Advice to the therapists working with military families
The military conflicts in Iraq and Afghanistan mark the first time in our nation's history of military service that we have attempted to maintain such an involved forward deployment with an all-volunteer force. To date, about 1.8 million troops have been deployed. This translates into 2.7 million family members who have experienced separation from their service member for extended periods of time.
The experience of deployment can be divided into three distinctive phases, each with its own associated stressors and emotions:
- First, predeployment begins when the service member receives his or her orders. It typically involves extended training and preparation for the upcoming mission. Families may become more distancing and argumentative during this phase of deployment as they vacillate between denial and sadness about the service member's departure.
- Second, deployment occurs when the service member begins his or her actual mission in or in support of the theater of war. Families typically experience a wide variety of emotions during the actual deployment including relief, sadness, numbing, or anxiety. These emotions can shift into feelings of independence and control as the deployment wears on.
- Finally, reintegration occurs when the service member returns to the United States and is reunited with his or her loved ones. This period may start as a honeymoon, but end in the reality of renegotiating roles and getting to know each other once again.
Service members ranked deployment length and family separation among their top noncombat-related stressors. Other studies have documented the impact of deployment on family members, noting the shifts needed for adjustment. For some children and youth, parental deployment has been associated with depression, anxiety, lower grades in school, and increased familial conflict. Deployment has also been linked to depression, anxiety, isolation, and sadness for some nondeployed spouses. Not surprisingly, the adjustment of the at-home parent (the nondeployed spouse) has repeatedly been shown to have the greatest impact on the overall adjustment of the children.
Depending on their geographic location, service members and their families can have access to a wide variety of mental health supports. These supports can include counseling through behavioral health, chaplains, or Military OneSource. Despite the availability of supports and the documented impact of the stressors of deployment, studies suggest that service members and their families are often hesitant to seek mental health services. Service members cite concerns about confidentiality, fear of appearing weak, and negative repercussions on career advancements (including threats to security clearance) as reasons for not seeking mental health support when needed.
Therapists outside the military community can be a valued support to service members and their families precisely because they are unaffiliated with any military branch. This nonaffiliation can be helpful in assuring confidentiality but it may also be accompanied by a lack of understanding about the military culture, which can compromise the therapeutic alliance.
Understanding Military Culture
How can therapists become the "inside" outsiders for service members and their families? The following suggestions are designed to familiarize the militarily naive therapist to the military culture and potential issues of special concern for military service members and their families.
One of the most important things to recognize when working with military service members or their families is what has been termed the "warrior ethos." Service members and their families pride themselves on their strength and ability to successfully confront challenge. The notion of asking for help or support often carries with it the stigma of weakness. In our studies, service members have reported concerns about appearing weak in front of their peers or commanders; commanders have reported concerns of appearing weak to their subordinates. In a culture where respect and teamwork reign, such fears are not unwarranted. No one wants to be considered the "weakest link" and many believe their families to be a direct reflection on them. These beliefs, which help make our military strong, can also place service members in a double bind when they do find themselves in need of support,€ˆespecially when that support entails mental health services. It is imperative that therapists have an awareness of this tension if they are to successfully work with military service members and their families.
As with any culture, the military has its own set of acronyms and terms that flow throughout their everyday conversations. While it is not necessary to become completely fluent in "military-ese," an understanding of common terms can go a long way in establishing a therapeutic alliance. Several websites provide excellent primers in this regard (e.g., http://www.militaryfamily.org/info-resources/). Some frequently used terms include: OEF (Operation Enduring Freedom); OIF (Operation Iraqi Freedom); PCS (Permanent Change of Station€ˆor moving to a new location); TDY (temporary duty going away for a conference, education, or training); MOS (Military Occupational Specialty); CONUS (located in the continental United States); OCONUS (located outside the continental United States); IA (individual augmentee, a service member who is deployed with a unit other than the one with whom he or she has trained); FRG (Family Readiness Group, provides support for spouses and families left behind, especially during deployment); and "in theater" (in the location of the conflict or battle).
Each service branch brings with it its own culture and pride. Each specializes in different contexts of battle (land, sea, sky) and each operates different lengths of deployment, ranging on average from 6-15 months. Identifying service members by their proper branch is a sign of respect. For example, those in the Army are called soldiers and their installations are referred to as forts or posts. Those in the Navy are called sailors and their installations are referred to as bases. Marines are affiliated with the Navy but are referred to as Marines. Those in the Air Force are airmen or airwomen and their installations are also called bases. Referring to someone in the Army as a sailor or to someone in the Navy as a soldier lessens the therapist's credibility and can be interpreted as disrespectful.
A service member's rank can provide information about his or her education, income, and job description. For example, those in the enlisted ranks usually have no prior college degree. Commissioned officers have either completed a college Reserve Officers' Training Corps (ROTC), a degree from a U.S. service academy, or officer training school. Noncommissioned officers have ascended up the ranks from enlisted to enlisted officer status, but they still remain part of the enlisted culture. In establishing a therapeutic relationship, it is important to acknowledge the rank initially (as a sign of respect), then to make it clear to the client that you view him or her as a person, rather than a position.
Several specialized areas of assessment may be needed in working with military service members and their families. Note that these suggestions are meant to supplement regular assessment of strengths and social supports as well as issues of depression, ATOD, violence, and the like as appropriate for the presenting issue.
Ask the service member about his or her experience with deployment. Ask specifically about combat exposure and trauma exposure. Estimates are that between 77%-87% of OEF and OIF veterans had combat exposure (i.e., shot or were shot at). Thus the vast majority have been involved in or witnessed trauma but may not be willing to share this information unless explicitly asked. The service member and his or her family need to know that you are aware of the reality of combat exposure and that you can handle hearing about it.
Depression and Suicide
The growing rate of suicide in the military has received increased attention. Given the warrior ethos, it is not surprising that service members would be hesitant to talk about suicidal ideation even if it were occurring. Again, be specific in asking about this.
Many service members may be experiencing survivor guilt. "Why did my comrade step on the IED and I didn't?" "Why did their convoy get attacked and mine didn't?" It is important to explore this issue and to help the service member make sense of the experience and surrounding feelings.
History of Trauma (Military and Nonmilitary)
As suggested above, ask about trauma exposure experienced during deployment. But don't limit the inquiry to this period of time. According to Seifert and colleagues (2011) 46% of service members report a history of childhood physical abuse; 25% report both physical and sexual abuse. Those who experienced both have a higher rate of developing PTSD. Additionally, for female service members, it is important to query about their experiences of sexual harassment or assault during deployment. Murdoch and colleagues (2003) reported that incidents of sexual harassment were reported by 80% of the military women in their study. In other studies, researchers have suggested that 28%-30% of female service members have experienced a rape while in military service.
Such experiences may be particularly difficult for female service members to make meaning of, given that the assault came from those who were supposed to be on their side.
Check for symptoms of PTSD, noting even subclinical levels and their impact on the service member's behavior and interactions with others. Also be mindful of the impact of vicarious trauma among family members of service members.
Assess the client's use of licit, illicit, and prescription drugs. Remember that admission of use of illicit drugs can be grounds for discharge, so service members may be particularly hesitant to be honest about their use. Don't forget to ask about prescription drug use, both in theater and at home. Spouses may also have turned to drug use as a coping response during the deployment.
Check with service members and spouses about their sleeping habits. Disrupted sleep can be sign of PTSD and other issues.
Check to see how service members are managing any issues with anger. Are they verbally lashing out at family members? Are they being physically aggressive with others or getting into physical fights?
Many returning service members report difficulty adjusting to "normal life." After having survived at a heightened sense of alertness for such an extended period of time, a service member may be tempted to engage in risk-taking behaviors in an effort to get the adrenalin rush that was such a part of everyday experience in theater. These behaviors may be consciously intentional or not, but can include driving recklessly, not wearing a motorcycle helmet, drinking too much, engaging in fights, and taking other chances.
How often were the service member and spouse able to communicate during deployment? How well do they communicate now that the service member has returned home? Look for changes from predeployment to reintegration phases.
Infidelity (Physical and Emotional)
During long separations, the threat of infidelity is high on both service members' and spouses' minds. Normalizing these concerns and assessing for extramarital relationships is important. Note that such relationships can be Internet-based, with emotional attachments formed at long distances or in person. Unprecedented access to the Internet and cell phones even in theater makes such concerns real. Be ready to assess for Internet pornography use and potential addiction.
It is not uncommon for families to experience great changes in their family income during deployment. Finances can often become a point of tension. How have money issues been handled during the deployment? Are couples able to communicate about their needs and the status of their finances?
Youth Internalizing and Externalizing Behaviors
Explore changes in behaviors and emotions among the children in military families. Falling grades, withdrawal, depression, anger, and sleep issues are all common responses to deployment. Some studies suggest that youth have more difficulty with the reintegration phase of deployment than do parents, in part because they are concerned about the potential for redeployment.
The need for military-savvy therapists has never been greater as the stress of repeated deployments takes its toll. Knowing something about the culture and specific issues can go a long way in brokering the relationship of mutual respect needed for a successful therapeutic experience.
Contact Angela Heubner at [email protected]