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.     

Mild Traumatic Brain Injury and Posttraumatic Stress Disorder in Returning Iraq and Afghanistan War Veterans: Implications for Assessment and Diagnosis

Mild traumatic brain injury (MTBI) and posttraumatic stress disorder (PTSD) are considered the “signature injuries” of combat soldiers returning from Iraq and Afghanistan. Both disorders can greatly affect the functioning of soldiers, yet the disorders often go undetected or are misdiagnosed by both military and civilian health care providers. This article provides information about MTBI and PTSD in returning combat soldiers along with implications for assessment and diagnosis.     

Mental Health Risk and Social Ecological Variables Associated with Educational Attainment for Gulf War Veterans: Implications for Veterans Returning to Civilian Life

This study examines how post-secondary educational attainment among young veterans of the first gulf war affects their mental health status. The all-volunteer military attracts recruits by offering them veterans’ educational benefits. Education should help veterans adjust to civilian life. Few studies have shown whether education following military service helps improve veterans’ mental health, however. Viewing resiliency, life span and life course, and social geography theories through the lens of social ecology, it is hypothesized that selected contextual factors in the personal, interpersonal, and organizational domains could mediate or moderate the relationship between education and veterans’ mental health. Informational social networks showed an association with obtaining mental illness treatment. Recent treatment for post-traumatic stress disorder (PTSD) showed an association with use of veterans’ educational benefits. Residing with a small nuclear family in conjunction with having higher levels of health and educational benefits and a higher family income was associated with higher educational attainment.     

The Significance of Military Contexts and Culture for Understanding Family Well-Being: Parent Life Satisfaction and Adolescent Outcomes

Formal systems and informal networks are presumed to be significant contexts that affect military families. Their effects on both parents and adolescents in active duty military families are examined (N = 236 families). Social organization and contextual model of family stress theories are employed as frameworks for the analyses of how dimensions of military culture influence parents’ life satisfaction, as well as key developmental outcomes of their adolescents (for example, mental health). Key findings from our analyses included a positive relationship between parents support from military leaders and fellow soldiers and parental well-being findings revealed the importance of civilian parents’ satisfaction with military life on adolescent outcomes for families that have experienced stressful military contexts. These findings provide support for the significance of multiple contexts for understanding resilience among military members and their families.     

Family-Centered Care to Promote Successful Community Reintegration After War: It Takes a Nation

The papers in this section focus on public health responses and implementation considerations in addressing the challenges military families confront when parents go to war. While many military families show resilience, the challenges resulting from a decade of war with multiple deployments are detailed, as are innovative military and civilian programs designed to help service members and their families reintegrate successfully into the community. As more and more service members leave active duty, the burden of meeting military families’ psychological needs will transition from the Department of Defense (DoD) and into the Veterans Administration (VA) and civilian arenas. While many strategies to support successful readjustment are offered, in this time of dwindling mental health resources and competing needs, it is unclear what priority the broader society places on meeting the needs of returning service members and their families. A growing emphasis on family-centered care in the Veterans Administration may help meet this gap.     

Screening,Brief Intervention,and Referral to Treatment for Military Spouses Experiencing Alcohol and Substance Use Disorders: A Literature Review

This paper provides an overview of alcohol and substance use issues in military spouses, and explore how the screening, brief intervention, and referral to treatment (SBIRT) model may enable health care providers to identify individuals at risk for developing substance use related disorders. The information presented is based on a broad literature scan relating to the characteristics of the military lifestyle, health infrastructure, screening and intervention processes, and the uses of SBIRT in military and civilian settings. Current literature suggests that military spouses, and families, tend to be at different points in their life course than civilian families of similar ages. Marrying earlier and having children sooner coupled with military lifestyle stressors place them at increased risk for developing adverse coping mechanisms, particularly during deployment. SBIRT has been recognized as an effective method among civilian patients although there is limited research on the efficacy of SBIRT for military spouses at risk of or experiencing substance use problems.     

Understanding and Supporting the Resilience of a New Generation of Combat-Exposed Military Families and Their Children

Taking our nation to war has exposed a generation of military families and children to combat and its consequences. Every dollar spent on bullets, trucks, fuel, and food carried a future ‘tax’ in the form of consequences for psychological and physical health and family relationships. In this commentary, I focus on several themes that emerge from the special collection or articles. For example, I consider how best to define the ecological niche(s) occupied by military-connected children and families. Not surprisingly given significant gaps in our knowledge, evidence regarding the well-being of military-connected children is mixed. I also consider the multi-layered environments within which individuals and families function, recognizing both the challenges and opportunities they provide. The need to respond rapidly to the evolving needs of military families has highlighted the value of both prevention science and implementation science. Public health models emphasizing a full continuum of care that emphasizes not only treatment but also universal, selective, and indicated prevention also are appealing given the uneven density, uncertain locations, and unknown identities of military families in civilian communities (Beardslee 2013; Murphy and Fairbank 2013). Finally, it is important to recognize that we are at the beginning, not the end, of the post-war lifetimes for the new generation of veterans and their families.     

Long-Term Trajectories and Service Needs for Military Families

The deployment of US military personnel to recent conflicts has been a significant stressor for their families; yet, we know relatively little about the long-term family effects of these deployments. Using data from prior military service eras, we review our current understanding of the long-term functioning and needs of military families. These data suggest that overseas deployment, exposure to combat, experiencing or participating in violence during war deployment, service member injury or disability, and combat-related post-traumatic stress disorder (PTSD) all have profound impacts on the functioning of military families. We offer several recommendations to address these impacts such as the provision of family-centered, trauma-informed resources to families of veterans with PTSD and veterans who experienced high levels of combat and war violence. Recent efforts to address the needs of caregivers of veterans should be evaluated and expanded, as necessary. We should also help military families plan for predictable life events likely to challenge their resilience and coping capacities. Future research should focus on the following: factors that mediate the relationship between PTSD, war atrocities, caregiver burden, and family dysfunction; effective family-centered interventions that can be scaled-up to meet the needs of a dispersed population; and system-level innovations necessary to ensure adequate access to these interventions.     

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.

     

Intimate partner cohesion and military unit cohesion: Different types of interpersonal relationships each uniquely predict soldier well-being

Although research on military populations has found that measures of personal well-being are correlated with both intimate partner cohesion and military unit cohesion, it is not clear how these correlations should be interpreted. Based on Relationship Regulation Theory, it was expected that each type of interpersonal relationship would have independent effects, that each would uniquely predict outcomes, and that effects would remain significant after controlling for person-level traits and experiences, such as trait resilience and exposure to combat. A sample of 273 active-duty military personnel completed self-report measures of cohesion in two types of interpersonal relationships (intimate relationships and military unit relationships), two control variables (trait resilience and combat exposure), and three outcome variables (well-being, negative emotionality, and trauma-related stress). Results indicated that cohesion in the two types of relationships were minimally related to each other, but both correlated with outcome variables. Effects for each type of interpersonal relationship remained significant after controlling for the other type and controlling for trait resilience and combat exposure. The results suggest that the effects of interpersonal cohesion are best understood as reflecting experiences in specific types of relationships rather than general characteristics of people in those relationships.     

Role of Group Affiliation and Gender on Attitudes Toward Women in the Military

The current study examined attitudes of West Point cadets (N = 218), Reserve Officer Training Corps (ROTC) cadets (N = 509), and non-military-affiliated students from civilian colleges (N = 598) toward a variety of roles that women may serve in the military. Respondents were queried whether a woman “should” or “should not” serve in the following military jobs: jet fighter pilot, truck mechanic, nurse in a combat zone, typist in the Pentagon, commander of a military installation, hand-to-hand combat soldier, jet transport pilot, air defense gunner, and crew member on a combat ship. A metric based on a sum of approval across all jobs indicated that women were significantly more approving than men; civilian college students were more approving than ROTC cadets; and West Point cadets showed the lowest overall approval.     

Pathways of Risk and Resilience: Impact of a Family Resilience Program on Active‐Duty Military Parents

Over the past decade, studies into the impact of wartime deployment and related adversities on service members and their families have offered empirical support for systemic models of family functioning and a more nuanced understanding of the mechanisms by which stress and trauma reverberate across family and partner relationships. They have also advanced our understanding of the ways in which families may contribute to the resilience of children and parents contending with the stressors of serial deployments and parental physical and psychological injuries. This study is the latest in a series designed to further clarify the systemic functioning of military families and to explicate the role of resilient family processes in reducing symptoms of distress and poor adaptation among family members. Drawing upon the implementation of the Families Overcoming Under Stress (FOCUS) Family Resilience Program at 14 active‐duty military installations across the United States, structural equation modeling was conducted with data from 434 marine and navy active‐duty families who participated in the FOCUS program. The goal was to better understand the ways in which parental distress reverberates across military family systems and, through longitudinal path analytic modeling, determine the pathways of program impact on parental distress. The findings indicated significant cross‐influence of distress between the military and civilian parents within families, families with more distressed military parents were more likely to sustain participation in the program, and reductions in distress among both military and civilian parents were significantly mediated by improvements in resilient family processes. These results are consistent with family systemic and resilient models that support preventive interventions designed to enhance family resilient processes as an important part of comprehensive services for distressed military families.     

Psychological stigma costs as barriers to healthcare use in former soldiers of the German Armed Forces: A qualitative analysis

Individuals decide to use healthcare when the expected benefits outweigh the perceived costs. One of these cost factors in this decision can be stigma. So far, it has not been researched how former soldiers of the German Armed Forces with a service-induced mental illness perceive stigma and how it influences their healthcare use. As stigma is shaped by the socio-cultural context, the setting of the potential healthcare use must be considered. Narrative interviews were conducted with 33 former soldiers with mental health problems. The data were analyzed using a thematic analysis approach, in which codes were formed and emerging themes were systemized. The relationship between stigma and healthcare use was analyzed. Occupational discrimination and social exclusion were experienced in both in the military and civilian context, but stigma functioned differently in each context. In the military context, former soldiers’ self-stigma of mentally ill individuals being weak was in stark contrast to their internalized military standards. This contrast let them avoid disclosure and subsequent healthcare use. In civilian context, the participants perceived 2 different stigma costs: mental illness stigma and former soldier stigma (i.e., stigmatization because of their military past). Both were perceived as barriers to healthcare use. A model, illustrating these different stigma costs in the different contexts, was developed. Further research on the link between stigma and healthcare use of this group is urgently needed.     

Accumulation of Risk and Promotive Factors Among Young Children in US Military Families

In the families of the new cohort of war veterans now entering the civilian population in the United States are over two million young children (Cozza, Haskins & Lerner, 2013; Institute of Medicine, 2013). Several noteworthy studies have shown that children exposed to separation from a parent due to combat‐related deployment are at elevated risk for a variety of negative consequences (Lester & Flake, 2013). Cozza et al. (2013) argue that existing studies of military children focus too much on the stresses or deficits they experience, failing to give sufficient attention to their strengths, the strengths of their families, or the supports around them. In the current study we focus on risk and promotive factors in the lives of children aged 0–10 in military families. We examine the likelihood of negative outcomes as functions of additive, cumulative, and interactive relationships between risk and promotive factors and children's outcomes. Risk factors, particularly parental depression, community poverty, and cumulative risk, were more strongly associated with children's outcomes than promotive factors. There was, however, a significant risk‐protective relationship between accumulations of risk and promotive factors, consistent with promotive conditions operating in a protective fashion under conditions of elevated risk.     

Sexism as a Predictor of Attitudes Toward Women in the Military and in Combat

This study examined four forms of sexist beliefs as predictors of attitudes toward women in the military and in combat. Survey data revealed that military-affiliated college students (n = 62) held more negative attitudes than civilian students (n = 254) toward women in combat, but the groups did not differ on attitudes toward women in the military. All forms of sexism contributed uniquely to the prediction of attitudes toward women in the military, and 3 forms were associated with approval of women in combat. Sexist beliefs mediated the relationship between military-affiliation status and approval of women in combat.     

Iraq and Afghanistan Veterans’ Experiences Living with their Parents after Separation from the Military

When military service members separate from the military, many return to their families of origin, living with their parents for a period of several weeks to years. While research with veterans and their spouses has documented the particular strain of this reintegration period on veterans and their partners, little research to date has examined veterans’ experiences living with their parents. The present study sought to fill this research gap by investigating veterans’ experiences living with their parents using qualitative, in-depth interviews with Iraq and Afghanistan veterans in California. Overall, veterans appreciated the instrumental and emotional support their parents provided when they separated. However, in some cases, living with parents also produced conflict and strain. In situations where adult veteran children had difficulty with the transition to civilian life or returned with mental health problems, parents were often the first to identify these problems and to support their children in accessing appropriate care. We analyze these findings in light of family systems theory, identifying ways in which adult veteran children continue a process of differentiation while living with their parents and maintaining emotional connectedness. We suggest ways that clinicians can better support veterans and their parents through the reintegration period and recommend that programming for military families explicitly include parents of service members in addition to conjugal families.     

Unit Social Cohesion in the Israeli Military as a Case Study of “Don't Ask,Don't Tell”

U.S. military policy “Don't Ask Don't Tell” (DADT) restricted integration of gays in the U.S. military based on the premise that knowledge of gay peers would decrease interpersonal bonds among unit members. Despite the heated debate over DADT, this social cohesion thesis, reflecting the tensions of homosocial desire, has not been tested empirically. The Israeli military provides an operative case‐study for this thesis, given its nonexclusionary policy and intensive combat experience. Measures of perceived social cohesion and knowledge of gay peers were obtained from a sample of 417 combat and noncombat male soldiers using an inventory of interpersonal emotions towards unit members. A MANOVA of social cohesion by knowledge of gay peers and combat/noncombat unit yielded the hypothesized increase in cohesion in combat versus noncombat units. Yet contrary to the DADT premise, knowledge of gay peers did not yield decreased social cohesion. Comparisons with the U.S. military are presented, suggesting in both cases a loose coupling between stated policies and soldiers' experience on the ground. Implications of these findings for the reassessment of DADT and its repeal are discussed.     

Interactive effects of cumulative lifetime traumatic brain injuries and combat exposure on posttraumatic stress among deployed military personnel

Growing research links Traumatic Brain Injury (TBI) with greater posttraumatic stress disorder (PTSD) symptoms. Much of this research has focused on the influence of the presence or severity of a single TBI while neglecting the potential cumulative effects of multiple TBIs incurred across an individual’s lifetime on combat-related PTSD. The present study addressed this gap using a sample of 157 military service members and 4 civilian contractors who underwent structured TBI interviews at a military hospital in Iraq and completed the Combat Experiences Scale (CES) and Posttraumatic Checklist – Military (PCL-M). Results indicated that a greater number of lifetime TBIs were associated with greater PTSD symptoms when accounting for the presence and severity of a recent, deployment-related TBI. Additionally, a significant interaction of number of lifetime TBIs and combat exposure emerged, indicating that exposure to combat yielded greater PTSD symptoms among those with multiple lifetime TBIs compared to those with one or zero lifetime TBIs. These data suggest that incurring multiple TBIs may amplify the link between combat exposure and PTSD and underscore the need to screen for lifetime TBI history.     

On the home front: stress for recently deployed Army couples

Military couples who have experienced deployment and reintegration in current U.S. military operations frequently experience stress regarding the dangers and effects of such experiences. The current study evaluated a sample of 300 couples with an active duty Army husband and civilian spouse who experienced a deployment within the year before the survey (conducted in 2007). Wives generally reported greater levels of emotional stress compared with husbands. Overall, higher levels of stress were found for couples who reported lower income and greater economic strain, perceive the need for more support and are unsure about how to get support, have more marital conflict, and are generally less satisfied with the Army and the current mission. Husband combat exposure was also associated with more stress for husbands and wives. Additionally, for wives, stress was related to greater child behavior problems and a sense of less Army concern for families. The results suggest areas of intervention with military couples to help them cope with the challenges of military life and deployment.     

Moral Injury: A Mechanism for War-Related Psychological Trauma in Military Family Members

Recent research has provided compelling evidence of mental health problems in military spouses and children, including post-traumatic stress disorder (PTSD), related to the war-zone deployments, combat exposures, and post-deployment mental health symptoms experienced by military service members in the family. One obstacle to further research and federal programs targeting the psychological health of military family members has been the lack of a clear, compelling, and testable model to explain how war-zone events can result in psychological trauma in military spouses and children. In this article, we propose a possible mechanism for deployment-related psychological trauma in military spouses and children based on the concept of moral injury, a model that has been developed to better understand how service members and veterans may develop PTSD and other serious mental and behavioral problems in the wake of war-zone events that inflict damage to moral belief systems rather by threatening personal life and safety. After describing means of adapting the moral injury model to family systems, we discuss the clinical implications of moral injury, and describe a model for its psychological treatment.