MILITARY MEDICINE, 178, 12:1316, 2013
Postdeployment Experiences of Military Mental Health Providers Maj Phil E. Miller, USAFR BSC; Bud Warner, PhD ABSTRACT The deployment experiences of military mental health providers (MMHP) since September 2001 have been largely unexamined. MMHP are an integral part to the military health system and play a key role in maintaining a fit fighting force. MMHP deploy and are expected to help others manage their deployment experiences while being faced with their own emotional challenges duting deployment and while transitioning home. This study examines two questions: First, how do MMHP experience réintégration to their families and jobs after being deployed, and second, how do MMHP assess and cope with their own postdeployment issues. In this study, 27 mental health professionals including social workers, psychiatrist, and psychologist were interviewed to examine their deployment and postdeployment experiences. Results indicated 81 % of MMHP recognized some level of dysfunction in their lives, at home, at work, or at both, upon their return frotri deployment. The ability for MMHP to manage their own réintégration issues has significance for their own personal well-being as well as their ability to provide specialized care for others. Attention needs to be given to how MMHP are supported postdeployment and possibly tailor a transitional process for postdeployment réintégration based on the unique nature of their work.
INTRODUCTION Much attention has been given to the condition of soldiers returning from combat operations in Iraq and Afghanistan.'"" Focus has been given to the prevalence of post-traumatic stress disorder (PTSD),"* alcohol and drug abuse,** and the incidence of marital atid/or family problems.' Little research has been done to exarnine deployment among military mental health providers (MMHP). Mental health providers have been "an important component in maintaining the operability of military units."'' Although the contributions of MMHP to the overall military effort and their responsibility for the well-being of troops reintegrating after deployment have been examined, little attention has been given to the deployrnents and réintégration experiences of the MMHP. This preliminaiy descriptive study addresses the réintégration experience from two perspectives: first, how MMHP experience réintégration to their families and jobs after being deployed, and second, how MMHP assess and cope with their own postdeployrnent issues. LITERATURE REVIEW The origins of mental health providers in the military can be traced to civilian workers, most notably Red Cross personnel, working with soldiers during World War l7 The traditional roles of mental health providers were to address the mental health care needs of both service personnel and their families, with the goal of keeping the active duty personnel healthy to fulfill their assigned duties. In the War on Terror, Operation Iraqi Freedorn (OIF) and Operation Enduring Freedom (OFF) have brought additional developments in the use of MMHP. MMHP refers to psychiatrists, psychologists, and social workers assigned to provide Human Service Studies, Elon University, Campus Box, 2338, Elon, NC 27244. doi: 10.7205/MILMED-D-13-00023
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mental health sei-vices for military personnel. Current practice advocates the use of "forward psychiatry," the use of MMHP in combat theaters, to address combat stress.** Others conclude that providing mental health services in theater, as close to the combat soldiers as possible, provides them the best chance of returning home "as free from psychological and emotional problems as possible."^ MMHP who deploy directly with combat troops "confront many of the same threats" faced by the combat soldier.'" Overall, the experiences of MMHP have significantly changed as new roles have emerged during the OIF and OFF campaigns. An increased presence of MMHP in combat zones through frequent deployments has forced the MMHP to perform roles outside typical clinical services, address ethical dilemmas that are atypical, and work in unfavorable conditions with some level of risk to personal safety, and sorne degree of professional isolation. Depioyment While the War on Terror has resulted in increased deployment for soldiers, deployment-related mental health problems have also increased. Four common sources of mental health problems while deployed were identified: isolation, or a sense of aloneness; powerlessness, or a need to manage personal expectations; danger, the threat of injury or death; and workload, which is affected by variables such as operational tempo and the amount of enemy contact." It was further noted that MMHP live and work under these same conditions when deployed, leading to risk of compassion fatigue and of developing their own stress-related problems. When examining Stressors faced by clinical military psychologists, Linnerooth et al'^ identified compassion fatigue, vicarious traumatization, and secondary traumatic stress as important factors. A study of British MMHP found that deployment created challenges for these personnel in three areas.'"^ First, it was
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at times difficult for the MMHP to fit in and attain a sense of belonging, especially if they were working with a different branch of service than their own. Second, ob.stacles such as limited resources and a perceived stigma of accessing services created their own challenges. Finally, ethical challenges arose from having multiple-role dilemmas and maintaining confidentiality. Sitnultaneous fulfillment of the roles of officer and clinician created potential ethical dilemmas, because of eonflicts between the two sets of professional guidelines.
Returning From Deployment Although deployment to combat areas creates patterns of Stressors and challenges, returning home from deployment has its own unique ehallenges. A study of military health care providers found that 9% of all deployed respondents met the full criteria for PTSD and 5% met the criteria for depression. It was also noted that this rate of PTSD was lower than that of returning combat soldiers, which ranged from 12% to 20%.'"* This rate is lower than that found by Katz et al who estimated that between 19% and 38% of returning combat soldiers were having emotional difficulties as measured by the PostDeployment Readjustment Inventory (PDRI).'"' The PDRI has a high correlation with the PTSD Checklist-Military version (PCL-M) but also assesses other domains of functioning, such as social relationships and intimacy issues.'"' They suggest that more soldiers experience more problems after deployment than had been recognized earlier. When examining the effects of deployment, a distinct difference was found when comparing male and female soldiers who were deployed health care providers.'* Female soldiers self-reported more depression, serious psychological distress, and more harmful drinking patterns when compared to their male counterparts. Although this study looked at health care providers, this could also be an issue for MMHP, as the proportion of providers with an operational specialty in this area is often higher for women than men. The potential negative consequences of deployment can also lead to stress on the soldier's family.'' In studying military marriages, a prevalence of high marital discord in families with lengthy military deployments was found. A returning soldier may have to address his or her own postdeployment issues and also those of a spouse and other family members. This pilot study expands the literature by examining how well MMHP cope with the Stressors of their own deployment experiences and how they adapt to their postdeployment family and work life. METHODOLOGY The postdeployment experiences of MMHP were studied using a qualitative inquiry approach. A two-pha.se sampling design was used during the course of this study. After receiving university institutional review board approval, we began the first phase by using a snowball satnpling approach with the reseai-chers using personal contacts to begin finding and
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interviewing participants, who then referred us to their colleagues; this resulted in 13 partieipants. Inclusion in this study required participants to have been deployed at least once. However, as it became more difficult to reach additional participants, we initiated the second phase based on convenience sampling. The researchers completed formal Air Force paperwork requesting support for the research. This garnered support from the social work and psychology consultant to the Air Force surgeon general. Subsequently, an e-mail request to participate in our study was disseminated to approximately 400 active duty Air Force psyehologists and social workers. Thirty MMHP responded to the invitation to participate; participants were selected based on the order of response and availability. Time constraints and available resources limited the study to 27 respondents. An initial codebook was created before the interviews based on the interview questions and subsequently refined to include subcategories to clarify research themes that emerged during post-interview analysis. Each researcher independently coded the interviews using the refined codebook; an inter-rater reliability coefficient of 0.84 was found. Computer software program (ATLAS ti) was used to facilitate coding and retrieval processes. SAMPLE Our sample included 27 MMHP living in the United States and internationally. The mental health specialties represented included 10 social workers, 13 psychologists, and 4 psychiatrists. Of those, 26 participants represented the Air Force and 1 member represented the Navy. All participants were officers, and included 7 Captains, 9 Majors, 7 Lieutenant Colonels, and 4 Colonels. Military status included 24 active duty members, 1 reservist, 1 retired officer, and 1 previous active duty officer. The sample consisted of 10 men and 17 women. PROCEDURE Interview data were collected from 27 MMHP who had been deployed at least once in their military career. The mean number of deployments was 1.69 with a bimodal distribution of 1 and 2 deployments, ranging from i to 6. The mean and modal length of deployment was 6 months with a range from 4 to 15 months. Almost all deployments (95.4%) were located in combat areas associated with OIF and OEF. All participants except two were interviewed either by phone or in person by the researchers; those two participants were unable to schedule interviews but reviewed the interview questions and e-mailed their responses. These responses addressed the questions but were less robust than the information found in the interviews. With the exception of the two written responses, all interviews were digitally recorded and then transcribed for analysis. Most interviews were conducted jointly, with both researchers present during the interview. An interview script was used to standardize the interview, which addressed MMHP experiences in six areas; Career, Role After 9/11, Personal Care
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and Development, Skills, Ethics, and Relationships. For the purposes of this article only two domains were analyzed: Personal Care and Development (experience during the entire deployment process, self-awareness, self-care measures) and Relationships (impact of relafionships while deployed and back home). For example, an item from the Personal Care and Development heading was "What was it like returning from deployment?" FINDINGS
Postdeployment
Reintegration
The MMHP described using a homogenous set of behaviors to care for their own personal well-being during deployment (which will be addressed in a later section). However, MMHP shared a mixture of responses when addressing their own reactions to returning from deployment. Twenty-two of the 27 respondents (81%) indicated some level of difficulty adjusting to life after deployment. These difficulties ranged from minimal impact to adverse functioning at work and within relationships. The difficulties of adjusting from deployment were recognized but even with the recognition, MMHP felt somewhat powerless to deal with them. As one respondent stated, "I was giving the briefings to the guys in Afghanistan of what to expect, so I knew some of the stuff was going to happen as well." MMHP also reported having difficulty reintegrating after deployment. Consider these statements: It took me a good year and a half to be even 75%. It took two years to be at where I am now. I feel comfortable. You're never going to be the same person... but I was so miserable. Nothing mattered, I didn't care about anything or anyone, I was so disconnected, I had given so much of myself that I didn't have anything else. Obviously, sleep was an adjustment. I truly for the first time in my responsible, adult life—when I got home, I was like. Wow, I really want to drink. Not excessively, but it was getting a lot more common for me to say to my partner, "I'm going to make a rum and coke." I was surprised, so, my parents came to visit soon after I got home and I realized that I was concerned that my parents were going to be concerned so I was trying to strategize ways to have a drink at night without having my mom and dad ask questions that it was time for me to quit drinking. Many of the readjustment difficulties had to do with reintegrating into family life. Ten of the respondents (37%) identified issues of réintégration with their families. Respondents reported being short-tempered with their children and spouses over relatively minor issues. One respondent stated: The relationship was hard on my partner. And the parenting piece, definitely, because my partner had done it all while I was deployed. Had done it all, literally. And
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to come home and not want to be a parent who wanted to discipline once I came home—I felt so guilty—that no matter what I did, I wasn't going to be angry at the child.. .1 would give him whatever he wanted because it was like "I've missed you so much, you can have and do whatever you want.".. .And my partner is looking at me like, "You're undoing everything." But what about me? What about me feeling guilty about not being here? I don't want him mad at me. Other respondents spoke of symptoms of arousal or a sense of detachment that took time to work through with their family. For example, I got back and I found that small things really irritated me. And I was very abrupt and somewhat short with my partner and kids. And I'm blessed with an amazing partner and I think my family was very understanding and forgiving, but I was aware that I was agitated and irritable and short. And then I had trouble with my blood pressure, and it took about 4 to 6 months for my blood pressure to return to normal. The nature of the work performed by the MMHP also had its impact on postdeployment life. Several MMHP, especially those trained in social work, told of serving in forward outposts, travelling from one remote base to another, to provide basic mental health services to the troops stationed there. Many MMHP ended up working and assisting in aspects of health care that presented additional challenges to them. One responded shared the following: I was in some pretty intense stuff. I ended up doing stuff on that deployment that I wouldn't normally expect to do and I was in running [physical] traumas, I was helping patch people together because we were such a small unit when we took some significant casualties, I was in actually providing healthcare to them because I was an extra body that could do it. So, I had my own issues to deal with for that. I found that I had to recognize my own stress responses that I had become accustomed to while I was there. It probably took me a good 4 or 5 months to finally get down to a more normal level of my responses. Another area of significant challenge for many MMHP returning from deployment was returning to work. Fourteen of the respondents (64%) indicated that returning to work presented challenges to them. These challenges come from several sources, most notably the nature of the work after deployment, a sense that the work to which they returned was of less value or importance, and in some cases, logistical challenges. MMHP spoke of their time during deployment as "mission driven"—they knew their role to support the accomplishment of their unit's mission. Or as one MMHP stated, "There is a freeing thing about deployments. You are right skill, right time, right place". Returning from deployment often created a sense of lack of purpose or mission. One MMHP, returning
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from a first deployment, said he "just didn't feel like I had much of a job to do., ,1 felt like I didn't know where I fit back in," Another stated, The hardest part actually was going back on the job and working in a clinic surrounded by Air Force people who really had no concept of what it was like to be on the ground in the middle of nowhere Afghanistan. They just didn't get it. After experiencing the "right skill, right time, right place" phenomenon of deployment, many MMHP expressed sense of frustration or loss of focus and purpose in the work they returned to. It wasn't that the stateside work was unimportant, but that its level of importance seemed low when compared to the work required during deployrnent. The following anecdote illustrates this point clearly: So that transition back can be very, very difficult... when I got back to [location deleted], you get two weeks off and all that, and they handed me a chart and said, "Are you ready to see a patient?" and I opened it up and it said, "I'm not sure my new puppy likes me," I'm told that my face got very red and that I was shaking, because a colleague just walked by and said, "I'll take it!" It's difficult to readjust your filter after you've sat across from a Colonel with 25 KIAs to the worried well in a stateside clinic. The compassion level—that's an adjustment. Logistics can also create their own set of challenges when returning to work after deployment. Respondents spoke of not getting leave (returning on a Saturday and at work on Monday), returning and immediately dealing with a PCS (Permanent Change of Station), and coming back to their home base only to find that the entire personnel group they were working with had been reassigned or deployed, making the "familiar" workplace seem very unfamiliar. One respondent returning from deployment experienced the following: I didn't have anybody who really cared I was back. I basically had to hunt people down to let them know I was back. I had to tell my Readiness Office, I walked in there and couldn't find the person who had watched my car while I was gone, so I had to pay for a taxi to get to base that morning and walked up to Readiness with my two giant packs because the taxi couldn't come on base so I had to walk with these giant packs, went up there and was like, "Hey, you guys have a checklist for me or something?" (laughs) Interspersed with the stories of their deployments and returns, many MMHP expressed surprise at their own readjustment experiences. Even knowing about deployment Stressors did not inoculate or prevent the MMHP from having adjustment challenges: I didn't think it would last as long as it did. And, yeah, I wasn't completely surprised, I had really good training on the deployment cycle. And of course I had taught
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classes and interacted with people for years before deploying and then during and after as well, I was surprised that knowing everything I did that it lasted as long and I think that was related to the physiological component of all that stimulus and arousal that you get when you're in a combat zone.
Coping With Postdeployment Issues MMHP had to cope with numerous challenges when returning from deployment, much like any other soldier, they approached this task from a variety of perspectives. For most respondents, there was an awareness that coping with postdeployment issues was a process and that the process required time. One key to successfully handling the challenges on returning home was to be patient with self and others, which could be challenging in its own right. Having the support from a spouse who understood the need for time to process and reintegrate was very helpful: My partner was also pretty good at not over-burdening me with car problems, and house problems, and whatever else right when I got back, and it helped get me back slowly rather than dumping it on me all at once. Another avenue to help cope with readjustment issues was religion. Many (46%) of the respondents indicated that they were people of faith. Their faith had helped sustain them during deployment and also provided a place of strength and support for them after they returned. If the MMHP was an active participant in a religious community before deployment, they took up a similar role when they returned. Physical exercise was also seen as a way of coping with Stressors both while deployed and upon return. Physical fitness is an important component of any soldier's life; 69% of respondents related how they engaged in more exercise while deployed as a means of finding some private time and relieving stress. Similar behaviors continued on their return home. One respondent described returning home from deployment on a Wednesday and running in an endurance relay race that Saturday. A final approach to coping with readjustment involved trying to stay connected to the deployed experience despite transitioning home. Strategies included keeping in contact with colleagues who remained deployed, seeking counsel from those who had returned earlier, or staying current with news about their area of deployment. Although this helped validate their deployment experience, it also reminded them of how difficult it was to share their experiences with those that had no frame of reference to understand what they had lived through, DISCUSSION As the results indicate, MMHP found challenges with the postdeployment experience in the areas of work and family. The MMHP are not immune to Stressors related to deployment
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Postdeployment Experiences of MMHP
and consideration needs to be given to how the postdeployment transition impacts the ability of the MMHP to function in a helper role. Only one of the 27 respondents (4%) sought professional mental health support, and it was unclear if that was for a diagnosis of PTSD or some other mental health issue. Certainly the experiences of the MMHP were not the same as that of the combat soldier. Fven with that recognition, it was noted that 81% of the respondents in this study recognized some degree of disruption in their lives, at home, at work, or at both, upon their return from deployment. The experience of vicarious trauma raises an issue for MMHP.'''' There is the possibility that such trauma may hinder the ability of MMHP to work effectively. The work of MMHP involves the healing of others. This requires the MMHP to be emotionally healthy, able to be empathetic, and have the capacity to care. The effects of this vicarious trauma on the capacity of MMHP for their work, although not the focus of this article, may be connected with their postdeployment experiences. This also raises the question of whether MMHP need a different type of transition after deployment. The standard leave for postdeployrnent soldiers tnay not allow the MMHP to "recharge" before again dealing with the emotional difficulties of others, leaving the MMHP operating at less than optimal capacity. Exploring this issue could be the focus of future research on postdeployment issues. It was clear frorn most respondents that they were prepared to experience some negative effects from being deployed. All mental health professions train their members to maintain a high level of self-awareness. Perhaps their professional training, combined with their military training, lead them to have a higher level of awareness of such experiences than other soldiers would have, and the negative experiences they reported rnay be a result of such heightened self-awareness. The length and frequency of deployment appear to have an effect on postdeployment experiences, with longer and more frequent deployments resulting in more severe mental health diagnoses.'^ After first deployment, in general, a larger number of those deployed showed higher levels of drug and alcohol use and psychosocial problems when cornpared to repeat deployers.'^ The length of deployments for MMHP was also much shorter than that of combat troops. The typical deployment for an MMHP was between 4 and 6 months; combat troops were often deployed for more than a year. The typical number of deployments was one for MMHP. MMHP, while operating in cotnbat zones and experiencing the same mortar and rocket attacks that other deployed soldiers experienced, were not combatants. Their unique role coupled with length of tours of duty tnay also factor into their awareness of their own experiences. MMHP found various ways to cope with the stresses of both being deployed and returning home. The choice of coping strategies were usually consistent across both dotnains; for example, if exercise was an important coping strategy before deploymetit, it was used to help cope during deploy-
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ment and when returning home. The most frequently mentioned coping approaches were exercise; maintaining faith and religious beliefs; and staying in touch with family, friends, and colleagues. The U.S. military has greatly improved its screening for mental health problems, including PTSD, in all pha.ses of deployment—predeployment, deployment, and postdeployment. Services are available for soldiers experiencing difficulties. The culture of the military remains one, however, where seeking such services could have negative consequences on one's career. The MMHP in this study sought counsel and support from their peers and friends rather than seeking mental health services. As soldiers, it is not unlikely that the MMHP also responded to the culture of the military and chose not to seek professional help. There is no way to accurately gauge the severity of the symptoms that were related during the interviews, although respondents indicated having adverse effects on work and family environments. Another possibility is that there adjustment difficulties didn't rise to the level of clinical severity and did not require professional services. It is recognized that this research is based on self-report. It was outside the scope of this study to formally assess respondents before and after deployment. Pre-existing conditions may have influenced the deployment experience. No attempts were made to verify the accuracy of information given by respondents. Additional limitations to this study include potential selection bias, the wide variety of settings in which the MMHP served, and the wide range of combat exposure they experienced. The interviews with the respondents provided minimal opportunity to infer the severity of either symptoms or the efficacy of coping strategies to deal with stress.
IMPLICATIONS FOR FUTURE RESEARCH This study of the postdeployment experiences of MMHP raises sorne additional questions. It is unclear if the training to help other soldiers deal with postdeployment challenges rnakes the deployed MMHP more aware of his or her own challenges when returning from deployment, or if their experiences are similar to that of all soldiers. It is unclear if the sense of purposelessness in their stateside work that seemed comrnon to returning MMHP is also found in other returning soldiers, especially combat soldiers or if it is indicative of emotional numbing from the deployed experience. Perhaps MMHP need a different type of postdeployment transition than other soldiers to regain the capacity to care for the emotional health of others. Further study on whether the length of deployment, the relative safety during deployrnent, and the frequency of deployment experienced by MMHP change their experience in substantive ways from that of other deployed soldiers is needed. This article did not attempt to identify if differences in deployrnent experiences and réintégration were connected at all to the sex of the MMHP. As there is a high number of MMHP female soldiers, there may be differences in how
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they experience deployment and cope with postdeployment transition. Further research in this area is needed. MMHP, often serving in forward bases next to combat troops, serve an important function in assisting the military to accomplish its mission. Their experiences, although unique, do not diminish their roles as soldiers. Their stories of their experiences during deployment are often inspirational and heroic, yet often unknown or ignored. REFERENCES 1. Hoge CW, Castro CA. Messer SC; Combat duty in Iraq and Afghanistan; mental health problems and barriers to care. N Engl J Med 2004; 35; 13-22. 2. Vasterling JJ, Proctor SP. Friedman MJ; PTSD symptom increases in Iraq-deployed soldiers; comparison with nondeployed soldiers and associations with baseline symptoms, deployment experiences, and postdeployment stress. J Trauma Stress 2010; 23(1); 41-51. 3. Smith TC. Wingard DL. Ryan MAK. Kritz-Silverstein D. Slymen DJ. Sallis JF; PTSD prevalence, associated exposures, and functional health outcomes in a large, population-based military cohort. Public Health Rep 2009; 124(1); 90-102 4. Eisen SV. Schultz MR, Vogt D, et al; Mental and physical health status and alcohol and drug use following return from deployment to Iraq or Afghanistan. Am J Pub Health 2012; 102(51); 566-73. 5. Asbury TE. Martin D; Military deployment and the spouse left behind. FamJ 2012; 20(1); 45-50. 6. Kieman M, Hill D. McManus F. Turner M; Management of mental illness by the British Army. Brit J Psychiatry 2003; 182; 337-41. 7. Harris J; History of Army social work. In; Social Work Practice in the Military. Edited by JG Daley. New York. Haworth Press. 1999.
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8. Jones E, Wessely S; "Forward psychiatry" in the military; its origins and effectiveness. J Trauma Stress 2003; 16(4); 411-9. 9. Moore BA. Reger GM; Clinician to frontline soldier; a look at the roles and challenges of Army clinical psychologists in Iraq. J Clinical Psych 2006; 62(3); 395-403. 10. Pischke PJ, Hallman CJ; Effectiveness of critical event debriefings during Operation Iraqi Freedon II. U.S. Army Med Dept J 2008; July-September. 18-23. 11. Applewhite L. Arincorayan D; Provider resilience; the challenge for behavioral health providers assigned to brigade combat teams. U.S. Army Med Dept J 2009; April-June; 24-30. 12. Linnerooth PJ. Mrdjenovich AJ. Moore BA; Professional burnout in clinical military psychologists; recommendations before, during, and after deployment. Prof Psych Res Pract 2011; 42(1); 87-93. 13. McCauley M, Liebling-Kalifani H, Hacker Hughes J; Military mental health professionals on operational deployment; an exploratory study. Community Ment Health J 2012; 48; 238-48. 14. Kolkow TT. Spira JL, Morse JS. Grieger TA; Post-traumatic stress disorder and depression in health care providers returning from deployment to Iraq and Afghanistan. Mil Med 2007; 172(5); 451-5. 15. Katz LS. Cojucar G. Davenport CT, Pedram C, Lindl C; PostDeployment Readjustment Inventory; reliability, validity and gender differences. Mil Psychol 2010; 22; 41-56. 16. Gibbons SW, Hickling EJ, Watts DD; Combat Stressors and posttraumatic stress in deployed military healthcare professionals; an integrative review. J Adv Nurs 2011; 68(1); 3-21. 17. Armed Forces Health Surveillance Center. Data between deployment and mental health incidents—Associations between repeated deployments to Iraq (OIF/OEF) and Afghanistan (OEF) and post-deployment illnesses and injuries, active component. U.S. Armed Forces, 2003-2010; Part II. Mental disorders by gender, age group, military occupation, and "dwell times" prior to repeat (second through fifth) deployments. Med Surv Monthly Rep 2011; 18(9); 2-19.
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Postdeployment Experiences of Military Mental Health Providers Maj Phil E. Miller, USAFR BSC; Bud Warner, PhD ABSTRACT The deployment experiences of military mental health providers (MMHP) since September 2001 have been largely unexamined. MMHP are an integral part to the military health system and play a key role in maintaining a fit fighting force. MMHP deploy and are expected to help others manage their deployment experiences while being faced with their own emotional challenges duting deployment and while transitioning home. This study examines two questions: First, how do MMHP experience réintégration to their families and jobs after being deployed, and second, how do MMHP assess and cope with their own postdeployment issues. In this study, 27 mental health professionals including social workers, psychiatrist, and psychologist were interviewed to examine their deployment and postdeployment experiences. Results indicated 81 % of MMHP recognized some level of dysfunction in their lives, at home, at work, or at both, upon their return frotri deployment. The ability for MMHP to manage their own réintégration issues has significance for their own personal well-being as well as their ability to provide specialized care for others. Attention needs to be given to how MMHP are supported postdeployment and possibly tailor a transitional process for postdeployment réintégration based on the unique nature of their work.
INTRODUCTION Much attention has been given to the condition of soldiers returning from combat operations in Iraq and Afghanistan.'"" Focus has been given to the prevalence of post-traumatic stress disorder (PTSD),"* alcohol and drug abuse,** and the incidence of marital atid/or family problems.' Little research has been done to exarnine deployment among military mental health providers (MMHP). Mental health providers have been "an important component in maintaining the operability of military units."'' Although the contributions of MMHP to the overall military effort and their responsibility for the well-being of troops reintegrating after deployment have been examined, little attention has been given to the deployrnents and réintégration experiences of the MMHP. This preliminaiy descriptive study addresses the réintégration experience from two perspectives: first, how MMHP experience réintégration to their families and jobs after being deployed, and second, how MMHP assess and cope with their own postdeployrnent issues. LITERATURE REVIEW The origins of mental health providers in the military can be traced to civilian workers, most notably Red Cross personnel, working with soldiers during World War l7 The traditional roles of mental health providers were to address the mental health care needs of both service personnel and their families, with the goal of keeping the active duty personnel healthy to fulfill their assigned duties. In the War on Terror, Operation Iraqi Freedorn (OIF) and Operation Enduring Freedom (OFF) have brought additional developments in the use of MMHP. MMHP refers to psychiatrists, psychologists, and social workers assigned to provide Human Service Studies, Elon University, Campus Box, 2338, Elon, NC 27244. doi: 10.7205/MILMED-D-13-00023
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mental health sei-vices for military personnel. Current practice advocates the use of "forward psychiatry," the use of MMHP in combat theaters, to address combat stress.** Others conclude that providing mental health services in theater, as close to the combat soldiers as possible, provides them the best chance of returning home "as free from psychological and emotional problems as possible."^ MMHP who deploy directly with combat troops "confront many of the same threats" faced by the combat soldier.'" Overall, the experiences of MMHP have significantly changed as new roles have emerged during the OIF and OFF campaigns. An increased presence of MMHP in combat zones through frequent deployments has forced the MMHP to perform roles outside typical clinical services, address ethical dilemmas that are atypical, and work in unfavorable conditions with some level of risk to personal safety, and sorne degree of professional isolation. Depioyment While the War on Terror has resulted in increased deployment for soldiers, deployment-related mental health problems have also increased. Four common sources of mental health problems while deployed were identified: isolation, or a sense of aloneness; powerlessness, or a need to manage personal expectations; danger, the threat of injury or death; and workload, which is affected by variables such as operational tempo and the amount of enemy contact." It was further noted that MMHP live and work under these same conditions when deployed, leading to risk of compassion fatigue and of developing their own stress-related problems. When examining Stressors faced by clinical military psychologists, Linnerooth et al'^ identified compassion fatigue, vicarious traumatization, and secondary traumatic stress as important factors. A study of British MMHP found that deployment created challenges for these personnel in three areas.'"^ First, it was
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at times difficult for the MMHP to fit in and attain a sense of belonging, especially if they were working with a different branch of service than their own. Second, ob.stacles such as limited resources and a perceived stigma of accessing services created their own challenges. Finally, ethical challenges arose from having multiple-role dilemmas and maintaining confidentiality. Sitnultaneous fulfillment of the roles of officer and clinician created potential ethical dilemmas, because of eonflicts between the two sets of professional guidelines.
Returning From Deployment Although deployment to combat areas creates patterns of Stressors and challenges, returning home from deployment has its own unique ehallenges. A study of military health care providers found that 9% of all deployed respondents met the full criteria for PTSD and 5% met the criteria for depression. It was also noted that this rate of PTSD was lower than that of returning combat soldiers, which ranged from 12% to 20%.'"* This rate is lower than that found by Katz et al who estimated that between 19% and 38% of returning combat soldiers were having emotional difficulties as measured by the PostDeployment Readjustment Inventory (PDRI).'"' The PDRI has a high correlation with the PTSD Checklist-Military version (PCL-M) but also assesses other domains of functioning, such as social relationships and intimacy issues.'"' They suggest that more soldiers experience more problems after deployment than had been recognized earlier. When examining the effects of deployment, a distinct difference was found when comparing male and female soldiers who were deployed health care providers.'* Female soldiers self-reported more depression, serious psychological distress, and more harmful drinking patterns when compared to their male counterparts. Although this study looked at health care providers, this could also be an issue for MMHP, as the proportion of providers with an operational specialty in this area is often higher for women than men. The potential negative consequences of deployment can also lead to stress on the soldier's family.'' In studying military marriages, a prevalence of high marital discord in families with lengthy military deployments was found. A returning soldier may have to address his or her own postdeployment issues and also those of a spouse and other family members. This pilot study expands the literature by examining how well MMHP cope with the Stressors of their own deployment experiences and how they adapt to their postdeployment family and work life. METHODOLOGY The postdeployment experiences of MMHP were studied using a qualitative inquiry approach. A two-pha.se sampling design was used during the course of this study. After receiving university institutional review board approval, we began the first phase by using a snowball satnpling approach with the reseai-chers using personal contacts to begin finding and
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interviewing participants, who then referred us to their colleagues; this resulted in 13 partieipants. Inclusion in this study required participants to have been deployed at least once. However, as it became more difficult to reach additional participants, we initiated the second phase based on convenience sampling. The researchers completed formal Air Force paperwork requesting support for the research. This garnered support from the social work and psychology consultant to the Air Force surgeon general. Subsequently, an e-mail request to participate in our study was disseminated to approximately 400 active duty Air Force psyehologists and social workers. Thirty MMHP responded to the invitation to participate; participants were selected based on the order of response and availability. Time constraints and available resources limited the study to 27 respondents. An initial codebook was created before the interviews based on the interview questions and subsequently refined to include subcategories to clarify research themes that emerged during post-interview analysis. Each researcher independently coded the interviews using the refined codebook; an inter-rater reliability coefficient of 0.84 was found. Computer software program (ATLAS ti) was used to facilitate coding and retrieval processes. SAMPLE Our sample included 27 MMHP living in the United States and internationally. The mental health specialties represented included 10 social workers, 13 psychologists, and 4 psychiatrists. Of those, 26 participants represented the Air Force and 1 member represented the Navy. All participants were officers, and included 7 Captains, 9 Majors, 7 Lieutenant Colonels, and 4 Colonels. Military status included 24 active duty members, 1 reservist, 1 retired officer, and 1 previous active duty officer. The sample consisted of 10 men and 17 women. PROCEDURE Interview data were collected from 27 MMHP who had been deployed at least once in their military career. The mean number of deployments was 1.69 with a bimodal distribution of 1 and 2 deployments, ranging from i to 6. The mean and modal length of deployment was 6 months with a range from 4 to 15 months. Almost all deployments (95.4%) were located in combat areas associated with OIF and OEF. All participants except two were interviewed either by phone or in person by the researchers; those two participants were unable to schedule interviews but reviewed the interview questions and e-mailed their responses. These responses addressed the questions but were less robust than the information found in the interviews. With the exception of the two written responses, all interviews were digitally recorded and then transcribed for analysis. Most interviews were conducted jointly, with both researchers present during the interview. An interview script was used to standardize the interview, which addressed MMHP experiences in six areas; Career, Role After 9/11, Personal Care
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and Development, Skills, Ethics, and Relationships. For the purposes of this article only two domains were analyzed: Personal Care and Development (experience during the entire deployment process, self-awareness, self-care measures) and Relationships (impact of relafionships while deployed and back home). For example, an item from the Personal Care and Development heading was "What was it like returning from deployment?" FINDINGS
Postdeployment
Reintegration
The MMHP described using a homogenous set of behaviors to care for their own personal well-being during deployment (which will be addressed in a later section). However, MMHP shared a mixture of responses when addressing their own reactions to returning from deployment. Twenty-two of the 27 respondents (81%) indicated some level of difficulty adjusting to life after deployment. These difficulties ranged from minimal impact to adverse functioning at work and within relationships. The difficulties of adjusting from deployment were recognized but even with the recognition, MMHP felt somewhat powerless to deal with them. As one respondent stated, "I was giving the briefings to the guys in Afghanistan of what to expect, so I knew some of the stuff was going to happen as well." MMHP also reported having difficulty reintegrating after deployment. Consider these statements: It took me a good year and a half to be even 75%. It took two years to be at where I am now. I feel comfortable. You're never going to be the same person... but I was so miserable. Nothing mattered, I didn't care about anything or anyone, I was so disconnected, I had given so much of myself that I didn't have anything else. Obviously, sleep was an adjustment. I truly for the first time in my responsible, adult life—when I got home, I was like. Wow, I really want to drink. Not excessively, but it was getting a lot more common for me to say to my partner, "I'm going to make a rum and coke." I was surprised, so, my parents came to visit soon after I got home and I realized that I was concerned that my parents were going to be concerned so I was trying to strategize ways to have a drink at night without having my mom and dad ask questions that it was time for me to quit drinking. Many of the readjustment difficulties had to do with reintegrating into family life. Ten of the respondents (37%) identified issues of réintégration with their families. Respondents reported being short-tempered with their children and spouses over relatively minor issues. One respondent stated: The relationship was hard on my partner. And the parenting piece, definitely, because my partner had done it all while I was deployed. Had done it all, literally. And
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to come home and not want to be a parent who wanted to discipline once I came home—I felt so guilty—that no matter what I did, I wasn't going to be angry at the child.. .1 would give him whatever he wanted because it was like "I've missed you so much, you can have and do whatever you want.".. .And my partner is looking at me like, "You're undoing everything." But what about me? What about me feeling guilty about not being here? I don't want him mad at me. Other respondents spoke of symptoms of arousal or a sense of detachment that took time to work through with their family. For example, I got back and I found that small things really irritated me. And I was very abrupt and somewhat short with my partner and kids. And I'm blessed with an amazing partner and I think my family was very understanding and forgiving, but I was aware that I was agitated and irritable and short. And then I had trouble with my blood pressure, and it took about 4 to 6 months for my blood pressure to return to normal. The nature of the work performed by the MMHP also had its impact on postdeployment life. Several MMHP, especially those trained in social work, told of serving in forward outposts, travelling from one remote base to another, to provide basic mental health services to the troops stationed there. Many MMHP ended up working and assisting in aspects of health care that presented additional challenges to them. One responded shared the following: I was in some pretty intense stuff. I ended up doing stuff on that deployment that I wouldn't normally expect to do and I was in running [physical] traumas, I was helping patch people together because we were such a small unit when we took some significant casualties, I was in actually providing healthcare to them because I was an extra body that could do it. So, I had my own issues to deal with for that. I found that I had to recognize my own stress responses that I had become accustomed to while I was there. It probably took me a good 4 or 5 months to finally get down to a more normal level of my responses. Another area of significant challenge for many MMHP returning from deployment was returning to work. Fourteen of the respondents (64%) indicated that returning to work presented challenges to them. These challenges come from several sources, most notably the nature of the work after deployment, a sense that the work to which they returned was of less value or importance, and in some cases, logistical challenges. MMHP spoke of their time during deployment as "mission driven"—they knew their role to support the accomplishment of their unit's mission. Or as one MMHP stated, "There is a freeing thing about deployments. You are right skill, right time, right place". Returning from deployment often created a sense of lack of purpose or mission. One MMHP, returning
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from a first deployment, said he "just didn't feel like I had much of a job to do., ,1 felt like I didn't know where I fit back in," Another stated, The hardest part actually was going back on the job and working in a clinic surrounded by Air Force people who really had no concept of what it was like to be on the ground in the middle of nowhere Afghanistan. They just didn't get it. After experiencing the "right skill, right time, right place" phenomenon of deployment, many MMHP expressed sense of frustration or loss of focus and purpose in the work they returned to. It wasn't that the stateside work was unimportant, but that its level of importance seemed low when compared to the work required during deployrnent. The following anecdote illustrates this point clearly: So that transition back can be very, very difficult... when I got back to [location deleted], you get two weeks off and all that, and they handed me a chart and said, "Are you ready to see a patient?" and I opened it up and it said, "I'm not sure my new puppy likes me," I'm told that my face got very red and that I was shaking, because a colleague just walked by and said, "I'll take it!" It's difficult to readjust your filter after you've sat across from a Colonel with 25 KIAs to the worried well in a stateside clinic. The compassion level—that's an adjustment. Logistics can also create their own set of challenges when returning to work after deployment. Respondents spoke of not getting leave (returning on a Saturday and at work on Monday), returning and immediately dealing with a PCS (Permanent Change of Station), and coming back to their home base only to find that the entire personnel group they were working with had been reassigned or deployed, making the "familiar" workplace seem very unfamiliar. One respondent returning from deployment experienced the following: I didn't have anybody who really cared I was back. I basically had to hunt people down to let them know I was back. I had to tell my Readiness Office, I walked in there and couldn't find the person who had watched my car while I was gone, so I had to pay for a taxi to get to base that morning and walked up to Readiness with my two giant packs because the taxi couldn't come on base so I had to walk with these giant packs, went up there and was like, "Hey, you guys have a checklist for me or something?" (laughs) Interspersed with the stories of their deployments and returns, many MMHP expressed surprise at their own readjustment experiences. Even knowing about deployment Stressors did not inoculate or prevent the MMHP from having adjustment challenges: I didn't think it would last as long as it did. And, yeah, I wasn't completely surprised, I had really good training on the deployment cycle. And of course I had taught
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classes and interacted with people for years before deploying and then during and after as well, I was surprised that knowing everything I did that it lasted as long and I think that was related to the physiological component of all that stimulus and arousal that you get when you're in a combat zone.
Coping With Postdeployment Issues MMHP had to cope with numerous challenges when returning from deployment, much like any other soldier, they approached this task from a variety of perspectives. For most respondents, there was an awareness that coping with postdeployment issues was a process and that the process required time. One key to successfully handling the challenges on returning home was to be patient with self and others, which could be challenging in its own right. Having the support from a spouse who understood the need for time to process and reintegrate was very helpful: My partner was also pretty good at not over-burdening me with car problems, and house problems, and whatever else right when I got back, and it helped get me back slowly rather than dumping it on me all at once. Another avenue to help cope with readjustment issues was religion. Many (46%) of the respondents indicated that they were people of faith. Their faith had helped sustain them during deployment and also provided a place of strength and support for them after they returned. If the MMHP was an active participant in a religious community before deployment, they took up a similar role when they returned. Physical exercise was also seen as a way of coping with Stressors both while deployed and upon return. Physical fitness is an important component of any soldier's life; 69% of respondents related how they engaged in more exercise while deployed as a means of finding some private time and relieving stress. Similar behaviors continued on their return home. One respondent described returning home from deployment on a Wednesday and running in an endurance relay race that Saturday. A final approach to coping with readjustment involved trying to stay connected to the deployed experience despite transitioning home. Strategies included keeping in contact with colleagues who remained deployed, seeking counsel from those who had returned earlier, or staying current with news about their area of deployment. Although this helped validate their deployment experience, it also reminded them of how difficult it was to share their experiences with those that had no frame of reference to understand what they had lived through, DISCUSSION As the results indicate, MMHP found challenges with the postdeployment experience in the areas of work and family. The MMHP are not immune to Stressors related to deployment
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and consideration needs to be given to how the postdeployment transition impacts the ability of the MMHP to function in a helper role. Only one of the 27 respondents (4%) sought professional mental health support, and it was unclear if that was for a diagnosis of PTSD or some other mental health issue. Certainly the experiences of the MMHP were not the same as that of the combat soldier. Fven with that recognition, it was noted that 81% of the respondents in this study recognized some degree of disruption in their lives, at home, at work, or at both, upon their return from deployment. The experience of vicarious trauma raises an issue for MMHP.'''' There is the possibility that such trauma may hinder the ability of MMHP to work effectively. The work of MMHP involves the healing of others. This requires the MMHP to be emotionally healthy, able to be empathetic, and have the capacity to care. The effects of this vicarious trauma on the capacity of MMHP for their work, although not the focus of this article, may be connected with their postdeployment experiences. This also raises the question of whether MMHP need a different type of transition after deployment. The standard leave for postdeployrnent soldiers tnay not allow the MMHP to "recharge" before again dealing with the emotional difficulties of others, leaving the MMHP operating at less than optimal capacity. Exploring this issue could be the focus of future research on postdeployment issues. It was clear frorn most respondents that they were prepared to experience some negative effects from being deployed. All mental health professions train their members to maintain a high level of self-awareness. Perhaps their professional training, combined with their military training, lead them to have a higher level of awareness of such experiences than other soldiers would have, and the negative experiences they reported rnay be a result of such heightened self-awareness. The length and frequency of deployment appear to have an effect on postdeployment experiences, with longer and more frequent deployments resulting in more severe mental health diagnoses.'^ After first deployment, in general, a larger number of those deployed showed higher levels of drug and alcohol use and psychosocial problems when cornpared to repeat deployers.'^ The length of deployments for MMHP was also much shorter than that of combat troops. The typical deployment for an MMHP was between 4 and 6 months; combat troops were often deployed for more than a year. The typical number of deployments was one for MMHP. MMHP, while operating in cotnbat zones and experiencing the same mortar and rocket attacks that other deployed soldiers experienced, were not combatants. Their unique role coupled with length of tours of duty tnay also factor into their awareness of their own experiences. MMHP found various ways to cope with the stresses of both being deployed and returning home. The choice of coping strategies were usually consistent across both dotnains; for example, if exercise was an important coping strategy before deploymetit, it was used to help cope during deploy-
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ment and when returning home. The most frequently mentioned coping approaches were exercise; maintaining faith and religious beliefs; and staying in touch with family, friends, and colleagues. The U.S. military has greatly improved its screening for mental health problems, including PTSD, in all pha.ses of deployment—predeployment, deployment, and postdeployment. Services are available for soldiers experiencing difficulties. The culture of the military remains one, however, where seeking such services could have negative consequences on one's career. The MMHP in this study sought counsel and support from their peers and friends rather than seeking mental health services. As soldiers, it is not unlikely that the MMHP also responded to the culture of the military and chose not to seek professional help. There is no way to accurately gauge the severity of the symptoms that were related during the interviews, although respondents indicated having adverse effects on work and family environments. Another possibility is that there adjustment difficulties didn't rise to the level of clinical severity and did not require professional services. It is recognized that this research is based on self-report. It was outside the scope of this study to formally assess respondents before and after deployment. Pre-existing conditions may have influenced the deployment experience. No attempts were made to verify the accuracy of information given by respondents. Additional limitations to this study include potential selection bias, the wide variety of settings in which the MMHP served, and the wide range of combat exposure they experienced. The interviews with the respondents provided minimal opportunity to infer the severity of either symptoms or the efficacy of coping strategies to deal with stress.
IMPLICATIONS FOR FUTURE RESEARCH This study of the postdeployment experiences of MMHP raises sorne additional questions. It is unclear if the training to help other soldiers deal with postdeployment challenges rnakes the deployed MMHP more aware of his or her own challenges when returning from deployment, or if their experiences are similar to that of all soldiers. It is unclear if the sense of purposelessness in their stateside work that seemed comrnon to returning MMHP is also found in other returning soldiers, especially combat soldiers or if it is indicative of emotional numbing from the deployed experience. Perhaps MMHP need a different type of postdeployment transition than other soldiers to regain the capacity to care for the emotional health of others. Further study on whether the length of deployment, the relative safety during deployrnent, and the frequency of deployment experienced by MMHP change their experience in substantive ways from that of other deployed soldiers is needed. This article did not attempt to identify if differences in deployrnent experiences and réintégration were connected at all to the sex of the MMHP. As there is a high number of MMHP female soldiers, there may be differences in how
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they experience deployment and cope with postdeployment transition. Further research in this area is needed. MMHP, often serving in forward bases next to combat troops, serve an important function in assisting the military to accomplish its mission. Their experiences, although unique, do not diminish their roles as soldiers. Their stories of their experiences during deployment are often inspirational and heroic, yet often unknown or ignored. REFERENCES 1. Hoge CW, Castro CA. Messer SC; Combat duty in Iraq and Afghanistan; mental health problems and barriers to care. N Engl J Med 2004; 35; 13-22. 2. Vasterling JJ, Proctor SP. Friedman MJ; PTSD symptom increases in Iraq-deployed soldiers; comparison with nondeployed soldiers and associations with baseline symptoms, deployment experiences, and postdeployment stress. J Trauma Stress 2010; 23(1); 41-51. 3. Smith TC. Wingard DL. Ryan MAK. Kritz-Silverstein D. Slymen DJ. Sallis JF; PTSD prevalence, associated exposures, and functional health outcomes in a large, population-based military cohort. Public Health Rep 2009; 124(1); 90-102 4. Eisen SV. Schultz MR, Vogt D, et al; Mental and physical health status and alcohol and drug use following return from deployment to Iraq or Afghanistan. Am J Pub Health 2012; 102(51); 566-73. 5. Asbury TE. Martin D; Military deployment and the spouse left behind. FamJ 2012; 20(1); 45-50. 6. Kieman M, Hill D. McManus F. Turner M; Management of mental illness by the British Army. Brit J Psychiatry 2003; 182; 337-41. 7. Harris J; History of Army social work. In; Social Work Practice in the Military. Edited by JG Daley. New York. Haworth Press. 1999.
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8. Jones E, Wessely S; "Forward psychiatry" in the military; its origins and effectiveness. J Trauma Stress 2003; 16(4); 411-9. 9. Moore BA. Reger GM; Clinician to frontline soldier; a look at the roles and challenges of Army clinical psychologists in Iraq. J Clinical Psych 2006; 62(3); 395-403. 10. Pischke PJ, Hallman CJ; Effectiveness of critical event debriefings during Operation Iraqi Freedon II. U.S. Army Med Dept J 2008; July-September. 18-23. 11. Applewhite L. Arincorayan D; Provider resilience; the challenge for behavioral health providers assigned to brigade combat teams. U.S. Army Med Dept J 2009; April-June; 24-30. 12. Linnerooth PJ. Mrdjenovich AJ. Moore BA; Professional burnout in clinical military psychologists; recommendations before, during, and after deployment. Prof Psych Res Pract 2011; 42(1); 87-93. 13. McCauley M, Liebling-Kalifani H, Hacker Hughes J; Military mental health professionals on operational deployment; an exploratory study. Community Ment Health J 2012; 48; 238-48. 14. Kolkow TT. Spira JL, Morse JS. Grieger TA; Post-traumatic stress disorder and depression in health care providers returning from deployment to Iraq and Afghanistan. Mil Med 2007; 172(5); 451-5. 15. Katz LS. Cojucar G. Davenport CT, Pedram C, Lindl C; PostDeployment Readjustment Inventory; reliability, validity and gender differences. Mil Psychol 2010; 22; 41-56. 16. Gibbons SW, Hickling EJ, Watts DD; Combat Stressors and posttraumatic stress in deployed military healthcare professionals; an integrative review. J Adv Nurs 2011; 68(1); 3-21. 17. Armed Forces Health Surveillance Center. Data between deployment and mental health incidents—Associations between repeated deployments to Iraq (OIF/OEF) and Afghanistan (OEF) and post-deployment illnesses and injuries, active component. U.S. Armed Forces, 2003-2010; Part II. Mental disorders by gender, age group, military occupation, and "dwell times" prior to repeat (second through fifth) deployments. Med Surv Monthly Rep 2011; 18(9); 2-19.
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