Being a Female Veteran: A Grounded Theory of Coping With Transitions

No Women's Land: Australian Women Veterans' Experiences of the Culture of Military Service and Transition

Women's experiences of military service and transition occur within a highly dominant masculinized culture. The vast majority of research on military veterans reflects men's experiences and needs. Women veterans' experiences, and therefore their transition support needs, are largely invisible. This study sought to understand the role and impact of gender in the context of the dominant masculinized culture on women veterans' experiences of military service and transition to civilian life. In-depth qualitative interviews with 22 Australian women veterans elicited four themes: (1) Fitting in a managing identity with the military; (2) Gender-based challenges in conforming to a masculinized culture-proving worthiness, assimilation, and survival strategies within that culture; (3) Women are valued less than men-consequences for women veterans, including misogyny, sexual harassment and assault, and system failures to recognize women's specific health needs and role as mothers; and (4) Separation and transition: being invisible as a woman veteran in the civilian world. Gendered military experiences can have long-term negative impacts on women veterans' mental and physical health, relationships, and identity due to a pervasive masculinized culture in which they remain largely invisible. This can create significant gender-based barriers to services and support for women veterans during their service, and it can also impede their transition support needs.

Transition Needs Among Veterans Living With Chronic Pain: A Systematic Review

INTRODUCTION

A third of Canadian Armed Forces veterans report difficulty adjusting to post-military life. Moreover, an estimated 40% of Canadian veterans live with chronic pain, which is likely associated with greater needs during the transition from military to civilian life. This review explores challenges and transition needs among military personnel living with chronic pain as they return to civilian life.

METHODS

We searched MEDLINE, EMBASE, CINAHL, Scopus, and Web of Science from inception to July 2022, for qualitative, observational, and mixed-method studies exploring transition needs among military veterans released with chronic pain. Reviewers, working independently and in duplicate, conducted screening and used a standardized and pilot-tested data collection form to extract data from all included studies. Content analysis was used to create a coding template to identify patterns in challenges and unmet needs of veterans transitioning to civilian life, and we summarized our findings in a descriptive manner.

RESULTS

Of 10,532 unique citations, we identified 43 studies that reported transition challenges and needs of military personnel; however, none were specific to individuals released with chronic pain. Most studies (41 of 43; 95%) focused on military personnel in general, with one study enrolling individuals with traumatic brain injury and another including homeless veterans. We identified military-to-civilian challenges in seven areas: (1) identity, (2) interpersonal interactions/relationships, (3) employment, (4) education, (5) finances, (6) self-care and mental health, and (7) accessing services and care.

CONCLUSIONS

Military personnel who transition to civilian life report several important challenges; however, the generalizability to individuals released with chronic pain is uncertain. Further research is needed to better understand the transition experiences of veterans with chronic pain to best address their needs and enhance their well-being.

Learning from women veterans who navigate invisible injuries, caregiving, and reintegration challenges

BACKGROUND

As women comprise a greater proportion of military service members, there is growing recognition of how their experiences in the early phase of military to civilian transitions have an important influence on their health and reintegration outcomes. Qualitative accounts of women veterans can inform programs that support transitioning service members.

OBJECTIVES

We examined narratives of civilian reintegration among women veterans to understand their experiences of adjusting to community life while coping with mental health challenges.

METHODS/PARTICIPANTS

We interviewed 16 post-911 era women who were within 5 years of separating from military service and developed a case study based on three participants.

MAIN APPROACH

Interviews were audio-recorded and transcribed verbatim. Inductive thematic analysis was conducted to establish categories about reintegration. Immersion/crystallization techniques were used to identify exemplary cases that illustrated salient themes.

KEY RESULTS

Women veterans identified establishing a future career direction, drawing on social support, and navigating health care services as major factors influencing how they adjusted to civilian life. In addition, participants also highlighted the navigation of complex and intersecting identities (i.e., wife, mother, employee, friend, veteran, patient, etc.), further magnified by gender inequalities. These women performed emotional labor, which is often rendered invisible and oriented toward their family and loved ones, while simultaneously monitoring self-care activities. During the early period of reintegration, they described how they felt marginalized in terms of accessing healthcare compared to their military spouses and male veteran peers.

CONCLUSIONS

Our case study suggests that there are key gaps in addressing healthcare and readjustment needs for women servicemembers, a high priority VA group, as they transition into post-military life. It is important to consider innovative ways to address specific needs of women in veteran-focused policies and programs.

Moral injury: understanding Swedish veterans who are assessed but not diagnosed with PTSD

This article is based on an interview study of 24 Swedish veterans who experienced deteriorating mental health and increased suffering without meeting the criteria for a PTSD diagnosis. With no clinical answers as to the cause of their deteriorating mental health, they have been thrown into a veteran's health limbo. The analysis was based on an inductive logic. A key finding of the analysis was a kind of deep-seated permanent moral conflict that could be conceptualized as moral injury. Such an injury can give rise to intense guilt, shame, anxiety, anger, dejection, bitterness, identity issues and more. The results section of the article details five different yet for the sample representative cases of moral injury and their implications. The notion of moral injury is linked to Mead's division of the self into an I and me, where me is the socially constructed part of the self that is charged with the morality of a group. Thus, a moral me played a key role in the development of moral injury. The conceptual apparatus illustrates a new way of understanding experiences that can create suffering and negatively impact a veteran's mental health. Future research is encouraged that examines this topic, national designs for addressing moral injury, screening for moral injury, and methods for healing included.

Service and demographic factors, health, trauma exposure, and participation are associated with adjustment for former Australian Defense Force members

Approximately 50% of transitioning service members report difficulty adjusting to civilian life. However, there is limited research exploring factors that influence adjustment for former Australian Defence Force (ADF) members. The aim of this study was to investigate the influence of demographic and service-related characteristics, trauma exposure, health, and participation in meaningful occupations on adjustment for former ADF members. One hundred and ninety-eight former ADF members completed a voluntary, online survey containing validated self-report measures for adjustment, health, and exposure to combat and military sexual trauma. Participation in meaningful occupations was assessed using open-ended questions and a rating scale for frequency of participation. A more difficult adjustment was reported by participants who had completed operational service, reported exposure to combat and/or military sexual trauma, had poor physical health and were discharged for medical reasons. Other characteristics associated with a difficult adjustment included emotional distress, involuntary discharge, age category 30-49 years, final rank of Senior Noncommissioned Officer/Warrant Officer or below, and discharge 6-8 years previously. Employment, voluntary work and care, and social and community interaction were associated with an easier adjustment. Screening tools that consider health, age, deployment type, final rank, type of discharge and exposure to combat or military sexual trauma may be helpful to identify and refer high risk individuals to employment, rehabilitation or transition support programs.

Military Veterans' End of Life: Supporting Them in Their Last Deployment

More than 600,000 U.S. Veterans die from illness each year. Clinicians in civilian settings are increasingly providing care to Veterans at end of life. Veteran care should be distinctive and individualized to meet their unique needs. There is limited information to guide civilian clinicians in providing care to Veterans at end of life. This article provides bio-psycho-social information to holistically guide Veteran healthcare and assist them with solace, respect, and serenity at end of life. Various options for end-of-life care are discussed, as well as specific concerns of women, lesbian, gay, bisexual, and transgender Veterans. Some end-of-life entitlements for all Veterans and sometimes their spouses/children are included.

Families serve too: military spouse well-being after separation from active-duty service

BACKGROUND AND OBJECTIVES

Transitioning from military to civilian life can be challenging for families, but most research focuses only on the service member. We applied a life course model to assess spouse well-being following this important transition.

DESIGN

Prospective, longitudinal survey of service members and their spouses.

METHODS

We captured three spouse well-being domains: psychological health, physical health, and family relationships. We identified differences between families who separated from service and those still affiliated (N = 4,087) and assessed baseline factors associated with spouse well-being after the family separated from service (N = 1,199).

RESULTS

Spouses of service members who had separated from the military (versus those who had not) reported poorer mental health and family relationship quality at baseline and follow-up. After controlling for baseline differences, spouses whose families transitioned experienced a greater increase in PTSD symptoms and a steeper decline in quality of marriage. Spouses of active-duty service members reported greater increases in work-family conflict. Among families who had transitioned, the most consistent predictor of positive outcomes was baseline well-being. Protective factors included having more psychological and social resources and less financial stress.

CONCLUSIONS

Several protective and risk factors identified in the study may inform programming for families transitioning from active duty.

Thank You for Hearing My Voice - Listening to Women Combat Veterans in the United States and Israeli Militaries

The military service of combat soldiers may pose many threats to their well being and often take a toll on body and mind, influencing the physical and emotional make-up of combatants and veterans. The current study aims to enhance our knowledge about the combat experiences and the challenges that female soldiers face both during and after their service. The study is based on qualitative methods and narrative analysis of in-depth semi-structured personal interviews with twenty military veterans. It aims to analyze the narratives of American and Israeli female combat soldiers regarding their military service, with emphasis on the soldiers' descriptions, in their own words, about their difficulties, challenges, coping and successes during their service and transition to civilian life. A recurring theme in the interviews with the veterans of both militaries was the need to be heard and the fact that societies, therapists, and military institutions do not always truly listen to female veterans' experiences and are not really interested in what actually ails them. Our research suggests that conventional methods used in research relating to veterans might at times be inadequate, because the inherent categorization might abstract, pathologize, and fragment a wide array of soldiers' modes of post-combat being. Moreover, female veterans' voices will not be fully heard unless we allow them to be active participants in generating knowledge about themselves.

Psychological Resilience in West Point Graduates: Results From a Nationally Representative Study

Background: The purpose of this study was to examine factors associated with psychological resilience in a nationally representative sample of West Point graduates. Aims: The aims of this study were to (a) employ a dimensional approach to operationalizing psychological resilience in a trauma-exposed population that had been highly trained and educated in persisting in the face of stress, was previously unstudied, and in which we could examine correlates of resilience, (b) identify key psychosocial factors, character traits, health variables, military experiences, and coping strategies as potential correlates of psychological resilience; and (c) examine whether reported gender moderated any of these associations in this population. Methods: A nationally representative sample of 1342 West Point graduates after gender integration from classes 1980 to 2011 were surveyed. Psychological resilience was operationalized using a discrepancy-based approach in which a measure of composite psychological distress (current posttraumatic stress disorder, generalized anxiety and depression symptoms) was regressed on measures of cumulative trauma burden. A multivariable linear regression model was then employed to identify factors that were independently associated with psychological resilience scores. Results: Purpose in life (29.8% of relative variance explained [RVE]), fewer perceived negative experiences in the military (20.6% RVE), social support (9.6% RVE), and grit (9.5% RVE) were the strongest correlates of psychological resilience scores for both women and men. Time in service was positively associated with resilience in women only. Conclusion: This study identifies key correlates of psychological resilience in West Point graduates, individuals who are highly trained to persevere in the face of stress and then were trauma-exposed. Most of these factors are modifiable and can be targeted in stress prevention and treatment interventions, especially for high-stress professions such as the military, frontline health care providers, and first responders.

Grief and Loss Among Veterans With Spinal Cord Injury: A Qualitative Study

PURPOSE

The objective of this study was to understand veteran perspectives of grief/loss associated with their spinal cord injury (SCI).

DESIGN/METHODS

Qualitative descriptive design using semistructured interviews with veterans with SCI (n = 15) was performed using interview questions informed by the literature. Analysis was conducted using a deductive/inductive approach.

RESULTS

The 15 participants' mean age was 64 years; six had paraplegia, eight had tetraplegia, one had unknown level of injury, six were ambulatory, and nine were not ambulatory. The grief/loss experience was individual and constant, consisting of seven phases: experiencing shock, releasing emotion, withdrawing, focusing on losses, problem solving, realizing strength and motivation, and accepting a new life. Veteran coping strategies used in each phase of the grief experience were also identified, as well as triggers that increased or decreased the grief/loss experience.

CONCLUSIONS/CLINICAL RELEVANCE

A better understanding of veterans living with SCI grief experience, coping strategies, and triggering events can help healthcare providers support veterans with SCI.

Expanded Roles and Recommendations for Stakeholders to Successfully Reintegrate Modern Warriors and Mitigate Suicide Risk

This article draws upon the legends of warriors from ancient Greece and other traditions to illuminate the journey of Modern Warriors (MWs) who have served in the United States military over the last century. It then turns to stakeholders that can assist current MWs in their reintegration to civilian life and mitigate suicide risk. Until this point, without an existing and coordinated local, federal, non-profit, and private system, rates of suicide for post-9/11 MWs after leaving the military have greatly increased, especially for young and women MWs. This is due in part to the military satisfying many of MWs’ needs by providing units, leaders, and a mission during the Departure and Initiation stages of the MW journey. However, as MWs exit the military and face the difficult task of reintegration, the absence of units, leaders, and mission leads to deteriorating psychological health and increasing suicide risk. Written primarily by post-9/11 MWs, this article proposes recommendations for stakeholders to better reintegrate MWs and mitigate suicide risk. The authors strive to develop a system that satisfies MWs’ reintegration needs and enables MWs to be well positioned to continue their next ‘mission’ – to serve and improve society.

Advancing an understanding of the body amid transition from a military life

In this article, we explore the process of transitions from a military life to a civilian life. Making use of the concepts offered by Dialogical Self Theory, we explore how individuals negotiate the acquisition of new, civilian identities by integrating different, sometimes conflicting, cultural I-positions. Moreover, in this article, we explore how this narrative process is reflected through embodied processes of becoming civilian. We do so by presenting an in-depth analysis of two case studies: that of former Lieutenant Peter, who fully transitions to civilian life, and of Sergeant Emma, who opts for a hybrid outcome, combining a civilian job with working as an instructor in the military. We will argue that the narrative and embodied process of transition are intertwined in self-identity work, and that attention to the specifics of this entanglement can be useful for professionals who counsel military personnel who transition to civilian life.

Leaving Military Service with a Military Body: Insights for Pastoral Care and Counseling

The significance of the body has emerged as a vital yet neglected element in the transition from military to civilian life. The recognition of a military body enhances the understanding of potential pastoral and counseling needs among veterans beyond the mind and the soul. This article attempts to contribute to further knowledge about this topic, drawing from both theory and empirical research, in an effort to provide insights for pastoral care and counseling.

Suicide in U.S. Women Veterans: An Interpersonal Theory Perspective on Suicide Prevention Policies

Increases in suicide rates for U.S. women Service Members and Veterans have emerged as a public health issue of great concern. Women Veterans are more likely than their civilian counterparts to die by suicide, and rates of suicide for women Veterans are rising faster than rates for male Veterans. Given higher rates of suicide in combat-exposed males and increased rates of suicide associated with military deployment for women, the expansion of women into direct combat roles may further escalate their rates of suicide. The interpersonal theory of suicide provides a framework for the examination of women Veterans' risk factors and how implementation of policy provisions can more effectively ameliorate suicide risk. Recent suicide prevention policy initiatives that target women Veterans' unique needs are important steps; however, suicide prevention efforts should address specific risk factors contributing to thwarted belongingness, perceived burdensomeness, and the acquired capability for suicide in Veteran women.

Suffering for Others While Making Others Suffer: Military Narratives of Sacrifice

Voices from theology seldom participate in a contemporary conversation on military cultures and identities; this article attempts to stimulate this conversation from such a perspective. The article combines a literature review with narratives of sacrifice from real-life cases. It presents a reflective perspective on the formation of military identities with regard to responsibilities and sacrifices. Forgiveness and atonement are discussed as pathways to cultivate growth which can lessen feelings of guilt and regret.

Clearing Away Past Wreckage: A Constructivist Grounded Theory of Identity and Mental Health Access by Female Veterans

Women Veterans are the largest veteran population yet have significant mental health disparities, greater than both civilian women and veteran men. This article used constructivist grounded theory methods to explore the experiences of women Veterans that led to mental health outpatient service use. Twelve women Veterans revealed meaningful stories on their experiences of trauma and their use of mental health services. A broader grounded theory process model emerged, linking the categories of Trauma, Transitions, Identity, and Structure. This research provides key insight into how women Veterans make health care-related choices and process traumatic events such as military sexual trauma.

The Phenomenology of Military Sexual Trauma Among Women Veterans

Although researchers have examined health outcomes among survivors of military sexual trauma, knowledge regarding the phenomenology of military sexual trauma among women veterans remains limited. We used a qualitative, phenomenological approach to describe the experience, context, and perceived effects of military sexual trauma among women veterans. Thirty-two cisgender female military sexual trauma survivors participated in interviews, which we analyzed through thematic analysis. The following themes emerged: (1) sexual harassment: “expected,” “constant,” and “normal”; (2) silencing and disempowerment: “If you want a career, then shut up”; (3) changed attitudes toward the military: “I lost faith”; (4) loss of relational trust: “I can protect me if I’m not involved with someone”; (5) survivor internalization of messages conveyed by military sexual trauma: “If I looked different, none of this would have happened”; (6) coping by escape and avoidance: “I put my head in the sand and hoped it would go away”; and (7) a path to healing through validation and justice: “You’ll get through it.” Results suggest the importance of increasing stakeholders’ knowledge regarding military sexual trauma complexities and contexts. Military sexual trauma survivors should be heard, believed, and supported in pursuing justice. We also suggest cultural shifts and continued efforts to prevent military sexual trauma. Online slides for instructors who want to use this article for teaching are available on PWQ's website at http://journals.sagepub.com/page/pwq/suppl/index

Advancing an understanding of selves in transition: I-positions as an analytical tool

Self-identity work appears to be a challenge for many service members as they transition and reintegrate into civilian life. When other cultural influences seem to threaten an established self as it labors with transition, tension and conflict may arise and can potentially impact mental health. Insights from an ongoing longitudinal project on the subject matter indicate that an analysis of an individual, which utilizes the concept of I-positions may serve as a useful analytical tool during these processes. A longitudinal methodology combining a narrative approach with such an exploration of I-positions derived from a dialogical self framework may prove to be a promising avenue to advance the understanding of selves in transition beyond the dichotomy of the military and civilian spheres. The bridging capacity of I-positions lies partly in the capacity of significant others to link the self to both spheres and to help fill the perceived void between these two realms, which in reality may be overlapping and intertwined. The findings suggest, facilitated by two case study examples, that military transition to civilian life may benefit from a dialogical approach. This dialogical mind-set could even already be introduced and established during basic training. However, there is also a shared responsibility for individuals in civilian contexts to invite former service members into open dialogue just as the service members themselves shall strive to initiate earnest dialogue. Future research is encouraged to widen the methodology and knowledge of selves in transition.

An Evidence Map of the Women Veterans' Health Research Literature (2008-2015)

BACKGROUND

Women comprise a growing proportion of Veterans seeking care at Veterans Affairs (VA) healthcare facilities. VA initiatives have accelerated changes in services for female Veterans, yet the corresponding literature has not been systematically reviewed since 2008. In 2015, VA Women's Health Services and the VA Women's Health Research Network requested an updated literature review to facilitate policy and research planning.

METHODS

The Minneapolis VA Evidence-based Synthesis Program performed a systematic search of research related to female Veterans' health published from 2008 through 2015. We extracted study characteristics including healthcare topic, design, sample size and proportion female, research setting, and funding source. We created an evidence map by organizing and presenting results within and across healthcare topics, and describing patterns, strengths, and gaps.

RESULTS

We identified 2276 abstracts and assessed each for relevance. We excluded 1092 abstracts and reviewed 1184 full-text articles; 750 were excluded. Of 440 included articles, 208 (47%) were related to mental health, particularly post-traumatic stress disorder (71 articles), military sexual trauma (37 articles), and substance abuse (20 articles). The number of articles addressing VA priority topic areas increased over time, including reproductive health, healthcare organization and delivery, access and utilization, and post-deployment health. Three or fewer articles addressed each of the common chronic diseases: diabetes, hypertension, depression, or anxiety. Nearly 400 articles (90%) used an observational design. Eight articles (2%) described randomized trials.

CONCLUSIONS

Our evidence map summarizes patterns, progress, and growth in the female Veterans' health and healthcare literature. Observational studies in mental health make up the majority of research. A focus on primary care delivery over clinical topics in primary care and a lack of sex-specific results for studies that include men and women have contributed to research gaps in addressing common chronic diseases. Interventional research using randomized trials is needed.

Making dialogue with an existential voice in transition from military to civilian life

Dialogical Self Theory has contributed to the endeavors to map and grid self-identity work in transition from military to civilian life throughout an empirical and longitudinal research project which focuses on existential dimensions. This article is based on a case study from this project and centers upon Sergeant Jonas, who, upon his return from deployment in Afghanistan, struggled with his transition as a new existential position was vocalized throughout the following annual interviews. This voice narrated feelings of meaninglessness, emptiness, and of having been deceived. In turn, this existential voice required an answer to a question which apparently had no answer. The meaning-making eventually evolved into an acceptance which enabled Jonas to proceed with his life. Dialogical processes between positions are important in order to go on with life amid existential concerns in the aftermath of military service since dialogicality of the self opens up a complex of dynamics of meaning-making processes, negotiations, and transformations. Based on the findings, it is suggested that the Personal Position Repertoire could potentially be strengthened by the addition of an internal existential position to its standard repertoire, at least when working with military personnel and/or veterans.

The Experience of Women Veterans Coming Back from War

Issues surrounding mental health are common for women veterans who have served in Iraq and Afghanistan wars. The goal of this phenomenological study was to document themes in the stories gathered from eight women veterans who had come back from war. Themes in the stories were: arriving with mixed sentiments; evolving to a changed view of self; permeating aggravation; confounding broken relationships, frequent deployments, and change in military status; remembering war experiences; and seeking opportunity for what is possible. Mental health issues can be observed in the themes. Including story as part of the mental health visit with veterans may be beneficial to veterans as they deal with the transition of coming back.