Introduction

The military has been described as the most engrossing and demanding institution in American society [1]. The authors are military medical officers who provide care to service members and their families. Medical officers share a set of behaviors, beliefs, and values within their service members and family members. They experience the challenges of military life daily, not only in their professional life as military physicians but also in their personal lives as sailors, soldiers, and airmen. The aim of this article is to illuminate mental health providers unfamiliar with military mental health regarding the unique challenges military families face and their impact on individual and family health.

Deployment

The most significant changes military families experience is during a service member’s deployment [2]. As the authors have experienced in their professional and personal lives, the non-deployed military spouse is recognized as the cornerstone of the health and wellness of the military family, a role which becomes even more central during deployment periods. However, military spouses continue to be an understudied population and most of the research has been limited to females married to male military service members [3•]. Existing research links limited contact with deployed family members to military spousal depression, increased relationship problems, and decreased overall family functioning. Furthermore, military spouses report higher levels of stress, as well as poor physical health, particularly during deployments [4•], and report being disproportionately responsible for making decisions for the family, especially regarding care of children and pets, and wondering how their deployed spouses would react to their decisions. Some military spouses report feeling like single parents during deployments and children may sense their parent’s distress and anxiety and internalize these emotional states. Military families as a whole feel more distress with longer deployments and may need extra support [5].

Deployment places families of service members at increased risk for family hardships to include an increased susceptibility to mental health diagnoses and hospitalizations, worse academic achievement in their children, and higher rates of child maltreatment, specifically, neglect. There is also an established dose-dependent relationship between parental deployment and emotional/behavioral problems in children, with higher doses corresponding to longer deployments. Symptoms in children and spouses have also been correlated with a service member’s deployment to a known combat zone. While younger children may be more immune to the anxiety that comes when a parent is deployed, they still show signs of stress in the form of clinginess, tantrums, defiance, appetite changes, and nightmares, all of which persist for an average of 1 month after the parent returns. School-age children have the highest rates of deployment-related stress manifesting as deployment-related fears, sadness, and concentration problems. Children also show an increase in mental health diagnoses during a parent’s deployment, with acute stress reaction/adjustment, mood, and behavior disorders being the most common. Adolescents are commonly called upon to take on roles to support the family during deployments and may be expected to give up sports, hobbies, and extracurricular activities during this period of time. This age group also shows an increase in alcohol use when a parent is deployed as well as an increased lifetime risk of tobacco use that increases with an increased frequency of deployments. In terms of academic performance, children who have a deployed military parent are more likely to receive Cs, Ds, and Fs in school than their civilian counterparts. Children’s behavioral responses have been reported to frequently mirror the depressive response exhibited by their mothers when fathers are deployed. In addition, female children have been reported to experience more negative effects related to the deployment of a father than males [6].

Child neglect increased during and following deployments; and seen in both the service member and the parent who stayed home during the deployment. One study cited showed an increase by 400% in Army families that had already experienced some form of child maltreatment [7•].

Reintegration

Post-deployment reintegration is another significant military family challenge and it follows a service member’s return home. Uncertainty about their role in the home, no longer feeling needed, adjusting to new routines, and establishing joint decision-making with their intimate partners contribute to struggles during the reintegration period [8]. During deployment, military spouses often develop new social support networks so the transition to finding emotional support within the couple once again can be difficult.

The fluid nature of military family structure results in constantly changing roles, which can lead to inconsistent family functioning, including parenting, which can be disturbing for children. When deployed service members return, children have to rebuild their emotional connection to the parent and, if the parent has been injured physically or psychologically, the child may become the caretaker [9].

Aside from the usual reintegration stressors, some service members return from deployments with debilitating mental and medical health problems requiring treatment, and some spouses and children become caregivers. Traumatic brain injury (TBI), depression, post-traumatic stress disorder (PTSD), and suicide risk are prevailing issues, with both sexual assault and combat exposure carrying equivalent risk for PTSD [10•]. In 2015, it was estimated that since 2001, about 2.5 million active-duty and reserve members of the military were deployed to Iraq and Afghanistan, of which 20% have struggled with mental health concerns such as PTSD and depression after returning from deployment. Despite the fact that these issues impact the entire family, most of these service members do not seek professional help even when screening positive for mental health problems [11].

When service members transition out of the military, they often experience even more challenges as they work to reintegrate into the civilian world. The military culture is one of the total integration achieved through training and organization to minimize individual differences; however, different subgroups, including infantrymen, guardsmen, reservists, military spouses, wounded warriors, and others do maintain individual subcultures. The military warrior ethos encourages perseverance, responsibility for others, accepting dependence on others, and focuses on continuous training, health, and self-improvement. “Ceremonial acts of discipline,” including the salute, uniform maintenance, shoe shining, and following orders, are unique to military life, and adherence to uniformity, order, and discipline is essential for combat operations. Conversely, the civilian world rarely shares these values, which can lead to, at a minimum, frustration, disenchantment, and isolation, among service members transitioning out of the military [10•].

Upon leaving the military, the top priority of most veterans is their next employment. However, due to frequent relocations, they have fewer opportunities to rely on professional relationships or social networking compared to their civilian peers, and, out of ignorance of the civilian system, may underutilize the resources available to them. Reservists and National Guardsmen face special challenges when returning from deployment, including being laid off, entering into a different, unfamiliar position, being passed over for career opportunities, outdated expertise, and unemployment. A total of 15.1% of reservists/National Guardsmen report problems with finances post-deployment, presumed to be related to employment problems, at least in part [5].

Employers lacking military cultural competence may also negatively impact veterans and spouses seeking employment. They may overlook candidates if they cannot appreciate how military skills translate to the civilian sector. Interviewers may ask inappropriate or offensive questions related to their military service. Employers may also misinterpret employees’ behavior, such as when a military veteran employee is reluctant to act if not given explicit instructions due to their experience with the military culture of chain of command [5].

Compounding employment and financial challenges for the military family, military spouses are twice as likely to be unemployed, more likely to be seeking employment, and, when employed, tend to earn less. Marrying young, frequent moves, and family demands can make it hard for spouses to complete college or pursue a steady career. Marital stress that began during a deployment can worsen during reintegration, especially in the setting of TBI and PTSD, both of which have been tied to lower ability to communicate and poor intimacy, less positive engagement, sexual functioning issues, and higher divorce rates. Research shows that 75% of veteran suicides were linked to a failed relationship. Intimate partner violence (IPV) in military families is positively correlated with PTSD, depression, substance use disorders, enlisted status, and length of deployment. Military veterans and families could benefit from more support during deployment and reintegration, especially with young children and when a service member is experiencing physical or mental health challenges [12].

The severity of the violence experienced at home correlates with the severity of PTSD. Notably, emotional numbing related to PTSD was most positively associated with behavioral issues in children. Multiple programs exist to address these well-known issues, with notable successful programs sharing models which work across multiple disciplines and settings to include school, family, home, and command, which is also noted to often be the most significant challenge [13].

Relationships Within the Military Family

Extended separations, emotional isolation, and frequent relocations are military-specific stressors that can test the relationship between service members and their spouses. Rates of seeking behavioral health and counseling services among service members are low due to the stigma surrounding career implications and resistance to being vulnerable. Emotional numbing during deployments, often used as a tactic to stay focused and cope with separation from loved ones, is associated with a loss of intimacy. Military couples face difficulty when re-establishing an emotional connection after deployments or extended training exercises. Security restrictions placed on service members prevent them from sharing information about deployment operations when they return home, further alienating them from their spouses. Research indicates that 60% of military spouses believe that being a military spouse had an adverse impact on their own employment prospects as frequent job changes prevent advancement and training opportunities [7•].

Studies show that 700,000 children have experienced a parental deployment since 2001. Multiple deployments and relocations can build resilience in young children and positively augment their ability to cope with parental separation during deployments. However, evidence has shown that these frequent and multiple relocations can lead to children feeling socially disconnected, frustrated with their new academic environment, and resentful toward their parents. Military children also regularly experience loss in the form of relocations, extended separation from loved ones, parental estrangement and divorce, and their shifting roles within the family, school, and social systems. From K-12 grades Military children average 6–9 moves; straining friendships, creating gaps in learning and education, and adding stress from repeatedly navigating new surroundings. Frequent relocations can lead to children becoming distant, and they often befriend other military children who are similarly aloof. Their parents and siblings are generally aloof as well, and so children have limited emotional resources, creating difficulties when faced with stressors. Military children have also been shown to have higher blood pressure and more frequent headaches than civilian counterparts [9].

Despite real challenges, military families also have protective factors to maintain healthy intrafamilial relationships, including stable and predictable incomes, access to comprehensive health care, and an abundance of community resources [14].

Female service members and their families experience a different set of unique challenges. Most military programs are not tailored to families of female service members, given that they comprise less than 20% of all military members. Therefore, their partners may not have their needs met during these stressful periods, and the unemployment (or underemployment) can be particularly problematic for civilian husbands. Divorce rates for female service members are nearly double the rates of their male counterparts. Moreover, female service members are more likely to be married to another service member, which poses additional challenges with juggling two demanding military jobs and even more frequent separation [2].

Mental Health

The military has been recognized as having particular principles and beliefs which may make it more difficult to obtain mental health care. In particular, the military has a greater emphasis on collectivism that values collectivism, conformity, and interdependence, as evidenced by uniforms, grooming standards, and an ethos of self-sacrifice for the group. Reluctance to seek mental health care may be due to these military cultural values, such as avoiding mental health care due to worry it will impact their larger unit [13].

Among service members, 83% have children under the age of twenty [12]. Parental deployment is associated with an increase in maltreatment, most often neglect, and is attributed to the increase in responsibilities, decreased social support, and diminished family cohesion when the household becomes a single-parent home. When the deployed parent returns home, the risk of severe child abuse increases, and is associated with increased alcohol use by the parent [6]. There is a well-established link between parenting stress, substance use, and child behavior problems. Military children with a deployed parent have more outpatient mental health visits than military children without a deployed parent [12]. Mental health problems in service members can manifest as parenting disengagement, emotional numbing, and avoidance, which can lead to neglect, IPV in presence of children, and harsh discipline. Up to 30–60% of families reporting IPV also report child maltreatment. Treating the family system could be as important as treating the individual. Currently, most VA family services focus on the couple, and VA providers are not trained to treat whole families, including children [12].

LaGrone (1978) first defined “military family syndrome” as military families exhibiting above-average mental health issues and challenges, which were thought to be related, at least in part, to frequent relocations and deployments. Military families who are active duty move twice as often as civilians and many relocations involve international moves. Relocations require building a new social/support network, changing schools, finding a new home, new doctors, etc. Other issues that arise in military families include financial stressors, worries about infidelity, sexual trauma, and child maltreatment. This military family syndrome approach also suggests that military families experience more behavioral health concerns among children, related to the military authoritarian style of parenting and an increased prevalence of depression in military mothers [14].

Research has shown that significant relationship distress was reported in 70% of couples where the service member had PTSD vs. 30% in military couples without PTSD. Service members may develop an insecure attachment style and sexual functioning is also commonly affected (60% in TBI couples). In effect, the service member’s mental health problems become couple problems, which can become family problems [5].

Civilian Warfighters

It is important to note that studies find that National Guard and Reservist (NG/R) families are impacted more severely by these hardships likely due to a lack of social support and understanding that comes from living on or near military bases, and other families experiencing similar challenges. Furthermore, NG/R members experience a loss of civilian pay while deployed and their families do not benefit from support resources during extended separations that are available on military bases. While NG/R families are not as connected to military communities, they have the benefit of remaining established in civilian communities. However, these communities may not understand the stressors experienced by military families, contributing to a sense of isolation [15].

In studies looking specifically at NG/R families, 1/3 of military spouses in the post-deployment period reported significant clinical symptoms of anxiety, depression, and PTSD, and 1/10 reported a recent history of suicidal thoughts. Studies have also found elevated levels of parenting stress can contribute to or worsen these mental health symptoms. Researchers continue to elucidate characteristics of families that have demonstrated “resilience” in order to develop more useful and effective interventions. Several successful programs for NG/R families are available, and clinicians are encouraged to identify and become familiar with the stressors facing these families in order to provide better care [15].

Research suggests that early behavioral health intervention is associated with better outcomes, but once active duty status ends for reservists and National Guard personnel, families bear the burden of helping service members access services that were more readily available on active duty status. The available services may require treatment in facilities that are less familiar with the stress of combat exposure or military sexual trauma and less equipped to effectively support these service members [5].

Interventions

Military culture affects how service members and their families access healthcare services. Incorporating military cultural competence among healthcare providers may avoid additional barriers to care [16]. Multiple programs are in place and have shown promise in their ability to provide resources and other support to military families, using a culturally competent approach.

Families Over Coming Under Stress (FOCUS), a prevention intervention for at-risk military families, was founded in the context of the lengthy wars in Iraq and Afghanistan, which saw longer and more frequent deployments, and serious physical and psychological harm to service members. This intervention was informed by prior data suggesting that a family-centered approach to behavioral health is more likely to be appealing and have less stigma attached. FOCUS employs a web-based standardized assessment, family psychoeducation on parenting and military-related stressors, narratives on transition, and resilience skill building. In 2016, Lester et al. studied the longitudinal outcomes of FOCUS and found each family member showed a significant improvement in depressive and anxiety symptoms, as well as PTSD symptoms. Researchers also observed improvements in family resiliency represented by the ability to cope with family adjustment [17].

The Family Advocacy Program (FAP), used in all military branches, has a primary mission to promote healthy, non-violent families and communities through community outreach, prevention strategies, interventions, and collaborations. FAP works to increase public awareness and education about child maltreatment, encourages early identification, and provides assessment and appropriate treatment and services. They conduct community outreach and home-based prevention services for at-risk families, and their interventions in cases of child maltreatment involve military leaders, community organizations, and the criminal justice system when necessary [18].

Another program, Home Front Strong, promotes positive psychological health with a focus on individual resiliency, and supports military family adjustment needs, using six core modules that are specific to the military lifestyle, including the following: grounding, building community, managing stress, allowing emotions, rethinking thinking, and cultivating optimism [19].

And many other programs exist and are available to service members and their families. However, fewer than half of military families reported services and agencies to be helpful and more research is needed to determine how supports, resources, and interventions could be enhanced or changed to be more beneficial for families.

Currently, supports for individuals who exhibit negative effects due to military-unique challenges are delivered primarily on an individual basis rather than to the family as a whole. The military employs family life educators (FLEs) who are professionals trained to use a life course approach to “strengthen and enrich individual and family well-being.”

Additionally, the National Military Family Association (NMFA) (2003) has suggested the following supports to assist families in managing multiple deployments, specifically:

  • Train military support providers to adapt support service locations and hours so they are most accessible to the families they serve.

  • Train parents, school personnel, and child care providers about how to help children cope, especially with longer deployments and repeated deployments.

  • Train all service members, families, and caregivers to know rights, benefits, and entitlements throughout the process of mobilization to demobilization.

  • Expand child care services to meet the changing needs of families and to facilitate their participation in training opportunities (e.g., hourly care, respite care, care for children with special needs, evening care, weekend care).

Given the volume of literature outlining the unique challenges that military families face, and the not infrequently negative impact that military life has on the health of the family, specific areas that are ripe for intervention for service members and their families include how to form and maintain healthy relationships, especially within a marriage, and how to be an effective, loving parent. Relationship education and counseling should be tailored specifically toward the struggles faced by military couples, and would ideally include flexibility in schedule as military members are often working day and night shifts, can be deployed for long periods of time, and are also assigned to trainings without notice. Sessions should be timed to align with upcoming deployments, relocations, new babies, or before marriage. Important military-specific topics include the following: coping with separations, long distance communications, what to share while separated, trauma symptoms, reintegration, and domestic violence. Ideally, the educator should be trained or familiar with military lifestyles, terminologies, and the specific hardship encountered by military families [14]. Furthermore, educational programming around relationships and parenting should be part of regular in-person training of all service members, an approach which could remove some of the stigma of asking for extra support, and which could allow educators to better identify at-risk individuals and families who may need extra education or support.

Although military families face many significant and unique challenges, they also report general satisfaction and joy with military service and the opportunities afforded by it. Military families are also resilient and thrive with support services when available. Multiple resilience factors were identified:

  • Psychoeducation and developmental guidance: help families understand reactions to military experiences and identify when professional attention is warranted

  • Improve communications and demonstrate empathy: develop a shared sense of meaning

  • Help parents to working together and be consistent with limits and warmth for their children

  • Help families improve their abilities to cope with complex challenges

Clinicians can build on families’ strengths and pay close attention to possible vulnerabilities, to maximize a positive impact on service members and their families [2].

Conclusion

Traditionally, physicians are trained to focus primarily on their patient. However, for the last two decades, medical systems have evolved toward more comprehensive patient-centered medical homes [20]. This approach is particularly needed when caring for our military families [21•, 22•, 23•, 24]. We need to shift our focus from individual care for the active duty service member to improving the health of military families. As authors and service members who care for military families, we hope this article improves the cultural competence of providers caring for military families while highlighting the importance of treating the whole family as part of the military and their health as valued and pivotal to the military mission. Children who grow up in military families are more likely than those raised in non-military families to enlist in the armed services. The care that we provide to our military families now has an effect on the future of our Armed Forces and our nation [25].