By Eric Mason
Military personnel or embassy officials and their families must contend with certain life stressors, which make their experiences unique from many perspectives. For example, military personnel and their families must relocate often, as they are frequently deployed to various bases around the country. At times, the military requires military personnel to move abroad to bases outside of the United States. Frequent moves, which require military personnel and their families to uproot and leave behind friends and family on a regular basis, can be stressful and problematic for many individuals. Moving out of the country may multiply this stress exponentially, as families are forced to adapt to a foreign culture (Lee, 2007).
Moving abroad forces one to go through the process of cultural transition. Cultural transition involves a great amount of change. Change, even when it viewed positively, is generally stressful for those experiencing it. Studies using Holmes’ and Rahe’s Social Readjustment Scale have indicated that the drastic life change that occurs when one relocates from one country to another is so great that it may put one at risk for major illness or depression (Lee, 2007).
Immigrants, refugees, international students, military personnel, business assignees, and Peace Corps volunteers are all affected by [the cultural transition] process. It is estimated that 2-10% of business people on foreign assignments have adjustment difficulties and 33% of their families return to the United States earlier than planned. Similarly, 15-25% of international students have been reported to experience significant adjustment difficulties and as many as 35-40% of Peace Corps volunteers in some years terminate prematurely (Lee, 2007).
Unlike business people and Peace Corps volunteers, military personnel and their families do not have a choice when it comes to moving abroad or coming home early. They must go where their orders dictate them to or they may face court marshal. Counselors may help military personnel and their families deal with acculturative stress (culture shock) by providing education about the cultural transition process prior to their departure. For example, counselors may brief them on the types of feelings they may experience as they are go through the cultural transition process—letting them know that such feelings are a normal part of cultural transition. In addition, many individuals experience reentry shock, stress that occurs as individuals try to readjust to their native culture, when returning home. Therefore, counseling may also be advisable when military personnel and their families return home (Lee, 2007).
Sometimes military personnel must deploy and leave their families behind. When a member of the armed services is deployed overseas without his or her family, it likely places a great deal of stress on his or her family. Members of such families may be forced to take on additional familial roles as a result of the deployment, as well as experience greater financial insecurity. Such burdens inevitably produce mental and emotional strain on even the most resilient families. Although deployment into non-combat areas may be very stressful for military families, when a family member is deployed into a combat zone, however, there is little doubt that families experience greater and more intense stress.
It is well known that stress often causes or precipitates mental illness. Military families probably experience stress more often, as a result of frequent military deployments. I, therefore, believe that mental health difficulties may be more prevalent in military families than in the general population.
Mother Absence in Military Families
Since the U.S. military became an all-volunteer military in 1973, it has found filling its ranks to be evermore challenging. As a result, the military has increasingly allowed more women to serve in roles that were traditionally reserved for men. In 1972, women comprised less than two percent of the military. As of 1992, women made up more than 12 percent of the military. This percentage is probably much higher as of 2008, and will surely continue to grow in future years (Applewhite and Mays, 1996).
Operation Desert Storm was the first recent military conflict in which women were allowed to directly engage in combat. During Operation Desert Storm, women combatants were helicopter, airplane, and jet pilots (Applewhite and Mays, 1996). However, the present war in Iraq and Afghanistan has seen women combatants on the ground fighting along side men. Although the idea of women ground troops was once very controversial, it has become an acceptable practice in recent years.
During Operation Desert Storm, almost 37,000 children were separated from either both parents or their only parent. In other words, these children were left without their sole caretaker(s) as a result of the war. Out of all the single parents in the military, women comprise 35 percent (Applewhite and Mays, 1996).
Depending on a child’s developmental stage, he or she may respond to separation from his or her mother differently. According to Stolz, when a child is separated from his or her mother during infancy, he or she may become fearful, nervous, and shy. Many of these children develop an anxious belief that their mothers may never return (Applewhite and Mays, 1996).
Furthermore, a child’s sex may determine his or her reaction to the absence of his or her mother. Although boys tended to have more negative reactions to the absence of their mother as a result of a military deployment than girls, boys responded even more negatively when their fathers were absent as the result of a military deployment (Applewhite and Mays, 1996).
Father Absence and Mental Illness
Father absence has notoriously contributed to mental health difficulties in children—especially in males. Father absence is an increasing phenomenon in American society. Children who have fathers in the military may be forced to deal with the absence of a father figure more often than children in the general population (Ryan-Wenger, 2001).
Absence of a father reportedly contributes to lower scores on achievement tests, lower mathematical ability, and higher rates of emotional difficulties. Although a “child’s sex, socio-economic status, presence of siblings, type of absence, time of onset and duration” all appear to play an important role in determining how the child reacts to paternal absence, the probability of developmental and emotional difficulties appears to increase when the child’s is father absent (Ryan-Wenger, 2001). For example, paternal absence earlier in life is associated with aggressive behaviors, depression, irritability, and impulsiveness in children (Ryan-Wenger, 2001).
In short, fathers appear to play an important role in a child’s development. Father absence is associated with developmental delays, mental health difficulties, and, overall, maladjustment in children. Although children in the military may have caring fathers, they are forced to deal with paternal absence more frequently than most children (Ryan-Wenger, 2001).
Military Deployment into Combat Zones and its Effects on Military Families
The possibility of being deployed into a combat zone is an ongoing stressor that military personnel and their families must deal with constantly. Certainly, this possibility is a stressor during peacetime; however, with the United States currently engaged in combat in Afghanistan and Iraq, military personnel who are not already deployed in combat zones surely live with a heightened sense of stress that they may soon be deployed to these combat zones. Indeed, the families of military personnel are under greater amounts of stress, as they also live with the constant threat that their loved ones could be deployed to combat zones. Such stress certainly places a great deal of strain on the family unit.
Although maternal and paternal absence is difficult for most children, when their parent is deployed into a combat zone, they likely experience even more stress. These children must deal with the fact that their parent may be killed or wounded, in addition to the difficulties associated with the absence of the parent. As a result, these children probably experience more mental and emotional difficulties than children whose parents are deployed into non-combat zones (Ryan-Wenger, 2001).
There are 3.36 million children who have parents in the armed forces. Although the U.S. is currently at war, these children must deal with the possibility of war even when the U.S. is not at war. This ongoing stress is associated with mental and emotional difficulties in many children who have parents in the military (Ryan-Wenger, 2001). Furthermore, spouses of deployed soldiers may fail to recognize their children’s own distress, as they are dealing with their own difficulties of having a husband or wife deployed overseas. Such unintentional neglect may compound the child’s distress even further. (Murray and Kuntz, 2002)
Since the U.S. is currently at war, however, it is important that research is conducted in this area to help these 3.36 million children cope with the stress they must face as the result of possible deployment of family members into a combat zone (Ryan-Wenger, 2001). The ongoing war on terror, a war that may continue well into the future, will ensure that many of these 3.36 million children continue to experience this high-intensity stress. The notion of an ongoing war with no real end in sight is unprecedented in American history, which puts mental health practitioners in a unique situation. To be sure, mental health practitioners will encounter more frequently children with emotional and mental health issues as a result of this unprecedented struggle (Murray and Kuntz, 2002).
With the Unites States currently at war in Afghanistan and Iraq, military families are forced to deal with the frequent deployment of their family members into combat zones. Repeatedly having to deal with stress on such an intense level surely results in more mental health related difficulties in these families. In addition to experiencing stress as a result of a military deployment, when a family members is injured, killed, or becomes mentally ill as a result of his or her deployment, military families are forced to deal with a great deal of change and uncertainly that undermines familial structure. Likewise, such change may result in the development of mental illness in some family members. When military personnel become mentally ill, as a result of a deployment (e.g., PTSD), the mental illness may become transferred onto other family members. For example, the spouse of a depressed combat veteran may also become depressed, which may, in turn, affect the mental health of their children.
As a consequence of the United States’ current wars, those working in the mental health field may more frequently encounter individuals who are experiencing mental health issues. Indeed, the war on terror is a military conflict, seemingly with no end in sight. Many American families will surely be affected by such foreign policy. In order to help these families cope with mental health difficulties, it is essential that more research is conducted in this area.
When military personnel are deployed into combat zones, the psychological stress under which they must live dramatically increases the likelihood that they (and their families) will develop a psychological disorder. The most common disorders that afflict military personnel are Post-Traumatic Stress Disorder (PTSD), depression, Substance Use Disorders (SUD’s), as well as anxiety disorders, such as Generalized Anxiety Disorder (GAD). Suicidal ideation may occur without the presence of a psychological disorder, but it it most often a “byproduct” of a psychological disorder.
The stress and anxiety of having their loved one deployed into a combat zone may lead the spouses and children of military personnel to become depressed, as well as develop anxiety disorders and SUD’s. The spouses and children of military personnel are also at risk of developing symptoms of PTSD via a phenomenon known as secondary traumatization. Although not a psychological disorder, interpersonal conflict increases significantly for combat veterans and their families. These issues are explored in more detail below (Renshaw, Rodrigues, & Jones, 2008).
Posttraumatic Stress Disorder
Post-Traumatic Stress Disorder (PTSD) is the psychological disorder that most frequently affects combat veterans (Brinker, 2007). PTSD may occur in individuals who have been exposed “to a severe and extraordinary stressor: a massive fire, hurricane, holocaust, rape, mugging, military combat, or terrorist bombing” (Maxmen & Ward, 1995). In contrast to a normal response to a severe stressor, in which one’s response to it dissipates and diminishes (i.e., the psychological stress experienced by the individual decreases), a diagnosis of PTSD requires that one’s response does not dissipate or diminish over time, but remains at the level at which one experienced the stressor. In fact, those with PTSD often experience greater levels of psychological stress long after the severe stressor (i.e., their psychological stress worsens over time) (Million, Blaney, & Davis, 1999).
Hours to months after experiencing the traumatic event, clients with PTSD may begin to alternate between the two stages of PTSD—namely, intrusion and avoidance. The avoidance stage is usually first to appear. During this stage clients attempt to minimize, deny, and forget their psychological stress (Maxmen & Ward, 1995). Behaviorally, they may “lose interest in life, display constricted affect, daydream, and abuse drugs or alcohol” (Maxmen & Ward, 1995).
In the intrusion stage, clients repeatedly re-experience (against their will) the traumatic event. They may be hypervigilant and flooded with unwanted images connected to the traumatic event (e.g., hallucinations, nightmares, mental images, etc.). They may cry frequently, become agitated and angry easily, as well as develop somatic anxiety. Clients in the intrusion stage are often unable to think about anything else, as they compulsively relive the traumatic event (Maxmen & Ward, 1995).
In addition to psychological symptoms, combat veterans with PTSD frequently display poorer general physical health than combat veterans without a PTSD diagnosis. These veterans often report health problems, complain of somatic symptoms, visit their doctors more frequently, and miss more days of work. A recent study, which controlled for demographic variables, risky behaviors (such as smoking and drug use), environmental contaminates (such as exposure to chemicals and toxins), revealed that Afghani and Iraqi war veterans with PTSD had more physical health problems than Afghani and Iraqi war veterans without PTSD (Jakupcak, 2008).
Veterans with PTSD over and over again present to primary care physicians with physical illness, rather than with psychological complaints. As is the case with most all mental disorders, there is a stigma attached to PTSD—especially within the military culture. Veterans may, therefore, prefer to disclose (consciously or unconsciously) physical health difficulties over psychological troubles. It is important for health care providers to be aware of the link between physical health, mental health, and PTSD. The more health care providers who are aware of this link, the greater the likelihood that veterans with PTSD will get the mental health care they deserve (Jakupcak, 2008).
Although the lifetime prevalence rates of PTSD for the general population are relatively low at 8%, for those who have experienced a traumatic event, the rates are much higher. Combat veterans are unique in that they represent a large group that has experienced traumatic events, which are similar (i.e., the tragedies of war). Veterans of the Gulf War (a brief war in which casualties were low) have a lifetime prevalence rate for PTSD of 19%, more than double that of the general population (Brinker, 2007). For those veterans with extreme traumatic experiences, PTSD is virtually a guarantee. For example, veterans who were captured while fighting in the Pacific theater during World War II have shown lifetime rates higher than 90% (Dikel, 2005).
A recent study of 88,235 veterans who served in the war in Iraq indicated that 69.6% of reservists experienced traumatic, combat-related events, while 66.5% of active soldiers reported similar experiences (Milliken, Auchterlonie, & Hoge, 2007). Although we do not yet know the total number of combat veterans who will be affected by PTSD as a result of their traumatic experiences in Afghanistan and Iraq (as the wars are ongoing), the above figures indicates that there is a high potential that many of these combat veterans may have to deal with symptoms of PTSD long after the fighting has stopped.
Delayed-Onset Posttraumatic Stress Disorder
Clinicians providing mental health services to veterans should be aware that clients who do not currently display symptoms of PTSD may later develop PTSD. This phenomenon is known as Delayed-Onset Posttraumatic Stress Disorder (Andrews, 2007). “The DSM-IV-TR describes delayed onset as a specifier for PTSD indicating that at least 6 months have passed between the traumatic event and the onset of the symptoms” (Andrews, 2007). There is no real consensus on the prevalence of Delayed-Onset PTSD, but some studies estimate that it compromises up to 68% of current PTSD cases (Andrews, 2007).
Reportedly, Delayed-Onset PTSD is high among those who have experienced combat. It has been hypothesized that the symptoms of PTSD are often not expressed while one is still in a combat zone, as they are not an adaptable response to war (i.e., the expression of PTSD may put one at greater risk when one is still engaged in war). PTSD symptoms may, therefore, be unconsciously suppressed until it is safe to express them (e.g., when the soldier has returned home) (Andrews, 2007).
Furthermore, physical injuries may retard the development of PTSD for several months. In other words, soldiers preoccupied with their physical injuries may only begin to express symptoms of PTSD once their physical wounds have healed. The current conflicts, in which the U.S. is engaged, have seen more soldiers surviving injuries that in earlier conflicts would have resulted in death. This is, in part, thanks to advances in medicine and quick evacuation of wounded soldiers. Many of these wounded soldiers may express symptoms of PTSD after their wounds have healed. Military studies indicate that Delayed-Onset PTSD is common among combat veterans returning from the wars in Afghanistan and Iraq (Andrews, 2007).
Subthreshold PTSD is a phenomenon experienced by many veterans returning from the wars in Afghanistan and Iraq. Subthreshold PTSD occurs when an individual has some symptoms of PTSD, but not enough to be diagnosed with PTSD. Like those diagnosed with PTSD, these individuals regularly have other complicating factors, such as substance abuse, unemployment, and interpersonal conflict. Furthermore, they are more like to have physical health problems, as well.
The risk of suicide is elevated for individuals with Subthreshold PTSD. Since the beginning of the wars in Afghanistan and Iraq, it has become apparent that more and more veterans are choosing to commit suicide. There is little doubt that this increase in suicides is the result of mental disorders, such as PTSD and depression, which were precipitated by veterans’ traumatic experiences in Afghanistan and Iraq.
Tragically, veterans with Subthreshold PTSD may go unnoticed by mental health professionals, as they may initially come across as asymptomatic. It is imperative that mental health professionals remain vigilant and consider the possibility of Subthreshold PTSD, especially in regards to clients with traumatic experiences (such as combat veterans). There appears to be a dearth of research on Subthreshold PTSD. Indeed, more research is needed on Subthreshold PTSD in combat veterans in order to ensure that they receive proper mental health care.
Posttraumatic Stress Disorder and Substance Use Disorders
Substance use disorders (SUD) are common among people with PTSD, with some studies indicating a comorbid prevalence rate of 30-59%. These individuals tend to have worse psychological symptoms and treatment outcomes than people with PTSD or SUD alone. Furthermore, individuals with SUD-PTSD are more likely to relapse after receiving treatment than those with only SUD. It is believed that people with PTSD have a greater likelihood of developing a SUD, as they may use drugs and alcohol to self-medicate their PTSD symptoms (Norman, 2006).
As is the case with the general population, there is a high rate of alcohol and drug abuse among veterans with PTSD (Taft, 2007). For those with combat-related PTSD, alcohol and drug abuse is especially high. Unfortunately, treatment outcomes for these veterans are particularly poor (Rotunda, O’Farrel, Murphy, & Babey, 2007).
It is imperative for clinicians to recognize PTSD symptoms in veterans, especially those who have experienced combat. Since it is well known that those with PTSD often use alcohol and drugs as a way of self-medicating their symptoms, it is important to ensure that veterans get proper treatment for their PTSD as means of preventing the development of a SUD (especially, considering that treatment outcomes are better for veterans with PTSD alone than veterans with SUD-PTSD). In addition, veterans with SUD-PTSD are more likely to have occupational problems, aggressive tendencies, and experience more interpersonal conflict (Taft, 2007).
Interpersonal Conflict and PTSD
A recent study found that spouses of combat veterans with PTSD reported higher levels of psychological stress and marital dissatisfaction than did spouses of combat veterans without PTSD (Renshaw, Rodrigues, & Jones, 2008). Several studies have indicated that wives of veterans with PTSD often present with feelings of tension, depression, anxiety, low self-esteem, self-blame, and loss of control, all of which were absent or existed at significantly lower levels before their husband became PTSD symptomatic. Such negative feelings are likely the result of the rigidity, conflict and violence, low levels of cohesiveness, reduction of personal intimacy and self-expression, as well as enmeshment that frequently characterize families in which one spouse has PTSD (Dekel, 2005).
Spouses of combat veterans with PTSD who perceived that their spouse (the combat veteran) did not experience significant levels of trauma reported the highest level of marital dissatisfaction, according to one study. In other words, does who felt that their spouses should not show signs of PTSD (because they perceived their traumas to be insignificant) were most likely to report marital discord. Perhaps, spouses who held perceptions that their wives or husbands were involved in highly traumatic events were more likely to be empathetic and compassionate and, therefore, more likely to endure the negative effects of their spouse’s PTSD (Taft, 2008). Such findings highlight the interplay between mental illness, perception, and interpersonal functioning.
Both male and female veterans, who experienced high levels of combat, reported high levels of PTSD symptoms, which was also associated with poorer family functioning. However, female veterans with PTSD reported the highest levels of family maladjustment (Taft, 2009). Perhaps, this is due to the reality that many women fulfill central roles in their families. Women with PTSD may be unable to fulfill these roles as well as they once could. Indeed, more research may need to be conducted in this area.
Many other factors may contribute to interpersonal conflict for individuals with PTSD. In addition to the “standard” PTSD symptoms, which by themselves surely cause stress in interpersonal relationships, those with PTSD are more likely to abuse drugs and alcohol, be unemployed, as well as have elevated rates of anger and aggression. A recent study by Jakupcak revealed that veterans with PTSD displayed higher rates of anger, hostility, and aggression (2007). According to the study, veterans with PTSD engaged in aggressive behaviors more often than veterans without PTSD. The authors hypothesized that anger served to facilitate emotional disengagement for those with PTSD (Jakupcak, 2007). Therefore, the increased anger displayed by those with PTSD may be doubly destructive, as it alienates the spouse and other family members while--in essence--allowing the family member with PTSD to remove him- or herself from the family, psychologically.
DEPRESSION AND SUICIDE
Secondary traumatization is defined as “the natural consequent behaviors and emotions resulting from knowledge about a stressful event experienced by a significant other (Figley, 1998).” In other words, this phenomenon occurs when one does not necessarily experience the stressful event firsthand per se, but when a loved one is experiencing the stressful event. It may also occur when one is forced to care for a loved one who is experiencing PTSD. Such secondary traumatization is commonly called compassion fatigue or burnout. Compassion fatigue or burnout may occur when caring for a loved one with PTSD, and is characterized by emotional exhaustion. Such emotional exhaustion is, indeed, stressful for the caretaker and may result in the development of mental and emotional difficulties, as well. (Dirkzwager, 2005)
This transference of mental and emotional difficulties onto the caretaker (often a spouse) will ultimately affect any children who reside within the household. When both parents are burden with mental health difficulties, it becomes doubly tragic for any children involved. These children often experience more depression, aggressiveness and other maladaptive behaviors. One could argue that the mental health issues of the parents ultimately become transferred onto the children of the household. (Golf, 2006)
The absence of either a mother or a father often promotes mental and emotional difficulties in children. When a parent is deployed overseas into a combat zone, children experience much more stress, which ultimately results in the development of more mental and emotional difficulties in children. Furthermore, when a parent is suffering from mental and emotional difficulties as a result of a military deployment, the parents’ issues may be transferred onto the child and result in the development of mental and emotional difficulties in the child, as well. With the ongoing wars in Iraq and Afghanistan, as well as the seemingly never-ending war on terror mental health practitioners will likely more frequently encounter families experiencing mental and emotional difficulties as a result of these wars. Therefore, it is essential that more research is conducted in this area in order to help mental health practitioners better help these families.