Implementation and Dissemination of Military Informed and Evidence-Based Interventions for Community Dwelling Military Families

Community dwelling military families from the National Guard and Reserve contend with deployment-related stressors in relative isolation, living in communities where mental health providers may have little knowledge of military culture. When they are community residents, active duty service members and families tend to live in close proximity to their military installations. This article will focus primarily on the challenges to quality mental health care for reserve component (RC) families. Where studies of RC families are absent, those of active component (AC) families will be highlighted as relevant. Upon completion of a deployment, reintegration for RC families is complicated by high rates of symptomatology, low service utilization, and greater barriers to care relative to AC families. A paucity of providers skilled in evidence-based treatments (EBTs) limits community mental health capacity to serve RC military families. Several emergent programs illustrate the potential for better serving community dwelling military families. Approaches include behavioral health homes, EBTs and treatment components, structured resiliency and parent training, military informed schools, outreach methods, and technology-based coping, and psychoeducation. Methods from implementation science to improve clinical skill acquisition and spread and sustainability of EBTs may advance access to and quality of mental health treatment and are reviewed herein. Recommendations related to research methods, military knowledge and treatment competencies, and transition to a public health model of service delivery are discussed.     

Associations of Stress Exposures and Social Support With Long-Term Mental Health Outcomes Among U.S. Iraq War Veterans

The long-term mental health effects of war-zone deployment in the Iraq and Afghanistan wars on military personnel are a significant public health concern. Using data collected prospectively at three distinct assessments during 2003–2014 as part of the Neurocognition Deployment Health Study and VA Cooperative Studies Program Study #566, we explored how stress exposures prior, during, and after return from deployment influence the long-term mental health outcomes of posttraumatic stress disorder (PTSD), depression, anxiety disorders, and problem drinking. Longer-term mental health outcomes were assessed in 375 service members and military veterans an average of 7.5 years (standard deviation = 1.0 year) after the initial (i.e., “index”) Iraq deployment following their predeployment assessment. Anxiety disorder was the most commonly observed long-term mental health outcome (36.0%), followed by depression (24.5%), PTSD (24.3%), and problem drinking (21.0%). Multivariable regression models showed that greater postdeployment stressors, as measured by the Post-Deployment Life Events scale, were associated with greater risk of depression, anxiety disorders, and problem drinking. Anxiety disorder was the only outcome affected by predeployment stress concerns. In addition, greater postdeployment social support was associated with lower risk of all outcomes except problem drinking. These findings highlight the importance of assessing postdeployment stress exposures, such as stressful or traumatic life events, given the potential impact of these stressors on long-term mental health outcomes. This study also highlights the importance of postdeployment social support as a modifiable protective factor that can be used to help mitigate risk of long-term adverse mental health outcomes following war-zone exposure.     

Military Stressors,Parent-Adolescent Relationship Quality,and Adolescent Adjustment

Elements of military life can create challenges for all family members, including military-connected adolescents, and can have detrimental consequences for their adjustment. Although research with samples of military-connected adolescents has examined the influences of military stressors for adolescent adjustment (e.g., depressive symptoms, anxiety), less research has identified possible mechanisms responsible for these effects, particularly the role of specific familial factors. Drawing from social ecological theory and attachment theory, we examined the associations between military stressors (e.g., parental rank, combat deployments, permanent change of station moves) and self-reported adolescent adjustment (e.g., depressive symptoms, self-efficacy) along with examining adolescents’ perceptions of parent-adolescent relationship quality with both the active duty and civilian parent as a linking mechanism. Using a path analysis, data from 265 Army families were examined to identify the direct and indirect associations between military stressors and adolescent adjustment through parent-adolescent relationship quality. Most military stressors were not significantly related to relationship quality of either parent or indicators of adolescent adjustment. However, parent-adolescent relationship quality with each parent (active duty and civilian parent) was uniquely related to adolescents’ adjustment. Discussion is provided regarding how military stressors and familial factors are conceptualized within the context of military families and implications for future research, family therapy, and policies are suggested.

     

An empirical examination of stigma toward mental health problems and psychotherapy use in Veterans and active duty service members

Although many Veterans and active duty service members experience mental health problems, most do not seek out any sort of mental health help. Stigma (a significant predictor of treatment-seeking) has been documented among Veterans and active duty service members; however, previous research on stigma in these groups has primarily utilized correlational and qualitative designs. The purpose of this study was to gain a better understanding of stigma toward mental health problems in Veterans and active duty service members using an experimental design. One hundred sixty-five Veterans and active duty service members were randomized to read a vignette that described a Veteran who either did or did not experience a mental health problem and did or did not seek psychotherapy. Results indicated that the participants held more stigmatizing attitudes toward the Veteran who was described as having a mental health problem, but not toward the Veteran who was described as seeking psychotherapy. Additionally, participants held more positive attitudes toward the Veteran, compared to the attitudes that they believed other military members would hold. Last, with this sample of Veterans and active duty service members, self-stigma toward seeking psychotherapy was found to partially mediate the relationship between perceived public stigma and attitudes. Implications for addressing stigma in military service members and Veterans are discussed.     

STRESS AMONG PALESTINIAN WOMEN UNDER MILITARY OCCUPATION; WOMEN'S APPRAISAL OF STRESSORS,THEIR COPING MODES,AND THEIR MENTAL HEALTH

Psychological responses and mental health of 174 Palestinian women living in the occupied West-Bank and the Gaza Strip were studied through a stress model. Thirty-five Palestinian women living in Israel proper who had not been exposed to military occupation were interviewed as a comparison group. The stress process studied consists of women's appraisal of threat and the importance of the stressors in their lives, the estimation of their own resources to cope with stress, actual coping modes, and mental health outcomes. Women living under military occupation tended to appraise their environment as highly threatening and their experiences as strain-producing. At the same time they believed they had sufficient assets, especially collective and ideological resources, to deal with the stressors. This tendency was particularly evident among victims of political violence. Women strongly exposed to hardships of military occupation tended to employ more social and political activity and less inactive and accommodative coping modes than did less traumatized women. Exposure to stressful events, characteristic to military occupation and armed conflict, tended to deteriorate women's mental health, as indicated by severe anxiety, depression, hostile feelings and psychiatric symptoms, and also deteriorating their general health. Multiple regression analysis of the data pertaining to the stress process indicated not only the existence of objective stressors but also the appraisal of their harmfulness, the coping modes as well as vulnerability-protective factors which determine the outcomes of the stress process. A good economic situation, sufficient social support, and religious commitment functioned as protective factors in stress process, i.e., they were able to diminish the impact of exposure to stressors on women's mental health. In the case of the Palestinian women the hardships due to military occupation and national struggle initiated a different stress process than did the daily life difficulties. This indicates that in studies on psychological functioning in a political and armed conflict, the collective level of coping, values, norms, ideology as well as the concrete political aims of the society should be included in analysis and interpretation.     

Assessment and Treatment of Combat-Related PTSD in Returning War Veterans

Over the past 9 years approximately 2 million U.S. military personnel have deployed in support of Operation Iraqi Freedom in Iraq and Operation Enduring Freedom in and around Afghanistan. It has been estimated that 5–17% of service members returning from these deployments are at significant risk for combat-related posttraumatic stress disorder (PTSD). Many of these returning war veterans will seek medical and mental health care in academic health centers. This paper reviews the unique stressors that are related to the development of combat-related PTSD. It also reviews evidence-based approaches to the assessment and treatment of PTSD, research needed to evaluate treatments for combat-related PTSD, and opportunities and challenges for clinical psychologists working in academic health centers.     

The biopsychosocial-spiritual health of active duty women

ABSTRACT

Women have been an active part of the military since the beginning of American history, holding various roles in the military for centuries. The purpose of this review is to explore the literature pertaining to the biopsychosocial and spiritual health of active duty women. These comparisons help to highlight factors that are most unique to women who are serving in our active duty armed forces. The current review revealed that while active duty women and men report similar levels of resiliency, and women may be no more susceptible to the negative effects of combat than men, there is evidence that active duty women experience higher levels of posttraumatic stress due to physical and sexual trauma in the military aside from combat exposure. Findings suggest that further research is needed to better understand the unique challenges of women in the military in order to create service delivery models that support the BPSS health of women in order to maintain mission readiness and retain women in the military.     

Self-regulation,health, and behavior: A perceptual-cognitive approach

Abstract

Self-regulation systems are designed to adapt to threats via coping procedures that make efficient use of resources based upon valid representations of the environment. We discuss two components of the common-sense model of health threats: illness representations (e.g., content and organization) and coping procedures (e.g., classes of procedure and their attributes - outcome expectancies, time-lines, dose-efficacy beliefs, etc.). Characteristics of each of these domains, and the connection between the two, are critical to understanding human adaptation to problems of physical health. Rather than posing a barrier to factors outside the person that control behavior, an emphasis on subjective construal involves a view of the person as an active problem-solver embedded in a bidirectional system of sensitivity and responsiveness vis á vis the social, physical, and institutional environments in which health threats occur and through which intervention efforts may be directed.     

Low Intensity Conflict Stress in Soldiers: Building Coping Skills and Resources

With the conventional wars being rarer, low intensity conflict (LIC) operations have now become a norm. This new military environment is characterized by ambiguous and unpredictable situations, complex goals, invisible enemy combatants, political sensitivities, undefined restraints on weaponry tactics and associated multiple microstressors that make it highly stressful and cognitively demanding for soldiers. Considering LIC stress under a holistic / interactionistic paradigm, this review paper examines (i) the unique stressors of LIC operations and their impact on soldiers?? mental health and fitness, cognitive functioning, combat readiness and effective performance; (ii) preventive training programmes (Hardiness Training and Comprehensive Soldier Fitness) for developing and sustaining resilience; (iii) the central role of military leadership and structure as key components of combat stress control, unit cohesion, institutional support and other HR practices (e.g., command consultation, grievance redresssal, performance appraisal, communication, conflict resolution); and (iv) mental health services as coping resources and potential stress countermeasures such as psychological first aid, after-action debriefing, operational stress training, suicide prevention, treatment of stress casualities, help-seeking skills and self-care as part of preventive mental health training and post-trauma rehabilitation. The roles of both the skill-building and the stress-combating aspects of training, leadership, organizational support / HR practices and mental health services seem important as potential moderators of stress-strain relationship in LIC operations.     

The role of community context and psychological well-being for physical health: A dyadic study of military couples

Drawing from the social organizational theory of community action and change (SOAC) within a systemic biopsychosocial perspective, associations between community context (military community connections and satisfaction with military life), psychological well-being (depressive symptoms, anxiety, and self-efficacy), and physical health were examined for a sample of active duty service members and their civilian spouses (N = 236 couples) using an actor partner interdependence framework. Service members with higher levels of military community connections reported better psychological well-being. When civilian spouses were more satisfied with military life, both partners reported better psychological well-being. In turn, both spouses’ psychological well-being was related to their own reports of physical health. Statistically significant indirect effects were found between community contexts and spouses’ physical health. Enhancing community connections may be an important leverage point for supporting health and family readiness.     

The State of Dyadic Methodology: An Analysis of the Literature on Interventions for Military Couples

ABSTRACT

Military members and their spouses experience unique stressors compared with civilian couples, making them distinctively vulnerable to a number of marital and mental health concerns. However, the amount and quality of intervention research to guide treatment for military couples are unknown. Therefore, a systematic literature search of interventions for military couples was completed resulting in 10 articles that met the study's inclusion and exclusion criteria. Further, a rubric to assess dyadic methodology was created and utilized to determine the dyadic quality of the methodology of the sampled articles. The results of the systematic literature review revealed that (a) there are few evidence-based interventions for military couples in which both members of the dyad are included and (b) the methodology by which treatments are evaluated largely do not employ systemic or dyadic measures. Recommendations for future research with military couples includes the need for couple-focused interventions using experimental methodology, systemic theories to guide intervention and research, and appropriate dyadic assessment and analysis tools to determine the effectiveness of couple's interventions for military, reserve, and veteran populations.     

Roles of Leisure in Coping with Stress Among University Students: A Repeated-Assessment Field Study

This article reports findings of a study to examine the effects of leisure coping on various stress coping outcomes including: immediate outcomes (perceived coping effectiveness, perceived satisfaction with coping outcomes, and perceived stress reduction) and distal or long-term outcomes (physical and mental ill-health and psychological well-being), above and beyond the contributions of general coping - coping not directly associated with leisure. A repeated-assessment field design was used to examine ways in which university students cope with stressors in their daily lives. The study found that leisure coping beliefs (leisure-generated dispositional coping resources) significantly predicted lower levels of mental and physical ill-health and greater levels of psychological well-being above and beyond the effects of general coping. Also, the use of leisure coping strategies (situation-specific stress coping strategies through leisure) was significantly associated with higher levels of perceived coping effectiveness and stress reduction when the effects of general coping were taken into account. Significant contributions of specific leisure coping dimensions were found as well.     

The Coping Paradox: Work,Stress, and Coping in the U.S. Army

The military environment has unique stressors. This study investigates the types of stressors, appraisals, and coping responses of U.S. soldiers and their leaders. A qualitative analysis of interviews indicates that the traditional coping buffers of social drinking and seeking social support from fellow soldiers, family, and leaders can potentially serve as sources of stress. While this paradox may be a result of the unique types of stressors in the military work environment, these results should direct researchers to better understand individuals' perceptions and appraisals of stress, with a focus on the meaning of stress, given contextual factors inherent in the workplace. The findings are discussed in relation to the literature on the impact of stress on physical and psychological health.     

Relation between coping and posttrauma cognitions on PTSD in a combat-trauma population

Individual differences in cognitive processes and coping behaviors play a role in the development and maintenance of posttraumatic stress disorder (PTSD). Given the large numbers of combat-exposed service members returning from the Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) conflicts, exploring individual differences in cognitive-affective processes is important for informing our understanding of PTSD etiology and early intervention in military samples. The present study examined the unique main and interactive effects of negative posttrauma cognitions (i.e., negative beliefs about self [NS], the world [NW], and self-blame [SB]) and coping strategies (i.e., positive behavioral, positive cognitive, avoidant coping, and social and emotional coping) on PTSD diagnosis within 155 (M_age = 30.7, SD = 4.48) OEF/OIF/OND combat trauma-exposed Veterans recruited from an ongoing study examining the effects of combat trauma and stress reactivity. In the final, stepwise logistic regression analysis, avoidant coping, but no other coping strategy, was significantly positively related to PTSD diagnosis in the initial step. Higher levels of NS, but not NW, were significantly associated with having a PTSD diagnosis, whereas SB was associated with decreased likelihood of PTSD, above and beyond coping strategies. A significant interaction effect was found between NS and positive cognitive coping, such that greater positive cognitive coping weakened the relationship between NS and PTSD. Examining and addressing coping behaviors and negative thoughts of self jointly may benefit assessment and intervention approaches in a combat-trauma population.     

Family Systems and Ecological Perspectives on the Impact of Deployment on Military Families

The scope of sustained military operations in Iraq and Afghanistan has placed great demands on the Armed Forces of the United States, and accordingly, military families have been faced with deployments in more rapid succession than ever before. When military parents fulfill occupational duties during wartime, military children and families face multiple challenges, including extended separations, disruptions in family routines, and potentially compromised parenting related to traumatic exposure and subsequent mental health problems. Such challenges can begin to exert a significant toll on the well-being of both individuals and relationships (e.g., marital, parent–child) within military families. In order to respond more effectively to the needs of military families, it is essential that mental health clinicians and researchers have a better understanding of the challenges faced by military families throughout the entire deployment experience and the ways in which these challenges may have a cumulative impact over multiple deployments. Moreover, the mental health field must become better prepared to support service members and families across a rapidly evolving landscape of military operations around the world, including those who are making the transition from active duty to Veteran status and navigating a return to civilian life and those families in which parents will continue to actively serve and deploy in combat zones. In this article, we utilize family systems and ecological perspectives to advance our understanding of how military families negotiate repeated deployment experiences and how such experiences impact the well-being and adjustment of families at the individual, dyadic, and whole family level.     

Improving Mental Health on College Campuses: Perspectives of Indian College Students

The mental health of college students is increasingly viewed as an important public health priority. However, there has been little attention paid specifically to college students’ perspectives on factors that contribute to mental health challenges or on potential initiatives that could address them. Even less research has focused on students in low- and middle-income countries. In an effort to better understand how to improve mental health and wellness on college campuses, we administered an open-ended survey to 141 Indian college students (M_age = 19.47, 65% female). We asked the students to identify: (a) issues that contribute to mental health problems among college students, (b) potential initiatives or strategies that could be used to improve mental health and wellness, and (c) topics that students would like to learn about in a course about mental health and wellness. Applying thematic analysis, we identified academic stressors (e.g., pressure to succeed, competitiveness) and social stressors (e.g., lack of community, party culture and substance abuse) that students reported as contributors to mental health problems. Students also described mental health promotion strategies that could be implemented by faculty members (e.g., providing academic accommodations for students with mental health concerns), the student body (e.g., establishing peer counseling groups), and individual students (e.g., checking in with others). Finally, they identified topics that they would like to learn about in mental health and wellness courses (e.g., how to identify mental health concerns, how to support friends). By raising several potential targets for mental health and wellness interventions for Indian college students, our study illustrates how open-ended surveys can be a useful and feasible way to solicit input from stakeholders in low- and middle-income countries. Future research will be needed to assess the effectiveness and feasibility of mental health promotion strategies, including those proposed by students.     

Public religious activities,stress, and mental well-being in the United States: the role of religious reframing in coping

Religious reframing is applying religious beliefs to an assessment of stressful personal situations. If public religious activities (e.g., religious volunteering) meet the necessary criteria to enable religious reframing, they may serve to limit (or “buffer”) the negative impact of stressors (e.g., family conflict) on mental well-being. Based on this dynamic, two out of three public religious activities (i.e., religious volunteering and religious group activities, but not religious service attendance) were predicted to buffer stress based on their capacity to enable religious reframing. Predictions were supported by hierarchical linear regressions using data for Americans aged 40 and older (N?=?2579). This research proposes a framework for using religious reframing as the basis for making predictions about relative stress-buffering performances. It also finds that religious service attendance – the most common form of public religious involvement – does not enable religious reframing to the point of effectuating stress buffering.     

Application of the Minority Stress Theory: Understanding the Mental Health of Undocumented Latinx Immigrants

This paper applies the Minority Stress framework to data collected from an ongoing community-based participatory research project with health and social service agencies in Southeast Michigan. We examine the stressors and coping strategies employed by undocumented Latinx immigrants and their families to manage immigration-related stress. We conducted in-depth interviews with 23 immigrant clients at Federally Qualified Health Care Centers (FQHC) in Southeast Michigan and 28 in-depth interviews with staff at two FQHC's and a non-profit agency serving immigrants. Findings suggest that immigrants face heightened anxiety and adverse mental health outcomes because of unique minority identity-related stressors created by a growing anti-immigrant social environment. Chronic stress experienced stems from restrictive immigration policies, anti-immigrant rhetoric in the media and by political leaders, fear of deportation, discriminatory events, concealment, and internalized anti-immigrant sentiment. Though identity can be an important effect modifier in the stress process, social isolation in the immigrant community has heightened the impact of stress and impeded coping strategies. These stressors have resulted in distrust in community resources, uncertainty about future health benefits, delayed medical care, and adverse mental health outcomes. Findings provide a framework for understanding the unique stressors experienced by immigrants and strategies for interventions by social service agencies.