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Course: Mental Health Nursing

Topic: Military Families

The Nurses International Community

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COPYRIGHT

NI Privacy Policy and Terms of Use.

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Module Goals

Learners will be able to:

Discuss the impact of deployment on military families.
Discuss various treatment modalities for clients with traumatic brain injury.
Discuss various treatment modalities for clients with post-traumatic stress disorder.
Discuss the nurse’s role in education and prevention related to risks to the emotional health of military families.

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Military

Military:

A country’s professional defense system.
May consist of Army, Marine Corps, Navy, Air Force, Space Force and Coast Guard and referred as the Military.
The branches vary with the countries.

Deployment: Is the state of the movement of the soldiers or equipment to a place where they can be used when they are needed (Cambridge Dictionary, 2022).

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Deployment

Deployments are always stressful for the deployed and other family members associated with the deployed.
Deployed to the hostile environments are associated with increased mental health disorders for military parents, including posttraumatic stress disorder (PTSD).
Indeed, poor mental health is among the most common complaints among veterans.
Longer the deployment more chances of having mental, physical and behavioural problems.

Trautmann et al., 2015

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Impact of Deployment

Potential family instability and relationship breakdown due to long period of separation and adaptation.
Lack of resilience.
Difficulty in financial management resulting debts.
Potential isolation or bereavement.
Lack of knowledge to assess the health care services.
Limited relevant maternal health support for the child or the parent.

Trautmann et al., 2015

Image by: Pixabay

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Impact of Deployment on the Parents

Poor family or couple functioning, poor general well-being.
Increased use of mental health services for the military spouse.
Increased mental health problems.
High levels of distress associated with parenting.
Fears that their children would forget them while deployed.
Concerns about the children and the family.
PTSD and traumatic brain injuries are evident.

Trautmann et al., 2015

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Parenting Challenges in Postdeployment

Discomfort asking for parenting advice from their spouse or partner.
Difficulties reconnecting emotionally with their children.
Reticence to discipline their children.
Difficulty communicating with spouse and children.
Those who return from deployment injured or with PTSD, parenting stress associated with reintegration is particularly high while struggling with their physical recoveries.

Trautmann et al., 2015

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Impact on Children

Separation from a parent results high level of anxiety.
Worry for their life and the deployed parent.
Potential detachment with the parent.
Lack of resilience.
Potential isolation or bereavement.
Risk of bullying and isolation.

Public Health England - Department of Health, 2015

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Children of service families are exposed to unique experiences, which may include:
Separation from a parent
Frequent moving of house or school
Caring for a sibling or parent
Taking responsibility for the household or sudden deployment to a combat zone, all of which may impact the way children lead their lives both now and in the future.
The challenges or difficulties each face may vary; however, high levels of anxiety and stress are evident.
Their health, the continuity of their records, and their ability to learn may also be disrupted, especially when their parents are deployed to armed conflicts overseas.
In addition, children with additional or complex health needs may find continuity of care a problem due to regular moves and may feel isolated or find it difficult to cope without support from the extended family or local community networks.

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Impact on Children

Risk of domestic violence and substance use.
Frequent school transfers.
Difficulty developing friendship and peer support.
Lack of knowledge to assess the health care services.
Taking responsibility in early age.

Public Health England - Department of Health, 2015

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Case Study

Do you know any family whose member is in the military?

How do you think it has impacted the family?

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Traumatic Brain Injury

“A disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head, or penetrating head injury” (CDC, 2021a)

According to VA (2017):

May occur from direct contact to the head or concussion from blast or whiplash in a car accident.
The person may suffer from a loss of memory for the time immediately before or after the event that caused the injury.

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According to the US Department of Veterans Affairs( 2021),

The Centers for Disease Control and Prevention (CDC) defines a traumatic brain injury (TBI) as "a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head, or penetrating head injury." Individuals can experience a TBI through everyday activities like playing contact sports, being involved in a car accident, or falling and striking their head. Military service members and Veterans are also at risk of brain injury from explosions experienced during combat or training exercises.

Depending on the severity of the brain injury, a person with TBI may experience a change in consciousness that can range from being dazed and confused to losing consciousness. They may also experience memory loss.

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Traumatic Brain Injury

Between 2000-2020, more than 430,000 U.S. service members were diagnosed with a TBI.
Studies suggest that service members and Veterans who have sustained a TBI may:

Have ongoing symptoms.
Experience co-occurring health conditions, such as post-traumatic stress disorder (PTSD) and depression.

CDC, 2021b

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Symptoms of TBI

Lindquist et al., 2017

Immediate symptoms following TBI:

Dazed, confused, or ‘seeing stars’
Dizziness
Blurred vision
Loss of coordination
Ruptured eardrums
Headaches
Memory problems/lapses
Sleep problems
Irritability
Balance problems or dizziness
Sensitivity to bright light

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Mechanism of Injury Causing TBI

Blast or explosion (RPG, landmine, IED, grenade)
Object hitting head or head hitting object
Fall
Vehicular accident/crash (including aircraft)
‘Knocked out’ by another person
Fragment or bullet wound above the shoulder

Lindquist et al., 2017

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Treatment of TBI

Trauma focused treatment
Treatments should be symptom-focused and evidence based
Memory aids
Occupational rehabilitation and case management
Referrals
Rehabilitative treatment
Lithium
Protein treatment

U.S Department of Veterans Affairs, 2017

U.S Department of Veterans Affairs, 2021a

Image by: Wikimedia

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Treatment

Trauma center treatment: Clients with traumatic brain injury have also experienced musculoskeletal, neurologic, and psychological trauma.
Treatments should be symptom-focused and evidence-based

For example, early data shows that the treatments that have worked well in Veterans with PTSD alone, such as cognitive processing therapy, prolonged exposure, or SSRIs, can also work well for Veterans who have suffered a mild traumatic brain injury as well as emotional trauma.

Memory aids: Can also be helpful to the client suffering from TBI
Occupational rehabilitation and case management: Research has found that clients with TBI can also benefit from occupational rehabilitation and case management, depending on the severity of their injuries.
Referrals: Depending upon the condition, the client should be referred to consultants, such as neurologists, neuropsychologists, and substance abuse or other specialized treatment as needed.
Rehabilitative service: It is needed to improve job skills, social skills, problem-solving skills, recreation. This service also provides psychological support and support groups to the victim, enhancing memory and controlling physical symptoms.
Lithium: Treating the client with lithium helps in stabilizing mood, improving cognitive function, supporting motor function, and preventing suicide.
Protein treatment: It may protect against TBI damage improve cognitive function.

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Critical Thinking Question

A military nurse finds an injured soldier irritable, holding his head, and lying down in a dark corner of room.

Why do you think that this person needs an immediate medical help?

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Post Traumatic Brain Injury Among Military/Veterans

“A mental health problem that some people develop after experiencing or witnessing a life-threatening event, like combat, a natural disaster, a car accident, or sexual assault. During this kind of event, one may not have control over what's happening, and may feel very afraid”

U.S Department of Veterans Affairs, 2021b

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Post Traumatic Brain Injury Among Military/Veterans

Upsetting memories, feel on edge, or have trouble sleeping after a traumatic event/trauma.
Most people start to feel better after a few weeks or months.
For some people, PTSD symptoms may start later, or they may come and go over time.
Anyone can develop PTSD at any age.
Common after certain types of trauma, like combat and sexual assault.

U.S Department of Veterans Affairs, 2021b

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Symptoms of PTSD

Usually starts soon after the traumatic event, but may not appear for months or years
May come and go over several years
Symptoms vary among individuals
4 major types of PTSD symptoms

Reliving the event/re-experiencing symptoms
Avoiding thing that reminds one of the event
Increased negative thoughts/feelings than before the event
Feeling on edge/keyed up (hyperarousal)

U.S Department of Veterans Affairs, 2021b

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Symptoms of PTSD

PTSD symptoms usually start soon after the traumatic event but may not appear until months or years later. They also may come and go over many years. Each person experience symptoms in different ways. However, there are 4 major types of PTSD symptoms. At first, it may be hard to do daily activities you are used to, like going to work, going to school, or spending time with people you care about.

Reliving the event (also called re-experiencing symptoms). Memories of the traumatic event can come back at any time. They can feel very real and scary. For example: having nightmares, flashbacks (feel like you are going through the event again), triggers (see, hear, or smell something that causes you to relive the event), news reports, seeing an accident, or hearing fireworks are examples of triggers.
Avoiding things that remind you of the event: A client with PTSD may try to avoid situations, events, people that remind of the traumatic event. They may even avoid talking or thinking about the event. For example: avoiding crowds, crowds, avoiding driving ( if the military convoy was bombed), keeping oneself busy to prevent thinking about the event.
Having more negative thoughts and feelings than before the event: Feeling numb, unable to have positive or loving feelings towards other people, loss of interest in things/hobbies, not being able to talk about the traumatic eb=vent, feeling of guilt or shame, feeling insure about the world and the people.
Feeling on edge or keyed up (also called hyperarousal): A client may be jittery or always alert and on the lookout for danger. You might suddenly become angry or irritable. May have a hard time sleeping, problem in concentration, startle or fear of loud noise or surprises, pursue unhealthy habits like drinking, smoking, driving aggressively.

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PTSD: Treatment

Trauma Focused treatment/therapy
A detailed assessment of symptoms to tailor the treatment.
Active monitoring: Watchful waiting – symptoms have to be monitored to see whether they improve or worsen without treatment.

Psychotherapies

Cognitive behavioural therapy (CBT)
Eye movement desensitisation and reprocessing (EMDR)
Support and advice

Psychopharmacology: Antidepressants like paroxetine or mirtazapine.

National Health Service, 2018

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Active monitoring

If you have mild symptoms of PTSD or you've had symptoms for less than four weeks, an approach called active monitoring may be recommended. Active monitoring involves carefully monitoring your signs to see whether they improve or get worse. It's sometimes recommended because 2 in every three people who develop problems after a traumatic experience get better within a few weeks without treatment. If active monitoring is recommended, you should have a follow-up appointment within one month.

Psychological therapies: If you have PTSD that requires treatment, psychological therapies are usually recommended first. A combination of psychological therapy and medicine may be recommended if you have severe or persistent PTSD. There are three main types of psychological therapies used to treat people with PTSD.
Cognitive behavioural therapy (CBT)
Eye movement desensitization and reprocessing (EMDR): A psychological treatment that is involved recalling the traumatic incident in detail while making eye movements, usually by following the movement of your therapist's finger/tapping finger or playing a tone. It's not clear exactly how EMDR works, but it may help you change the negative way you think about a traumatic experience.
Support and advice: There are a number of charities that provide peer support and advice for PTSD.For example:
Combat Stress – a military charity specializing in helping ex-servicemen and women
Rape Crisis – a UK charity providing a range of services for women and girls who have experienced abuse, domestic violence, and sexual assault
Victim Support – providing support and information to victims or witnesses of crime
CRUSE – a UK charity providing support and information for people who have experienced bereavement
Medicine: Some specific SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin-norepinephrine reuptake inhibitors). Antidepressants, such as paroxetine, sertraline, mirtazapine, amitriptyline, or phenelzine, are sometimes used to treat PTSD in adults. Of these medicines, only paroxetine and sertraline are licensed specifically for the treatment of PTSD. But mirtazapine, amitriptyline, and phenelzine have also been found to be effective and may be recommended as well.

These medicines will only be used if:

you choose not to have trauma-focused psychological treatment
psychological treatment would not be effective because there's an ongoing threat of further trauma (such as domestic violence)
you have gained little or no benefit from a course of trauma-focused psychological treatment
you have an underlying medical condition, such as severe depression, that significantly affects your ability to benefit from psychological treatment

But they're not usually prescribed for people younger than 18 unless recommended by a specialist. If medicine for PTSD is effective, it'll usually be continued for a minimum of 12 months before being gradually withdrawn over the course of 4 weeks or longer. If a medicine is not effective at reducing your symptoms, your dosage may be increased.

Children and young people

Trauma-focused CBT is usually recommended for children and young people with PTSD. This typically involves a course of 6 to 12 sessions that have been adapted to suit the child's age, circumstances, and level of development. Where appropriate, treatment includes consulting with and involving the child's family. Children who do not respond to trauma-focused CBT may be offered EMDR.

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Case Study

A nurse is assessing a community for types of mental health issues. Which of the following clients would the nurse consider most vulnerable for having post traumatic stress disorder?

A teenage boy who complains of always being second in the class
A couple whose son has recently moved to another city
A woman whose father frequently gets drunk and beats her mother
An older man whose wife died 6 months ago

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Nurse’s Role in TBI and PTSD

Education for the client and family early in the course of recovery may improve outcomes in clients with TBI and PTSD as this helps to prevent the development of other psychological problems.
Encourage family involvement.
Refer client to support groups.
Aware of the unique stressors that military families may be experiencing.
Help relocate the family if they have been assigned and moved to a new location.

Owen & Combs, 2017

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Nurse’s Role to Promote the Mental Health of

the Military Families when they Relocate

Assess their health and condition
Understand the physical exhaustion associated with the separation
Anticipate and intervene the mental exhaustions among the spouse/partner
Anticipate stressors of the children
Guide to nearby resources
Meet with them frequently to navigate the process

Owen & Combs, 2017

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Geographic relocation: If the family has moved/arrived in a new location, a nurse must evaluate the family and find the negative impacts of moving into the new place. A nurse has to understand that the family may feel powerless and unaware of all their services. Therefore, a nurse has to encourage the family members to share their understanding and show them their options. A nurse may provide them with a safe space to express their feelings and emotions regarding relocation.
Understand the Physical exhaustion: Physical exhaustion is a common issue in military families and even the person who is deployed. These exhaustions are associated with the separations. Anger, sadness, insecurities of lives are common feelings when change happens. A nurse has to support the families and care to balance their lives at these times.
Understand the mental health issues are evident in the spouse: A nurse has to understand that a single military spouse may experience overwhelming stress signs of depression and may be filled with guilt. The spouse may understand the stress but may not understand the causing factors. Factors that may increase the spousal risk of ineffective coping include young age, first time away from home, foreign birth, and difficult finances. Therefore, helping them identify these factors may create an understanding and solution to their problems. A nurse may also help them develop a healthy coping mechanism to deal with the stressors, join the support group and even help them find employment opportunities. A nurse can make them aware that certain programs are available to help military spouses with resumes, job placement, and education on the job market in their new location.
Understand the Military children: When separation occurs, a child may be at a greater risk of maltreatment from the remaining parents (single parenting is very stressful). Therefore, a nurse has to understand and support the child if necessary. A nurse can help by providing 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. Depending upon the age of the children, a nurse can help identify the stressors for the children assess their mental health, substance use, and vulnerability.
A nurse must have to include the family in the whole process. Sometimes, the greatest intervention will be to sit with the family as they navigate this process.

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What Would the Nurse Do?

A spouse of a military complains that she is exhausted and overwhelmed. She complains that she does not sleep well at night, worries excessively and is constantly yelling at her children.

What might the nurse understand this client is experiencing?

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Understand the Physical exhaustion and mental health issues are evident in the spouse: Physical exhaustion is a common issue in military families and even the person who is deployed. These exhaustions are associated with the separations. Anger, sadness, insecurities of lives are common feelings when change happens. A nurse should support the family and understand that a single military spouse may experience overwhelming stress signs of depression and may be filled with guilt. The spouse may understand the stress but may not understand the causing factors. Factors that may increase the spousal risk of ineffective coping include young age, first time away from home, foreign birth, and difficult finances. Therefore, helping them identify these factors may create an understanding and solution to their problems. A nurse may also help them develop a healthy coping mechanism to deal with the stressors, join the support group and even help them find employment opportunities. A nurse can make them aware of available programs to help military spouses with resumes, job placement, and education on the job market in their new location.

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Red Flags in family members

Headaches
Memory problems/lapses
Sleep problems
Irritability
Balance problems or dizziness
Self harm or harm to others
Isolation
Hyperarousal

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References

Cambridge Dictionary. (2021). Definition: Deployment. https://dictionary.cambridge.org/dictionary/english/deployment

CDC-Centers for Disease Control and Prevention. (2021a). Injury Centre: Get the Facts About TBI. https://www.cdc.gov/traumaticbraininjury/get_the_facts.html

CDC-Centers for Disease Control and Prevention. (2021b). Injury Centre: TBI Among Service Members and Veterans. https://www.cdc.gov/traumaticbraininjury/military/index.html

Lindquist, L. K., Love, H. C., & Elbogen, E. B. (2017). Traumatic Brain Injury in Iraq and Afghanistan Veterans: New Results From a National Random Sample Study. The Journal of neuropsychiatry and clinical neurosciences, 29(3), 254–259. https://doi.org/10.1176/appi.neuropsych.16050100

Public Health England - Department of Health. (2015, November). The role of health visitors and school nurses: Supporting the health and wellbeing of military families. Williams Lea for Public Health England. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/479525/2903829_PHE_Military_Families_Accessible_v0.2.pdf

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References

National Health Service (2018). Treatment: Post-Traumatic Stress Disorder. https://www.nhs.uk/mental-health/conditions/post-traumatic-stress-disorder-ptsd/treatment/

Owen, R., APRN, Combs, T. (2017, May 12). BC Caring for military families. The Nurse Practitioner. Vol 42(5) 26-32 doi: 10.1097/01.NPR.0000515421.15414.fb

Trautmann,J., Alhusen, J., Gross, D. (2015). Impact of deployment on military families with young children: A systematic review. Nursing Outlook,63(6), pp. 656-679. https://doi.org/10.1016/j.outlook.2015.06.002

U.S Department of Veterans Affairs. (2021a, March 15). VA research on traumatic brain injury. https://www.research.va.gov/topics/tbi.cfm.

U.S Department of Veterans Affairs. (2019, October 10). Traumatic Brain Injury and PTSD: Focus on Veterans https://www.ptsd.va.gov/professional/treat/cooccurring/tbi_ptsd_vets.asp

U.S Department of Veterans Affairs. (2021b, June 15). PTSD: National Center for PTSD. https://www.ptsd.va.gov/understand/what/ptsd_basics.asp

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