NPs who provide care for military families may be unaware of the unique stressors that military families may bear. Several of these uncertainties are germane to the feeling of safety and security basic to family life. Three unique stressors to note include geographic separation and relocation, obstacles faced by military spouses, and the impact of these first two stressors on military children. This article discusses these unique stressors and addresses the NP's role in understanding and assisting military families.
Employing the theory of causal uncertainty, this article also provides direction for NPs to support, care for, and treat families by recognizing signs and symptoms of personal and family distress.
The Causal Uncertainty Model
The Causal Uncertainty Model is an appropriate model to describe alterations in the function and structure of the military family. Causal uncertainty is used to help patients describe feeling a loss of control, powerlessness, and confusion that are an inherent part of military life. Causal uncertainty describes negative feelings when there is no reliable cause for an event. An example is the manner in which causal uncertainty interferes with the feeling of safety, protection, and predictability that is germane to family life. Causal uncertainty provokes doubt and confusion in attributional ability. If left untreated, certain military families may perceive their entire environment as one of confusion, disappointment, lack of control, with no ability to intervene.1
An increase in symptoms of depression, anxiety, and insomnia are noted as psychological symptoms of causal uncertainty. Headaches and gastrointestinal problems are identified as physiologic symptoms of causal uncertainty.1-3 When the cause of an event is unclear, individuals who experience causal uncertainty frequently experience confusion, doubt, and a feeling of powerlessness. This is associated with believing they are unable to influence a change in unwanted events. Consequently, individuals may feel they have to accept the fate that “others” place on them. The longer individuals accept this position, the more the perception of lacking personal control becomes entrenched.3
When deployment is unexpected, a family may feel vulnerable, unsafe, and insecure. Causal uncertainty can provoke doubt and confusion. Military families that endure frequent relocations with little input into the process may perceive their military environment as one of confusion, disappointment, and hostility. Fortunately, when the NP allows space for family members to express these emotions, the family is able to learn coping skills, such as the use of effortful cognition or personal attributes.
Edwards and colleagues describe effortful cognition as the act of increasing cognitive processing to improve the ability to understand a situation.2 From a family perspective, effortful cognition is necessary to better understand how an event will influence family structure and function. To some, effortful cognition may appear as hypervigilance or even paranoia. However, it actually stimulates the necessary action that will help minimize the negative effects of causal uncertainty.
A creative use of the Causal Uncertainty Model is to encourage each family member to identify and contribute their personal attributes to help them navigate through the transition of deployment, geographic separation, or frequent relocations. By encouraging the family to employ the attributes at their disposal, the NP can help strengthen the structure and function of the family's resiliency.3
Geographic separation and relocation
Military family members now outnumber military members by a ratio of 1.4 to 1.4 Given the increased military operations of the last decade, this means that more families have been separated for long periods of time because of deployments or are being assigned to duty stations that do not accommodate their families.
The effect of long-term separation has a negative impact on family homeostasis and has led to an increase of anxiety levels in both military members and their families.5 Deployments can affect the military family in many ways, including psychological difficulties, high levels of parenting stress, psychological symptoms in children, and emotional difficulties in all family members.6 Deployments could cause spouses and children to have high levels of anxiety and stress for fear that their loved one may not return. Military members may miss out on their children's milestones and important life events, and they may feel guilty that they have left such a heavy burden on their spouses.
Military assignment relocation also has an effect on the military family's well-being. They may feel overwhelmed by the myriad of required checklists and move preparation along with a lack of control over the frequency of geographic relocation. The military family cannot necessarily decide what time of year they move, where they move, or how long they can stay at one location before transitioning to another.
Military members may experience internal conflict if the family is forced to move to a location that is not desirable for one or more family members. This undue stress from a geographic relocation can lead to tension, arguing, and marital discord. If parents display stressful behaviors or mood changes such as anxiety, irritability, anger, social withdrawal, overeating, or vulnerability, their children are more likely to manifest similar behaviors and mood changes.7
In addition, the entire family loses their primary healthcare provider when relocating. While some individuals may not mind this type of change, spouses with difficult-to-manage and chronic health conditions and children with special needs benefit from continuity of care. Moreover, the new location may not have appropriate specialists or medical services available. In this case, the spouse and children might have to stay behind while the military member moves across the country or the world.
Military spouse obstacles
Military spousal employment is a unique stressor to the family as a system. An employed military spouse either has to transfer within the same company or quit and find new employment following relocation. Furthermore, based on the spouse's earning potential, the family might learn that expenses (such as childcare) at their new location exceed their income.
Furthermore, if there is a waiting list for daycare, a spouse may have to stay home until an opening becomes available. If he or she has to look for new employment or wait to start working until childcare is available, the interim income loss might be detrimental to the family. Military spouses often acknowledge that frequent moves pose problems when seeking employment and can contribute negatively to career establishment or progression.
Young active-duty military families often struggle financially because they are in the process of attaining rank and financial stability. During this early phase of their careers, dual incomes are necessary to meet financial demands and allow spouses to build their career skills and advance in their respective fields.
Military spouses may have to sacrifice their careers by beginning with new companies in entry-level positions after a move. This precludes their ability to attain enough time with a company for career advancement.8 They may also have a hard time finishing a higher degree of education, especially when enrolled part-time or in a 4-year degree program. Oftentimes, spouses begin the educational requirements to pursue a degree, and during the time of this pursuit, the military member may be relocated. When this occurs, there is a struggle to find a college that accepts credits from previous schools. In addition, there is a necessary wait period until the spouse attains residency status to qualify for in-state tuition rates. The NP can assist by being familiar with resources to help the military spouse, such as the Department of Defense (DoD) Military Family Readiness Council and local Military and Family Readiness Centers.
Even those with advanced degrees face challenges. Military spouses who require licensure for their career, such as physicians, nurses, lawyers, and teachers, are subject to the governing regulations and professional requirements of the state in which they have just been transferred. This is difficult for those in professions with licensure requirements, which are not always uniform across states. Moreover, previous educational and licensure requirements may not have been required in a previous state where the service member was located. Consequently, the ability for the spouse to attain employment in the new location is delayed.
All of these hurdles to sustained and meaningful employment take an extended toll on the family as a unit. The unemployment or even the underemployment of the military spouse first takes a financial toll on the family unit. Young service members raising a family are often unable to meet their financial needs and are forced to turn to state and federal assistance programs in order to provide essentials for the family. The distress placed on the family, coupled with the financial difficulties due to spousal employment difficulties, may have an ancillary effect on the service member's job performance.
Often, this distress creates a decline in work performance. As a consequence, the distress may limit the service member's ability for career advancement. This, in turn, keeps the family unit in the same financial status from which they need to progress. When these stressors become overwhelming, there is often a decision to separate from military service prior to the attainment of a military retirement. This decision to prematurely separate from the military is often perceived as a failure.8
Impact on the military child
Children are inherently affected by the frequent requirements of their military parents. Relocations and deployment periods (with at least one parent absent for an extended period of time) present additional stress. Military families relocate 50% more often than the general population, resulting in more frequent stressors and issues.4
Young children are especially vulnerable when it comes to a military parent separating from the family unit for any given period of time. Children can experience a lack of trust, increased behavioral problems, cognitive problems, and mood problems during a parent's deployment. Sories and colleagues described the impact of the Global War on Terrorism on the military family and children, noting high levels of tension in the family, difficulty connecting with peers, sustainment of close relationships, adjustment problems to a new school, and community/academic challenges.6 Young children can also experience increased neediness, confusion, and distressed behavior when the parent returns.6
With parental deployment, there is not only the aspect of an absent parent but also the fear for the parent's safety and knowing there is a real possibility that the parent will not return home. Young children may not understand the risks of deployment; however, with the vast media coverage of today's military conflicts, children now have the potential for exposure to this information more readily than in the past.
It is important to remember that adolescents are experiencing a critical developmental period that can cause increased difficulties. They are developing their identities, yet it may not be stable enough to encounter such significant interruptions in attachment. Milburn and Lightfoot identified several struggles in adolescents related to the safety of a deployed parent that include feelings of loss, depression, and anxiety.9 Additionally, these adolescents reported concern for their siblings and parent in the home. All of the instability that comes with relocating can lead to mental health manifestations, such as depression, anxiety, powerlessness, or hyperactivity.9
Any parent will tell you that relocating with a special needs child stretches the family reserves to its limits and generally has more negative implications than positive benefits compared with children without special needs. In general, many special needs children have a harder time with transitions; this is particularly true in new living environments. Depending on where the family moves, access to special needs programs may be challenging at best and often nonexistent. Consequently, there is a disruption or delay in therapy.10
More concerning is that special needs programs differ greatly from state to state. Children who require adaptive environments can experience additional hurdles. This type of setback is potentially harmful to the child and may create extra stressors on the family. Additionally, getting specialized medical care at a new duty assignment can delay treatment for special needs children, causing more frustration and a decrease in resiliency for the entire family.10
Implications for the NP
Geographic relocation. NPs are uniquely positioned to support families in recognizing and then implementing their unique attributes. This is most effective when it occurs before the relocation and again once the family has arrived at their new location. An NP should evaluate the family and discover the negative effects that the geographic relocation is having on the family. The NP should keep in mind that some members of the family may feel powerless and unaware of the reason that their family or service member was selected to relocate. During this time, the NP should identify if other family members may have a better understanding of what they are experiencing and should be encouraged to share their understanding with their family.
NPs can provide a safe space where the spouse and the children are free to express the emotional experience of the relocation/separation and can evaluate the physical effects associated with geographic separation.
Physical exhaustion is a common issue associated with somatic complaints. It is important to note that once a separation occurs, the family is often angry and sad as they adjust to the change. This can be especially true for parents with special needs children who require increased resources and efforts to maintain a balanced life.10
Military spouse obstacles. The NP plays a key role in issue identification for the military spouse, who may experience overwhelming stress and possible symptoms of depression or guilt.11 Spouses may recognize their stress but not understand the underlying causative factor. Factors that may increase spousal risk of ineffective coping include young age, first time away from home, foreign birth, and difficult finances.11 One key factor is the lack of a career.12 Identifying this creates a focus for the NP and spouse to create a plan of care.
The most important part of the care plan established by the NP is to help patients understand and attain healthy coping skills. Other interventions beneficial to a military spouse who is currently lacking employment should focus on the spouse's social resources.11 The NP can guide the spouse toward educational opportunities provided by military organizations and universities. These resources can help spouses in their search for employment opportunities.12
Another resource should focus on job assistance, relocation, and licensure fee assistance. Programs are available to help military spouses with resumes, job placement, and education on the job market in their new location. (See Resources for the military family.)
Military children. There is an old adage that claims “military children are so resilient.” NPs should be leery of this pronouncement and ask, “Is the military child as resilient as adults would like to believe?” The age of a child is major factor in how the NP will approach and care for the military child.
When there is a geographic separation, a preverbal child is at greater risk for maltreatment from the remaining parent.13 The changing role from a child being cared for by two parents to one parent can greatly increase the stress levels of the now single parent.13 This is especially true when the return time of the military member is unknown or if this separation is one in a series of separations.13
With each separation, the NP should include a discussion of the risk of increased stress. The NP can provide resources such as local military base DoD Family Readiness Centers, DoD Military Family Readiness Council, chaplain services, or a psychiatric NP for further assistance. Moreover, parents should be assured that many other parents experience these feelings during a geographical separation.
When working with toddlers, refer to Erikson's stages of psychosocial development. At this age, “what is not known is made up.” In addition, fantasy is used to clarify the unknown during this age. This group needs age-appropriate information, with an emphasis on safety at home.13 The toddler may experience an emotional overload when the information is presented in the context that the separating parent is “going to war” or “going to fight for our country.” Finally, interrupting attachment at the toddler developmental stage is difficult.13 Therefore, the NP can prepare the parents before and after the separation or relocation by normalizing the possible changes in mood and behaviors.
School-aged children (ages 6 to 11 years) are able to verbalize their confusion and lack of control. It is common for parents to start noticing somatic and behavioral problems. Furthermore, separations may weaken attachment bonds between the separated parent and the school-aged child.14 This is also the age in which children may insert themselves in the role of the missing parent. This is believed to have a twofold purpose: It is frequently meant to support the remaining parent and to stand in the gap for the separated parent.15 This can be complicated because the parent remaining home actually needs the help the child offers; however, the NP should encourage the at-home parent to allow school-aged children to maintain their age-appropriate role.15
Adolescents (ages 11 to 17) are experiencing multiple transitions that include physical changes (puberty), social changes (friend groups), and psychological changes (self-differentiation). At this age, the symptoms related to causal uncertainty are more visible. Gilreath and colleagues found that adolescents with parents who deploy are at greater risk for substance abuse.16 Furthermore, they found that the risk of substance abuse increases with the number of parental deployments.16
Similarly, Lucier-Greer reported that adolescents with a deployed parent were more likely to report symptoms of depression and a decrease in academic performance.17 However, these symptoms may be ameliorated when adolescents have the opportunity to discuss what matters to them before, during, and after deployment.
Finally, the family must be engaged in this process as a whole. NPs should make every effort to be present and in the moment with the family by recognizing when a family is experiencing the confusion or lack of control found with families experiencing causal uncertainty. Oftentimes, the greatest intervention will be to sit with the family as they navigate this process.
A way forward
NPs have a range of knowledge that military families lack. Similarly, military families have valuable information that NPs lack. Therefore, working through the effects of causal uncertainty with families requires a collaborative effort from start to finish. Each family system is unique with their needs and perceptions. Two interventions may strengthen interactions with military families.
First, the NP should allow time to understand the perceptions that the service member and family have regarding their unique stressors. This is critical because the family perception offers insight into the family's cognitive processing. In addition, it helps to identify the attributes the family has to influence their situation.3
Second, the NP should learn what matters most to the family. Examples include the interruption of the attachment with the children during the separation; the loss of the person separating; the loss of emotional support from extended family and friends; the loss of intimacy; the labor related to securing care for a special needs child; and the loss of financial security as a result of unemployment. The willingness of the NP to learn what matters and how the family perceives the situation will allow for a dynamic and authentic healthcare interaction.3 NPs can provide families with resources for support through these transitions.
Because causal uncertainty is most problematic when attributional efforts and effortful cognition are ineffective or not employed, family and psychiatric mental health NPs must empower military families to recognize their attributional efforts and encourage the activation of effortful cognition. The goal is for the military family to transition through the military lifestyle with less stress and minimal negative effects of causal uncertainty.
Resources for the military family
The Military Family Research Institute at Purdue University
National Military Family Association
Substance Abuse and Mental Health Services: Veterans and Military Families