Journal of Loss and Trauma, 16160–179, 2011 Copyright # Taylor .docx

Journal of Loss and Trauma, 16:160–179, 2011
Copyright # Taylor & Francis Group, LLC
ISSN: 1532-5024 print=1532-5032 online
DOI: 10.1080/15325024.2010.519281
PAGE 160
When Veterans Return: The Role of Community in
Reintegration
ANNE DEMERS
Health Science Department, San Jose State University, San
Jose, California, USA
Experiences of Iraq and Afghanistan war veterans were explored
to understand the challenges of reintegrating into civilian life
and the impact on mental health. Respondents completed
preliminary electronic surveys and participated in one of six
focus groups. High levels of distress exist among veterans who
are caught between military and civilian cultures, feeling
alienated from family and friends, and experiencing a crisis of
identity. Narrative is identified as a means of resolution.
Recommendations include development of social support and
transition groups; military cultural competence training for
clinicians, social workers, and college counselors; and further
research to identify paths to successful reintegration into
society.
War is widely acknowledged as a public health issue, and there
is a growing body of literature documenting the negative health
effects of war on military personnel who have served in either
the Iraq or Afghanistan wars. According to the Department of
Defense (2010), over 5,500 military service members have died
and approximately 38,650 have been physically wounded since
March 19, 2003. Tanielian and Jaycox (2008) report that 31% of
veterans overall have posttraumatic stress disorder (PTSD), and
combat experience itself is related to increased risk for anxiety,
depression, and anger symptomology. Suicides among troops

have been well-publicized, and soldiers without comorbid
diagnoses report high levels of stress and the use of alcohol as a
coping mechanism (Miles, 2004). Additionally, several studies
(Cascardi & Vivian, 1995; Gelles & Cornell, 1985; Riggs,
Caulfield, & Street,
Received 16 April 2010; accepted 10 July 2010. Address
correspondence to Anne Demers, Assistant Professor and MPH
Fieldwork Coordinator, Health Science Department, San Jose
State University, 1 Washington Square, San Jose, CA 95192-
0052, USA. E-mail: [email protected]
PAGE 161
2000; Seltzer & Kalmuss, 1988; Strauss, 1990) have found that
stress brought about by economic strains, chronic debt, and
income shortfalls increases the likelihood of engaging in
interpersonal violence upon return from deployment. These
stressors are all common to the challenges of readjustment for
veterans. Research on veterans’ readjustment has focused
primarily on psychosocial adjustment within the context of
PTSD (King, King, Fairbank, Keane, & Adams, 1998; Koenen,
Stellman, Stellman, & Sommer, 2003; Mazeo, Beckham,
Witvliet, Feldman, & Shivy, 2002), adult antisocial behavior
(Barrett et al., 1996), and physical injury (Resnik & Allen,
2007; Resnik, Plow, & Jette, 2009), and social support appears
to act as either a protective factor against developing PTSD
(Brewin, Andrews, & Valentine, 2000; Pietrzak, Johnson,
Goldstein, Malley, & Southwick, 2009; Westwood, McLean,
Cave, Borgen, & Slakov, 2010) or a moderating factor against
PTSD symptoms (Barrett & Mizes, 1988; Schnurr, Lunney, &
Sengupta, 2004). Fifty years after reintegration, World War II
veterans identified social support from comrades, wives, and
family members as an important lifelong coping strategy (Hunt
& Robbins, 2001). The literature documents the mental and
physical outcomes of deploying to war, and there is a body of
work that addresses psychosocial adjustment to combat
experiences; however, there are few qualitative studies, and
there is a paucity of research examining current soldiers’ and

veterans’ lived experiences of returning home and transitioning
into civilian life. This qualitative study sought to uncover these
experiences in veterans’ own words.
LITERATURE REVIEW
Unlike quantitative research in which a complete literature
review is conducted prior to implementing the study, the
relevant literature for qualitative research emerges during data
analysis. Identity and the role of military culture in the
formation of identity emerged as cross-cutting themes during
the analysis process; hence, these topics formed the basis of the
literature review and the lens through which the experiences of
participants were interpreted.
Culture
Culture is the web of significance that humans create (Geertz,
1973), and it is within culture that we learn socially accepted
norms, how selves are valued, and what constitutes a self (Adler
& McAdams, 2007; Pasupathi, Mansour, & Brubaker, 2007).
Although men and women come to the military from diverse
cultural backgrounds, the one thing they ultimately share is
PAGE 162
assimilation into military culture. One of the primary goals of
boot camp, the training ground for all military personnel, is to
socialize recruits by stripping them of their civilian identity and
replacing it with a military identity. The passage from one
identity to another comprises three stages: separation, liminality
(or transition), and incorporation (Van Gennep, 1960).
Separation involves the removal of an individual from his or her
customary social life and the imposition of new customs and
taboos. The second stage, liminality, is one of transition
between two social statuses. The individual is ‘‘betwixt and
between’’ statuses, belonging to neither one nor the other
(Turner, 1974, p. 232). Transition rites create new social norms,
and initiates become equal to each other within emergent
‘‘communitas’’ (a ‘‘cultural and normative form...stressing
equality and comradeship as norms’’ within relationships that
develop between persons) (Turner, 1974, pp. 232, 251). In the

third stage, the individual reenters the social structure,
oftentimes, but not always, with a higher status level than
before. Military identity is infused with the values of duty,
honor, loyalty, and commitment to comrades, unit, and nation.
It promotes self-sacrifice, discipline, obedience to legitimate
authority, and belief in a merit-based rewards system (Collins,
1998). These values are in conflict with more individualistic,
liberty-based civic values, which embrace materialism and
excessive individualism.
Military training is rooted in the ideal of the warrior,
celebrating the group rather than the individual, fostering an
intimacy based on sameness, and facilitating the creation of
loyal teams, where recruits develop a ‘‘bond that transcends all
others, even the marriage and family bonds we forge in civilian
life’’ (Tick, 2005, p. 141). At the same time, recruits become
capable of fighting wars by learning how to turn their emotions
off and depersonalizing the act of killing ‘‘the other.’’ The
process of war involves dehumanizing everyone involved (on
both sides) and placing everyone in kill or be killed situations.
According to Tick (2005, p. 21), war ‘‘reshapes the imagination
as an agent of negation.’’ To create strategies and use weapons
for the destruction of others, the imagination is ‘‘enlisted in
life-destroying service’’ (Tick, 2005, p. 21).
The differences in values between civilian society and military
society create a ‘‘civil-military cultural gap’’ (Collins, 1998, p.
216), which is exacerbated by the fact that there is an all-
volunteer military. Today, fewer families have direct contact
with someone serving in the military than ever before. The
move away from a draft and to a volunteer force has allowed
most Americans to become completely detached from military
issues and the men and women who are sent to war, leading to a
lack of understanding about the differences between the two
worlds (Collins, 1998). This is complicated further by the
absence of a national consensus about war, the lack of
validation of soldiers’ efforts, and the general lack of
acknowledgment of soldiers who return from war (Doyle &

Peterson, 2005).
PAGE 163
Identity
Identity is socially, historically, politically, and culturally
constructed (Weber, 1998) within communities (i.e., within
social or civic spaces) (Kerr, 1996). Ideally, these are places
where others recognize, acknowledge, and respect one’s
experiences, thus providing a sense of belonging. The way in
which our identities are constituted is through narrative, or
storytelling. Stories are the primary structure through which we
think, relate, and communicate, actively shaping our identities
by enabling us to integrate our lived experiences into a cohesive
character (Mair, 1988; Cajete, 1994). Not only do the stories
that we tell and live by shape our individual continuity by
connecting past, present, and future, they also shape our
communities. Thus, a reciprocal relationship exists between
individual narratives and cultural narratives, each serving to
inform the other and to maintain continuity of a sense of self
and culture over time (Chandler & Lalonde, 1998; O’Sullivan-
Lago, de Abreu, & Burgess, 2008; Sussman, 2000).
According to Ricoeur (1992) and others (Baerger & McAdams,
1999; Bruner, 1987; Howard, 1991; Pasupathi et al., 2007;
Sarbin, 1986; Whitty, 2002), we can only know ourselves and
find meaning in our lives through narrative. It is through the
continual retelling of our stories (i.e., weaving together our
day-to-day experiences with reinterpretations of our past
experiences) that we know who we are today. These narratives
create our personal myths that change over time (McAdams,
1993). We choose to remember events in a particular way, we
set goals and expectations, we regulate emotions, and we can
imagine possible future selves based on our current lives
(Pasupathi, Weeks, & Rice, 2006). Understood in narrative
terms, identity belongs in the sphere of the dialectic between
sameness (that part of us that holds constant, i.e., genetic

makeup, physical traits, and character) and selfhood (our
experiences over time) (Abes, Jones, & McEwen, 2007;
Ricoeur, 1992); it is constructed in connection with the story
elements in a life’s narrative (Ricoeur, 1992). Life stories
address the issue of identity by describing how a person came to
be his or her current self, via remembering and the
interpretation of past experiences.
Traumatic experiences create an additional challenge to
maintaining a continued sense of personal identity because of
their highly disruptive and emotionally charged nature (Janoff-
Bulman, 1992). Burnell, Hunt, and Coleman (2009) and others
(Crossley, 2000; Pillemer, 1998; Westwood, Black, & McLean,
2002) assert that reconciliation comes about when negative
narratives are integrated as one coherent chapter of a life story.
Coherence is ensured when the story is linked together and not
merely a succession of separate chronological events. The
narrative must contain a theme that integrates events (Burnell et
al., 2009), and dysfunctional integration (Berntsen, Willert, &
Rubin, 2003)—integration of the trauma into one’s narrative
whereby the traumatic experience becomes the focal point of
one’s life story
PAGE 164
and the lens through which all other experiences are then
interpreted—must be avoided. In their work with veterans,
Burnell et al. (2009) and Pillemer (1998) found that veterans
identified telling their stories to others as an effective way to
cope with war memories. Some achieved coherence through
professional aid, and others achieved it through positive
interactions with informal social support networks, including
comrades, family and friends, and the general public (Burnell et
al., 2009). When we do not have the opportunity to reflect on
the history of our life and our place in it, an interval opens
between sameness and selfhood (Ricoeur, 1992). Individuals
may find themselves living between two social contexts that
offer incompatible cultural narratives and unable to articulate
an integrated personal narrative that avoids a crisis in identity

(Adler & McAdams, 2007; O’Sullivan-Lago et al., 2008).
Hermans and Kempen (1998) identify the spaces where cultures
meet and individuals are confronted with the challenge of
constructing new identities as contact zones that become the
‘‘habitus for constructing an identity through a socially shared
repertoire of cultural knowledge, practices, and values with
clearly marked power asymmetries in one’s ability to freely
negotiate this process’’ (Mahalingam, 2008, p. 368).
Uncertainties that are caused by contact with others in contact
zones lead to developing strategies to either avoid or reconcile
contradictions that arise from these interactions in order to
protect the continuity of one’s identity (Hermans, 2001;
O’Sullivan-Lago & de Abreu, 2010). Under ideal circumstances,
people identify the similarities between themselves and others
in the ‘‘I as a human being’’ strategy (O’Sullivan-Lago et al.,
2008, p. 359), a dialogical strategy that allows connections with
others based on sameness and allows one to take in the past,
thus easing cultural uncertainty and permitting the rejection of
unwanted identities, which results in the creation of a hybrid
identity (Mahalingam, 2008). The reality is that a process of
hegemonic bargaining occurs (Chen, 1999) between the
dominant culture and persons from other cultures that may have
negative mental health consequences for those outside the
dominant culture (Mahalingam, 2008). At best, this may lead to
limited opportunities for adult development; at worst, it leads to
poorer mental health (Main, 1995), including depression
(Baerger & McAdams, 1999) and other forms of
psychopathology (White & Epston, 1990), and may predict
vulnerability to suicide (Chandler & Lalonde, 1998).
METHODS
Design
A qualitative study utilizing focus groups to explore active duty
soldiers’ and veterans’ experiences of returning home was
conducted. Qualitative
PAGE 165
interviews are a key way to learn about other people’s feelings

and thoughts and achieve new shared understandings about
people’s lived experiences. Focus groups were selected because
this method is recognized as an appropriate way to obtain in-
depth information about individuals who share similar
experiences, using group interaction as a catalyst for generating
innovative ideas that might not be revealed in individual
interviews (Morgan, 1998).
Participants
Purposive sampling was employed to identify and recruit
participants who had served in Afghanistan, Iraq, or both since
the beginning of the wars in those countries in October 2001
and March 2003, respectively. Participants were recruited in
both northern California (San Francisco Bay area) and southern
California (San Diego) through Internet advertisements;
dissemination of flyers at 2- and 4-year colleges and
universities, coffee houses, and veterans’ centers; and word of
mouth primarily through area veteran groups and veterans’
family groups, veterans’ hospitals and medical facilities, and
community nonprofit organizations.
Recruitment materials directed potential participants to the
Swords to Plowshares (an agency that has worked with veterans
since the early 1970s) Web site, where they were asked to
complete an electronic survey using Survey Monkey.
Demographic data were collected via the survey, including age,
branch of service, rank, military status, and number of
deployments to Iraq and=or Afghanistan. Respondents were
asked to provide an e-mail address to receive detailed
information about locations and times of focus groups. These
methods resulted in 45 male and 3 female participants. Because
so few females responded, they were contacted and asked to
consider participating in a future study. Each of them consented
to do so.
Procedures
The San Jose State University Institutional Review Board
approved this study. Respondents who were eligible for the
study were given a date and time that was most convenient for

them to participate in one focus group session. The interviewer
reviewed all relevant points contained in the consent form,
emphasizing that results would be reported only in aggregate
form. All participants provided written informed consent before
participating in the study. Confidentiality was explained to
participants and maintained throughout the study. A list of local
mental health and social service resources was provided to
participants. A semistructured interview guide was used to
conduct the focus groups. The guide was developed by the
principal investigator (PI) and reviewed
PAGE 166
and endorsed by Swords to Plowshares staff, including three
veterans. The interview guide consisted of open-ended questions
to elicit responses among participants about (a) the ways in
which their deployments impacted their lives, (b) the ways in
which their deployments affected their interactions with family
members and friends, and (c) the types of support they sought
out and received (both formal and informal).
Six focus groups were held—one each in San Francisco (n=5),
Oakland (n=5), and San Jose (n=8) and three in San Diego,
California (n=27; 9 in each group)— Jose (n¼8) and three in
San Diego, California (n¼27; 9 in each group)—between
September 2006 and September 2008. Focus groups were held in
community rooms at local hospitals, nonprofit organizations,
and churches. All sessions were audiotaped. Before the start of
each focus group, participants were presented with a list of
guidelines in order to facilitate effective communication during
the discussions. The tape recorder was placed in full view of
participants. Each participant was provided with the opportunity
to respond to each question but was informed that he did not
have to do so. Data saturation was used to determine the number
of focus groups needed to fully explore the topic of this study.
Data saturation was achieved when no new information was
gathered during the focus groups and statements were
supportive of previously identified categories and themes.
Data Analysis

Data from Survey Monkey were downloaded and descriptive
data analysis was conducted using SPSS. Focus group data were
analyzed as group data. Audiotapes were transcribed into
verbatim written records. Transcripts were read and compared
with the audiotapes on two separate occasions by the PI and a
research assistant to ensure accuracy of the data transcription.
Transcripts were read and reread in order to find commonalities,
and themes were developed inductively.
Lincoln and Guba’s (1985) four criteria for determining
trustworthiness of qualitative research were used for this study:
credibility, dependability, confirmability, and transferability.
Credibility was established through the use of peer debriefings
and member checks. In this study, peer debriefings were
accomplished by sharing the data and ongoing data analysis
with colleagues, and member checks involved two participants
who were asked to provide feedback at periodic intervals during
data analysis, interpretation, and the formulation of
conclusions. Dependability and confirmability were ensured by
having an independent judge categorize 15% of the data and
compare categories and themes with those of the researcher. An
agreement rate of 93% was reached, with 85% being considered
very good for coding purposes (Rosenthal & Rosnow, 2007).
Transferability was ensured by collecting participants’
demographics and thick descriptions of the data.
PAGE 167
RESULTS
Participants Recruitment methods yielded a diverse group of
participants (N=45) ranging in age from 19 to 51 (Mdn=25) and
representing almost all branches of the U.S. military: Army
(n=12), Marines (n=24), Navy (n=6), and Air Force (n=3). Of
the total sample, 15% were in either the Reserves (n=4) or
National Guard (n=3), and 93% (n=42) were enlisted as opposed
to officers. They had deployed to either Iraq or Afghanistan
between 1 and 4 times (M=2). They reported their current status
as active duty (n=12), reserve (n=3), or separated from the
military (veterans) (n=30). It is acknowledged that each branch

of the military uses different terms to refer to members (e.g.,
marines); however, soldier is commonly used to refer to active
duty military personnel across branches, and it is used
throughout this article to refer to all participants prior to
redeployment from Iraq or Afghanistan to the U.S. Once
soldiers returned home, some of their experiences differed
according to status. Thus, beginning with the ‘‘No one
understands us’’ subtheme below, they are referred to by status:
(a) soldiers (those who remain on active duty and reside on or
near military bases and the National Guard), (b) reserves (those
who return to their home communities and can be recalled at
any time), and (c) veterans (those who separate from the
military and return to communities).
Themes and Subthemes
The major themes and subthemes that emerged from this study
are presented in Table 1.
DEPLOYING TO WAR
This theme describes soldiers’ experiences of leaving for war,
thoughts and emotions in the midst of war, and feelings about
returning home. It is divided into three subthemes: ‘‘we are
warriors,’’ ‘‘no fear,’’ and ‘‘feeling high.’’ Each is described
below and supported by selected material from the focus groups.
PAGE 168
We are warriors. This theme addresses soldiers’ experiences in
the war theater and their psychological state of mind while
there. Military personnel are trained to go to war, and some
soldiers said they ‘‘were actually kind of gung ho on the way
over’’ and ‘‘eager to go,’’ because ‘‘this was what we trained
for.’’ One element of the training included how to become
angry on demand. Many soldiers referred to their ‘‘anger
switch,’’ which was described by one participant as ‘‘an act that
you learn from your drill instructors’’ that you can go into at
any time. He elaborated, saying that ‘‘it’s not because [you are]
really angry, but just because [you]...communicate that way.’’
Participants’ narratives revealed the ‘‘life or death’’ nature of

day-to-day existence while in the war theater: ‘‘You cannot
afford to care. You’re constantly scanning the roads, looking for
anything out of place, looking for IEDs [improved explosive
devices].... You can’t trust anybody; they’re all the enemy—
women, children, all of ’em.’’ Speaking about the course of his
days, one soldier said, ‘‘You know, we’ve got this operation,
everything is so fast paced, so fast paced. It’s like something in
the movies.’’ Referring to this pace, another soldier described
the level of stress he had to endure as ‘‘almost unbearable,’’
and an Army soldier shared, ‘‘It’s so awful, there are no words
to describe it, and it’s not just fear, there’s an unstoppable
stress that doesn’t turn off.’’ Participants described seeing
‘‘stuff so bad, you can’t put it into words’’; however, they
noted that they had done what they were trained to do and were
forced to do for their own survival and that of their comrades.
No fear. In addition to describing the stress they experienced,
soldiers also explained how they attempted to cope with the
stress and their surroundings. One soldier said:
I saw a lot of combat, and the people around me had an attitude
that it’s like a lottery; [if] it’s your time, it’s your time. You get
in that mindset and then, pretty much, go on with your day.... I
mean, yeah, you would always have it in the back of your head
that, you know, snipers might be taking aim at you, or you
might hit something.
Another soldier shared, ‘‘I would just put in to my mind, every
time I go out, every day, this is the last day you have to live, so
it doesn’t matter.’’ All participants agreed that this attitude
‘‘definitely made it easier to just kind of live life normally’’
while they were in the war theater.
Feeling high. Some soldiers’ narratives revealed that while they
were struggling with the stress of war during their time in the
war theater, their attitudes shifted substantially when they
received news that they were going
PAGE 169
home. They variously said that ‘‘you’re kind of euphoric at that
point’’ and ‘‘you got an artificial high going on.’’ They

described ‘‘just want[ing] to see family’’ and wanting to ‘‘be
with my wife and kids.’’ All soldiers agreed that ‘‘getting out
kind of makes you suppress what you’re feeling because you’re
so excited.’’ They talked about working through emotional and
psychological issues at a later time, after they returned home.
One soldier said, ‘‘I was like what do I care? I’m going home!
I’ll figure it out later.’’ He added, ‘‘I think that was the
consensus with the other guys. It was ‘well, I’m going home, I
don’t really—I’m not going to feel.’ If they were going to feel
anything, they’re not going to feel it right then.’’ Nevertheless,
their euphoria was relatively short-lived as they came face to
face with reality upon returning to the United States.
COMING HOME
This theme illustrates soldiers’ reactions to returning home,
perceptions of difference (between themselves and civilians and
between who they were prior to war and who they are now),
tension between wanting to reconnect with civilians (including
family) and wanting to retreat from them, coping mechanisms,
and support for transition. There are three subthemes: ‘‘time
travelers,’’ ‘‘no one understands us,’’ and ‘‘crisis of identity.’’
Each is described below and supported by selected focus group
material.
Time travelers. This subtheme illustrates the disconnection that
soldiers experienced when they returned to the U.S. They all
described their experiences as ‘‘surreal’’ and ‘‘like landing on
Mars.’’ One soldier said:
I remember coming into LAX, and getting off the plane, and
looking around, thinking ‘‘Damn, I’m back in the U.S.’’ It’s
like...there’s a sense of time gone from my life. Their [family]
lives go on, but...your life is stopped for 2 years.
Two soldiers elaborated, contrasting their experiences between
where they had been and where they were now, in terms of both
geographic location and psychological space. They described
being’’ in a completely different place’’ where ‘‘one day you
put a bullet in a guy’s head...you’re getting shot at, and then
you rotate back to Germany, to the States.’’ Soldiers appear to

have been caught between two cultures: military culture, where
they understood what was considered appropriate behavior, and
civilian culture, where they did ‘‘not know the rules of the
game, [and] if you kill somebody, you’ll go to jail.’’ This led to
significant confusion, as illustrated by one soldier’s comment:
‘‘In my mind, I’m like, what the hell is going on here?’’ All of
the soldiers acknowledged that this had been their experience,
and that it was overwhelming. They described the challenges of
‘‘turning your emotions
PAGE 170
on and off like a light switch,’’ of ‘‘being a killer,’’ and of the
expectation on the part of civilians that they act ‘‘like a
gentleman at the same time.’’
No one understands us. All soldiers (active duty, reservists, and
veterans) acknowledged that they were no longer the same
individuals who went off to war. They shared that they felt
different from civilians when they returned to the U.S. One
reservist commented, ‘‘Civilians don’t understand you.’’ Other
veterans added that ‘‘[people] think you’re just a regular
civilian’’ and ‘‘they think you’re just a normal dude walking
around [the city]. They have no idea that 72 hours ago you were
whacking dudes in a house in Iraq.’’ One veteran expressed,
‘‘It’s really hard for anyone else to understand, to know what’s
going on.... You know, they don’t understand the military
concept, and it’s hard to blend in with them.... It’s a different
atmosphere.’’
The experience of returning was different for soldiers (active
duty), reservists, and veterans who returned to civilian
communities. Soldiers and reservists identified readjusting to
family life as the most challenging aspect of returning home.
The primary tension was knowing that they would be deployed
again and not knowing where or when it would be. This led to
fighting between soldiers and their spouses. One soldier
summarized the stress, saying, ‘‘These rotations are killing
people’s families.’’ One of the strategies soldiers employed to
address the tension of leaving again was to receive permission

to stay behind during the next deployment. However, that did
not seem to resolve the issue. Another soldier said:
Some guys stay back for family situations, not to piss their wife
off anymore, not to miss another kid born, but then you’re
stressed out by being the guy that’s left. So, you’re not the nice
guy when you come home. It doesn’t help the situation at all;
you’re there, but you’re not there. You’re wishing you were in
Iraq.
Veterans described three key challenges to returning home: lack
of respect from civilians, holding themselves to a higher
standard than civilians, and not fitting into the civilian world.
Many veterans said that one of the greatest difficulties they
faced ‘‘was the difference in the amount of respect [they] had’’
in the military compared to what they perceived in civilian life.
One veteran said, ‘‘I felt like I had a purpose over there—
worthwhile [and] I felt pretty good about it.’’ Another
participant added, ‘‘I was good at my job in the Marine Corps. I
was in charge of people, and I did a good job.’’ He added, ‘‘Out
here, [I am] just a regular civilian.’’ The change in status led to
loss of self-esteem and sense of self-worth. They described
attempts to fit into the civilian world: ‘‘I just try to blend in
with the population.... I don’t deny it [being in the military], but
I keep it really low key. I just try to, in a sense, forget that I
was a marine.’’
PAGE 171
Veterans recognized that they hold themselves to a different
standard than civilians hold themselves to. One participant
shared, ‘‘I think dealing with the zero defect mentality that the
military ingrains in you makes it difficult to adjust.’’ This was
discussed in the context of human behavior; that is, everyone
knew what was expected of them and acted accordingly, leading
to a level of predictability. Participants were both frustrated and
disappointed by the behavior of civilians. These behaviors
ranged from cell phones ringing at inappropriate times, to
students disrupting classes, to what were considered ‘‘petty
conversations about shit that means nothing.’’ Many veterans

said that they oftentimes sought to meet ‘‘someone to prove you
wrong about themselves,’’ adding, ‘‘You want to meet someone
decent with a brain...someone worth your time to talk to.’’ One
participant said, ‘‘It’s a lot easier to go back into combat where
everything is normal than to deal with this stuff here. Another
participant shared, ‘‘The idea of being a marine in the United
States, being put back into the box with this stupid shit...I’d
rather die in Iraq than fake it over here.’’
Veterans described a deeper disconnection from families and
other civilians than either soldiers or reservists described. This
is illustrated in their comments: ‘‘I felt really confused and out
of place when I got back’’; ‘‘I felt like I didn’t belong’’; ‘‘I
was afraid of going home’’; and ‘‘I was afraid of being alone
among family and friends, because they don’t get you.’’ Their
fears may indicate something deeper than merely being
misunderstood by family members and may actually have been
fear of confronting the loss of who they were before. They
appear to have sensed that the person who would be reflected
back to them by family members, the person who they once
were, was someone they could no longer relate to, someone they
could no longer see in themselves, someone they no longer
were. One veteran shared, ‘‘You go home, [and] you don’t know
how much you’ve changed until you start to get around family
and friends...with them, I realize I’m not how I used to be.’’
Another extended this thought, saying, ‘‘I had been gone for so
long, I just wasn’t able to keep up with everything even though
I was in close contact with family.’’ This suggests that while he
may have been able to stay abreast of the little details, he was
not able to engage in the narratives that would have facilitated
his ability to maintain a clear sense of identity. Many of the
veterans shared that they had been forced to ‘‘become someone
else.’’ One veteran said that this experience had ‘‘emotionally
wrecked’’ him, and another veteran said, ‘‘Now, I’m kind of
waiting to become someone else.’’
Crisis of identity. Veterans used a variety of metaphors to
describe the crisis of identity they experienced, each of which

illustrated either psychological darkness or death. Two veterans
shared, respectively, ‘‘I just didn’t see a light at the end of the
tunnel,’’ and ‘‘You’re just black; you can’t get through that.’’
Two other veterans described their experiences in the following
ways: ‘‘It’s like being in a sea of strangers’’ and ‘‘It’s like
being in the
PAGE 172
ocean and having something to stand on, and that takes off, and
then you’re drowning.’’ Most of the veterans acknowledged a
tension between wanting to reconnect with civilians and
simultaneously wanting to retreat. One veteran’s narrative
exemplified this tension: ‘‘I became, you know, I had this need,
this want to meet [other people], but you’re still, at the same
time, antisocial. You’re not happy alone, but you’re not happy
with people...it’s really confusing.’’ Returning home was
challenging in various ways, and all veterans struggled with the
process. As one veteran summarized, ‘‘[You] come back, and
[you] have to turn around and deal with the civilian world, and
[you] can’t do it if [you are] mentally, physically, and
financially not ready to do it.’’ Many veterans described the
difficulty they had in adjusting to a slower pace; one veteran
summarized it as ‘‘want[ing] to do something instead of sit
there, sleep, watch TV, [and] study.’’
Veterans also had a hard time coping with feeling alone. One
veteran said, ‘‘When you’re alone, you’re at the bottle,’’ and
others indicated that they also used alcohol to cope. A few
participants said they used ‘‘drugs, marijuana, and all that’’ to
address their feelings; one veteran said, ‘‘I was so alone, I
attempted suicide.’’ Although all soldiers (active duty,
reservists, and veterans) agreed that they needed a period of
adjustment to transition back into life in the U.S., veterans’
narratives suggest that they are faced with greater challenges
and may need additional support. Soldiers may continue to
experience a sense of camaraderie with their fellow soldiers
while at work and on duty; however, veterans had no
opportunity to be with others who are like them. Veterans

identified the need for ‘‘space and time to help [them]
reintegrate’’ and described the desire to talk with others ‘‘who
have served time over there...because [they] have a common
base,’’ and ‘‘they can relate to what you’re going through.’’
Veterans’ comments further validated their sense of being
different from nonveteran civilians. They identified a need for
‘‘that connection, the face-to-face contact [with] a real person
[another veteran]’’ who could ‘‘see [them] as a person.’’
DISCUSSION
Soldiers (active duty, reservists, and veterans) face significant
challenges upon returning home from war. Those who remain on
active duty must reintegrate into families, and while this is no
easy task, they appear to face fewer challenges than veterans
do. Veterans struggle to reconnect with family and friends and
to fit into civilian society. There is a tension between their
yearning to be with people and their feelings of being
misunderstood. They isolate themselves, waiting and hoping to
become comfortable in their own skins again.
PAGE 173
For veterans, boot camp facilitated the passage from one
identity to another—civilian to military (Van Gennep, 1960).
Veterans left civilian culture (separation phase), were stripped
of those cultural norms (transition phase), and engaged in the
rituals of boot camp that taught them to shut their emotions off,
as a protective mechanism designed to assist them in coping
with their tasks; to accept death as their fate; and to dehumanize
the enemy. These behaviors are normal by military standards
and key to soldiers’ survival. It was in boot camp where
communitas—a normative form stressing comradeship (Turner,
1974)—most likely occurred, facilitating a complete break from
civilian culture and full incorporation (third phase) into military
culture, which afforded veterans higher status, increased their
expectations of themselves and others, and inculcated strong
team loyalty. Although soldiers (active duty, reservists, and
veterans) described feeling excited and euphoric upon receiving
news that they were returning to the U.S., those feelings were

quickly replaced by shock and confusion. In part, the change
might be attributed to the rapid return to the U.S.; that is, one
day they are in the desert under fire, and the next they are in
communities where houses and streets are still intact, and where
they are surrounded by civilians shopping in malls, eating at
fast food restaurants, and going on with lives that soldiers left
behind 12 to 18 months before. However, the civilian-military
cultural gap (Collins, 1998) and theories of cultural identity
(Van Gennep, 1960; Hermans, 2001; O’Sullivan-Lago &
deAbreu, 2010; Turner, 1974) provide additional lenses through
which we might understand veterans’ experiences. The
disorientation that veterans experienced upon their return home
is most likely explained by interactions that were influenced by
the civilianmilitary cultural gap (Collins, 1998).
Veterans described being misunderstood and disrespected by
civilians who had no appreciation for either who veterans were
or what they had been through. In the military, they worked
hard to earn the respect of their comrades, they were highly
trained and experienced in their roles as leaders, and they felt
they had a purpose. Veterans’ remarks about civilians suggested
a lack of understanding about ‘‘the military concept’’ and the
inability to find common ground (sameness) (Mahalingham,
2008), leading veterans to feel as though they were ‘‘in a
different atmosphere’’ where they felt alone even in the midst
of family and friends who did not understand them because they
had become ‘‘someone else.’’
Veterans’ narratives suggest that they were, once again, thrust
into a separation phase of passing from military identity to
civilian identity. Similar to when veterans separated from
civilian culture, entered the military, and experienced liminality
(Van Gennep, 1960), they were caught again between two
cultures. Veterans’ statements, that they no longer understood
‘‘the rules of the game’’ and that ‘‘it’s hard to blend in’’ when
they return home, illustrate the confusion they experienced.
Veterans referred to themselves as not being ‘‘normal’’ or
‘‘regular’’ when compared to civilians, and they were clear that

the civilian world was not normal for them. In fact, the culture
in the United States felt so abnormal that some veterans would
rather return to war where they felt they fit in, instead of trying
to fit themselves back into the ‘‘box’’ of civilian culture.
Identity is inextricably linked to community, each creates the
other, and it is within community—where we see the similarities
between ourselves and others and where others recognize,
acknowledge, and respect our experiences—that we acquire a
sense of belonging (Adler & McAdams, 2007; Kerr, 1996;
Pasupathi et al., 2007). Returning veterans appear to be in the
second stage of identity development—liminality—and caught
between who they knew themselves to be in the military and
who they are now that they are in the civilian world. They are
‘‘waiting to become someone else [again],’’ and must create
hybrid identities that incorporate military and civilian cultural
knowledge, values, and practices (Mahalingam, 2008).
However, veterans revealed that the time spent waiting was not
positive. They described it as feeling ‘‘black’’ on the inside and
feeling as though they were drowning, intimating the death of
oneself or the death of identity. Although they are surrounded
by civilians in various contact zones, they are in a ‘‘sea of
strangers’’ who ‘‘don’t get you,’’ leading to uncertainties about
their identities and the need to avoid contradictions between
who they see themselves to be and how others perceive them
(Hermans, 2001) through self-isolation and the use of alcohol.
Veterans need to reenter the social structure (Turner, 1974) in
order to create hybrid identities; however, there are power
asymmetries that impact their ability to negotiate the process.
They must be able to engage in the ‘‘I as human being’’
strategy (O’Sullivan-Lago et al., 2008) with others in
supportive contact zones in order to incorporate their past
experiences, create connections based on sameness, and reject
unwanted identities.
Ultimately, veterans must be able to articulate a fully integrated
(Berntsen et al., 2003) and coherent (Burnell et al., 2009)

personal narrative in order to avoid a crisis in identity (Adler &
McAdams, 2007; Baerger & McAdams, 1999; Bruner, 1987;
Howard, 1991; Pasupathi et al., 2007; Ricoeur, 1992; Sarbin,
1986; Whitty, 2002). This is challenging given most civilians’
lack of understanding about military culture (Collins, 1998), the
lack of validation of soldiers’ efforts, and the general lack of
acknowledgment of soldiers who return from war (Doyle &
Peterson, 2005). Veterans identified the need to connect with
other veterans who can ‘‘see [them] as a person,’’ supporting
Hunt and Robbins’s (2001) findings from World War II veterans
who identified social support from comrades, wives, and family
members as an important lifelong coping strategy. Through
these connections, veterans will be able to create meaning in
their lives and shift their imaginations from being ‘‘enlisted in
life-destroying service’’ (Tick, 2005) to creating new
possibilities for a future in the civilian world, thus reducing the
probability of poor mental health outcomes. Not only will
opportunities for storytelling facilitate veterans’ ability to
relearn civilian social norms and become
PAGE 175
‘‘re-membered’’ into civilian culture, but they have the
potential for teaching civilians about military culture, thus
narrowing the civilian-military cultural gap (Collins, 1998) and
creating stronger support networks for returning veterans.
Limitations
This exploratory study increases our understanding about some
of the challenges facing returning Iraq and Afghanistan war
veterans as they attempt to reintegrate into civilian life.
However, it is not without limitations: (a) Neither mental health
status nor the role of trauma in identity construction was
assessed; (b) the amount of time between participants’ return to
the U.S. and=or separation from the military and participation
in the study was not assessed; (c) the impact of the number of
deployments was not explored; and (d) differences between
veterans from different branches of the military were not
qualitatively explored. Each of these limitations should be

examined in future studies in order to better inform our
understanding of this complex issue.
Recommendations
SERVICES AND PROGRAM IMPLICATIONS
There are three areas in which services that benefit veterans,
either directly or indirectly, are suggested: (a) support groups
for veterans, in which they would have the opportunity to share
their stories; (b) transition groups for families and friends of
veterans, in which they would have the opportunity to learn
about military culture and how to best support their veteran; and
(c) military cultural competence training for mental health
practitioners (i.e., therapists, social workers, and college and
university counselors). Training should elucidate the
reintegration challenges veterans face and inform models to
address the unique needs of veterans.
FUTURE RESEARCH
Findings from this study indicate the need for further research
among this population in three primary areas. First, additional
focus groups should be held to explore the reintegration
challenges that are unique to veterans according to number of
deployments, branch of service, and length of time since
separation from the military. Second, mixed methods should be
implemented to obtain a better understanding of the continuum
of distress that veterans experience and to explore links between
identity, culture, mental health, and reintegration. Third, a
longitudinal study should be conducted to illuminate the ways
in which veterans resolve reintegration challenges. Results
could be used to inform services, programs, and, ultimately,
policy.
PAGE 176
Conclusion
In summary, we are just beginning to acknowledge the
magnitude of work ahead to address veterans’ mental health
issues. Based on current findings, the numbers of veterans with
diagnosed mental health disorders do not tell the whole story.
Participants’ narratives about their experiences of war and

homecoming reveal their confusion, their frustration, and their
distress. Since veterans without clinically diagnosed mental
illness do not qualify for services from the Veterans
Administration (VA), they do not receive treatment from the
VA; thus, there will be many who will not receive the support
they need to successfully reintegrate into society. Furthermore,
not all veterans should be pathologized. While there are many
veterans who have diagnosable mental health disorders, it
appears that others may merely need a way to transition from
military culture into civilian culture. Although boot camp
provides the necessary transition rites to become part of
military culture, there is no equivalent civilian camp to assist
veterans with successful reintegration once they leave military
settings. Many veterans are experiencing a crisis of identity,
and a continuum of services—both formal and informal—is
needed to support them. Opportunities to develop integrated
personal narratives could provide a way to prevent or at least
mitigate poor mental health outcomes. The costs of ignoring
veterans are great, and we owe it to them to provide the care
and support they need to imagine themselves in new ways,
reintegrate into civilian culture, and live healthy and productive
lives.
REFERENCES
Abes, E., Jones, S., & McEwen, M. (2007). Reconceptualizing
the model of multiple dimensions of identity: The role of
meaning-making capacity in the construction of multiple
identities. Journal of College Student Development, 48, 1–22.
Adler, J., & McAdams, D. (2007). Time, culture, and stories of
self. Psychological Inquiry, 18, 97–128.
Baerger, D., & McAdams, D. (1999). Life story coherence and
its relation to psychological well-being. Narrative Inquiry, 9,
69–96.
Barrett, T., & Mizes, J. (1988). Combat and social support in
the development of posttraumatic stress disorder in Vietnam
veterans. Behavior Modification, 12, 100–115.
Barrett, D., Resnick, H., Foy, D., Dansky, B., Flanders, W., &

Stroup, N. (1996). Combat exposure and adult psychosocial
adjustment among U.S. Army veterans serving in Vietnam,
1965–1971. Journal of Abnormal Psychology, 105, 575–581
. Berntsen, D., Willert, M., & Rubin, D. (2003). Splintered
memories or vivid landmarks? Qualities and organization of
traumatic memories with and without PTSD. Applied Cognitive
Psychology, 17, 675–693.
Brewin, C., Andrews, B., & Valentine, J. (2000). Meta-analysis
of risk factors for posttraumatic stress disorder in trauma-
exposed adults. Journal of Consulting Clinical Psychology, 68,
748–766.
Bruner, J. (1987). Life as narrative. Social Research, 54, 11–32.
Burnell, K., Hunt, N., & Coleman, P. (2009). Developing a
model of narrative analysis to investigate the role of social
support in coping with traumatic war memories. Narrative
Inquiry, 19, 91–105.
Cajete, G. (1994). Look to the mountain: An ecology of
indigenous education. Durango, CO: Kivaki Press.
Cascardi, M., & Vivian, D. (1995). Context for specific
episodes of marital violence: Gender and severity of violence
differences. Journal of Family Violence, 10, 265–293.
Chandler, M., & Lalonde, C. (1998). Cultural continuity as a
hedge against suicide in Canada’s First Nations. Transcultural
Psychiatry, 35, 191–219.
Chen, A. (1999). Lives at the center of the periphery, lives at
the periphery of the center: Chinese American masculinities and
bargaining with hegemony. Gender and Society, 13, 584–607.
Collins, J. (1998). The complex context of American military
culture: A practitioner’s view. Washington Quarterly, 21, 213–
226.
Crossley, M. (2000). Narrative psychology, trauma, and the
study of self=identity. Theory & Psychology, 10, 527–546.
Department of Defense. (2010). U.S. casualty status. Retrieved
from http://www.defense.gov/news/casualty.pdf
Doyle, M., & Peterson, K. (2005). Re-entry and reintegration:
Returning home after combat. Psychiatric Quarterly, 76, 361–

370.
Geertz, C. (1973). The interpretation of cultures. New York:
Basic Books. Gelles, R., & Cornell, C. (1985). Intimate
violence in families. Beverly Hills, CA: Sage.
Hermans, H. (2001). The dialogical self: Toward a theory of
personal and cultural positioning. Culture and Psychology, 7,
243–281.
Hermans, H., & Kempen, H. (1998). Moving cultures: The
perilous problems of cultural dichotomies in a globalizing
society. American Psychologist, 53, 1111–1120.
Howard, G. (1991). Culture tales: A narrative approach to
thinking, cross-cultural psychology, and psychotherapy.
American Psychologist, 46, 187–197.
Hunt, N., & Robbins, I. (2001). World War II veterans, social
support, and veterans’ associations. Aging and Mental Health,
5, 175–182.
Janoff-Bulman, R. (1992). Shattered assumptions: Towards a
new psychology of trauma. New York: Free Press.
Kerr, D. (1996). Democracy, nurturance, and community. In R.
Soder (Ed.), Democracy, education and the schools (pp. 37–68).
San Francisco: Jossey-Bass.
King, L., King, D., Fairbank, J., Keane, T., & Adams, G.
(1998). Resilience-recovery factors in posttraumatic stress
disorder among female and male Vietnam veterans: Hardiness,
postwar social support, and additional stressful life events.
Journal of Personality and Social Psychology, 74, 420–434.
Koenen, K., Stellman, J., Stellman, S., & Sommer, J., Jr.
(2003). Risk factors for course of posttraumatic stress disorder
among Vietnam veterans: A 14-year follow-up of American
Legionnaires. Journal of Consulting and Clinical Psychology,
71, 980–986.
Lincoln, Y., & Guba, E. (1985).Naturalistic inquiry. Beverly
Hills, CA: Sage.
Mahalingam, R. (2008). Power, social marginality, and the
cultural psychology of identities at the cultural contact zones.
Human Development, 51, 368–373.

Main, M. (1995). Recent studies in attachment: Overview, with
selected implications for clinical work. In S. Goldberg, R. Muir,
& J. Kerr (Eds.), Attachment theory: Social, developmental, and
clinical perspectives (pp. 407–474). Hillsdale, NJ: Analytic
Press.
Mair, M. (1988). Psychology as storytelling. International
Journal of Personal Construct Psychology, 1, 125–137.
Mazeo, S., Beckham, J., Witvliet, C., Feldman, M., & Shivy, V.
(2002). A cluster analysis of symptom patterns and adjustment
in Vietnam combat veterans with chronic posttraumatic stress
disorder. Journal of Clinical Psychology, 58, 1555–1571.
McAdams, D. P. (1993). The stories we live by: Personal myths
and the making of the self. New York:
Morrow. Miles, D. (2004). Stress levels high among service
members: Some red flags raised. Retrieved from
http://www.defenselink.mil/news/Mar2004/n03092004_
200403092.html
Morgan, D. (1998). The focus group guidebook. Newbury Park,
CA: Sage.
O’Sullivan-Lago, R., & de Abreu, G. (2010). Maintaining
continuity in a cultural contact zone: Identification strategies in
the dialogical self. Culture and Psychology, 16, 73–92.
O’Sullivan-Lago, R., de Abreu, G., & Burgess, M. (2008). ‘I
am a human being like you’: An identification strategy to
maintain continuity in a cultural contact zone. Human
Development, 51, 349–367.
Pasupathi, M., Mansour, E., & Brubaker, J. (2007). Developing
a life story: Constructing relations between self and experience
in autobiographical narratives. Human Development, 50, 85–
110.
Pasupathi, M., Weeks, T., & Rice, C. (2006). Reflecting on life:
Remembering as a major process in adult development. Journal
of Language and Social Psychology, 25, 244–263.
Pietrzak, R., Johnson, D., Goldstein, M., Malley, J., &
Southwick, S. (2009). Psychological resilience and
postdeployment social support protect against traumatic stress

and depressive symptoms in soldiers returning from Operations
Enduring Freedom and Iraqi Freedom. Depression and Anxiety,
26, 745–751.
Pillemer, D. (1998). Momentous events, vivid memories.
Cambridge, MA: Harvard University Press.
Resnik, L., & Allen, S. (2007). Using International
Classification ofFunctioning, Disability and Health to
understand challenges in community reintegration of injured
veterans. Journal of Rehabilitation Research and Development,
44, 991–1006.
Resnik, L., Plow, M., & Jette, A. (2009). Development of CRIS:
Measure of community reintegration of injured service
members. Journal of Rehabilitation Research and Development,
46, 469–480.
Ricoeur, P. (1992). Oneself as another (K. Blamey, Trans.).
Chicago: University of Chicago Press.
Riggs, D., Caulfield, M., & Street, A. (2000). Risk for domestic
violence: Factors associated with perpetration and
victimization. Journal of Clinical Psychology, 56, 1289–1316.
Rosenthal, R., & Rosnow, R. (2007). Essentials of behavioral
research: Methods and data analysis (3rd ed.). Boston: McGraw-
Hill.
Sarbin, T. (1986). The narrative as the root metaphor for
psychology. In T. R. Sarbin (Ed.), Narrative psychology: The
storied nature of human conduct (pp. 3–21). New York: Praeger.
Schnurr, P., Lunney, C., & Sengupta, A. (2004). Risk factors for
development versus maintenance of posttraumatic stress
disorder. Journal of Traumatic Stress, 17, 85–95.
Seltzer, J., & Kalmuss, D. (1988). Socialization and stress
explanations for spouse abuse. Social Forces, 67, 473–491.
Strauss, M. (1990). Social stress and marital violence in a
national sample of American families. In M. A. Strauss, R. J.
Gelles, & C. Smith (Eds.), Physical violence in American
families: Risk factors and adaptations to violence in 8,145
families (pp. 181–200). New Brunswick, NJ: Transaction.
Sussman, N. (2000). The dynamic nature of cultural identity

throughout cultural transitions: Why home is not so sweet.
Personality and Social Psychology Review, 4, 355–373.
Tanielian, T., & Jaycox, L. (Eds.). (2008). Invisible wounds of
war: Psychological and cognitive injuries, their consequences,
and services to assist recovery. Santa Monica, CA: RAND
Corporation.
Tick, E. (2005). War and the soul: Healing our nation’s veterans
from post–traumatic stress disorder. Wheaton, IL: Quest Books.
Turner, V. (1974). Dramas, fields, and metaphors: Symbolic
action in human society. Ithaca, NY: Cornell University Press.
Van Gennep, A. (1960). The rites of passage (M. Vizedom & G.
Caffee, Trans.). London: Routledge.
Weber, L. (1998). A conceptual framework for understanding
race, class, gender, and sexuality. Psychology of Women
Quarterly, 22, 13–22.
Westwood, M., Black, T., & McLean, H. (2002). A re-entry
program for peacekeeping soldiers: Promoting personal and
career transition. Canadian Journal of Counselling, 36, 221–
232.
Westwood, M., McLean, H., Cave, D., Borgen, W., & Slakov, P.
(2010). Coming home: A group-based approach for assisting
military veterans in transition. Journal for Specialists in Group
Work, 35, 44–68.
White, M., & Epston, D. (1990). Narrative means to therapeutic
ends. New York: Norton.
Whitty, M. (2002). Possible selves: An exploration of the utility
of a narrative approach. Identity: An International Journal of
Theory and Research, 2, 211–228.
Anne Demers is an assistant professor in the Health Science
Department at San Jose State University. She has many years of
experience in the study of organizations, social systems, and
community change. Her research interests are in the related
areas of disenfranchisement from community, actions that
compromise mental health, and evaluation of policy and service
interventions designed to help people reintegrate into

communities.
Professional Psychology: Research and Practice
In the public domain
2011, Vol. 42, No. 1, 1–7
DOI: 10.1037/a0022322
An Evidence-Informed Guide for Working With Military
Women and Veterans
Marjan Ghahramanlou-Holloway, Daniel W. Cox, Elisabeth C.
Fritz, and Brianne J. George Uniformed Services University of
the Health Sciences
Psychologists and other behavioral health professionals working
in civilian, military, or Veterans Affairs settings are expected to
provide optimal assessment and treatment services to military
women and veterans (MWVs). Yet many providers have
minimal knowledge and training on the unique psychological
stressors and associated mental health issues common to this
understudied population. As the number of women in all
components of the military continues to grow, the manner in
which men and women differentially interpret and react to
military service challenges is receiving more attention from
scientists and practitioners. In the current article, we highlight
eight critical areas for psychologists who conduct assessment,
treatment conceptualization, and planning for their MWV
patients. Within each of these areas, a brief description of the
empirical literature is presented followed by empirically and
experientially derived clinical recommendations. Overall, the
informational guide presented here will equip psychologists
with knowledge, clinical tools, and considerations for the
delivery of evidence-informed care to women with current or
prior military service.
Keywords: women, military, veterans, clinical
recommendations, treatment, guide, health disparities
Editor’s Note. This article was submitted in response to an open
call for submissions concerning the provision of Psychological

Services by practitioner psychologists to veterans, military
service members, and their families. This collection of 12
articles represents psychologists’ perspectives on the mental
health treatment needs of these individuals along with
innovative treatment approaches for meeting these needs.—JEB
MARJAN GHAHRAMANLOU-HOLLOWAY received her PhD
in Clinical Psychology from Fairleigh Dickinson University and
completed her postdoctoral fellowship at the University of
Pennsylvania. She is an Assistant Professor of Medical and
Clinical Psychology at the Uniformed Services University of the
Health Sciences and maintains an independent practice in Chevy
Chase, MD. Her research interests include inpatient cognitive
behavioral interventions for the prevention of suicide,
psychotherapy outcome research, and promotion of
psychological health among military personnel. DANIEL W.
COX received his PhD in Counseling Psychology from the
University of Kansas. He is a postdoctoral fellow at the
Uniformed Services University of the Health Sciences. His
research interests focus on the role of trauma, emotional
regulation, and problem solving skillsas potential mechanisms
of change in the cognitive behavioral treatment of suicidal
individuals. ELISABETH C. FRITZ received her BA in
Psychology from Cornell University. She is a doctoral student
in Clinical Psychology at American University and a research
assistant at Uniformed Services University of the Health
Sciences. Her research interests include mindfulness as an
intervention and prevention strategy for posttraumatic stress
disorder. BRIANNE J. GEORGE received her BS in Psychology
from University of Maryland University College. She is a First
Lieutenant in the United States Air Force and a doctoral student
in Clinical Psychology at Uniformed Services University of the
Health Sciences. Her research interests include psychological
health of military women, postpartum depression in military
women, and gender differences in suicide-related inpatient
admissions. DISCLAIMER: The opinions or assertions
contained herein are the private views of the authors and are not

to be construed as official or as reflecting the views of the
Department of Defense. CORRESPONDENCE CONCERNING
THIS ARTICLE should be addressed to Marjan Ghahramanlou-
Holloway, Department of Medical & Clinical Psychology,
Uniformed Services University of the Health Sciences, 4301
Jones Bridge Road, Room B3039, Bethesda, MD 20814-4799.
E-mail: [email protected]
More than ever before in our nation’s history, psychologists are
delivering services to women with current or prior military
service. Currently, women comprise an estimated 14.3% of the
active duty United States (U.S.) military, 17.7% of the reserve,
and 15.1% of the national guard (Women in Military Service for
America Memorial, 2009). Approximately 8% of U.S. military
veterans are women and 10% are projected to be women by
2020 (Office of Policy and Planning, 2007). Since women first
entered the Armed Services in 1948, their duties have evolved
and the nature of combat has changed. Currently, about 11% of
the U.S. forces in Iraq and Afghanistan consist of women
(Blank, 2008). While women continue to be prohibited from
serving in most official combat roles, the increasing service
opportunities in Operation Enduring Freedom (OEF) and
Operation Iraqi Freedom (OIF) have resulted in a growing
number of women being exposed to combat and noncombat
related stressors, placing them at increased risk for subsequent
psychopathology (Street, Vogt, & Dutra, 2009). As the nature of
women’s involvement in the military evolves, psychologists
across various Department of Defense (DoD), Veterans
Administration (VA), and civilian healthcare settings have an
increasing responsibility to recognize, understand, and respond
to the psychological issues these women encounter. This article
serves as an evidence-informed guide for psychologists working
with military women and veterans (MWVs). Eight critical areas
have been identified for inclusion in the guide presented below.
Inclusion decisions are the result of a comprehensive review of
the
PAGE 2

scientific literature as well as our clinical observations and
experience. Topics covered (in no specific order) include
trauma exposure; suicide-related ideation and behaviors; body
dissatisfaction and eating disorders; menstruation and
pregnancy; relationship and marital functioning; parenthood;
perceived barriers to care and stigma; and social support. The
discussion of each critical area includes a brief review of the
existing literature followed by specific clinical
recommendations. Our discussion is hoped to advance the
clinical-, research-, and policy-related issues pertaining to the
promotion of psychological well-being of, MWVs.
Empirically Driven Critical Areas
Exposure to Traumatic Event(s)
Vignette: Kim is seeking care for having been sexually
assaulted by a superior officer. . .
Brief review. Trauma exposure for MWVs may occur prior to,
during, and/or after military service (Street et al., 2009). Types
of traumatic life events experienced by women may include
military combat, adult sexual assault, childhood sexual abuse,
and intimate partner violence. Overall, military women are at an
increased risk of being exposed to traumas resulting from
combat, natural disasters, and major accidents compared to their
civilian counterparts (Zinzow, Grubaugh, Monnier, Suffoletta-
Maierle, & Frueh, 2007). Approximately 12% of women
deployed to OEF and OIF report moderate levels of combat and
up to 40% of deployed women come under mortar or artillery
fire (Street et al., 2009). In addition, military sexual trauma
(MST), defined as sexual assault or severe and threatening
sexual harassment during military service, has been reported in
22% of women compared to 1% of men (Kimerling, Gima,
Smith, Street, & Frayne, 2007). The lifetime prevalence of
sexual assault among women veterans is estimated at 38%
(Zinzow, Grubaugh, Frueh, & Magruder, 2008). Further, adult
sexual assault rates are greater for military women (24%– 49%)
than civilian women (13%–22%; Zinzow et al., 2007). Overall,
approximately 80% of military women report exposure to one or

more sexual stressors, which include sexual identity concerns,
harassment, and/or assault (Murdoch, Pryor, Polusny, &
Gackstetter, 2007). Military women are also more likely to have
experienced multiple types of childhood trauma compared to
military men and demographically matched civilian women
(Zinzow et al., 2008).
Military women, compared to their male counterparts, may react
differently to specific or cumulative traumatic life events and
display a varied pattern of psychological symptoms and
disorders in response to such experiences (Vogt, Pless, King, &
King, 2005). A history of trauma prior to military service may
increase a woman’s risk for cumulative trauma exposure and
subsequent mental health problems during and after her military
service (Zinzow et al., 2007). For instance, military women
more likely develop posttraumatic stress disorder (PTSD)
following exposure to military-related traumatic events (Tolin
& Foa, 2006) and screen positive for psychiatric disorders after
deployment (Felker, Hawkins, Dobie, Gutierrez, & McFall,
2008). In addition, women who experience MST are more likely
to have subsequent physical or emotional health problems, to be
diagnosed with PTSD or major depressive disorder (MDD), and
experience difficulties in post deployment adjustment (Murdoch
et al., 2007; Street, Gradus, Stafford, & Kelly, 2007; Zinzow et
al., 2007).
Clinical recommendations. MWVs with a history of trauma
often have complex symptoms and biopsychosocial stressors
that could complicate and lengthen mental health treatment.
Providers would serve female service members well by
screening for lifetime and recent exposure to traumatic events at
intake and on regular intervals based on their clinical judgment.
Assessment should focus on both military and nonmilitary-
related traumatic events. Psychologists must consider that
victims of military sexual trauma or domestic violence may face
obstacles to receiving care if the victim and assailant are both
service members and must live and work together after the
incident(s)—particularly when deployed (Zinzow et al., 2007).

Some women, because of career-related concerns and/or shame,
may be reluctant to disclose information about exposure to
traumatic events. Thus, a multimethod assessment approach is
recommended to maximize the likelihood of detecting exposure.
Some military women may be more likely to disclose traumatic
experiences on self-report measures (e.g., the PTSD Checklist
[PCL]; Weathers, Litz, Herman, Huska, & Keane, 1993) because
they are impersonal, while others may be more likely disclose
such information on clinician administered measures (e.g., the
Clinician Administered PTSD Scale [CAPS]; Blake et al., 1995)
because of rapport with the assessor. In particular, careful
attention must be paid to assess for childhood trauma, military
sexual trauma,1 and trauma resulting from military service
related events.
Additionally, the construction of a trauma timeline (to
determine the number, type, and chronology of traumas) may be
helpful. Psychologists would also benefit from training in
empirically supported treatments such as prolonged exposure
(PE; Foa, Hembree, & Rothbaum, 2007) and/or cognitive
processing therapy (CPT; Resick & Schnicke, 1992) for PTSD.
Online training programs such as the one offered through the
Center for Deployment Psychology at the Uniformed Services
University of the Health Sciences can be valuable resources (see
http://deploymentpsych.org/training/online-courses). For
providers with minimal experience treating trauma related
reactions, referring to professionals who specialize in this area
or regular consultation with more seasoned colleagues is
appropriate. Finally, striving to provide a safe and supportive
environment for MWVs seeking services is an important
recommendation. Research indicates that comfort of women
with treatment programs offered at a VA treatment facility was
associated with treatment adherence, and comfort increased as
exposure to treatment increased (Fontana & Rosenheck, 2006).
Manualized treatments typically do not take into account
complicating factors such as multiple traumas, stigma, and
reporting concerns when recommending length and course of

treatment. Hence, if using a treatment manual, timelines may
need to be extended to increase patient comfort. Also,
awareness of the therapeutic alliance is critical. Thus,
addressing demographic differences between clini
PAGE 3
cian and patient such as gender, race, and military-civilian
differences may be necessary to increase patient comfort.
Suicide-Related Ideation and Behaviors
Vignette: Candace can generate no reasons for living following
an aborted suicide attempt. . . Briefreview. Suicide is a
significant public health problem in the military as it impacts
unit morale, cohesion, and bears a significant emotional cost
and resource drain for the individual’s family and friends (Kang
& Bullman, 2008). In general, DoD and VA suicide surveillance
programs do not provide specific epidemiological data on
military women suicides since a significant number of military
personnel who die by suicide are men. Furthermore, DoD and
VA prevalence rates associated with suicide attempts are not
systematically tracked; therefore, the significance of the high
female to male ratio for suicide attempts may not receive the
attention it requires.
Suicide has been identified as the fourth leading cause of death
for military and civilian women (Washington Headquarters
Services Directorate for Information Operations and Reports,
1999; Web-based Injury Statistics Query and Reporting System
[WISQARS], 2009). Further, military women have a three-fold
increased risk for suicide compared to their civilian
counterparts (Cassels, 2009). Female veterans are 79% more
likely to die by suicide than civilian women (Cassels, 2009;
McCarthy et al., 2009). In particular, higher suicide mortality
rates among veteran women age 40–59 years, as compared to a
civilian population, have been reported (McCarthy et al., 2009).
One explanation for the higher observed suicide rates in MWVs
is related to their access, familiarity, and use of firearms as
compared to their civilian counterparts who may choose other
methods such as drug overdose (Cassels, 2009). Clinical

recommendations. Psychologists need to regularly assess for
suicide-related ideation and behaviors using psychometrically
sound measures such as the Columbia Suicide Severity Rating
Scale (C-SSRS; Posner et al., 2006).
Another option is the Suicide Status Form (SSF), a
collaborative assessment, treatment planning, and
documentation source for interviewing a patient about suicide-
related risk and protective factors (Jobes, 2006). Risk
assessment and management can be aided by identifying
precipitants for suicide-related ideation and behaviors. For
example, the case conceptualization model used in Cognitive
Therapy for suicide prevention (Ghahramanlou-Holloway,
Brown, & Beck, 2008) or the chain analysis method used in
Dialective Behavior Therapy (Linehan, Camper, Chiles,
Strosahl, & Shearin, 1987) may be helpful for understanding
cognitive, affective, behavioral, environmental, and
physiological precipitants for suicide-related ideation and
behaviors. Based on our experience, such precipitants
commonly include legal problems (e.g., Article 15), thoughts of
being trapped in the military, deployment related stressors,
reexperiencing of traumatic life events, and relationship issues.
Risk management responsibilities when working with MWVs
with suicide ideation, intent, and/or planning are complicated
by the availability of and increased likelihood of access to
lethal means of suicide, such as firearms. Providers must
address the removal of such lethal means and the conditions
under which the lethal means would be returned to MWVs.
Depending on the imminence of the suicide threat, providers are
encouraged to
consider collaborative work with family members, trusted peers,
and/or the service member’s command to ensure safety. In our
experience, patients are often willing to work with providers on
limiting access to potential sources of harm. If an active duty
patient is judged to be at imminent risk for suicide and resists
interventions, psychologists can notify the service member’s
direct chain of command or military police. Finally, providers

are encouraged to be mindful of the stigma, harassment, and
possible ridicule within the military environment that MWVs
may experience because of how suicide-related behaviors may
be perceived by others. Within the military, suicide related
behaviors may be perceived and labeled as malingering.
“Women are still seen as weak, whiny, hormonal, and
incapable,” (Blank, 2008, p. 19) and such negative perceptions
may lead to a minimization or dismissal of their symptoms.
Regardless of the level of recognized risk, providers are
encouraged to collaboratively prepare safety plans with their
patients. The VA’s guide for constructing safety plans is a
helpful resource (Stanley & Brown, 2008).
Body Dissatisfaction and Eating Disorders
Vignette: Joy reports a mirror checking ritual to rate her
muscular development. . .
Brief review. Though subject to the same types of fitness and
body composition standards as military men, military women
have reported higher levels of body dissatisfaction and more
depressive and anxious symptoms associated with their weight
(Carlton, Manos, & Van Slyke, 2005; Kress, Peterson, &
Hartzell, 2006). Compared to civilian women, military women
are more often diagnosed with an Eating Disorder, Not
Otherwise Specified (NOS; i.e., 63% compared to 35%) and use
compensatory strategies such as laxatives and fasting (McNulty,
2001). McNulty suggests that such disturbances in eating result
from military pressures to attain and maintain fitness and
weight standards. In fact, military women who express a higher
drive for thinness and greater body dissatisfaction appear to be
at greater risk for developing an eating disorder (Lauder &
Campbell, 2001). In a recent study, military women with
deployment experience were 1.78 times more likely to develop
disordered eating and 2.35 times more likely to lose a large
amount of weight than nondeployed military women (Jacobson
et al., 2008).
Clinical recommendations. Psychologists should screen for
current and lifetime eating disorders in MWVs and follow-up

with validated measures such as the Eating Disorder Inventory
(EDI; Garner, Olmstead, & Polivy, 2006). Providers should also
maintain awareness of complexities that arise regarding weight
in active duty women. First, there are objective weight and body
fat percentage standards that must be met while serving in the
military. Second, MWVs in our experience often believe that
they are inferior to their male colleagues if their bodies do not
perform in the same ways. Trained providers can help women at
risk for disordered eating find and adhere to healthy ways of
maintaining weight standards. Knowledge of empirically
supported treatments for eating disorders such as Fairburn and
colleagues’ (2009) transdiagnostic approach is suggested, as is
referring clients to eating disorder specialists.
PAGE 4
Menstruation and Pregnancy
Vignette: Kathy has missed work due to distressing images
about harming her baby. . .
Brief review. Military women have physiologically based
challenges related to their menstrual cycles that are not always
compatible with military deployment and service
(PowellDunford, Deuster, Claybaugh, & Chapin, 2003). Some
military women who desire menstrual suppression due to
perceived and/or actual inconvenience report difficulties in
maintaining proper hygiene during certain military-related
activities (e.g., during combat), experience more intense
menstrual periods during deployment, and hold negative views
of military service and menstruation (Trego, 2007). Menstrual
irregularities, due to stress, exercise, dietary habits, or some
combination of these, have been noted in 98.3% of the U.S.
Military Academy women cadets (Schneider, Bijur, Fisher,
Friedman, & Toffler, 2003). Further, iron deficiency in almost
80% of female military recruits has been reported (Dubnov et
al., 2006). Iron deficiency may result in low energy, low
motivation, or depressive symptoms and can be especially
problematic in military occupations requiring frequent physical
activity.

Pregnancy in MWVs may activate or exacerbate pressures to
balance work and family demands, similar to working civilian
women who are pregnant (Rychnovsky & Beck, 2006). Rates of
postpartum depression in active duty military samples are
roughly equivalent to civilian rates (Rychnovsky, 2007).
Further, Biggs, Douglas, O’Boyle, and Rieg (2009) found that
married mothers reported their command as supportive during
their pregnancy; comparatively, single mothers reported a less
supportive command environment during pregnancy and were
more likely to be reassigned, often resulting in loss of training
or experience.
Clinical recommendations. Awareness of the unique physical
conditions that affect MWVs is important when conducting
initial mental health assessments and when delivering treatment.
Medical consultations may be necessary to investigate whether
emotional irregularities, particularly for depressive symptoms
such as low mood, energy, and motivation, may be partially or
completely due to physical conditions (e.g., anemia). Often,
referrals to and consults with nutritionists, dieticians, and
primary care physicians including gynecologists knowledgeable
about the specific concerns of military women are greatly
beneficial. Moreover, women recruits could benefit from
focused psychoeducation on topics such as menstruation and
military service. Psychologists should help service members
become aware of their rights and the regulations in their
branches regarding pregnancy, which may involve referrals to
lawyers or the Judge Advocate General’s (JAG) office if
concerns arise about not being treated according to military
regulations. From our experience, pregnancy may be perceived
as a way to get out of the military or assigned duties such as
deployment. Real and/or perceived discrimination may
contribute to a host of psychological difficulties and
psychologists can help the patient problem solve an approach to
such stressors. For postpartum depression, early
psychoeducation would be beneficial so that symptoms can be
immediately recognized by the patient and her family to

promote early intervention and close monitoring of
symptomatology.
Relationship and Marital Functioning
Vignette: Cindy loves her husband but lacks sexual desire after
return from her deployment. . .
Brief review. Military women face unique challenges while
separated from their families because of deployments, remote
assignments, or temporary duty. The 2002 DoD Survey of
HealthRelated Behaviors indicates that military women
(particularly those under 25 years old), geographically
separated from their spouses due to work, experienced more
occupational and family stress than those not separated
(Hourani, Williams, & Kress, 2006). During the months prior to
and after deployment, increased marital stress and decreased
marital satisfaction for both women and men have been reported
(McLeland, Sutton, & Schumm, 2008). Exposure to trauma
during deployment adds another layer of complexity. Trauma
symptoms resulting from combat exposure have been correlated
with decreased marital satisfaction (Goff, Crow, Reisbig, &
Hamilton, 2007). Such marital dissatisfaction may result from
trauma-related symptoms and an imbalance in the perceptions of
traumatic symptoms by service members and their spouses;
some spouses reported trauma symptoms that the service
member did not report (Renshaw, Rodrigues, & Jones, 2008).
Although we are unaware of any research on the impact of
military sexual trauma on perceived satisfaction in romantic
relationships and sexual intimacy, clinically we have observed
that sexual trauma can significantly alter the victim’s views of
own sexuality and comfort with sexual intimacy.
Clinical recommendations. We encourage psychologists to be
aware of the stress that a military lifestyle places on
relationships. Issues such as intimacy and role changes are
important to address due to the often frequent and long
separations experienced by military couples. Psychologists
confronting such beliefs as, “This marriage should not be so
hard,” and “No one else has the problems we do,” may reduce

the pressure that military women put on themselves. Individual
or group psychoeducation sessions may additionally be offered
to significant others. The primary objective of these
psychoeducation sessions would be to increase family members’
understanding of their loved one’s symptoms and treatment.
When appropriate, couples therapy may be beneficial for
learning more effective communication and conflict resolution
skills that improve the psychological health of MWVs.
Parenthood
Vignette: Joan feels numb toward her children in the days
leading up to her departure for Iraq. . .
Brief review. Military mothers face the challenge of balancing
demands of military service and parenthood. Deployments and
other physical separations can have a tremendous impact on
military women’s families, including their children. Military
women’s perception of the impact of a deployment on their
children is a significant predictor of the decision about
reenlistment (Kelley et al., 2001). A pilot study of mothers
returning from deployment found themes of concern to include
communication difficulties with loved ones, feelings of
isolation, and short reintegration period (Lange, Quigley, &
Santos, 2009). Deployed mothers face unique challenges.
Examples include more often being single parents, more
childcare complications, and
PAGE 5
more difficulty in balancing mental health concerns with the
needs of their family (Street et al., 2009). In addition, deployed
single mothers are more likely than married mothers or
nondeployed single mothers to report depressive symptoms
(Kelley et al., 2002). Children may also be at increased risk of
maltreatment by the nondeploying parent during the times prior
to and just after a military deployment (Rentz et al., 2007).
Further, combat exposure has been linked to increased family
adjustment problems even after controlling for PTSD symptoms
(Taft, Schumm, Panuzio, & Proctor, 2008).
Clinical recommendations. Though research in this area is

limited, military women, especially those preparing for or
transitioning home from deployment, may benefit from focused
problem-solving on the topics of childcare or temporary child
custody. For instance, psychologists can collaboratively
construct a child care and communication plan for women
expecting deployment or other military transitions. Providers
should be knowledgeable or, if not, ready to locate resources
targeted at MWVs (e.g., Family Advocacy Programs) to provide
appropriate referrals.2 MWVs may also benefit from the
validation and normalization of their concerns about military
life transitions, balancing a military career and motherhood, and
separation from family. Examining school and/or behavioral
health resources for children of military women, particularly if
there is a concern about their adjustment or mental health, may
also be warranted. Focused psychoeducation, parenting classes,
and family therapy may serve as additional treatment options.
Perceived Barriers to Care and Stigma
Vignette: Nancy is certain that she will lose her security
clearance if she discloses her troubles. . .
Brief review. Service members’ concerns about stigma are a
major barrier to care and those with psychiatric symptoms are
more likely to report such concerns (Hoge et al., 2004). The
good news is that military women are more likely than military
men to utilize mental health services during basic training and
while deployed (Carbone, Cigrang, Todd, & Fiedler, 1999;
Crawford & Fiedler, 1992). The bad news is that in a recent
study, over 40% of women veterans reported needing
psychological services but not getting them (Owens, Herrera, &
Whitesell, 2009). Not knowing that women’s services exist
(“VA is for men”), a negative perception regarding the quality
of VA healthcare, long wait periods, and prior bad experiences
with the VA system are reported reasons for not acquiring
services (Washington, Kleimann, Michelini, Kleimann, &
Canning, 2007). A significant portion of women veterans
choosing to seek treatment from non-VA settings report feeling
some stigma going to the local VA and/or feeling unwelcomed

at the VA. In addition to perceived stigma regarding own
utilization of mental health services, some military women view
the mental health needs of their children as having negative
implications on their military careers (Sansone, Matheson,
Gaither, & Logan, 2008).
Clinical recommendations. Psychologists can address perceived
barriers to care and stigma on several fronts. Most importantly,
open dialogue and understanding of MWVs’ concerns should
guide clinical work. In addition, increasing outreach activities
aimed at reducing perceived barriers to care and mental health
stigma is crucial. For instance, psychologists can visit a
military
base and provide informational seminars targeted at problems
commonly reported by military women. Behavioral health
integrated and collaborative services with primary care may be
extremely beneficial. Service members and veterans may view
seeking treatment as a sign of weakness, and this perception
may be especially true for MWVs trying to distance themselves
from traditional female stereotypes. Normalizing reactions and
providing information about symptoms and treatment to
individual service members and to military commands may help
to reduce institutional stigma. Another way to reduce mental
health stigma is to describe symptoms using medical models and
terminology. This may help MWVs view their psychological
symptoms analogously to physical symptoms, and facilitate
their conceptualization of treatment in familiar terms (Nash,
Silva, & Litz, 2009). For example, instead of talking about
diagnostic criteria for PTSD, psychologists can review normal
human physiological responses to stress and trauma.
Confidentiality concerns may be a barrier to care for military
women, particularly for those being treated by a military service
provider. Military regulations present complications for
uniformed military psychologists when conflicts arise with the
APA Ethics Code. For instance, patient records are not the
property of the psychologist, but the property of the
government. Therefore, patient information may be accessed by

the patient’s command, military investigative services, or other
military personnel (McCauley, Hughes, & Liebling-Kalifani,
2008). Psychologists should spend sufficient time informing
patients how they approach such privacy and confidentiality
issues to increase the therapeutic alliance. Military women may
also be informed of confidential services provided by Military
OneSource (http://www.militaryonesource.com).
Social Support
Vignette: Since separation from service, Mary feels neglected
by her military friends. . .
Brief review. Female veterans have reported less perceived
social support than male veterans (Frayne et al., 2006). This
disparity is a concern since social support has been shown to
protect against psychological symptoms and PTSD (Kelley et
al., 2002; King,King,Foy,Keane,&Fairbank,1999)while
improving service members’ personal and career development
(Baker & Hocevar, 2003). In nonmilitary populations, women
mentored by other women have reported increased emotional
support, skills and collaborations, companionship, sense of
voice, work promotions, and career satisfaction (Files, Blair,
Mayer, & Ko, 2008; Settles, Cortina, Stewart, & Malley, 2007;
Wallace, 2001).
Clinical recommendations. Assisting MWVs create a social
support network with others in their group has personal and
professional benefits. Interacting, sharing, and learning from
women who have gone through similar experiences can be
validating and normalizing as well as provide opportunities to
receive emotional support, give support, and to problem-solve.
Support can also take the form of individual peer mentorship.
Psychologists
PAGE 6
can help military women establish professional mentoring
relationships with more occupationally advanced military
women. Whether it is social support groups or individual
mentorship, helping MWVs find a community within the context
of a male dominated environment is extremely valuable.

Future Directions for the Advancement of Clinical Care of
Military Women and Veterans
In this article, we have provided an evidence-informed guide
for psychologists who deliver clinical services to military
women and veterans—a group that sacrifices just as much for
their country as their male counterparts. Health disparities
continue to exist because most often clinical and research
endeavors are directly targeted at problems typically
encountered by military men. To best inform our clinical
decisions and practices, gender focused research for MWVs
must, at a minimum, focus on the three following objectives: (1)
establish prevalence rates for psychiatric conditions among
MWVs; (2) build evidence on causes and mediating factors for
these psychiatric conditions; and (3) empirically adapt
evidence-based psychosocial treatments for MWVs. Moreover,
research that directly addresses the unique needs of MWVs must
span from their acculturation to military life upon service entry
to basic training, technical training, and finally to the entire
course of their professional military service, overall career
trajectory, separation, and reintegration into civilian life. In
terms of clinical practice, psychologists are encouraged to
continually monitor their own sex biases, gain a better
understanding of the unique military service stressors that
MWVs experience, and strive to offer gender-fair services.
References
Baker,B.T.,&Hocevar,S.P.(2003).The prevalence and nature of
service academy mentoring: A study of Navy midshipmen.
Military Psychology, 15, 273–283.
Biggs, R. L., Douglas, B. H., O’Boyle, A. L., & Rieg, T. S.
(2009). The impact of pregnancy on the individual and military
organization: A postpartum active duty survey. Military
Medicine, 174, 61–75.
Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G.,
Gusman, F. D., Charney, D. S., & Keane, T. M. (1995). The
development of a Clinician-Administered PTSD Scale. Journal
of Traumatic Stress, 8, 75–90.

Blank, K. (2008). Women in the military: Overcoming
challenges. Retrieved from
http://www.samhsa.gov/samhsanewsletter/
volume_16_number_6/womeninmilitary.aspx
Carbone, E. G., Cigrang, J. A., Todd, S. L., & Fiedler, E. R.
(1999). Predicting outcome of military basic training for
individuals referred for psychological evaluation. Journal of
Personality Assessment, 72, 256– 265.
Carlton, J. R., Manos, G. H., & Van Slyke, J. A. (2005).
Anxiety and abnormal eating behaviors associated with cyclical
readiness testing in a naval hospital active duty population.
Military Medicine, 170, 663–667.
Cassels, C. (2009). APA 2009: Young women Veterans at high
risk for suicide. Retrieved from
http://www.medscape.com/viewarticle/703424
Crawford, S. L., & Fiedler, E. R. (1992). Childhood physical
and sexual abuse and failure to complete military basic training.
Dubnov, G., Foldes, A. J., Mann, G., Magazanik, A., Siderer,
M., & Constantini, N. (2006). High prevalence of iron
deficiency and anemia in female military recruits. Military
Medicine, 171, 866–869.
Fairburn, C. G., Cooper, Z., Doll, H. A., O’Connor, M. E.,
Bohn, K.,
Hawker, D. M.,...Palmer, R. L. (2009). Transdiagnostic
cognitive behavioral therapy for patients with eating disorders:
A two-site trial with60-weekfollow-up. American Journal of
Psychiatry, 166, 311–319.
Felker, B., Hawkins, E., Dobie, D., Gutierrez, J., & McFall, M.
(2008). Characteristics of deployed Operation Iraqi Freedom
military personnel who seek mental health care. Military
Medicine, 173, 155–158.
Files, J. A., Blair, J. E., Mayer, A. P., & Ko, M. G. (2008).
Facilitated peer mentorship: A pilot program for academic
advancement of female medical faculty. Journal of Womens
Health, 17, 1009–1015

. Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007).
Prolonged exposure therapy for PTSD: Emotional processing of
traumatic experiences, therapist guide. New York: Oxford.
Fontana, A., & Rosenheck, R. (2006). Treatment of female
Veterans with posttraumatic stress disorder: The role of comfort
in a predominantly male environment. Psychiatric Quarterly, 77,
55–67.
Frayne, S. M., Parker, V. A., Christiansen, C. L., Loveland, S.,
Seaver, M. R., Kazis, L. E., & Skinner, K. M. (2006). Health
status among 28,000 women Veterans. The VA Women’s Health
Program Evaluation Project. Journal of General Internal
Medicine, 21 Suppl, 3, S40–S46.
Garner, D. M., Olmstead, M. P., & Polivy, J. (2006).
Development and validation of a multidimensional eating
disorder inventory for anorexia nervosa and bulimia.
International Journal of Eating Disorders, 2, 15–34.
Ghahramanlou-Holloway, M., Brown, G. K., & Beck, A. T.
(2008). Suicide. In M. A. Whisman (Ed.), Adapting cognitive
therapy for depression: Managing complexity and comorbidity
(pp. 159–184). New York, NY:
Guilford Press. Goff, B. S., Crow, J. R., Reisbig, A. M., &
Hamilton, S. (2007). The impact of individual trauma symptoms
of deployed soldiers on relationship satisfaction. Journal of
Family Psychology, 21, 344–353.
Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D.,
Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq
and Afghanistan, mental health problems, and barriers to care.
New England Journal of Medicine, 351, 13–22.
Hourani, L. L., Williams, T. V., & Kress, A. M. (2006). Stress,
mental health, and job performance among active duty military
personnel: Findings from the 2002 Department of Defense
Health-Related Behaviors Survey. Military Medicine, 171, 849–
856.
Jacobson, I. G., Ryan, M. A., Hooper, T. I., Smith, T. C.,
Amoroso, P. J., Boyko, E. J.,...Bell, N. S. (2008). Alcohol use
and alcohol-related problems before and after military combat

deployment. Journal of the American Medical Association, 300,
663–675.
Jobes, D. A. (2006). Managing suicidal risk: A collaborative
approach. New York:
Guilford.
Kang, H. K., & Bullman, T. A. (2008). Risk of suicide among
US Veterans after returning from the Iraq or Afghanistan war
zones. Journal of the American Medical Association, 300, 652–
653.
Kelley, M. L., Hock, E., Jarvis, M. S., Smith, K. M., Gaffney,
M. A., & Bonney, J. F. (2002). Psychological adjustment of
Navy mothers experiencing deployment. Military Psychology,
14, 199–216.
Kimerling, R., Gima, K., Smith, M. W., Street, A., & Frayne,
S. (2007). The Veterans Health Administration and military
sexual trauma. American Journal of Public Health, 97, 2160–
2166.
King, D. W., King, L. A., Foy, D. W., Keane, T. M., &
Fairbank, J. A. (1999). Posttraumatic stress disorder in a
national sample of female and male Vietnam Veterans: Risk
factors, war-zone stressors, and resilience recovery variables.
Journal of Abnormal Psychology, 108, 164–170.
Kress, A. M., Peterson, M. R., & Hartzell, M. C. (2006).
Association between obesity and depressive symptoms among
U.S. Military active duty service personnel, 2002. Journal of
Psychosomatic Research, 60, 263–271.
Lange, G., Quigley, K., & Santos, S. L. (2009). Pilot study of
reintegration and service needs for women veteran mothers.
Retrieved from http://
www.warrelatedillness.va.gov/nj/provider_research.asp#reintigr
ation
Lauder, T. D., & Campbell, C. S. (2001). Abnormal eating
behaviors in female reserve officer training corps cadets.
Linehan, M. M., Camper, P., Chiles, J. A., Strosahl, K., &
Shearin, E. (1987). Interpersonal problem solving and

parasuicide. Cognitive Therapy and Research, 11, 1–12.
McCarthy, J. F., Valenstein, M., Kim, H. M., Ilgen, M., Zivin,
K., & Blow, F. C. (2009). Suicide mortality among patients
receiving care in the Veterans Health Administration Health
System. American Journal of Epidemiology, 169, 1033–1038.
McCauley, M., Hughes, J., & Liebling-Kalifani, H. (2008).
Ethical considerations for military clinical psychologists: A
review of selected literature. Military Psychology, 20, 7–20.
McLeland, K., Sutton, G. W., & Schumm, W. R. (2008).
Marital satisfaction before and after deployments associated
with the global war on terror. Psychological Reports, 103, 836–
844.
McNulty, P. A. (2001). Prevalence and contributing factors of
eating disorder behaviors in active duty service women in the
Army, Navy, Air Force, and Marines. Military Medicine, 166,
53–58.
Murdoch, M., Pryor, J. B., Polusny, M. A., & Gackstetter, G.
D. (2007). Functioning and psychiatric symptoms among
military men and women exposed to sexual stressors. Military
Medicine, 172, 718–725.
Nash, W. P., Silva, C., & Litz, B. (2009). The historic origins of
military and veteran mental health stigma and the stress injury
model as a means to reduce it. Psychiatric Annals, 39, 789–794.
Office of Policy and Planning. (2007). Women Veterans: Past,
present and future. Washington, DC: Author.
Owens, G. P., Herrera, C. J., & Whitesell, A. A. (2009). A
preliminary investigation of mental health needs and barriers to
mental health care for female Veterans of Iraq and Afghanistan.
Traumatology, 15, 31–37.
Posner, K., Brent, D., Lucas, C., Gould, M., Stanley, B., Brown,
G., . . .Mann, J. (2006). Columbia Suicide-Severity Rating Scale
(CSSRS). New York: New York State Psychiatric Institute
. Powell-Dunford, N. C., Deuster, P. A., Claybaugh, J. R., &
Chapin, M. G. (2003). Attitudes and knowledge about
continuous oral contraceptive pill use in military women.

Journal of Loss and Trauma, 16160–179, 2011 Copyright # Taylor .docx

Recommended

Recommended

More Related Content

Similar to Journal of Loss and Trauma, 16160–179, 2011 Copyright # Taylor .docx

Similar to Journal of Loss and Trauma, 16160–179, 2011 Copyright # Taylor .docx (20)

More from croysierkathey

More from croysierkathey (20)

Recently uploaded

Recently uploaded (20)

Journal of Loss and Trauma, 16160–179, 2011 Copyright # Taylor .docx