what's wrong or get help." Additionally, I Do Not Talk About Military Experiences was used 18 times across the focus groups, often consisting of simply "I don't" when asked how they discussed their military experiences with civilians.
Limited help sources. Two themes captured how veterans might consider only a few help sources to discuss their time in the military. Both themes (Only Talk to Other Veterans, E = 7; Talk to Mental Health Professional(s), E = 3) were used sparingly. An Army veteran in his 30s stated, "I don't have anyone, outside of people I knew over there, that I can speak with because they won't understand what I just went through or they'll worry too much. So, you don't want that burden to be put on them, as well." Discussion Recent training initiatives (e.g., the Department of Veterans Affairs, 2018; Center for Deployment Psychology, 2018) address a need to provide culturally informed care to veterans. Seeking to bolster these programs, the current study examined qualitative descriptions of military culture and post-military transitioning across distinct cross-sections of veterans in Southwest Alabama. Across seven focus groups, veterans' responses coalesced into four distinct clusters of superordinate categories, providing preliminary empirical footing for defining key aspects of military culture that could equip providers to honor veterans' post-military values and beliefs.
The veterans of this study described their perception of military culture in the first cluster of themes. Many of the identified core qualities and values aligned with prior conceptualizations of military culture (e.g., Brim, 2013;Siebold, 2006). For example, patriotism was pervasive in veterans' responses, embodying a sense of nationalistic pride and belief that enlistment in the military enabled them to serve something greater than themselves (e.g., defense of Constitutional rights). Camaraderie was also highly prevalent in the group discussions, highlighting a sense of responsibility within the military to work together, regardless of differences in individual cultures or personal beliefs, to protect one another and accomplish mission objectives. The values and characteristics identified by the focus groups provide an empirical foundation for understanding how the "average" veteran may perceive and define military culture. Furthermore, the themes' extensiveness statistics, derived from the qualitative analyses, provides insight into the potential prioritization of military values among veterans.
Integrating these military values into the provision of services could lead to improved outcomes from various programs and treatments. Indeed, therapeutic paradigms, such as Acceptance and Commitment Therapy, emphasize the importance of understanding client values to foster valuecentered living as targets in treatment (Hayes, Follette, & Linehan, 2011). In medical care, increasing attention is focused on tailoring the patient-centered medical home (PCMH) to vulnerable populations to reduce the amount of time spent in an inpatient setting and lower costs associated with emergency care (O'Toole et al., 2011). Of note, assertive community treatment (Stein & Test, 1980;Bond & Drake, 2015) has demonstrated considerable effectiveness for veterans who live in moderately structured communities as part of their care delivery (Mohamed, Neale, & Rosenheck, 2009), perhaps, in part, due to the shared values with other members of the community and provider immersion within that community.
In considering assertive community treatment and tailoring the PCMH to veteran populations, heeding the values engendered by prior military service may be as important in fostering interpersonal connectedness and rapport with providers as in identifying targets of treatment. Along these lines of interpersonal connectedness and building on the core value of camaraderie articulated by veterans in this study, community-based interventions that incorporate veteran peers may be an important strategy to improve mental health outcomes. For example, research supports the unique benefits of veteran peer support specialists as an integrated component of treatment, with veterans reporting increased social and emotional support, stigma-reduction, and adherence (Hundt, Robinson, Arney, Stanley, & Cully, 2015). In addition, recent findings have indicated that veteran peer contact is associated with higher attendance and lower dropout during psychotherapy among a sample of 102 Post-9/11 treatment-seeking veterans (Goetter et al., 2018). Taken together, using peer supports within the context of a value-directed treatment approach may be a key for cultivating a community of recovery.
The second cluster of themes entailed military experiences that conflicted with the individual's or military's core values. Within this cluster, the veterans described experiences where they felt betrayed (e.g., betrayed by politicians/bureaucracy or leadership/superior officers) and/or perceived transgressions of values or beliefs by self and others (i.e., internal conflict of killing, incongruent behavior with values) during their military service. Such descriptions align with the emerging construct of moral injury. Within the moral injury literature, morally injurious experiences (MIEs) are defined as "perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations" (Litz et al., 2009, p. 700). Furthermore, Shay (1995Shay ( , 2014 has contributed a three-part definition of MIEs, suggesting these experiences consist of "(a) a betrayal of 'what's right'; (b) by someone who holds legitimate authority; (c) in a high-stakes situation" (2014, p. 183). Evidence suggests MIEs can lead to intra-and interpersonal distress (dysphoric moral emotions [e.g., guilt, shame, and anger] and negative cognitions [e.g., self-blame, distrust of others]; Currier et al., 2018) and impair psychosocial functioning among veterans (e.g., Farnsworth et al., 2014;Jinkerson, 2016;Kopacz et al., 2016). Veterans struggling from experiences that conflicted with deeply held values and beliefs may be reluctant to engage in help-seeking behaviors due to perceiving themselves as undeserving of "getting better" (shame-based cognitions) or mistrust of authority (e.g., US Department of Veterans Affairs, healthcare providers). By being aware of and sensitive to these types of intra-and interpersonal struggles among some veterans, healthcare providers could improve upon their customer service, promote development of outreach programs that encourage help-seeking behaviors, and increase implementation of motivational interviewing techniques which foster medical compliance (Rollnick, Miller, & Butler, 2008).
The third cluster of qualitative themes captured veterans' changes while transitioning to civilian culture post-military service. The veterans in the current study described a variety of examples for how they experienced personal struggles, personal growth, and continuity of military culture after separating from the US Armed Forces. Their descriptions of growth provide positive insight into post-military changes, including increased interpersonal relationships and/or more gratitude for their life after military service. However, several veterans also discussed a perceived disparity between themselves and civilian culture or reported interpersonal difficulties post-military service. Such struggles have been noted as impediments to successful reintegration post-military service (Sayer et al., 2010;Koenig, Maguen, Monroy, Mayott, & Seal, 2014). For healthcare providers, helping veterans navigate perceived cultural conflict and develop interpersonal relationships might foster adaptive transitioning post-military service. One targeted intervention to address these concerns may be encouraging veterans to engage in volunteer service activities within their community. Volunteerism has been shown to associate with decreased feelings of depression and increased help seeking behaviors among veterans enrolled in postsecondary education (Albright et al., 2019). Some work has also been done suggesting that mass media provides a narrow representation of what it means to be a veteran (Parrott, Albright, Dyche, & Steele, 2018;Parrott, Albright, Steele, & Dyche, in press), perhaps further creating barriers to successful integration. By increasing their activity and exposure in the community, veterans may promote community members' awareness of military culture and encourage more accurate perceptions of military culture in the community at large. Furthermore, assisting media outlets in providing more accurate portrayals of veterans and their experiences, as exemplified by organizations such as Got Your 6 (www.gotyour6.org), might foster wider acceptance and understanding of transition-related challenges many veterans experience.
Finally, consistent with prior research on help-seeking behaviors (e.g., Currier, Deiss, & McDermott, 2017;Currier, McDermott, & Sims, 2016), the fourth cluster suggested that veterans experience considerable ambivalence toward help-seeking, often preferring not to disclose military experiences with individuals who have not personally served in the US Armed Forces. The focus groups expressed that individuals without military experience are often unable to understand the experiences of veterans due to disparity between military and civilian life. Furthermore, our veterans expressed a willingness to seek help from mental health professionals due to the perception that they are professionally trained to understand and address military-related problems. These results highlight veterans' desire for healthcare providers to demonstrate military cultural competence. When veterans perceive providers as lacking competence of military culture, they may not seek treatment or discontinue services due to fear of stigma and/or perceived inability of others to understand their experiences. For example, Greene-Shortridge, Britt, and Castro (2007) outlined how cultural barriers and stigma, including societal and self-directed stigma, may interact to create circumstances wherein SMs and veterans are less likely to seek help.
Indeed, the American Psychological Association Task Force on Evidence-Based Relationships and Responsiveness highlights the considerable empirical support for attending to the psychotherapy relationship and matching appropriate interpersonal approaches in conjunction with evidence-based treatments (see Norcross & Lambert, 2018;Norcross & Wompold, 2011). Relatedly, a recent metaanalysis on patients' reactance level (low versus high avoidance/resistance) suggests therapy effectiveness is associated with clinicians' corresponding level of directiveness (Beutler, Edwards, & Someah, 2018). When considering the findings of the present study concerning possible situational and/or dispositional resistance towards treatment among some veterans, maintaining an open, reflective, collaborative, and transparent therapeutic posture (as opposed to more directive and/or structured approaches) may increase engagement and/or improve therapy-related outcomes. Moreover, conveying cultural competence could foster empathic understanding from civilian service providers, promoting rapport development with military veterans (Martin, Albright, & Borah, 2017). By providing education and resources to veterans for addressing perceived discrepancies between civilian and military cultures (Pease, Billera & Gerard, 2016), a two-fold approach could be enacted whereby collaborative healthcare is promoted and veterans' needs are addressed in a more effective manner.
The narratives collected from the veterans illuminate specific areas where healthcare service provision could be improved through consideration and integration of military culture. Nevertheless, this investigation had several limitations that need to be considered. First, the qualitative analyses provide preliminary insight into the components of military culture but do not support definitive theoretical or clinical implications. Additional research is needed to evaluate the effectiveness of integration strategies and treatments. This may include exploring providers' perceptions of military culture and tactics for improving awareness of mental health concerns among veterans. In turn, this could shed light on cultural misunderstandings that may exist between healthcare providers and the veterans they serve. A second limitation is generalizability. Because the focus groups were conducted with veterans living in Southwest Alabama, the results might not generalize to veterans in other regions. Notwithstanding these limitations, the current study provides initial practical implications to improve culturally competent care and tailoring services in the civilian sector. It is hoped these findings can support a foundation to meet the needs of those who have taken an oath to guard their nation and its way of life.