Overview

Much has been written on the effects of deployment and war on military servicemen and women, including experiences of post-traumatic stress and readjustment to civilian life after deployment. However, the effects of the various phases of deployment on the family system are often overlooked. The goal of this course is to provide practitioners with an overview of the psychosocial effects of deployment on family members. The course will discuss the five phases of the deployment cycle and each phase's unique challenges. In addition, the military culture and how this culture affects how families cope, readjust, and seek help will be explored. Finally, various treatments, interventions, and best practices will be offered for practitioners working with military families.

Education Category: Psychiatric / Mental Health
Release Date: 04/01/2017
Expiration Date: 03/31/2020

Audience

This course is designed for social workers, therapists, counselors, psychologists, and other mental health professionals involved in the care of veterans and active-duty military troops and their families.

Accreditations & Approvals

NetCE has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6361. Programs that do not qualify for NBCC credit are clearly identified. NetCE is solely responsible for all aspects of the programs. NetCE, #1092, is approved as a provider for social work continuing education by the Association of Social Work Boards (ASWB) www.aswb.org through the Approved Continuing Education (ACE) Program. NetCE maintains responsibility for the program. ASWB Approval Period: 03/13/2016 to 03/13/2019. Social workers should contact their regulatory board to determine course approval for continuing education credits. NetCE is accredited by the International Association for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU. NetCE SW CPE is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers #0033. This course is considered self-study, as defined by the New York State Board for Social Work. NetCE is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for licensed mental health counselors. #MHC-0021. This course is considered self-study by the New York State Board of Mental Health Counseling. NetCE is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for licensed marriage and family therapists. #MFT-0015. This course is considered self-study by the New York State Board of Marriage and Family Therapy. Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of licensed master social work and licensed clinical social work in New York. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice for an LMSW and LCSW. A licensee who practices beyond the authorized scope of practice could be charged with unprofessional conduct under the Education Law and Regents Rules.

Designations of Credit

NetCE designates this continuing education activity for 2.5 NBCC clock hour(s). Social workers participating in this intermediate to advanced course will receive 5 Clinical continuing education clock hours. NetCE is authorized by IACET to offer 0.5 CEU(s) for this program.

Individual State Behavioral Health Approvals

In addition to states that accept ASWB, NetCE is approved as a provider of continuing education by the following state boards: Alabama State Board of Social Work Examiners, Provider #0515; Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling, CE Broker Provider #50-2405; Illinois Division of Professional Regulation for Social Workers, License #159.001094; Illinois Division of Professional Regulation for Licensed Professional and Clinical Counselors, License #197.000185; Illinois Division of Professional Regulation for Marriage and Family Therapists, License #168.000190; Texas State Board of Social Worker Examiners, Approval #3011; Texas State Board of Examiners of Professional Counselors, Approval #1121; Texas State Board of Examiners of Marriage and Family Therapists, Approval #425.

Course Objective

The purpose of this course is to provide mental and behavioral health professionals with the tools necessary to address and prevent the negative repercussions of deployment on military families.

Learning Objectives

Upon completion of this course, you should be able to:

  1. Describe the basic demographic profile of military personnel.
  2. Explain how the military culture affects how family members cope and adjust to deployment and help-seeking.
  3. Identify stressors for family members associated with each stage of the deployment cycle.
  4. Evaluate different theoretical frameworks to understand how deployment affects military families.
  5. Discuss the physical, social, and psychologic effects of deployment on the family.
  6. Outline the impact of social problems in military families.
  7. Describe assessments when working with military families in relation to coping with deployment.
  8. Explain different interventions and treatments for military family members experiencing deployment.
  9. Identify ethical issues for practitioners working with military personnel and families within a military context.

Faculty

Alice Yick Flanagan, PhD, MSW, received her Master’s in Social Work from Columbia University, School of Social Work. She has clinical experience in mental health in correctional settings, psychiatric hospitals, and community health centers. In 1997, she received her PhD from UCLA, School of Public Policy and Social Research. Dr. Yick Flanagan completed a year-long post-doctoral fellowship at Hunter College, School of Social Work in 1999. In that year she taught the course Research Methods and Violence Against Women to Masters degree students, as well as conducting qualitative research studies on death and dying in Chinese American families.

Previously acting as a faculty member at Capella University and Northcentral University, Dr. Yick Flanagan is currently a contributing faculty member at Walden University, School of Social Work, and a dissertation chair at Grand Canyon University, College of Doctoral Studies, working with Industrial Organizational Psychology doctoral students. She also serves as a consultant/subject matter expert for the New York City Board of Education and publishing companies for online curriculum development, developing practice MCAT questions in the area of psychology and sociology. Her research focus is on the area of culture and mental health in ethnic minority communities.

Faculty Disclosure

Contributing faculty, Alice Yick Flanagan, PhD, MSW, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Table of Contents

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#76331: Working with Military Families: Impact of Deployment

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INTRODUCTION

The effects of deployment on the family system tend to be overlooked. If families are viewed as a system in which all the parts are interdependent, inter-related, and interconnected, it is easy to see that a change in one dimension of the family system will affect the other parts of the system. The stressors for the ones who remain behind are great. It has been said, for example, that spouses of deployed military personnel are the "overlooked casualties" of war [1]. They experience increased levels of anxiety, marital maladjustment and discord, and depression [1]. Children are also affected, with the effects somewhat contingent on age. Preschool-age children may display regressive behaviors such as bedwetting, crying for attention, and aggression [2]. Because school-age children are more cognitively developed than preschool-age children and can begin to understand the potential implications of deployment, they may exhibit their stress with depression and inattentiveness in school [3]. Adolescents have even greater comprehension regarding the implications of deployment and can easily access news stories. Consequently, they are exposed to the realities of military operations as well as the public's sentiment toward a military mission [4]. They also have an understanding of what it means to have a parent injured or die. As such, parental deployment can affect them negatively in a variety of ways.

The goal of this course is to provide practitioners with an overview of the psychosocial effects of deployment on family members. The course will discuss the five phases of the deployment cycle and each phase's unique challenges. In addition, the military culture and how this culture affects how families cope, adjust, and seek help will be explored. Finally, various treatments, interventions, and best practices will be offered for practitioners working with military families. In this course, the terms "military personnel" or "service member" will refer to any individual who is a member of any branch of the military, including the Army, Air Force, Navy, Marines, and Coast Guard, and all duty statuses (e.g., active or reserve) [5]. Although there are unique aspects of each branch of military service, a discussion of these differences is beyond the scope of this course.

MILITARY PERSONNEL: DEMOGRAPHIC OVERVIEW

According to the U.S. Department of Defense, there were 3.5 million military personnel as of 2014 [6]. The Army has the largest number of active duty members, followed by the Navy, the Air Force, and the Marine Corps [6]. In 2014, California, Virginia, and Texas were home to the greatest number of active duty military personnel [6]. Men make up the majority of active-duty personnel at 84.9%, with women comprising the remaining 15.1%. Since 2000, the percentage of female officers has increased from 14.8% to 16.7% [6]. Women are a growing segment of users of Veterans Administration services [8]. In addition, more than 30,000 single mothers have been deployed to Afghanistan and Iraq since 2003 [8].

The majority of active-duty personnel are white, with 31.2% classifying themselves as belonging to a racial/ethnic minority group. An estimated 32.9% of enlisted members and 22.5% of officers are from a racial/ethnic minority group [6].

Slightly more than 25% of active-duty officers are 41 years of age or older. However, 49.6% of enlisted active-duty personnel are 25 years of age or younger [6]. A large proportion (83.8%) of officers hold a Bachelor's degree or higher education, and the vast majority (92.1%) of enlisted individuals have graduated from high school and/or have completed some college [6].

More than half (55.3%) of the active-duty force is married [6]. In general, military individuals tend to marry at a younger age compared to the civilian population [9]. In addition, 6.4% of active-duty personnel are in dual military marriages [6]. Both active duty and reserve personnel have an average of two children [6].

MILITARY CULTURE AND LIFESTYLE

It has been said that the military is an example of a social institution that is "greedy," meaning that the military requires from its members a great amount of commitment, loyalty, time, and energy, which ultimately affects other role commitments [10]. Family members of military personnel are expected to relocate frequently, and this uprooting necessitates spouses and children to make transitions and adjustments to their lifestyles, to make new friends, and to develop new social networks [10]. For example, it is estimated that 20% of families in the United States relocate annually; however, approximately 33% of military families relocate each year [11]. It is estimated that children of active-duty parents will move more than 20 times over the course of their childhood, three times more often than their civilian counterparts [7]. Inevitably, the frequency of relocations brings about multiple levels of stress. In a focus group of military youths, military spouses, and school personnel, the youths stated that they sometimes felt angry toward their parents for having to move multiple times and expressed a feeling of loss for having to separate from friends. Some wondered whether it was even worthwhile to invest in making new friends. Some parents felt that multiple relocations could help children learn important skills of adjusting, but indicated concern that it would affect the children's ability to make commitments to relationships.

Military spouses tend to have a more difficult time finding jobs because their transience makes them less desirable to employers [10]. When they do find jobs, their wages tend to be lower compared to their civilian counterparts who share the same demographics (e.g., age, educational level, ethnicity/race) [12]. In some cases, career advancement may be negatively affected [7]. Those who are not working and not seeking work report that there are too many barriers to employment including child care issues and the demands of the military lifestyle. Although some of these barriers are experienced by civilians as well, military families frequently cannot rely on extended family members for support [12]. In addition, military personnel often work long and unpredictable hours, which also impacts the family and the scheduling of activities. It is estimated that service personnel work an average of more than 50 hours per week, and it is higher (60 hours per week) for officers [10].

Despite the negatives of a military lifestyle, there are many positive benefits for families as well. There is a sense of belonging among families living on base or post, and they rely on each other for support. Military service members experience a sense of camaraderie, and their family members may also experience this sense of deep rootedness and affiliation. There are also financial benefits, as military families have access to medical care, job security, and other benefits, often extending into retirement [10].

The military culture is also a powerful factor. This military culture has specific institutional laws, traditions, vocabulary, symbols, codes of justice and discipline, norms, and values shared by a specific collective group [13,102]. Military culture strongly influences military personnel's behaviors and value system and, as a by-product, affects their families [102]. Although each branch of the military has its own ethos, there are some common themes that run throughout the institution [14]. As mentioned, it is a culture that demands loyalty, integrity, commitment, and courage from its members. They have to be ready at any given moment to deploy and relocate, and their family members are expected no less [14,15]. It is also a culture that draws itself into the personal lives of its personnel and their family members. For example, the military is involved in marital discord, substance abuse, and health and mental health issues because these factors can impede how military personnel do their work [15]. This has both positive and negative ramifications. On the one hand, the military has programs and resources such as counseling, mental health services, and health resources available to address these issues. However, because of the closed nature of the culture, some military personnel are reluctant to seek help for fear it might have negative impact on their careers, and family members may be fearful that private information will not be kept confidential and that they will become objects of public scrutiny [15].

Military culture is also hierarchical and male-dominated. Consequently, ideals of being tough, self-sufficient, and strong (i.e., "the masculine warrior") are reinforced, with the belief that these norms will help to ensure that service members are mission-prepared and will survive in difficult circumstances [16,17]. Emanating from this norm is the belief that all problems can be solved given enough time and effort [103]. This belief, referred to as the "warrior ethos," is based on the conviction that the mission is paramount and defeat should not be accepted [104]. However, the downside of this type of promoted ideal is that experiences of psychologic, social, and/or emotional distress are viewed as signs of weakness; the military tends to reinforce the notion that a true soldier (or airman, seaman, etc.) does not need assistance [13,16]. Therefore, obtaining formal help further places them at risk for stigmatization [16]. As a result, many rely on the peer support of other military service members rather than professional help [18]. This mutual support has its benefits, but it only goes so far.

The military culture has been described as authoritarian and marked by a rigid class system. In terms of it being authoritarian, Hall notes [19]:

There are clear rules, often with narrow boundaries, for behavior and speech; there is little tolerance for questioning of authority or disagreements; there are often frequent inappropriate violations of privacy; and often children are discouraged from engaging in activities or behavior that hint at individuation. Not only do military personnel have to adapt to the authoritarian structure, but their families do as well.

The military culture places emphasis on hierarchy and adherence to the hierarchical system by employing rank and grade [104]. This automatically communicates the individual's position and authority and the amount of power he or she has [104]. The military class system is divided into officers and enlistees [19]. Families are not only isolated from "civilian society," but the class system at times inhibits the intermingling of families of officers and of enlisted military personnel. Consequently, families may feel alienated [19].

The military culture is also characterized by values that emphasize teamwork, obedience, and the collective [16,17]. Individualism and autonomy are not the predominant values; rather, members are expected to dedicate themselves wholeheartedly and sacrifice for their unit, their mission, and the military system [14,20,103]. Although there is a sense of great solidarity and camaraderie, this can foster an "us" and "them" attitude, where "us" is the military and "them" is civilians [14].

CYCLE OF DEPLOYMENT

The cycle of deployment and the associated transitions made by military personnel and their family members are significant. This cycle consists of five different phases: pre-deployment, deployment, sustainment, redeployment, and post-deployment or reintegration. In each of these phases, military personnel, spouses, children, and other family members experience a range of challenges and adjustments [21].

PRE-DEPLOYMENT

In the pre-deployment phase, the individual receives a notice that he/she will be deployed. This phase involves "looking ahead" (planning) and saying good-bye [21]. The exact timing of departure is not always clear, and it can range from a few days to a year [22]. During this phase, the stress of uncertainty and the vacillation among different emotions (e.g., anger, resentment, fear, anxiety) can trigger family members lashing out at each other and children regressing or acting out at home and/or in school [22]. In addition, the deployed military member and his/her spouse or partner may be busy arranging their legal affairs, such as wills or powers of attorney, and home preparations [105]. Such discussions and arrangements may affect the marital dyad [22].

DEPLOYMENT

The next phase is the actual deployment, when the service member departs. It is the separation phase, and for some families, the holding pattern of the pre-deployment phase is so stressful that the actual deployment is viewed as a temporary relief of the anticipation of separation [21]. This loss associated with deployment is referred to as "ambiguous loss," meaning it is not physical but psychologic [23]. Unlike death, a permanent physical loss, the family of the military personnel experiences ongoing psychologic loss, and this uncertainty can lead to difficulties in decision making and planning for the future [22]. Within this context, spouses may experience negative mental health symptoms. In one study, spouses of deployed service members experienced higher levels of anxiety, depression, sleep disorders, and adjustment disorders compared with those without deployed spouses [24]. In a qualitative study about the stressors impacting military families during the Desert Storm deployment in the early 1990s, researchers found that families experienced three types of stressors: emotional (e.g., missing the deployed family member, feeling anxious about his/her safety), the day-to-day practicalities of life (e.g., budgets, powers of attorney, child care), and general life events [25]. The major stressors the families identified were loneliness, financial concerns, and childcare and disciplining. Not all families had social support networks readily available, as family, friends, and/or other extended family members were often not living nearby [25]. With modern video communication options (e.g., Skype), family members can see and speak in real time with the deployed family member. These opportunities may mitigate anxiety and loneliness, but witnessing realities of combat (e.g., hearing explosions or seeing injuries) may be traumatic, especially for children [105].

SUSTAINMENT

In the sustainment, the family works at sustaining itself without one of its family members. This phase takes place approximately during the second through the fifth month of deployment [26]. New routines emerge without the deployed family member, and each family member readjusts to the challenges, stressors, and new responsibilities [21,106]. New social support structures may develop, and the family members who are left behind begin to see some equilibrium and experience some sense of control [26].

REDEPLOYMENT

The redeployment phase, also called the reunion phase, involves notification that the deployed family member is returning home. Both the deployed individual and the family members prepare themselves for the homecoming, and there is tremendous amount of anticipation [26,27]. As with any potential change in the family system, there may be some anxiety about how the returning family member will affect the routines that have been established and the power and role dynamics and relationships [26,27]. During this time, family members are often attempting to prepare for the homecoming to ensure that everything is as perfect as possible [28]. Children may be asked to help in order to prepare.

POST-DEPLOYMENT

During the post-deployment or reintegration phase, the service member returns and the entire family is involved in helping him/her integrate back into the system [21]. There is usually a honeymoon phase, but awkwardness and tension often follow [106]. Family roles may have changed during this time, and the returning member will need time to adjust. For example, new parenting strategies may have surfaced in order to deal with being a "single parent" during the deployment. Upon homecoming, the soldier should not expect family dynamics to have remained the same, but he/she may report feeling like a guest in his/her own home [22]. Some may not recognize their child, especially if the child was recently born or just an infant when they left. Similarly, children may not recognize the returning parent or express wariness of this returning stranger. As a result, the military parent may experience distress and hurt [105].

Some military families will encounter challenges during the post-deployment phase, including substance abuse, post-traumatic stress, and domestic violence. In fact, it is estimated that the rate of relationship and family problems is four times higher during this phase than the other phases [29]. In a study involving 19,227 active U.S. soldiers from brigade combat teams who served in Iraq or Afghanistan between 2003 and 2009, problems of marital quality were reported and separation/divorce intentions increased during the reintegration period [51].

THEORETICAL FRAMEWORKS

Theories are logical systems that provide a framework for organizing and understanding observations and concepts. They are intended to offer comprehensive, simple, and dependable principles for the explanation and prediction of observable phenomena. In addition, theoretical frameworks guide how the service provider will proceed during various phases of the change process. They define the problem and its etiology and, ultimately, guide assessments and interventions. The following theoretical frameworks can offer practitioners a foundation to understanding the context of deployment and how it impacts military family members and how to best assess and intervene in these families.

FAMILY SYSTEMS THEORY

Family systems theory asserts that changes in the environment will inevitably result in changes (not necessarily negative) within the family structure [30]. The family structure is further defined as the organizational patterns or characteristics of the family [31]. Within all family structures, there are boundaries that determine who is in or out of the family system and who belongs in which subsystem. Subsystems consist of members of the larger family system on either a temporary or permanent basis with specific roles and can be organized by sex/gender, age, power/rank, past history, interests, or other factors [31]. Furthermore, family structures are guided by family rules, which are the expectations for behaviors that shape and direct family function, and family roles, which consist of beliefs regarding each individual's specific function(s) [30]. Ultimately, healthy family systems have clear boundaries between the subsystems and flexible rules and roles to promote individuality but still maintain healthy generational hierarchies and promote growth and adaptability [32].

When applying family systems theory to military families, some questions arise. How does deployment affect the entire family system and each individual family member? To what extent is the family an open or closed system? For example, the more open a family system is, the greater flexibility members have to maintain its viable-ness and use outside resources [33]. When tasks and responsibilities alter as a result of deployment, it is necessary to examine the family boundaries [107]. Consider how the family system adjusts in order to meet the challenges of having one member temporarily gone. Does any family member take on new roles? How does this affect the overall family structure?

Ambiguous loss, which is a type of grief, can ensue as a result of ambiguous family boundaries [108]. This type of loss can result when the military family member is absent physically (i.e., deployment) but remains psychologically in the family system, or if the military family member is physically present but is psychologically absent [108].

ECOLOGIC THEORY

Ecologic theory is based on the inter-relationships of the individual and his/her behaviors on four different levels: macrosystem, exosystem, microsystem, and ontologic [34]. The core assumption is that alignment between individuals and the environment in which they operate is necessary, as resources and support are derived from the environment [35].

The macrosystem level of ecologic theory includes the broad social and cultural values that affect the individual. In understanding the impact of deployment on military families, practitioners should examine how the sociocultural context of the military affects families. What are the social norms about relocation, military readiness, and resilience? How are families of the deployed individual expected to respond and cope?

The influence of formal and informal social structures (e.g., work, peer groups, support groups, friendships, school settings, community, neighborhoods) on larger social problems and individual behaviors is referred to as the exosystem level [34]. In terms of understanding how military families cope and adjust to deployment, understanding how the family draws upon formal and informal structures in their network is helpful. For example, consider how military families who relocate often adapt to their new communities, jobs, schools, and/or religious/spiritual organizations [103]. Do military spouses have a supportive network of family members, friends, and community members from which to draw strength and resources?

The microsystem level refers to the family unit. This level includes the physical characteristics of the immediate family, interactions within the family system, and how each family member perceives the familial environment [34]. On the family level, military families struggle with loneliness, communication problems, and parenting, all of which can lead to maladaptive coping and even violence [109]. Therefore, it is important to assess the emotional states of all family members.

The ontologic level refers to the factors inherent to the individual (e.g., developmental history, skill level, behavior patterns, personality structure). When considering these levels, assess the individual's personality styles, coping skills, and ability to adapt and be resilient.

RESILIENCE THEORY

As the name implies, resilience theory focuses on humans' capacity to overcome challenges, adversity, struggles, and pain, ultimately leading to transformative changes in their lives [36]. This is a move in focus from pathology and dysfunction to the positive effects of healthy coping and perseverance [37]. Resilience has been linked to internal factors, such as temperament and attitude, and external factors, such as community, family, faith, spirituality, and religiosity [36]. Many military families are able to transition from crisis to coping and adaptation in response to war and deployment [38].

There are three categories of resilience [39]. The first is overcoming the odds, which encompasses positive outcomes despite adverse conditions. The second category is sustained competence, which involves being able to harness inner and outer resources to cope with adverse conditions. Finally, the third category is recovery from trauma, which comprises the capacity to move on, progress, and function in a healthy manner despite past and ongoing stressors.

In the context of military families, instead of focusing on the crisis and challenges that deployment and war might bring, resilience theory would explore the factors that allow some families to stay healthy and even thrive in the face of risk and adversity [40]. For example, there is some research that suggests military families' frequent relocation may not lead to negative outcomes (e.g., poor social and academic adjustments in children). Rather, some studies have shown that increased levels of family coping were a result of frequent relocations and that the many relocations brought new opportunities, including meeting new people and appreciating diverse cultures [41]. As another example, some have argued that aspects of military training such as field exercises, promotion of leadership, and sense of cohesion in military units can lead to preparedness and stress inoculation [41].

There is a misconception that military spouses fall apart when their spouses are deployed. Some research indicates that spouses who are left behind take over family decision making, assume new roles, and seek assistance, ultimately demonstrating tremendous role flexibility [41]. Indeed, military families tend to be resourceful, flexible, and adaptable due to the many transitions they have undergone. Examples of resiliency in these families include an enhanced ability to make new friends, deftly transitioning from dual-parent to single-parent households and back, and adjusting to diversity [39].

Psychologic processes that help foster resiliency include making meaning and finding hope/positives. More than 65% of spouses of active-duty military members reported that understanding the larger mission of their spouses' deployment helped with their coping [110].

Similarly, interventions based on resilience theory focus on promoting resilience and identifying specific mechanisms that promote resiliency [37]. For example, family members often experience anxiety, sadness, and worry in anticipation of deployment but may feel they should avoid discussing these emotions in order to protect the deploying family member. Interventions focusing on resilience could involve coaching family members to develop methods for checking in with each other or encouraging them to access internal resources, such as religion and spirituality [110]. Specific behavioral coping strategies include teaching relaxation techniques, reframing, and activity planning [37]. This is based on the belief that families are resilient and can be provided additional skills to enhance their resilience. Some studies have shown that spouses who feel they have mastered negotiating roles and responsibilities when their spouses were deployed experience higher levels of marital quality during the post-deployment phase [110].

STRENGTHS-BASED PERSPECTIVE

The strengths-based perspective was developed in the 1980s in order to move away from traditional theoretical models in mental health care that emphasized deficits and pathology [42]. It is now applied in many areas of mental and behavioral health. The core assumptions of the strengths-based perspective are that humans have the strengths and resources necessary to change the circumstances of their lives, and in doing so, they can learn and grow [42]. Strengths include a client's innate abilities and skills as well as external resources in the community and family. After the problem is identified, the goal is to move away from focusing on naming the problem or deficit and to move toward identifying possible solutions [43]. The strengths-based perspective encompasses honoring the past and acknowledging the gifts of varied life experiences [111]. In the case of working with families with a deployed member, the practitioner will not necessarily focus on asking one family member why he or she is depressed. Instead, the practitioner will spend time and effort with the client identifying the strengths within the individual, the family, and the community that can be garnered to help support the family members during deployment. Military families, like any family, experience challenges and strengths, and the strengths-based perspective is beneficial in working through issues unique to these families' circumstances [44]. For example, a family can focus on the benefits the result from the numerous relocations (e.g., new skills, adaptability) [103].

A study with 6,382 adolescents whose parents serve in the military found that the children tended to do well in school, have good relationships with their teachers, engage in extracurricular activities, and report good parental support, all of which are resources during times of stress [45]. Furthermore, because of their early socialization to the military structure, military children generally demonstrate greater levels of respect for authority figures and are more adaptable, flexible, and responsible and have greater ability to make friends with those who are different from themselves [46]. So, based on the strengths perspective, the role of the practitioner is to collaborate with clients to identify the strengths and resources already available to them and to pursue whatever actions and solutions the client decides [43].

EFFECTS OF DEPLOYMENT

With a solid theoretical backdrop and foundation having been set, it is important to explore the specific effects of deployment on the family unit, the marital dyad, and children.

FAMILY SYSTEM

It has been said that it is not only the military member who serves the country when he/she enlists in the military, but the entire family [29]. When military personnel deploy, the associated stressors can affect marital and parental relationships and the family's integrity and stability [13]. The family system is expected to adapt rapidly to establish equilibrium after the deployment; however, this equilibrium can be difficult to re-establish because the separation may be unanticipated, lengthy, and/or fraught with uncertainties [13].

The types of stressors that military families experience vary tremendously depending upon numerous factors; therefore, it is important to keep in mind that there is no one homogenous military family system. Families who have experienced multiple deployments may have developed coping mechanisms and family rituals to handle the family member's departure. Living on or off a military base can also affect the types of stress family members experience. For example, if a family is surrounded by others with deployed members, there may be a shared understanding of deployment and necessary adjustments. Living in a non-military community may translate to less understanding of the emotional strains that a military family member is going through and greater levels of isolation [29]. Young, recently married military families may experience the greatest amount of stress because they are less financially stable [13]. Young enlistees are usually a lower hierarchical rung of the military, with low pay, and the economic stress can be great for family members who are left behind. Some may require government assistance, which can negatively impact self-esteem [13].

When a family member deploys, a spouse is often left behind to make decisions about the day-to-day functioning of the family, including medical, financial, schooling, parenting, and childcare issues. Although technology can foster better communication over significant distances, the spouse who is left behind must decide how much to communicate with the deployed spouse. For example, if there are troubles at home, should they be communicated to the deployed spouse? Is it better to minimize bad news so he/she can focus on the military assignment [29]? The extent of communication and what is shared during deployment also affect how the family reintegrates when the military family member returns [47].

In a qualitative study with 12 military service men and 18 military wives, one of the main themes that emerged was the importance of staying connected and communicating [48]. They spoke about wanting to be connected by sharing events of the day, and although the wives understood that their deployed husbands withheld information from them, they still derived much value of communicating frequently. Just as the spouse at home wrestles with how much to share, the deployed individual also must determine how much information he/she can and wants to disclose. Some of this is due to the confidential nature of military operations [48]. Again, this can contribute to family members feeling that they should be stoic and reticent about events at home [29].

In research involving deployed military personnel and their communication with their spouses, barriers to communication included security restrictions, technical challenges related to unreliable communication, and translation issues. Because family members are so far removed from the realities of a war zone, it can be difficult for military personnel to satisfactorily express their experiences and feelings. The problems with translation stemmed from being unable to convey intent with nonverbal gestures, facial expressions, and tone of voice can lead to "mistranslated" information [49].

Family members also report constantly worrying about the welfare of the deployed member. In order to learn more about their loved one's whereabouts or activities, they may obsessively watch television news, search for information on the Internet, and/or read newspapers [29]. If a deployed individual sustains a combat injury, this will also affect the family system. In a study of 41 spouses of service members who sustained a combat injury, spouses reported high levels of distress among their children after the injury was sustained [50]. This often affects sleep quantity and quality. In a large-scale survey of 1,805 of female military spouses found that 18% reported short sleep duration, with worse sleep quality when their spouse was deployed [112].

MARITAL DYAD

The military lifestyle places tremendous stress on marriages. Military spouses not only have to deal with the challenges of having their spouse deployed and the stressors of being a single parent, but the military structure and traditions place inordinate amount of implicit pressure on them. Spouses at home are expected to assist in volunteer efforts in their community and within the military structure. Many military spouses feel that volunteering is necessary to help their spouses advance in their military careers [13].

When individuals are deployed, the spouse who is left behind assumes the responsibility of keeping the family intact and maintaining traditions and family rituals (e.g., birthdays, holidays). They tend to feel responsible for the morale of the family and fulfilling the roles of the deployed spouse. Many essentially become single parents, which can be overwhelming and taxing, leaving them feeling isolated [13,48]. Depression, loneliness, and other mental health problems are common, and many are reluctant to seek help for fear of the stigma and of damaging their spouses' military careers.

Others may find that, after an initial period of adjustment, they assume these new roles well, feeling more self-confident and enjoying a new sense of independence [48]. But this can cause problems as well. If a military spouse does not want to forfeit these new roles when his/her spouse returns, marital tensions can result [48].

In a study of 300 married couples in which the deployed husband was active duty in the Army and the wife was a civilian, stress existed for both partners [52]. However, it was higher overall for the wives, despite the fact that the husbands experienced more physical threat. The researchers speculate that there may be several reasons for this trend. First, the husbands' military training may help them to better deal with the stressors or perhaps make them more reluctant to admit to stress. The lack of information given to the wives was found to increase their stress levels [52]. It is not surprising then that a study examining outpatient medical visits of wives of active-duty Army personnel during a three-year period found that 36.6% had at least one mental health diagnosis, compared with 30.5% of wives whose husbands were not deployed [24]. The most common diagnoses included depression, anxiety, sleep disorders, and acute stress and adjustment disorders [24]. Prolonged periods of deployment were associated with higher risks of mental health diagnoses and greater frequency of medical outpatient visits [24].

The risk of divorce increases as the cumulative number of deployments increases [113]. The majority of divorces typically occur after the military spouse returns. The risk of divorce also increases when the service member is female, suggesting that male spouses are less willing to adapt compared with female spouses.

Extensions to deployment are also related to a range of mental health, household, work-related, and marital problems in spouses at home. For example spouses of active-duty Army personnel whose deployments were extended expressed higher dissatisfaction with the Army, more communication problems with their spouses, a greater number of mental health issues, and more work issues (e.g., having to leave a job or reduce work hours) [53].

It is interesting to note that anxieties and fears about deployment can also bring couples closer. Some military wives indicated that the fear of possibly losing their spouse increased the level of communication and intimacy in the marital dyad. The deployed husbands expressed similar sentiments, reporting valuing their wives and marriages more [48]. Consequently, it is crucial not to generalize all military marriages as burdened with stress and marital discord due to deployment. For example, older spouses, those who are married to military personnel in higher ranks, and spouses with more military experience tend to experience fewer challenges [53].

PARENT/CHILD DYAD AND CHILDREN

Attachment theory may provide a helpful theoretical framework in understanding the potential effects of parental deployment on children. Attachment theory is based on the belief that children have a need to attach themselves to a key figure, such as a parent, and separation results in displays of emotional distress. The parental bond is crucial to developing healthy emotional relationships when the child moves to adulthood; childhood separation is linked to depression, anxiety, aggressive behaviors, and other emotional and psychologic problems throughout life [54]. Based on attachment theory, parental deployment may negatively impact a child's need for security and can result in despair, anger, withdrawal, or detachment [7]. However, empirical findings are somewhat mixed when it comes to understanding how this extends to children's mental health. Some studies have found that children with deployed parents exhibit higher levels of depression and anxiety compared to children with nondeployed parents, although the symptoms were not pathologically severe. In a 2011 quantitative research study with 106 military parents and 72 youths, children with a deployed parent experienced higher levels of school-related problems and internalizing and externalizing symptoms compared to children of nondeployed parents [55]. Twice as many children with a currently deployed parent scored in the "at-risk" category for emotional and behavioral problems compared with children of nondeployed parents. For example, in one study, teenagers were nine times more likely to binge drinking during the parental deployment [114]. However, the relationship between psychosocial outcomes and status of parental deployment is not simple; there is a host of other variables. Greater number of deployments and longer deployment periods are correlated with increased behavioral problems, although not significantly so [56]. Indeed, it is not merely the length of a deployment but the cumulative length of all separations experienced during the child's lifetime that correlates with psychosocial challenges during the deployment and reintegration phases [57].

Children may experience distress and have higher maladaptive behaviors immediately after they separate, but this appears to lessen over time [115]. Further research indicates no statistically significant relationship between deployment and negative social and emotional development for children between birth and 5 years of age [116]. However, older children (6 to 10 years of age) tend to experience more problems with peers if one of their parents were deployed in their early childhood.

The mental health of the primary caregiver is also an important factor. The most consistent predictor of how well a child will adjust to a parent's deployment is the primary caregiver's own psychopathology [58]. In families with deployed members, there is a direct relationship between caregivers who experience poorer mental health outcomes and poorer academic functioning among their children [57].

Gender differences also exist. Girls tend to have more difficulties during the reintegration phase when the deployed parent returns than boys [57]. This may be because girls typically assume more household responsibilities during the military parent's absence.

As noted, although there are studies indicating that military children experience more negative emotional, social, and psychologic outcomes compared to their non-military counterparts, there are studies that show no differences between the two groups. In a study with 213 children of military parents, between 6 and 12 years of age, the children's emotional symptoms were similar to national norms. However, the parents' reports of their children's emotional problems were higher than the national norms. It is possible that parents' own stress levels influence the reports of their children's functioning [59].

Social support is also crucial. Children of military families who live on the bases and attend schools sponsored by the Department of Defense have additional social supports, including peers who understand deployment and the military milieu [115]. It is clear that military children are not a homogenous group. There are variables that influence the diversity of this group and how they respond to parental deployment. Like any other children, most responses are contingent on age, developmental level, cognitive ability to understand the situation, pre-existing parental-child relationships, and the family environment [2].

OTHER KEY SOCIAL PROBLEMS

DOMESTIC VIOLENCE

The prevalence of domestic violence among military families is difficult to determine due to the closed nature of the military. It is also important to note that most statistics related to domestic violence in the military are derived from samples from only the Army, so it can be difficult to derive conclusions about trends across the different military branches [117].

In one review of the Army's central registry, researchers found that, between 1989 and 1997, there were 61,827 initial substantiated cases, 5,772 subsequent incidents, and 3,921 reopened cases [60]. Victim rates varied between 8 and 10.5 per 1,000 married persons. More than 65% of the victims were female, and almost half of the referrals were from law enforcement. The vast majority (93%) involved physical violence resulting in minor injuries [61]. Other Department of Defense data indicate that 19 of 1,000 Navy and Air Force wives and 21 of 1,000 Army wives were abused in the last year. In a 2010 analysis of data from the U.S. Air Force Family Advocacy Program, there were a total of 33,787 substantiated incidences of spousal abuse [62]. Physical abuse was the most frequent type of abuse to be substantiated, while neglect was the least likely to be substantiated.

In a study of enlisted military women across all branches of military, 30% reported ever experiencing physical and/or sexual abuse by an intimate partner [63]. Twenty-two percent indicated that the abuse occurred while in military service. Of those who disclosed abuse during their military service, 38% indicated that the perpetrator was retired from the military and 57% reported a civilian partner [63]. In a study examining directionality of abuse, a sample of 248 women enlisted in the Army and married to civilian spouses were assessed for domestic violence [64]. Researchers found that the enlisted women were four times more likely to be victimized by minor violence and three times more likely to be victims of severe violence than to be perpetrators. A disconcerting 60% of all types of violence reported was bi-directional (i.e., both parties were inflicting the violence) and severe [64]. These couples tended to be younger and more recently married. Furthermore, if an enlisted woman's spouse was employed less than full-time, bi-directional violence was more common compared to families with full-time employed civilian spouses.

The stressors associated with deployment and perhaps even being in the military have been explored as possible predictors of domestic violence. However, research findings are mixed. In a mail survey with wives of deployed and nondeployed soldiers, military deployment did not predict domestic violence during the first 10 months of the post-deployment period, even after taking into account race, age, and previous history of domestic violence [65]. Another study examined whether the cultural milieu of the military (i.e., violence as part of training) would spill over into domestic violence. Using the National Survey of Families and Households dataset, researchers compared male veteran and non-veteran use of violence in marriages and found that the veterans had lower incidences of spousal abuse compared with their non-veteran counterparts. However, a study of Army wives found that they were more likely to experience moderate (13.1%) or severe (4.4%) abuse perpetrated by their husbands compared with demographically matched civilian wives (10% and 2%, respectively) [66].

Having a psychiatric disorder can also increase the risk of domestic violence. In a systematic review, 27.5% of men with PTSD disclosed to perpetrating physical violence in the last year and 91% reported psychologically abusing their partner [118]. A male military member with depression has an almost four times increased likelihood of perpetrating physical violence against his partner compared with male members without depression [118]. It is difficult to determine whether the psychiatric disorder in itself heightens the risk or whether there are other underlying factors. For example, veterans with PTSD express feeling less satisfied in their intimate relationships and struggle with emotional expressiveness compared with veterans without PTSD [119].

Prior to 2006, the Department of Defense required healthcare personnel to report all domestic violence incidences. However, this mandatory requirement was revised in 2006 to include two types of reports. Restricted reports give victims the chance to report domestic violence and access health, social services, and advocacy services through the Family Advocacy Program. The caveat is that this does not automatically instigate any legal investigations or processes [67]. With unrestricted reports, however, domestic violence victims can report the incident to the police or military commanders and the incident would be investigated. Victim advocacy and health services are available in either case [67].

CHILD ABUSE

The overall rate of child maltreatment in the United States appears to be decreasing, but rates in military families may be increasing. According to a study published in 2013, there was a 40% increase in cases of child abuse in Army families between 2009 and 2012 [68]. Interestingly, in a study of child abuse in Air Force families, emotional abuse was the most likely to be substantiated, with physical abuse the least likely to be substantiated [62].

It is unclear if child abuse rates differ among military and non-military families. A study using the National Child Abuse and Neglect Data System examined all cases of child maltreatment in Texas between 2000 and 2002 [69]. Researchers found that the rate of child maltreatment in military families was 5.05 for every 1,000 children, while in civilian families the rate was 7.89 for every 1,000 children. The higher rates in the civilian population were attributed primarily to greater financial difficulties (18.7%) and use of public assistance (28.2%) compared with their military counterparts (5.2% and 8.9%, respectively) [69]. In a study of records from four Army installation bases, lack of supervision (35.3%) was the most common form of child neglect/abuse, followed by emotional neglect (31.8%) [120]. Instances of child abuse/neglect were most likely in young enlisted families [120].

Identifying factors that may predict child abuse is complex, as child abuse/maltreatment is a multidimensional social problem. In one study that examined perpetration of child abuse among military mothers and fathers, marital dissatisfaction, low levels of social support, and low levels of family cohesion predicted perpetrating child abuse for mothers. For fathers, low levels of family expressiveness predicted abuse. In both cases, depression, family conflict, and parental distress were predictive factors [70]. Deployment appears to be another predictor. The risk of moderate-to-severe child maltreatment by a female civilian parent is 3.85 times higher during deployment than times of nondeployment [121]. In a study of 1,771 dual-parent families of enlisted Army soldiers who experienced at least one combat deployment between 2001 and 2004, a total of 1,858 parents abused their children [71]. Researchers found that the overall rate and severity of child abuse increased during combat-related deployments. Child neglect rates nearly doubled during deployment, but physical abuse rates decreased [71]. Furthermore, the rate of child abuse increased 30% for each 1% increase in active-duty military being deployed or returning from a military operation [72].

SUBSTANCE AND ALCOHOL ABUSE

Among all military service members, the overall prevalence rate for heavy alcohol use in the past 12 months is 8.4% [73]. A Department of Defense report indicates that the heaviest rates of drinking were among Marines (15.5%), followed by the Navy (9%), Army (8.6%), Coast Guard (7.5%), and Air Force (3.8%) [73]. When comparing illicit substance use among civilian and military populations, civilian past-year usage is higher (8.9%) compared with military servicemen and women (1.3%). This lower rate of illicit substance use is due in part to the military's random testing procedures and zero-tolerance policies [73]. Binge drinking has spiked since the wars in Iraq and Afghanistan started; in 2008, almost half of active-duty military members reported binge drinking [122]. In that some time, the use of prescription pain medications (particularly opioids) have increased; between 2001 and 2009, the number of prescriptions written by military physicians increased fourfold [122]. Because drugs and alcohol can inhibit negative feelings and disconcerting memories, it may be used to self-medicate, particularly among those who have witnessed or experienced suffering related to war and deployment.

Substance and alcohol abuse can cause tremendous harm, strain, and burden on the family system. It inevitably impacts communications, roles, finances, routines, parenting, employment, and other dimensions of family life [74]. The Stress-Strain-Coping-Support (SSCS) model has been employed to understand how substance and alcohol abuse impact the family [75]. This framework postulates that: a family member using substances or alcohol causes stress and strain on the entire family; family members may exhibit stress or strain through a variety of physical, emotional, and psychologic symptoms; family members frequently try to determine what is wrong and what they can do to fix the problem; and the way family members cope and respond to the situation is often influenced by how others in their immediate social support system respond [75].

For military families, deployment and reintegration trigger additional stressors that can lead to substance and alcohol abuse. For example, servicemen and women returning from deployment have a higher prevalence rate of new-onset drinking problems compared to nondeployed active-duty personnel [76]. In a study examining veterans returning from Iraq, 13.9% of the veterans were determined to have probable post-traumatic stress disorder (PTSD), 39% probable alcohol misuse, and 3% probable substance abuse [77]. Military members who have been in combat and who have PTSD are more likely use substances and alcohol to cope [78]. However, one study found that a clinical diagnosis of PTSD was a less important predictor of alcohol, substance, or aggressive behavioral problems than the presence of symptoms of a stress response [78].

ASSESSMENT

Military personnel returning from deployment are required to complete the Post-Deployment Health Assessment [79]. This medical screener is composed of 10 mental health questions and must be completed by a medical provider within 30 days of returning from military assignment [79]. In addition, the mental health departments in the Army and Navy use the Post-Deployment Psychological Screener, which consists of 22 questions assessing for symptoms for depression, PTSD, communication issues, interpersonal problems, alcohol abuse, and anger [79]. PTSD is commonly assessed due to the many distressing events that military personnel experience in combat. However, avoidance behaviors such as substance and alcohol abuse, withdrawing from others, and dissociating should be assessed as well [80].

Holistic family assessments that include the family, community, school, and social structures are crucial to understanding how deployment and reintegration affect each family member's emotional, social, spiritual, psychologic, and physical well-being and how these domains are impacted by the larger environment. As such, the ecologic theoretical framework and the person-in-environment perspective are beneficial in evaluating military families' needs [81]. For some families, a military member's injury may affect the family system and result in new challenges in the family in terms of roles, communication, stress, and coping skills [81].

For other families, combat stress can trigger secondary traumatization for family members [82]. Those who witness their loved one's startled responses, nightmares, irritability, sleep difficulties, and hypervigilance may express fear and anxiety, particularly children [79]. Therefore, family members should be included in assessments. Children should be assessed for behavioral issues. Difficulties in school, declining grades, poor peer relationships, and/or aggressive behaviors should be noted, as they may be symptoms of difficulty adjusting to family transitions [82]. Parents should be asked about overall family functioning and adjustment and how they are dealing with child-rearing.

VISUAL ASSESSMENT TOOLS

Visual assessment tools can be helpful during the assessment phase. Deployment narrative maps, for example, can be used. The goal with these tools is to have family members tell their stories about deployment individually and describe how it brought about concerns, stresses, and challenges [82]. Any family challenges identified in the stories are graphically depicted on a timeline. After everyone completes their narrative, all family members are brought into a family session to review the deployment narrative maps and see how certain events triggered stress or reactions. Not only can narrative maps be used as an assessment tool but they can instigate greater communication and foster problem-solving strategies [82].

Genograms are another useful visual assessment tool that can be employed to help families see intergenerational transmissions of trauma, mental health issues, emotional disturbances, behavioral problems, and patterns of coping [39]. Risk factors and protective factors/strengths can be identified, which can be empowering for families [39]. Given the unique needs and circumstances of military families, military genograms are tailored to address specific challenges. For example, the following assessment questions may be used to generate a military genogram [39]:

  • What is the military member's history of service, rank, length of service, honors, discharge status, and nature of discharge?

  • What is the immediate family's attitude toward the military?

  • What is the extended family's attitude toward the military?

  • What is the family's cultural attitude toward military service? Attitude toward war?

  • Was the military family member drafted or did they volunteer?

  • Has the service member served during a time of war? If so, when? What war(s)?

  • Has the military family member ever experienced wartime trauma? If so, what? Has it affected their functioning? If so, how?

  • Has the service member experienced and/or witnessed casualties, injuries, disabilities, or prisoners of war?

  • Did the service member lose friends or comrades in a war? If so, how many? What were the circumstances?

  • What is the level of self-disclosure about the military experiences for the service member?

  • What is the attitude toward mental health treatment or emotional illness?

  • Does the service member have a drinking/drug use problem? If so, was it a problem prior to deployment?

  • Does the service member use military-extended networks or Veterans Affairs services?

  • What was the service member's role prior to deployment? Has it changed post-deployment?

  • What are the family members' political affiliations?

  • Does the family live on or off base?

  • What is the current sociopolitical climate and how does it impact the family?

An ecomap and a genogram may be employed when analyzing how deployment affects various generations in a family system [123]. An ecomap is a visual depiction that portrays all the systems at play in an individual's life (i.e., micro, mezzo, and macro). Within each system, a genogram diagrams each generation. For example, on the microsystem level, the practitioner would assess how relationships and roles are negatively affected by deployment and post-deployment with an emphasis on multidirectional effects [123].

A military genogram is meant to be used within a solution-focused framework; instead of focusing on problems and barriers, the goal is to identify strengths and protective mechanisms and to generate concrete, specific, and workable tasks for the military member and family members to work toward [39].

ONLINE RESOURCES

The Department of Defense maintains a website, http://t2health.dcoe.mil/programs/afterdeployment, that offers self-assessment tools for use by the military community, their families, and practitioners [83]. If a practitioner has a meeting with a military family member or military personnel, he/she can use this online resource portal to learn more about military culture and services offered by the military and/or use the military-specific online assessments or handouts [83]. Future interventions can also be designed using the resources offered online, including plans that include viewing videos about anger, PTSD, depression, adjustment, and wellness and completing assignments based on the information provided for future sessions [83].

INTERVENTIONS

Collaborative relationships between practitioners in the civilian and military community are important [15]. Many veteran medical centers offer family psychoeducation services. However, military personnel and their families may not always seek mental health, counseling, and social services from the military. Therefore, providers in the civilian community should have a good understanding of the issues military personnel and their family members' experience.

EMOTIONAL REGULATION

Interventions to teach family members and military personnel how to regulate emotional responses, such as anger, frustration, and numbness, are vital. This includes skills such as deep breathing, yoga, meditation, exercise, and other deactivation activities that can decrease the intensity of stress reactions and even trauma [84]. When a deployed man or woman returns home, it is inevitable that things will have changed for the whole family. All family members will have to adapt to a "new normal" [84]. This "new normal" may mean adjusting to physical injuries and the new caregiving activities associated with new limitations. Practitioners may help the caregiving spouse engage in self-care and reduce stress [85]. During deployment, there is also a "new normal," however temporary, and the now single parent may benefit from concrete child-rearing and parenting strategies (e.g., specific scripts to use when feeling angry or tips for providing clear directions to children) [85]. Similarly, children may require assistance regulating their emotions and communicating their fears and anxieties when a parent deploys or returns home injured or traumatized [85].

FAMILY EDUCATION AND SUPPORT

Military families can benefit from education and support during the various phases of the deployment cycle. As discussed, each phase brings unique stressors and challenges, and interventions should be tailored both to the family and to the phase. One resource is Families OverComing Under Stress (FOCUS), a service initiated by the Navy's Bureau of Medicine and Surgery, tailored for military family members and offered at 18 Navy and Marine Corps installations across the United States and Japan with the goal of providing family resiliency services [86]. Family members can use the tools available online at http://www.focusproject.org to develop or enhance their ability to regulate emotions, communicate, problem solve, set goals, and manage deployment.

The Sesame Workshop provides a service to military family members and children addressing the challenges related to deployment [8,124]. In videos and toolkits created specifically for young children, familiar characters work through issues of grief, coping with parental absence or injuries, and new traditions. The initiative also provides materials for parents with information on starting difficult conversations with young children and using appropriate language. Families can view various videos together and have the opportunity to talk about the feelings and emotions they experience.

MilitaryKidsConnect is a website that provides resources for military families with an emphasis on assisting children in enhancing their coping skills [125]. It offers web-based psychoeducation along with online support groups [125].

Traditional psychoeducation can also be adapted for the different issues related to deployment and military life. One example is a psychoeducational program for families of veterans who have experienced traumatic brain injury [87]. Educational workshops and group sessions would include topics such as injury, stigma, communication, marital commitment and distress, focused strategies and problem-solving skills, and family functioning [87]. Other family educational topics could include parenting skills, coping with stress, violence, coping with loneliness and isolation, and adjusting to loss [109].

FAMILY THERAPY

As discussed, family systems theory maintains that the family is composed of subsystems that are defined by boundaries, rules, power structures, and rituals, and stress and challenges will inevitably affect the entire family system [30]. Establishing a "new normal" for military families after the return of a military spouse is often the primary goal for family therapy. The family therapist can facilitate communication in order to generate a shared story of the deployment and its effects on the present and the future [84].

Another goal for family therapy is to address the stress emanating from all phases of a deployment. A therapist can help assist the nondeployed parent to establish equilibrium in the family system by maintaining existing rules, routines, and rituals during all phases of deployment [85]. Humans in general, but particularly children, strive for stability and predictability, so maintaining routines, rules, and rituals can be very grounding [85]. Before deployment, spouses should work together to agree on parenting, disciplining, and child-rearing practices so a united front is presented to children [85].

Because the family system is not isolated, it is important for family therapists to garner resources from schools, the community, neighborhoods, and institutional systems. A community family therapist navigates networks and collaborates with various systems in order to supplement existing family strengths with external resources [88]. First, therapists may work with the client and family members to cope with the stressors specific to deployment and the military lifestyle; coping involves using both internal and external resources [88]. Second, the therapist assists the family in identifying a personal network system, which may consist of extended family members, friends, neighbors, and the community, that can be used for support. Practitioners can facilitate contact with available social services, such as day care, legal services, parenting classes, and other services, as needed. Finally, practitioners should empower clients and family members so they may serve as advocates for other military families, in a sense giving back to their communities. This could involve a military spouse helping run a support group for other military family members and sharing his/her experiences [88]. Families that have successfully coped with the challenges associated with deployment are the best equipped to empower and support other military family members [89].

PROMOTION OF FAMILY RESILIENCE

A strengths-based approach may be used to develop interventions that promote family members' resilience [85]. This is crucial in a military context, in which self-sufficiency and strength are emphasized among military personnel and their family members. In these cases, a pathology-based model might impede military members and their families from seeking mental health and social services due to the stigma. Exploring spouses', parents', and children's strengths and how to integrate those identified strengths into interventions can foster empowerment and develop a collaborative relationship between the practitioner and families. Identifying goals rather than problems promotes a positive outlook toward the future [85].

Home visiting interventions have become more popular for military families in part because they reduce the stigma of public help-seeking [126]. These interventions are implemented in the home and reflect a strengths-based perspective; many help family members handle deployment, address communication challenges, cope with isolation and loneliness, and connect family members to support and resources [126].

COLLABORATING WITH SCHOOLS

School-age children in military families do not necessarily attend a school for military children. It is estimated that more than 80% of military children attend public schools [127]. It is very important for practitioners to work with administrators and teachers to formulate holistic interventions for children of deployed parents. When schools integrate information related to the military into curricula, children from military families may feel there is less of a dichotomy between home and school. Children from non-military families may also gain greater empathy for schoolmates with a deployed parent. In English classes, a curriculum could include pen pal programs with deployed military personnel or reading novels with military themes [90]. Math classes could integrate calculations of differences in time zones [90]. Teachers in computer technology classes may design activities involving developing websites for deployed men and women that allow for posting encouraging notes, photos, or poems [90].

Practitioners can provide professional development or in-service training for teachers regarding best practices when working with children from military families. Outlining the deployment cycle and normal reactions versus more problematic academic, emotional, and behavioral issues that require referrals is vital, as are teaching strategies to help children who are in transition [90,127]. Schools can also support children and parents of the military by offering extra services, such as support groups or seminars on coping, dealing with anger, and/or communication. Students who have a deployed parent may benefit from partnering with others for peer support [90].

ETHICAL ISSUES

Unique ethical issues emerge when working with military personnel and their families. Throughout this course, no distinction was made between practitioners who are affiliated with the military and those who are civilians. However, there are specific ethical issues that emerge for the military practitioner, and this section will cover both scenarios.

DUAL RELATIONSHIPS

One of the main ethical dilemmas for practitioners employed by the military is the issue of dual relationships. Practitioners working with military families often have multiple roles, which can cause ethical tension [128]. For example, counselors should have a goal of building rapport and conveying empathy, but this can be difficult if the counselor outranks the client. Alternatively, counselors are expected to act in the role of expert, but this can be difficult if he or she is subordinate to the client [128].

In general, practitioners have two obligations: to the client (i.e., the military member and/or his or her family member) and to the military institution (e.g., the Department of Defense) [91,92]. This is also referred to as mixed or dual agency, indicating the military practitioner must take into account the needs of both the client and the military [91]. For example, if a military member is referred by his commander for an evaluation to determine if he is fit for duty, the practitioner must take into consideration both the needs of the mission and the well-being of the individual. This then raises the ethical issue of beneficence and determining whose best interest is ultimately to be served [93]. The civilian practitioner's focus is on the client's best interest, but in the military environment, multiple stakeholders are often involved, all of whom have a vested interest in the military member's disposition [93]. Unfortunately, referring to one's professional code of ethics and the mandates of the Department of Defense is not always definitive. There can be incongruities between the two, which can result in dissonance for the military practitioner [93]. Civilian practitioners do not confront the issue of dual relationships as strongly because they do not have an affiliation with the military and can refer the client elsewhere. However, this is not an option for the military practitioner [92]. Furthermore, military practitioners may be more likely to see their clients in day-to-day settings (e.g., at the commissary), making boundary crossings more likely [128].

CONFIDENTIALITY

Another ethical challenge is in the area of client confidentiality and informed consent. In a civilian environment, confidentiality in the client/practitioner relationship is paramount. However, in the military environment, client records usually belong to the military, not the practitioner [92]. Military commanders may feel a client's information is crucial to the management and safety of the unit. Consider a military family member who seeks counseling. If a military commander contacts the practitioner for information on the case because she feels that issues at home affect the military member and ultimately the unit, a civilian practitioner could easily invoke confidentiality. However, military practitioners have additional reporting obligations that are not part of the usual protocols as delineated in the ethical codes for counseling, social work, or psychology [129]. Consequently, they may feel that their responsibilities to their employers and/or higher ranking officers are more important. Military clients should be advised of the different components of informed consent and, particularly, the limits of confidentiality.

The ethical values of self-determination/autonomy and social justice that underpin professional ethical codes take on different meanings in the military environment [94]. Practitioners working with military personnel and their family members must resolve the needs of the military along with the needs of the client [94]. Informed consent forms should clearly outline the limits to confidentiality outside standard protocols [128,129].

CULTURAL COMPETENCE

For civilian practitioners, cultural competence is one of the most salient ethical challenges when working with military personnel and family members [95]. Civilian practitioners without a longstanding history and experience working with military personnel and their family members will find that the military is a distinct cultural entity. In many cases, professional training does not adequately prepare practitioners to work in this environment. The first area for civilian practitioners to become familiar with is the military language, norms, and etiquette [95]. Military-specific acronyms, procedures, ranks, and terms associated with missions and the general lifestyle arise frequently in work with military personnel and their family members. Practitioners who do not have a full grasp of the meanings of these terms can miss crucial information during the assessment and treatment phases. Stopping to ask for a definition of a term during the therapeutic encounter can interrupt the flow and impede the clinical process in addition to jeopardizing the practitioner's credibility [95]. Civilian practitioners should seek supervision from a practitioner who has experience in working in the military mental health system [129].

VICARIOUS TRAUMA AND SELF-CARE

For both military and civilian practitioners, the issues of vicarious (or secondary) trauma and self-care are vital. The stressors and challenges encountered when working with military members and their families can trigger acute trauma reactions, burnout, and compassion fatigue, which can ultimately have negative outcomes for a practitioner's professional competence.

Burnout refers to extreme stress experienced by practitioners that depletes emotional, mental, physical, and psychologic resources [96]. Signs of burnout include depression, physical and mental exhaustion, anger, cynicism, acting out, frustration, lack of productivity at work, and difficulty controlling feelings [97]. A practitioner experiencing burnout often feels drained or tired and at times emotionally detached from clients [96]. Vicarious trauma is defined as "the natural, consequent behaviors and emotions resulting from knowledge about a traumatizing event experienced by a significant other. It is the stress resulting from helping or wanting to help a traumatized or suffering person" [98]. Vicarious trauma can affect practitioners' beliefs about the world, others, and self, including concepts of safety, trust, control, and intimacy [99]. Hearing stories of trauma, military missions, and killings, as well as family members' anxieties and fears, can affect practitioners' worldviews, their own sense of safety and control, and sense of self [100]. Some practitioners will help deal with a military member's death and family members' loss and grief, which can ultimately raise personal reactions to death [100]. Practitioners should engage in self-care techniques, including seeking social support, spending time with friends, engaging in hobbies and recreational activities, and seeking out other professionals for consultation and professional supervision in order to address vicarious trauma and avoid burnout.

Practitioners should also exercise self-compassion, which involves being gentle with oneself, realizing that everyone has failings, and acknowledging it is not possible to do everything [130]. Along with vicarious trauma, there can also be personal post-traumatic growth [130]. By focusing on the potential to grow as a person and professional, coping can be enhanced.

CONCLUSION

Since September 2001, military families have been experiencing longer and more frequent deployments. As of 2008, there have been 1.8 million deployments by American military personnel [101]. For each deployment, those left behind continue caring for their families, raising children, and navigating the different challenges that come with the day-to-day aspects of life. Military families have to create and adapt to a "new normal" when an individual is deployed while coping with the continual worry for their safety and ambiguous loss, which can be taxing for the entire family. Practitioners can work with families to facilitate the identification of family members' inner resources and resiliencies, empower family members and military personnel, and link families with various resources.

RESOURCES

Center for Deployment Psychology
http://www.deploymentpsych.org
Families OverComing Under Stress (FOCUS): Resiliency Training for Military Families
http://focusproject.org
Military.com Spouse
http://www.military.com/spouse
MilitaryBridge
http://www.militarybridge.com
MilitaryKidsConnect
http://www.militarykidsconnect.dcoe.mil
Military One Source
http://www.militaryonesource.mil
National Guard Family Program
http://www.jointservicessupport.org/FP
National Military Family Association
http://www.militaryfamily.org
Operation Homefront
http://www.operationhomefront.net
Our Military Kids
http://ourmilitarykids.org
SAFE Program: Mental Health Facts for Families
http://www.ouhsc.edu/safeprogram
Sesame Street Talk, Listen, Connect
http://www.sesameworkshop.org/what-we-do/our-initiatives/military-families
U.S. Army Families
https://www.army.mil/families
U.S. Department of Defense
After Deployment
https://afterdeployment.dcoe.mil
U.S. Department of Veterans Affairs
National Center for PTSD
https://www.ptsd.va.gov

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