© 2013 American Orthopsychiatric Association DOI: 10.1111/ajop.12054

American Journal of Orthopsychiatry 2013, Vol. 83, No. 4, 550–558

The Challenges of Reintegration for Service Members and Their Families Steven J. Danish and Bradley J. Antonides Virginia Commonwealth University

The ongoing wars in Afghanistan and Iraq have posed a number of reintegration challenges to service members. Much of the research focuses on those service members experiencing psychological problems and being treated at the VA. In this article, we contend that much of the distress service members experience occurs following deployment and is a consequence of the difficulties encountered during their efforts to successfully reintegrate into their families and communities. We propose a new conceptual framework for intervening in this reintegration distress that is psycho-educational in nature as well as a new delivery model for providing such services. An example of this new intervention framework is presented. to deployment and at two follow-ups spaced 3 years apart. Each analysis revealed remarkably similar posttraumatic stress trajectories across time. The level of worsening chronic posttraumatic stress disorder (PTSD) was 6.7% for single deployers and 4.5% for multiple deployers. Over 80% of the sample had a stable trajectory of low posttraumatic stress level from pre- to postdeployment or exhibited resilience. This is true despite the media’s efforts to make PTSD a household term. What accounts for the differences in PTSD rates? Most previous studies have been carried out with convenience samples, many with service members being seen at Veteran Administration Medical Centers (VAMC), which may introduce sampling or reporting bias and limit generalizability. Moreover, if cross-sectional designs are used, it is impossible to distinguish one’s reaction to being in a combat environment from preexisting conditions (Bonanno et al., 2012). What does happen to service members when they return? Data collected by the California National Guard provide one window into this group. The Guard kept track of the total number of mental health contacts from 2006 through May 2010 in four separate categories: self-initiated, provider-initiated, requested by the Commander, and suggested by a peer (California National Guard, 2010). Of the almost 14,000 contacts, less than 25% were for PTSD symptoms, a little over 10% were for substance abuse issues, almost 40% were for marriage and family issues, and about 20% were for job or finance issues (California National Guard, 2010). So it is possible that as many as 60% of these Guard members’ difficulties were related to the reintegration process itself rather than the effects of being in combat. These numbers are only for one state and do not include service members in the active forces. Although these results represent just one perspective on the issue, they are instructive. In this article, we concentrate on the distress that occurs following deployment and suggest a new conceptual framework and delivery process for coping with this distress. One of the most difficult problems facing those who work with service members is how to distinguish service members whose problems

Nobody can cross this river without getting wet. Paul Rieckhoff, Executive Director, Iraq and Afghanistan Veterans of America

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pproximately 2.2 million service members have served in either Afghanistan (OEF-Operation Enduring Freedom), Iraq (OIF-Operation Iraqi Freedom), or in Operation New Dawn, with 800,000 having served more than once (Tan, 2009). The cost of these wars, particularly the health care costs, is considerably higher than in previous wars, in part, because, in contrast to Vietnam, for example, where the ratio was 2.6 wounded service members per fatality, in Iraq, seven of eight wounded service members survive (Department of Veterans Affairs, 2006). By health care costs, we are referring to both physical and mental health injuries. Bilmes (2007) suggested that the long-term costs of providing medical care and disability benefits to those who served in Iraq and Afghanistan would be from $350 to $700 billion, depending on the length of deployment for our troops, the speed with which they claim disability benefits, and the growth rate of benefits and health care inflation. Given the forthcoming cuts in the military budget, health care costs have increasingly become an issue that is being examined by Congress. All service members return changed, but most return uninjured physically and without a mental health problem that requires psychotherapy. Bonanno et al. (2012) analyzed a sample of 77,047 U.S. military service members in all branches, including active duty, Reserve, and National Guard, who deployed once (n = 3,393) or multiple times (n = 4,394). Selfreported symptoms of posttraumatic stress were obtained prior

The authors would like to acknowledge the help and comments of Col. Thomas Morgan and Drs. Tanya Forneris, Treven Pickett, Suzette Chopin, Kathryn Conley, and Bill Nash. Correspondence concerning this article should be addressed to Steven J. Danish, Virginia Commonwealth University, PO Box 842018, 800 W. Franklin Street, Williams House, Richmond, VA 23284-2018. Electronic mail may be sent to [email protected]. 550

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are the result of deployment and combat and who cannot successfully reintegrate from those who return home with combat stress but without serious problems requiring psychological help, but who have difficulty reintegrating because of the transition to civilian life. The problems of these two groups are different, and the appropriate intervention may be different as well. For the most part, the focus to date has been on those service members whose problems occur during deployment; however, recently researchers have begun to attend to those service members experiencing reintegration difficulties (Sayer et al., 2010). The Armed Services too have recognized the need to attend to those experiencing reintegration difficulties. The Marines have developed the Warrior Transition program, and the Army has developed Comprehensive Soldier Fitness (Seligman & Matthews, 2011) and Battlemind. However, there is little or no published research on the effectiveness of these programs. Despite these more recent efforts, it is our belief that service members experiencing reintegration difficulties may represent the untreated casualties of the longest U.S. war in history.

The Problems of Help Seeking in the Military Culture To better understand the failure to attend to service members who return from deployment and then experience difficulties, it is useful to begin with the problems of help seeking experienced by all service members. These two wars put an unprecedented strain on the health care system for veterans. As a result, the VAMCs were unprepared for the number of service members needing health care services. There were an insufficient number of mental health providers, and many returning service members were unable to receive help at the VA when they returned. As a consequence, between 2005 and 2008, the VA funded more than 800 new psychology positions, a 36% increase (De Angelis, 2008), and by April 1, 2010, had doubled the number of psychologists to 3,361, about 5% of the licensed psychologists in the United States. Since the early influx of psychologists into the VA system, there have been additional efforts to increase the number of providers. Despite these efforts, many service members, their families, and the public continue to believe that the VA is poorly equipped to adequately treat all service members needing help. The RAND report (Tanielian & Jaycox, 2008) identified another big issue for all service members—stigma. Stigma has been defined as “an attribute that is deeply discrediting” (Goffman, 1963, p. 13). It is seen as a mark of disgrace on one’s reputation and may occur at all stages of an illness, from help seeking to treatment and discharge (Byrne, 2001). It has been suggested that stigma can be more devastating, life limiting, and longer lasting than the primary illness itself (Schulze, Richter-Werling, Matschinger, & Angermeyer, 2003). A number of researchers have studied the effects of stigma on service members’ willingness to seek help. For example, Hoge et al. (2004) surveyed some 6,000 soldiers and Marines, who had served in either Afghanistan or Iraq, for major depression, generalized anxiety, or PTSD. Of those who met the criteria for these psychological injuries, only 38%–45% indicated an interest in receiving help and between 23% and 40% actually received mental health care. Furthermore, for those who met

the criteria for these diagnoses, concern about possible stigmatization and other barriers to seeking mental health care was twice as likely as for those who did not meet the criteria. Tanielian and Jaycox (2008) reported that as of May 2008, although over 850,000 OIF and OEF service members were eligible for VA services, only about 40% of those eligible had sought care or other VA entitlements, including the opportunity to receive Education and Vocational Training. More specifically, only about half of returning service members reporting symptoms of PTSD or major depression sought treatment. This RAND Report concluded that many service members failed to seek treatment because they feared that the stigma of seeking help would harm their careers and because they were unsure that they would receive adequate treatment. Warner et al. (2011) most recently conducted a study of 3,500 Army soldiers in an infantry brigade combat team going through their mandatory Post-Deployment Health Assessment (PDHA). Of the total being assessed, 2,500 were invited to complete an additional anonymous survey, and 1,712 participated (response rate, 68.5%). Reports of depression, PTSD, suicidal ideation, and interest in receiving care were 2–4 times greater on the anonymous survey compared with the traditional PDHA. Overall, 20.3% of soldiers who screened positive for depression or PTSD reported that they were uncomfortable reporting their answers honestly on the routine postdeployment screening. Over the years, the Department of Defense (DoD) has taken several steps to try to improve the stigma situation: (a) They have revised their security clearance questionnaire so that people who seek mental health care for combat-related reasons do not have to report it, (b) two Army generals stepped forward to share their struggles with PTSD, and (c) a $2.7 million servicewide antistigma campaign was launched, where ordinary service members tell their stories of seeking help (Dingfelder, 2009). Trying to change stigma-related beliefs has been, and continues to be, extremely difficult because the beliefs are so ingrained in our civilian culture, let alone in the military culture. The unwillingness to seek help is not just related to a fear of stigma and career harm; military culture also plays an important part. The military has its own culture that sets it apart from the larger society it serves (Danish & Antonides, 2009). The culture of Army Strong and Semper Fidelis (for Marines) discourages the appearance of needing help and may prevent help seeking, especially if help will delay or interfere with service members’ returning to the wars and being able to fight alongside their buddies.

Transitioning to Home Although lack of confidence in the VA and the fear of stigma are major reasons for the decision not to seek mental health services, there are other possible explanations. For many returning service members, their stress is at preclinical levels and does not threaten their capacity to function effectively in theater. However, they have difficulty readjusting to being home and reintegrating into their families, workplaces, and communities. Part of the readjustment difficulty is that during predeployment training, they learned a mindset for surviving in a war zone. Now some of what they were taught is not helpful.

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For example, (a) the appropriate need to account for one’s subordinates (know their location at all times) in the war zone may be seen as controlling when at home, and (b) the appropriate aggressiveness needed in the war zone may be inappropriate at home, especially when families expects a different, calmer interaction style. Family members may misinterpret this behavior as PTSD when really this level of intensity is what works in the combat zone. (c) The appropriate lack of emotion may be seen as anger or detachment at home, and (d) combat driving methods in the war zone may be seen as dangerous and aggressive at home (Danish, 2013). Being at home requires an unlearning process to successfully acclimate. Service members experiencing a difficult transition may feel misunderstood and separate from their families and communities, and these feelings may exacerbate their reintegration difficulties. The result may lead to unhealthy and illegal behaviors.

Expanding Our Understanding of Postdeployment Distress There is often a lack of understanding about the diverse stressors associated with the deployment cycle, not all of which are a result of violent enemy actions. The intensity, frequency, and duration of stressful combat, combined with the life history and personality differences among service members, are likely to produce a varied and unpredictable array of reactions to coming home. There are a number of accounts in books and movies of the experiences of soldiers in combat so that readers and viewers can better understand what this experience is like. Unfortunately, less is known about the experience of being home. Aidan Hartley was a war correspondent living in Kenya but covering the war in Somalia. When he came home to Nairobi, he wrote in his book, The Zanzibar Chest: I fell into a dark mood at home. I decided all I wanted was to be with Lizzie, and I felt an immense distance from those who did not share our world. Time spent with them was embarrassing; we had so little to talk about. Yet, when Lizzie and I were together I was short-tempered, “It’s as if you only thrive when you have discord around you,” she said. “As if you actually enjoy conflict.” I simply couldn’t get used to normal domestic life. As one correspondent said, there was no common ground between Somalia and coming home to someone complaining about the toothpaste being squeezed in the middle of the tube (Hartley, 2003, p. 299).

Later, he wrote: Looking back, the truth is that we often had the best of times. … Having lived for the moment, we never considered that we might end up living alone in an apartment with the utility bills piling up. Re-entry taught me a new sort of fear that was slow and dull rather than quick and thrilling. … The hardest part of reentry to a humdrum life was not recovering from the bad stuff. It was missing the good times, the friendship, intensity, fear, sense of purpose, the sheer exotic escapism of it all (Hartley, 2003, p. 401).

Paul Bartone suggested in his presidential address to Division 19 at the 2004 meeting of the American Psychological Associa-

tion that more than anything, “Soldiers have a tremendous need to see their work as meaningful and important” (2005, p. 319). Bartone was addressing his experiences that the vast majority of U.S. troops seek to do the right thing and want to believe that their endeavors are worthwhile and valued. Maddi’s (1967) description of “existential neurosis” sheds light on the importance of having meaning in one’s life and the potentially damaging influence when one has questions about the significance of what one is doing. In service members, Bartone (2005) refers to this feeling as existential boredom, a growing sense that one’s efforts and sacrifices are unimportant and unappreciated. Returning home may elicit this sense of boredom, ambiguity, isolation, powerlessness, and lack of meaning in service members’ lives. If service members feel misunderstood when they return home, they may become isolated from those around them, including from friends and family members who observe the changes in them and see the struggles they are experiencing but do not know how to help or what to do. If this situation persists over an extended period of time, it may have a pervasive and unpredictable effect on an individual. The ultimate outcome may be the beginning of the downward slide of the service member toward substance abuse, homelessness, and even suicide. Perry and Jessor (1985) referred to the result of stressors that occur during transitions such as these as health-compromising behaviors (behaviors that threaten the well-being of an individual resulting in inappropriate use of substances or physical risk-taking behavior such as speeding and reckless driving). See Table 1 for a description of the changes that may take place upon returning home from a deployment that may lead to health-compromising behaviors. However, Perry and Jessor (1985) also discuss that transitions may also result in health-enhancing behaviors (behaviors that tend to improve an individual’s well-being). As a result of their combat experiences, many service members may come home with a changed sense of self—a new sense of confidence and self-efficacy that results from the way they have responded to the challenges they have faced (e.g., see Greene, 2009; Kim, 2010). Dozier (2008) provides another example. When she was a journalist working in Iraq, she was severely injured by a car bomb. She describes the recovery experience as making her stronger and wiser and the difficulty she went through to convince others at home to let her return to the war zone. She also talked about how many service members come home with new skills as a result of their war zone experiences and have trouble explaining this new-found knowledge and skills to potential employers. Unfortunately, for too many of today’s service members, upon returning home, the feeling of accomplishment and satisfaction may not disappear, but the context that supported this meaning (combat) most likely has disappeared. Many of the service members are proud of their accomplishments and are considered by family and friends at home as heroes. However, adjusting to what has been called the new normal has the potential for reducing some of the self-respect and pride they feel. How best can we understand how service members view their experiences? Joseph Campbell, a 20th century mythologist,

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Table 1. Potential Postdeployment Changes Social or interpersonal Changes in relationships with family and friends from home (e.g., being misunderstood by them) Changes in job-related relationships and responsibilities Changes in service-related relationships Feeling abandoned by the military

Personal

Emotional or cognitive

Changes in career-related goals

Changes in self-esteem and self-efficacy

Changes in sense of purpose and meaning Changes in belief system Changes in sense of belonging

Changes in locus of control Changes in emotional control Changes in cognitive processing Feeling unsafe and helpless

believed that myth provided a road map or cultural framework for society to understand how to cope with life’s passages. In The Hero with a Thousand Faces (1949), he described what it meant to be a hero and to seek conquests. He defined a hero as someone who has given his or her life to something bigger than oneself. He then delineated the three phases of all great mythical life journeys: separation, initiation, and return. It is not surprising that these phases parallel the real-life experiences of service members going to war and the difficulties they have in returning from combat. Campbell’s description is especially apt because, in these two wars, all the service members are volunteers, and, as a result, they are often seen as engaging in a heroic act. According to Campbell (1949), the separation phase is characterized by an awakening from the present world to pursue a higher calling. However, this quest is not without danger and requires guidance and help. Once heroes cross the threshold (begin actual combat), they are changed. During the initiation phase, they encounter many tests or trials that help them achieve a level of self-reliance and selflessness. They are bestowed with a boon or gift to share upon return. The return phase is especially difficult, and, as a result, they may not want to return, because those in the former world may not grasp what they have learned. They may want to stay in the new life and avoid the burdens of the past life. Just as heroes need guidance during the quest, assistance is needed in the return to everyday life, especially if they have been wounded or weakened. The real accomplishment of a hero is to be able to retain the wisdom gained during the quest and integrate this wisdom into everyday life as well as share it with others. This task requires learning to live in the moment, neither anticipating the future nor living in the past, or as conceptualized by Deci and Ryan (1985), true rather than contingent self-esteem and by Kernis (2003a, 2003b) as self-esteem stability. This depiction by Campbell quite accurately portrays what many service members experience during the deployment cycle and the difficulties they encounter in returning safely and being strong during their reintegration. For those who struggle with identity issues, maintaining the identity as a combat veteran beyond the combat environment provides them with an opportunity to hold on to their status as a hero as they face living with a new and perhaps incongruent or undesirable identity.

Physical Changes in risk-taking behavior (e.g., aggressive driving) Changes in substance use (e.g., unlimited access to alcohol) Changes in physical activity levels Changes in sleep behavior

Spirituality Having difficulty making sense of what you did in combat Feeling guilty

Having conflicting values Questioning your religious beliefs

Changes in diet and nutrition habits

Self-esteem may be maintained, but it is an unstable system with diminishing returns over time. The boon, which may be the amplified awareness of death, or in theoretical terms, mortality salience (Pyszczynski, Greenberg, Solomon, Arndt, & Schimel, 2004), is often too difficult to articulate, awkwardly received, and painfully unappreciated. Attempts to bestow this gift on those who misunderstand what is being offered often increase the perception of separation between the service member and a grateful, yet inadequately responsive, society. It is rejection based not in malice, but in naivete and cultural differences. It is rejection nevertheless, and, so, it becomes the service member’s burden to integrate this awareness into a new identity. This new identity may be especially confusing for younger service members. A 2005 report by the Army Human Resources Department, responsible for compiling demographic data, identified 46% of the then-current active force as being between the ages of 17 and 24 and 65% were 29 years old or younger (Office of Army Demographics, 2009). From a developmental perspective, some researchers believe that this age group (17–29) is a distinct stage called emerging adulthood that exists between late adolescence and early adulthood (Arnett, 2000). Arnett (2002) contends that the industrialization of Western society has resulted in an expansion of adolescence, causing a new stage or an in-between stage of development. Such a stage did not exist for service members who fought in WW II. As noted by many, but initially by Erikson (1956) and later by Marcia (1966), the key developmental issues to be resolved by individuals in late adolescence, and now in this new stage, are identity development and social or interpersonal integration (Erikson, 1956, 1980). If a proportion of the distress experienced by returning service members is attributable to identity confusion resulting from the inability to successfully transition from one environment to another, it may be necessary to consider an alternative framework or perspective for understanding and helping these service members. One such framework is a life-span developmental perspective (Baltes, Reese, & Lipsett, 1980; Danish & D’Augelli, 1983; Ford, 1987). What we are proposing in this next section is a new conceptual framework for what services are needed and a new service delivery model for service members and their families experiencing reintegration difficulties.

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A Life Skills Approach to Facilitating Reintegration The Life Development Intervention (LDI) Framework we are proposing is psychoeducational in nature and focuses on teaching the necessary skills to be successful in the different domains in which one lives. It differs significantly from the more medically oriented framework that is more prevalent in the VA. The two models are contrasted in Figure 1. In the LDI framework, it is assumed that many of the difficulties experienced by service members during postdeployment, and perhaps even some of the distress experienced at other times in the deployment cycle, are not a result of psychopathology or psychological injuries. Instead, the distress experienced during reintegration is likely the result of the biological, psychological, and social changes that service members experience upon returning home. For example, service members returning home from deployment experience a biological change from hyperarousal (probably the result of some combination of epinephrine, serotonin, and dopamine) to a more relaxed state; a reference change from a warrior to a spouse, parent, son or daughter, or community member; a relocation change from a combat zone to a community; and a social change from being part of a military family to a civilian family (Danish & Antonides, 2009). Changes resulting from life situations such as these for which one is not totally prepared are called critical life events. Some have referred to these situations as crises. Individuals’ reaction to a critical life event may result in stress and impaired functioning, little or no change in life circumstances, or may serve as a catalyst for growth. Factors that influence these reactions depend on the resources that service members have prior to the event, their level of preparation for the event, and their history in dealing with similar events. For example, while being unexpectedly deployed may be seen as a crisis, depending on the service members’ military occupational specialty (MOS), they may learn new skills that enable them to get a better job following deployment than they had prior to deployment. So while coming home from deployment may be difficult for many service members, the process may not be experienced as a problem requiring psychological help. The LDI intervention is a goal-setting approach designed to teach one how to achieve one’s dreams and goals. A goal-setting approach is a good fit for what returning service members and their families face in that its emphasis is on self-directed change, being goal-directed, and focusing on the future. Deci and Ryan (2000) identify autonomy, competence, and relatedness as the three basic psychological needs. Working on personal and family-developed

Figure 1. The difference between a medically oriented and psychoeducational framework.

goals together represents a clear example of meeting these needs. The process of learning to set and attain goals involves the acquisition of life skills (Danish & Antonides, 2009; Danish & Forneris, 2008). By life skills, we are referring to those skills that enable individuals to succeed in the different environments in which they live, be it at war, at home, or at work. Life skills can be behavioral (communicating effectively in these different environments), cognitive (making effective decisions in these different environments), interpersonal (taking and giving directions in these different environments), or intrapersonal (setting goals for these different environments). By describing life skills as skills, we are emphasizing that the process of learning life skills parallels the learning of any skill, whether it is shooting a weapon or driving a car. Identifying the failure to reach a goal as a lack of skill means the service member has a skill deficiency as opposed to a personal (characterological) deficiency and that the process of overcoming the deficiency involves teaching as opposed to psychotherapy. As such, it is consistent with the manner in which service members learn many of the tasks that they are required to perform. It is also consistent with the recovery-oriented approach adopted by the VA and DoD. To learn more about Life Development Intervention and life skills, the reader is referred to Danish and Forneris (2008) and Hodge, Danish, and Martin (2012).

A Community-Based Delivery System What we are describing is more than a different conceptual framework; it is also a different delivery system, closely related to a public health model. One critical characteristic of this model is the need to be proactive. It is important to identify groups in the community that can assist the reintegration process and actively seek their involvement rather than waiting for the service member to ask for help (Rappaport, 1977). It may require psychologists to learn a new set of skills, the indirect provision of services, such as program development and evaluation, consultation, training, supervision, and administration (Danish, 1974). For example, teachers and school counselors may not understand what effect deployment has on children. Training can be provided to schools and school personnel to help them respond to the needs of these children (Cohen, Wood, & Danish, 2009). Providers who work with returning service members must be taught about military culture and the impact deployment has on service members and their families. Their experiences during deployment are like no other experience that the rest of us have had. A second important element in the delivery of services is that we recognize that the service member is at the center of the circle surrounded by a community, perhaps an employer, friends, and most of all, a family. The family, be it the family of origin or a spouse and their children or even the service member’s girlfriend or boyfriend, are really the key to reintegration. Therefore, it is essential that the family be part of any reintegration efforts with the service member. For example, family members should be included in the planning of career goals. Families also need to be knowledgeable and prepared about the changes that veteran family members undergo when they return from deployment and be sensitive to the changes

CHALLENGES OF REINTEGRATION

that they have experienced in their lives as a result of the deployment. Integrating family members into the services provided to service members has been one of the big initiatives pushed throughout DoD and the VA. Readers wanting to know more about the needs of military families are encouraged to visit the Military Family Research Institute website, www. mfri.purdue.edu at Purdue University. A third facet of the delivery system is the use of technology. Almost 40% of the returning OEF and OIF service members who are enrolled in the VA Health Care System live in rural areas (Department of Veterans Affairs, 2007). If we are to serve their needs as well as those service members experiencing reintegration difficulties, more creative ways must be found to provide them with the needed services. One approach is through telehealth, using technology such as the telephone, Skype, or videoconferencing.

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Adopting a life skills intervention model and a communitybased delivery model is in many ways a radical departure from how veterans have received services to date, and we are just starting to review the effectiveness of such an approach. However, the potential benefits of adopting such an approach are clear: (a) More service members and their families can be reached this way with less fear of stigma; (b) if this approach proves effective, more resources can be directed toward those services members who can benefit from more intensive interventions; (c) the cost of caring for those who have served may be reduced, which is especially important when there are numerous calls to reduce the military budget; and (d) this system may have utility for civilian health care as well. It is the answer to these questions that serves as our initial evaluation framework.

Implications for the Future Examples of the Life Skills Approach To date, we have developed several technology-based interventions that are psychoeducational, skill-based, self-directed, manualized interventions online and that are designed to be taught either via the web with toll-free access for issues and questions, virtually through a chat room led by trained peer veterans, or in small groups led by a trained peer. The programs can be completed by the individual at his or her own pace. Prior to developing the program, the first author decided, after going through the programs personally with several veterans and a family member, that the intervention had considerable potential. He decided to let veterans and families use the material selectively. After providing the written programs to about 20 veterans or family members and finding generally positive responses, we decided that the programs should be more accessible and technologically up to date. We did not want veterans or families feeling that a psychologist was evaluating their answers, as there is often a basic distrust of psychologists by military members. We also wanted to have access to how effective the program was for them. In other words, we wanted to be able to research the program’s effectiveness. Given these parameters, we proceeded to develop essentially E-workshops. The first E-workshop, FREE 4 Vets Family, Relationships, Education, Employment (Danish, 2012), is for service members and can be accessed on the web at www.lifeskills4you.com. Veterans and others interested in either viewing or completing the intervention are able to register as users. Names are not required, but registrants are asked to provide their age, sex, marital status, branch of service, MOS, whether they have been deployed, and if so, when and how many times, whether they have received VA services, whether they are currently employed and if so, full or part-time, whether they are currently students, and if so, full or part-time, and their e-mail. Requesting this information assists us in evaluating the program’s effectiveness. Asking for e-mail addresses and a user-created password at registration allows the individuals to log in, so that they can return to their current place in the program via automatic bookmarking. Participants may also access the privacy policy that is posted. See Table 2 for a summary of the FREE 4 Vets workshop content and Figure 2 for an image of the cover page.

It is important to remember that there have been over two million service members deployed in OEF and OIF, and, although they have returned changed, the changes are not necessarily for the worse. We must also remember when we read our psychology journals about the effects of the war on service members and their families that we are generally reading about service members who have incurred psychological and physical injuries and are being treated for their injuries. We are not reading about the effects of the deployment experience on service member’s autonomy, competence, and relatedness, the basic psychological needs as defined by Deci and Ryan (2000). If we are to take a larger perspective on the effect of deployment, and especially reintegration, on service members and their families who have served in war, we must also look beyond those who have been injured or negatively affected. How many service members have overcome the stress of reintegration and have moved forward in their lives either to further service in the military or to a civilian life? How many families have become more independent and self-sustaining during their family member’s deployment? What does this mean for our society and our work as psychologists? The work of Elder (1974), who has studied children who grew up in the Great Depression (1929–1939), is instructive in this regard. He studied two cohorts from California: 167 children born in 1920–1921 in Oakland and 214 children born in Berkeley in 1928–1929. Both cohorts came into maturity during World War II and were followed longitudinally through the 1960s. In both cohorts, despite the expectations of a disadvantaged life, there was clear evidence of resilience. Elder reported that one of the major reasons for this resilience was being in the military. Most of the males in the two cohorts were mobilized into the armed forces. Military service became the key transition because it frequently enhanced the education of men and led to stable marriages. Elder identified three aspects of the military experience that contributed to this resilience: separation from family, which resulted in increased social independence and expanded social relationships; a break from expected career decisions; and increased understanding of self and others. Related to these three aspects was the opportunity that came with the GI Bill. How relevant are these findings for those who have served in Afghanistan and Iraq?

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Table 2. Summary of FREE4 Vets Workshops Workshop 1

Workshop 2

Workshop 3

Workshop 4

Workshop 5

Workshop 6

Workshop 7

Workshop 8

Workshop 9

Workshop 10

Workshop 11 Workshop 12

Workshop 13

Workshop 14 Workshop 15

Workshop 16

Workshop 17

How Am I Doing?—Service members learn about different physical and psychological injuries, including combat stress, posttraumatic stress disorder (PTSD), and TBI. They learn how to self-assess whether they have any of these injuries and the skills needed to overcome these injuries. Returning Home: An Overview—Service members assess whether they are different postdeployment than they were prior to deployment, and if so, how. They consider these potential differences in a number of different areas, including family, friends, physical and mental health, hobbies and sports, work, finances, education, spirituality, and other, and what skills they will need to learn to deal with these changes effectively. How We Think Can Cause Stress—Service members first learn about the relationship between arousal or stress and performance; then, they learn the ABCs of stress—how confused thinking can lead to stress. In other words, how negative thoughts can lead to ineffective behaviors. Finally, they practice changing the way they talk to themselves so that their thoughts do not lead to stress. Dealing with Stress You Cannot Control—Sometimes, service members have stress as a result of their situation (such as an injury) that they cannot control. Five methods for controlling such stress are taught—Exercise, Deep Breathing, Relaxation, Using a Mantra, and Tracking Your Progress. These methods can be helpful regardless of the source of stress. Practice strategies for these methods are also taught. Developing Better Sleep Habits—Service members are taught to keep a diary related to sleep. They then learn about sleep hygiene and a number of suggestions for improving their sleep. Finally, following practicing good sleep habits for 2 weeks, they are asked to assess their progress. Dealing with Interpersonal or Relationship Stress—Service members are taught how to improve communication skills. They learn that their deployment has affected how they communicate and relate to important others in their lives and that working on improving relationships requires commitment, patience, and time. Finally, they are taught a step-by-step process for improving communication skills. Putting the Past Behind You and Moving Forward—Service members review how they changed as a result of deployment, how and if the first set of skills taught in this program has helped them and what it means to move forward. They are then asked to think how important the areas identified in Workshop 2—family, friends, physical and mental health, hobbies and sports, work, finances, education, spirituality—are for their future and to identify their dreams (their best possible future) in at least two of those areas. Turning Dreams into Goals—Service members learn the difference between dreams and goals and how to turn a dream into a goal. They also learn the four characteristics of a reachable goal (positively stated, specific, important to the goal setter, and under the goal setter’s control) and practice setting goals that meet the four characteristics of a reachable goal. Going for Your Goal—Service members apply the four characteristics of a reachable goal to their own goals and set a 6-week goal. They also learn the importance of developing plans to reach goals (called a Goal Ladder) and make plans to reach the goal they have set. Making a ladder involves placing the goal at the top of the ladder and identifying 10 steps to reach the goal. Identifying and Overcoming Roadblocks to Reaching Goals—Service members learn how different roadblocks (e.g., lack of knowledge, skills, social support, and risk-taking ability) can prevent them from reaching their goals. They identify possible roadblocks and how to overcome them. Making Effective Decisions—Service members learn and practice a problem-solving strategy called STAR (Stop, Think, Anticipate, and Respond). Seeking Help From Others—Service members learn the importance of seeking social support when working on their dreams and goals. They identify people in their lives, between 5 and 10 individuals, who can provide doing or caring help to assist them in achieving their goals. Taking Risks to Reach Your Goal—Service members learn that risks equal the benefits minus the costs. To take a risk, the benefits must be greater than the costs. They learn a game to assess the benefits and costs and how to maximize the likelihood of taking a risk. Reaching for Your Dream and Assessing Your Progress—Service members learn the meaning of resilience and assess how willing they are to pursue their dreams and goals, and how likely it is that they will be successful in reaching their best possible dream. Matching a Career or Job to You—Service members will work toward their job or career plan for the future. They will identify what kinds of work they enjoy and do well, delineate their work values, seek to identify their best possible career, and understand what they need to do to pursue it. Learning About and Applying Transferable Skills—Service members identify what skills they have, where and how they learned them, and how they can transfer them to the work world. They then determine how they can communicate the skill to an employer during a job interview. How to Find the Career or Job that Best Fits You—Service members develop a personal profile, a career exploration plan, consider the options to pursue their plan, and develop a resume.

Taking care of our service members and families is first and foremost our duty, as they are protecting our freedoms that we so proudly cherish. However, there is another important reason to help these men and women and their families rebound and rise above what they have endured. Just as Elder (1974) has written about the value that military service has had for those who served during World War II, Brokaw (2004) has written about these same men and women as the greatest generation

our nation has ever produced. According to Brokaw and other historians, members of this generation had a common purpose and common values—duty, honor, courage, service, love of family and country, and, above all, belief in, and responsibility for, themselves. With the GI Bill authorized in 1944, some 8 million World War II veterans received assistance to attend college. The result was monumental advances in science, literature, art, and industry as well as economic prosperity.

CHALLENGES OF REINTEGRATION

Figure 2. Cover page for FREE 4 Vets.

As those WWII veterans reach the twilight of their lives, we are in need of a new “greatest generation” to move us forward. We believe that generation is those who have served or are now serving in Iraq and Afghanistan. The parallels are eerily similar between these service members and those who served in WWII. In contrast to the Vietnam War, we are celebrating these warriors’ service regardless of our feelings about the war. Our country is experiencing serious economic problems somewhat like the Great Depression. The Congress passed a new GI Bill in 2008 that paves the way for these men and women to attend college and graduate school. Our country is in need of some new energy and new ideas to rescue us from what has been called a crisis. The future may depend on these service members and their families, and it is our task not only to help them reintegrate successfully but to give them the skills and confidence to become the next greatest generation. Keywords: combat veterans; wounded U.S. service members; military families; combat stress; posttraumatic stress disorder; deployment; military culture; reintegration; Veterans Administration

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The challenges of reintegration for service members and their families.

The ongoing wars in Afghanistan and Iraq have posed a number of reintegration challenges to service members. Much of the research focuses on those ser...
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