Help-Seeking Among Airmen in Distressed Relationships: Promoting Relationship Well-Being - Spotlight on Research

Welcome to the Spotlight on Research Column. This column showcases research activities and projects underway in many of the research laboratories within Department of Defense (DOD), partnering organizations and the academic and practitioner community in military psychology. Research featured in the column includes a wide variety of studies and programs, ranging from preliminary findings on single studies to more substantive summaries of programmatic efforts on targeted research topics. Research described in the column is inclusive of all disciplines relevant to military psychology—spanning the entire spectrum of psychology including clinical and experimental, as well as basic and applied. If you would like your work to be showcased in this column, please contact Colleen Varga.

This edition of the newsletter addresses the intersection of help-seeking, individual mental health concerns and relationship problems postdeployment in a sample of U.S. Air Force Security Forces members. This group is at high risk for posttraumatic stress disorder (PTSD), depression and alcohol problems, and evidence suggests that high rates of relationship problems and dissolution are present after the year-long deployments these members faced. While many psychologists tend to think of couples counseling as a lower-stigma, more approachable avenue to seeking mental health treatment, evidence from this study shows very low rates of help-seeking for relationship problems. Coupled with a historical dearth of resources within the DOD for relationship counseling, the authors offer a potential approach for targeting airmen with relationship problems as an avenue for reducing both relationship and individual distress.

Editor's Note: The following is an abridged version of the authors' article published in the March 2016 issue of Psychotherapy: Snyder, D. K., Balderrama-Durbin, C., Cigrang, J. A., Talcott, G. W., Smith Slep, A. M., & Heyman, R. E. (2016). Help-seeking among airmen in distressed relationships: Promoting relationship well-being. Psychotherapy, 53 , 1–12. http://dx.doi.org/10.1037/ pst0000045

Research Overview

Various surveys of service members returning from combat operations in Iraq and Afghanistan have found alarming rates of postdeployment mental health symptoms but low levels of formal help-seeking (Cigrang et al., 2014; Hoge et al., 2004; Kim, Britt, Klocko, Riviere, & Adler, 2011; Osório, Jones, Fertout, & Greenberg, 2013). Paradoxically, service members' anticipation that mental health help-seeking would lead to stigmatization by peers and supervisors has been shown to be greatest among those most in need of help. Such findings have galvanized researchers and government leaders to focus on stigma as a dominant problem associated with the provision of mental health care to our newest veterans. However, studies directly examining the association between perceived stigma and seeking of mental health services have yielded little evidence to support this hypothesized linkage (Sharp et al., 2015). For example, a handful of cross-sectional studies involving active-duty service members (Kehle et al., 2010; Kim et al., 2011; Valenstein et al., 2014) as well as prospective studies of veterans seeking care (Harpaz-Rotem, Rosenheck, Pietrzak, & Southwick, 2014; Hoerster et al., 2012; Rosen et al., 2011) have found stigma to be unrelated to receiving subsequent mental health care.

A large proportion of service members and veterans reporting emotional or behavioral disorders do not seek mental health services for these difficulties. Levels of anticipated stigma for mental health help-seeking do not reliably influence whether active-duty service members or veterans choose to obtain help. Although the association between perceived stigma and help-seeking may be more nuanced—for example, influencing where service members with greater concerns for social stigma may seek help—no studies have addressed this specifically. Level of psychological distress and one's own attitude toward mental health treatment appear to be better potential predictors of help-seeking. And finally, given the comorbidity of individual disorders and intimate partner distress in civilian samples and the association of marital distress with mental health care utilization and response to treatment (Snyder & Whisman, 2004), the influence of relationship distress on patterns of help-seeking in military and veteran populations seems particularly important to examine.

The year was 2008, and the U.S. Air Force had committed personnel from its Security Forces to one-year deployments to train Iraqi police, a high-risk mission that required patrolling in communities with a high insurgent presence. Anecdotal reports to U.S. Air Force command following the first detachment of these Security Forces indicated high rates of mental health difficulties during and immediately following deployment. In response to those reports, the U.S. Air Force command enlisted the assistance of our research group—comprising both military and civilian researchers—to address the following questions: What individual and relationship dysfunctions were Security Forces at greatest risk for incurring during deployment?

Approach and Findings

The Impact of Combat Deployment on Psychological and Relationship Health

Our team followed two consecutive detachments of U.S. Air Force Security Forces incurring one-year deployments to Iraq, assessing them across a broad spectrum of individual and relationship health prior to, during (in theater) and six to nine months following deployment (Cigrang et al., 2014). Our findings revealed substantial deterioration in airmens' individual and relationship functioning from pre- to postdeployment. Rates of posttraumatic stress disorder (PTSD) at moderate or severe levels increased by more than sixfold from 7 percent to 47 percent. Similarly, rates of depression at moderate or severe levels increased across deployment from 3 percent to 29 percent. Problematic alcohol use—already substantial at predeployment (at 25 percent)—nearly doubled to 45 percent. And of the 92 airmen in a committed relationship prior to deployment, at the six to nine-month follow-up, over half (54 percent) reported their relationship as significantly distressed, dissolving or already dissolved, whereas only 25 percent had reported significant relationship distress at predeployment.

Patterns of Help-Seeking

At each of the three assessments, airmen were asked whether they had sought any mental health or related counseling services and, if so, for what reasons and from which providers. Overall, at follow-up, 37 percent of airmen indicated that they had sought counseling services of some kind since returning from deployment. More importantly, rates of help-seeking increased among airmen screening positive for mental health problems—reaching 59 percent for individuals with clinical levels of PTSD, 50 percent for those with depression and 42 percent for those meeting criteria for alcohol misuse (Figure 1).

Figure 1. Rates of help-seeking across the deployment cycle for any reason among Airmen reporting clinical levels of posttraumatic stress disorder (PTSD), depression, or alcohol misuse at 6 –9 months postdeployment. ADAPT alcohol/drug abuse prevention and treatment program.

Nevertheless, many service members needing mental health services were not receiving them—in part because they were not seeking them out. Of those airmen who sought mental health care, the most common reasons were for deployment-related experiences (22 percent), depression or anxiety (19 percent) and anger (19 percent; Figure 2).

Only a small percentage of partnered participants (4 percent) sought couples counseling with their partner, although a larger group (11 percent) sought individual counseling for relationship problems.

We had anticipated that perceived stigma associated with receiving mental health services and negative attitudes toward mental health treatment might be related to subjective distress of specific mental disorders and, hence, adversely impact help-seeking from any source or possibly influence the specific source of services sought. Indeed, both perceived stigma and negative attitudes toward mental health services were positively associated with levels of PTSD symptoms, depression and alcohol misuse. However, neither perceived stigma nor attitudes toward mental health treatment discriminated between those airmen who sought mental health services versus those who did not. Moreover, over half of airmen reporting clinical levels of PTSD, depression or alcohol misuse sought services from a mental health provider, whereas fewer than 10 percent sought counseling from a chaplain or military family life consultant, or from Military OneSource or an alcohol/drug abuse prevention and treatment program (ADAPT; Figure 3).

That is, contrary to our hypothesis that higher anticipated stigma might lead to help-seeking from more anonymous providers, there was no significant difference in perceived stigma ratings for airmen who used specialty mental health services versus those who used other counseling services.

Figure 2. Rates of reported help-seeking at 6 –9 months postdeployment by type of problem.

Figure 3. Rates of help-seeking at 6 –9 months postdeployment from specific providers by Airmen with posttraumatic stress disorder (PTSD), depression, or alcohol-use disorder. ADAPT alcohol/drug abuse prevention and treatment program.

Do Patterns of Help-Seeking Differ for Airmen in Distressed Relationships?

We were especially interested in whether help-seeking patterns would differ for airmen in committed intimate relationships versus nonpartnered airmen and, if so, whether those patterns might also vary as a function of relationship quality or couple distress. Several factors contributed to our interests in this regard. First, the majority of service members (70 percent of officers, and 50 percent of enlisted personnel) are married, and there is considerable evidence indicating the adverse impact of mental health problems of returning service members on their intimate partners and relationships (Gewirtz, Polusny, DeGarmo, Khaylis, & Erbes, 2010). Second, multiple studies affirm the association between high levels of intimate partner support and lower levels of PTSD symptoms, and one study (Balderrama-Durbin et al., 2013) suggests that this association is mediated by the partner providing a safe context for the service member's disclosure of painful combat-related experiences. And finally, couple-based interventions have been developed for a broad array of emotional and behavioral disorders confronting service members and veterans—with additional evidence that these couple approaches are more effective than individual treatments when such disorders and relationship distress are comorbid (Snyder & Monson, 2012).

However, in our longitudinal study of U.S. Air Force Security Forces, both relationship status (partnered vs. nonpartnered) and, for partnered airmen, relationship quality (distressed vs. nondistressed) were largely unrelated to help-seeking patterns. Moreover, only about one in six airmen in a distressed intimate relationship actually sought help for relationship problems and, of those, the majority sought help through individual counseling rather than couple counseling.

The Challenge of Promoting Relationship Well-Being

Although various counseling resources exist for service members and veterans with individual emotional and behavioral disorders, resources in both the DOD and Veterans Health Administration specifically targeting distressed intimate relationships have historically been scarce. There are numerous reasons for this, but one in particular has been a generalized slowness in the mental health field to recognize the comorbidity of individual and relationship disorders and their recursive effects. The majority of mental health providers in the DOD and VA systems have been trained in individual treatments, and efforts to disseminate evidence-based couple treatments for specific disorders and general relationship distress in those environments comprise a relatively recent phenomenon. Moreover, when active-duty service members or veterans seek services for intimate relationship problems from well-trained couple therapists in the civilian sector, too often those clinicians have little familiarity with unique challenges of military life and reintegration into the family or community following military deployments—and hence their credibility and effectiveness can be compromised.

Implications

It is neither reasonable nor feasible to require that the majority of mental health providers in the DOD or VA systems become competent in the delivery of intensive couple-based interventions; nor is it likely that a majority of couple and family therapists in the civilian sector will develop in-depth familiarity with the language, culture and unique challenges of military service across the entire deployment and reintegration cycle. But it is important that a critical mass of providers in both environments become equipped to strengthen and protect the intimate partner relationships of men and women who have served their country. Doing so requires that they become well-versed in basic relationship skills, knowledgeable about military contexts that impact and challenge service members' and veterans' intimate relationships and competent in disseminating evidence-informed resources for promoting relationship well-being.

Promoting Relationship Well-Being in the Military and Veteran Communities

The data affirming the need to preserve and protect the intimate relationships of service members and veterans are compelling. In a recent study, over half (51 percent) of suicides among active-duty service members were associated with the failure of a marriage or similar intimate relationship, with the majority of those (59 percent) having failed within the past 30 days (Bush et al., 2013). Among veterans, 42 percent report struggles in getting along with their spouse or intimate partner, and roughly a third (35 percent) report experiencing a divorce or separation since their deployment (Sayer et al., 2010).

Mental health counselors, providers across the allied health professions, family life consultants, personnel affiliated with the broad spectrum of family support services and designated supervisors and other “natural helpers” identified at any point of potential interaction can all be trained to offer “brief conversations” that direct the service member or veteran to evidence-based, self-directed resources or low-intensity consultations. An example of such a brief conversation follows:

Consultant or “natural helper” (CNH): Last week we were talking about problems you were having sleeping, and you said you thought it might be related in part to stress at home.

Service member or veteran (SMV): Yeah, that's not the only reason, but it could be a part.

CNH: Stress with your partner?

SMV: Sometimes.

CNH: Have you and she ever tried to get any help with that—talking with someone or reading anything for advice?

SMV: I do not think we're up for marriage counseling or anything like that.

CNH: Well, that's okay. You may not need it. But would it be all right with you if I shared some information that other couples have found useful in similar situations?

SMV: Sure, that would be fine.

CNH: I've got a couple of short, easy-to-read pamphlets that folks sometimes find helpful. They're based on some specific strategies that often work for couples dealing with various issues—and they offer some step-by-step advice for making some small changes that sometimes can make a big difference.

SMV: What kinds of pamphlets?

CNH: Well, actually, I have a whole set of them—almost 20. But, let's see, I've got one here on “Couples Coping with Stress”—let's take a look. Inside here, it just talks a bit about what stress is, and how it affects relationships. And then over here it lists some simple strategies for supporting each other and doing some problem-solving together.

SMV: Seems pretty basic. Then what?

CNH: Well, sometimes “basic” is good—or good enough. On the back side here, it helps you make an “action plan”—deciding what you'd most like to change, what you could do differently, why that might be worth the effort, and then creating a plan for trying it out and seeing how it works.

SMV: I'd do this on my own?

CNH: Well, probably best if you shared it with your partner, and maybe you could each decide on something you could do on your own that would help reduce the stress for both of you, and see if that makes a difference.

SMV: What if doesn't make any difference at all?

CNH: Well, that's certainly a possibility. But if you want to try it out and then check back in with me in a couple of weeks, we could chat some about how it went—and see then if you want to revise your strategy and give it another shot.

SMV: I guess it couldn't hurt.

Conclusions

Over 2.6 million members of the U.S. military have deployed in support of Operations Enduring Freedom, Iraqi Freedom, and New Dawn since the Global War on Terrorism began in 2001. As they return home and reintegrate into their families and communities, many of these service members and veterans will struggle with individual mental health problems as well as serious relationship difficulties. Significant numbers of these men and women, however, will not seek appropriate counseling services, even when effective treatments exist alongside adequate resources in the DOD, VA and civilian communities.

In our own longitudinal work with airmen experiencing year-long high-risk deployments and high rates of traumatic experiences, we observed significantly increased rates of PTSD, depression, alcohol misuse and intimate relationship problems up to six to nine months after returning home. Those experiencing the highest levels of individual distress were more likely to seek counseling services and, in our study, most of those seeking assistance did so from mental health specialists rather than alternative resources potentially lower in anticipated stigmatization. However, many airmen experiencing significant problems sought no formal assistance of any sort. Help-seeking for relationship difficulties was particularly infrequent, despite well-documented comorbidity of such difficulties with individual mental health disorders.

To meet the diverse needs of these men and women, both prevention and intervention efforts will need to span a range of modalities (e.g., self-guided resources, online programs, phone-based coaching and face-to-face services) across varying degrees of intensity and a broad spectrum of both formal and informal providers (Sherman, Larsen, & Borden, 2015).

Our own program has emphasized an integrated multitiered approach based on evidence-informed relationship interventions that progress in intensity across the continuum of care from self-directed resources, to brief consultations with informal or “natural” helpers, to more systematic brief relationship education modules that can be implemented by paraprofessionals specifically trained to disseminate these resources.

For full contents the reader is referred to the complete article:

Snyder, D. K., Balderrama-Durbin, C., Cigrang, J. A.,Talcott, G. W., Smith Slep, A. M., & Heyman, R. E. (2016). Help-seeking among airmen in distressed relationships: Promoting relationship well-being. Psychotherapy, 53 , 1–12. http://dx.doi.org/10.1037/pst0000045

Footnote

For further information, please contact: Gerald W. Talcott.

References 

Balderrama-Durbin, C., Snyder, D. K., Cigrang, J., Talcott, G. W., Tatum, J., Baker, M., . . . Smith Slep, A. M. (2013). Combat disclosure in intimate relationships: Mediating the impact of partner support on posttraumatic stress. Journal of Family Psychology, 27, 560–568. http://dx.doi.org/10.1037/a0033412

Bush, N. E., Reger, M. A., Luxton, D. D., Skopp, N. A., Kinn, J., Smolenski, D., & Gahm, G. A. (2013). Suicides and suicide attempts in the U.S. Military, 2008–2010. Suicide and Life-Threatening Behavior, 43, 262–273. http://dx.doi.org/10.1111/sltb.12012

Cigrang, J. A., Talcott, G. W., Tatum, J., Baker, M., Cassidy, D., Sonnek, S., . . . Smith Slep, A. M. (2014). Impact of combat deployment on psychological and relationship health: A longitudinal study. Journal o f Traumatic Stress, 27, 58 – 65. http://dx.doi.org/10.1002/jts.21890

Gewirtz, A. H., Polusny, M. A., DeGarmo, D. S., Khaylis, A., & Erbes, C. R. (2010). Posttraumatic stress symptoms among National Guard soldiers deployed to Iraq: Associations with parenting behaviors and couple adjustment. Journal of Consulting and Clinical Psychology, 78, 599–610. http://dx.doi.org/10.1037/a0020571

Harpaz-Rotem, I., Rosenheck, R. A., Pietrzak, R. H., & Southwick, S. M. (2014). Determinants of prospective engagement in mental health treatment among symptomatic Iraq/Afghanistan veterans. Journal of Nervous and Mental Disease, 202, 97–104. http://dx.doi.org/10.1097/NMD.0000000000000078

Hoerster, K. D., Malte, C. A., Imel, Z. E., Ahmad, Z., Hunt, S. C., & Jakupcak, M. (2012). Association of perceived barriers with prospective use of VA mental health care among Iraq and Afghanistan veterans. Psychiatric Services, 63, 380–382. http://dx.doi.org/10.1176/appi.ps.201100187

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. The New England Journal of Medicine, 351, 13–22. http://dx.doi.org/10.1056/NEJMoa040603

Kehle, S. M., Polusny, M. A., Murdoch, M., Erbes, C. R., Arbisi, P. A., Thuras, P., & Meis, L. A. (2010). Early mental health treatment-seeking among U.S. National Guard soldiers deployed to Iraq. Journal of Traumatic Stress, 23, 33– 40. http://dx.doi.org/10.1002/jts.20480

Kim, P. Y., Britt, T. W., Klocko, R. P., Riviere, L. A., & Adler, A. B. (2011). Stigma, negative attitudes about treatment, and utilization of mental health care among soldiers. Military Psychology, 23, 65–81. http://dx.doi.org/10.1080/08995605.2011.534415

Osório, C., Jones, N., Fertout, M., & Greenberg, N. (2013). Perceptions of stigma and barriers to care among UK military personnel deployed to Afghanistan and Iraq. Anxiety, Stress, and Coping, 26, 539–557. http://dx.doi.org/10.1080/10615806.2012.725470

Rosen, C. S., Greenbaum, M. A., Fitt, J. E., Laffaye, C., Norris, V. A., & Kimerling, R. (2011). Stigma, help-seeking attitudes, and use of psychotherapy in veterans with diagnoses of posttraumatic stress disorder. Journal of Nervous and Mental Disease, 199, 879–885. http://dx.doi.org/10.1097/NMD.0b013e3182349ea5

Sayer, N. A., Noorbaloochi, S., Frazier, P., Carlson, K., Gravely, A., & Murdoch, M. (2010). Reintegration problems and treatment interests among Iraq and Afghanistan combat veterans receiving VA medical care. Psychiatric Services, 61, 589 –597. http://dx.doi.org/10.1176/ps.2010.61.6.589

Sharp, M. L., Fear, N. T., Rona, R. J., Wessely, S., Greenberg, N., Jones, N., & Goodwin, L. (2015). Stigma as a barrier to seeking health care among military personnel with mental health problems. Epidemiologic Reviews, 37, 144–162. http://dx.doi.org/10.1093/epirev/mxu012

Sherman, M. D., Larsen, J., & Borden, L. M. (2015). Broadening the focus in supporting reintegrating Iraq and Afghanistan veterans: Six key domains of functioning. Professional Psychology: Research and Practice, 46, 355–365. http://dx.doi.org/10.1037/pro0000043

Snyder, D. K., & Monson, C. (2012). Couple-based interventions for military and veteran families: A practitioner's guide. New York, NY: Guilford Press.

Snyder, D. K., & Whisman, M. A. (2004). Treating distressed couples with coexisting mental and physical disorders: Directions for clinical training and practice. Journal of Marital and Family Therapy, 30, 1–12. http://dx.doi.org/10.1111/j.1752-0606.2004.tb01218.x

Valenstein, M., Gorman, L., Blow, A. J., Ganoczy, D., Walters, H., Kees, M., . . . Dalack, G. W. (2014). Reported barriers to mental health care in three samples of U.S. Army National Guard soldiers at three time points. Journal of Traumatic Stress, 27, 406–414. http://dx.doi.org/10.1002/jts.21942