DSM, Psychotherapy, Counseling and the Medicalization of Mental Illness: A Commentary from Allen Frances

Jul 1, 2014 | Article, Volume 4 - Issue 3

Let us start with two important disclaimers. First, I will be identifying the many ways that the Diagnostic and Statistical Manual of Mental Disorders (DSM) system has been detrimental to psychotherapy and how the fifth edition (DSM-5; American Psychiatric Association [APA], 2013) will make the current situation even worse. However, this does not mean that I consider DSM diagnosis irrelevant to psychotherapy and counseling, nor do I believe that psychotherapists and counselors should neglect learning about diagnosis. I do not trust therapists who focus their contact with the client exclusively around the DSM diagnosis. Hippocrates believed that it is more important to know the person who has the disease than the disease the person has. Nevertheless, I also do not trust therapists who are completely free-form, impressionistic and idiosyncratic in their approach to clients. DSM diagnosis is only a small part of what goes into therapy, but it is often a crucial part. We need to know what makes each person different and unique; on the other hand, we also need to group clients with similar problems as a way of choosing interventions and predicting the treatment course.

The second disclaimer relates to the proper roles of medication, psychotherapy and counseling. The DSM has promoted a reductionistic medicalization of mental illness that, in combination with misleading drug company marketing strategies, has created a strong bias toward treatment with medication and against treatment with psychotherapy and counseling. I am greatly disturbed by the resulting enormous overuse of psychotropic drugs among both adults and children, many of whom do not need psychotropic drugs and would do much better without them. However, we must be equally alert to the fact that many people who need medication do not receive it. Psychotherapists and counselors are important gatekeepers who should recognize when medication is needed and when it is not. It makes no sense to be for or against medicating clients. It is crucial that medication not be used carelessly, but also essential to realize that it is sometimes absolutely necessary.

I will offer a brief history. Before the publication of the DSM-III (APA) in 1980, psychiatric diagnosis was a subject of little interest or importance because it was unreliable and not particularly useful for treatment planning. The DSM-III marked a sudden and dramatic change—it made diagnosis a major focus of clinical attention and the starting point of all treatment guidelines. Its provision of clearly defined criteria allowed for reasonably reliable diagnosis and for targeting specific symptoms that became the focus of treatment. The DSM-III’s influence exceeded all expectations, in some ways useful, but also with a significant defect. The prevailing mental health approach before the DSM-III was the well-rounded biopsychosocial model. At that time, clinicians conceptualized symptoms as arising from the complex interplay of brain functioning, psychological factors, and familial and social contexts. Perhaps without intention, the DSM-III downgraded the psychological and social factors and promoted undue emphasis on the biological factors. The DSM-III was advertised as “atheoretical” and neutral, usable by practitioners of all professional orientations. To some small degree, this was true; yet the DSM-III’s emphasis on purely descriptive psychiatry strongly favored biological treatments over cognitive-behavioral treatments. This bias proved to be irrelevant and eventually destructive to family and psychodynamic therapies. The descriptive DSM-III method focused attention on surface symptoms in the individual and ignored both deeper psychological understanding and the social and familial contexts. Clinicians often adopted a symptom checklist approach to evaluation and forgot that a complete evaluation must account for psychological factors, social supports and stressors.

In addition to its considerable impact on the mental health profession, the DSM-III also significantly affected the pharmaceutical industry. Drug companies benefited greatly from the DSM-III approach, particularly since 1987 when Prozac established the template for promoting blockbuster psychiatric drugs. Pharma realized that the best way to sell pills is to promote disease-mongering. Their marketing campaign offers the misleading idea that mental disorders are underdiagnosed, easy to diagnose due to chemical imbalances in the brain and best treated with a pill. The marketing targeted psychiatrists first, then primary care physicians and, since 1997, the general public. In the United States and New Zealand, drug companies have successfully bullied the government into allowing direct advertising to consumers on television, in print and on the Internet. Use of medication has skyrocketed as a result of these billion-dollar marketing budgets, turning us into a pill-popping society. This increase in drug use is great for Pharma shareholders and executives, but often inappropriate for clients and terribly costly to the economy. More than $40 billion a year are spent on psychiatric drugs. Most of these (80%) are prescribed by primary care doctors with little training or interest in psychiatric diagnosis or treatment, while under strong pressure from patients and drug company representatives, and after only seven minutes of evaluation on average. During the last decade, many drug companies have received enormous fines (e.g., one fine was $3.3 billion) for illegal marketing practices, but they continue because the rewards are so great.

For mild to moderate psychiatric problems, psychotherapy and counseling are just as effective as medication, and their effects are much more enduring. Most people taking medication would probably have been better off had they received psychotherapy or counseling. Unfortunately, psychotherapy and counseling suffer from two great disadvantages in their competition with drug treatment. Drug companies are enormously profitable industrial giants with billion-dollar budgets to push their products. In contrast, the mental health field is more of a nickel-and-dime, mom-and-pop operation with absolutely no marketing punch. Insurance companies further tilt the playing field by consistently favoring medication management over psychotherapy and counseling based on the mistaken assumption that it will be cheaper. In fact, brief treatments are often much more cost-effective because their effects are lasting, whereas medication may be necessary for years or a lifetime.

The medicalization of mental illness has had a dire impact on our clients and our society. Twenty percent of the population regularly takes a psychiatric drug, many for problems of everyday life more amenable to watchful waiting or psychotherapy and counseling than to drug treatment. It is astounding that there are now more overdoses and deaths from prescription drugs than street drugs. The tremendous societal investment in psychiatric drugs also misallocates resources much better spent on terribly underfunded social investments. Would it not be better for children to have smaller classes and more gym periods than for so many of them to be on pills for ADHD?

In preparing the DSM-IV (APA, 1994), we attempted to hold the line against diagnostic inflation and the medicalization of normality; however, we failed. During the past 20 years, the United States has experienced fad epidemics of ADHD, autism and bipolar disorder. We were conservative in writing the DSM-IV, but failed to anticipate or prevent its careless misuse under external pressure, particularly drug company marketing and the requirement of a psychiatric diagnosis for clients to qualify for school services and disability benefits. The quick fix is to give a diagnosis, but often this does more harm than good in the long run. Inaccurate diagnoses are easy to give but hard to remove. Often they haunt the client for life with stigma, unnecessary treatments and reduced expectations. Making an accurate diagnosis requires really knowing one’s client, which may take weeks or even months. In uncertain situations, it is better to underdiagnose than overdiagnose a symptom pattern, and better to be safe than sorry.

The DSM-5 will considerably increase medicalization and may turn our current diagnostic inflation into hyperinflation. Overdiagnosis transforms normal grief into major depressive disorder, normal temper tantrums into disruptive mood dysregulation disorder, normal forgetfulness of old age into minor neurocognitive disorder, poor eating habits into binge eating disorder, and expectable worry about physical symptoms into somatic symptom disorder. It also further loosens the already far too slack criteria for attention deficit disorder and contains a completely confusing definition of autism. Experience teaches that whenever the diagnostic spigot is unrestricted, drug company revenues increase, and less funding is available to support psychotherapy and counseling visits.

The DSM is only one guide to diagnosis—it is not a bible or official manual of diagnosis. The DSM codes that clinicians routinely use for reimbursement are in fact all International Classification of Diseases, Clinical Modification (ICD-CM) codes that are available for free on the Internet. DSM-5 is one suggested way to arrive at an ICD-CM diagnosis, but it is not the only or best way. Other more reliable guides to psychiatric diagnosis are available. Therapists do not have to buy or use the DSM-5 unless they work for an institution that requires it.

Receiving a psychiatric diagnosis can be a turning point in a client’s life. An accurate diagnosis can lead to an effective treatment plan; an inaccurate diagnosis can lead to side effects, stigma, high costs, reduced opportunities and needless suffering. Severe and classic presentations require quick diagnosis and immediate intervention, usually including medication. Milder, equivocal presentations allow for and require a more cautious approach. Therefore, watchful waiting or brief counseling is usually best.

Conflict of Interest and Funding Disclosure

The author published two books that critically

review the DSM-5, titled Saving Normal and

Essentials of Psychiatric Diagnosis.

References

American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Revolving Doors: The Impact of Multiple School Transitions on Military Children

Apr 6, 2014 | Article, Volume 4 - Issue 2

S. Beth Ruff, Michael A. Keim

There are 1.2 million school-age children with military parents in the United States, and approximately 90% attend public schools. On average, military children move three times more often than their civilian peers. Tensions at home, enrollment issues, adapting to new schools, and a lack of familiarity with military culture by public school professionals may adversely impact the academic, social and emotional growth of these students. Public school faculty and staff need to understand the challenges that multiple school transitions impose on military children in order to effectively meet the needs of this student population. In this article, the authors review the literature concerning obstacles and challenges mobile military children face, and discuss positive interventions that professional school counselors can employ to ease these transitions.

Keywords: school counselors, school transitions, military children, military culture

The Department of Defense (DOD) Demographics Report (2010) revealed that approximately 1.85 million children have one or both parents serving in the U.S. military. The report further explained that 1.2 million of these children have active-duty parents, and approximately 660,000 children have parents that serve in reserve positions in the military. Out of the 1.85 million military children, 1.2 million of them fall into the K–12 education range of 6–18 years of age (DOD, 2010). The Department of Defense Dependents Education (DODDE, 2012) budget for fiscal year 2013 estimated that 90% of these school-age military children attend public schools that are not sponsored by the DOD.

On average, military children move and change schools 6–9 times from the start of kindergarten to high school graduation (Astor, 2011; Berg, 2008; Kitmitto et al., 2011; Sherman & Glenn, 2011). Additionally, these military children move three times more often than their civilian peers, relocating every 1–4 years (Berg, 2008; Bradshaw, Sudhinaraset, Mmari, & Blum, 2010; Hipps, 2011). With military children comprising nearly 4% of the nation’s entire school-age population, public school administrators, teachers and school counselors should expect military students to transition in and out of their school populations (Rossen & Carter, 2011). Public school faculty and staff need to understand the challenges that multiple school transitions impose on military children in order to effectively meet the needs of this student population. In this article, the authors review the literature concerning the obstacles and challenges mobile military children face, and discuss positive interventions that professional school counselors can employ to ease transition.

Stressors for Military Families and Children

Military families face a unique set of life stressors specific to their culture. Hall (2008) describes the challenges faced by military families by stating that “the defining word for the military family is change; change is what their lives are about” (p. 193). As such, military families experience change and transition so frequently they often do not have time to grieve over the last transition before planning and preparing for the next. Relocation becomes a consistent stressor in the lives of military families, as the average military move occurs every 3 years, and some families, particularly families of high-ranking officers, move more frequently (Hall, 2008).

As noted in Weber and Weber (2005), previous studies (Pribesh & Downey, 1999; Simpson & Fowler, 1994; Wood, Halfon, Scarlatta, Newacheck, & Nessim, 1993) found relocation stress to have a detrimental effect on civilian child populations. School-age military children are especially vulnerable to the stress related to frequent transitions, as they must simultaneously cope with normal developmental stressors such as establishing peer relationships (Kelley, Finkel, & Ashby, 2003), conflict in parent/child relationships (Gibbs, Martin, Kupper, & Johnson, 2007; Lowe, Adams, Browne, & Hinkel, 2012), and increased academic demands (Engel, Gallagher, & Lyle, 2010). These additional stressors in conjunction with multiple school transitions could negatively affect the children’s adaption to new school environments. In addition to normative developmental stressors and frequent relocations, military children’s parents are often deployed, which can exacerbate stress in the children and may result in more barriers and maladjustment (Mmari, Bradshaw, Sudhinaraset, & Blum, 2010).

Transitional Barriers for Military Adolescent Students

Recognizing that these significant stressors for military children may be further complicated by multiple school transitions, the U.S. Army began to explore the lives of these children in order to identify ways to minimize the negative impacts of frequent relocation (Berg, 2008). In conjunction with the Military Child Education Coalition (MCEC), the Secondary Education Transition Study (SETS) was completed, which revealed specific educational challenges associated with multiple transitions (MCEC, 2001). The SETS study exposed several obstacles to transition between schools that impacted military children socially, emotionally and academically. Specific transition challenges identified by SETS for military adolescents include the following: slow transfer of school records and differences in curricula between schools, adapting to new school environments and making friends, limited access to extracurricular activities, a lack of understanding of military culture by public school teachers and staff, and tension at home and parental deployment (MCEC, 2001). The authors reviewed the literature for relevant information on each stressor.

Slow transfer of records and differences in curricula between schools. With each move to another state and school, military children encounter the challenges of slow transfer of records and differences in school curricula, which increase frustration with the transition process for parents and students (Sherman & Glenn, 2011). Kitmitto et al. (2011) found that enrollment into a new school could take up to 3 weeks, as the new school awaits the arrival of official records from the previous school. The lack of communication between the previous and receiving schools regarding history of schools attended, curricula, achievements, and stresses and traumas can lead to academic weaknesses (Berg, 2008).  As military parents fulfill their duties to serve and protect the United States, the nation’s schools may hinder student progress by requiring them to take classes over again or denying them placement into gifted or special needs education due to slow school record exchange (Astor, 2011).

Military children face several academic challenges as a result of frequent school transition. The differences in curricula and school requirements result in educational gaps for military children, which might entail repeating classes and lessons, and missing crucial topics such as multiplication and fractions (Bradshaw et al., 2010). Mmari et al. (2010) noted that parents expressed their concern for their children’s education quality; because of the differences in grade levels between schools, children had to learn the same material or read the same books repeatedly. A recent study by the MCEC reported that the differences in curricula continue to vary from school to school; and parents’ most commonly discussed concerns were the differences in scope and sequence in mathematics, specifically as it leads up to algebra and higher-level coursework (MCEC, 2012). Military parents work hard to fill the gaps in their child’s education due to transition, but many feel that if they do not advocate for their children, they will fall significantly behind their peers academically (Mmari et al., 2010).

Adapting to new school environments and making friends. With each move, military children must cope with the stress of making new friends and leaving others behind, adapting to a new school environment at awkward times, and figuring out how to fit in (Kitmitto et al., 2011). In a study conducted by Bradshaw et al. (2010), military students reported that some significant stressors in school transition were adjusting to the physical campus and to the culture of the school, including being aware of the school’s procedures and policies. Military students often transition at random times throughout the school year and experience added stressors such as learning the layout of the school and assimilating into already-established social groups (Bradshaw et al., 2010). Lack of information from the new school, such as not providing a campus map or an explanation of the course schedule, may lead the child to believe that the school is not supportive, which in turn can negatively impact the child’s adjustment to transition to the new school environment (Bradshaw et al., 2010).

Military children are frequently forced to end relationships with friends at a previous school and begin new peer relationships at the new school. In a qualitative study of military children, the most commonly mentioned stressor related to school transitions was the challenge of making and maintaining close friendships (Bradshaw et al., 2010). Many students described that the inevitable ending of close relationships led them to avoid making close connections with peers at new schools. With each move, letting go and saying goodbye to friendships becomes harder for the military students; and to avoid the inevitable grief, many students will choose to have superficial relationships instead of close friendships. It is more difficult with such relationships to gain acceptance from established cliques and social networks. This leads to military students often lacking a feeling of connectedness with others in their new schools, which in turn may lead to maladjustment in the transition (Bradshaw et al., 2010).

Limited access to extracurricular activities. With each school transition, military students encounter further challenges to retaining or gaining eligibility to participate in athletics and extracurricular activities at their new school (Sherman & Glenn, 2011). Students involved in sports who move late into the school year may miss tryouts for teams. Additionally, transferring to another state may mean that the new school does not offer the same athletic programs (Bradshaw et al., 2010). Even when students are eligible to participate in sports, military students can have difficulty breaking into established athletic programs and teams. Mmari and colleagues (2010) found that military children often experience discrimination when they participate in athletics at the new school. Athletic coaches were reluctant to put military students on teams or in starting positions, as doing so could disrupt the team dynamics.  Military students also struggled to bond with their new teammates, especially if a military student’s new position on the team resulted in an established teammate losing a starting position (Mmari et al., 2010).

Students taking part in other extracurricular activities, like student government, face similar challenges that limit their involvement. New military students may find that student government elections either happened before they entered the school or rely heavily on established popularity and previous school involvement, which would be difficult or impossible for a new student to demonstrate (Bradshaw et al., 2010). These challenges can negatively affect the military student’s adjustment to a new school, as they may hinder connectedness to the new school environment or create a sense of loss if the student was involved in high-status positions at a former school (Bradshaw et al, 2010). Limited access to these activities can lead to additional mental health concerns for the military student, as a decline in participation in such activities can cause further withdrawal and depressive symptoms (Rossen & Carter, 2011). The transition to a new school includes challenges both in the classroom and beyond.

Lack of understanding of military culture by public school teachers and staff. The way in which school teachers and staff interact with military students who transfer to their school can either increase or reduce the students’ stress. Unfortunately, administrators, educators and counselors in public schools tend to be unfamiliar with the specific issues and stressors that mobile military students encounter (Harrison & Vannest, 2008). Horton (2005) noted that because of their limited experience with the military, civilian school staff have a knowledge gap that affects their competence and effectiveness in working with military students and families. The school staff’s lack of understanding about the military students’ culture results in varying degrees of interactions ranging from overly sensitive to completely insensitive to their needs. Bradshaw et al. (2010) found that teachers’ expectations differ because they struggle with the right thing to do. Some teachers have high expectations for new military students and expect them to assimilate rather than acknowledging their unique issues. Other teachers recognize some of the issues military students face because of deployment, but choose to avoid the topic of war in the classroom or discourage the students from talking about their experiences as to not upset the students (Bradshaw et al., 2010).

In addition to the issue of sensitivity, teachers who are not familiar with military culture may maintain negative stereotypes or political ideologies that influence the way they interact with military students (Fenell, 2008). Horton (2005) explained that it is also possible for public school staff members to harbor strong negative feelings about the military, which may impact their treatment of the military students. Fear of discrimination may also be a factor that impedes school staff from identifying military students in their schools, as parents and students may not reveal their military connection (Bradshaw et al. 2010; Mmari et al., 2010). Additionally, Mmari and colleagues (2010) found that many teachers and counselors had not received information that would help them identify students connected to the military. While part of the school staff felt that properly identifying military students could aid in assisting and connecting with these students, others felt that labeling this population could result in prejudice toward the students by anti-military staff. A majority of the parents in the study reported that school staff did not know how to deal with and support military children and issues such as deployment, and that more training is needed (Mmari et al., 2010).

Tension at home and parental deployment. Relocation increases stress for all military family members. In preparing to move, parents are swamped with concerns and to-do lists, and may not have the patience or time to consider a child who is resistant to the transition (Hall, 2008). The numerous moves can leave parents feeling physically and emotionally exhausted, and less emotionally able to help their children cope with stress related to relocation (Bradshaw et al., 2010). Several studies reported that parental stress directly impacts the child’s ability to cope during stressful situations (Hall, 2008; Mmari et al., 2010; Waliski, Bokony, Edlund, & Kirchner, 2012). Further, parental stress increases the likelihood of conflicts between the parent and child and could lead to child maltreatment (Rentz et al., 2007; Waliski et al., 2012). Parents’ stress can exacerbate the emotional stress and frustration already felt by the military child due to transition.

In a qualitative research study by Bradshaw et al. (2010), the majority of military students reported that moving increased tension in the home. Some students reported feeling anger and resentment toward their parents and the military because of the constant uprooting and disruption due to change of duty stations. Many students reported telling parents that they refused to move or would run away to avoid moving again (Bradshaw et al., 2010). This negative and resistant behavior from a child can be an additional source of stress for the family. Parents may in turn view the behavior as a problem and punish or avoid the child instead of acknowledging the emotional strain the student is facing with transition (Harrison & Vannest, 2008).

The emotional stress of relocation can be further complicated if the military parent is deployed or at risk of being deployed. The constant fear for a parent’s safety can negatively affect a child academically, emotionally and behaviorally (Chawla & Solinas-Saunders, 2011; Harrison & Vannest, 2008; Mmari et al., 2010). Having a parent deployed in conjunction with a transition can lead to increased feelings of depression and anxiety. In a qualitative study of military students, many participants reported increased fear and anxiety for deployed parent’s safety. These military students also reported difficulty coping with the absence of the deployed parent at special occasions such as birthdays, school programs and sporting events (Mmari et al., 2010). Absence of the deployed parent from these significant life events can cause stress, depression, feelings of loss, and anxiety for the military child. These feelings are often externalized in the form of declining grades and behavior problems at home and school (Harrison & Vannest, 2008). Adolescents also may experience increased stress with role ambiguity during a parent’s deployment—as the family instantly becomes a single-parent home, the adolescent may take on additional responsibilities to support the remaining parent (Chawla & Solinas-Saunders, 2011; Harrison & Vannest, 2008).

Research following Operations Desert Shield and Desert Storm during the Gulf War in 1991 confirmed that stresses do occur within families during and after deployment (Jensen & Shaw, 1996; Kelley, 1994; Norwood, Fullerton, & Hagen, 1996; Pierce, Vinokur, & Buck, 1998; Rosen, Teitelbaum, & Westhuis, 1993). In their study of absent Navy mothers due to deployment during the Gulf War, Kelley, Herzog-Simmer, and Harris (1994) found that maternal depression, decreased self-esteem, and dysphoria were significantly correlated with children’s internalizing behavior (e.g., anxiety, depression).

Likewise, nondeployed parents also experience stress during times of deployment (Mmari et al., 2010), which in turn may be felt by children in the home (Chawla & Solinas-Saunders, 2011). Harrison and Vannest (2008) report that in addition to feelings of worry and fear for their spouse’s safety, the remaining parent also grapples with the stress of increased role expectation and responsibilities as a single parent. Without support, the remaining parent may cope with role strain and anxiety by withdrawing emotionally from their children or responding with severe punishment to misbehavior (Harrison & Vannest, 2008). These children may face an increased risk of maltreatment or neglect as the remaining parent may become abusive to the children when a spouse is deployed (Chawla & Solinas-Saunders, 2011; Gibbs et al., 2007; Rentz et al., 2007). Deployment can have significant detrimental effects on an entire military family’s well-being and coping skills.

Support Systems and Military Children       

While researchers have found many negative outcomes associated with school transitions for military children, supportive relationships appear to have a positive influence on outcomes for this group. Although the majority of the literature discusses the damaging consequences that multiple school transitions have on children from military families, some studies found that multiple school transitions fostered strength and resiliency. Lyle (2006) reported that there are mixed results in the literature regarding the effects of multiple school transitions. Multiple transitions have been shown to equip military children with more adaptability, accelerated maturity, deeper appreciation for cultural differences, and strong social skills in comparison to their civilian peers (Bradshaw et al., 2010; Mmari et al., 2010; Sherman & Glenn, 2011; Strobino & Salvaterra, 2000). Weber and Weber (2005) actually reported a lower rate of problems experienced by military adolescents exposed to increased frequency and number of relocations. Strobino and Salvaterra (2000) stated that whether transition affects military children positively or negatively depends largely upon their support systems. Students’ preoccupation with feelings of isolation and loneliness during school transition could result in poor grades and a decline in academic achievement. In contrast, military students who welcome change and find a new sense of responsibility during school transition may experience improved academic performance and achievement. It also was found that despite five or more school transitions, military children reported average to above-average grades, active involvement in extracurricular activities, and support of teachers and parents. This study attributed the positive adjustment of military students during multiple school transitions to supportive school cultures and strong parental involvement. The positive and negative results reveal that the level of school and parent support may be indicators of how well military students adjust during multiple school transitions (Strobino & Salvaterra, 2000).

Implications for School Counselors

Given the extensive influence that the school environment has on military students’ adjustment during school transitions, the importance of developing a supportive and understanding relationship with this student population is paramount. Rush and Akos (2007) note that school counselors are uniquely qualified to assist students with social, emotional and academic concerns. School counselors are specifically trained in child development, and they work closely with numerous sources of student support including parents, teachers and peers. Waliski et al. (2012) confirm that counselors possess the education and skills needed to help military students and are readily accessible within their community. Professional school counselors also have access to academic data that can be used to identify the specific needs of an enrolling military student, such as standardized test scores, attendance records, discipline referrals and report cards. Moreover, school counselors serve students directly by developing and implementing preventive programs and interventions that facilitate support and social belonging such as classroom guidance, intentional guidance groups and peer mentoring (Rush & Akos, 2007). The role of school counselors within the school environment places them in a unique position to serve and advocate for enrolling military students and consequently transform school transition into a positive experience. The following sections will provide an overview of ways that school counselors can support military students in their own schools.

Becoming Informed About Military Life

To initiate change, school counselors must first be informed about military life and become knowledgeable about resources and culturally sensitive interventions suited for military students (Waliski et al., 2012). Understanding the challenges and the unique needs of military students will help school counselors support military students and families during times of crisis (Harrison & Vannest, 2008). Several resources are available to assist school counselors in becoming advocates for and providing resources and interventions to military students. Organizations such as Operation Military Kids (OMK) and Military One Source provide specific tools and trainings on assisting military children and parents for school staff and community stakeholders (Eason, 2012). These resources could be used in staff development, classroom guidance, parent/teacher conferences, and small group and individual counseling (see Table 1).

Student-to-Student Interactions

With regard to strategies and programs that acclimatize new students to schools and ease the transition process, student-to-student programs were noted repeatedly in the literature (Berg, 2008; Bradshaw et al., 2010; Harrison & Vannest, 2008; Mmari et al., 2010; Strobino & Salvaterra, 2000). These programs connect new students with current students, who act as guides to the school grounds and reduce anxiety by initiating the friend-making process. One such program is noted by Rush and Akos (2007) in working with middle school students. The authors developed a 10-session, combination psychoeducational-counseling group created by school counselors to increase student knowledge concerning the deployment process. In addition to information sharing by the group leaders and group members early in the process and at the beginning of each session, the “later sessions, and the latter part of each session, are purposefully structured to be less directive and more process oriented to allow group members to pursue individual goals and provide more intrapersonal focus to help with particular issues that emerge” (Rush & Akos, p. 116). Students are further supported through the development of coping skills in a safe, encouraging environment.

Table 1

Web Resources to Support Military Students with Transition

Community Resources

Another avenue to help students adjust and adapt is connecting parents and caregivers to community resources. Mmari et al. (2010) found that some military parents did not utilize resources simply because they did not know they were available. Waliski et al. (2012) explained that counselors can serve as gatekeepers through whom military families can gain access to appropriate programs and services. Additionally, school counselors are in an advantageous position to develop partnerships between families and communities, to identify challenges such as transitions, to address these issues, and to advance student progress (Epstein & Van Voorhis, 2010). As military families transition, they may be unfamiliar with their new community and struggle to locate health care providers, childcare, tutoring, and mental health and counseling resources. School counselors are often equipped with lists for local providers and resources that could ease the transition for mobile military families. In addition to local resources, school counselors can proactively assist military children and their families by maintaining a record of resources specific to military families. For example, Tutor.com provides free tutoring and resources for military students (“Tutor.com for U.S. military families,” 2014). Also, a new Web site sponsored by the Department of Veterans Affairs, “Parenting for Service Members and Veterans,” has been launched just for military families (Department of Veterans Affairs, 2013). This resource addresses the unique challenges of parenting in military families through an online anonymous parenting course, interactive activities, and stories of real military and veteran families that provide valuable skills for the everyday challenges of raising military children. The course and content were developed by experts from the DOD. By connecting parents to resources, the school counselor can assist in reducing tension at home and increasing parental support and school involvement.

Staff Trainings

An important strategy for school counselors to implement in their schools is facilitating school staff trainings specific to military culture and needs of military students. Harrison and Vannest (2008) suggest that teachers receive professional development focused on military culture and the skills necessary to assist their military students. Strobino and Salvaterra (2000) explain that it is important for all stakeholders to be aware of the relationship between the student’s experiences and school success.  School counselors and other school professionals are encouraged to focus on identifying the strengths of military students. Staff training can facilitate cultural sensitivity and supportive student/teacher relationships that contribute to positive school experiences.

A number of organizations—from the community to the national level—can provide training to assist educational professionals in working with the military community. Veterans’ organizations, such as Veterans of Foreign Wars (VFW) or the American Legion, have posts in local communities with representatives appointed to serve schools and other civic institutions. National Guard or reserve posts and active-duty military installations have a public affairs officer (PAO) who is available to discuss military-related issues such as deployment with the educational community as well. Additionally, the MCEC (2012), a federally recognized nonprofit organization, is specifically “focused on ensuring quality educational opportunities for all military children affected by mobility, family separation, and transition.” They provide ongoing training for school counselors and other education professionals both online and in face-to-face settings. Two MCEC programs in particular relate directly to school transitions. The Supporting Military Children through School Transitions: Foundations focuses on the military-connected child’s experience with transitions by addressing “military lifestyle and culture, school transition perspectives, and identifying local transition challenges.” The second program—Supporting Military Children through School Transitions: Social/Emotional Institute—focuses on the social and emotional effects of student transitions, including “deployment and separation, building confidence and resiliency, and supporting children through trauma and loss” (MCEC, 2012).

Advocating for Military Students

In addition to interventions used at the individual school level, school counselors can advocate for military students at the local, district and state levels. A valuable resource for school counselors is the Military Children Interstate Compact Commission. The Council of State Governments and the DOD worked collaboratively to develop an Interstate Compact that would address the challenges military families face with each school transition (Kitmitto et al., 2011). The Compact addresses transition issues such as slow transfer of records, course and curriculum differences and equivalents, attendance, accessibility to extracurricular activities, and graduation requirements. Through the guidelines and detailed governance structure, the Compact allows for the uniform treatment of these challenges at the state and local district level. Currently, 43 states have signed the Interstate Compact (Matthews, 2012). It is important for school counselors to be aware of their state’s standing on the Compact. School counselors can advocate for compliance with the guidelines set by their adoption and for implementation of the guidelines if their state has not become a signatory.

Conclusion

Military families experience unique stressors related to the military culture, such as parental deployment and multiple relocations. The literature attributes the negative effects of multiple school transitions to factors such as tension at home and parental absence, slow transfer of school records and differences in curricula between schools, adapting to new school environments and making friends, limited access to extracurricular activities, and a lack of understanding by school teachers and staff of military culture. The majority of the reviewed literature found that the challenges of mobile military students can lead to a decline in academic achievement and social/emotional problems.

Research seems to suggest that supportive relationships and an encouraging school environment can help military students adjust to the struggles that they are likely to face. The literature points to the professional school counselor as being the most appropriate staff member to foster these positive experiences and advocate for new enrolling military students. School counselors can create a positive experience for new enrolling military students by connecting parents and caregivers to community resources, advocating for quick transfer of school records, creating programs that acclimate new students to school grounds and culture, encouraging accessibility to extracurricular activities, and facilitating school staff trainings specific to military culture and the particular needs of military students.

References

Astor, R. A. (2011, June 8). The need to support students from military families. Education Week, 30(33), 27, 32. Retrieved from http://www.edweek.org/ew/articles/2011/06/08/33astor_ep.h30.html

Berg, K. F. (2008). Easing transitions of military dependents into Hawaii public schools: An invitational educational link. Journal of Invitational Theory and Practice, 14, 41–55.

Bradshaw, C. P., Sudhinaraset, M., Mmari, K., & Blum, R. W. (2010). School transitions among military adolescents: A qualitative study of stress and coping. School Psychology Review, 39, 84–105.

Chawla, N., & Solinas-Saunders, M. (2011). Supporting military parent and child adjustment to deployment separations with filial therapy. The American Journal of Family Therapy, 39, 179–192. doi:10.1080/01926187.2010.531647

Department of Defense. (2010). Demographics, 2010: Profile of the military community [Annual report]. Retrieved from http://www.militaryonesource.mil/12038/MOS/Reports/2010_Demographics_Report.pdf

Department of Defense Dependents Education. (2012). Fiscal year 2013 budget estimates: Department of Defense Dependents Education (DODDE) [Annual report]. Retrieved from http://comptroller.defense.gov/Portals/45/Documents/defbudget/fy2013/budget_justification/pdfs/
01_Operation_and_Maintenance/O_M_VOL_1_PARTS/O_M_VOL_1_BASE_PARTS/DoDDE_OP-5.pdf

Department of Veterans Affairs. (2013). Parenting for service members and veterans. Retrieved from http://militaryparenting.t2.health.mil

Eason, M. (2012, November). Operation military kids. Program session presented at the annual conference of the Georgia School Counselors Association, Athens, GA.

Engel, R. C., Gallagher, L. B., & Lyle, D. S. (2010). Military deployments and children’s academic achievement: Evidence from Department of Defense Education Activity schools. Economics of Education Review, 29, 73–82. doi:10.1016/j.econedurev.2008.12.003

Epstein, J. L., & Van Voorhis, F. L. (2010). School counselors’ roles in developing partnerships with families and communities for student success. Professional School Counseling, 14, 1–14.

Fenell, D. L. (2008, June 14). A distinct culture. Counseling Today, 50(12), 8–9, 35. Retrieved from http://ct.counseling.org/2008/06/a-distinct-culture/

Gibbs, D. A., Martin, S. L., Kupper, L. L., & Johnson, R. E. (2007). Child maltreatment in enlisted soldiers’ families during combat-related deployments. Journal of the American Medical Association, 298, 528–535. doi:10.1001/jama.298.5.528

Hall, L. K. (2008). Counseling military families: What mental health professionals need to know. New York, NY: Routledge.

Harrison, J., & Vannest, K. J. (2008). Educators supporting families in times of crisis: Military reserve deployments. Preventing School Failure, 52(4), 17–24. doi:10.3200/PSFL.52.4.17-24

Hipps, T. (2011, June). Removing educational obstacles for military kids. Soldiers, 66(6), 16–19.

Horton, D. (2005). Consultation with military children and schools: A proposed model. Consulting Psychology Journal: Practice and Research, 57(4), 259–265. doi:10.1037/1065-9293.57.4.259

Jensen, P. S., & Shaw, J. A. (1996). The effects of war and parental deployment upon children and adolescents. In R. J. Ursano & A. E. Norwood (Eds.), Emotional aftermath of the Persian Gulf War: Veterans, families, communities, and nations (pp. 83–109). Washington, DC: American Psychiatric.

Kelley, M. L. (1994). The effects of military-induced separation on family factors and child behavior. American Journal of Orthopsychiatry, 64, 103–111. doi:10.1037/h0079499

Kelley, M. L., Finkel, L. B., & Ashby, J. (2003). Geographic mobility, family, and maternal variables as related to the psychosocial adjustment of military children. Military Medicine, 168, 1019–1024.

Kelley, M. L., Herzog-Simmer, P. A., & Harris, M. A. (1994). Effects of military-induced separation on the parenting stress and family functioning of deploying mothers. Military Psychology, 6, 125–138.

Kitmitto, S., Huberman, M., Blankenship, C., Hannan, S., Norris, D., & Christenson, B. (2011). Educational options and performance of military-connected school districts research study – final report. San Mateo, CA: American Institutes for Research. Retrieved from http://www.militaryk12partners.dodea.edu/docs/2011-air-report.pdf

Lowe, K. N., Adams, K. S., Browne, B. L., & Hinkle, K. T. (2012). Impact of military deployment on family relationships. Journal of Family Studies, 18, 17–27.

Lyle, D. S. (2006). Using military deployments and job assignments to estimate the effect of parental absences and household relocations on children’s academic achievement. Journal of Labor Economics, 24(2), 319–350. doi:10.1086/499975

Matthews, W. J., III. (2012, June). Commission picks up member states 42 and 43. MIC3…News, Views, and Transitions: Newsletter for the Interstate Commission on Educational Opportunity for Military Children, 3, 5. Retrieved from http://www.mic3.net/documents/MIC3June2012InteractiveNewsletter2.pdf

Military Child Education Coalition. (2001). U.S. Army secondary education transition study: Executive summary. Arlington, VA: Military Resource Center.

Military Child Education Coalition. (2012). Programs. Retrieved from http://www.militarychild.org/professionals/programs

Mmari, K. N., Bradshaw, C. P., Sudhinaraset, M., & Blum, R. (2010). Exploring the role of social connectedness among military youth: Perceptions from youth, parents, and school personnel. Child and Youth Care Forum, 39, 351–366. doi:10.1007/s10566-010-9109-3

Norwood, A. E., Fullerton, C. S., & Hagen, K. P. (1996). Those left behind: Military families. In R. J. Ursano & A. E. Norwood (Eds.), Emotional aftermath of the Persian Gulf War: Veterans, families, communities, and nations (pp. 163–196). Washington, DC: American Psychiatric.

Pierce, P. F., Vinokur, A. D., & Buck, C. L. (1998). Effects of war-induced maternal separation on children’s adjustment during the Gulf War and two years later. Journal of Applied Social Psychology, 28(14), 1286–1311. doi:10.1111/j.1559-1816.1998.tb01677.x

Pribesh, S., & Downey, D. B. (1999). Why are residential and school moves associated with poor school performance? Demography, 36, 521–534.

Rentz, E. D., Marshall, S. W., Loomis, D., Casteel, C., Martin, S. L., & Gibbs, D. A. (2007). Effect of deployment on the occurrence of child maltreatment in military and nonmilitary families. American Journal of Epidemiology, 165, 1199–1206. doi:10.1093/aje/kwm008

Rosen, L. N., Teitelbaum, J. M., & Westhuis, D. J. (1993). Children’s reactions to the Desert Storm deployment: Initial findings from a survey of Army families. Military Medicine, 158, 465–469.

Rossen, E., & Carter, C. D. (2011, February). Supporting students from military families. Principal Leadership, 11(6), 14–18.

Rush, C. M., & Akos, P. (2007). Supporting children and adolescents with deployed caregivers: A structured group approach for school counselors. The Journal for Specialists in Group Work, 32(2), 113–125. doi:10.1080/01933920701227034

Sherman, M. D., & Glenn, M. A. (2011, January/February). Opportunities for school psychologists working with children of military families. Communiqué: The Newspaper of the National Association of School Psychologists, 39(5), 17–19.

Simpson, G. A., & Fowler, M. G. (1994). Geographic mobility and children’s emotional/behavioral adjustment and school functioning. Pediatrics, 93, 303–309.

Strobino, J., & Salvaterra, M. (2000). School transitions among adolescent children of military personnel: A strengths perspective. Social Work in Education, 22, 95–107.

Tutor.com. (2014). Tutor.com for U.S. military families. Retrieved from http://www.tutor.com/military

Waliski, A., Bokony, P., Edlund, C. N., & Kirchner, J. (2012). Counselors called for service: Impact of parental deployment on preschool children. The Family Journal: Counseling and Therapy for Couples and Families, 20(2), 157–163. doi:10.1177/1066480712438531

Weber, E. G., & Weber, D. K. (2005). Geographic relocation frequency, resilience, and military adolescent behavior. Military Medicine, 170, 638–642.

Wood, D., Halfon, N., Scarlata, D., Newacheck, P., & Nessim, S. (1993). Impact of family relocation on children’s growth, development, school function, and behavior. Journal of the American Medical Association, 270, 1334–1338. doi:10.1001/jama.1993.03510110074035

S. Beth Ruff is a school counselor at Bright Star Elementary School in Douglasville, GA, and a doctoral student at the University of West Georgia. Michael A. Keim, NCC, is an Assistant Professor of Professional Counseling at the University of West Georgia. Correspondence can be addressed to S. Beth Ruff, Bright Star Elementary School, 6300 John West Road, Douglasville, GA 30134,  Beth.ruff@douglas.k12.ga.us.

Wounded Warriors with PTSD: A Compilation of Best Practices and Technology in Treatment

Apr 5, 2014 | Article, Volume 4 - Issue 2

Mary Alice Fernandez, Melissa Short

This article offers mental health counselors a compilation of best practices and technology in the treatment of combat veterans suffering from post-traumatic stress disorder (PTSD). The goal is to increase counselors’ awareness of the resources available to enhance their repertoire of tools and techniques to assess, diagnose, case-conceptualize and treat the growing population of combat veterans with PTSD. The National Center for PTSD provides guidelines for diagnosing PTSD using the DSM-5. PTSD is now recognized as a trauma disorder related to an external event rather than an anxiety disorder associated with mental illness. The authors describe assessment tools and treatment strategies for PTSD validated on veteran populations. The paper also highlights new technology and mobile apps designed to assist in the treatment of combat PTSD.

Keywords: combat PTSD, trauma disorder, treatment of combat veterans, National Center for PTSD,  mobile apps

Volunteering to serve one’s country during wartime is an act of heroism, and counselors working with combat veterans are in a unique position to honor these heroes. Combat veterans have offered the supreme sacrifice and some are paying a price by suffering from combat post-traumatic stress disorder (PTSD). The task of providing mental health services to a growing veteran population and their immediate family members is complicated by the lack of accessible services and the complexities of the disorder. To begin to address this challenge, Senator Jon Tester (D-MT) recently introduced legislation focused on improving access to mental health counselors by tasking the Department of Veterans Affairs (VA) with recruiting more licensed professional mental health counselors (Tester, 2013).

This article offers an overview of resources available to mental health counselors to assess, case-conceptualize, diagnose and treat a growing population of combat veterans with PTSD. The goal is to increase the awareness of both beginning counselors and more experienced counselors of new therapies as well as best practices in treating combat PTSD. The compilation of resources begins with diagnostic criteria, assessment tools, and evidence-based practices, including new technologies for treating PTSD, and culminates with a list of resources available to counselors and veterans.

Diagnosing PTSD

Changes in the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5) place PTSD under a new heading, Trauma and Stressor-Related Disorders, and remove it from the DSM-4 anxiety category. This new DSM-5 categorization de-stigmatizes PTSD because it recognizes PTSD as a trauma disorder related to an external event rather than an anxiety related to mental illness (Staggs, 2014). The DSM-5 provides eight clear criteria for diagnosing PTSD, beginning with identifying a traumatic event (criterion A) and then noting behavioral symptoms related to PTSD. It organizes symptoms into four clusters: intrusions (criterion B), avoidance (criterion C), negative symptoms (criterion D), and arousal (criterion E) (American Psychological Association, 2013). In order for a client to meet the full criteria for a PTSD diagnosis, his or her symptoms must last longer than a month (criterion F), must prevent him or her from functioning well in significant area(s) of life (criterion G), and cannot be due to physical factors such as a medical condition or substance use (criterion H).

The National Center for PTSD (2014a) provides guidelines for diagnosing PTSD using the DSM-5. Criterion A (stressor) indicates that the person was exposed to at least one of the following: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence. The person must persistently re-experience at least one of the intrusion symptoms (criterion B) of the traumatic event and one of the avoidance efforts (criterion C) of distressing trauma-related stimuli. Two negative symptoms or alterations in cognition or mood (criterion D) and two alterations in arousal and reactivity (criterion E) that began or worsened after the traumatic event must be present for a diagnosis of PTSD.  Although symptoms may occur soon after the event, a person does not qualify for a PTSD diagnosis until at least six months after the traumatic event. An individual with PTSD will experience high levels of either depersonalization or derealization (National Center for PTSD, 2014a).

Nussbaum’s (2013) brief version for diagnosing PTSD begins by asking the following:

What is the worst thing that has ever happened to you? Have you ever experienced or witnessed an event in which you were seriously injured or your life was in danger, or you thought you were going to be seriously injured or endangered? (p. 90)

If the client answers in the affirmative, the counselor is to ask these questions: “Do you think about or re-experience these events? Does thinking about these experiences ever cause significant trouble with your friends or family, at work, or in another setting?” (Nussbaum, 2013, p. 90). Nussbaum (2013) provides a set of questions for each cluster and its associated symptoms to guide the process of diagnosis.

Assessment Tools

Ottati and Ferraro (2009) describe three assessment tools, validated on veteran populations, to screen for combat-related PTSD: the 17-item self-report PTSD Checklist (PCL), the 35-item self-report Mississippi Scale for Combat-Related PTSD (M-PTSD), and the Clinician-Administered PTSD Scale (CAPS). The PCL was recently updated to 20 items to reflect the changes in DSM-5. PCL-5 is a self-report measure that takes 5–10 minutes to complete and may be used to screen, diagnose and monitor changes during and after treatment of PTSD (Weathers et al., 2013). The M-PTSD uses a 5-point Likert scale to rate PTSD symptoms and related symptoms of substance abuse, suicidal ideation, and depression. It provides a PTSD symptom severity index with scores ranging from 35–175. The M-PTSD has not been revised since DSM-3, but may still be useful since it was normed with veteran populations (National Center for PTSD, 2014b). CAPS is a diagnostic structured interview that also measures the severity of symptoms and was recently revised to assess the DSM-5 PTSD symptoms. CAPS-5 is a 30-item questionnaire that takes 45–60 minutes to administer and yields a single score of PTSD severity (Weathers et al., 2013).

Other instruments are available to counselors for consideration. The PTSD Symptom Scale, Interview Version (PSS-I) with 17 items is a shorter clinical interview comparable to CAPS (Peterson, Luethcke, Borah, Borah, & Young-McCaughan, 2011). The PSS-I can be administered in about 20 minutes by a trained lay interviewer, and each item consists of a brief question so that an initial assessment can be made in shorter time (Peterson et al., 2011).The Emotion Regulation Questionnaire (ERQ) assesses differences between expressive suppression and cognitive reappraisal during treatment intake and discharge (Boden et al., 2013). The ERQ assessment assists the counselor in targeting and reducing maladaptive regulation strategies within the context of PTSD treatment in order to help the veteran develop alternative coping skills (Boden et al., 2013). The Quick Test for PTSD (Q-PTSD) is useful for identifying individuals with a true disability (Morel, 2008). Q-PTSD is a time-efficient method of detecting malingering in veterans applying for disability; it may be used by the counselor as an initial assessment of the disorder (Morel, 2008).

Other useful instruments can be incorporated into a treatment plan, such as a strengths-based assessment, depression inventory, substance abuse assessment, and insomnia inventory. Seligman (2011) also recommends the Post-Traumatic Growth Inventory (PTGI) for use with veterans. The 21-item PTGI “measures the extent to which survivors of traumatic events perceive personal benefits, including changes in perceptions of self, relationships with others, and philosophy of life accruing with their attempt to cope with trauma and its aftermath” (Tedeschi & Calhoun, 1996, p. 458). Seligman (2011) suggests that trauma often sets the stage for growth; a counselor may use the PTGI to facilitate veterans’ understanding of the conditions under which growth can happen.

Making a diagnosis of PTSD requires assessing symptoms and also gathering data from multiple assessments, a structured interview, and other knowledge of the client in order to make an evaluative judgment that leads to the development of a sound treatment plan (Ottati & Ferraro, 2009).

PTSD Treatment

Cognitive behavioral therapy (CBT) is unanimously endorsed as the best-practice treatment for PTSD by the VA and the Department of Defense (DOD; U.S. VA & U.S. DOD, 2010), the International Society for Traumatic Stress Studies (Foa, Keane, & Friedman, 2000), and the American Psychiatric Association (Ursano et al., 2010). Tramontin (2010) specifically states that the VA supports Prolonged Exposure (PE) therapy and Cognitive Processing Therapy (CPT).

In CPT and CBT, counselors challenge clients’ automatic thoughts connected with trauma. Through the use of written narratives in CPT, counselors target issues of safety, trust, power, control and self-esteem. Counselors also work with veterans to identify and label feelings as they work through impasses in their stories (Moran, Schmidt, & Burker, 2013). Exposure therapy is an evidence-based practice for many types of trauma including PTSD. According to Rauch, Eftekhari, and Ruzek (2012), PE therapy reduces PTSD symptoms and aids in treating comorbid issues. Rauch et al. (2012) explain that PE therapy consists of four components: psychoeducation, in vivo exposure, imaginal exposure, and emotional processing. Psychoeducation can help those suffering from trauma to understand their PTSD (Rauch et al., 2012). In vivo exposure consists of literally confronting the variables associated with the trauma (i.e., people, places and things; Rauch et al., 2012). Imaginal exposure involves reliving the memories associated with the trauma and engaging the accompanying emotions (Rauch et al., 2012). Emotional processing involves the counselor posing open-ended questions to the client in order to elicit both the emotions the client felt associated with the trauma and present emotions (Rauch et al., 2012).

Virtual reality exposure. In recent years, a new development of a virtual reality exposure therapy has surfaced. Albert “Skip” Rizzo developed a program titled “Virtual Iraq,” a virtual reality simulation designed to assist in the treatment of PTSD (Virtually Better, Inc., 2013). Rizzo developed the program after stumbling upon a video game called “Full Spectrum Warrior” that was originally created to train military service men and women. According to Rothbaum, Rizzo and Difede (2010), the current generation of military service members may be more comfortable participating in virtual reality treatment than conventional talk therapy, due to its similarity to gaming. After viewing several videos that demonstrate the Virtual Iraq system, the authors understand the connection between the exposure to trauma variables in PE and the exposure to trauma variables in virtual reality programs. Sharpless and Barber (2011) found several studies demonstrating the efficacy of virtual reality in treating veterans.

The protocol for virtual reality treatment involves veterans selecting a traumatic combat experience that relates closely to their most severe PTSD symptoms (McLay et al., 2012). Counselors create a realistic experience for the veteran by utilizing various sensory components of the virtual reality environment. Clients then use their senses and are immersed into the virtual reality world where they relive their trauma. Following the treatment, the counselor and the veteran process the material that surfaced in the exposure (McLay et al., 2012). In a study using virtual reality exposure therapy, McLay et al. (2012) found that “75% of participants experienced at least a 50% reduction in PTSD symptoms” (p. 635).

In addition to Virtual Iraq, Virtually Better, Inc. (2013) has developed other programs, including Virtual Vietnam, Afghanistan, Airports, and the World Trade Center. During a phone interview with Emilio Coirini, Director and Business Developer at Virtually Better, Inc., the interviewee stated that a soldier who suffers PTSD costs the government about $50,000 a year to treat, with the average treatment lasting 20 years. In contrast, the virtual reality system costs only about $30,000 with clinical training (E. Coirini, personal communication, November 16, 2012). At the time of the interview, there were about 70 systems installed throughout the United States, and Coirini explained that it is possible to receive grants for the cost of the system.

Animal-assisted treatment. In contrast to the relatively new use of virtual reality technology, animals have been assisting persons with disabilities for many years; there are a growing number of organizations that provide trained animals, specifically canines, to veterans who suffer from PTSD. According to Thompson (2010), in order to qualify as a service animal, the animal must undergo training to do work or perform helpful tasks. McConnell (2011) conducted a study that found that having a pet can provide meaningful social support that improves lives. One organization, Pets for Vets, provides animal companions to veterans with PTSD who are capable of caring for a pet. Pets for Vets states the following (2014):

Our goal is to help heal the emotional wounds of military veterans by pairing them with a shelter animal that is specially selected to match his or her personality. Professional animal trainers rehabilitate the animals and teach them good manners to fit into the veteran’s lifestyle. Training can also include desensitization to wheel chairs or crutches as well as recognizing panic or anxiety disorder behaviors. (para. 2)

Animals have been therapeutic partners to persons with disabilities for generations, and they are now serving wounded warriors.

Utilization of mobile phone applications. While researching other tools to help in treating PTSD, the authors discovered a few mobile applications available for both the iPhone and the Android that are well-developed, user-friendly and comprehensive. The first application, PTSD Coach (U.S. VA, 2014b), is elaborate in design, taking into account potential areas of concern for those who suffer from PTSD. The four main divisions of the application include Learn, Self-Assessment, Manage Symptoms and Find Support. The learning division of the application provides a comprehensive base and answers questions such as What is PTSD? and Who develops PTSD? In addition, the learning division includes answers regarding who should seek professional assistance and possible treatment protocols. The questions in the professional care subsection include Will it really work? and What if I am embarrassed about seeking help? The self-assessment section gives a person insight into the possibility of having PTSD. An example of an evaluative question is, “In the past month how often have you been bothered by disturbing memories, thoughts or images of the traumatic experience?” Users can track the history of their symptoms and schedule assessments to take periodically to provide a comparison of improvement or decline. When utilizing the manage symptoms option, users can select a mental state such as sadness or hopelessness, and the application will provide a suggestion to improve mood, depending on mood severity. Finally, users can set up their own support network, get support immediately or find professional care by choosing the finding support option. (The Apple phone app version may be found at https://itunes.apple.com/us/app/ptsd-coach/id430646302?mt=8, and the Android version may be found at https://play.google.com/store/apps/details?id=gov.va.ptsd.ptsdcoach.)

Another application, T2 Mood Tracker (The National Center for Telehealth and Technology, 2014), aids individuals in keeping track of their moods, which they can then report to their medical or mental health professional(s). The application can be used as a daily tool to track a client’s mood, keep notes regarding stressors, and chart a graph of the information provided. The initial screen asks whether the user would like to rate anxiety, depression, general well-being, head injury, post-traumatic stress, or general stress. The user selects one of the previously stated fields and is then required to rate several factors associated with the chosen field. The user can then graph results, create reports, save reports, or view notes. The application is user-friendly and simple in design, yet intricate enough to help the user and counselor in developing treatment protocols. (The Apple phone app version may be found at https://itunes.apple.com/us/app/t2-mood-tracker/id428373825?mt=8, and the Android version may be found at https://play.google.com/store/apps/details?id=com.t2.vas.)

A third application worthy of acknowledgement is the PE Coach, developed by the VA (2014a). The PE Coach requires a counselor trained in PE therapy. According to the National Center for PTSD (2014c), the PE Coach is a treatment companion that helps the client and counselor work through the PE treatment manual. The features of this application include the following: learning about PE therapy and the most common reactions to trauma, recording therapy sessions for personal use, setting reminders for homework and future therapy appointments, tracking tasks between sessions, practicing breathing exercises, and tracking PTSD symptoms. Currently, anecdotal accounts from veterans indicate that the mobile applications are helpful (U.S. DOD, American Forces Press Service, 2012). (The Apple phone app version may be found at https://itunes.apple.com/us/app/pe-coach/id507357193?mt=8, and the Android version may be found at https://play.google.com/store/apps/details?id=org.t2health.pe.)

Conclusion

Wendling (2008) reported results from an online survey administered to mental health practitioners after they had attended a conference called “Healing the Scars of War.” She found that most counselors did not understand military culture or appear to follow best-practice guidelines. The authors hope this paper serves to increase understanding of this critical area.

Technology makes it possible to access information about military families and resources to serve this special population. The VA has PTSD videos, training courses, and other materials available to inform counselors of the needs and unique cultural experiences of a diverse veteran population experiencing PTSD.

The resources identified (see Table 1) can be readily accessed by counselors and veterans to begin the therapeutic journey. We, the authors, salute the wounded warriors and continue to fight for their healing as they have fought for freedom.

Table 1

Informative Resources about Veterans and PTSD

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). Washington, DC: American Psychiatric Publishing.

Boden, M. T., Westermann, S., McRae, K., Kuo, J., Alvarez, J., Kulkarni, M. R., … Bonn-Miller, M. O. (2013). Emotion regulation and posttraumatic stress disorder: A prospective investigation. Journal of Social & Clinical Psychology, 32(3), 296–314. doi:10.1521/jscp.2013.32.3.296

Foa, E. B., Keane, T. M., & Friedman, M. J. (Eds.). (2000). Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies. New York, NY: The Guilford Press.

McConnell, A. R. (2011, July 11). Friends with benefits: Pets make us happier, healthier. Psychology Today. Retrieved from http://www.psychologytoday.com/blog/the-social-self/201107/friends-benefits-pets-make-us-happier-healthier

McLay, R. N., Graap, K., Spira, J., Perlman, K., Johnston, S., Rothbaum, B. O., … Rizzo, A. (2012). Development and testing of virtual reality exposure therapy for post-traumatic stress disorder in active duty service members who served in Iraq and Afghanistan. Military Medicine, 177(6), 635–642.

Moran, S., Schmidt, J., & Burker, E. J. (2013). Posttraumatic growth and posttraumatic stress disorder in veterans. Journal of Rehabilitation, 79(2), 34–43.

Morel, K. R. (2008). Development of a validity scale for combat-related posttraumatic stress disorder: Evidence from simulated malingerers and actual disability claimants. Journal of Forensic Psychiatry & Psychology, 19(1), 52–63. doi:10.1080/14789940701594645

National Center for PTSD. (2014a, January 3). DSM-5 criteria for PTSD. Retrieved from http://www.ptsd.va.gov/professional/PTSD-overview/dsm5_criteria_ptsd.asp

National Center for PTSD. (2014b, January 3). Mississippi Scale for Combat-Related PTSD (M-PTSD). Retrieved from http://www.ptsd.va.gov/professional/assessment/adult-sr/mississippi-scale-m-ptsd.asp

National Center for PTSD. (2014c, January 28). Mobile app: PE coach. Retrieved from http://www.ptsd.va.gov/public/materials/apps/pecoach_mobileapp-public.asp

The National Center for Telehealth and Technology. (2014). T2 Mood Tracker [Mobile application software]. Available from https://itunes.apple.com/us/app/t2-mood-tracker/id428373825?mt=8 or https://play.google.com/store/apps/details?id=com.t2.vas

Nussbaum, A.M. (2013). The Pocket Guide to the DSM-5 Diagnostic Exam. Washington, DC: American Psychiatric Publishing.

Ottati, A., & Ferraro, F. R. (2009). Combat-related PTSD treatment: Indications for exercise therapy. Psychology Journal, 6(4), 184–196.

Peterson, A. L., Luethcke, C. A., Borah, E. V., Borah, A. M., & Young-McCaughan, S. (2011). Assessment and treatment of combat-related PTSD in returning war veterans. Journal of Clinical Psychology in Medical Settings, 18(2), 164–175. doi:10.1007/s10880-011-9238-3

Pets for Vets. (2014). Healing vets and saving pets. Retrieved from http://pets-for-vets.com

Rauch, S. A. M., Eftekhari, A., & Ruzek, J. I. (2012). Review of exposure therapy: A gold standard for PTSD treatment. Journal of Rehabilitation Research & Development, 49(6), 679–687.

Rothbaum, B. O., Rizzo, A., & Difede, J. (2010). Virtual reality exposure therapy for combat-related posttraumatic stress disorder. Annals of the New York Academy of Sciences, 1208, 126–132. doi:10.1111/j.1749-6632.2010.05691.x

Seligman, M. E. P. (2011). Flourish: A visionary new understanding of happiness and well-being. New York, NY: Free Press.

Sharpless, B. A., & Barber, J. P. (2011). A clinician’s guide to PTSD treatment for returning veterans. Professional Psychology: Research and Practice, 42(1), 8–15. doi:10.1037/a0022351

Staggs, S. (2014). Symptoms & diagnosis of PTSD. Retrieved from http://psychcentral.com/lib/symptoms-and-diagnosis-of-ptsd/000158

Tedeschi, R. G., & Calhoun, L. G. (1996). The posttraumatic growth inventory: Measuring the positive legacy of trauma. Journal of Traumatic Stress, 9(3), 455–471. doi:10.1002/jts.2490090305

Tester, J. (2013, June 13). Tester introduces comprehensive veterans’ health care legislation [Press release]. Retrieved from http://www.tester.senate.gov/?p=press_release&id=2965

Thompson, M. (2010, November 22). Bringing dogs to heal. Time, 176(21), 54–57. Retrieved from http://p2v.org/wp-content/uploads/2010/11/p2v-time-web.pdf

Tramontin, M. (2010). Exit wounds: current issues pertaining to combat-related PTSD of relevance to the legal system. Developments in Mental Health Law, 29, 23–47.

U.S. Department of Defense, American Forces Press Service. (2012, July 31). DOD, VA release mobile app targeting post-traumatic stress [News release]. Retrieved from http://www.defense.gov/news/newsarticle.aspx?id=117339

U.S. Department of Veterans Affairs. (2014a). PE coach [Mobile application software]. Available from https://itunes.apple.com/us/app/pe-coach/id507357193?mt=8 or https://play.google.com/store/apps/details?id=org.t2health.pe

U.S. Department of Veterans Affairs. (2014b). PTSD coach [Mobile application software]. Available from https://itunes.apple.com/us/app/ptsd-coach/id430646302?mt=8 or https://play.google.com/store/apps/details?id=gov.va.ptsd.ptsdcoach

U.S. Department of Veterans Affairs, & U.S. Department of Defense. (2010). VA/DoD clinical practice guideline for management of post-traumatic stress. Washington, DC: Management of Post-Traumatic Stress Working Group. Retrieved from http://www.healthquality.va.gov/ptsd/cpg_PTSD-FULL-201011612.pdf

Ursano, R. J., Bell, C., Eth, S., Friedman, M., Norwood, A., Pfefferbaum, B., … Benedek, D. M. (2010). Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Arlington, VA: American Psychiatric Association. Retrieved from http://psychiatryonline.org/pdfaccess.ashx?ResourceID=243186&PDFSource=6

Virtually Better, Inc. (2013). Virtual Iraq. Retrieved from http://www.virtuallybetter.com/virtual-iraq/

Weathers, F. W., Blake, D. D., Schnurr, P. P., Kaloupek, D. G., Marx, B. P. & Keane, T. M. (2013). The clinician-administered PTSD scale for DSM-5 (CAP-5). Retrieved from http://www.ptsd.va.gov/professional/assessment/adult-int/caps.asp

Wendling, P. (2008). Knowledge gap exists on best practices for PTSD. Retrieved from http://www.thefreelibrary.com/Knowledge gap exists on best practices for PTSD.-a0199814983

Mary Alice Fernandez, NCC, is an assistant professor at Texas A&M University – Corpus Christi. Melissa Short is a doctoral student at Walden University Online. Correspondence can be addressed to Mary Alice Fernandez, 6300 Ocean Drive, Unit 5834, Corpus Christi, TX 78412-5834, mary.fernandez@tamucc.edu.

The Implications of Attachment Theory for Military Wives: Effects During a Post-Deployment Period

Apr 4, 2014 | Article, Volume 4 - Issue 2

Kristin A. Vincenzes, Laura Haddock, Gregory Hickman

Past research has indicated the negative and positive impacts of deployment on military wives.  Furthermore, research has indicated the need to further understand the different deployment stages, specifically the post-deployment period. The authors examined Bowlby’s and Ainsworth’s attachment theories, specifically separation anxiety occurrence as experienced by stay-behind wives during their husbands’ post-deployment period. Purposive/volunteer sampling was used to survey 57 military wives currently experiencing the post-deployment period. A linear regression analysis produced a significant positive relationship between duration of deployment and the wife’s psychological distress during the post-deployment period. As deployments increased in duration, specifically to longer than 6 months, the levels of psychological distress significantly increased.  Implications for counselors and researchers are addressed. 

Keywords: post-deployment, attachment, military wives, separation anxiety, deployment

Between 2001 and 2012, the U.S. government sent 2.4 million soldiers to Iraq and Afghanistan (U.S. Department of Veteran Affairs, 2012). According to Demers (2008), deployments affected both the soldier and the stay-behind wife (over 56% of the soldiers reported being married according to the Department of Defense, 2012). The couple’s relationship may play an intricate role in identifying effects that a deployment could have on a stay-behind wife. Specifically, stay-behind wives may have both positive and negative experiences in response to prolonged separation from their husbands (Barker & Berry, 2009; Demers, 2008; Morse, 2006).  

This study focuses specifically on wives of male soldiers, and applies Bowlby’s and Ainsworth’s attachment theories (Ainsworth & Bell, 1970; Bowlby, 1969) to military wives’ post-deployment experiences. Bowlby (1969) asserted that an accumulation of early attachment experiences create expectations for future relationships. Over 40 years ago, Ainsworth and Bell (1970) identified three primary types of attachment: secure, avoidant and ambivalent. More specifically, the researchers found that children with an ambivalent attachment style exhibited anxiety following separation when the mother returned, going near the mother, but also exhibiting signs of anger by pushing her away (Ainsworth & Bell, 1970). In comparison, children with a secure attachment welcomed their mother’s return, and children with an avoidant attachment showed little interest in their returning mother (Ainsworth & Bell, 1970). Robertson and Bowlby (1952) also examined the idea of separation anxiety, identifying specific infant stages of attachment. The three phases an infant goes through when separated from their mother include protest, despair, and denial or detachment (Robertson & Bowlby, 1952).

The three separation anxiety phases may be applied to attachment issues that military wives experience during and after their husbands’ out-of-country deployment (Basham, 2008; Riggs & Riggs, 2011). The first phase, protest, occurs when a child is separated from his or her mother, with sadness and anxiety presenting as the most common initial emotional reactions. The protest phase is linked to pre-deployment and deployment time periods, as wives often feel numb, angry and abandoned due to an upcoming or current separation from their husbands (Pincus, House, Christenson, & Adler, 2001). Furthermore, wives also may experience sadness, loneliness and anxiety during this phase (SteelFisher, Zaslavsky, & Blendon, 2008).

The second phase of separation anxiety is despair, characterized by feelings of extreme sadness (Riggs & Riggs, 2011; Robertson & Bowlby, 1952). A wife may often go through similar stages of grief and mourning when her husband is deployed (Pincus et al., 2001). Initially a wife may be in denial that her husband is gone, believing that she will be fine and that he is only away for a few days’ training (Pincus et al., 2001). As time passes, she may experience depression and withdrawal as she realizes that her husband will not return for a long time, if at all (Vormbrock, 1993).

The nature of the military deployments to Iraq and Afghanistan are characterized by continual life-threatening experiences, coupled with the absence of any “safe” place (Demers, 2008). Constant media coverage spotlights the dangers of deployment to active combat zones and undoubtedly impacts a wife’s ability to trust that her husband will safely return (Demers, 2008). Wives have reported being in constant fear for their soldiers’ safety, which may result in feeling helpless throughout the deployment (Demers, 2008; Spera, 2009). Eventually, a wife may begin to accept that her husband is gone, and transfer her love to someone else, such as a child or different partner (Morse, 2006).

The final phase of separation anxiety, denial or detachment, can occur during both the deployment period and the post-deployment period (Morse, 2006). Robertson and Bowlby (1952) postulated that this last phase serves as a defense mechanism, which wives utilize when their husbands abruptly rejoin their families (Pincus et al., 2001; Riggs & Riggs, 2011). Anxiety combined with excitement has been found to impact the restabilization of the couple (Morse, 2006; Pincus et al., 2001). Attempting to regain a physical and emotional connection with one another after a long, seemingly permanent separation has been found to be extremely stressful, resulting in struggles with communication, coparenting, returning to pre-deployment routines, and marital intimacy (Orthner & Rose, 2005).

Additional challenges during the post-deployment period may entail negotiating new roles and boundaries within the family system, household management, financial status, parental rejection and new social supports (Drummet, Coleman, & Cable, 2003). If the husband returns and attempts to resume roles that existed prior to his deployment, it may diminish the stay-behind wife’s feelings of worth and accomplishment, since she successfully managed the various facets of daily life in her husband’s absence (Drummet et al., 2003), further straining the attachment between the couple. Although each endured the deployment simultaneously, the experiences were likely uniquely and vastly different from one another (Pincus et al., 2001).

Purpose

This quantitative study examined how stay-behind wives experience separation anxiety, through examining the relationship between duration of deployment and psychological distress during post-deployment. The theoretical framework for this study focused on attachment between a husband and wife and how a couple cope with separation. Surveys of wives were conducted during the post-deployment period in an effort to capture data from the time that couples were reattaching. For the purposes of this study, post-deployment is defined as the 12-month period after the husband has returned from deployment.

Research Design

A nonexperimental, correlational design was chosen for this study. In order to gain access to a multitude of military wives, there was no specific inclusion criteria with regard to the soldier’s branch in the military, rank, or if the husband was active duty, Reserves, or National Guard. In order to attempt to control for the potential confounding variable of gender, this study included only stay-behind wives. Stay-behind wives may or may not have children. Finally, stay-behind wives must currently be in the post-deployment stage; therefore, the husbands must have returned from their deployment within the past 12 months (Vincenzes, 2013).

Data Collection

The sampling method used for this research was volunteer purposive sampling. Inclusion criteria included the following: female, currently married and experiencing the post-deployment period (within the 12 months since her husband returned from the deployment), and a deployment that had lasted 6 or more months. Approximately 30 original e-mails were sent out to military advocacy groups, current military wives, the Army Wives Network, and a military advocacy group called Pennsylvania Americans showing Compassion, Assistance, and Reaching out with Empathy for Service members (PA C.A.R.E.S.). These individuals were asked to forward the initial e-mail soliciting military wives for the current study (Vincenzes, 2013).

If individuals agreed to volunteer for the study, they immediately received a background questionnaire, which assessed the duration of deployment (independent variable). Duration of deployment was operationalized as the total number of months that the soldier was deployed, from the day he left until the day he returned (Vincenzes, 2013). Furthermore, the participants took the Depression Anxiety Stress Scales (DASS-21; Lovibond & Lovibond, 1995), which was used to operationally define the dependent variable of psychological distress. The DASS-21 is a 21-item Likert scale survey and consists of three subscales (Depression, Anxiety, and Stress). In addition to individual scores on the subscales, the assessment provides an overall global psychological distress level, which was the score this particular study used. The reliability for this measure was high with a .93 internal consistency on the overall global scale (Henry & Crawford, 2005). In addition, the DASS-21 illustrated good convergent and discriminant validity as compared to the Hospital Anxiety and Depression Scale and Personal Disturbance Scale (Henry & Crawford, 2005).

Results

Of the 145 participants who responded to the survey, 48.9% (n = 68) met the criteria, but 14.7% (n = 10) had missing data. Thus, the final data sample contained 40% (n = 58) of the participants who volunteered. The inclusive sample accurately depicted the dispersion of active duty military (56.9% Army, 22.4% Air Force, 12.1% Navy, and 1.4% Marine Corps); however, fewer participants were associated with the National Guard (5.2%) and Reserves (1.7%) than expected.

The age of the wives ranged from 21–47 (M = 31.2, SD = 6.7), and 50% were 29 years old or younger. The majority of the participants (93.1 %) had some years of college (only 6.9% had a high school diploma/GED or less). Furthermore, 29.3% had some college, but no degree; 20.7% had an associate degree, 31% had a bachelor’s degree, and 12.1% had a graduate degree. With regard to employment status, 53.4% of the participants were not employed and 46.6% were employed. The number of years couples were married ranged from 1–20 (M = 7.2, SD = 5) and 48.3% of the participants had been married 5 years or less. The number of children under 17 who lived in the household ranged from 0–4 (M = 1.5, SD = 1.3) and 51.7% had either no children or one child. The length of deployments ranged from 6–16 months (M = 9.5, SD = 2.8). Finally, the length of time since the husband returned from deployment ranged from 0–12 months (M = 6.0, SD = 4.2).

The study’s null hypothesis stated that in the population under investigation, the proportion of variance in post-deployment psychological distress level explained by the duration of deployment (as measured by the DASS-21) was zero. Linear regression analysis predicted psychological distress from the duration of husband’s deployment. Results from the analysis indicated that duration of deployment significantly predicted psychological distress: F(1, 57) = 5.384,  p = .024, R=.296, Adj. R² = .071. Duration of deployment accounted for 8.8% of the variance in psychological distress and was positively related to psychological distress ( = .296, sr ² =.088). Based on these results, the null hypothesis, which stated that distress levels would be zero or not change following longer deployments, was rejected. Thus, as the duration of deployment increases, the psychological distress levels for stay-behind wives also increases.

Discussion

This study confirmed prior research and extended existing literature regarding attachment theory as it relates to stay-behind military wives. For example, researchers have found that when husbands are deployed or away on military duties for several months, the wives not only demonstrate feelings of anger during the deployments, but that their feelings of anger persist even after their husbands return from deployment and military duties (Pincus et al., 2001; Riggs & Riggs, 2011; Zeff, Lewis, & Hirsch, 1997). Indeed, the findings from this current study supported prior research, as the author found a positive relationship between deployments of increasing length and an increase in distress levels among stay-behind military wives. Although this study did not specifically evaluate wives’ anger, other researchers have found that high distress levels are correlated with the development of anger among military wives (Drummet et al., 2003).

The results of this study illustrate that post-deployment is indeed very stressful for the wife, particularly when the husband was deployed for 6 months or more. Since deployments lasting 6 or more months significantly predicted psychological distress for the wives, it may be that as deployment length increases, stress levels also may increase, resulting in a wife emotionally withdrawing from her husband. The findings from this study support prior research that has identified the coping strategy of emotional withdrawal, which results from psychological distress and may enable the wife to continue her daily life, while also creating a new support system and sense of emotional equilibrium (Pincus et al., 2001).

Some stay-behind wives function well on a daily basis while their husbands are deployed; however, other stay-behind wives appear to struggle with their husbands’ deployment (Riggs & Riggs, 2011). Such research supports the notion that wives who made secure attachments while growing up may be better able to cope with military separations (Riggs & Riggs, 2011). It should be noted, however, that only in the past several years have some deployments lasted up to 15 or 16 months (Sheppard, Malatras, & Israel, 2010). The length of deployments, especially 6 or more months, may significantly alter the ability of stay-behind wives to successfully cope, regardless of their attachment styles. Further research should examine the impact of lengthy deployments (e.g., 6 or more months) on stay-behind wives’ ability to cope as it relates to attachment style, as there may be a point of diminishing returns at which, regardless of one’s attachment to her parents growing up, the ability to cope disappears.

Vormbrock (1993) predicted that as the duration of deployment increased, so too would distress levels during the couple’s reunion. This was hypothesized to be due to the continual unavailability of the attachment figure. The current study supports Vormbrock’s theory in that participants’ reported distress levels during post-deployment were significantly higher (p = .023) as deployment duration increased. Perhaps when the husband is gone for 6 months or more, the potential for the marriage to grow apart or detach may increase. Vormbrock (1993) found that wives can successfully focus on the brevity of their separation as a means of coping; however, as the deployments increase in length, it may affect wives’ ability to maintain the mentality that this separation is only temporary. Deployments that require the couple to be apart for 6 or more months may result in the wife feeling that the separation is more permanent. The longer the husband is away, the more independent the wife may become by creating new schedules and ways of doing things (Morse, 2006; Pincus et al., 2001).

Although this research elaborated on the relationship of the post-deployment period and distress among stay-behind military wives, there are some limitations to the study. The first limitation may be a self-selection bias, which may have impacted the internal validity. More specifically, since participants were volunteers, some individuals may have extremely negative feelings toward the military and may have opted not to participate. This could have inadvertently skewed the population sample, thus impacting the results. Indeed, researchers have discussed that volunteer samples may have biased tendencies as a motivation for their participation in a specific study (Frankfort-Nachmias & Nachmias, 2008). In addition to self-selection bias, an instrumentation threat could be present, as this survey relied on participants’ honesty. Another possible limitation is that this study was a regression study, which relies on the correlational nature of two variables. Perhaps there are extraneous variables that could be moderating or mediating the relationship of deployment length and distress level among stay-behind military wives.

Conclusions and Implications

Despite existing limitations, this study supported research regarding military deployment as a significant concern for military families, as well as for military leaders who rely on the husbands of these stay-behind wives to provide national security. As surveys within the last decade indicate that nearly 60% of American military members are married (Sierra & Kemp, n.d.), the results of this study also offer further insight into the contextual factors that are part of a therapeutic treatment intervention. Military couples are unique and a counselor’s awareness of needs particular to this group is imperative for therapeutic success.

The current research found a positive correlation between the duration of deployment and stay-behind wives’ psychological distress levels during post-deployment. This finding corroborates the research on separation anxiety for children, particularly when children illustrate signs of detachment from their mother following a separation. Attachment figures may include other vital individuals in one’s life, especially for military couples. Since many military couples do not live close to immediate biological family members, the wife may solely depend on the husband to meet her emotional, physical and social needs, just as an infant child often relies on their mother to meet these same basic needs. With this in mind, the notion of separation anxiety may not be just applicable to young children but also adults, particularly military wives.

Counselors may want to educate stay-behind wives on separation anxiety and assist them in processing their experiences, as well as recognize wives’ desire for a stable, secure relationship and assist them to this end. Furthermore, since deployments are unpredictable and out of the wives’ control, it may be helpful for counselors to assist the wives in gaining a greater sense of control throughout their daily lives. Just as counselors often recommend that children with separation anxiety have a consistent routine, as well as partake in positive social activities, it also may be helpful to encourage stay-behind wives to create predictable routines that include engaging in various social events with friends and/or other military wives.

This study also has implications for further research regarding the human services industry (e.g., clergy, educators) who directly work with such military families. One might assume that not all soldiers or their wives experience deployment the same way, and thus counselors must be prepared to individualize interventions and compose treatment plans according to the needs of the individual as well as needs as a couple. For example, the post-deployment period may entail negotiating new roles and boundaries within the family system. Wives frequently experience the emotion of celebration for the return of their husbands, while also feeling confusion over what it will mean to share a home again after becoming more independent. This experience of boundary ambiguity can be very confusing for wives who recognize that their husbands are physically present, but who are still transitioning toward psychological acceptance that he is present.

Role ambiguity may increase if the couple is not comfortable communicating with each other regarding roles, responsibilities and needs. Simultaneously, a soldier may feel disconnected and unaware of how to reengage without interfering with the family’s new roles. Thus, helping professionals must be prepared to work with the couple on strengthening basic communication skills and nurturing a climate that facilitates safe and transparent information exchange.

Future research could evaluate the experiences of deployed husbands in terms of understanding how the distress level of their stay-behind wives impacts their duties while deployed. Such research might have national security implications. In addition, future research could examine deployments of 6 months or more regarding the struggles, challenges, resiliency, social and psychological effects, educational outcomes, parenting styles, and attachment of the deployed husbands, the stay-behind wives, and their children.

One particular variable that may moderate the relationship between duration of deployment and psychological distress is the stay-behind wife’s social support system. Larsen and Kia-Keating (2010) found that a social support system significantly aided resiliency for stay-behind wives who experienced a military deployment. Furthermore, a wife’s well-being was positively impacted by having a mentor who had previously experienced a deployment herself (Larsen & Kia-Keating, 2010). This brings up an interesting perception of what social support may be necessary for a military wife. Whereas some social support indices examine tangible support (i.e., someone to help around the house), the stay-behind wife may need a social support that relies more on reducing emotional stress.

Future research could qualitatively explore the social support construct further by interviewing stay-behind wives and identifying the indices of social support that they deem important in terms of reducing stress during the post-deployment period. Such a qualitative process could then lead to the quantitative development of a more valid measure of social support necessary to reduce stress for stay-behind military wives, and therefore indirectly for their deployed husbands. Perhaps such a study could examine whether social support serves as a moderating or mediating influence on the relationship between deployment length and psychological distress of stay-behind wives. Such research could have both positive and negative implications for their families, the military, and society at large, as American society depends greatly on its military for national security.

References

Ainsworth, M. D. S., & Bell, S. M. (1970). Attachment, exploration, and separation: Illustrated by the behavior of one-year-olds in a strange situation. Child Development, 41, 49–67.

Barker, L. H., & Berry, K. D. (2009). Developmental issues impacting military families with young children during single and multiple deployments. Military Medicine, 174, 1033–1040.

Basham, K. (2008). Homecoming as safe haven or the new front: Attachment and detachment in military couples. Clinical Social Work Journal, 36, 83–96. doi:10.1007/s10615-007-0138-9

Bowlby, J. (1969). Attachment and loss: Volume 1: Attachment. New York, NY: Basic Books.

Demers, A. (2008). The war at home: Consequences of loving a veteran of the Iraq and Afghanistan wars. Internet Journal of Mental Health, 6, 1–12. doi:10.5580/5ac

Drummet, A. R., Coleman, M., & Cable, S. (2003). Military families under stress: Implications for family life education. Family Relations, 52, 279–287.

Frankfort-Nachmias, C., & Nachmias, D. (2008). Research methods in the social sciences (7th ed.). New York, NY: Worth.

Henry, J. D., & Crawford, J. R. (2005). The short-form version of the Depression Anxiety Stress Scales (DASS-21): Construct validity and normative data in a large non-clinical sample. British Journal of Clinical Psychology, 44, 227–239. doi:10.1348/014466505X29657

Larsen, J., & Kia-Keating, M. (2010, August). Resilience based ecological model of military family coping during deployment. Poster session presented at the annual conference of the American Psychological Association, San Diego, CA.

Lovibond, P. F., & Lovibond, S. H. (1995). The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behaviour Research and Therapy, 33(3), 335–343. doi:10.1016/0005-7967(94)00075-U

Morse, J. (2006). New emotional cycles of deployment for service members and their families. U.S. Department of Defense: Deployment Health and Family Readiness Library. San Diego, CA. Retrieved from http://deploymenthealthlibrary.fhp.osd.mil/Product/RetrieveFile?prodId=241

Orthner, D. K., & Rose, R. (2005). SAF V survey report:  Reunion adjustment among Army civilian spouses with returned soldiers. Retrieved from www.army.mil/fmwrc/docs/saf5reunionreport.pdf

Pincus, S. H., House, R., Christenson, J., & Adler, L. E. (2001, April/June). The emotional cycle of deployment: A military family perspective. U.S. Army Medical Department Journal, 15–23. Retrieved from http://cdm15290.contentdm.oclc.org/cdm/ref/collection/p15290coll3/id/898

Renshaw, K. D., Rodrigues, C. S. & Jones, D. H. (2008). Psychological symptoms and marital satisfaction in spouses of operation Iraqi freedom veterans: Relationships with spouses’ perceptions of veterans’ experiences and symptoms. Journal of Family Psychology, 22, 586–594.

Riggs, S. A., & Riggs, D. S. (2011). Risk and resilience in military families experiencing deployment: The role of the family attachment network. Journal of Family Psychology, 25, 675–687. doi:10.1037/a0025286

Robertson, J., & Bowlby, J. (1952). Responses of young children to separation from their mothers. Courrier of the International Children’s Centre, Paris, II, 131–140.

Sheppard, S. C., Malatras, J. W., & Israel, A. C. (2010). The impact of deployment on U.S. military families. American Psychologist, 65, 599–609. doi:10.1037/a0020332

Sierra, T. A. & Kemp, H. (n.d.). Strategies for working with military couples in hope focused couples approach. Retrieved from

http://j.b5z.net/i/u/2043019/i/Strategies_for_Working_with_Military_Couples_in_Hope_Focused_Couples_Approach.pdf

Spera, C. (2009). Spouses’ ability to cope with deployment and adjust to Air Force family demands: Identification of risk and protective factors. Armed Forces & Society, 35, 286–306. doi:10.1177/0095327X08316150

SteelFisher, G. K., Zaslavsky, A. M., & Blendon, R. J. (2008). Health-related impact of deployment extensions on spouses of active duty Army personnel. Military Medicine, 173, 221–229.

U.S. Department of Defense. (2012). 2012 demographics profile of the military community. Retrieved from http://www.militaryonesource.mil/12038/MOS/Reports/2012_Demographics_Report.pdf

U.S. Department of Veteran Affairs. (2012). Analysis of VA health care utilization among Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF) and Operation New Dawn (OND) veterans. Retrieved from www.publichealth.va.gov/docs/epidemiology/healthcare-utilization-report-fy2012-qtr1.pdf

Vincenzes, K. A. (2013). The impact of social support on the relationship between length of deployment and psychological distress for military wives during post-deployment. (Doctoral dissertation). Retrieved from ProQuest/UMI. (13775).

Vormbrock, J. K. (1993). Attachment theory as applied to wartime and job-related marital separation. Psychological Bulletin, 114, 122–144. doi:10.1037/0033-2909.114.1.122

Zeff, K. N., Lewis, S. J., & Hirsch, K. A. (1997). Military family adaptation to United Nations operations in Somalia. Military  Medicine, 162, 384–387.

Kristin A. Vincenzes, NCC, is an Assistant Professor and Director of the Clinical Mental Health Counseling program at Lock Haven University. Laura Haddock, NCC, is a Core Faculty member and CES Program Coordinator at Walden University. Gregory Hickman is a Core Faculty member at Walden University. Correspondence can be addressed to Kristin A. Vincenzes, 401 N. Fairview Street, Courthouse Annex Room 301, Lock Haven, PA, 17745, KAV813@lhup.edu.