DQ Veterans

Needs of Veterans

Many needs of military personnel are evident at the time of their separation from military service. Other needs, however, such as the residual psychological and physical effects of war and combat, may not be obvious until many years after military personnel have returned to civilian life. In addition, the federal government has established services for aging veterans, but the veterans and their families may not be aware of these services or know how to obtain them.

Required Readings

Demers, A. (2011). When veterans return: The role of community in reintegration. Journal of Loss and Trauma: International Perspectives on Stress & Coping, 16(2), 160–179.

Ghahramanlou-Holloway, M., Cox, D. W., Fritz, E. C., & George, B. J. (2011). An evidence-informed guide for working with military women and veterans. Professional Psychology: Research and Practice, 42(1), 1–7.

Heflin, C. M., Wilmoth, J. M., & London, A. S. (2012). Veteran status and material hardship: The moderating influence of work-limiting disability. Social Service Review, 86(1), 119–142.

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(5), 355-366.


Laureate Education (Producer). (2013). Reintegration and the military family [Video file]

(Betsy Flanigan describes her family’s transition from military life to civilian life and identifies aspects of military culture that civilians need to understand)

Discussion Question

To prepare for this Discussion, review the Betsy Flanigan video

· Post a description of the interviewee you selected. Describe your initial reaction to the individual and his or her situation and explain why you had this reaction.

· Based on this scenario and the other resources, explain what would be the most important need that helping professionals should address with the veteran in the scenario and why.

Be sure to support your post with specific references and Required Readings to the resources. If you are using additional articles, be sure to provide full APA-formatted citations for your references.

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: mholloway@usuhs.edu

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


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


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.


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.


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


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


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.


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. Military Medicine, 157, 645–648.

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:


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#reintigration

Lauder, T. D., & Campbell, C. S. (2001). Abnormal eating behaviors in female reserve officer training corps cadets. Military Medicine, 166, 264–268.

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. Military Medicine, 168, 922–928.

Renshaw, K. D., Rodrigues, C. S., & Jones, D. H. (2008). Psychological symptoms and marital satisfaction in spouses of Operation Iraqi Freedom Veterans: Relationships with spouses’ perceptions of Veterans’ experiences and symptoms. Journal of Family Psychology, 22,586–594.

Rentz, E. D., Marshall, S. W., Loomis, D., Casteel, C., Martin, S. L., & Gibbs, D. A. (2007). Effect of deployment on the occurrence of child maltreatment in military and nonmilitary families. American Journal of Epidemiology, 165, 1199–1206.

Resick, P. A., & Schnicke, M. K. (1992). Cognitive processing therapy for sexual assault survivors. Journal of Consulting and Clinical Psychology, 60, 748–756.

Rychnovsky, J., & Beck, C. T. (2006). Screening for postpartum depressioninmilitarywomenwiththePostpartumDepressionScreeningScale. Military Medicine, 171, 1100–1104.

Rychnovsky, J. D. (2007). Postpartum fatigue in the active-duty military woman. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 36, 38–46.

Sansone, R. A., Matheson, V. G., Gaither, G. A., & Logan, N. (2008). Concerns about career stigma by military parents of children with psychiatric illness. Military Medicine, 173, 134–137.

Schneider, M. B., Bijur, P. E., Fisher, M., Friedman, S. B., & Toffler, C. P. (2003). Menstrual irregularity in female military cadets: Comparison of data utilizing short-term and long-term recall. Journal of Pediatric and Adolescent Gynecology, 16, 89–93.

Settles, I. H., Cortina, L. M., Stewart, A. J., & Malley, J. (2007). Voice matters: Buffering the impact of a negative climate for women in science. Psychology of Women Quarterly, 31, 270–281.

Stanley, B., & Brown, G. (2008). Safety plan treatment manual to reduce suicide risk: Veteran version. Retrieved from www.mentalhealth.va.gov/College/docs/VA_Safety_planning_manual.doc

Street, A., Vogt, D., & Dutra, L. (2009). A new generation of women Veterans: Stressors faced by women deployed to Iraq and Afghanistan. Clinical Psychology Review, 29, 685–694.

Street, A. E., Gradus, J. L., Stafford, J., & Kelly, K. (2007). Gender differences in experiences of sexual harassment: Data from a male dominated environment. Journal of Consulting and Clinical Psychology, 75, 464–474.

Taft, C. T., Schumm, J. A., Panuzio, J., & Proctor, S. P. (2008). An examination of family adjustment among Operation Desert Storm Veterans. Journal of Consulting and Clinical Psychology, 76, 648–656.

Tolin, D. F., & Foa, E. B. (2006). Sex differences in trauma and posttraumatic stress disorder: A quantitative review of 25 years of research. Psychological Bulletin, 132, 959–992.

Trego, L. L. (2007). Military women’s menstrual experiences and interest in menstrual suppression during deployment. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 36, 342–347.

Vogt, D. S., Pless, A. P., King, L. A., & King, D. W. (2005). Deployment stressors, gender, and mental health outcomes among Gulf War I Veterans. Journal of Traumatic Stress, 18, 272–284.

Wallace, J. E. (2001). The benefits of mentoring for female lawyers. Journal of Vocational Behavior, 58, 366–391.

Washington, D. L., Kleimann, S., Michelini, A. N., Kleimann, K. M., & Canning, M. (2007). Women Veterans’ perception and decision-making about Veterans Affairs health care. Military Medicine, 172, 812–817.

Washington Headquarters Services Directorate for Information Operations and Reports. (1999). Worldwide U.S. active duty military deaths, comparison of military personnel strength and manner of death, females total. Washington, DC: Author.

Weathers, F., Litz, B., Herman, D., Huska, J., & Keane, T. (1993). The PTSD checklist (PCL): Reliability, validity, and diagnostic utility. Paper presented at the Annual Convention of the International Society for Traumatic Stress Studies, San Antonio, TX.

Web-based Injury Statistics Query and Reporting System (WISQARS). (2009). 10 leading causes of death, United States 2006, all races, females. Retrieved from http://webappa.cdc.gov/cgi-bin/broker.exe

Women in Military Service for America Memorial. (2009). Statistics on women in the military. Retrieved from http://www.womensmemorial.org/Press/stats.html

Zinzow, H. M., Grubaugh, A. L., Frueh, B. C., & Magruder, K. M. (2008). Sexual assault, mental health, and service use among male and female Veterans seen in Veterans Affairs primary care clinics: A multi-site study. Psychiatry Research, 159:226–236.

Zinzow, H. M., Grubaugh, A. L., Monnier, J., Suffoletta-Maierle, S., & Frueh, B. C. (2007). Trauma among female Veterans: A critical review. Trauma Violence Abuse, 8, 384–400.

Received June 25, 2010

Revision received September 24, 2010

Accepted October 26, 2010