Family members of Veterans with mental health problems: Seeking, finding, and accessing informal and formal supports during the military-to-civilian transition
Publication: Journal of Military, Veteran and Family Health
Volume 7, Number 1
LAY SUMMARY
LAY SUMMARY
Veterans and their families in the military-to-civilian transition (MCT) face a multitude of changes and challenges. Family members of those Veterans experiencing a significant mental health problem (e.g., posttraumatic stress disorder, depression, anxiety) may find that navigating the MCT is made more complex, especially as they seek to find social support during this transition. The present study set out to hear from family members and learn about their obstacles and successes in accessing formal and informal support during the MCT and how this was affected by the Veteran’s mental health problems. Interviews and focus groups were completed with 36 English- and French-speaking Veteran family members across Canada. Family members shared how significant issues (e.g., mental health stigma, caregiver burden and burnout) were barriers to seeking and finding both informal (i.e., extended family, friends, online support) and formal (i.e., operational stress injury clinics, Military Family Resource Centres) support systems helpful in navigating the MCT. Despite setbacks and frustrations in accessing these supports, Veteran military families demonstrated resiliency and resolve as they pursued comfort, financial aid, respite, and counsel for themselves and for the Veteran with mental health problems during the MCT.
Abstract
Introduction: For some Canadian Armed Forces Veterans who are released, the military-to-civilian transition (MCT) process may be complicated by significant mental health problems (e.g., posttraumatic stress disorder, depression, anxiety). Family members (i.e., spouses, adult children, parents) who serve as the primary caregivers for Veterans with mental health problems devote significant energy to seeking and finding social support as they navigate the MCT. The primary purposes of this qualitative study were to 1) hear from these family members and learn about the obstacles to and successes in accessing formal and informal social supports during the MCT and 2) understand how accessing such supports was affected by the Veteran’s mental health problems. Methods: A sequential, multiple qualitative design was used, involving both in-depth individual interviews and focus groups with English- and French-speaking family members (N = 36) living in Eastern, Central, and Western Canada (i.e., individual, n = 27; focus groups, n = 9). Data coding was facilitated through the qualitative data analysis software MAXQDA, and data analysis was conducted using grounded theory strategies. Results: Amid numerous indicators of significant resolve and commitment to health, family members revealed significant issues (e.g., mental health stigma of the Veteran, caregiver burden and burnout) that contributed to notable barriers in accessing both informal (i.e., extended family, friends, online support groups) and formal (i.e., Operational Stress Injury Social Support, Military Family Resource Centres) support systems helpful in navigating the MCT. Discussion: Results are discussed in the context of how the Veteran’s mental health compounded barriers for family members who sought to access informal and formal support services that would provide comfort, financial aid, respite, and counsel to the Veteran family in the MCT. Building on the resilience of military-connected families, gaps in the systems of formal and informal care are discussed in the context of how bold and creative changes (e.g., proactive signposting) might facilitate the MCT for Veterans with mental health problems.
Résumé
Introduction : Pour certain(e)s vétéran(e)s libérés des Forces armées canadiennes, le processus de transition de la vie militaire à la vie civile (TMC) peut être compliqué par d’importants troubles de santé mentale (p. ex., état de stress post-traumatique, dépression, anxiété). Les membres de la famille (conjoints ou conjointes, enfants adultes, parents), qui sont les principaux proches aidants des vétérans aux prises avec des troubles de santé mentale, consacrent beaucoup d’énergie à chercher et trouver des services de soutien social pendant qu’ils composent avec la TMC. La présente étude qualitative avait comme objectifs principaux : 1) d’écouter les membres de ces familles et de découvrir les obstacles et les réussites dans l’accès aux services de soutien social formels et informels pendant la TMC et 2) de comprendre les effets des troubles de santé mentale du vétéran sur la capacité d’accès à ces services de soutien social. Méthodologie : Les chercheur(e)s ont privilégié une méthodologie qualitative multiple et séquentielle faisant appel à la fois à des entrevues individuelles approfondies et à des groupes de travail formés de membres de la famille francophones ou anglophones (n = 36) qui habitaient dans les Maritimes, le centre du Canada ou l’Ouest canadien (27 personnes et neuf groupes de travail). Le codage des données a été facilité par le logiciel d’analyse qualitative MAXQDA, et les chercheurs ont analysé les données selon les stratégies de théorie ancrée. Résultats : Parmi les nombreux indicateurs de détermination et d’engagement envers la santé, les membres des familles ont fait ressortir des problèmes importants (p. ex., honte reliée aux troubles de santé mentale pour les vétérans, fardeau pour les proches aidants et épuisement) qui ont contribué aux obstacles importants à l’accès à des services de soutien informels (famille élargie, amis, groupes d’entraide en ligne) et formels Soutien social blessures de stress opérationnel et Centres de ressources pour les familles des militaires) utiles pour faire face à la TMC. Discussion : Les résultats sont examinés dans le contexte de la façon dont la santé mentale du vétéran s’est aggravée par les barrières pour les membres de la famille qui cherchent à accéder à des services de soutien formels et informels qui leur apporteraient du réconfort, de l’aide financière, du répit et des conseils à la famille du vétéran en TMC. S’appuyant sur la résilience des familles liées aux militaires, les lacunes des services de soins formels et informels sont exposées en fonction des changements audacieux et créatifs (p. ex., indications proactives) qui pourraient faciliter la TMC des vétérans qui ont des troubles de santé mentale.
INTRODUCTION
The Canadian Armed Forces (CAF) includes more than 110,000 Regular and Reserve Force members with approximately 140,000 family dependents (i.e., spouses, children) residing across Canada and around the world.1 These individuals will join the more than 600,000 CAF Veterans and their families living in Canada via the military-to-civilian transition (MCT) process.2 Although there is no consensus on an operational definition of the MCT, it is recognized as a period of adaptation and adjustment to civilian life after military service,3,4 with implications for Veterans and their families.
Pearson and colleagues reveal that 1 in 6 full-time Regular Force CAF members experiences an array of physical and mental health problems,5 many of which are the result of operational stress injuries (OSIs), including posttraumatic stress disorder (PTSD), generalized anxiety disorder, and alcohol abuse and dependence. Results from both the 2010 and the 2013 Life After Service Surveys (LASS) indicate higher prevalence rates of both chronic health conditions and mental health problems among Veterans compared with serving members.6
Successful adjustment to civilian can both affect and be affected by family support. MacLean and colleagues found that 25% of recently released Regular Force Veterans reported a difficult adjustment to civilian life,7 with higher rates of difficulty associated with low social support and low family income. The 2016 LASS survey found that 28% of Veterans reported that release had been difficult (i.e., very or moderately) for the partner or spouse, and 17% deemed the MCT to be difficult for their children.8 Of note, these estimates come from the Veterans, not the family members, who may have responded differently.
Little research has investigated how Veterans’ mental health can complicate the support seeking experiences of family members during the MCT, although recent studies have summarized the impact on family members in general.9,10 Unique issues during the transition may affect the family, because it is typically family members who urge Veterans to seek assistance for health challenges.7 Black and Papile found that 36% of those surveyed indicated their family,11 or their relationship with their spouse, was the most important aspect of a successful transition. Hachey and colleagues also found that the process of transitioning was easier when Veterans were satisfied with their family relationships.12 Similarly, the odds of an easier adjustment were lower for Veterans who were dissatisfied with their family relationships.12
Given this background, this study explored the lived experiences of CAF military-connected families who recently experienced the MCT process while supporting a Veteran with a mental health problem. By investigating the social, relational, and psychological well-being of family members supporting Veterans with mental health problems, this article focuses on a single stated purpose: to identify the formal and informal supports accessed by the family during the MCT and their perceptions of how Veteran mental health problems present barriers to accessing these supports. The findings reveal the comprehensive and systemic factors that are affected by, and that affect, the Veteran’s family as they process the MCT.
METHODS
In-depth qualitative interviews were conducted with participants from military-connected families, facilitating understandings of multiple standpoints and processes of meaning construction. Interview data were analyzed before the focus groups to identify areas for further exploration with new focus group participants and refine themes generated through the interviews while also widening the sample’s range of geographic and socio-demographic representation. The focus groups provided the opportunity for dialectical exchanges, or comparing and contrasting of perspectives, and were designed to support the development of new understandings of experience. Use of multiple data collection strategies enhances the rigour of the findings.13 Ethical clearance for this research was obtained from research ethics boards at Queen’s University, Mount Saint Vincent University, and the University of Calgary.
Recruitment and eligibility
Family members of CAF Veterans with a mental health problem were recruited. CAF Veterans were defined as individuals who had previously served full time in the Regular Forces. Family members were defined as spouses or partners, siblings, parents, adult children, and individuals considered family who were not biological relatives. Mental health problems of the CAF Veteran were not restricted to those resulting from service, or beginning before release, and were operationalized as family member-reported diagnosed and undiagnosed issues that affect mood, thinking, and behaviour. Convenience sampling was used to select participants with heterogeneity in geography, rank, length of service, type or frequency of deployments, type of service (i.e., army, navy, air force), time since release, gender, and other factors, such as type of mental health condition. Participants were recruited through Military Family Resource Centres (MFRCs), Operational Stress Injury Support Services (OSISS) clinics, Veterans Affairs Canada (VAC), the Canadian Institute for Military and Veteran Health Research network, philanthropic organizations (e.g., The Royal Canadian Legion), and social media channels (e.g., Facebook, Twitter).
Procedure
Interviews and focus group guides were developed, piloted, and refined by the principal investigators. Consistent with the interpretive/constructivist framework, the guides structured the dialogue and allowed flexibility for participants to bring forth issues. Interpretive/constructivist research focuses on developing interpretations of lived experience from the perspectives of those who live it,14 yielding the in-depth knowledge needed when little is known about the phenomenon under study. The dialectical exchanges between the researcher and the participants common to this method create newly formed perspectives as varying interpretations of these experiences are brought into view, revealing the details, complexities, and subjective meanings underpinning the experiences of family members accessing supports and, in some cases, the barriers impeding access. Both the focus groups and the interviews were conducted in such a way that both the researchers and the participants were active agents in the research process.
Researchers collected demographic information about each family participant, the Veteran, and the family structure (see the Appendix for the interview guide). Recorded and transcribed verbatim, all individual interviews and focus groups were conducted by telephone or in person, in English or French, and ranged from 75 to 120 minutes in length. Researchers maintained field notes to identify observations, thoughts, and reflections on underlying assumptions and expectations, understandings, misunderstandings, and analytical decisions, as well as contextual factors (e.g., participants’ mood, vocal intonations).
Data analysis
Grounded theory was selected as the framework for analyzing data in this study because it offers a clear sequence of analytical procedures and specific techniques for developing in-depth and integrated conclusions about experience and meaning central to this interpretive/constructivist research.5–17 In each interview or focus group transcript, significant passages and powerful moments were identified within the interviews,18 followed by open, axial, and selective coding.19,20 Open coding involved the practice of breaking down, examining, and classifying data.16,20 Axial coding proceeded by comparing and contrasting the codes generated through open coding, resulting in a classification tree.16,20 Selective coding identified core themes or central issues around which all other themes were integrated.16,20 Constant comparison of emerging themes was used throughout the analysis process until saturation was achieved,17,21 with opposing interpretations resolved through team discussion.
Using an iterative approach, the coding tree was piloted across three researchers at two universities and refined to move toward consistency. Consensus meetings occurred between the two sites to ensure concordance in implementation and interpretation, and data coding was facilitated through the qualitative data analysis software MAXQDA (12.3.2 ed.; VERBI Software Consult Sozialforschung, Berlin).
RESULTS
Sample description
Twenty-seven family members of CAF Veterans living with a mental health problem were individually interviewed (21 in English, six in French); an additional nine family members (six English speaking, three French speaking) participated in the focus groups. Demographic information can be found in Table 1. Family members of Veterans reported PTSD as the most common mental health problem experienced by Veterans. Most mental health problems were reported as being formally diagnosed; however, clinical classification (e.g., according to the Diagnostic and Statistical Manual of Mental Disorders, 5th ed.) was not completed to confirm diagnoses. Informal and formal support systems were described, along with barriers complicating access to those supports.
Informal support systems accessed by family members and perceived barriers
Informal supports
Family members identified a number of informal supports that provided them with the greatest assistance during the MCT, including social support received or sought from family and friends, social media (e.g., online supports through Facebook), community advocacy or philanthropic associations, and pets or animals. For example, some spouses described the importance of time with their children throughout the MCT. For others, extended family was identified as an important informal support. One family noted the importance of visits to extended family during the MCT: “My parents are in the country, it is vast, there is space, fresh air. And on weekends, when we were just a couple, we always went down to [name of town], on weekends.” Friends were identified as a source of support for spouses and children, providing temporary reprieve from home and caregiving responsibilities.
| Sample | n* | |||||||
|---|---|---|---|---|---|---|---|---|
| Female spouse/common law | 29 | |||||||
| Male spouse | 1 | |||||||
| Parent(s) | 3 | |||||||
| Adult child | 2 | |||||||
| Sibling | 1 | |||||||
| Total | 36† | |||||||
| Age, y | ||||||||
| Range | 20–63 | |||||||
| Mean | 42.6 | |||||||
| Length of relationship with Veteran, y | ||||||||
| Range | 3–42 | |||||||
| Mean | 21.1 | |||||||
| Veteran | ||||||||
| Age, y | ||||||||
| Range | 32–80 | |||||||
| Mean | 45.5 | |||||||
| Years of service | ||||||||
| Range | 10–35 | |||||||
| Mean | 21.6 | |||||||
| Service branch | ||||||||
| Navy | 3 | |||||||
| Army | 11 | |||||||
| Air Force | 1 | |||||||
| Combined service branch | 5 | |||||||
| Family did not disclose | 16 | |||||||
| No. of times deployed, range, mo | 2–11 | |||||||
| Deployment service length, range, mo | 3–13 | |||||||
| Reason for release | ||||||||
| Mental or physical problems | 23 | |||||||
| Voluntary | 2 | |||||||
| Mandatory (age >60 y) | 2 | |||||||
| Release date (2013 or later) | 35 | |||||||
| Release date (2009) | 1 | |||||||
*
Unless otherwise indicated.
†
All but 3 participants (one child, sibling, and parent) lived with the Veteran and engaged regularly with the Veteran over the past 5y.
Pets and online support systems served as important avenues of informal support: “Well, we bought a dog. It is dumb eh? But my 12-year-old son has a bit of anxiety like his father, and the dog goes to bed with him at night and it brings a lot [of comfort].” Spouses developed new friendships with other military spouses through both online and in-person groups:
I am in many groups. But not in person, because even in [city], there is not that. You have to go to [city], go to [city]. On Facebook we can meet up pretty well. I speak with another Veteran wife. I do not know her personally, we just speak on the Internet.
Barriers to informal support: Stigma and burden
Although civilian-based informal supports were often identified as important and effective sources of support, stigma or judgment about the Veteran’s mental health, stemming from a limited understanding of the military lifestyle, rendered some inadequate or inaccessible. Some participants recounted how lack of knowledge about OSIs and their impacts may limit the capacity for perceived empathy extended to the Veteran and their family: “It’s the loneliest thing, not having anyone to know what it’s like. You can’t just call someone up and — they just, they don’t always get it, right?” Another noted, “My friends, just because they don’t want to be around him … I’d say my civilian friends really don’t understand him. They just don’t understand.” Although stigma regarding mental disorders is not unique to Veterans, how this stigma prohibits access to informal supports for family members during the MCT was a consistent theme.
These reactions may impede access to informal support systems, creating a reluctance to reach out. Family members suggested that they felt like a burden to their informal support systems, and some extended family members were reportedly disengaged, given the Veteran’s mental health problems. An English-language focus group participant noted:
In addition to the lack of emotional support, many spouses reported that the absence of logistical, day-to-day supports from family and friends compounded the stresses related to child care. Many spouses disclosed that leaving the Veteran at home with their children could be problematic because challenges in parenting often exceeded the Veteran’s capacity to cope on their own.I don’t have any support. Like, last night I talked to my dad and said, “Can you call me?” And he’s like, “Yeah, well, yes I can.” He said, “I will tonight.” I said, “I just need someone to talk to about what’s going on.” He didn’t call. He didn’t text. Um, we both don’t have friends, because we pushed everybody away. Because it’s a burden on other people.
Barriers to informal support: Confidentiality and privacy
Some family members were intent on finding anonymous avenues of support, which was particularly difficult to achieve in smaller or more geographically isolated communities. One spouse living in a rural setting said, “It’s such a small community and the few people that — I think, I think it’s harder for people like myself who feel like they want a little bit more anonymity, but to reach out. To have a space to do that.”
Formal supports accessed by family members and perceived barriers
Formal supports
When asked to identify formal support systems they accessed as they navigated the MCT with a Veteran with mental health problems, family members described OSISS groups, OSI clinics, MFRCs, Couples Overcoming PTSD Everyday (COPE), and CanPraxis. OSI clinics provide outpatient assessment, treatment, and support to serving CAF members and Veterans, with family supports extended if indicated for the patient’s health.22 MFRCs are arms-length, independent organizations that provide a range of support services to CAF members and their families, with additional supports extended to families of those who have medically released.23 COPE is a program sponsored by Wounded Warriors Canada that provides support to military and first responder couples via participation in a five-day relational development retreat, followed by ongoing coaching for up to six months.24 CanPraxis is an equine-based treatment method based on meaning-centred counselling that uses horses to help soldiers recover from the effects of war and to regain their family relationships.25
Participants reported varying levels of success in gaining access to, and benefiting from, formal support programs. Regarding the OSISS program, peer support groups funded through VAC for family members of those living with an OSI, a family member from Eastern Canada stated, “OSISS has helped me so much. You know, education is power. So I took it upon myself to try and learn everything I could about PTSD.” Citing less success, another family member from Central Canada commented that:
I tried the OSISS support group, and then I went. And I didn’t like it, because a lot of the women that were there were married or with the Veterans before they released and before diagnosis, so they knew [sic] a different aspect to what it was like.
Family members who lived near communities with an MFRC also found it to be helpful: “Oh, the MFRC here was a lot of help. Because [families] there would be living through the same thing, so talking with those people helped a lot.” Those who seem to have benefited most from formal supports were those who actively sought out connection with available programs and found affinity with others who could identify with their family situation.
Barriers to formal social support: Navigating the military-to-civilian transition administrative process
Family members consistently reported that systemic barriers impeded access to formal support systems, a challenge exacerbated by the Veteran’s mental health difficulties. As one participant noted, “You have somebody that has PTSD and can’t do all that stuff … there’s lots of people out there who have benefits that they don’t get because they can’t do the paperwork.” Moreover, some participants indicated that they had few, if any, opportunities to learn about available supports, resources, and administrative processes or health care options for the Veteran after they leave the CAF: “and then there’s nobody communicating with me to help him with that process.” Families members were unclear on how to access services for themselves: “Nobody gave me a list of … places that I could go, support I could have.”
Pushing to have the Veteran’s mental health issues tied to service, and the bureaucracy associated with qualifying for and starting to receive benefits through VAC, were also significant sources of strain for some family members. These barriers created a sense of abandonment, betrayal, and a toxic environment within which to seek and receive needed supports and services, leaving the family with the burden of care. As one family member commented:
In several cases, as a result of conflict between the VAC case manager and the Veteran, the family member had to formally act as a communication liaison: “VAC is now to contact me, because every time VAC contacted him, it, like, it just sets him off for, like, two days.” Family members identified significant administrative barriers embedded within the processes of existing formal support systems, even after eligibility for services was confirmed. The challenges of dealing with the paperwork were also noted by the parent of a Veteran who participated in one of the English-language focus groups:They don’t even acknowledge that her depression has to do, is related to her service. They, they, they won’t even go so far as to recognize that her service exacerbated her depression and made it worse. And it did … just this downhill slide that no one will recognize. So you leave me to deal with the aftermath. And you leave me to try to be the glue that holds us together.
This perceived adversarial relationships between Veterans and VAC, along with concern about the power imbalance, left some feeling:If you have a Member, um, who has, you know, PTSD and OSI, I mean, filling out a little form is enough, but when you’ve got pages and pages of forms and then you send them to them, and they lose them, and then you got to start all over again, um.
vulnerable, totally and permanently incapacitated, and you have somebody with all the power who can control what you will and will not receive … there’s no healing involved, right, because there’s something else that will spring up that you’ll have to fight.
Barriers to formal social support: Lack of awareness and increased isolation
Lack of awareness and increased isolation were also significant issues identified in accessing formal support services. There was a range of awareness among family members of programs such as OSISS or COPE. A family member living in Quebec commented on regional differences: “I think that’s very present in English provinces, but I think it’s not present here. I don’t think so, anyway.” Other family members living in Quebec were aware, for instance, of the OSISS groups, but distance precluded participation. Some families living with a Veteran with mental health problems reported that they felt:
quite alone. Nobody to reach out to, to the families, and that’s just a big, big lack that is, you know, that I was dealing with, and nobody helped me in between the time [the CAF diagnosed him] and when he left.
Although supports and services were available to the Veteran, families were left on their own to find family-specific supports, which reinforced the isolation experienced by the family. On the whole, Veterans’ families believed the formal support systems were obligated to recognize the impact of the Veteran’s service on the family and to provide accordingly: “We gave up our daily lives of a normal life.” Family members reported the need to feel equipped with knowledge and strategies to be able to support the Veteran’s recovery, and some felt that they were left floundering:
My frustration was just the fact that nobody was telling me anything. Like, here I am with him 24/7 and I’ve had, like, no contact with anybody saying, “This is what he should be trying to do,” and “If this happens you should do this.”
DISCUSSION
The results presented here summarize the experiences of accessing formal and informal supports of 36 family members of CAF Veterans living with mental health problems. These family members affirmed that navigating the MCT process alongside a Veteran with significant mental health problems is both daunting and complex. In attempting to access informal or formal supports, they experienced barriers of stigma and burden, confidentiality and privacy, exclusion from MCT administration processes, and lack of awareness and increased isolation, which, when added to the stress of the MCT itself, created a sense of hopelessness and helplessness.
Taken together, family members perceived lack of control over their life circumstances, with inconsistent access to informal and formal resources that are critical for successful adjustment to civilian life.12 Family members described their experiences as disorienting, burdensome, and even dehumanizing, especially as the psychological symptoms and behaviours of the Veteran demanded more resources, care, and attention from those family members closest to that Veteran — supports that were inaccessible or unavailable to some. In the midst of their efforts to seek support from both formal and informal sources, many of the family members were providing care essential for managing the activities of daily living. Research shows that caregiver burden is heightened for family members whose assistance is required for such activities of daily living,26 and the effects of this burden on the family member who is seeking support were evident in the tone and urgency of the responses collected in this study. This finding highlights the need to provide caregiving supports to families.
Family and friends constituted the main sources of informal support during the MCT. For some family members of Veterans, stigma and discomfort with discussing mental health issues impeded their capacity to access and benefit from social supports, specifically from family and friends. Although previous studies have highlighted the importance of “critical partners” (e.g., spouses, parents, siblings) in the care of Veterans,27 it was evident from the family members’ responses that psycho-education and mental health literacy training could enhance their capacity to provide safe, informed, and non-stigmatizing care.28,29 Fear of being a burden and concerns about confidentiality complicated social interactions as well, and although informal peer-to-peer networks are springing up across the country (e.g., COPE via Wounded Warriors Canada), those who are experiencing ongoing isolation may require supports that are offered virtually, such as mobile apps (e.g., OSI Connect) or informal online chat groups (e.g., Facebook groups).
For some family members, access to formal supports, such as those provided by VAC and other military-centric organizations, was affected by social and geographic isolation, lack of awareness of information about interventions and supports, and the complexity of administrative processes. A previously cited study notes a lack of what is called proactive signposting, which engages key gatekeepers who “provide caregivers with adequate and accurate documentation of service providers [who] they can contact for support to minimize the risk to themselves and the client.”28(p.391) Interprovincial variation in available programs and services, as well as the severity of Veterans’ mental health problems, constituted further barriers to access for some. These barriers acted to both cause, and compound, gaps in service to Veterans and their family.
Limitations
Although the inclusion criteria used in recruitment for this study were intentionally broad, such that spouses, adult children, parents, siblings, and fictive kin were eligible to participate, some voices were absent. In particular, only one male spouse participated in the study. Moreover, only intact families are represented in the sample. The impacts of Veterans’ mental health problems on their families persist through the process of separation or divorce, particularly if children are involved. As a result, there are some gaps in the understanding of the full spectrum of details, complexities, and situated meanings characterizing the experiences of family members of Veterans with mental health problems throughout the MCT. In addition, several family members whose first language was French elected to participate in the research study in English, which complicates the meaningful division of the analysis across French-language and English-language interviews.
The study participants are supporting Veterans with mental health problems, most of which appear to be in the severe range. The degree to which these findings apply to those with mild to moderate health problems is unclear, and it is important to note that recruitment efforts and inclusion criteria did not require the Veteran’s mental health problems to be in the severe range. The combination of the complex MCT and the severity of the mental health problems likely resulted in the messages from family members being communicated with greater urgency and fortitude. Moreover, the relationship between physical health problems and mental health problems experienced by the Veterans was not explicitly addressed in this study. Because this study was not designed to collect data on physical health, family members may be underestimating the role of chronic physical health problems and chronic pain in exacerbating the behaviours associated with the Veterans’ mental health problems. As a result of these weaknesses, the recruitment of family members willing to share their experiences of living with a Veteran who had a mental health problem during the MCT likely attenuated the sample’s heterogeneity.
Implications
The implications of this study are likely best summarized in this statement: military families are experiencing both small successes and formidable barriers in accessing evidence-based care systems that identify and address the unique needs of Veterans with mental health problems in the MCT. In supporting Veteran families during the MCT, especially those families whose Veterans have mental health problems, it is likely necessary for more time and resources to be invested in collecting data from sequential cohorts of Veteran families regarding their developmental, familial, and ecological strengths. Although pertaining to family members much younger than those in our sample, this echoes the recommendations of other recent meta-analysis (e.g., Lambert and colleagues10) and literature mapping (e.g., Rayce and colleagues9) studies that call for consideration of the contexts of how Veterans’ mental health affects family members, including family variables (i.e., sex of parent, parent–child attachment, cultural background) and child variables (i.e., pre-existing psychological distress, peer relationships, school engagement).
The results of this study suggest that several practical changes might benefit Veteran families during the MCT, particularly families of Veterans who have a mental health problem. First, given the barriers experienced by families who sought formal support, it is apparent there would be value in enhancing mental health literacy training for frontline VAC staff. In particular, education on the additional stressors experienced by family members advocating on behalf of a Veteran with a mental health problem might allow for informed and compassionate communication between family members and frontline staff to develop.
In line with this, a second practical implication might be to provide psycho-educational training opportunities for family members to learn about the effects of trauma and toxic stress on Veterans’ social, neurological, psychological, and physical functioning. Understanding how OSIs are carried into, and affect, family relationships, communication patterns, and coping capacities of Veteran families might assist family members to better understand what their immediate support needs are and also where to best seek support.
Finally, given that interviewees also noted accessibility to information as a barrier, Veteran families may benefit from online resources that would assist them in navigating the MCT process. In particular, such resources could include tailored links to formal (e.g., MFRCs) and informal (e.g., local peer-to-peer groups) support resources and summaries of research related to Veteran mental health problems and mental health disorders.
Conclusion
Amid the barriers experienced by family members supporting Veterans living with mental heath difficulties, there was also evidence of the resolve and commitment to supporting the Veteran’s health and well-being that have enabled the family system to adapt. Although it was apparent that family members’ access to, and engagement with, both formal and informal support systems were compromised by the Veteran’s mental health, the emotion conveyed in the words of family members as they described their MCT journey was indicative of the commitment and resilience undergirding these families. Although the ongoing and considerable health needs and issues of Veterans continue to absorb significant resources within the family system, gains can be made through policy and programming that simplify and diversify access to services and supports and that extend outreach and compassion to the families who support these Veterans in daily life and long-term recovery.
Future studies focusing on the presence and power of adaptation and coping, nurturing relationships via work and community connections, the role of religion and spirituality, and even inquiry into the importance of family rituals and routines (e.g., family meals) may be helpful to families in the midst of the MCT. Such data could be used to create family-specific resources that would serve to more intentionally include the family in the MCT process and in coming to understand how families as a whole experience change during MCT.
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REGISTRY AND REGISTRATION NO. OF THE STUDY/TRIAL
N/A
ANIMAL STUDIES
N/A
PEER REVIEW
This manuscript has been peer reviewed.
APPENDIX: INTERVIEW GUIDE
Introduction
Thank you for agreeing to participate in this study. Your input is extremely valuable to increasing our understanding of how Veteran families are dealing with a Veteran’s mental health problems, especially during the military-to-civilian transition process.
Before we begin, do you have any questions about the introduction or consent form you signed?
Can we also confirm that you consent to this interview being recorded?
Just as a reminder, the purpose of this study is to better understand the impacts of Canadian Armed Forces (CAF) Veterans’ mental health challenges on the family, factors that contribute to the mental health and well-being of CAF Veterans and their families, and your perception of the effectiveness of current support services during the military to civilian transition period. We are interested also in identifying whether any changes or additions can be made to enhance the capacity of the current support services available to assist Veterans with mental health challenges and their families during this transition.
In this study we define mental health in very broad terms. It can include a wide range of diagnosed and undiagnosed issues that affect mood, thinking, and behavior.
You can choose not to respond to any question or stop the interview at any time for any reason.
| Interview question | Potential probes |
|---|---|
| General Information | |
| 1. Would you like to select a pseudonym we will use for the interview, or would you like us to assign one? 2. What is your age? And the Veteran’s age? 3. What is your current relationship with the Veteran? 4. Are there any children living in the home? 5. When did the Veteran leave the military”? 6. What has the Veteran been doing since release? | How long have you lived with the Veteran? How strongly would you say you and the Veteran are/were engaged with one another on a daily basis? Probe for examples, e.g., meals, socially, physical and mental care. From this relationship? Previous relationships? How many? What were their ages when the Veteran released? How about ages during any deployments? In the last 5 years, how many months of the year would the family unit be living together? How long did your family member serve in the military? What was the nature of the Veteran’s work in the military? Trade? Officer? Deployment? If deployed, how many times? Can you tell us about the nature of the deployment(s)? What prompted the decision to release/leave the military? Plan to retire? Health issues? Family needs? Did you go through the transition process with the Veteran? Work? Volunteering? Hobbies? Caregiving for other family members? Fitness? Managing health? |
| Objective 1: Identify the impacts of CAF Veterans’ mental health problem(s) (including OSIs), on family members and on the functioning of the family unit during MCT. | |
| 7. How did the Veteran’s military service impact the household and family life? 8. Tell us about the Veteran’s health. How does the health of the Veteran impact the family life? If his/her health has affected family life, tell us more about this. 9. What has changed since the mental health issues have been identified (including clinical diagnosis)? | What was fulfilling; what did you like? What were the challenges? Highlights/lowlights? Was there a medical release? For what kind of condition? Physical, mental? Has there been a diagnosis of a mental health condition? How and when was the problem identified/first became apparent? Is he/she presently receiving treatment, e.g., therapy/counselling, consultation, medication? Who is providing the mental health support — family physician, psychiatrist, psychologist, occupational therapist? Other? What has been the impact of the treatment? |
| Objective 2: Describe the mental health and well-being of family members of CAF Veterans who have mental health problems. | |
| 10. How, if at all, have the mental health issues in your Veteran family member impacted you? Your family? How would you describe this effect/these effects? 11. How, if at all, have you or other members of your family made adjustments to manage the impact of the Veteran’s mental health? 12. Tell me about the relationship between your family member’s mental health and your/your family’s health/well-being? | Determinants of well-being, e.g., employment effects, financial effects, impacts on health and disability, changes to social integration, impacts on housing, psychological effects. Are you experiencing any impacts? For example, hypervigilance, sleep disturbances, irritability, parenting, intimacy. For example, adjusting your behavior or expectations, using strategies like exercise to help calm or day planners to organize health appointments? Are there are other mental health issues in the family and how those have been impacted by the Veteran’s health? |
| Objective 3: Identify, from the family member’s perspective, how family life is impacting and being impacted by the Veterans’ well-being during MCT (there will be no contact with the Veterans themselves). | |
| 13. Your Veteran/family member has been managing both mental health issues and the transition into civilian life. Tell us more about how that’s been. 14. How have the mental health issues of the Veteran affected the transition to civilian life? 15. Has your daily routine changed during or since your Veteran has transitioned to civilian life? In what way? Other changes? 16. What impact do you feel family life has had on your Veteran’s mental health during the military to civilian transition? | For example, child care or other daily responsibilities. Other determinants of well-being — employment effects, financial effects, impacts on health and disability, changes to social integration, impacts on housing, psychological effects Has it affected the relationships with children? With parents? Siblings? With family? With friends? Have your social relationships changed? Do you still have the same routine with friends and family? How has this affected your relationship with the Veteran? How has it been a positive factor? A negative factor? |
| Objective 4: Identify interventions and supports accessed during the MCT and their success in addressing the needs of the family. | |
| 17. What do you do to take care of yourself and your family through the transition process? 18. How do these things help you manage the transition experience? Your family member’s mental health? | Physical, social, spiritual supports. Formal/informal? Hobbies? Career? |
| 19. Where do you find the greatest support during this transition period? 20. What does this support mean to you? 21. As your family has made the transition to civilian life, what have you learned about your support system(s)? 22. Have you or would you seek support targeted to Veterans and/or their families? families? | Family, friends, community, church/mosque/synagogue, military/Veteran family services What are the positive aspects of this support? What are the negative (if any) aspects of this support? Are you familiar with the OSI clinics, or other programs offered through military/Veteran family services? If yes, what was your experience of those services? What were the key ingredients that were most helpful for you? Why or why not? |
| Objective 5: Based on the findings, identify interventions and supports that could enhance the overall health and well-being of families during MCT and into the future. | |
| 23. Given your experience, what services and programs would help you and other families supporting members/Veterans with a mental health issue through the transition from military to civilian life? 24. Is there anything you would change to existing programs to help make them better meet your needs now, or in the future? 25. Is there anything else you think would be useful for us to know about mental health and transition that we haven’t already covered? | How did you learn about these? Enhanced communication channels, greater awareness of supports and services, changes to financial benefits, use of technology to promote access How would you like to get information about supports? |
Note: CAF = Canadian Armed Forces; OSI = operational stress injury; MCT = military-to-civilian transition.
Information & Authors
Information
Published In
Journal of Military, Veteran and Family Health
Volume 7 • Number 1 • February 2021
Pages: 21 - 34
Copyright
For permission to share, copy, or redistribute, contact [email protected].
History
Published ahead of print: 25 January 2021
Published in print: February 2021
Published online: 26 February 2021
Key Words:
Mots-clés :
Authors
Contributors
All authors were integral in the study design, collection of data, interpretation of results, and drafting of the manuscript. All authors approved the final version submitted for publication.
Competing Interests
Kelly Dean Schwartz reports funding from Veterans Affairs Canada.
Funding
The authors gratefully acknowledge the funder of this study, Veterans Affairs Canada.
Ethics Approval
The study protocol was approved by the research ethics boards at Queen’s University, Kingston, Ontario, Canada; Mount Saint Vincent University, Halifax, Nova Scotia, Canada; and the University of Calgary, Calgary, Alberta, Canada.
Informed Consent
N/A
Metrics & Citations
Metrics
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Journal of Military, Veteran and Family Health 2021 7:1, 21-34
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