Julianna Petrone Dissertation

Institute for Clinical Social Work

The Effect of Deployment on Relationships: A Phenomenological Study of Female Global War on Terrorism Mental Healthcare Providers & Technicians

A Dissertation Submitted to the Faculty of the Institute for Clinical Social Work in Partial Fulfillment for the Degree of Doctor of Philosophy

By Julianna Marie Petrone

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Abstract This qualitative study investigated and examined the lived experience of veteran female Global War on Terrorism (GWOT) mental healthcare providers and technicians who served with at least one deployment in support of the GWOT. This study’s main research question was: How might the deployed experience impact the relationships of veteran female GWOT mental healthcare providers and technicians during and post reintegration? The GWOT was an era of conflict in which many service members faced multiple deployments and long separations from family and friends back home. The present study is the only qualitative study of its kind that has sought examine the impact the deployed experience might have on the relationships of veteran female mental healthcare providers and enlisted technicians during and post reintegration. This study provides a rich and detailed examination of participants lived deployed experience as well as the potential impact it had their relationships. This study utilized interpretative phenomenological analysis as its methodology. Six GWOT female mental healthcare providers and one mental healthcare technician participated in two semistructured interviews revealing three major themes: Stabilizing Function of the Military, The Interconnection Among Self, Relationships and Deployment and Dear Relationships. Results support that the deployment may serve as a selfobject experience that promotes self-cohesion and relational changes. Results also suggest that the deployed experience may result in an increase or decrease in empathic attunement and a shift in capacity for intersubjectivity in relationships. Formal psychodynamic theories were used to examine the findings. Implications for social work practice and additional research were discussed. Study limitations were also identified in this study.

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For my parents, Frank and Patricia and my cohort battle buddies, Mary and Claire.

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Acknowledgements

I would like to acknowledge the direct guidance and support of my dissertation committee Barbara Berger, PhD, Denise Duval-Tsioles, PhD, Paula Ammerman, PhD as well as Kerstin Blumhardt, PhD and Lynne Tylke, PhD. A special thank you to my parents for their endless support, love, and guidance. I would also like to acknowledge the endless professional support of my mentor, Holli Dunayer-Shalvoy, MSW. She has witnessed my growth since graduating with my MSW in 2009. Furthermore, I would like to thank all my brothers and sisters in arms for their contribution to military mental healthcare and providing me with inspiration during my service in the Air Force. Lastly, thank you is extended to all the participants in this study as I have grown and benefited from their rich stories.

JMP

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Table of Contents

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General Statement of Purpose....................................................................................................... 11 Significance of the Study of Clinical Social Work ................................................................... 11 Statement of the Problem .......................................................................................................... 13 Research Questions ................................................................................................................... 15 Theoretical and Operational Definitions of Major Concepts .................................................... 16 Statement of Assumptions......................................................................................................... 19 Epistemological Foundation of the Project ............................................................................... 19 Foregrounding ........................................................................................................................... 21 Literature Review.......................................................................................................................... 25 Inroduction ................................................................................................................................ 25 History of Military Mental Health throughout Major Wars ...................................................... 25 Psychodynamic Literature and War Trauma ............................................................................. 31 v

Historical Psychodynamic Literature ................................................................................... 31 Contemporary Psychodynamic Literature............................................................................ 37 Self Psychological Lens………………………………………………………………………40 Impact of Deployment on the Mental Health of Female Veterans. .......................................... 42 Vicarious Trauma and Medical Professionals ........................................................................... 47 Impact of Deployment on Relationships ................................................................................... 57 Conclusions ............................................................................................................................... 64 Methodology ................................................................................................................................. 65 Introduction ............................................................................................................................... 65 Rationale for Research Design & Methodology ....................................................................... 67 Research Sample ....................................................................................................................... 70 Research Design ........................................................................................................................ 72 Data Collection.......................................................................................................................... 74 Data Analysis ............................................................................................................................ 79 Ethical Considerations............................................................................................................... 82 Issues of Trustworthiness .......................................................................................................... 83 Credibility .............................................................................................................................. 84 Dependability......................................................................................................................... 85 Confirmability ....................................................................................................................... 85 Transferability ....................................................................................................................... 86 vi

Limitations and Delimitations ................................................................................................... 86 The Role and Background of the Researcher ............................................................................ 87 Results ........................................................................................................................................... 89 Phases of Research .................................................................................................................... 90 Superordinate Themes, Subthemes, and Participants’ Experiences .......................................... 93 Theme 1: Stabilizing Function of the Military ...................................................................... 93 Theme 2: The Interconnection Among Self, Relationships, & Deployment....................... 106 Theme 3: Dear Relationships .............................................................................................. 117 Conclusion............................................................................................................................... 141 Findings and Implications ........................................................................................................... 143 Introduction .......................................................................................................................... 143 Research Questions & Themes ............................................................................................ 143 Findings & Therotical Lens ................................................................................................. 145 Finding 1: The Military & Deployment as Self Object Experiences that May Contribute to a Cohesive Sense of Self…………………………………………………………………….147 Finding 2: Deployment as a Postive Self Object Experience that Leads to Relational Changes ............................................................................................................................... 152 Finding 3: Empathic Attunement & Mis-Attunement in Relationships .............................. 155 Finding 4: Shift in Intersubjectivity in Relationships because of Deployment……………161 Limitations .............................................................................................................................. 165

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Implications for Social Work and Future Research ................................................................ 167 Summary……………………………………………………………………………………..168 Concluding Thoughts .............................................................................................................. 171 Appendix A ................................................................................................................................. 172 Appendix B: ................................................................................................................................ 175 Appendix C ................................................................................................................................. 177 Appendix D ................................................................................................................................. 179 Appendix E ................................................................................................................................. 181 Appendix F.................................................................................................................................. 185 References ................................................................................................................................... 186

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List of Tables

Table 1 Demographic Information............................................................................................. 91 Table 2 Themes and Sun-Themes ................................................................................................ 92

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List of Abbreviations

ADAPT

Alcohol and Drug Abuse Prevention and Treatment

AOR

Area of Responsibility

COB

Contingency Operating Base

COSC

Combat Operation Stress Control

CRC

Combat Readiness Center

FOB

Forward Operating Base

GWOT

Global War on Terrorism

IPA

Interpretative Phenomenological Analysis

RIF

Reduction in Force

STS

Secondary Traumatic Stress

VT

Vicarious Trauma

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Chapter 1

Introduction General Statement of Purpose

The purpose of this interpretive phenomenological study was to explore the impact deployments have on the relationships of Global War on Terrorism (GWOT) veteran female military mental healthcare providers and enlisted mental healthcare technicians during and after reintegration. The sample for this study was selected from GWOT veterans. The deployed experience is defined as an overseas noncombat or combat deployment in support of the wars in Iraq and Afghanistan, as well as other Middle Eastern territories since the attacks on September 11, 2001.

Significance of the Study for Clinical Social Work The social work profession has a unique mission to promote the well-being of clients from various backgrounds within complex social environments. The National Association of Social Workers Code of Ethics (2017) incorporates the impact of the environment on the individual directly within its mission statement: A historic and defining feature of social work is the profession’s focus on individual wellbeing in a social context and the wellbeing of society. Fundamental to social work is attention to the environmental forces that create, contribute to, and address problems in living. (p. 1) Military mental health providers and technicians provide a distinct service to the military community both at their assigned bases and during deployment.

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A primary mission for military mental health providers and enlisted technicians is to treat and ultimately ensure the emotional stability of all service members from various specialties so that they are fit to deploy and able to carry out duties that support the deployed mission. In particular, female mental health providers and technicians have been uniquely tasked with serving the mission while maintaining various roles outside of the military including but not limited to mother, wife, daughter, friend, and sister.

In August 2021, President Biden ended the war in Afghanistan. However, deployments are inevitably a part of the military and a unique experience service members will face in the future. Those who have served and continue to serve in the conflicts in response to the GWOT have experienced long deployments with extended periods of separation from family and friends, which in turn can enhance and promote closeness to their deployed military peers and units.

Exploring the impact of deployments on veteran female military mental health providers and enlisted technicians has critical significance for the field of clinical social work.

A study of this nature may provide valuable insight to the mental health field on the relational impact of deployments on female military mental healthcare providers and technicians.

Depending on the nature of the impact, this study can potentially offer understanding on what is needed to promote the intrapsychic health of females serving in the military as well as mental health providers and technicians. Additionally, this study may deliver understanding on the postdeployment reintegration needs of a subset of female veterans who served their country by taking care of the emotional needs of fellow service members. Female military mental healthcare providers and enlisted technicians are tasked with providing care to fellow service members while having to limit their many roles outside of the military. This detachment or separation from mainstream societal roles and relationships may result in reintegration issues with family and

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friends after spending months attuning to the emotional needs of their peers and clients. An understanding of the reintegration challenges and needs of this subset of female veterans can provide invaluable training to mental healthcare providers, as well as future female military mental healthcare providers and technicians seeking to join military service. Finally, this study may provide military units across all branches with foundational knowledge on retaining female service members serving in mental health career fields.

Statement of the Problem The Global War on Terrorism was an international military campaign launched by the United States in response to the September 11, 2001, attacks. It was the longest military campaign in US history and encompasses both the Afghan and Iraq wars and countless conflicts.

Various conflicts comprise the wars in Iraq and Afghanistan. According to the Defense Casualty Analysis System (n.d.), these conflicts include Operation Freedom’s Sentinel (OFS-Afghanistan 2015–August 2021), Operation Inherent Resolve (OIR-Iraq, 2014), Operation Iraqi Freedom (OIF-Iraq, 2003) Operation Enduring Freedom (OEF-Afghanistan, 2001–2014), Operation New Dawn (OND-Iraq, 2007–201).

Countless services members from across all military branches have deployed in response to the GWOT. Since the attacks on September 11, 2001, many service members on active, reserve, and National Guard duty have been mobilized multiple times during their military contracts. A large portion of deployed service members identify as females and are trained along with their male counterparts. The mission and deployed environment for all service members becomes the focal point of everyday life during the deployment, while maintaining some presence in their lives back home. When deployed, service members may develop close

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relationships with their peers to cope with separation and stay focused on the mission, which is true for both male and female service members.

Service members within the military mental health career fields are responsible for attending to the mental health needs of their peers. When deployed, it is critical for military mental healthcare providers and technicians to assess, treat, and implement appropriate treatment plans for those struggling to meet the deployed mission. Female mental healthcare providers and technicians can offer essential insight into the impact of deployments on their relationships during and after reintegration. Furthermore, the prolonged separation and stressors associated with being a deployed female mental health provider and technician place this group at higher risk for developing mental health and addiction issues. Additionally, female mental health providers and technicians are faced with the dichotomy of engaging in the deployed enviroment while maintaining various civilian roles back home that differs from their male counterparts.

Few studies have been conducted on the lived experience of deployment for female veterans. It is essential, to explore briefly some of the existing literature on female and male veterans as well as clinicians treating this populations.

To date there are zero studies exploring the lived experience of female mental healthcare providers and technicians that examines the impact the deployed experience has during and post deployed experience. Some studies have explored the overall experience of deployment for female service members and how the event places them at risk for suicide (Gutierrez, 2013).

Conrad and Scott-Tilley (2015) conducted a study on the lived experience of combat female veterans deployed to Iraq and Afghanistan from 2001 to 2013. In a quantitative study, Chapman et al. (2013) examined the experiences, combat exposure, and rate of seeking mental health services among 799 male and female Army medics who were deployed in Operation Iraqi

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Freedom and Operation Freedom. Haddock et al. (2014) conducted a study exploring the impact of deployment on family reintegration issues between deployed husbands and their female spouses. Additionally, in a qualitative study, DeMarni-Cromer and Louie (2014) identified that deployed service members will experience fewer attachment issues upon reintegration with children 6 years and under if parents prepare children for the deployment. Horrell et al. (2011) explored various factors that can positively or negatively impact civilian clinicians working with OIF and OEF veterans suffering from military-related trauma. This brief dive into literature raised questions in my mind of ton how the deployed experience impacts mental health providers and technicians, specifically the impact of deployed experiences on the relationships of female mental healthcare providers during and after reintegration when considering the dichotomy of societal female role expectations.

A gap in research exists when exploring the impact of the deployed experience on the relationships of military female mental healthcare providers and technicians. The problem is that female military mental health providers and enlisted technicians face a unique set of challenges while deployed, which in turn can affect their relationships inside and outside of the military.

The military role expectations of female mental healthcare providers and technicians, as well as the demands of the overall mission, can conflict with societal role expectations such as mother, wife, sister, and friend. This dichotomy warranted further exploration on the impact of deployment on the relationships of female mental health providers and technicians during and after deployment.

Research Questions This study, explored and examined the effect of GWOT deployments on the various relationships of female mental healthcare providers and enlisted technicians. The GWOT has

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fueled frequent deployments since 2001 for all service members and veterans, and many have deployed more than once during their service career. My objective was to analyze data through various psychodynamic theoretical lenses. I focused on the impact of the deployed experience might have on the relationships of veteran female mental healthcare providers and enlisted technicians during and post reintegration. Concepts within object relations and self psychology during analysis of this phenomenon. The central research question of this study will be as follows: •

How might the deployed experience of veteran GWOT female military mental healthcare providers and enlisted mental healthcare technicians impact their relationships during and post reintegration?

Sub research question for this study is: •

How might military role expectations in the deployed environment impact existing garrison roles?

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How might vicarious trauma and exposure to secondary trauma in the deployed environment impact relationships during and post reintegration?

Theoretical and Operational Definitions of Major Concepts Concepts to define include Global War on Terrorism, service member, armed forces, veteran, overseas deployment, self, narcissism, Area of Responsibility (AOR), and self-objects etc.

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Global War on Terrorism (GWOT): Also referred to as the War on Terror or the U.S. War on Terror. According to the Defense Casualty Analysis System (n.d.), the following conflicts fall under the GWOT: Operation Freedom’s Sentinel (OFS-Afghanistan, 2015–present), Operation Inherent Resolve (OIR-Iraq, 2014),

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Operation Iraqi Freedom (OIF-Iraq, 2003) Operation Enduring Freedom (OEFAfghanistan, 2001–2014), Operation New Dawn (OND-Iraq, 2007–2011).

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Female Service member: Is any individual who identifies as female and is currently serving in the armed forces on active duty or is in the reserves or the National Guard. The concept of female has been debated in literature and use of “woman” is more in line with the experience of being female. However, for the purpose of this study the use of female will embody identified gender along with the experience of being a woman.

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AOR: Area of Responsibility or the deployed environment.

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Deployed veteran female mental healthcare provider: Female veteran social workers, psychologists, and psychiatrists who were deployed in support of the GWOT. These veterans were also officers within their designated specialties.

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Deployed veteran female mental healthcare technicians: Prior enlisted personnel who served in the mental health career field and were deployed in support of the GWOT. The deployed mental health technician will typically provide counseling service with the support of their provider.

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Armed forces: Comprising the Army, Air Force, Navy, Marine Corps, Coast Guard and Space Force.

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Veteran: A former member of the armed forces. In this study, participants will be GWOT veterans.

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Garrison: Military base assignment outside of the deployment.

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Overseas deployment: Official orders to deploy outside of the United States in support of the GWOT. These deployments can be classified as combat or noncombat.

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Roles: A role in this study will be defined in the context of role theory. Roles are “those behaviors characteristic of one or more persons in a context” (Biddle, 1979, p. 58). Roles constitute behaviors, are performed by people within a context (Biddle, 1979).

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Self: Exists at birth and comprises three unique poles: the grandiose self, idealized parent imago, and twinship (Kohut & Wolf, 1978).

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Narcissism: The concept of narcissism will be conceptualized through a selfpsychological lens. Kohut defined narcissistic personality disorder as a condition resulting from a fragmentation of the self. Such a fragmentation in the self structure is caused by a paucity of selfobject experiences and functions (Kohut & Wolf, 1978).

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Selfobjects: Objects intended to contribute to the development of a cohesive core nuclear self (Kohut & Wolf, 1978).

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Vicarious Trauma: “Vicarious trauma (VT) describes the cumulative transformative effect of working with trauma victims. Following trauma, victims undergo a transformation in their beliefs and systems of meaning. It is theorized that through chronic (vicarious) exposure and discussion with clients, therapists inevitably go through a similar transformative process, both in their self- and professional identity. VT involves pervasive, longer-lasting shifts in the worker’s

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inner experience, resulting in altered psychological needs, and world beliefs” (Schmidt, et. al, 2022, p. 2) •

Shared Trauma Stress: The effects on the mental healthcare providers and other healthcare professionals caused by repeated exposure to the trauma of others is known as Secondary Traumatic Stress (STS) and interchanged with Compassion Fatigue which can result in both behavioral and emotional negative outcomes (Schmidt, et. al, 2022).

Statement of Assumptions This interpretative phenomenological study aimed to understand the impact of deployment on the relationships of GWOT veteran female mental healthcare providers and technicians during and post reintegration. Participant experiences will be examined via an interpretative stance. Researcher biases include the following assumptions: •

An overseas deployment poses unique challenges for female veterans and in particular female veteran military mental healthcare providers and technicians.

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An overseas deployment impacts the relationships of female veteran mental healthcare providers and technicians during and after deployment.

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The length of deployments may play role in impacting female veteran mental healthcare providers’ and technicians’ relationships during and after deployment.

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Separation from home, family, and friends affects various relationships during and after deployment.

Epistemological Foundation of Project The epistemological foundation of this study is an interpretative phenomenological framework rooted in the hermeneutic paradigm. Gadamer (1965), who was critical in advancing 19

hermeneutics as an epistemology (Dowling, 2004), emphasized how past achievements of social sciences are not static or fixed, and new meaning attained in the present is always rooted in history. According to Gadamer (1965), If we examine the situation more closely, however, we find that meanings cannot be understood in an arbitrary way. Just as we cannot continually misunderstand the use of a word without its affecting the meaning of the whole, so we cannot stick blindly to our own fore-meaning about the thing if we want to understand the meaning of another. All that is asked is that we remain open to the meaning of the other person or text. But this openness always includes our situating the other meaning in relation to the whole of our own meanings or ourselves in relation to it. (p. 268) Gadamer (1965) advanced hermeneutics with two central concepts. The first is that individuals’ prejudices are part of the linguistic experience of meaning making. The second is that universality in communication and connection with others is fundamental to the process of making meaning and understanding (Dowling, 2004). “A phenomenological study describes the common meaning for several individuals of their lived experiences of a concept or phenomenon” (Cresswell & Poth, 2018, p. 75). A phenomenological study seeks to identify what all participants have in common surrounding a particular experience (Cresswell & Poth, 2018).

An interpretative phenomenological analysis framework as the epistemological foundation for understanding how the deployed experience affects the self and adult attachment styles of the veteran participants in this study. “Interpretative phenomenological analysis involves a double hermeneutic as it integrates not only the participant’s sense of their lived experience but also the researchers’ attempt in understanding how the participant makes sense of their personal and social world” (Cresswell & Poth, 2018, pp. 82–83). My experience as a

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deployed medic and mental healthcare provider in the Air Force influenced my analysis of the data. My assumption is that the deployed experience impacts the self of the participants regardless of military specialty. The primary focus of this study was to explore the common impact of the deployed experience on the relationships of veteran female mental healthcare providers and technicians during and post reintegration.

Foregrounding Since I was a child, I have been drawn to the military and those who have served our country. I remember sitting in my paternal grandfather’s garage in Brooklyn, in awe, looking at photographs from his time in the Army Air Corps during World War II. I proudly inherited his military pictures to includedhim being photographed with a young Frank Sinatra, Betty Davis, and James Cagney. He was a natural-born musician and served in the Army Air Force band. I was intrigued with how proud my grandfather was of his deployment in World War II as well as how his service shaped his sense of identity. This prompted my interest in the military and eventually led to me working as a congressional liaison for veteran case management at my local congressional office. When I was 33 years old, in 2009, I began the process of pursuing a commission in the United States Air Force as a clinical social worker. I had just graduated with my Master of Social Work and obtained my lower-level license in the State of New York. I had to fight to serve my country due to health issues I endured as a child. While serving in the Air Force’s social work residency, I attained my independent license to practice as a social worker.

Most of my career to date has been spent as an active-duty clinical social worker. When I arrived at my first duty station in Biloxi, Mississippi, in 2011, I received orders within approximately 7 months for a 6-month deployment to Qatar in support of OEF. I was a new therapist fresh out of school and about to deploy to a completely new country that was unfamiliar to what I was

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accustomed to in the United States. I remember telling my mother about the deployment, and she decided to purchase a new phone and plan so that she would have access to me. I ended up having to contact the sales provider and explain the situation. It took several attempts at reassuring my mother that we would maintain contact using a Wi-Fi application known as WhatsApp messenger. After this experience with my mother, I wondered how I was going to manage both the job of being a female deployed mental healthcare provider and my relationships back home.

When I arrived in Qatar, I experienced an onslaught of anxiety because the environment was so drastically different compared with bases in the United States. During the first month of deployment, I was juggling treating the mental health needs of service members from all branches while maintaining three phone calls per day to my family back home. If I missed a phone call, I would receive a text or email expressing worry over how I was adjusting to the deployment. Managing the demands of my patients and leadership along with making sure I contacted my family was making me anxious and therefore taxing to both my physical and mental health. I had to call my family and tell them that I could only manage to call every other day and if I missed a phone call, it was due to my workload, so they should not be concerned about my safety. In essence, to emotionally survive the experience, I had to make my deployment my home. Additionally, I became acutely aware of how most of my patients were struggling to meet the demands of the deployment while maintaining some connection to their loved ones back home. At the time, this also prompted me to think about my reintegration after deployment and how my own relationships might be impacted by the deployment.

I remember the excitement I felt as my deployment was nearing its end. I felt thrilled to see my parents, friends, and especially my cat, Gille Beans. My mother was able to greet me at

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the Biloxi airport, and we were scheduled to leave for New York a few days later for my rest and relaxation. When I signed back into base, my supervisor told me to not be surprised if I struggled relating to family and friends. I also discovered that my flight commander reassigned me as the Family Advocacy Program Officer. I was immediately angry because I had a background in addictions treatment and loved being the ADAPT (Alcohol and Drug Abuse Prevention and Treatment) program manager at Keesler Air Force Base. I had worked hard at developing the program to include relationships with command and a sense of unity among my staff. I felt as if I were being punished because I deployed and left the program. My relationship with my new commander was forever strained because of this. Furthermore, my mother fell ill with diverticulitis within two days of my returning home. I therefore had to tend to my mother while she was in the hospital. When my mother and I departed for New York, I had no idea what was awaiting me when I stepped off the plane. My father was at the gate with flowers and two police officers. In a post 911 world I knew my father was not allowed to meet us at the gate. I inquired about what was going on and he told me to just “smile.” An entire crowd along with a band was at the airport to welcome me home. My stomach was covered in knots, and I wanted to run in the opposite direction. After a long 6-month deployment, all I wanted was to get home, see my cat, and indulge in eating sushi. As the days passed, I noticed feeling on edge and a sense of irritability when interacting with family and especially when I was out in public. Living in a contained space for 6 months resulted in feeling overwhelmed with all the stimuli I encountered.

My family and friends noticed that I was distancing myself and was on edge regarding my surroundings. I was also hypervigilant about safety in all areas of my life, including when I was driving in and out in public locations. I remember my family expressing both concern and

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frustration over my behavior. To date, I still struggle with a milder version of hypervigilance while driving and in public.

My own experience with being deployed and how it impacted my relationships after deployment prompted my interest to conduct this study.. As previously stated, little research has been conducted on the deployed female and medical personnel experience. Furthermore, there is a gap in the current research on how the deployed experience impacts female mental healthcare providers and technicians.. Moreover, this impact may differ when comparing this subpopulation against other female veterans who deployed in support of the GWOT because of the potential exposure to constant vicarious trauma that is innate in this profession. My main assumption is that relationships are impacted by deployment. My research question is as follows: How might the deployed experience impact the relationships of GWOT veteran female mental healthcare providers and technicians during deployment and after reintegration?

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Chapter 2 Literature Review Introduction A gap in literature exists on the impact deployments have on the relationships of female mental health providers and technicians during and post deployment reintegration. However, this section provides a literature review on the history of mental health throughout major US wars, psychodynamic literature on war trauma as well as empirical based literature on the impact deployments have on the mental health of female service members. I have also explored the effect of vicarious trauma on military medical personnel. Finally, I present a review of literature on the relational impact of parent-child and spousal/partner relationships post deployment. In all, this literature supports the need for this study which is to explore the impact deployments have on the relationships of GWOT female mental health providers and technicians during and post deployment reintegration.

History of Military Mental Health Profession throughout Major US Wars The field of psychology and social work is deeply rooted within the military. It is essential to provide a contextual background on the history of military mental health during US war times to highlight the intricacies of serving as a military mental health provider in a deployed environment. The military as an institution requires its members to engage in duties outside of what is required of civilian mental health providers. Throughout out this history we also see a shift in service for women. Thus, an exploration on the history of military mental

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health professions throughout wartime will provide a greater understanding to how the deployed environment impacts the relationships of female military mental healthcare providers and technicians during and post deployment.

Civil War Psychological warfare dates back to the American Revolution. Operations entailing psychological warfare are designed to reduce the moral of the opponent (Moore & Bennet, 2013). However, it was not until the Civil War that medical doctors began to take notice of the psychiatric symptoms associated with war (Moore & Bennet, 2013) and the impact those symptoms have on service members deployed in combat.

The brutality of the Civil War contributed to significant psychiatric trauma. Nostalgia was the second most common diagnosis made by Union doctors. New terms were coined, including “soldier’s heart” and “exhausted heart.” Like “nostalgia,” these new terms explicated the symptoms exhibited by emotionally distraught soldiers, particularly paralysis, tremors, sudden changes in mood, and a deep desire to return home. (Moore & Bennet, 2013, p. 4) According to Ruben et. al (2013), military social work is historically rooted in Clara Barton’s creation of the American Red Cross. Barton assisted Civil War veterans via the American Red Cross with medical needs, finding community resources, and with communication to family members. A critical component of military mental health in the deployed environment is access communication with family members. The Red Cross was pivotal and remains a critical organization for service members and families during deployments.

World War I 26

It was not until World War I, that military physicians began to take notice of trauma symptoms occurring because of combat. Initially, physicians viewed combat related symptoms as a shock to the nervous system. The term “shell shocked” was coined as result of returning WWI veterans exhibiting trauma related symptoms. However, military mental healthcare for service members was not implemented in the deployed environment during WWI. It was during this war that psychologists were primarily used for testing and selection processes (Moore & Bennet, 2013). However, psychiatric social work evolved in 1918 when the first social worker was employed at a military hospital to assist psychiatry. “The social worker’s duties were to assist the medical officers by obtaining information regarding the personal, family, and community background of the soldiers under treatment, as an aid in diagnosis, treatment, and plans for aftercare” (Rubin et.al, 2013, p. 4). This demonstrates the progression of military mental healthcare within the institution during this time period. Social work was utilized to gather what we know today as a biopsychosocial assessment.

World War II World War II birthed a new era in military mental healthcare. Psychologists continued to be used for psychological testing which became a pre-screening measurement for forward deployment. However, forward deployment of military mental healthcare workers was not implemented in the battlefield which resulted in early discharges due to combat stress. Common combat related stress reaction terms during the World War II phase of military mental healthcare were coined as combat exhaustion and fatigue. It was during this time that psychologists were assigned to VA hospitals to assist physicians in the treatment of combat related trauma (Moore & Bennett, 2013). Psychologists engaged in testing, group, and individual psychotherapy.

According to Moore & Bennett (2013), 27

Just as after WWI, the end of WWII saw the demobilization of psychologists. However, the growing consensus among decision makers was that a benefit to having a psychologist in the military is the power of influence, which might not be available from a civilian psychologist working within the military system. (p.5) Additionally, it was during the time that the diagnostic term of “gross stress reaction” was coined to provide clinicians a structured guideline to explain mental health reactions of service members suffering from combat related stress (Moore & Bennnett, 2013).

The entire Armed Forces expanded in the early 1940s with the impending involvement of the United States in WWII. However, the social work profession did not have a strong national leadership that was needed to promote the profession with the National Resources Planning Board (Rubin, et.al, 2013). Due to the lack of leadership on national level the Red Cross took on the responsibility of providing psychiatric social workers at the start of WWII. The military subsequently granted both psychologists and social workers permission to join the armed services on active-duty status as military officers during this time period. In 1942 the US Armed Forces approved active-duty service members serving as psychiatric social workers.

Furthermore, in 1945 the Army granted commissioned status for social workers due to the lobbying of the Wartime Committee on Personnel of the American Association of Social Workers. However, after the conclusion of WWII most social workers were separated from service. Nevertheless, in 1946 the Army officially created a military occupation specialty for trained psychiatric social work officers (Rubin, et. al., 2013).

Korean War, Vietnam War, & Persian Gulf War

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The Korean, Vietnam War, and the Persian Gulf War ushered in a new era of military mental health. It was during this war that active-duty mental healthcare providers to include psychologists, were stationed overseas, on naval ships and in combat zone areas.

During the Korean War gross stress reaction or combat stress psychological clinical treatments and interventions were employed which increased the rate of service members returning to active-duty service. However, specific military mental health units were not implemented during the Korean War which created some lack of continuity within military mental healthcare (Moore & Bennet, 2013). Active-duty psychologists were continued to be deployed to combat zones, but a shift from mental health diagnosis and treatment to an emphasis on problematic behavior and character disorders became the focus during the Vietnam War. Service members during deployment and post deployment from Vietnam began to exhibit problems with drugs and alcohols. Many of these service members who exhibited diagnostic criteria for alcohol or drug use disorders were discharged on character separations because of how the country viewed individuals suffering with drug and alcohol disorders. Moore & Bennet (2013) write, Prior to the 1970s, attempts to solve these problems in both military and nonmilitary settings were woefully inadequate because of the belief that substance abuse and dependence emerged from a lack of discipline. Not understanding the “disease” component of substance use disorders, treatment options gave way to a variety of other mechanisms to address this apparent dereliction of duty. (p. 5) The military treated many Vietnam veterans returning from combat as lacking core military values rather than looking at core mental health issues behind drug and alcohol use during this 29

era. It is also important to note that with the Vietnam war we witnessed a shift from traditional to guerrilla warfare along with an increase in the tempo of deployments. This was a ripe environment for an increase in combat stress and what we know today as posttraumatic stress disorder. It was during this period that social workers worked in various programs that involved family advocacy to assignments in military prisons. Additionally, during this era social workers began to deploy with mental health units in combat zones (Rubin, et. al., 2013).

The Persian Gulf War was period in military mental health in which we saw both psychologists and social workers continuing to serve aboard Naval ships in combat zones.

However, mental healthcare services were decreased in size which accounted for the decrease in service members returning to active-duty service after exposure to combat trauma. The activeduty force was drawn down upon which significantly impacted access to mental healthcare services for those service members remembers remaining on active-duty service. (Moore & Bennet, 2013). This would change drastically after the attacks on September 11, 2001.

The Global War on Terrorism in response to the worst act of terror in the United States ushered in a new age for military mental healthcare. “This was the first time since Vietnam that the U.S. military was in a prolonged war, and with a prolonged comes changes in the social environment of the military (Rubin et. al, 2013, p. 16). Like the Vietnam War, there were no front lines that delineated each side. Additionally, women were allowed to fight in combat missions which led to more complexity in treating female veterans for mental health issues post deployment. Female veterans were more at risk at becoming victims of sexual assaults with greater equality in military job specialties. Moreover, the military as whole also began to enhance programs aimed at suicide and sexual assault awareness in response to the increase in the tempo of deployments and significant change of women fighting alongside men (Rubin, et.

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al, 2003). The length of the Global War on Terrorism also led to an increase in military mental healthcare active-duty personnel in all service branches to meet the demands of this war. This increase in deployments and advanced weaponry during this 20-year long war resulted in many active duty, reserve and guard personnel completing multiple deployments overseas which in turn would have an impact on their relationships.

This history of military mental health throughout major US wars provides a foundation to understanding the complexities of the institution and how challenging the job can be for our service men and women. Furthermore, it is crucial to provide a background on the evolution of military mental healthcare in order conceptualize the complexity of serving in the military as a female mental healthcare provider and technician.

Psychodynamic Literature and War Trauma An exploration of psychodynamic literature on the treatment of war trauma is critical a component to answering the main research question of this study. To understand how the lived experience of deployment impacts the relationships of female mental healthcare providers and technicians during and post deployment it is essential to evaluate the psychodynamic perspective on psychotherapy for war trauma. A review of historical and current psychodynamic literature on war trauma along with critical self-psychology theoretical concepts will provide an essential understanding on the impact a deployment might have on the intrapsychic and interpersonal world of female mental healthcare providers and technicians.

Historical Psychodynamic Literature Freud, Ferenczi, Abraham, and Simmel are historical pivotal figures who greatly contributed to the psychoanalytic understanding of the intrapsychic and interpersonal impact of 31

war trauma. These figures studied and explored psychoanalysis as an effective treatment for those suffering from war trauma.

Sigmund Freud provides us with an early psychoanalytic understanding of what he referred to as war neurosis. He viewed war neuroses as traumatic experiences made possible because of conflict in one’s ego (Freud, 1919). “The conflict is between the soldier’s old peaceful ego and his new warlike one, and it becomes acute as soon as the peace-ego realizes what danger it runs of loosing it’s life owing to the rashness of its newly formed, parasitic double” (Freud, 1919, p. 209). Freud references what we now know as the nervous system’s fight, flight and freeze response to danger. He describes how the original ego takes flight into a state of neurosis which is in defense against the new ego created by war trauma.

Moreover, he suggests the military as an institutional cause of war neuroses or what we know today as combat trauma as well as the impact peace-time traumatic neurosis has on the ego. Freud highlights the fundamental difference between war and peace time traumatic neuroses as the libido. In traumatic neuroses “the enemy from which the ego is defending itself is actually the libido, whose demands seem to be menacing” (Freud, 2019, p. 210). Whereas in war neuroses the ego is in an outward defense against external danger that manifests as a pseudo internal threatening ego (Freud, 1919). Freud discussed electric shock therapy as an early treatment of trauma caused by war. This is in part due to the early medical belief that war neuroses was first believed to be an organic condition of the nervous system. Moreover, he emphasized that the same symptomatology occurred in both traumatic and war neuroses.

In Beyond the Pleasure Principle (1920) Freud makes a clear distinction on the traits associated with traumatic neuroses. The traits include what he identifies as fright anxiety and a repetitious injury to the ego. Freud (1920) writes, 32

‘Fright’, ‘fear’ and ‘anxiety’ are improperly used as synonymous expressions; they are in

fact capable of clear distinction in their relation to danger. ‘Anxiety’ describes a particular state of expecting the danger or preparing for it, even though it may be an unknown one. ‘Fear’ requires a definite object of which to be afraid. ‘Fright’, however, is the name we give to the state a person gets into when he has run into danger without being prepared for it; it emphasizes the factor of surprise. (p.12) Here, Freud describes an early definition of a trauma response which is known today as the window of tolerance. The window tolerance (Hershler, et. al, 2021) encompasses both hyper and hypo arousal symptoms when one experiences fear of an object, anxiety as the affective state in response to the trauma and fright or fight, flight or freezing states when encountering trauma.

“As individuals reactions stressors intensify, it becomes more difficult to access strategies and resources to manage distress” (Hershler, et. al, 2021, p. 25). The duty of both female mental healthcare providers and technicians when deployed is to treat and prepare service members for existing trauma or the potential of exposure to it when down range. The repetition of exposure to the repeated trauma of others can have an impact on the provider and technician. In a later section we will explore literature on vicarious trauma.

Sandor Ferenczi is a critical figure who made significant contributions to present day understanding and conceptualization of trauma and specifically, war trauma. Like Freud, Ferenczi et. al (1923) also emphasized the medical field’s lack of understanding on the impact of traumatic and war neuroses. He emphasized the explanation and cause of war neuroses coming from physical breakdowns in the nervous system as antiquated and lacking any psychical explanation for such symptoms. Ferenczi et. al (1923) cites the work of Stumpell who “was one of the first to oppose the purely organic-mechanistic idea of the war neuroses” (p. 8). However, 33

Strumpell suggested that the psychological trauma symptoms developed out of one’s desire for some sort of interpersonal gain within the military or what we now refer to as malingering.

However, Ferenczi highlights that mechanism of gain were not present in prisoners of war.

Prisoners exhibited similar trauma symptoms which did not fit this early malingering model.

This also does not take into account the time factor present in individuals suffering with war neuroses during this time period (Ferenczi et. al, 1923). Time is a critical factor in the development of modern-day PTSD and Ferenczi explored this further in his studies.

Ferenczi (1949) was pivotal in examining the repetition feature within trauma. The length of modern days deployments typically ranges from 3 months to 2 years depending on the military job specialty and branch of service. For example, during the Global War on Terrorism a typical medical Air Force deployment was 6 months. This was 6 months of 24hr hour medical care to service members with a vast range of immediate health issues in the deployed enviroment. Ferenczi (1949) was particularly interested in the repetition of the trauma he experienced with his patients in the analytic session. He would experience success analyzing the symptoms of a trauma attack but realized how such symptoms repeated throughout the session and outside of the analysis. Ferenczi (1949) wrote, Although we were able to analyze conscientiously the threatening symptoms of such an attack, which seemed to convince and reassure the patient, the expected permanent success failed to materialize and the next morning brought the same complaints about the dreadful night, while in the analytic session, repetition of the trauma occurred. (p. 225) Ferenczi emphasized the importance of listening to his patients suffering with trauma. He was crucial to exploring the connection between repression and repetition of trauma experiences.

Furthermore, he highlighted how important it is to analyze both past traumas along with the 34

criticism directed at us by our patients. This is a key aspect of what many mental healthcare providers and technician face from their patients in a high stress deployed environment.

Karl Abraham is another major analytic theorist who explored the origins of war neuroses. Like Freud and Ferenczi he also emphasized the importance of sexuality in traumatic neuroses. Abraham (1918) explored the impact of war on soldiers but also sought to link trauma symptoms to sexuality and narcissistic injury. Abraham was particularly curious why certain soldiers were impacted psychically by war and others came home with no issues. Furthermore, he explored pre-existing issues as a factor to veterans developing war neuroses. Abraham (1918) writes, It transpires with great regularity that the war neurotics already before the trauma were labile people — to designate it, to begin with, by a general expression — and especially so as regards their sexuality. Many of these men were unable to carry out their tasks in practical life, others that were capable of doing this, however, showed little initiative and manifested little impelling energy. In all of them sexual activity was diminished, their sexual hunger (libido) being checked through fixations; in many of them already before the campaign potency was weak or they were only potent under certain conditions. (p. 22 & 23) He suggested that those who develop war neuroses have preexisting issues with their libido making them more susceptible to the condition. Furthermore, Abraham (1918) implied that war neurotics suffered with the narcissistic belief of immortality. “The effect of an explosion, a wound, or things of a like nature suddenly destroy this belief” (Abraham, 1918, p. 26).

Therefore, from Abraham’s perspective preexisting narcissistic injuries make an individual more susceptible to developing trauma symptoms related to war. Today, werecognize that preexisting 35

mental health conditions impact the development of PTSD Abraham’s work is relevant to this current study aimed at exploring how the deployed experience impacts relationships during and post deployment when considering potential pre-existing narcissistic injuries prior to deployment. Any pre-existing narcissistic injuries may play a role in how the deployed experience impacts participant relationships.

Ernest Simmel is another pioneer who explored and studied the psychoanalytic treatment of war neuroses. Like his peers he believed the etiology of traumatic neuroses was rooted in sexuality, but different for those suffering with war neuroses (Ferenczi, et. al, 1921). He viewed the symptomatology of war neurotics “for the most part of a non-sexual nature, there being exhibited in them all those war-produced effects of terror, anxiety, rage, etc.” (Ferenczi, et. al, 1923, p. 30). Simmel did not deny the etiology of other forms of neurosis stemming from infantile sexuality. Furthermore, he states that once war neuroses symptoms are removed issues of infantile sexuality are discovered upon completion of analysis. However, Simmel (Ferenczi, et. al, 1923) brilliantly explores the complexities of what a service member must encounter while serving in combat zones. In his time, he emphasized the unique stressors associated linked to the combat soldier. Simmel (Ferenczi et. al, 1923) writes, One must have experienced the war occurrences themselves or their recapitulation under analytical-cathartic hypnosis in order to understand to what attacks the mental life of a man is exposed in time of war. For instance, a man after being wounded several times has to return to the front, or is separated from important events in his family for an indefinite time, or finds himself exposed irretrievably to that murderous monster, the tank, or to an enemy gas attack which is rolling towards him; again, shot and wounded by shrapnel he 36

has often to lie for hours or days among the gory and mutilated bodies of his comrades, and, not least of all, his self-respect is sorely tried by unjust and cruel superiors who are themselves dominated by complexes, yet he has to remain calm and mutely allow himself to be overwhelmed by the fact that he has no individual value, but is merely one unimportant unit of the whole. (p.31) Simmel highlighted the extreme stressors of war that modern day service members and veterans of the Armed Forces continue to face while deployed in service to their country. Although, he is discussing veterans serving in military specialties like infantry, artillery and special forces the duty to remain calm while encountering deployment stressors that includes the potential of enemy attacks and separation from loved ones is required of all service members to include those operating in healthcare specialties. In the Air Force, many mental healthcare providers and technicians continually encounter service members facing a myriad of stressors. Furthermore, some Air Force mental healthcare providers and technicians were deployed with a joint expeditionary task supporting other branches. These taskings are called JET taskings and many mental healthcare providers and technicians were tasked to venture outside the wire to forwarding operating bases and command posts to provide mental healthcare support. Simmel’s (Ferenczi, et. al, 1923) contributions to conceptualizing war trauma paved the way to understanding both the intrapsychic and interpersonal impact of war. This is relevant to the current study because military mental healthcare providers and technicians are tasked with treating the stressors of others while coping with their own deployment stress.

Contemporary Psychodynamic Literature Current Psychodynamic literature in terms of exploring the impact of military or war related trauma is an area needing further exploration within the psychodynamic community.

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However, Carr (2013) is an Iraq veteran and psychiatrist who explored the potential and effectiveness of approaching the treatment of miliary related PTSD through a two-person intersubjective therapeutic model. He found inspiration in Robert Stolorow’s intersubjective approach to treating trauma. Carr (2013) presents his findings with a case study and a patient he refers to as Major B. This individual was a combat pilot who flew several missions in Iraq and Afghanistan. His PTSD symptoms began after returning home from a traumatizing experience while deployed to Afghanistan. This service member tried many forms of evidence-based and VA approved treatment that failed until he connected with Carr in an inpatient military psychiatric unit. The intersubjectivity and connection began with this patient’s recognition that Carr was a combat veteran. Carr (2013) writes, I immediately focused on understanding Major B's subjective experience of the world after his trauma. I tried to hold in mind a few intersubjective attitudes taken from Stolorow's writings. These include (1) the primacy of affect, (2) the radical contextualization of emotional life, (3) striving to understand the patient's experience and organizing principles through empathic introspection, and (4) the conceptualization of trauma as unbearable affect. (p. 115 &116) Carr (2013) also believed in Storolow’s view on intrapsychic areas impacted by emotional trauma which include sense of loss in safety, time, and social norms as well as heightened awareness around death. In his analytic treatment with this client, he identified themes of shame and guilt, but also noticed how his own experiences in Iraq arose in his consciousness and how treating combat veterans skewed his own sense of safeness. However, he provided him with a relational home in which an Other was present to bear witness to his pain, fear, and internal battle. Carr (2013) noted the struggle he endured to have his patient live in the present and not 38

the past. In this case study he notes the importance of how a shared existence occurred between himself and his patient. This shared existence is fundamental to providing a safe relational experience rooted in vulnerability and trust and what Carr (2013) which was demonstrated in his patient’s self-reported progress.

Although limited, there is some psychodynamic literature demonstrating the use of relational concepts in psychodynamic treatment of war veterans suffering with PTSD. Hendin (2017) presents a 12-step psychodynamic therapeutic approach to treating veterans with combat PTSD who are at high suicide risk. Like, Carr (2013) the relational component of psychotherapy is emphasized as essential in treating this population. The issue of feeling disconnected and alienated from the rest of the world is highlighted as a characteristic of veterans suffering with PTSD. This 12-step approach suggests developing trust and rapport in the first 3 sessions. “If a good contact has been made, by the fourth session the most traumatic combat experience of the veteran can usually be elicited and the feelings about it before, during, and afterward, as well as any recurrent nightmare connected with it, can be addressed” (Hendin, 2017, p.226). The exploration of the actual trauma occurs in session 4 through 6. Hendin (2017) emphasizes that this exploration is not done through an exposure therapy model but through a shared connection between therapist and patient that provides a safe place to engage in trauma processing. The models stresses that the last 6 sessions focuses on guilt, emotional regulation, and addressing interpersonal issues as well as transitioning out of therapy. Hendin (2017) provides case examples showing success in this approach with at risk Vietnam veterans, but concludes additional work is needed with Iraq and Afghanistan veterans to demonstrate the potential of this model.

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The contemporary psychodynamic literature on treating trauma in combat veterans demonstrates the benefit of utilizing relational based approaches treating this population.

However, a gap in current psychodynamic literature exists in exploring how the deployed experience impacts relationships during and post reintegration. In terms of the significance this has on the current study aimed at exploring the impact deployment has on the relationships of GWOT female mental health providers and technicians it is important to note how relational concepts such as intersubjectivity and connectedness may impact one’s readjustment post deployment. Therefore, how much one can intersubjectively connect may be a factor influencing the impact a deployment has on relationships.

Self-Psychological Lens Self-Psychology is a psychodynamic theory that can offer a unique perspective on exploring the lived experience of GWOT veteran female mental healthcare providers and technicians. This theory can shed light on how deployment can impact relationships during and post reintegration.

Kohut and Wolf (1978) outline how self-psychology became a treatment for different self-disorders. Kohut, as classically trained in Freud’s psychoanalysis discovered that certain patients who were treated with traditional psychoanalysis did not experience an alleviation of certain narcissistic injuries. He also noted how narcissistic transference was played out within the analyses. Kohut and Wolf (1978) write, The psychopathological syndrome from which these patients suffer was designated as narcissistic personality disorder. The narcissistic transferences which are pathognomonic for these syndromes were subdivided into two types: (1) mirror transference in which an 40

insufficiently or faultily responded to childhood need for a source of acceptingconfirming mirroring is revived in the treatment situation, and (2) the idealizing transference in which a need for merger with a source of idealized strength and calmness is similarly revived. (p. 413) The core self according to Kohut (1978) is developed through interactions between the self and early selfobjects. “Selfobjects are objects which we experience as part of our self” (Kohut & Wolf, 1978, p. 414) which are influenced by our earlyexperiences. Kohut emphasized the importance of societal expectations of one’s self control over their selfobjects. In his early writings, Kohutidentified the two major selfobjects as the mirroring and idealized parent imago selfobjects. He later conceptualized the twinship selfobject. It critical to note that selfobjects are not people but functions that are performed by individuals which generate the selfobject experience (Wolf, 1988). Mirroring selfobjects provide children with a function of feeling affirmed and recognized wehereas the idealize parent imago selfobject provides and fulfills the child’s selfobject need to merge with a powerful figure (Kohut & Wolf, 1978). “The period of greatest vulnerability ends when an idealized nuclear superego has been formed, since the capacity for the idealization of his central values and standards which the child thus acquires exerts a lasting beneficial influence on the psychic economy in the narcissistic sectors of the personality” (kohut, 1968, p. 88-89). Here Kohut underscores how a healthy idealized parent imago selfobject experience is crucial to the formation of the superego. Whereas the twinship selfobject experience provides a critical function that fulfills a child’s need for likeness and similarity. This fulfills a selfobject need centered on sameness and inclusion.

Kohut and Wolf (1978) emphasize how the self can be damaged when the interaction between self and selfobjects is dysfunctional or even absent. These are identified as primary and

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secondary disturbances of the self or what is referred to as self disorders. These include but are not limited to psychoses, borderline states, narcissistic behaviors, and narcissistic personality disorder. This dysfunction between the self and selfojects will result in a core self that can be either under stimulated, fragmented, over stimulated, or overburdened (Kohut & Wolf, 1978).

These psychopathological self states, early selfobject experiences, failure in selfobjects being met can influence how an individual views themselves and the world.

In terms of this study, the deployed experience may be considered a selfobject experience by providing feelings of affirmation and recognition, a sense of merger with powerful figures as well as a sense of similarity, sameness and inclusion with others. However, a deployment may be experienced in more dysfunctional ways depending on the resonance between the deployed experience and the nature of the participants early life experiences. Participants’ early selfobject experiences might be an influential factor in how the deployed experience impacts relationships during and post deployment. A deployment may be internalized through a maladaptive self state if a paucity in selfobject experiences exists from early in childhood. That can place additional strain on existing relationships outside of the deployed environment. Moreover, if participants experienced a deficiency in selfobject needs such as mirroring, idealized parent imago, and twinship then a deployment may provide the selfobject function to fulfill those needs. The theory of self psychology provides a potential theoretical lens to evaluate the lived experience of GWOT female mental healthcare providers and technicians in how the deployed experience impacted their relationships during and post reintegration.

Impact of Deployment on the Mental Health of Female Veterans A review of empirically based literature on the impact deployments has on female veterans yielded a connection between female wartime experiences and the development of 42

mental health symptoms. During the Global War on Terrorism significant policy changes to female service members serving in the military came to fruition. In 2016, women were granted permission to serve in combat units and in combat military specialties. Prior to this change, females were only serving in supportive roles to their male counterparts. Women are still the minority gender within combat specialties, but since 2016 many women have deployed in a vast number of roles within combat units (Breeden, et. al 2018). In some studies women are reporting less direct exposure to combat and more indirect experiences with traumatic events. Female military mental healthcare providers and technicians will typically experience more indirect exposure trauma in the deployed environment. However, it also important to note differences in coping mechanisms between male and females which can influence the impact deployment has on female veterans. Additionally, women are more likely to engage in behavioral strategies and seek out additional support as compared to men (Breeden, et. al, 2018). It is essential to this research study to explore empirically based literature on the impact deployments and wartime experiences have on the mental health of the female veteran population as whole in an effort to determine factors that might contribute to the impact deployments have on relationships.

Breeden, et. al (2018) conducted a quantitative study seeking to examine the relationship between the frequency of deployed wartime experiences and development of PTSD symptomatology in female US Air Forces veterans. “Like men, women exposed to combat show increased risk for mental health disorders compared to women who have never been deployed to war zones. In contrast to nondeployed women, deployed women display higher post deployment levels of PTSD and depression and face greater reintegration challenges upon returning home” (Breeden, et. al, 2018, p. 2). These researchers conducted an analysis of female responses to the USAF Community Assessment survey over a 3-year period. They utilized a stratified sampling 43

method and sampled 18, 012 female USAF veterans in 2008, 12,249 in 2011, and 8,061 in 2013 for this analysis. Results from this study showed a significant increase in female deployments in 2013 compared to 2008. However, data from this study indicates non deployed females reporting higher rates of PTSD. However, across the 3 years an increase in report of PTSD among deployed females was found. Regarding wartime experiences respondents reported more indirect wartime (deployed) experiences but the rate of these indirect experiences increased when comparing data from 2008 and 2013. Lastly, this study determined a correlation exists between traumatic war experiences and the onset of mental health disorders like PTSD. The researchers found that as wartime events increased so did the number of positive PTSD screeners (Breeden, et. al, 2018).

Conrad and Scott-Tilley (2015) conducted a qualitative study on the lived experience of combat female veterans deployed to Iraq and Afghanistan from 2001 to 2013. This was a phenomenological descriptive study that identified seven themes on how the deployed experience impacted the overall health of combat female veterans during and after deployment.

Those themes were consistently living in a state of fear during the deployment, differences in the meaning assigned to combat, feeling the effects of combat at home, fear of being irrevocably changed by the experience, being disrespected by both male and female peers, change in physicality, and having rewarding experiences (Conrad & Scott-Tilley, 2015). The researchers conducted this study so that the nursing would have a better understanding for treating female veterans. These seven themes highlight the impact deployments have on female veterans and providejustification for studying the impact deployments have on a specific female military sub population during and post deployment.

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Gutierrez et. al (2013) conducted a qualitative study to examine the deployed experience and suicide risk for female veterans with combat deployments to Iraq and Afghanistan. They examined suicide utilizing the Interpersonal Psychological Theory of Suicide. “According to the Interpersonal-Psychological Theory of Suicide (IPTS; Joiner, 2005), lethally suicidal individuals perceive that they are an unbearable burden on their family, friends, and/or society (burdensomeness), and their efforts at establishing and maintaining social connections have repeatedly been thwarted or have failed (failed belongingness)”(Gutierrez et. al. 2013, p. 925).

The sample size in this study was 19 participants with 18 designated as OIF and 1 as OEF and data yielded multiple themes associated with the impact deployment has on the mental health of female veterans.

This study generated several themes related to the concepts of burdensomeness, failed belonging, within Joiner’s 2005 IPTS model (Gutierrez et. al, 2013). A flaw in this study is the lack of data showing the breakdown of participant answers. Regarding perceived burdensomeness many of the participants verbalized seeking support as a sign of weakness. This belief was reported as part of their initial training. However, other participants viewed serving their country as a warranted reason to deserve help while others believed it is the responsibility of a service member to seek help and not doing so is burdensome to the unit. All participants commented on the theme of belonginess. Most verbalized feeling out of place in a male world during their deployment. Others also reported withdrawing in their relationships to cope. “Some of these women reported feeling convinced that belongingness is not necessarily important, and that people can be just fine on their own, or that maintaining relationships at this point simply is too much work” (Gutierrez et. al, 2013, p. 930). Another theme identified was Acquired Ability for Suicide through Habituation to Pain. In this theme the researchers are connecting the 45

connection between war experiences and emotional dysregulation. Many of respondents reported avoiding addressing the major emotional impact of their war experiences and identified an interpersonal impact associated avoidance and isolation. Lastly, these researchers discovered that their participants alluded to suicide as an extreme trauma coping mechanism based on feelings and thoughts related to a sense of burdensome and lack of belonging (Gutierrez et. al, 2013).

This study demonstrates how war experiences impact relationships and justifies conducting a study aimed at examining how deployments impact relationships during and after deployment.

Some studies explored the impact of deployment on the mental health of deployed female veterans while consider social factors as a mediator. Sairsingh et. al. (2018) performed a quantitative cross-sectional study examining the relationship between social factors and mental health readjust in a sample size of 128 GWOT female veterans from various campaigns. These researchers were specifically evaluating depressive symptoms in relation to mental health readjustment and social factors. According to this study, “Women currently make up over 15% of total active-duty military personnel and 20% of new recruits” (Sairsingh, et. al, 2018, p. 133).

The researchers hypothesized that combat experiences would lead to higher reports of depression symptomatology and that social support would impact the relationship between the two. This study’s results did not support the hypothesis with statistical significance. However, results indicate a connection between greater levels of social support and finances with a decline in depressive symptoms. Furthermore, results showed greater success in psychotherapy when combined with positive social support (Sairsingh et., al, 2018). The researchers emphasized the importance of conducting future research on the link between mental health symptoms, combat exposure, and social support. A study exploring the impact deployment have on the relationships of female mental healthcare providers and technicians during and post reintegration while taking 46

into consideration mediating factors such as social support would be a significant contribution to the understanding and mental health treatment of this population.

In another studying exploring the impact of war experiences on the mental health of veterans, Welsh, Olson and Perkins (2019) completed a qualitative study that “examined gender differences in exposure to wartime events and post-deployment post-traumatic stress disorder (PTSD) and depressive symptoms, as well as mediators of these relations, in a large sample of male and female active-duty Air Force personnel” (p. 229). They hypothesized a correlation between combat experiences and PTSD in both men and women and that women would report fewer combat experiences but increased rates of mental health symptomology. They also hypothesized that females would report less unit solidarity and “self-efficacy and unit cohesion would mediate the relation between combat stressors and mental health” (Welsh, et. al, 2019, p.230). Results of this study yielded a positive correlation between greater war time experiences and higher rates of PTSD and depression. Furthermore, the results also connected a decrease in unit cohesion and self-efficacy to a self-reported increase in war time experiences and PTSD and depression symptoms in both men and women. Moreover, this study also demonstrated that selfefficacy was a partial mediator between wartime experiences and the onset of mental health symptoms in only the female participant sample. This study demonstrates a connection between frequency of wartime experiences, self-efficacy, unit cohesion and the development of mental health issues. The current study seeks to explore how the deployed experience impacts the relationships of a specific military population and reported wartime experiences may be a sub factor within the deployed experience that has an impact on the relationships of female mental healthcare providers and technicians during and post reintegration.

Vicarious Trauma and Medical Professionals 47

A career in mental health poses a greater risk in developing VT based on the nature of exposure to repeated mental health problems and trauma of the people seeking such a unique service. The effects on the mental healthcare providers and other healthcare professionals caused by repeated exposure to the trauma of others is known as Secondary Traumatic Stress (STS) and interchanged with Compassion Fatigue which can result in both behavioral and emotional negative outcomes (Leung, Schmidt, & Mushquash, 2022). The expansion of the definition of a traumatic event in the DSM-IV to exposure to an actual or threatened death or injury placed a spotlight on STS and the impact it has on both medical and mental healthcare providers (Leung et. al, 2022). Vicarious trauma is caused by excessive STS or compassion fatigue. Schmidt et. al.

(2022) writes, Vicarious trauma (VT) describes the cumulative transformative effect of working with trauma victims. Following trauma, victims undergo a transformation in their beliefs and systems of meaning. It is theorized that through chronic (vicarious) exposure and discussion with clients, therapists inevitably go through a similar transformative process, both in their self- and professional identity. VT involves pervasive, longer-lasting shifts in the worker’s inner experience, resulting in altered psychological needs, and world beliefs. (p. 2) A review of literature on vicarious trauma within medical and mental healthcare workers is critical to this current study because of the impact such trauma has on an individual both intrapsychically and interpersonally. It is important to note this review did not yield results on vicarious trauma and deployed mental healthcare providers. If the process of vicarious trauma impacts world beliefs, then it might also impact relationships. Military mental healthcare providers and technicians in the deployed enviroment are tasked to provide support, listen to 48

service members and determine if individuals can continue on in their deployments. The nature of the job coupled with long deployments may be a factor in exploring and answering the main research question in this study.

In an article by Horrell et al. (2011) the authors explored various factors that can negatively impact civilian clinicians working with OIF and OEF veterans suffering from military-related trauma. The negative impact being the development of vicarious trauma (VT).

However, they also highlight protective factors noted in clinicians that can prevent VT. The factors contributing to VT include patients, clinician, and organizational factors. Regarding patient factors the authors note that OIF and OEF veterans are younger and as result clinicians experience higher missed appointments and drop out rates as compared to previous generations.

Additionally, OIF and OEF veterans are more likely to be diagnosed with comorbidities due to their experiences along with advancement in mental healthcare. Therefore, this population is more likely to present to treatment with acute symptoms of Posttraumatic Stress (PTS). These patient factors present complexities for the mental healthcare provider treating this generation of veterans which in turn can contribute to the development of VT. According to Horrell et. al (2011) “Several factors, including theoretical orientation, training, supervision, military affiliation, personal trauma history, spiritual and religious views, level of social support, and self-care activities, may serve as either protective or risk factors in clinicians working with OEF/ OIF veterans” (p. 82). However, Horrell et. al (2011) emphasizes that for many clinicians working it is a rewarding experience to work with this veterans diagnosed with PTSD. Regarding organizational factors within the VA, it is essential to provide diversity in training for clinicians on treating this specific population. The authors concluded with recommendations for enhancing 49

the positive attributes of treating individuals with trauma. The recommendations included acknowledgement of the complexity of working with this population, control over caseload and schedules, and addressing the impact of vicarious trauma on the clinician (Horrell, et al., 2011).

When considering long deployments during the era of GWOT it is beneficial to explore the connection between VT in the deployed environment and the impact this might have on relationships during and post reintegration.

Medical professionals working with individuals with trauma must employ vast amounts of empathy to bear witness and treat those suffering with trauma. VT can have devasting impacts on individuals, organizations, and entire societies. Hallinan et. al (2021) conducted a qualitative pilot study examining the experience of 47 first responders and victim advocates involved in an organizational processes aimed at changing how their organization responds to VT and to “confirm previous research about the impacts of VT within organizations” (Hallinan et. al, 2021, p. 317). The effects of VT on individuals include both mental and physical issues whereas organizations will suffer from high turnover rates. The research questions in this study were: “Research Question 1: How do organizational change agents within first response agencies perceive VT in their professional lives? Research Question 2: What do first response agencies encounter when they undergo an organizational change process to address VT” (Hallinan, et. al, 2021, p. 317)? The researchers used focus groups and individual interviews as part of their methodology to extrapolate data. They identified two themes regarding the need for organization change which were sources of stress or trauma exposure and effects of VT. The other two themes centered on the change process itself regarding organizational expectations and challenges.

Regarding the individual effect of trauma, the researchers found suicide to be a critical effect of VT. “According to our participants, suicide was seen to be unique in that it is both an effect of 50

VT and could itself be a source of VT, a finding that has been seen in independent practice therapists as well” (Hallinan et. al, 2021, p. 317). Suicide being both an effect and symptom of VT demonstrates a strong need for society to continue to research how to address VT within various populations, especially, first responders. Long term VT exposure may result in the development of mental health issues which in turn can impact relationships. The deployed environment for mental healthcare providers and technicians is focused on providing care to other service members with mental health needs with little time for selfcare. Chronic VT exposure might impact how mental healthcare providers and technicians manage relationships outside the profession which is an important fundamental component of this study.

An international study exploring VT in medical professionals, Mariean et. al (2014) performed a quantitative study that utilized a regression analysis to document VT in health professionals with the following objectives: “a) to identify the presence of dysfunctional vicarious trauma beliefs in relation with professional experience and b) to study the moderator role of professional experience and type of work (emergency vs. nonemergency) in the relationship between dysfunctional beliefs and posttraumatic stress symptoms (intrusion, avoidance, arousal)” (p. 9). Participants were 107 healthcare professionals from various hospitals in Romania. The 84 item Trauma and Attachment Belief Scale (TABS) as well as the 17 item Secondary Trauma Stress (STS) scale were employed as the instruments for this study. A significant finding of this study was that ER professionals were more likely to develop higher levels of trauma avoidance symptoms even with low levels of dysfunctional beliefs associated with VT. They also showed a correlation between dysfunctional VT beliefs and intrusion and avoidance trauma symptoms. In the deployed environment emergency work can be part of everyday life for healthcare professionals assigned to the medical group. VT beliefs and 51

avoidance symptoms may impact interpersonal relationships when examining the impact, a deployment has on the relationships of a GWOT veteran mental healthcare providers and technicians during and post deployment.

In another study, Yaakubov et. al (2020) conducted a quantitative study examining secondary trauma stress (STS) in emergency room nurses and physicians as well as posttraumatic growth in this population. This study provided statistics on the prevalence of STS in other healthcare professions. Yaakubov et. al (2020) writes, As mentioned, STS has also been found to differ across healthcare professions, e.g., STS prevalence was 15% in social workers and 19% in mental health providers treating military patients. Nurses from several fields displayed high STS prevalence, e.g., oncology nurses, 38%, intensive care nurses, 25%, and nurse midwives, 35%. STS in physicians is relatively understudied. In a mixed sample of heart/lung transplant teams which included physicians. STS prevalence was 43%. STS prevalence was 16% in Israeli physicians treating terror victims and in a more civilian context, 22% of surgeons displayed STS. The sample of this study included 82 ER physicians and 81nurses assigned to the emergency room. Instruments used were the 17 item STS scale and 21 item Vicarious Posttraumatic Growth Inventory (VPTG). This study yielded similar results of STS and VPTG in both ER physicians and nurses. However, STS was not a determining factor in developing VPTG in nurses as was seen ER physicians. The researchers emphasized how other factors play a role in VPTG in nurses. This is significant for the current study because STS can lead to posttraumatic growth which may have a positive impact on the relationships of GWOT veteran female mental healthcare providers and technicians post reintegration.

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Like the concepts of Secondary Traumatic Stress (STS), Vicarious trauma (VT) and compassion fatigue (CF); Pruginin et. al (2017) expanded on these terms with conducting a qualitative study on Shared Traumatic Reality among clinicians and patients living on the border of Israel and Gaza. “Shared traumatic reality (STR) in which clinicians function as caregivers while simultaneously being exposed to the same life-threatening conditions as their patients is a complex issue that has received increased attention over the last decade” (Pruginin, et. al, 2017, p. 685). This was a phenomenological qualitative study and participants were comprised of 20 clinicians. The purpose of this study was to explore STR within a specific population through a phenomenological lens. Participants were organized into groups and group discussions were the instrument used to obtain data. Results of this study revealed that STR is an evolving process that entails a clinician’s ongoing adaptation after a STR. Themes emerged that demonstrated the participants adaptation to STR. Two major themes were the participants’ use of the job as a resource for themselves and their clients. “Their professional role supplies clinicians with a sense of meaning, that enhances their perseverance— He who has a why to live can bear almost any how” (Pruginin, et. al, 2017, p. 696). Participant adaptation was made possible because they had a sense of purpose during the period of shared trauma.

Another phenomenological study explored the shared trauma experiences of 8 counselors and their patients after the Virginia Tech Shooting (Day et. al, 2017). The study demonstrated resilience in the face of shared trauma. The providers in this study verbalized a greater awareness and attunement in their duties along with how they were managing their own mental health response to the trauma. “Clinicians who shared this same traumatic event as their clients struggled to regain personal and professional balance” (Day, et. al, 2017, p. 275). The researchers 53

noted how the participants felt closer to their clients and struggled to maintain healthy limitations and boundaries during treatment. Moreover, support received from one another became a critical component to surviving and thriving within the shared trauma experience (Day et. al, 2017).

These studies on shared trauma reality provide relevance to the current study exploring the impact deployment have on the relationships of a particular population because the designation of being a fellow service member can create a shared trauma reality among provider and patient. The primary mission of military service is being physically and mentally fit for deployment. This value instills an automatic purpose when a service member is deployed. Many service members are faced with crises during deployment that impact entire units including medical. Shared trauma becomes implicit with the notation that service members share in the deployment experience. Moreover, it becomes crucial for service members to find support from one another during time of shared trauma. Therefore, shared trauma for deployed mental healthcare providers and technicians is not out of the realm of possibility. How the participants in this current study adapt to the demands of deployment may be an influential factor on the impact deployment had on their relationships.

Minimal research has been conducted on the impact of trauma exposure on medical staff in the deployed environment. However, Pitts and Safer (2016) conducted a study examining how combat experiences and the individual appraisal of those events impacts reported symptoms of PTSD and depression in 324 US Army medics. Furthermore, the researchers emphasize how limited studies have been conducted on the impact combat trauma experiences have on military specialties such as medics. Medics as a career field like mental healthcare is unique because they are tasked with providing physical care and required to engage in other duties within their assigned units. Similarly, certain mental healthcare taskings within the GWOT time frame 54

required mental healthcare providers and technicians to be prepared to engage in duties outside of the mental health career field.

Additionally, the researchers in this study underscored how one’s reflection on the experience is an indicator of whether the individual will develop PTS or other mental health symptoms. “For example, remembering that one felt threatened is an important predictor of PTS, anxiety, and mood disorders, even after adjusting for degree of combat exposure. Such negative appraisals of remembered threat may even be a more powerful correlate of PTS symptoms than are direct measures of combat exposure” (Pitt and Safer, 2016, p. 66). However, the researchers stressed that such appraisals can be either positive or negative. The results of this study generated a conclusion that positive and negative evaluations of combat exposure and deployment were mediators among the relationship between combat events and PTS symptomatology. Those medics who could not integrate a more positive view of the experience were more likely to develop PTS symptomatology. Moreover, the researchers also emphasized a correlation between increased symptoms and those medics who engaged in duties outside of their assigned role (Pitt and Safer, 2016). This has significance to thiscurrent study in that how a deployment is perceived by female mental healthcare providers and technicians can be contributing factor to how a deployment impacts the relationships of this specific population during and post reintegration.

Exploring vicarious trauma within ethnic populations not exposed to actual firsthand trauma first is worthy of noting in this literature review. Smith et. al (2014) conducted a quantitative study aimed at exploring vicarious trauma symptoms in Haitian Americans following the devasting 2010 earthquake in Haiti that killed 220,000 individual and left 1.5 million homeless. Participants in this study were 475 Haitian Americans living in southeastern 55

United States. The researchers developed their own 70 item survey focusing on trauma symptoms, past stressors, and support seeking behaviors. “Ninety-seven percent of participants reported worrying that family members and close friends were seriously injured, and 95.9% feared that loved ones may have died. Of the 471 participants surveyed, 65% reported the death of a close friend or family member, and 65.6% reported that a family member or close friend was injured” (Smith et. al, 2014, p. 6 &7). The study found that having a supportive network of close family and friends was connected to lower levels of trauma symptoms. However, the researchers noted that evidence did not show a connection between community support and decreased trauma symptomatology (Smith et. al., 2014). This study has relevance to the current study because of how a supportive family and friend network was essential to a population’s ability to cope with vicarious trauma.

A vast amount of empirically based studies has been conducted on exploring vicarious trauma within the medical profession. Foreman (2018) completed a pilot study examining the connection between a counselor’s own mental health and exposure to VT. The sample size for this pilot study was 68 participants and the Five Factor Wellness Inventory and Attachment Belief scales were used as the instruments. “The exposure to client trauma was hypothesized to significantly and negatively influence both wellness and vicarious traumatization” (Foreman, 2018, p.150). This study only captured current caseloads and results showed that there was not a correlation between exposure to client trauma and the overall mental health of the participants.

This raises the question for the current studying regarding how the amount and frequency of deployments may be an influential factor on the impact deployment has on relationships post deployment reintegration.

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Impact of Deployment on Relationships An essential component of this literature review is an examination of how deployments impact the relationships of deployed services members. A gap in the research exists when examining the impact deployment has on the relationships of GWOT veteran female mental healthcare providers during and post deployment. However, there are studies examining the impact deployment has on relationships which demonstrates a need for this current study to explore such an impact on a unique population such as GWOT female mental healthcare providers and technicians.

Past studies have linked exposure to combat events and PTSD symptomatology with family functioning post deployment within male veterans. However, Creech et. al (2016) conducted a quantitative study with recently deployed female veterans to determine if the same correlation exists for females’ veterans exposed to combat. Creech et. al (2014) write, The goal of this study was to examine associations between combat exposure, PTSD symptoms, and alcohol misuse with four different measures of family and close relationship functioning in a sample of 134 women veterans who deployed to the U.S. missions in Afghanistan and Iraq: post deployment family functioning, intimate relationship satisfaction, parenting satisfaction and parenting confidence. (p.44) Participants were 134 female veterans obtained through the VA and from various operations during the GWOT. Findings in this study linked combat exposure events to positive PTSD symptomatology and “and negatively associated with both post deployment family functioning and intimate relationship satisfaction through PTSD symptoms (Creech et. al, 2016, p. 47).

Positive PTSD symptomology therefore correlates with issues in family and intimate partner 57

relational issues post deployment. The findings in this study demonstrate a need for the current study to explore exposure to traumatic events during deployment and emotional coping mechanisms as factors that can impact relationships during and post reintegration.

Vincenzes et al. (2014) conducted a quantitative study exploring separation anxiety in the wives of Army soldiers throughout deployment and during the post reintegration phase. The theoretical framework for this study was Bowlby’s Attachment Theory and the sample size consisted of 57 military wives in the post deployment phase. “The study’s null hypothesis stated that in the population under investigation, the proportion of variance in post-deployment psychological distress level explained by the duration of deployment (as measured by the DASS21) was zero (Vincenzes, et. al, 2014, p. 125). The researchers concluded that length of deployment was a contributing factor to separation anxiety experienced among the participants (Vincenzes, et. al, 2014). This study provides the current study valuable data in that duration of deployments impact separation anxiety among family members. Emotional withdrawal is a common coping mechanism used to manage stressors associated with separation anxiety. The researchers emphasized that a deployment length of 6 months or more is impactful of on the participant’s anxiety level. The length of a deployment for GWOT veteran female mental healthcare providers and technicians is at least 6 months. Therefore, participants of the present study may face emotional withdrawal from their spouses during and post deployment reintegration thus impacting their relationships.

A Portuguese longitudinal study (Pessoa dos Santos, et. al., 2021) explored motivations, emotions, support and family dynamics experienced by soldiers and their spouses during a mission (deployment) and 6 months after reintegration into the home. This study included 255 male Portuguese soldiers and 58 female spouses. The findings of this study indicate motivational 58

factors were present for soldiers and their family regarding the deployment. Those factors were professional advancement and extra income. Spouses also matched these motivating factors in their responses. Additional results also indicated that the soldiers felt more anxiety during the deployment phase but more support in both phases. Soldiers in this study reported that they obtained support from their peers due to the nature of the deployment environment Furthermore, results during the post deployment phase revealed the existence of a “honeymoon” phase between soldiers and their spouses and that more communication during the deployment was helpful during reintegration. “Regarding family functioning, our results revealed higher difficulties in communication during deployment compared with those felt in the pre- and postdeployment phases” (Pessoa dos Santos, et. al., 2021, p. 48). The researchers indicate communication issues amongst soldiers and family members post deployment is related to the period of long separation. Data from spouse participants revealed them experiencing greater anxiety in the pre and deployment phases. The researchers speculate that lack of communication in the pre and deployment phases as a contributor to spousal anxiety but that an adaptation process occurs during the post deployment phase. Positive motivational factors, financial needs, and communication during deployment may be influential factors on the deployment experience of GWOT veteran female mental health providers and technicians during and post reintegration phases.

A major area of recent increased study has been the impact deployment has on the parentchild relationship. Louie & DeMarni-Cromer (2014) completed a mixed methods study om documenting the deployed experience of military families with young children for the purpose of identifying new parenting approaches that promote healthy child attachment during deployments.

Louie & DeMarni-Cromer (2014) write,

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The specific aims were to (a) describe the child-focused deployment preparation strategies employed by military families with young children; (b) document the ways that fathers communicated with their young children during deployment; (c) characterize the early stage of reintegration by describing the service members’ first few weeks home after deployment; and (d) explore the impact of pre deployment child-focused preparation and deployment communication on parenting stress at reintegration. We hypothesized that preparing children for deployment would reduce parenting stress during reintegration. (p. 498) Participants consisted of 30 males with children 6 years old or younger and who completed a deployment from 2012-2014. Regarding preparation strategies for pre-deployment, most participants prepared their children was information-based approaches that involved talking and reading books. Communication during deployment was reported by 100% by all participants with skype as the primary mode. The final focus of this study was on reintegration experiences with their children. According to Louie & DeMarni-Cromer (2014) 87% of participants verbalized a need for an adjustment period to reintegrate within the family. Moreover, 80% of participants reported stress among role confusion that led to conflict with their partners. The entire family required a readjustment phase to previous roles prior to deployment. The researchers concluded that deployed service members will experience fewer attachment issues upon reintegration with children 6 years and under if parents prepare children for the deployment. How the participants of the current study prepare their partners, children, family members, and friends may be a critical factor on how the deployed experience impacts relationships during and post reintegration.

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Nilsson et. al (2015) implemented a qualitative study exploring parent reintegration experiences of women who served in the Army National Guard. “This study was conducted to explore the unique challenges endured by members with children, by interviewing previously deployed women soldiers in the National Guard regarding their deployment and reintegration stressors concerning their children, with the goal of gathering data to support the development of needed and effective resources for this population” (Nilsson, et. al, 2015, p. 116). The sample consisted of 30 GWOT female veterans who deployed to combat areas and the instrument utilized was semi-structured interviews. Themes extrapolated from data analysis consisted of worry over the emotional health of their children, experiencing a sense loss over missing valuable time with their children, personal and child reintegration issues as it relates to the process of adjustment and issues with attachment. Many participants reported their children developing close bonds with other family members which created issues for the child to reattach to their mother. This is a significant area to explore in how the deployed experience might present parent-child reattachment issues for GWOT female mental healthcare providers and technicians.

The length of deployments in connection with reintegration issues is another area that has been empirically researched. In a study by Lowe et. al (2012) the researchers explored “how an active-duty member’s increased time away from home (deployments, temporary duty assignments, and trainings) affects family stress as reported by the dependent spouse” (p. 17).

The researchers emphasized how reintegration post deployment involves both a physical and emotional reunion. Specifically, the aim of this study was to examine the connection between the deployed parent’s stress levels and impact among parent-child relationships. The participants of this study were 30 military dependents with spouses stationed at Moody AFB, GA. Results of

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this study indicated increased parent-child stress among new dependents in the military system.

As the spouses adjusted to this system a decrease in parent-child stress was reported. However, results showed a correlation between attachment issues among dependent spouse-child relationships and length of their spouse’s deployment (Lowe, et. al, 2012). This is important to the current study because it demonstrates a link between deployment length and relationship issues during the deployment. Moreover, relational issues back home may be a predecessor to relational issues for the deployed member during and post deployment reintegration.

Issues associated with prolonged post deployment family reintegration is another area that has been studied involving the impact a deployment has on relationships. Freytes et. al, (2017) completed a qualitative study examining PTSD and TBI diagnosed OIF/OEF veterans and their intimate partner’s perceptions of family functioning post deployment. Participants for this study consisted of 12 couples that took part in a 90-minute semi-structured interview. Results highlighted a longer process of reintegration involving the deployed individual and family members. Various themes were extrapolated from the results of this study. Individual changes were one theme identified in both the veteran and their partners. A common individual change for the veterans “was the struggle to let go of their “military mindset” (i.e., their thoughts and behaviors influenced by military culture), which served them well during deployment, and reengage with others in civilian life” (Freytes, et. al, 2017, p. 152). The shift in responsibilities for partners during and post deployment was a frequent stressor reported by significant others during the reintegration phase. These individual changes impacted communication and emotional connectedness amongst the couples which affected their relationships. However, participants reported a commitment to working through relational issues. While this study focused on family functioning in a prolonged post deployment phase for veterans diagnosed with PTSD and TBI it

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provides value to this present s study in that it is critical to note the post deployment reintegration phase as a process existing without a designated time frame when evaluating the impact deployment has on relationships.

The impact of extended and lengthy deployments on the mental health of veterans is another area of interest within the research community. Cigrang et. al (2014) embarked on a longitudinal study exploring the impact extended deployments have on the mental health and relationships of Air Force Security Forces who were deployed to Iraq for a year long deployment. Participants were 164 airmen assigned to Security Forces. A component of the participants was designated to work with Iraqi police and the researchers noted that the sample completed measures in theatre to assess PTSD and depressive symptomatology, marital satisfaction, unhealthy alcohol use, and perceived social support. Results demonstrated a 20% increase in moderate to severe PTSD symptomatology, a 16% increase in depressive symptoms, and a 10% increase in moderate to severe drinking on the 6–9-month post deployment follow up.

Regarding intimate partner relationships 30.4 % reported either them or their partner had moved forward to end the relationship. Cigrang et. al., (2014) write, Similarly, overall social support from family, friends, and significant other during the post deployment period varied across airmen showing either resilience or deterioration, F(2, 148) = 4.90, p = .009; airmen experiencing severe deterioration differed from the groups of airmen demonstrating either resilience (p = .002) or only moderate deterioration (p = .042), who did not differ from each other (p = .221). p. 62 The researchers noted as part of their analysis resilience being a factor in participants reported social support from family and friends. They also noted participants’ ability to discuss emotions and thoughts about the deployment as enhancing to their resilience and perceived social support.

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This study further supports a correlation among mental health symptoms related to deployment and how such symptoms can impact relationships. This study will factor trauma events in the deployed experience as variable that can impact relationships during and post deployment reintegration.

Conclusion There is substantial empirically based literature connecting deployed trauma experiences to the development of mental health symptomatology in both male and female veterans.

Furthermore, empirical based studies in this literature review demonstratea link between exposure to trauma in the deployed environment to complex relational dynamics during and post deployment reintegration. Several studies also indicate the length of a deployment as a factor influencing relational issues. Vicarious trauma as indicated in the literature review may also be a factor in a provider’s occurrence of mental health symptoms. The focus of this study is not to explore the connection between mental health symptomatology because of deployment and relationships. I assumed that the deployed experience does impact the relationships of GWOT female mental healthcare providers and technicians. However, the focus of this study is to explore the impact a deployment has on relationships beyond the already demonstrated link between relationship functioning and mental health symptomatology as a result of deployment. It also not out of the possibility that deployed experience may also positively impact the relationships of GWOT female mental healthcare providers and technicians. Lastly, a gap in psychodynamic oriented studies on the impact deployment has on veterans is further evidence that supports this study.

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Chapter 3 Introduction This qualitative study used an interpretative phenomenological analysis (IPA) methodology (Flowers et al., 2009) to understand and describe the impact a deployment has on the lived experience of female veterans. The purpose of this study was to investigate and understand how the deployed experience impacts the relationships of female, veteran, Global War on Terrorism mental healthcare providers and technicians during and after reintegration.

Since the attacks on September 11, 2001, service members have endured multiple deployments in support of the GWOT.Astudy that focused on female veterans offers a unique perspective on the relational impact that accompanies the deployed experience during and after reintegration.

This study required a contextual background regarding the military and deployed environment: “Contextual information refers to the context within which the participants reside or work. It is information that describes the culture and environment of the setting, be it an organization or institution” (Bloomberg & Volpe, 2019, p. 187). It was essential to provide basic contextual information on military culture and military cultural competency for the reader to understand this study’s purpose.

As opposed to counterparts working in the civilian community, the U.S. military as a workplace poses various unique challenges to all service members and their families. The Department of Defense is the organizing governmental entity of all military branches. The U.S. Armed Services consists of the Air Force, Army, Marine Corps, Navy, and Coast Guard. Each branch has an active, reserve, and guard component with a rank structure of officer and enlisted personnel. All branches of military service require their members to function and abide by a

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unique set of laws, cultural norms, and values different from the civilian world. These laws, norms, and values are enforced in a hierarchical structure by senior officers and enlisted personnel, which is typically referred to as the chain of command (Barr et al., 2015).

Two major unique components of being a member of the military include the warrior ethos and deployment. “The warrior ethos emphasizes placing the mission above all else, not accepting defeat, not ever quitting, and not ever leaving behind another American” (Barr et al., 2015, p. 14). Deployment and the capability to deploy are fundamental expectations of all military branches, and a service member’s ability to deploy is valued the most across all the services. Deploying does come at a cost for service members and their families.

Overseas deployment requires service members to endure long periods of separation from family, friends, and colleagues living stateside. It is assumed in this study that periods of long separation result in some impact on the relationships of deployed female service members during and after reintegration. A contributing factor to this is the conflicting expectations between military and nonmilitary relational roles. This dichotomy of military life versus societal female role expectations places additional stressors on female service members. Female, GWOT mental health care providers and technicians who have been deployed abroad also face daily exposure to others’ trauma, making vicarious trauma part of their deployment experience. There is a gap in the research pertaining to the impact of deployment on the relationships of female mental health providers and technicians during and after deployment in terms of the dichotomy of role expectations and ongoing exposure to vicarious trauma. This study’s main research question is, how might the deployed experience of female, veteran, GWOT mental health care providers and technicians impact their relationships during and after deployment? Sub research questions of this study will focus on: How might military role expectations in the deployed environment

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impact existing garrison roles? How might exposure to secondary traumatic stress (STS) or the development of vicarious trauma affect relationships post reintegration?

This chapter is organized into sections that discuss the rationale for the following elements of the study: qualitative research design and methodology, research sample, research plan and process, data collection, data analysis, ethical considerations, issues of trustworthiness, limitations and delimitations, and the role and background of the researcher.

Rationale for Research Design and Methodology This study utilized a social constructivist qualitative research approach to explore the impact of the deployed experience on the relationships of female, veteran, GWOT mental health care providers and technicians: “Qualitative research is suited to promoting a deep understanding of a social setting or social activity as viewed from the perspective of the research participants” (Bloomberg & Volpe, 2019, p. 38). The objective of this study is to develop a deep and meaningful understanding of participants’ experiences while also considering the contextual framing and milieu of the study (Bloomberg & Volpe, 2019). Creswell and Poth (2018) defined qualitative research as follows: “Qualitative research is a situated activity that locates the observer in the world. Qualitative research consists of a set of interpretive, material practices that make the world visible. These practices transform the world” (p. 7). A foundational proponent of qualitative research is the interactive method of data retrieval by both the researcher and participants. The researcher conducts data analysis, but the intersubjectivity that occurs between the researcher and participants during the interactive process shapes the context of outcomes (Bloomberg & Volpe, 2019). The impact of the deployed experience on the relationships of female, veteran, GWOT mental health care providers and technicians is a lived experience and phenomenon worthy of this degree of study.

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A social constructivist paradigm was critical to this study because it provided a framework that views the reality or meaning making of an experience as socially, culturally, and historically constructed: “The central assumption of this framework is that reality is socially constructed, that individuals develop subjective meanings of their own personal experience, and that this gives way to multiple meanings” (Bloomberg & Volpe, 2019, p. 45). In this paradigm, the researcher’s goal is to understand the various experiences of all participants; to do this, it is critical for the researcher to interactively immerse him- or herself in the participant’s world. The process of meaning making is developed through historical and cultural norms that become ingrained and are alive within the lives of research participants. Furthermore, within a social constructivist paradigm, the researcher is aware that their interpretation of data is influenced by their own personal and historical experiences (Creswell & Poth, 2018). This study was suited for a social constructivist–interpretive approach because the researcher’s objective is to understand the impact that a specific experience has on the relationships of a particular subset of a large population. The process of understanding this impact will be an unfolding one that involves both participants meaning and the researcher’s own interpretation of data. Furthermore, the researcher’s experience as a deployed female, GWOT mental health care provider will be a contributing factor to understanding how the deployed experience impacts the relationships of the participants during and after deployment.

The impact of deployment on participants’ relationships is the major philosophical assumption of this study. Phenomenology is the qualitative approach that lends itself to this study because the research question is designed to understand and describe the impact a lived experience has on a homogenous population.

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Phenomenology is a qualitative research approach typically used to understand and document what participants have in common with a shared experience or phenomenon (Creswell & Poth, 2018). This approach is hermeneutical because it requires the researcher to use interpretation to comprehend, understand, and describe the lived experience. The phenomenon in this study is the impact the deployed experience has on the relationships of participants.

“Phenomenologists assume that there is some commonality in the human experience and seek to understand this commonality or essence” (Bloomberg & Volpe, 2019, p. 54). In classical phenomenology, the researcher “brackets out” their own experiences to maintain an objective stance in grasping the participant experience (Bloomberg & Volpe, 2019). However, this study utilized a contemporary methodological framework to phenomenological research known as Interpretative Phenomenological Analysis (IPA).

IPA focuses on how a specific homogeneous population in a unique environment makes meaning of a shared experience (Creswell & Poth, 2018). According to Flowers et al. (2009), “IPA also pursues an idiographic commitment, situating participants in their particular contexts, exploring their personal perspectives, and starting with a detailed examination of each case before moving to general claims” (Flowers et al., 2009, p. 32). IPA aims to examine the how and why an experience is significant in the lives of the population being studied (Flowers et al., 2009). The deployed experience of mental health care providers and technicians is composed of various and complex parts that are job requirements for those serving in this profession in a deployed environment. Moreover, during promotion cycles, the accomplishments one achieves during a deployment are critical to being promoted to the next highest rank.

Utilizing female, veteran, GWOT mental health care providers and technicians as the population in this study sheds light on how the deployed experience has impacted this group’s

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military and civilian relationships during and after deployment. Exploring and investigating the complex parts that make up a deployed experience and existing roles outside of a deployment are pivotal to understanding and providing meaning as to how the deployed experience impacts the relationships of female, veteran, GWOT mental health care providers and technicians during and after deployment.

IPA involves double hermeneutics or a two-stage interpretive process of data collection and analysis: “The participants are trying to make sense of their world; the researcher is trying to make sense of the participants trying to make sense of their world” (Smith & Osborn, 2015, p.

53). IPA data analysis tasks the researcher with empathically connecting to participants for the purpose of interpretive understanding and critical examination of the data (Smith & Osborn, 2015). I believe my experience as a female veteran who deployed as a mental health provider during the Global War on Terrorism is an advantage to use of IPA as the methodology for this study.

Research Sample The sampling approach for this study was purposive and criterion based. According to Flowers et al. (2009), a purposive and criterion-based sampling method aligns with the IPA methodology because the researcher utilizes a specific population that meets certain criteria needed to study the phenomenon behind the lived experience: “Criterion sampling works well when all the individuals studied represent people who have experienced the same phenomenon” (Bloomberg & Volpe, 2019, p. 187). The targeted population for this study was female, veteran, GWOT mental health care providers and enlisted technicians. It is critical to find a specific homogenous sample in which the data pulled from the study are meaningful to the research question. According to Flowers et al. (2009),

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By making the groups as uniform as possible according to obvious social factors or other theoretical factors relevant to the study, one can then examine in detail psychological variability within the group, by analyzing the pattern of convergence and divergence which arises. (p. 49) IPA recommends a small sample size ranging from three to six participants because this methodology is focused on the meaning behind individual experiences. Moreover, data saturation is achieved through conducting more than one interview for each participant (Flowers et al., 2009).

The intended sample size for the study was 5 to 8. The targeted population is female, veteran, GWOT mental health care providers and enlisted technicians. The researcher attempted to recruit an equal sample of providers and technicians. Providers are considered former officers and technicians are former enlisted personnel in the mental health care field. The participant inclusion and exclusion criteria for this study include the following: •

Female, veteran, GWOT mental health care providers and technicians

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At least one deployment in support of the GWOT

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Either a combat or noncombat zone serving as a deployed area

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Deployment length of at least 3 months

•

Exclusion of all current active duty

Participant recruitment was conducted via the use of social media, such as veteran-based Facebook groups, because the sample of this study was homogenous and purposive, and criterion based. An additional sampling strategy is snowball or chain sampling. This type of sampling strategy identifies potential participants from others already meeting the study criteria (Creswell

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& Poth, 2018). I am part of various veteran groups and have contact with prior service female mental health care providers and technicians which was helpful in the recruitment process.

Research Plan and Design The first step in this study’s research plan was to submit an IRB application to ICSW’s IRB committee for approval. This application included a copy of the researcher’s curriculum vitae and all required information and documentation as outlined in the ICSW IRB application.

Upon completion of the IRB application, approval of the study by the ICSW IRB, and passing the proposal hearing, the next phase in the plan was participant recruitment.

As indicated by Flowers et al. (2009), IPA promotes a smaller sample size of a homogenous population for the purpose of understanding the individual meaning behind an experience. According to Bloomberg and Volpe (2019), it is essential for the researcher to provide an outline of the data-collection process. The following steps were taken to conduct this research: •

Created a recruitment flyer detailing the intent, objectives, and participant inclusion and exclusion criteria for the study, as well as the researcher’s name, telephone, and email address.

•

Created a questionnaire with inclusion criteria and demographic data to gage interest in participating in this study as well as participant demographics.

•

Developed an email draft for a Facebook post for researcher’s own veteran/military Facebook contacts as well as various veteran groups. The flyer was attached in the post describing the intent, objectives, participant criteria for the study, and interview expectations, and create interest by offering a $50 VISA gift card per interview as an incentive for participation for two 60- 90 min interviews.

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•

Created a second Facebook post with the above information to be posted in veteranspecific Facebook groups such as Veteran2Veteran, Air Force Social Workers, Military Social Workers, and Women in the Military as a secondary recruitment tool. The questionnaire was also be attached in this post.

•

Researcher engaged with all interested parties either via email or messenger. o Emailed questionnaire and consent form to all interested parties after gauging they meet study inclusion criteria.

•

Obtained questionnaire information and conducted telephone screening interviews to confirm that all interested participants meet the criteria for participation, as well as review informed consent and the ethical considerations of the study. o Provided all participants with a signed copy of informed consent. o Informed all participants that they will be recorded in the interviews and discussed the use of pseudo names. o All interviews were conducted via Zoom due to the diverse geographic location of participants.

•

Conducted the first 60-90 min semistructured interview with all participants and scheduled the second interview at the conclusion of the initial interview.

•

Used two transcription services to transcribe both interviews (Transcription Puppy and Rev). I switched to Rev due to the poor transcription quality generated from Transcription Puppy.

•

Member checking provided a summary of major themes identified in the first interview to all participants.

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•

Conducted the second 60-90 min semi structured interview with all participants via Zoom. Utilized this second interview to discuss and review major themes identified in the first interview, asked additional questions based on the themes, and identified any needed clarifying questions.

•

Obtained transcriptions of all interviews.

•

Analyzed data via IPA methodology. o Employed IPA process using descriptive, linguistic, and conceptual coding. o Listened to transcriptions while reading and coding.

•

Identified and analyzed findings via psychodynamic theoretical lens.

•

Wrote a report of the findings.

•

Administered a final member-checking report from the second interview on the major theme findings to all interested participants and offered an optional telephone call to discuss final findings with participants.

•

Revised the findings report.

•

Disseminated the final findings report.

Data Collection A literature review on IPA provides a framework for the most ideal data-collection methods. In IPA, each participant’s lived experience drives the research (Alase, 2017). The data collection in this study will incorporate a triangulation of methods. According to Bloomberg and Volpe (2019), “Multiple data-gathering techniques are frequently used in qualitative studies as a deliberate strategy to develop a more complex understanding of the phenomenon being studied” (p. 192). The primary source of data collection for this study was two 60-90 min semistructured, flexible interviews with all participants.

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Participants were notified via the telephone screening about the ethical considerations, such as anonymity and use of pseudonyms, how the data obtained in the interviews will be used, and their right to ask questions and stop the interview at any time prior to their first 60-90-min semi structured interview. Utilization of semistructured interviews is considered the IPA gold standard of data collection. Flexibility with data-collection methods is crucial when using IPA because capturing participant narratives requires the researcher and participants to foster a connection that facilities the telling of their stories (Smith & Osborn, 2015). Thus, “In terms of devising a data collection method, IPA is best suited to one which will invite participants to offer a rich, detailed, first-person account of their experiences” (Flowers et al., 2009, p. 56). The researcher conducted two 60-90-min semistructured interviews using the video service platform known as Zoom. Prior to conducting the first official semistructured interview, the first point of data collection was a phone appointment with each participant. The telephone appointment was approximately 30 min in length and provided a space to gather demographic information, develop rapport, review the informed consent, and answer questions about the study. Successful interviews are dependent upon the comfort level between the researcher and participant as well as the types of questions elicited by the researcher that promote exploration and clarification (Bloomberg & Volpe, 2019). The semistructured interview provides a flexible framework that enables the researcher to go deeper in exploring complex areas that ultimately result in richer data. Furthermore, an interview schedule as outlined in IPA is an essential tool that was developed and revised throughout the data-collection process during this study. Smith and Osborn (2015) provided suggestions for creating an interview schedule and recommended outlining broader topics to be covered with open-ended questions under each section.

Furthermore, it is suggested to cover each topic in a sequential order that allows each subject of

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focus to build upon what is covered next in the interview, as well as incorporate prompts to stimulate further exploration (Smith & Osborn, 2015). Below is the semistructured interview schedule with overarching categories:

1. Opening question on joining the military: •

Tell me about why you decided to join the military and how that decision was received

by family and friends?

•

Prompt: What kind of support or lack of support did you receive from family and friends

once you decided to join?

2. Deployment: •

Tell me about how you prepared for your deployment in terms of your professional and

personal relationships back home?

•

Prompts: •

How did you prepare family and friends?

•

How did you prepare coworkers?

3. Relationships: •

Describe your relationship with family and friends during your childhood.

•

Prompt for all questions in this section: What was your relationship like with family, friends, leadership, coworkers, and peers during your childhood, before and after deployment,

•

Describe your relationship with family and friends before the deployment.

•

What was your relationship like with family and friends after the deployment?

•

Describe your relationship with friends before and after deployment?

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•

Describe your relationship with command and leadership at your garrison and

deployed location.

•

Describe your relationship with coworkers and peers at your garrison and

deployed location.

4. Role Expectations •

Describe the explicit and implicit military job expectations of a mental health care provider and technician.

•

Prompt: Describe what is written regarding job expectations versus what is unspoken?

•

What are some of your nonmilitary role expectations within your family and friendships?

•

Prompt: How might these role expectations positively aide to or create conflict with past military job expectations?

5. Exposure to Vicarious Trauma •

What is your understanding of vicarious trauma?

•

What is your understanding of secondary traumatic stress?

•

Describe your own experience with secondary traumatic and vicarious trauma at your garrison and deployment location.

•

Prompt: How might bearing witness to other’s pain impact you emotionally and your thoughts about your job and duties during deployment?

•

Describe how exposure to secondary traumatic stress might have impacted any of your relationships during and post deployment?

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•

Prompt: How did treating service members with mental health issues impact your relationships?

This sample interview schedule remained flexible throughout first-and second-round interviews.

Moreover, prompts will be utilized to elicit a more detailed response to questions. Prompts are particularly useful within an interview schedule because they are helpful in expanding upon a response without the researcher being too direct and overt in eliciting more detail from the participant (Smith & Osborn, 2015).

Triangulation of data collection is pivotal in ensuring a complex understanding of the phenomenon being studied. The researcher also employed participation observation and requested to review any documents, such as photos, emails, or letters, pertinent to each participant’s narrative experience as additional data-collections methods: Observation or participation observation is a central and fundamental method in qualitative inquiry and is used to discover and explain complex interactions in natural social settings. Through this type of open-ended entry, the researcher is potentially able to discover reoccurring patterns of behaviors, interactions, and relationships. (Bloomberg & Volpe, 2019, pp. 194–195) Moreover, the researcher utilized consistent field notes or journal entries on each interview, which was employed throughout the data-collection process. The process of member checking and highlighting the themes that emerge from the data were employed after the first and second interview. All participants were offered a summary of identified major themes for their review after each interview. The second interview was utilized to review initial findings, ask follow up questions, and make needed corrections. Participants received a final summary of the major themes after the second interview and were offered a follow up scheduled phone call to discuss

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findings. Member checking is a critical component of the data-collection process because it ensures participant voices are accurately captured and displayed in the findings.

Data Analysis Data analysis within qualitative research is a complex process that involves consideration of a multitude of factors. According to Creswell and Poth (2018), qualitative analysis involves organizing the data, conducting a preliminary read-through of the database, coding and organizing themes, representing the data, and forming an interpretation of them. These steps are interconnected and form a spiral of activities all related to the analysis and representation of the data. (p. 181) It is critical for the researcher to approach the analysis process through an ethical lens that protects the participants from harm and unintended disclosure of findings. Member checking and masking the identity of participants are essential ethical components of data analysis.

Flowers et al.’s (2009) IPA recommends a strategic process to data analysis that promotes a nonlinear and reflective approach to analyzing data. The researcher immerses him or herself within the data to promote reflexivity during this process. It is also critical to incorporate memo writing or journaling during this phase of the study. Each narrative account, to include additional documents regarding the phenomenon under study, is approached and analyzed before moving onto the next case. Flowers et al. (2009) described IPA as a single-case process of strategic steps.

Reading and Re-Reading The first step to IPA data analysis is reading and re-reading the data collected. This study incorporated listening to each audio and reading the transcript five times prior to engaging in the coding process: “If the transcript is from an interview, it is helpful to listen to the audio recording at least once while first reading the transcript” (Flowers et al., 2009, p. 82). Moreover, it is

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beneficial to visualize the interview and the participants’ voice while listening to the recording to ignite entry into their world. Critical themes within a narrative can be woven together, and pivotal data could be easily overlooked without incorporating listening to interviews and rereading transcripts (Flowers, et. al., 2009).

Initial Noting The second step of IPA data analysis entailed what Flowers et al. (2009) referred to as initial noting. This initial noting is incorporated after the listening and rereading of the transcript and additional data. During this step of IPA investigation, it is critical that the “analyst maintains an open mind and notes anything of interest within the transcript” (Flowers et al., 2009, p. 83).

This is the process in the data analysis phase in which the researcher takes notes and highlight aspects of the data that stand out as meaningful to the participants, specifically descriptive, linguistic, and conceptual comments that are noteworthy in the transcript (Smith et al., 2009).

Coding entailed a process of identifying descriptive, linguistic, and conceptual comments throughout the IPA methodological process (Smithe, et. al, 2009).

In the initial noting of data, this study utilized in-vivo coding to identify conceptual, linguistic, and descriptive codes as well as value coding as first cycle coding methods. These coding methods are recommended to be used when a study is focused on understanding participant insight and experience (Saldana, 2016). In vivo coding entails creating a code from the participant’s actual words. According to Saldana (2016), use of in vivo coding is “more likely to capture the meanings inherent in people’s experience” (p. 106). This IPA study was grounded in understanding how the deployed experience impacts the relationship of female, veteran, GWOT mental health care providers and technicians, which made in vivo coding the most effective coding method for this study. The participants’ values, beliefs, and attitudes were

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critical to answering the main research question in this study, which is why I also employed value coding when analyzing all data. The participants’ beliefs, values, and attitudes regarding their military versus civilian roles and expectations were vital to understanding the impact that the deployed experience has on their relationships during and after reintegration.

Developing Emergent Themes The third phase of IPA is developing emergent themes within the data (Flowers et al., 2009). This requires a move from working solely with the initial transcript or another data set to focusing on exploratory notes and first cycle coding occurring in the initial noting phase of IPA. This stage of IPA data analysis requires the researcher’s interpretation. Developing emerging themes requires interpretation of participant words by the researcher (Smith et al., 2009). This researcher identified subordinate themes in each data set which were later connected among each participant.

Connecting Emerging Themes The fourth step in IPA data analysis is looking for connections between emerging themes (Smith et al., 2009). This entails a mapping of how all emerging themes connect with one another. Smith et al. (2009) wrote that, in this stage, the researcher is “looking for a means of drawing together the emergent themes and producing a structure which allows you to point to all of the most interesting and important aspects of your participant’s account” (p. 96). This study incorporated a table in which various techniques, such as the use of abstraction, polarization, contextualization, and subsumption, were used to connect emerging themes under a larger theme (Smith et al., 2009).

Moving to Next Case and Connecting Thematic Patterns Among All Cases

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The fifth IPA data analysis stage entails moving on to the next case and repeating the entire process. Smith et al. (2009) recommended bracketing out what developed in the analysis of previous participant cases. The steps recommended for data analysis in IPA allow the researcher to immerse him- or herself completely in each participant’s experience. Data analysis in this study will entail following these five steps for each participant until this researcher reaches the final step of analysis. The last and sixth phase involves searching for connective relationships among all the participant cases. It is essential to examine all cases and determine if patterns exist among the themes developed across the analysis of data from all participants (Smith et al., 2009). I analyzed each participant’s data by utilizing the IPA six-step stage process outlined by Flowers et al. (2009).

Ethical Considerations When conducting all research, including qualitative and quantitative studies, the fundamental ethical consideration is to ensure that participants do not experience harm because of participating. The first ethical consideration for this study was submitting and attaining IRB approval from ICSW: IRB committees exist on campuses because of federal regulations that provide protection against human rights violations. The IRB committee requires the researcher to assess the potential for risk to participants in a study, such as physical, psychological, social, economic, or legal harm. (Creswell & Creswell, 2018, p. 91) All study participants were volunteers and appropriately screened to ensure they are physically and emotionally capable of participating in the study. Informed consent was developed detailing the appropriate identification elements of the study, potential risks for participants, specifics on

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assurances of confidentiality, rights regarding withdrawing from the study or stopping an interview, and appropriate contact information if questions arise.

One area of this study that requires further ethical consideration for the female, veteran, GWOT mental health care provider and technician population is the assurance of privacy. All participants were asked to choose their own pseudonyms, and a discussion on data storage was addressed prior to their first interview. Pseudonyms ensured anonymity in the study.

Additionally, transparency is a critical requirement for all researchers, and participants were informed of all potential risks, to include emotional and privacy areas, before signing consent forms. This included consent to record interviews. Participants received a signed copy of their informed consent along with a list of Department of Veterans Affairs mental health resources, the national veterans’ hotline number, and Military OneSource contact information.

Issues of Trustworthiness In quantitative studies, the trustworthiness of data is determined through validity and reliability. However, in qualitative studies, trustworthiness is dependent upon the researcher establishing significance and value through triangulation. These criteria include credibility, dependability, confirmability, and transferability (Bloomberg & Volpe, 2019). Credibility in a study is based on the researcher’s ability to accurately portray each participant’s perception of the phenomenon. Essential to credibility is the researcher’s ability to identify and monitor their subjective experiences and biases. Dependability refers to the researcher’s ability to accurately answer the research questions: “To achieve dependability, the researcher must ensure that the research process is clearly documented, logical, and traceable” (Bloomberg & Volpe, 2019, p.

204). Confirmability entails demonstrating how the findings are drawn from the data. Explaining how the findings are connected to the data rather than researcher biases establishes the study’s

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confirmability. Transferability equates to the goal of generalizability in quantitative studies.

Transferability in qualitative studies makes “it possible for readers to decide whether similar processes will be at work in their own settings and communities by understanding in depth how they occur at the research site” (Bloomberg & Volpe, 2019, p. 205). The goal is for the reader to be able to see the findings as being applicable in other communities and settings.

Credibility Smith et al. (2009) highlighted Yardley’s criteria for assessing validity and quality in qualitative research. The first principle closely related to credibility is sensitivity to the context.

The ability to conduct a good interview is one way to demonstrate sensitivity to the context because the researcher is required to attune to the participant through empathy and rapport.

Additionally, the IPA process is structured to ensure the researcher is immersed in the data in such a way that it promotes the accurate portrayal of participant meaning. Throughout this study, the researcher utilized active journaling as a method to enhance positive engagement with all participants. Moreover, journaling provided a space to continually track the researcher’s biases and subjective experiences during both data collection and analysis. Conducting two 60-90-min interviews and assessing additional data (e.g., emails and letters) demonstrates triangulation and thus added credibility to this study. I was transparent with the findings by discussing the challenges during data collection and analysis. Moreover, member checking was employed to confirm accurate representation of participant perception and meaning (Bloomberg & Volpe, 2019). IPA’s six-stage process of data analysis further demonstrates my sensitivity to this study’s context, which in turn establishes credibility. Sensitivity to the context in this study included direct quotes to highlight the voice of each participant in this study (Smith et al., 2009).

Dependability

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Demonstrating dependability in an IPA study is achieved through Yardley’s second principle of commitment and rigor: “With IPA there is an expectation that commitment will be shown in the degree of attentiveness to the participant during data collection and the care with which the analysis of each case is carried out” (Smith et al., 2009, p. 181). Rigor implies that the researcher has employed diligence in the study. For example, attention to detail in choosing a sample shows diligence in ensuring the population is homogenous. Dependability in a study is achieved with a detailed discussion on the methodological process (Bloomberg & Volpe, 2019).

In this study, a detailed discussion on data collection and analysis, as well as journaling notes, demonstrates dependability.

Confirmability According to Bloomberg and Volpe (2019), “Confirmability is concerned with establishing that the researcher’s findings and interpretations are clearly derived from the data, requiring the researcher to demonstrate how conclusions have been reached” (p. 204). This entails illustrating a clear process on how data were obtained and analyzed. It is critical for the researcher to discuss biases that could impact the interpretation of data. However, IPA is rooted in double hermeneutics, in which both the researcher and participant are engaged in an interpretive meaning-making process. Furthermore, in IPA, confirmability can be achieved in Yardley’s third principle of transparency and coherence (Smith et al., 2009). Transparency in this study is demonstrated through a detailed description of (a) the recruiting methods; (b) the participant-selection process; (c) the screening process; (d) the construction of questions; (e) the interview schedule; and (f) the IPA data analysis process. Coherence in this study was demonstrated through a written exploration that interconnects thematic findings with theoretical

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assumptions while keeping the participant experience as the focal point of the research (Smith et al., 2009).

Transferability Transferability in quantitative studies equates to the generalizability of findings to a larger population. However, according to Bloomberg and Volpe (2019), The goal of qualitative research is therefore not to produce truths that can be generalized to other people or settings but rather to develop descriptive context-relevant findings that can be applicable to broader contexts while still maintaining their content-specific richness. (p. 205) Transferability in a qualitative study allows the reader to envision how the findings might be applicable in other populations (Bloomberg & Volpe, 2019). In IPA, Yardley’s fourth principle is impact and importance. Essentially, the study leaves the reader with information viewed as important and useful (Flowers et al., 2009). This study provides rich descriptions detailing all stages of the research process in meeting transferability and thus validity. Moreover, utilization of purposeful sampling to reach a specific population, such as female, veteran, GWOT mental health care providers and technicians, provided readers an in-depth picture into the experiences of this population. Providing a detailed picture of a homogenous population will enable the reader to envision findings within other contexts (Bloomberg & Volpe, 2019).

Limitation and Delimitations A major limitation of this study is the issue of possible bias due to the researcher’s own classification as a veteran, female, USAF mental health care provider with one deployment in support of the GWOT. However, I utilized journaling throughout the data collection and analysis to address potential biases that might influence the interpretation of data.

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Acknowledging, discussing, and reflecting on my background as a member of the population under study in Chapter 1 and engaging in a journaling process reduced the impact of biases on interpretations and emergence of themes. Additionally, another limitation of this study might be the transferability of findings due to the specific population used to answer the research question.

Veteran, female, GWOT mental health care providers and technicians are a fraction of the females who have and are currently serving in the U.S. Armed Forces. However, Creswell and Creswell (2018) highlighted the importance of utilizing purposeful sampling in qualitative studies “that help the researcher understand the problem and the research question” (p. 185). I incorporated multiple interviews, coupled with the use of other data (e.g., emails or letters), to reach data saturation. Moreover, the use of thick descriptions, including quotes detailing participant experiences, provide readers with a comprehensive picture on how the deployed experience might impact the relationships of other veteran and nonveteran populations who are deployed in support of their jobs and separated from family and friends for extended periods.

Role and Background of Researcher This study sought to understand the lived experience of a small homogenous population, specifically how the deployed experience impacts the relationship of female, veteran, GWOT mental health care providers and technicians during and after deployment. In IPA, “researchers tend to focus upon people’s experiences and/or understanding of a particular phenomenon” (Flowers et al., 2009, p. 46). Critical to IPA research is the inductive practice of investigating, exploring, examining, and eliciting, including the researcher’s qualities of flexibility, patience, and empathy (Flowers et al., 2009). IPA also stresses the importance of reflexivity as a part of the researcher’s role. Remaining reflexive as a researcher was essential in understanding and interpreting the meaning behind this phenomenon.

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In Chapter 1 of this study, I acknowledged how my own deployed experience as a female, veteran, GWOT mental health care provider impacted various relationships during and after my reintegration. My experience as a USAF mental health care provider, along with my years of clinical experience, shaped the assumptions of this study.

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Chapter 4 Results

The purpose of this interpretative phenomenological study was to examine the subjective experiences of deployed female GWOT mental health care providers and technicians.

Specifically, the purpose was to understand how the deployed experience might impact the relationships of this population during and after reintegration from deployment. The confidentiality of the seven participants was my utmost priority. Each participant was asked to identify a pseudonym to ensure anonymity and protection of privacy. The pseudonyms for the participants are as follows: Samantha, Nikki, Smiley, Puzzles, Gina, Cindy, and Poppy. The researcher developed a table to organize the data for each participant and document each level of IPA coding, superordinate themes, and subordinate themes. Each participant’s data were cross analyzed to produce a final table of superordinate and underlying subthemes.

IPA incorporates a distinctive and reflective process for analyzing data. According to Smith et al. (2009), “, analysis is an iterative process of fluid description and engagement with the transcript” (p. 21). During the data analysis, I immersed myself in the subjective experiences of each participant while engaging in reflexive and flexible thinking about the data. A funneling process of reviewing all subordinate themes was used to develop all superordinate and connected subthemes. This process consisted of reviewing the transcripts line by line, identifying the appropriate codes (descriptive, linguistic, and conceptual) within the data, and extrapolating emergent themes and subordinate themes. I read and listened to each transcript five times while identifying codes and emerging themes in each of them. In every transcript, descriptive coding 89

was circled, linguistic coding was squared, and conceptual coding was placed in parentheses.

Throughout this process, I looked for divergent and convergent data while actively journaling my thoughts and feelings. I identified three major superordinate themes that emerged from the data: stabilizing function of the military; the interconnection among self, relationships and deployment; and dear relationships. A discussion on the stages of research will be presented in the next section. Lastly, the chapter will conclude with a dialogue on the emergence of each superordinate and subtheme as well as how the themes relate to the main and sub research questions.

Phases of Research I initially posted a flyer about the study to various Facebook groups to recruit participants. During the initial phase of research, all interested parties received a demographic questionnaire to determine eligibility for participation. It is crucial to note that based on the demographics, not all participants had a voice in each superordinate theme. Table 1 outlines the results of the demographic questionnaire.

Table 1 Demographic Results

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Pseudo Name

Age/Tim Race e of Interview

Highest Level of Education

Identified Gender

Officer or Branch Tech/Status of service

Samantha

44

White

Female

Nikki

48

Latina

Graduate Degree PhD

Smiley

45

Black

Female

Puzzles

49

White

Gina

47

White

Graduate Degree Graduate Degree PhD

Cindy

39

White

PhD

Female

Poppy

48

White

Some College

Female

OfficerActive OfficerActive OfficerActive OfficerActive OfficerActive OfficerActive MH Techactive

Female

Female Female

Deployed Location

Year

Relationship Amount status at time of of children deployment

Age Range

Married

3

5-7yrs

Air Force Manas/

2011

Air Force Kuwait

2011

Married

1

2-4yrs

Air Force Iraq

2008

Single

1

5-yrs

Army

Afghanistan 2x Air Force Afghanistan

2012/ 2018 2010

Single

0

n/a

Single

0

n/a

Iraq

2009

Married

0

n/a

2007

Married

1

1317yes

Kyrgyzstan

Army

Air Force Germany

During the second phase of research, participants completed two interviews in which they discussed their lived experience of joining the military and in particular their deployment. An emphasis was placed on noting the effect the deployment had on their relationships during and post reintegration throughout the interview process. Additional sub questions to this study are as follow: •

How might military role expectations in the deployed environment affect existing nonmilitary roles?

•

How might exposure to secondary traumatic stress or the development of vicarious trauma in the deployed environment affect relationships post reintegration?

To answer the main and sub-questions, I used an IPA formatted interview scheduled that encompassed questions on the following larger topics: reasons for joining the military and how it was received by family; job meaning before, during, and after deployment; health of 91

relationships before, during, and after deployment; and exposure to secondary traumatic stress and the development of vicarious trauma as well as the effect any exposure might have had on their relationships. The second interview lasted 20–30 mins and was used to review the accuracy of initial interview summaries as well as to identify any additional information they wanted to share about their lived experience. Moreover, the second interview did not reveal any new data and all participants agreed with the summaries of their interviews. I made only minor corrections to demographic data.

An IPA analysis of the data revealed three major superordinate themes with 2–4 subthemes under each major theme. Table 2 identifies all major superordinate and subthemes that were yielded during the data analysis phase of this study.

Table 2 Major Themes and Subthemes Superordinate Themes Stabilizing func�on of the military

Subthemes Security: I felt that I was going to get stability What about family?

The interconnec�on among self, rela�onships, and deployment

I loved it! Freedom to make it our own!

Deployment role One boot in the deployment and one back home

Dear rela�onships

Service before self and family: Coming back it felt like too much Mommy and me

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Bidirec�onal empathy post deployment: It changed me Courage to make changes in rela�onships

Superordinate Themes, Subthemes, and Participants’ Experiences Theme 1: Stabilizing Function of the Military The superordinate theme of the stabilizing function of the military illustrates that the military may provide stability across various life areas to include self and family prior to deployment experiences. This theme is crucial to answering the primary and secondary research questions in this study because stability in life can be a factor that affects relationships.

Moreover, it is important to consider the health of each participant’s relationships prior to deployment because this may influence how the deployment might affect relationships during and after reintegration. Military service as a stabilizing function emerged in the lived experiences of many participants. The participants in the study described varying levels of stability within their relationships. The word stability when referencing military experiences was common across the data. The subthemes that developed from this superordinate theme are labeled security: I felt I was going to get stability and what about family? These subthemes will be explored in greater detail in the subsequent section.

Security: I Felt That I Was Going to Get Stability The first subtheme that developed from the superordinate theme of the stabilizing function of the military was labeled security: I felt that I was going to get stability. Many participants said that their military service provided security and stability at the time of their joining. Participants were asked why they joined the military and how it was received by family and friends. Their stories illustrated a potential need for security for themselves and family 93

members, which may have contributed to relational stabilization. The next section provides rich descriptions highlighting this subtheme along with demographic information.

Samantha is a 44-year-old White female Air Force veteran who was an officer and clinical social worker. She deployed to Manas, Kyrgyzstan, in 2011, and at the time of her deployment, she was married to a man and had three boys between the ages of 5 and 7 years.

Prior to joining the Air Force, Samantha was a full-time “stay at home” mother and joined the Air Force because her spouse had difficulty maintaining a job. During this time, she noted that they were having marital and financial issues. She also shared that her spouse struggled with mental health issues. Samantha voiced feeling drawn to joining the Air Force so that she could provide for her family.

So, my husband at the time had a hard time keeping a job and, in hindsight, had a lot of depression and mental health issues. So, I was like, well I need to suck it up and go work.

I started applying for jobs, ended up getting a full-time job at a prison, which was cool.

And then I saw on Monster.com, licensed clinical social worker with United States Air Force, and we were dealing with a lot of marital stuff. We were going to lose our home.

We needed money and stuff, and I felt like I needed to step it up and be the provider since he couldn’t, and that was my frame of mind and still is. So, I said to him, “I’m joining.” I didn’t know what I was getting into, but I kind of didn’t care. I felt that I was going to get stability. We had no health insurance. I felt like I was going to have health insurance for myself and the children as well as retirement.

Samantha believed she needed to step up and “be the provider” for her family when basic needs such as health insurance and finances were on the verge of collapsing. One can conceptualize that joining the Air Force for Samantha was like covering herself and family with a secure and

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warm blanket. Perhaps Samantha sought security during a period in which her marriage and home life was not stable.

Poppy is a 48-year-old White female Air Force veteran who retired from the Air Force after serving as a mental health care technician for more than 20 years. She deployed to Germany in support of the GWOT in 2007. She joined the Air Force at age 20, was married for 5 years, and had one daughter who was 5 years old. At the time of her deployment, her daughter was 17 years old and entering college. Like Samantha, Poppy and her family were struggling financially and had no health insurance.

Well, at the time I was 20, married, with a five-year-old kid, well she was almost five, and we had no health insurance. I think I was making $850 a month and that was, like, high pay at the time. So, I decided to go in. I needed something more than what I was doing to help support my family.

Poppy was young, had a small child, and was not making enough income to ensure the stability of her family. The Air Force for Poppy was like a built-in family that offered financial and health insurance security. Moreover, it seems to have provided her with a corrective and stable environment after growing up in a home with an alcoholic father.

My dad and I, he was always drunk and passed out. We weren’t close during my childhood. He was always drunk and passed out. I remember having to drive the car home as a kid because he was too drunk. This is what made me gravitate towards working with ADAPT patients in the Air Force.

Serving in the military draws similar parallels to being raised in a stable family environment that provides security and a set of values to guide one’s life. When one enters the military, one is in the stage of infancy during boot camp, and one then graduates with a new set of values and a

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sense of belonging to something greater than what came before. Poppy seemed to be craving for stability that was lacking in her childhood. .

Nikki is a 48-year-old Latina female Air Force veteran who was an officer and psychologist. She deployed to Kuwait in 2011. At the time of her deployment, she was married with one son who was 5 years old. Nikki initially joined the Air Force as a line officer and crosstrained in the medical field because of the negative effect shift work was having on her life.

So, I was a line officer, and I was a human factors analyst. I was working with units assigned to space command. We were doing operational tests and evaluations. One of the things that I encountered was a lot of fatigue and sleep problems, especially doing shift work. I was interested in leaving shift work. I had been a human factors engineer and didn’t want to work with the system anymore. I wanted to work with the people, so I switched. I switched to medical. It was a good move for myself and my family. I had a set schedule, which balanced my life out.

Cross-training into a medical role seemed to have stabilized Nikki’s sleep schedule. A poor sleep schedule may influence an individual’s mood and thus affect how they might interact in relationships. It is important to note that Nikki appeared to be missing human interaction as a human factors engineer, thus prompting her to seek out a more balanced professional and personal life. It is possible that making the change from engineer to psychologist provided greater security and stability in her life.

Puzzles is a 47-year-old White female Army veteran who served as an officer and clinical social worker. She deployed to Afghanistan in 2012 and for a second time in 2018. She joined the Army later in life, at the age of 37, and was single throughout her entire Army career.

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Puzzle’s father was a Vietnam veteran and seemed to be a driving force in her joining the military as an active-duty clinical social worker. She noted in her interview that her father had suffered from post traumatic stress disorder (PTSD) throughout her childhood. She described having “secondary issues” with PTSD and believed she could make a difference in providing trauma treatment to soldiers in the Army. Joining the Army for Puzzles appears to have been an opportunity to connect with her father.

During my childhood, my dad was very distant. He came out of Vietnam and was just kind of a mess. He didn’t trust anybody because of his PTSD stuff. He also lacked any kind of interaction and engagement during my childhood. He was so very distant. I sort of went after that with him and pushed my mom away. So, here it is, this plays out in relationships today that I struggle with. My dad has PTSD from Vietnam, and knowing his life, me having secondary issues with him, I thought I could be very helpful, I thought it’d be nice to honor him by joining the Army later in life.

Joining the military for Puzzles may have been an experience that operated as a mechanism to resolve an early disconnection in her paternal relationship. As a family member of a veteran with PTSD, she noted the effect it had on her relationships. Serving in the Army appears to have been a corrective relational experience for Puzzles. She could make her father proud while helping other military members who were struggling with trauma. Puzzle described these experiences as enhancing her sense of security and stability within her relationship life.

What About Family?

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The subtheme of what about family? dives into the influence and noninfluence family had on participants’ decisions to join the military. In addition, it highlights from a participant perspective how family members received the news of an impending separation prior to deploying. This provides an added framework for the potential ways the deployed experience might affect relationships during and after reintegration. Early support in joining the military and the ways family members received the upcoming separation may have played a role in how relationships might have been affected during and after deployment. Did the participants need the support of family to make a life-changing decision to join the Armed Forces, and did support or lack of it affect their relationships during and after reintegration? The following sections provide rich stories illustrating the significance of this subtheme.

Smiley is a 45-year-old Black female Air Force veteran who served as an officer and clinical social worker. She deployed to Iraq in 2008 and was a single mother at the time of her deployment. In her interview, Smiley reflected on her internal decision-making process regarding joining the military, preparing for deployment, and presenting it to her family.

I talked to Colonel C., who was the core chief at the time, and I felt he was so genuine and so real. He was like, you know what Smiley, we just took over the hospital in Balad and it’s very likely you’re fully qualified, you’re already licensed, and it’s very likely you’ll get deployed within a year. Are you okay with that? I said, “Well, what does that look like?” And so, I got a good picture from him, you know, generally four months and how they support the families. I was like, okay, I think I can do that. And so, all in all, I think I had my mind made up at that point.

So, my family, I have a lot of sisters, very strong and opinionated women [laughs], which I appreciate. I have this model where I go through things for myself first

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because I don’t want somebody else’s fear to be implanted in me. Right? I wasn’t afraid of anything. I wasn’t doubtful. I know I’d already done my homework. So, it was kind of like, “Hey, I think I’m going to go into the military and I’m going to commission as an officer.” They were like, “No, you’re not.” I said, I’ve already talked to this person.

Julian, who’s now twenty-one, was five at the time. I was like, “I’ve already talked about family stuff and what it would look like.” They’re like, “No, you’re not.” I was like, “No, really I think I’m going to do it.” And so that was it. I told them probably a couple of months before my commissioning ceremony. Everything else was taken care of at that time.

Smiley was asked to expand on how her mother received the news about her joining the Air Force.

So, at first my mom was like, “Why would you do that? Why would you do that?” I was like, “I promise you this is gonna be okay.” She took a little bit more coaxing, but I say after a time, I think the idea grew on her. Because, I mean, she was used to me. So, I would, like in college, I’d come home over the summer and say, “Mom, I’m about to get a tattoo.” “Oh no, you’re not. Why would you do that, why’d you do that?” I’ll let it simmer with her for a minute. Two weeks later, I got a tattoo.

In the above description Smiley described possessing an internal decision-making process that was independent and outside of the sphere of influence of family members. She had already researched the Air Force along with the family support she would receive as a single mother with a 5-year-old child. Her confidence in her decision to join appeared to have left her family no other decision but to support her in this journey. The next description provides insight into how

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Smiley’s family received news of the deployment, her preparation process with family, and the status of family relationships pre-deployment.

So, personally, I said, “Hey, I got told that I may or may not deploy next summer. It’ll probably look like April or May.” I have a sister who’s mobile, right? No kids, no, whatever. So, she can, she can move around, and she enjoys the different variety of places that I went to because she got to come [laughs]. So, I had it set up that two of my sisters had to split the power of attorney for medical in case they needed it. And then that one sister came down and allowed my son to finish school.

So, I told my son, what did I tell him? I think I told him that it was part of my job being in the military. I still help people, and some of those people might be fighting for our country. So, I might have to go where they are instead of them coming where we are, but it will be just for a couple of months. Luckily, it was over summer vacation. It was over, like, summer break mainly. So, it wasn’t bad because his dad is in Illinois. So, that gave them a lot more time together considering that we had just moved [laughs] a year ago. Right? So that part was good.

So, my mom, I was just, like, hey, this is happening. But I told them all that beforehand. I told her before, “This is happening, and here’s what I’m going to do.”

Here’s the preparation, like, he’s, he’s good. We have Tricare. So anytime you, if he must go to the hospital just say, Tricare, here’s a copy, social’s right at the top, blah, blah, blah.

So, I made sure they had everything logistically right. And then I had to go back and, like, do some reverse psychology on them. Well, how do you consider yourself to be a Christian but you’re so worried about me leaving? Like, shouldn’t you be praying or something?

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Smiley seemed to have acquired an independent internal decision-making system early in life.

Her family had no other choice but to support her decision to join the military and later deploy.

She had researched the type of support she would receive from the Air Force and may have been drawn to serving in part due to the stability and security she would receive from this institution as a single mother. Furthermore, it appeared that she maintained close family ties prior to her deployment, which provided her with the means to be separated from her son for a 4-month period.

Gina is a 47-year-old White female veteran who served in the Air Force as an officer and clinical psychologist. She deployed to Afghanistan in 2010. At the time of her deployment, she was single with no children. Gina shared in her account that her parents easily adjusted to her decision to join the Air Force because her brother had enlisted a couple of years prior. Gina reflected on her process of joining along with how she prepared family members for her deployment. The description below also illustrates how a relational acquaintance was influential in her decision to join.

So, I decided to join the military when I was in my graduate training, to become a psychologist. A recruiter came to do a presentation that I missed. I still had some friends tell me about it. And then one of the people in my research lab joined. I kind of kept touching base with her, as she was going through it because she was a year ahead of me. I kept checking with her to see what it was like. I had never known that you could be a mental health provider in the military, so I’d never considered that. As I heard about her experience, I was like okay, that’s something that seems like I might be interested in doing. A few months into her first assignment after her . . . residency year, I kind of checked in with her again because that was about the time, I was doing my interview. I

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wanted to know more about her experience. I said, “Now that you had a residency, what’s real military life like?” [chuckle] I felt like it was, it felt right.

Gina depicted her family as being supportive of her deployment. She illustrated in her story that her parents did not express any lack of support because of their prior experience with her brother.

And then, my family was very supportive of it. I had at the time my brother who was a little bit older than me serving in the Air Force on active duty as well. So, he was the only member of my, like, immediate family, not counting grandparents that had been in the military. So, there wasn’t anything, nobody had any negative thoughts about it. They were very supportive of me.

Gina also expanded on how her family received the news of her deployment.

I came in in 2004, so, 9/11 happened as well as, then the Iraq invasion. So, all of that had already happened at that point. I don’t think they really expressed any anxieties to me about that. They were just very supportive.

Gina appears to have joined the Air Force and subsequently deployed to Afghanistan without any relational stressors from her family. The support of nonmilitary relationships seems to be a contributing factor to the stabilizing function of the military. In Gina’s case, the Air Force was an opportunity to grow into a secure and stable career.

Cindy is a 39-year-old White female Army veteran who served as an officer and clinical social worker. She deployed to Iraq in 2009 with her spouse who was a medical doctor in a combat infantry unit. They had met during commissioned officer training, married, and attained the status of dual military. Cindy reflected on how her family received her joining the military as well as the complexities of deploying with her spouse. Cindy was raised in a highly

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dysfunctional family and appears to have been parentified at a young age. Her initial experience in the Army seems to have been a stabilizing and secure force in her adulthood.

When asked about her relationships with family in childhood, she described them as not what she would have chosen if she had a choice in the matter.

I would have not chosen them growing up. My parents had a very toxic relationship, you know, verbal and physical abuse. I have more sad memories than positive ones. My brother and I hated each other all the time. At least, that’s how it came off rather when you throw in the psychology behind it. It must have been our way of coping and how we related to one another. He was super mean to me and was obviously physically stronger than me. We’re always just fighting, and then there was an element of like competition.

It’s like, I always felt like I was the gatekeeper for my brother. Even though I’m 15 minutes older, it’s like I was five years older than him. He was always my responsibility, “Where’s your brother?” I don’t, I don’t know like, “You’re the parent,” like, “Why don’t you know where he’s at?” So, it felt like it got placed on me, to know where he was. If I complained, he did this to me, or he said something, and my mom never really truly believed me. I felt hurt.

Cindy described herself as taking on the role of protector in relation to her brother and subordinating her needs at the expense of his. In her discussion on joining the Army, it seems Cindy saw it as an experience to follow her desire for a happy and healthy future. The next section describes Cindy’s experience of the way her family received her joining the Army.

Cindy had fallen in love with the idea of providing support to service members with combat related trauma after spending time at a college internship in Washington, D.C., at the beginning of the Iraq invasion.

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I had gone on a mission trip during spring break to D.C., where for two weeks I stayed at this big homeless shelter here in the city. I can’t recall the name of it now, but it still exists. And so, you stayed there, you worked with the residents there, you worked within the community, then, you would go to the hill and advocate for whatever you said your passion was to promote change. Mine was veteran health care.

When the war had kicked off, I started meeting people who needed treatment, you know, PTSD because of combat or other issues that came from that. It sort of fell into place from there, and so I then joined ROTC, and I guess in some ways like the rest is history. I’ll say, I had fallen in love with it. I fell into a strong passion to treat military members on the behavioral health care side.

Perhaps Cindy had found a calling in life that may have fulfilled missing needs from her childhood. She wanted and needed to feel special by being a part of something that functioned to provide her with a space where she could be purposeful and a powerful force in the eyes of others. However, in joining the Army, she received no support from her family, which is explored in the next account.

My mom was not pleased about me joining ROTC and thought it was a very bad decision, from her mom’s perspective, right? It’s, you know, your child is going to be in harm’s way without fully understanding that’s not always the case. There is risk, yes. But I was not infantry, a door kicker, I was a lower risk. She really was not supportive of it.

She said she was, but would make passive-aggressive comments, or just outright aggressive comments. It was not initially supported. But, of course, when I commissioned, she said in public, “Oh, my gosh, I’m so proud of you.” The type of things mom would do. My parents also divorced when I was in college. So, at the time,

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my dad had chosen to exile himself from a relationship with me, so during that time he had no idea what I was doing.

Cindy’s brother also appears to have been unsupportive towards her future career in the Army. She noted in her account that her brother possessed what appears to have been an indifferent attitude towards her decision to join the Army.

Thinking back, he really didn’t have any feelings directed at my decision. It wasn’t until I came back home, and here he was, had sort of been processed out, and he did not have a college degree. My brother was, like, the smart one. I envy my brother’s ability to speak languages or do math. I got the different parts of the brain to work [laughs]. So, he was just like, “Wow, my dumb sister growing up is now exceeding me in education and military status.” So, I want to frame it that way to you.

Cindy did not receive support or encouragement from her mother or brother at the start of her journey in the Army. Her father appeared to have abandoned them when she entered college and it seems her mother struggled to provide an environment where she could thrive in self and in her relationships. The lack of support drove Cindy to an environment in which she could blossom and find new relationships. The following explores how her family, friends, and spouse responded to Cindy’s upcoming deployment.

Familywise? I think I had delayed probably telling my mom because we had just gotten married and it was strategic in my mind on, like, planning it all out, must get married now, six months later were deploying. So, it’s kind of like, “Last minute, I am deploying!” And she wasn’t happy, but what can you do? We weren’t close but I felt obligated to try and prepare her for how this might impact my ability to stay in contact. I had friends that, you know, we’re excited and nervous wrecks. If they’re not military,

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they don’t quite understand all the time what is real. I was trying to tell them what is portrayed in movies isn’t always real.

Cindy described how her husband was also not supportive of her deployment. Perhaps his lack of support was due to them deploying together. However, the deployment for Cindy was an opportunity to grow as both an officer and behavioral health care provider.

Oh, before the deployment he was not a very emotionally supportive individual. I don’t know if gaslighting is how you would describe it. The deployment was an opportunity for me to grow into my profession and I was excited about it. I was like damn. I started to become used to giving up, a part of, like, who I was. There are times, I don’t even know who I am to this day because it’s just so easy to adapt to meet the needs of someone else all the time and to make sure everything’s fine for others. There were no ripples in the water on my part because I just wanted to be like, loved, supported, and just wanted to be chosen.

It appears the relationships in Cindy’s life at the time of her joining and then deploying to Iraq failed to provide the support she so desperately needed. These early experiences are noteworthy for the way the deployment seems to have affected Cindy’s various relationships during and after deployment, which will be highlighted in later themes.

The superordinate theme of the stabilizing function of the military provides a pre-context for the status of the participants’ relationships before military service and prior to their deployments. In some participant stories, it also highlights that the military seemed to be a stabilizing force in their lives. A lack of stability in one’s early personal world may impact how they function in their future relationships. Furthermore, stable relationships may play a meaningful role in one’s view of self. Therefore, the stabilizing function of the military sheds

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light on how the deployed experience may have affected participants’ relationships during and post reintegration when considering the unstable nature of this environment.

Theme 2: The Interconnection Among Self, Relationships & Deployment Joining the military may provide a sense of purpose and meaning to the individuals who comprise our Armed Forces. However, once an individual joins the military, they seem to be faced with the task of interweaving their military and personal lives into one. The second major theme of this study is called the interconnection among self, relationships, and deployment. The data that emerged from this theme illustrated a bidirectional influence between the effect relationships had on the deployed experience and the effect the deployment had on relationships during and post reintegration. The subthemes in this section are labeled I loved it! Freedom to make it my own and one boot in the deployment and one back home. The rich narratives highlighting these subthemes provide insight into answering the main and sub questions of this study.

I Loved It! Freedom to Make it My Own The subtheme labeled I loved it! Freedom to make it my own illustrates that deployment appears to have served as an experience in which many participants reported growth in their personal and professional relationships. Some participants vocalized experiencing a deeper sense of belonging within their perspective branches because of their deployment. They shared rich accounts of bonding with peers and other unit members during this period. Furthermore, many participants described being given the freedom by command to define their roles during the deployment. This freedom provided them with the space where they could grow their relationship with leadership in garrison and at the deployment.

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Samantha was given the freedom to define the role of mental health care during her deployment. It provided her with the space to demonstrate her skills.

Oh, I loved it. So, it was me and one other provider. She was in the reserves and was higher ranking but had not really been in the military for very long. So, I kind of had to sort of be the whisper in her ear for guidance and stuff like that. I loved it. I mean, I got to make it my own.

We befriended a couple of people and just went everywhere with them. I did love it. I mean I can’t recall the pace being horrible. I mean we decided how we were going to run it and how they would come into the clinic. It was a time in which I could utilize and show my skills as a provider. We had free reign to make an impact.

The lack of structure she experienced in the deployed environment appears to have provided Samantha with the space to connect with service members in need of mental health care services on a deeper level.

I did a lot of outreaches, a lot of out-and-abouts, and I had to do my out-and-abouts in some PT (physical training) gear or else people wouldn’t talk to me. There was freedom to conduct outreach on our own terms, so my goal was to just be out and about. I would talk to people and be, like, “Oh, yeah. Well, come see me in the clinic,” and again we sort of just decided how we were going to run things. But again, back then it was just sort of winging it.

Samantha also maintained a connection to her leadership in garrison during the deployment. She described facing a potential mandatory reduction in force (RIF) while she was deployed. She emphasized in her account that she received both professional and personal support from her garrison medical group commander.

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So, when I went to deploy, suddenly, our career field, BSC [Biomedical Science Corp] career field was going to go through a retention board, you know, it was a RIF board or whatever it’s called. I was like, “Great, so you now have to write a package to keep me in while I’m deployed.” It ended up getting canceled, whatever. But my med group commander would say to me, “No, we’re not going to let it happen, we’re going to make this strong.” They valued me. They knew that I was invaluable. I was valued.

So, anyways, while I was deployed, my med group commander continued to call me. He would say, “How’s it going? How’s the family?” And I remember I’m like, “Oh we’re fine, we’re fine.” But I had sent home for Easter, trying to connect with my kids and my husband, a basketball net that would allow them to play inside. Well, my ex would never put it up. And so, my commander was like, “Well, what can we do to help?”

I said, “Yeah, maybe someone can put together that basketball hoop for my kids because my ex won’t do it.” And so, they went over to the house and did it.

Cindy shared that deploying made her feel as though she was part of the team. She emphasized in her account the negative stigma she felt from other soldiers because she did not have a combat badge. She felt like an outsider before her deployment and had yet to establish relationships. Deploying for Cindy appears to have meant to her that she would finally be accepted as both a soldier and behavioral health care provider within her unit. Cindy discussed how relationships with unit members thrived during this time.

I remember landing in Iraq, and I was so happy, like a lot of people, like, “What’s wrong with you? “But I literally remember being in the Iraqi airport and I said, “Yes!” Like, I’ve made it because I’m no longer light on the right. I was so happy. And I remember kind of cheering out loud and someone said, “Uh, this is so not a happy thing.” I understand that,

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but it is for my job, I was so happy.

You were part of the team, and it made you have this sense of purpose, even on the days you’d be super bored, but if you were able to crack the code into one person who was so anti-behavioral health and suddenly, it just shifted. There’s one example, I was out visiting, and we were standing outside getting ready to go on our convoy brigade, and I had this little salt pack. I was totally capable of carrying all my stuff and I wanted to because of the stigma of being female and all that.

But there was this one guy that had such a terrible experience with a prior behavioral health care person. I mean he just did not like me initially, and I spent I think like two hours with this guy just being present, listening to all the things you’re supposed to. I remember standing listening to this brief, and the guy goes, “Hey, make sure you grab her bag. She’s one of us, she’s good.” I kind of just smiled, I just won his trust, and from then on there was this relationship, “Whatever you need, we will take care of you.”

Gina disclosed how the deployment was an experience that lacked the pressures of garrison-role expectations. She emphasized how her role as a behavioral health care provider during the deployment was not hindered by leadership. Moreover, Gina reported how the trust she developed with her technician during the deployment was a pivotal factor in delivering quality mental health care services.

Command was not hindering our ability to do things; they were supportive. I loved my deployed experience. It was one of my greatest professional experiences. I grew from it.

It was great to be able to work with somebody I already knew. So, I could trust my technician and her skill set, and it allowed us to be able to reach more people. We did great work during that deployment.

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In Poppy’s account, she described the deep and mutually respectful relationships she formed with her peers and leadership during the deployment. When asked about the meaning she attached to her deployment, she noted that she loved it and found it to be a supportive environment where others helped her learn her job. She also seems to have felt valued because leadership believed in her abilities and promoted her to work in an area where she had no experience.

Oh, my gosh. I loved it. So, when I first got over there, I was supposed to be the mental health tech, kind of keeping an eye out for the staff. The nature of the job that we were doing was going out to the flight line and getting all these injured off the plane, and it was pretty much still at the height of everything. So, we were pulling people off the planes that had amputees and were burned. We did a couple of death ceremonies, you know. And so, there was a reservist technician that showed up the same day as I did. We connected with each other.

Within probably a month, maybe even just a couple of weeks of me being there, they had asked me to switch to night shift and be the team lead. So, at that point, I was running the missions, making sure that we had somebody available—that we had all our equipment ready—so that we could get all our buses filled. We were also launching aircraft at night and had to make sure the manifest was correct. On top of that, we were making sure we had the correct patients, luggage, and stuff that they needed.

It was just me as far as mental health because there were four shifts, and they put one of us on each one of the shifts. So, I never saw any of the other mental health techs. I feel my leadership respected me as well because they put me in the team lead position, knowing I had no medical background. My coworkers were awesome. They helped me

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along the way. Anything I did not know, they helped me learn it—showed me—and they taught me how to drive a bus. So much fun. I felt valued by my peers and leadership.

Puzzles described contrasting accounts of her first and second deployed experiences. She vocalized how her commander at the first deployment appeared to engage in splitting behavior among herself and peers. This was a possible factor in the development of conflictual relationships among Puzzles and her peers. Although she found her mission rewarding, Puzzles relied heavily on communicating with her parents to get her through the first deployment.

Puzzle’s perception of her first deployment is divergent data that contrast with this subtheme.

I got to be a part of a warrior clinic that was an intensive work program. The Warrior Restoration program was a wonderful program, and the psychiatrist, as well as all of us participating in it, did get this program going; we put it together and did a wonderful job at helping these soldiers. We didn’t always see eye to eye, obviously, about different things. So, I felt good about that. But there was just a lot of interference from our commander. It caused problems with us as professionals, which was unnecessary. And then some of the professionals I worked with were aligned with her at times. It was just a mismatch. Like, some of that stuff was the problem.

The Warrior Restoration program was attached to the COSC (Combat Operation Stress Control). It was an interesting experience. The commander initially said, “I want to get to know all of you, and let’s have a conversation, getting to know my professed staff.”

So, we had this sit down, and she attempted to do that, but it was really just her telling us how she wanted things to be. It was very off-putting from the start. Everybody felt that.

She made it an adversarial environment from the beginning. This was most of the officers’ first deployment, and she gave them go marks (negative marks) for their first

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deployments. Those go marks were for things that were just minor mistakes and misunderstandings. This is how crazy this woman was. I had to become this person and officer who would not stand up for things out of fear of getting a go mark.

However, Puzzle described a feeling of mutual trust that existed between herself and command at her second deployment. It seems that she took on various roles in this deployment because of the relationship and trust she had built with her leadership.

My second deployment involved us deploying as an entire unit. I knew the commander.

We had been working together for a while before we deployed. At that time, we deployed for 6 months. They weren’t taking everybody at the time. So, it was a shorter deployment, but I got to meet the brigade commander. I got to know what their needs were. When we got there, we were there specifically to provide mission support to Charlie Company, which means we’re a medical company. We also supported any soldiers in the Kandahar region. There were lots of differences compared to the first deployment. I coordinated with all the Kandahar leaders about my role. I was also a part of the Navy because there was a joint Navy hospital there, and I was tasked with helping in the hospital. So, my brigade also coordinated with the Kandahar leaders. I was trusted and given a lot of leeway to be a behavioral health care provider.

The stories within the subtheme, I loved it! Freedom to make it my own, illustrate how the deployment enhanced some participants’ professional relationships. It also highlights how the deployment provided a space where some participants experienced growth in self-confidence.

Prior to deployment, several participants were not supported in their professional roles outside of the military. The deployment was an experience in which professional relationships were affected positively as compared to pre-deployment. The subsequent section will illuminate how

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some participants had trouble adjusting to the deployment because of relational roles outside of the military.

One Boot in Deployment and One Back Home The subtheme of one boot in deployment and one back home highlights how several participants in this study struggled to let go of the roles and responsibilities back home during their deployment. Their stories illustrate the effect deployment had on certain relationships because of the dichotomy between managing the deployed mission and family roles. On the other hand, some participants described the need to maintain their family relationships during their deployment so that they could survive the experience.

Nikki provides the reader with a rich account of conflicting role dynamics between herself and her spouse. She emphasized the initial difficulty of relinquishing her role as the “decision-maker” within her family. In the following account, Nikki outlines how their family was nontraditional and how their marital relationship was seemingly strained because she did not surrender her role as decision-maker during the deployment.

So, I felt a little bit of guilt about that. I knew he was working hard, and I knew he wasn’t complaining. He’d say, “You know, such and such broke down or this needs to happen.”

And, of course, I’d be like, “Have you done this? Have you done that?” “Well, yeah, I’ve done all this and that.” I would still say, “What do you need?” He’s like, “I’m just telling you. You don’t have to fix it for me.” I think a lot of the ideas and a lot of the decisions fell on me. We were a nontraditional family. I’m the primary breadwinner, and so he did a lot of the execution of tasks, but the decisions were often made through me. He’d have an idea and run it by me, which I think is great. Or he wouldn’t know what to do, and so I would make that call. And so, I was used to that, and I was still doing that over Skype. He

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kind of got used to the idea of, “She’s not here. I’m going to do it,” and so he would do it.

And it was a little bit like, “No, I already did it. I’m just telling you.” So, that happened during my deployment.

Puzzles described her needing to maintain communication with her parents because of the chaotic working relationships she experienced with her peers during her first deployment.

Puzzles appeared to need to retain a foot hold in communicating with her family in order to survive the chaos caused by her commander and peers during the deployment. Although it seems her family could not give her direct answers in dealing with an ongoing professional conflict, they appeared to have provided a scaffolding, a space, to contain her emotions and distress over what she was experiencing with leadership and her peers.

Yes. I communicated with my family a lot on the first deployment, probably more so than the second. I was just venting to them about how awful my commander was and the problems that were being caused, and I had no one to talk to. My family was very supportive in trying to help, but my dad was in a different era. I mean, he didn’t understand half the stuff that I was going through in this. I couldn’t get much from him other than his support, but he just didn’t know what to say about a lot of it. And he would be like, “Well, your rank outranks these people. You need to be tough. You need to put this person in place.” And then, I’m like, “Dad, you’re old school. That’s not how it goes.” He’s like, “Okay, whatever. Use your rank.” I would say, “I don’t know how to use my rank. I’ve never been in a power position like this.” And he would try to tell me about what that was like for him as a sergeant. It was tough for my mom to deal with, and she knew nothing. She knew less than him about what this was like. She would just try to say, “I hear that you’re lonely, and I want you to feel better. And I want you to get help if you

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need it.” And what does that look like? They couldn’t really help with the conflict, but I always felt better after talking with them.

Poppy shared the stressors associated with having to talk with her spouse multiple times per day during her deployment. She described the difficulty she faced in immersing herself in the deployment and how his need to speak incessantly during and after working hours put a strain on their marital relationship. . It is essential to note that when service members deploy, it is critical for their mental health to establish a deployed life that minimizes pressures from back home.

Oh, my God. I’m not even kidding. When I said that we talked at least four or five times a day, and if I was off, it was expected that I would talk to him six or seven times a day. I hated it. I hated it. It was awful, you know? And if I didn’t answer, oh, my God, he would say, where were you, and what were you doing? I would respond with, “I went to eat. I pretty much hung out around the room for the most part.” Every now and then, I would go up and see Sabrina up at Spangdahlem, but that was like just a couple of times, you know. I didn’t want to talk with him anymore. It affected us.

The subtheme of one boot in the deployment and one back home illustrates diverging data that emerged from the participants’ lived experiences. One participant claimed that maintaining contact with family was crucial to her completing the deployment. Another participant’s difficulty in letting go of family roles during the deployment placed strain on relationships back home. Finally, some participants reported not being given the space to experience the deployment without relational pressure from back home, thus resulting in a strain on nonmilitary relationships.

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The superordinate theme of the interconnection among self, relationships, and deployment highlights the effect the deployed experience had on the participants’ self-esteem and sense of belongingness in this study. It is vital to note that some participant voices were not captured in all subthemes due to the varying status of participant relationships at the time of their deployment. However, the experience of belonging in turn enabled several participants to develop deeper relational bonds with peers and the confidence to connect with the population they were serving. The lack of defined roles down range provided participants with the freedom to be creative in how they delivered mental health care services to various populations. However, additional data arose emphasizing the influence personal relationships and roles had on the deployed experience for some participants. The nonmilitary roles and expectations made transitioning into their deployed role difficult for some members. The final superordinate theme emphasizes the effect of the deployed experience on participants’ relationships after reintegration.

Theme 3: Dear Relationships The last superordinate theme, dear relationships, emerged from the data pertaining to the study participants’ lived experiences. Participants had varying relationship statuses during their deployment; therefore, not all are represented in this final theme.

This major theme highlights the effect deployment had on various participant relationships after reintegration. It is critical to note that the influence was both positive and negative in nature. Most participants described an implicit pressure from the military that emphasized service before self. Service before self was understood to mean that the military comes first above all other relationships. The subthemes under dear relationships are as follows: service before self and family: coming back it felt like too much; mommy & me; bidirectional

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empathy after deployment: it changed me; and courage to make changes in relationships. This superordinate theme provides significant insight toward answering how the deployed environment influenced the relationships of participants during and after reintegration.

Service Before Self and Family: Coming Back It Felt Like Too Much The first subtheme, service before self and family: coming back it felt like too much, encompasses the implicit pressure participants felt toprioritize military service above everything else in life. Furthermore, this theme illustrates how the management of family roles and expectations became overwhelming for many participants upon returning from deployment. This implicit pressure appears to be a factor in many participants feeling overwhelmed with life roles after deployment.

Several participants spoke about the implicit military expectation of needing to make the job their number one priority. This seems to have influenced the amount of time dedicated to their personal lives. Furthermore, many appeared to have experienced a great sense of being overwhelmed and disconnected with zero mental health care support once they returned from deployment.

Samantha shared how she managed multiple roles before deployment and how she felt disconnected in her relationships after reintegration. Samantha became frustrated over the lack of emotional support for mental health care providers upon reintegration.

I mean, you do everything. The job must be everything; you’re supposed to be on point all the time. You’re supposed to have all your crap together because you’re there caring for people. And I will say that the staff I worked with knew we weren’t perfect people, and I didn’t ever feel any issues with my staff. As an officer, also, you’re taking care of your team, and you must just suck it up.

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And then, the other thing is that I had to get my work done. So, that’s why I’m kind of thinking back to this, and I remember, at the end of the day, when I could start my admin work. Everyone else was gone, and it would be just me there. Because, during the day, I had to focus on being a provider, program manager, and an officer. I was in charge, and so I didn’t have time to do my notes, and my EPR, and all that stuff. And you learn to function at this level of heightened speed. We were groomed by the military to function at this heightened level, you know? So, it becomes your normal; you don’t know how to just let it all go, you know what I mean? I guess that speed prepares you for the deployment.

And with parenting, the other hard thing is that, and maybe this is what you’re getting at, I would like to think I’m a nurturing person, but I’m not as nurturing as I wish I could be. And in the military, you must have your bearing, and you must have this statuesque kind of thing. And so, then at home, I’m not the most nurturing. I don’t elude it. I’m not a hugger, okay? I mean, I hug my kids like crazy, but if I was to see you, I would be like, “Oh, hi,” you know, and not necessarily hug. So, it was a hard balance of this rigid thing to then be nurturing, and it was always a hard transition. It was even harder after the deployment.

Samantha also faced the requirement of being both mother and father to her children because, at the time of her deployment, her spouse was suffering from mental health issues.

Well, I feel like I was the one who had to figure everything out. So, I was the money, you know; I paid for everything. I had to figure it out. I had to problem-solve everything. I was a mom but also had to be everything to everybody. I’m not even close to being a domestic person, but if the house was messy, I’d figure it out. I had to because I was the

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functioning adult in my family. I had two kids with special needs, and I just had to figure it out. This juggling between work and family started before the deployment. I just got worse after the deployment. My ex unraveled when I got back, and I could barely manage it all.

Samantha was asked about how her deployment affected her ability to function in relationships at work and at home. She emphasized that her marriage significantly deteriorated because of her spouse’s mental health, and she appeared to be overwhelmed with life after deployment. Samantha seems to have felt isolated because of reintegration stressors and the lack of support from others after deployment.

We did Skype some, but I stayed very disconnected while deployed. Some of it was that I just was focused on the deployment. Well, with my husband, when I was gone, I just remember feeling freedom from it all when I was deployed. And then, coming back, I saw how dysfunctional he had been when I was gone. It was a struggle to manage work, my spouse’s mental health, and my children’s needs.

I was really struggling with my marriage, and I was struggling with a lot of different things. So, I started asking other social workers and other providers, “Wow. Did you go through this?” You know? And everyone was like, “Yeah,” but no one would talk about it. And so, shortly after I came home—I want to say, 2 months—we had a big mental health conference. So, I went there, and I started asking people, “Why aren’t we talking about this?” And everyone acknowledged that it was so normal, and they acknowledged the stress of the hard transition and that we don’t have anybody to talk to.

It was like I shouldn’t have had those issues and needed to figure it out on my own. I was

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expected to be a great officer and behavioral health care provider. Struggling with family issues was taboo.

Nikki also described in her account the experience of feeling besieged with transitioning back to multiple roles within her family. Nikki had come home wanting to focus on readjusting to her garrison position, which seemed to have affected her relationship with her spouse.

The deployment was tricky because, you know, my husband was kind of like, “Oh, good.

She’s home,” you know, relieved, and “She can start taking on some of these things.” My mindset had gotten into the, “Well, I’m trying to reintegrate into the job. I’m really behind.” You know, “Hang on just a little bit longer.” And so, there was a little friction in terms of, “You’re home now. Be home,” and my mind was still in that go mode of the mission, where I wanted to jump right back into my garrison mission, and leave things offloaded at home. So, I had a little adjustment of my own to make.

Smiley spoke about the implicit pressure of making the Air Force her first priority in life.

Balancing the expectations of the Air Force and those of a single mother seemed to have been a constant struggle for her. Smiley appeared to recognize the importance of establishing a personal life outside of her service in the Air Force.

So unspoken . . . It felt like, from certain aspects, that people expected you to be there, that there were no real clinic hours, and that you were supposed to be there—however long it took to get X, Y, and Z done. And, above everything else, you strive for that next rank. But, anyhow, I think with that kind of expectation, you’re 24/7; you jump off, and you have no life outside the military. It’s kind of unspoken, and it can take up the bulk of your life, but you can’t let it consume you. Because you do have to have a life after, outside of the military, because, when it’s time to let go of the military, what do you

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have? So, I think that really stood out for me. You felt the pressure, but it was important to me that I maintained that balance.

Cindy’s story provides a unique perspective on the subtheme, service before self and family: coming back it felt like too much. Cindy was dual military and deployed with her spouse.

This appeared to have created conflict in both her personal and professional relationships during and after deployment. Moreover, Cindy’s experience mirrors that of other participants regarding the implicit expectation to make the needs of the military her first priority. Like Samantha, she believes that the military was not an environment in which she was allowed to have her own issues.

The other thing is you devote your life to this. They don’t give a crap. If you got called and they said, “Uh, there’s a suicide; we need you to come down to do this debrief,” or “Ah, there’s this thing we need support on; do it now, come on,” you’re like . . . all right!

There’s no day off. You respond for anything and anyone, which I did many, many times.

Your issues come last; you’re not even supposed to have issues.

Cindy was asked questions on how the deployment affected her personal and professional relationships after reintegration. She described how her relationship with her command and spouse became intertwined during the deployment, which affected her professional relationships during and after reintegration. Cindy often relied on her spouse’s intervention when experiencing conflict with her command.

It wasn’t until right before we left for deployment that there was this big system crash. I was like, “Fuck it! I can’t go back to work. I’ll just be sitting there.” I made the mistake of not calling my leaders and saying, “Hey, this is the situation, and I’m about to leave work.” I just didn’t say anything, and then it created a rift. And the first sergeant

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called me out inappropriately, cussed me out, and all that stuff. I was brought to tears. I’m getting ready to spend a year with these people down range, and this is what I have to look forward to.

So, of course, I went to the husband who knew my first sergeant from a prior deployment. He goes to talk to him, and I’m thinking, “Okay, it’s going to be resolved as a misunderstanding, and it didn’t.” It just got worse. And then we were sitting with the commander, and I asked, “You let this first sergeant talk to a captain like this?” I’m like, “That’s disrespectful.” But, again, the dynamic of the relationship was, he didn’t care.

And so, it just ruined the relationship as we were leaving to deploy.

So, when we got to country, we were all butting heads. Leadership would say, “You’re going to go here.” I would say, “No I’m not; that’s not how this works.” Like, “Get out of my lane,” and it was this constant fighting. It was miserable. And so, when we got back, I was so mad, so jaded, that I just didn’t play nice anymore. I went rogue; I didn’t care.

Cindy’s spouse was a doctor in a combat unit. She spoke about the pressure of living up to his name, which was overwhelming and influenced their relationship.

You know, subtle waves of the 82nd . . . this pressure of, I had to be good; I had to be a good provider, because, if you’re shitty, then it’d be like, “What’s wrong with your fucking wife?” Why can’t she do this or that? So, it’s always this pressure of, I’m the wife of Captain D. Even though I was Captain D at the time, I just had to be good; I had to be the best wife and provider. I would spend extra hours trying to support his troops, even though I didn’t have to. This happened during and after the deployment. When we got back, we had little time for our relationship. It was all too much, and plus. I was

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getting out and needed to find a job. We didn’t prioritize each other. It contributed to us divorcing.

The subtheme of service before self and family: coming back it felt like too much, under the superordinate theme of dear relationships, ultimately illustrates the juxtaposition between the demand of the military to prioritize the job over all other roles, as well as the emotional flooding that occurred when participants reengaged in nonmilitary roles after deployment. The demands of the military, coupled with the separation during the deployment, appears to have caused some participants to experience relational disconnect post reintegration. The next subtheme centers on the maternal–child relationship among those participants who had children. It highlights the impact the deployment had on these relationships’ pre-deployment and post reintegration.

Mommy & Me Several participants faced the challenge of preparing their children for a separation lasting up to 6 months, as well as determining how to reintegrate as a parent figure after deployment. The parental relationship is critical to the intrapsychic development of all children.

Serving one’s country is like no other experience because service members are confronted with a mandatory separation from their children. The possibility that they might never come back is part of that separation. Historically, society holds the maternal relationship to a different standard compared to other early developmental relationships. The subtheme of mommy & me centers on the parent–child preparatory phase and the effect the deployment had on the maternal relationship upon returning home.

Samantha shared her experience of preparing her children for the deployment. She disclosed that she engaged in family-readiness activities with her children prior to deploying.

However, she emphasized that she should have done more to support her children’s needs, such 124

as communicating with their teachers about her deployment. She stressed that preparation for female service members is more complex and should be handled by the military differently compared to males.

Now, for the kids, we did some of the family-readiness activities, like the deployment line. The kids can go through it and experience the deployment. So, they would feel pride. I did some of those activities and read the little books to them. Oh, and they got a flat mommy. So, it was a huge life-size cutout of me in uniform. And they ended up taking that everywhere and deciding who would get to sleep with flat mommy, that kind of thing. So, they did have all of that.

In hindsight, I could have done a little better, especially with the kids. I could have had conversations with their teachers, but, you know, as a female, nobody prepares all of us the same way. I just don’t think it’s set up the same way, to deploy, you know. As a mom, it was hard to leave my children, and I feel like they could have done more to prepare me for the separation.

I skyped most nights with my kids and spouse for a little bit, but other than that, I stayed disconnected. If it didn’t, I think I would have had a hard time making it through the deployment.

Samantha also alluded to the effect the separation had on her eldest son when she returned home. Prior to the deployment, Samantha was managing her role as an officer and behavioral health care provider, on top of being both mom and dad to her sons. Her spouse struggled with his own mental health issues, which forced her to balance multiple roles. During her interview, it seemed difficult for Samantha to think about how her spouse treated her eldest son. However, she emphasized how much he needed her when she returned home, but she

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struggled to remember this part because she had returned home in what appears to be a hypervigilant state.

I just know my oldest . . . my mom thinks that my ex did not handle him well while I was deployed, but I don’t know. So, my brain just doesn’t go there; I don’t really know. I don’t know. I know it probably didn’t go well. He doesn’t know how to handle him.

I don’t necessarily think my ex was physically abusive or anything. I just don’t think he knew how to handle him because he was a hard kid. When I came home, I realized leaving was very hard for him. When I came home, he was probably a little clingier, if anything; he wanted to be around me. I was so busy at work; I don’t even remember all the details. I have blank spots of memories because of being in that hyperarousal state.

When exploring the impact the deployment had on the parent-child relationship Nikki emphasized how the only relationship she wanted upon her return was the maternal closeness she had with her son prior to the deployment. However, she remembered feeling frustrated because her son only wanted his father.

When asked about her relationship with her son prior to the deployment, she described feeling close and connected to him.

It was good. He was a little nugget, and, you know, kind of the typical things. I hate saying that you baby talk your 3- and 4-year-old, but you kind of do. And, you know, “Come here, and I’m going to pick you up and swing you around like an airplane,” and, you know, it was just good . . . just close.

Nikki was also asked how she prepared her son for the separation, as well as how she maintained a connection with him during the deployment.

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And he really didn’t understand. We sort of had the conversation, “Mommy’s going away.

It’s a really important thing mommy’s doing.” I think we made a jar of jellybeans and counted out 6 months’ worth of beans. I can’t do the math in my head right now, but it is 180 jellybeans. “And every night, you eat one and mommy’s coming home. And when you’re done, I will be home.” You know, we also downloaded Skype. Skype was the big thing then, and I got a new laptop. I didn’t know what to expect, but we sort of figured if we had Skype, we’d be okay. We skyped.

During the deployment, Nikki spoke to her husband and attempted to talk with her son via Skype every day. She emphasized how her son really did not understand what was going on.

I talked to him every day, usually in the morning. I tried to talk to my son, but it was Skype, so he just liked to look at his face and then run around. It was good. They were very supportive.

When Nikki returned home, she highlighted a deep need to connect and be with her son, but she remembered feeling upset because he only wanted his father.

So, with my son, of course, I wanted to snuggle and all that sort of thing, and he was indifferent to me, you know. Dad was everything. Dad had been doing everything, and he just wanted to be with dad. And he’d run up and shout out like, “Look, Dad,” this and that. And I would be thinking, “I’m right here. I miss you. I want to see it, too,” which still kind of happens to this day, as a matter of fact. Like, “Hey, Mom’s still here.” But he was pretty indifferent to me, and it was a little hurtful because I felt like, to my son, I was invisible. And he was probably the one person that I wanted most. Everything else was irritating to me. I’m not proud, but everything else was irritating to me. But my son, I wanted him close, and he wanted nothing to do with me. So, that was hurtful.

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When asked if her exposure to secondary traumatic stress during the deployment affected any relationships post deployment, she seemed to identify a need to feel closer with her son because of what she experienced down range.

I think the thing with my son . . . So, I mentioned that some of the things I heard involved kids. And I mentioned that my mission was supporting the convoy drivers. And there was a tactic of using kids as roadblocks. And there were a few stories where young people had to make pretty horrible decisions. And, you know, they had kids of their own. And I had a kid of my own in kindergarten, you know. So, you hear those stories, and you say, “Okay, don’t put yourself in there. Don’t put yourself in the kid’s shoes and the parents’ shoes.

Don’t put yourself in your patient’s shoes,” because they had to make a call. But then, you can’t help it. And so, all I wanted to do was just snuggle up with my kid when I got home, and he didn’t want to. So, I think there’s a little thread there.

Smiley was a single mother at the time of her deployment and was asked how she prepared her son for deployment, as well as if she noticed any changes in their relationship after reintegration. At the time of Smiley’s deployment, the Air Force was on a 4-month deployment cycle. Since her deployment was during her son’s summer vacation, she noted that he did not feel her absence as much as he would have if she deployed during the school year. He had spent the summer with his father seeing family. When she returned from deployment, she stressed that their relationship was the same as prior to her deployment. Smiley appeared to have a smooth reintegration with her son, in part because of her preparation and the timing of her deployment.

I have a sister who’s pretty mobile, right? No kids, whatever. So, she can move around and enjoy the different places that I went to, because she got to come [laughs]. So, I had it set up that two of my sisters had to split the power of attorney for medical in case they 128

needed it. And then one sister came down and allowed my son to finish school there. He was out at the very beginning of June.

So, I asked my son . . . what did I tell him? I think I told him that, as part of my job—as a member of the military—I still help people, and some of those people might be fighting for our country. So, I might have to go where they are instead of them coming where we are. But it will be just for a couple of months. Luckily it was over summer vacation, really. It was over summer break, mainly. So, it wasn’t bad because his dad is in Illinois and has always been in Illinois. So, that gave them a lot more time together, considering that we had just moved [laughs] a year ago. Right? So, that part was good.

He had spent time with his cousins, my nephews and nieces, and everything else—people who he didn’t see as regularly—because we were in Texas at the time.

In the subtheme of mommy & me, the reader is privy to deployment’s potential effect on mother–child relationships. In Samantha’s experience, she expressed a sense of guilt over leaving her children with her spouse and about how her eldest son was affected by the separation. The environment appeared to be one in which her eldest son struggled to thrive in her absence. On the other hand, Nikki was not expecting her son to need a transitional adjustment period after returning from deployment. She appeared to be emotionally disconnected after her deployment and had to adjust to her son’s acclimation to their restored maternal relationship. Smiley did not experience any impactful changes in her relationship with her son due to the timing of her deployment. Her deployment was only 4 months compared to a 6-month cycle, and she utilized their separation as a vacation for her son and his father. The next subtheme is entitled bidirectional empathy post deployment: it changed me, and it illustrates the apparent effect of deployment on empathic attunement in the relationships of some participants after deployment.

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Bidirectional Empathy Post-deployment: It Changed Me Several participants in the study shared stories that reflected a shift in their capacity for empathy with others after deployment. One subtheme, bidirectional empathy post deployment: it changed me, highlights the transformation in some participants’ ability to connect and empathize on an interpersonal level after reintegration. This shift in empathy was bidirectional and based on the participants’ experiences. In this study, bidirectional empathy delineates a growth and decline in one’s ability to feel and emote empathy. This change in empathy appears to have influenced participant relationships, to include the personal, professional, and relational connections among the patient and provider. Moreover, the emergence of secondary traumatic stress became visible in some participants.

In her story, Poppy described feeling intolerant towards certain patient populations after returning from her deployment. She spoke about a process of hardening that occurred after her deployment that appears to be a result of secondary traumatic stress. Furthermore, she recalled feeling disconnected in her marriage on a deeper level after deployment. It is crucial to note that, during her deployment, her spouse expected her to communicate several times per day, which seems to have impacted her ability to focus on the deployed mission.

I think the hardest part of my deployment was when you were going on the plane and you were getting people off who were burnt, and they were in ICU, you know, they had all the tubes and stuff hooked up to them. They didn’t have their arms or their legs, you know.

Taking them off the plane and putting them on the bus and moving them, I mean, you did see a lot of that. I can say that, like I said, I kind of hardened myself to all of that.

You know, you’re coming back and you’re back to managing a clinic and seeing patients that got in trouble for alcohol, right? They were doing something stupid. It

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wasn’t the same in-depthness as what I was doing during the deployment. So, it was just kind of menial, and shortly after that, I had my orders to go back to Korea. So yeah, like, at Keesler, after the fact, it was just kind of, like, “Why are you all complaining?”

[Chuckles] “No, you’re not burned. You have your legs. You haven’t died,” kind of thing.

Like, seriously, stop whining. It was hard to maintain a relationship with my patients in ADAPT back in garrison after doing the type of mission I did while deployed. I did not have much tolerance.

When prompted to describe this hardening process, Poppy verbalized how she worked hard to not let the exposure impact her on an emotional level. She described it as a process of turning off her ability to feel and empathize. This seems to have been a coping mechanism to combat exposure to secondary traumatic stress.

It’s like I turn off my thoughts about what I was seeing. I don’t really think about it, right? I know that this is a job that I need to do, and so I really try not to put myself in that personal situation where I’m going to empathize or sympathize with them. I try not to do all that.

In terms of her relationship with her spouse, Poppy had grown more distant with him during the deployment and appeared to no longer be able to empathize with his needs in the marriage.

I was back to doing my same old routine when I got back. You know, I think pretty much after I came back from Korea the first time, my ex-husband and I kind of drifted apart, to begin with, and so I feel like I got more aggravated with him when I came back from my deployment to Germany, just for the fact that he always wanted to talk. He always wanted to, and I never got my space while I was gone. It really impacted me. Because I worked

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nights, you know? So even during the day, when I tried to sleep, he would try to be calling me, and I’m, like, I’m just trying to get sleep before I go to work.

Samantha seems to have experienced a decline in her capacity to empathize in various situations and relationships after deployment. She disclosed that, in her current civilian position as a behavioral health care provider for the Air National Guard, she discusses with her members the effect deployment has on one’s ability to empathize after reintegration and how it can negatively impact relationships.

So, I actually talked about this a lot in what I do now. I mean, I do the same thing now, and during trainings I explain to people what can happen when I talk about empathy. So, when I came back, I had two weeks of R & R, I had such a disconnect. I was very, very much stuck in the middle of “I don’t belong at home” and “I don’t belong in the deployed environment.” And I had made some really deep connections in the deployed environment, and they were all gone because you don’t have them anymore. So, I don’t even know how to categorize it.

Now, a senior NCO had told me it takes about six months to adjust. So, I did know that what I was feeling wasn’t abnormal, but it was just so weird, and I was thrown right back into patient care thinking, “What’s the big deal? It shouldn’t be a problem.”

But I remember one of my first people. I had no empathy. I just kind of was, like, “Really? This is what you’re upset about?” That is not me. And so, I could sense—and even in hindsight, I should not have just gone back to patient care.

Samantha noted one secondary traumatic stress experience during the deployment that affected her empathy and shifted her view of the world.

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We had the embassy there, and so I would go to the embassy on Wednesdays and see anybody who needed to talk, even though they weren’t really our population, but it was like a partnership. And I remember when I first went, there was a family from the United States. I look back and I’m, like, “They shouldn’t have had me do this.” But, you know, when you’re in the military, you just do what you’re told. And this is a little sidetracking, but, I mean, I’ve had my chief doc, our SGH, say, “Oh, no. You will see that person even though they shouldn’t be seeing you anymore.” Like, “No, you must provide this care.”

So, you just kind of do it.

So anyways, there was a family that was terrorized. I got there in January. So, they were terrorized over Christmas by a group of people, where it was a husband, wife, and children. And so, they witness this trauma, being terrorized in their home. So, they had me just come in, and I will tell you, I didn’t know what I was doing, but I just kind of winged it and they had me meet with the kids. These kids were five years old. So, the only thing I tried to do is help the one boy not be scared when he turned the light off. I don’t know what I’m doing here, you know what I mean? This is not structured, and so, again, I was doing it because my med group commander told the wing commander that we can offer this.

I think, when I first got back, I had some loss of empathy. I remember my ex was trying really hard, and he left me a card on the car—my car, about how much he loved me. And I was, like, “This was stupid,” and I just think I lost some empathy. It took me a while. I think I lost some empathy and lost some perspective, and it was almost, like, “You’re worried about your fish dying? Really?”

I just came back from a place where blah-blah-blah—where a family got

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terrorized over Christmas, you know what I mean? So, I think that my perspective was a little off. It took me a little while. Again, I don’t think that our career field prepares us for this. I think that that’s a foul, because how can you expect me to go back into patient care two weeks later, and, well, that’s the expectation.

Samantha seems to have reported a shift in her worldview because of STS in the deployment but mentioned using humor as way to cope with this change. Using humor appears to have been a defense mechanism to cope with secondary traumatic stress and ward off further development of vicarious trauma. Vicarious trauma by nature denotes a significant decline in one’s ability to empathize (Leung, Schmidt, & Mushquash, 2022) Yeah. I mean, I think that my worldview shifted more after deployment. But I think that when I get to a point—it’s like a cycle. When I get closer to my burnout point is when my view of the world gets a little more cynical and my view of human suffering gets a little more cynical. My humor gets darker, and then I got to check myself, do what I need to do, and then, when I get further away from that burnout, then I’m better.

It just comes as a cycle, but I think that co-workers and I would make funny memes about suicide as part of that humor. We had this dark humor and joked in a way that, if outsiders saw it, you know, it was sarcastic and it was funny, but it was not something that non-mental health providers should joke about, you know? So, it was just a coping skill, the dark humor.

Nikki described a similar loss of empathy and patience for others upon returning from deployment. This apparent decline in empathy affected her relationship with her spouse.

I’m not the proudest of how things went. But much like the irritants of the computer training and stuff when I came back to the mission, coming back home, you know, I got

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irritated by a lot of it. It just felt like it was so much work because I had gotten used to someone else’s cooking and cleaning and all that sort of thing. And so, trying to do all of that and then trying to do stuff at home, it felt like too much. And I got irritated with my husband, like, “Why can’t you do this? You’ve been doing this.” Like, “Why can’t you keep doing this?” And he was kind of saying, “I need a break.” So, in the beginning, the reintegration was a bit rocky with my husband. The first few days were great, and we took a Disney World vacation, very stereotypical. But when it came to reintegrating into the flow of our lives, I was a little out of joint because I wasn’t used to it anymore. And it all seemed small to me compared to what I am doing in Kuwait. I couldn’t empathize with challenges my husband faced when I got back. It affected our relationship in the beginning.

However, Gina and Smiley expressed a growth in their ability to empathize as result of their experiences with secondary traumatic stress in their deployments. This increase in empathy for others may have positively affected how they functioned in their relationships.

In Gina’s story, she described an experience with a trauma incident on base that initially affected her because of how the military handled the event.

There was one that maybe it had primary and secondary trauma kind of stuff, I guess.

And I don’t even know how to describe it because I observed the situation happen. There was a contractor who came on the base to bring fuel, and he caught on fire. And they were running to him, I saw him run by, and then they were trying to get him put out. So, this is a local national, and they were trying to get him care. And so, you see all the medics were trying to save this guy’s life. He was known, he wasn’t a threat, he had a family and all these kinds of things, right? And so, the way that situation was handled,

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outside of the visual traumatic kind of thing, angered a lot of people on that FOB because there were questions about who’s going to take care of this person. They wouldn’t send him to Bagram to take care of him. They were trying to get him to the Afghan hospital, which didn’t really have the resources to care for those kinds of burns that he got.

When asked if exposure to secondary traumatic stress or the development of vicarious trauma affected her relationships after reintegration, Gina emphasized having more compassion for those suffering.

Right, yeah. I think maybe just appreciation, more appreciation for just the struggles that people go through, and that people do things for reasons, like, how they deal with it and how they make their choices and decisions, that nothing is black and white. It’s usually very complicated, and how people live and make their choices, sometimes you have two bad choices to make, and they have to pick which one is the least bad, you know. I just kind of have more compassion for that. I had more compassion in all my relationships.

Smiley described having more “grace” for people in her life after returning home from deployment. She emphasized feeling less judgmental when the people close to her made poor decisions or mistakes. This appears to have played out in her role as a family mentor.

Okay. So, role, I’m a sister, a daughter, a mom first and foremost. I think just maybe there was a role expectation of mentoring someone in my family, right, about their choices or whatever else.

I think maybe having more grace. Maybe I was right, I was thinking deployment doesn’t have to be negative. So that’s exactly what I was thinking, I think maybe having more grace for other people in their slip-ups, like, not as quick to have a Jedi-type personality. So, I don’t even know how to put this. Not as quick to make an assumption

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about why something happened, why an action occurred. Maybe that’s what it is.

Knowing that and definitely seeing that you never know what anyone is going through unless they 100% flat-out tell you. So, their decision or their actions may seem really shitty at whatever time, but I really don’t know what was behind their decision, right?

What was driving it, what were your true motivations for doing that? And so, I think being more aware of that, just based off the things that I was seeing in deployment. I think that was helpful in terms of my relationships post-deployment.

The subtheme labeled bidirectional empathy: it changed me under the superordinate theme of dear relationships demonstrates the converging and diverging data on the effect deployment had on participants’ ability to empathize in their relationships. Some participants noticed a shift in their ability to empathize in their relationships, while others discovered a growth in empathy for others because of their exposure to secondary traumatic stress during deployment. The commonality among all participants was that they experienced a change in themselves which affected how they functioned in their relationships. The final subtheme under the superordinate theme of dear relationships is the courage to make changes in relationships.

The deployment appears to have been an influential factor in several participants’ decision to make changes in certain relationships after reintegration.

The Courage to Make Changes in Relationships This subtheme draws a connection between the deployed experience and the decision of some of the participants in this study to make changes in certain relationships. It is important to note that several participants seemed to have viewed the changes they made in their personal and professional relationships as positive in nature. The data that emerged in this subtheme was both convergent and divergent in regard to the changes they made in their relationships after 137

deployment. Several participants described feeling confident in their ability to be independent, which seems to have prompted them to end unhealthy relationships, whereas one participant sought to improve her family relationships because of how her lack of empathy after deployment affected those interactions.

Cindy described in her interview that the deployment was an experience that seemed to drive a deeper wedge into her marital relationship. She experienced ongoing conflict with her leadership during the deployment and became dependent on her spouse to resolve that conflict.

The deployment also may have been a factor in her separating from the Army and the catalyst for her eventually divorcing her spouse.

So, when we came back to Plymouth, like I said, my time was, like, very short-lived. I was getting out in three months, so it’s, like, I was focused on prepping to get out. And usually, a lot of people are kind of, like, “I’m fine, I’m fine and, like, I’m home.” He continued to stay on active duty.

I wasn’t happy in the Army or in my marriage. The trust was gone. I know that, when I would confide in my husband at the time, I was definitely more jaded. And it’s, like, if I needed some empathic support, I couldn’t get it from him. He would be, like, “Oh, well, you know, I dealt with five legs being blown off, why are you complaining about it?” Right, I was, like, “Okay, it’s alright, I’m fine.” We were disconnected. It eventually helped me to recognize we were not good for one another.

Samantha shared in her account how she felt free during the deployment and came back eventually wanting a divorce. She was not able to obtain the divorce right away, but she ultimately ended her marriage. Samantha appeared to have realized while deployed that she was happier, and upon her return that happiness began to decline because of her spouse’s mental

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health. The deployed experience may have functioned as an experience in which Samantha grew in self-confidence and was able to find the courage to end an unhealthy relationship.

Well, yeah. I mean, with my husband—because, when I was gone, I just remember feeling, like, freedom when I was deployed. Coming back and seeing how dysfunctional he had been when I was gone, I came home wanting a divorce.

We did marital counseling and stuff like that until our PCS. I think I just felt like I didn’t have to stay married, like I didn’t want it anymore. And when I was deployed, it wasn’t—I was just happier, you know? I felt freer and happier and came home to, again, the chaos and the dysfunction and was, like, “This is not what I want,” you know?

When I confronted my ex about it, he had just kept so many secrets. He had a PTSD history that I never knew about. And, I mean, we got married. I mean, we had been married for a long time, but—just stuff that I had never known about, he had some suicide attempt, you know, stuff like that.

And so, as a mental health care provider, feeling, like, now I’m dealing with my mental health in my own home. I mean, one time he tried to hang himself, and I didn’t know what to do because if I take him to the local ER where they all know me—oh my God. I would have been like a deer in headlights. And so, there were his mental health coming out, you would think I’d have more empathy and understanding, but I didn’t. I was more, like, “You got to figure this out. I can’t do this, I can’t.” And he started seeing a counselor and trying, but his mental health caused so many problems in the relationship and in the home and then how he handled it, probably, too.

Again, I’m not the innocent party here, but I just couldn’t do it, you know? I couldn’t deal with mental health at work, and I can’t be a counselor at home. And so, our

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relationship just deteriorated. I’m a loyal person, but I didn’t want to be married. We eventually divorced, and with the freedom I had on the deployment, I knew I could be happy single.

Poppy described how her encounters with secondary traumatic stress during deployment helped her to not focus on trivial aspects of her life. She shared that her marital relationship became more strained during the deployment because her spouse seemed to be preventing her from fully embracing the deployment. When Poppy returned from deployment, she came to the realization that she did not need to stay in an unhappy marriage.

On what I witnessed during the deployment, as far as that goes, I think I adjusted my bullshit level in that it increased a little bit, right? The trivial stuff just didn’t bother me as much anymore, like the stuff that I was going through with my ex-husband; it wasn’t as important anymore. It’s kind of helped me make that decision, like, why am I still with him and why am I still married? We divorced, and I left for my second tour in Korea as a single woman.

Nikki was the outlier in this study regarding the courage to make changes in relationships. Nikki acknowledged in her account the struggle she had with family relationships after deployment and how it prompted her to work on those relationships.

I’d say we had a rough couple of months. I’d say two. There was a TDY that I went to around that point, and I think things changed after that. About two months after I came back, I got tagged for a TDY, and it was going to be about a week out of pocket. And my son just burst into tears when I went to the airport. I mean, he just burst into tears. And so, I thought, “Oh, he must have missed me,” you know. Maybe he thinks I’m leaving for a long time again. So, on that TDY, that break, I had a lot of downtime to sort of reflect

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on my life. And, like, “Hey, your son does miss you. You might have been a little hard on your husband. He’s held the ship down the whole time you’ve been gone without complaining, without pressuring you when you were off doing your grand war things.

He’s asking you to pick up dinner a few times. Like, you can do this.” So that TDY, that week break two months later, that was pretty significant in terms of changing things, turning things around for me and my relationship with my husband and son.

Dear relationships as a superordinate theme, along with the subthemes of service before self & family: coming back it felt like too much; mommy and me; bidirectional empathy post deployment: it changed me; and the courage to make changes in relationships demonstrate a potential connection between the deployed experience and the effect it had on individual participants and their relationships during and after reintegration. However, the effect was both positive and negative in nature. The military as an institution appears to have implicitly stressed to the participants in this study that active-duty service should be their top priority over their personal lives. Participants shared rich experiences illustrating similarities and differences in how the deployed experience affected them and their relationships. Several participants described being flooded by responsibilities in garrison and at home after deployment, which created an emotional disconnect in some of their relationships. Participants also expressed in their accounts a loss or a growth of empathic capacity, which seems to have affected how they functioned in their relationships. Finally, the deployed experience for several participants either gave them courage to end unhealthy relationships or was a catalyst for them working on themselves to save their relationships.

In conclusion, the superordinate themes and subthemes outlined in this chapter will be linked to study findings discussed in the subsequent chapter. Some participants in this study had

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more detailed experiences than others due to varying relationship statuses at the time of their deployment. It is vital to note that these themes and subthemes came to life because of emerging convergent and divergent data rooted in the accounts ofthe lived experiences of each participant in this study. Throughout the process of data analysis and development of study results, I actively journaled on the experience. IPA is rooted in hermeneutic phenomenology (Smith et. al, 2009) in that meaning making is constructed between researcher and participant. My active engagement with participants was crucial to meaning making and the emergence of study results. Smith et al.

(2009) wrote, “IPA involves a double hermeneutic. The researcher is making sense of the participant who is making sense of x. And this usefully illustrates the dual role of the researcher as both like and unlike the participant” (p. 35). However, I am a member of the population in this study. While journaling was crucial to bracketing my biases and own experiences, it was also a tool utilized to reflect on participant and researcher dynamics, which was fundamental to the emergence of study results.

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Chapter 5 Findings and Implications Introduction to Findings The primary focus of this chapter is to analyze the findings outlined in Chapter 4 of this study. Analysis is a process of deconstructing the findings to obtain a deeper meaning of the results. “You scrutinize what you have found in the hope of discovering what it means, or, more precisely, what meaning you can make of it” (Bloomberg & Volpe, 2019, p. 278). Throughout the analysis, I examined the implications while aiming to answer the main research questions and the research sub-questions of this study. This chapter is broken down into a brief review of research questions and themes, followed by a discussion of findings through a theoretical psychodynamic lens. Finally, there is a discussion on the limitations of this study and then a conclusion on future implications for search in social work practice.

Research Questions and Themes The aim of this study was to examine the lived deployment experience of female veteran GWOT mental health care providers and technicians. The main research question of this study is as follows: How might the deployed experience affect the relationships of female veteran GWOT mental health care providers and technicians during and after reintegration? The research sub questions are as follows: 1.

How might military role expectations in the deployed environment affect existing nonmilitary roles?

2. How might exposure to secondary traumatic stress or the development of vicarious trauma in the deployed environment affect relationships after reintegration?

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IPA was the methodology used to analyze the data and results for the purpose of formulating findings. This methodology is rooted in phenomenology and double hermeneutics. I was simultaneously engaged in making sense of what participants are sharing while describing their experiences. Moreover, the researcher couples with the participants by making meaning out of their lived experiences (Smith et al., 2009).

Theme 1: Stabilizing Function of the Military The stabilizing function of the military as an institution and a larger selfobject experience that provide a function for the self and the self in relation to others is the foundation of this theme. Selfobjest are entities that are experienced as part of oneself (Kohut, 1971). Furthermore, this theme is centered on the health of the participants’ relationships prior to joining the military.

The stability of self may play a factor in the health of one’s relationships. The subthemes are as follows: •

Security: I felt that I was going to get stability o Security for the self may result in stability for family and relationships.

•

What about family? o Exploration of family support for joining the military and deployment

Theme 2: The Interconnection Among Self, Relationships, and Deployment This theme centers on the effect the deployed experience had on the self and the relationships of participants. The subthemes are as follows: •

I loved it! Freedom to make it my own. o Growth in self and professional relationships

•

One boot in the deployment and one back home o Collision among military and non-military roles 144

Theme 3: Dear Relationships The final theme in this study illustrates the potential effect the deployed experience had on relationships after reintegration. However, imbedded deeper in this theme is the effect the deployed experience may have on the self, which in turn affected participants’ relationships. The subthemes are as follows: •

Service before self and family: Coming back, it felt like too much. o The military as the number one priority, feeling overwhelmed after deployment, and how that affected relationships.

•

Mommy and me o Mother–child deployment preparation and the effect the separation had on the maternal relationship.

•

Bidirectional empathy post deployment: It changed me. o A shift in empathic attunement occurring bidirectionally (growth and decline)

•

Courage to make changes in relationships. o A connection between the deployed experience and the decision to make changes in certain relationships.

Findings and Theoretical Lens IPA as a qualitative method of analysis involves an interpretive deductive process with phenomenological hermeneutics as its theoretical foundation. As stated earlier in this study, the researcher plays an active role in the meaning-making process. The data analysis yielded four findings that emerged from the lived experience of participants: 1. The first finding is that military and deployment are selfobject experiences that may contribute to a more cohesive sense of self. A paucity in early selfobject needs can lead to

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a deficit in an individual’s formation of self that may affect their ability to navigate interpersonal relationships. A correlation exists between the need for stability and early narcissistic injuries. This finding indirectly relates to the main research question: How might the deployed experience affect the relationships of female veteran mental health care provider and technicians during and after reintegration? Stability in one’s self is connected to a cohesive sense of self. The development of a cohesive sense of self is dependent on fulfillment of selfobject needs. This, in turn, has the potential to affect how individuals may function in their relationships.

2. Deployment as a positive adult selfobject experience that may result in relational changes is another finding in this study. Early selfobject experiences are crucial to the development of self. However, experiences in adulthood can serve as positive selfobjects that strengthen the self, thus resulting in a possible effect on relationships.

The deployment appears to have served as a positive selfobject experience for several participants, which may have been a factor that prompted them to make changes in some of their relationships. This finding directly relates to the main research question of this study.

3. An increase in empathic attunement and mis-attunement in relationships because of the deployed experience was an additional finding in this study. The capacity to empathize with others is fundamental to healthy interpersonal relationships. Empathy is defined through Geist’s (2009) definition. It is the capacity to think and feel our way into another’s subjective inner experience Conflict can occur in relationships when one or both individuals believe they are not being understood. This finding also relates to the main research question and the research sub-questions in this study.

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4. The final finding in this study is that deployment may cause a shift in a service member’s capacity for intersubjectivity within relationships. This study utilized Benjamin’s (1990) definition of intersubjectivity. Benjamin defines intersubjectivity as evolving out of one’s capacity to recognize another’s subjectivity. It is through this process that we are able to experience our own sense of self. Attunement in early life experiences is crucial to the development of one’s capacity for interpersonal intersubjectivity. This finding relates to both the main research question and the research sub-questions in this study.

The next section in this chapter will interconnect the findings and major themes of this study to psychodynamic theory.

Finding 1: The Military and Deployment as Selfobject Experiences that May Contribute to a Cohesive Sense of Self This finding suggests that joining the military and deploying in support of GWOT served as selfobject experiences that met the selfobject needs of several participants. The self as defined

by Kohut (1977) is a structure within the mind that has a psychic location. Kohut writes, A self (nuclear self) consists of a person’s nuclear ambitions and ideals in cooperation with certain groups of talents and skills. These inner attributes must be sufficiently strong and consolidated in order to be able to function as a more or less self-propelling, selfdirected, and self-sustaining unit which provides a central purpose to the personality and gives a sense of meaning to a person’s life. (p. 177) A selfobject is an object that is experienced as part of oneself. The formation of a cohesive self (Kohut, 1971) relies upon the responses a child receives from selfobjects in their environment.

“The experience of these self-sustaining responses are called selfobject experiences, because

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they emanate from objects, people, symbols, other experiences and they are necessary for the emergence, maintenance, and completion of my self” (Wolf, 1988, p. 14). It crucial to note that selfobject experiences are internalized on an intrapsychic level and are not observable from the outside. “Because the self-sustaining function of selfobject experiences is needed for life, and because the form of these experiences changes age-appropriately, we can talk about a developmental line of selfobject relations or, more precisely, of selfobject experiences” (Wolf, 1998, p. 53–54). Deployment is a subsystem imbedded in a larger, complex system comprised of individuals trained to function in a hierarchical society. Because the deployment is comprised of individuals who work and interact with one another, it can be conceptualized as a selfobject experience.

Kohut (1971) identified the self as bipolar in nature. One end of the pole consists of mirroring experiences, and the other end is comprised of idealizing experiences. Kohut and Wolf (1978) described an ongoing tension between these two poles and how they are balanced in equal strength. In self psychology, a cohesive self is maintained through selfobject needs that are attained through selfobject experiences. Within Kohut’s concept of the bipolar self exist mirroring and idealizing selfobject needs. Mirroring needs during a child’s development is the need to feel affirmed, special, and great which is attained through mirroring selfobjects. Whereas idealizing selfobject needs is the need to merge with a powerful selfobject that eludes stability and calmness. Additional selfobeject needs that are important to note in the maintenance of a cohesive self is twinship and efficacy selfobject needs. Twinship needs is the need to experience a sense of likeness with a selfobject (Wolf, 1988). On the other hand, efficacy selfobject needs “is the need to experience that one has an impact on the selfobject and is able to evoke needed selfobject experiences” (Wolf, 1998, p. 55). It is crucial to provide a discussion on basic self

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psychology concepts to frame how this finding emerged out of the superordinate theme the stabilizing function of the military and its subthemes security: I felt that I was going to get stability and what about family.

Joining the military appears to have been a stabilizing force for several participants in this study and may have served as a selfobject experience that fulfilled selfobject needs. The terms security and stability were repeatedly noted throughout the data. A cohesive sense of self may affect how an individual navigates their relationships. Moreover, “interpersonal relations between persons may give rise to selfobject experiences” (Wolf, 1988, p. 55) that fulfill selfobject needs. Samantha described in her story how her family was struggling financially and that she felt a strong pull to be the provider for her family. It can be inferred that Samantha may have met efficacy selfobject needs by joining the military. She shared that, due to her spouse’s mental health issues, he struggled to maintain employment. It can be understood that Samantha evoked a new selfobject experience to attain security and stability for her family, this new selfobject experience being joining the military. In her story, Poppy described a chaotic childhood in which her father suffered from alcohol addiction. She shared that she was not close to her father and remembers driving the car as child because he was too intoxicated. An interpretation can be made that joining the Air Force was a selfobject experience for Poppy that provided mirroring and idealizing selfobject needs. The Air Force afforded Poppy an experience to merge with an object that is powerful and stable. With this merger, perhaps Poppy viewed herself as special, with a new sense of purpose. In Puzzles’ account, she described being raised by a father who was Vietnam veteran. She emphasized how he had suffered with PTSD and how that created distance in their relationship. Perhaps Puzzles wanted to be a behavioral health care provider in the Army to repair her relationship with her father. She seems to have desired to 149

honor her father and make him proud. Joining the Army for Puzzles appears to have been a selfobject experience that functioned to provide idealizing and twinship needs. The Army also seems to have functioned as a selfobject experience that provided her stability as a single woman but also a sense of likeness and similarity in service that she could share with her father.

Another major component of Kohut’s self psychology are disorders of the self. Kohut proposed that poor interactions with selfobjects, along with failure to have selfobject needs met, can result in a damaged self (Kohut & Wolf, 1978). When a damaged self emerges, they can be characterized as psychopathological self-states. One self-state worthy of noting is the overburdened self. “Overburdened selves did not have the opportunity to merge with the calmness of an omnipotent selfobject” (Wolf, 1988, p. 72). Cindy provided an account of her childhood highlighting a deficiency in having her selfobject needs met. She described her parents as being in a “toxic relationship,” and she witnessed verbal and physical abuse. Her parents divorced when she was a child, and her father abandoned any form of relationship with her once she started college. Cindy appears to have been parentified at an early age and made to feel responsible for her twin brother. She described encounters with her mother in which she was asked the whereabouts of her brother. Cindy emphasized feeling frustrated because she was not the parent. Cindy seems to have lacked early mirroring and idealizing selfobject experiences in which she could experience a sense of safety and calmness with a powerful figure. In terms of joining the military, perhaps it fulfilled mirroring and idealizing selfobject needs. As a child, Cindy had to fend for herself, and the military appears to have been a place in which she could attain stability as well as thrive in terms of developing cohesion of the self.

Several participants shared rich descriptions that can be conceptualized as the deployment serving as a selfobject experience that also met selfobject needs. In Cindy’s story,

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she married while at officer training and dually deployed with her spouse. Cindy shared how she felt like she did not belong because she lacked a deployed combat badge. The deployment was necessary for Cindy to experience a sense of belongingness as a soldier in the Army. Perhaps this is an example of the deployment gratifying efficacy selfobject needs. The deployment seems to have served as an environment that affected her sense of efficacy as a soldier in the Army.

Furthermore, it also may have satisfied twinship selfobject needs for Cindy because she did not feel a sense of likeness with her peers prior to the deployment. Samantha describes in her account how the deployment served as an experience in which she was able to define her role as a mental health care provider. The deployment for Samantha was an environment in which fewer pressures existed in terms of patient counts and mandatory garrison training. She was given free rein to define her role and make an impact on delivering mental health care services to deployed service members. It can be conceptualized that the deployment may have satisfied mirroring and efficacy selfobject needs for Samantha. In this environment, her skills as a provider were affirmed, and she believed she had an impact on mental health care services.

This finding indirectly relates to the main research question in this study: •

How might female veteran GWOT military mental healthcare providers and technicians’ experiences with deployment impact their relationships during and after reintegration?

The military is an institution made up of ranks with their own rules and values separate from the civilian world. The individuals who are a part of this institution allow the military to function as a machine. Selfobjects are not people, but rather the experiences evoked by objects.

In this study, the military, along with the deployment environment, appears to consist of selfobject experiences that meet the selfobject needs of several participants. Deploying with a

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cohesive or fragmented sense of self may significantly impact relationships during and after reintegration. What that impact looks like may be dependent upon the way the participants internalized the deployment as a selfobject experience. It seems several participants may have made changes within their relationships because of what they gained from their experience with deployment. The findings illustrate a direct relationship with the main and sub-research questions in this study.

Finding 2: Deployment as a Positive Adult Selfobject Experience that Leads to Relational Changes This finding implies that deployment may be a positive selfobject experience that can lead to changes in relationships post deployment. All branches of military service have their own distinct culture that is part of the institution. The power of relationships is discussed in all psychodynamic theories, including Freud’s psychoanalysis. Kohut’s selfobject transference is a valuable theoretical concept relating to this study’s findings. Kohut (1978) believed that selfobjects are experienced narcissistically in childhood and that a fragmented self is born out of the empathic failures of early selfobjects. Kohut emphasized that the self can exist in various states that do not significantly affect one’s functioning in relationships. Selfobject transference “arises spontaneously in all intimate relationships: they are expressions of expectations that frustrated childhood yearning for acceptance and understanding will be responded to in these intimate encounters” (Ornstein, 2015, p. 134). Within selfobject transference is mirroring and idealizing transferences. Kohut conceptualized selfobject transference within the analytic dyad. I applied the occurrence of selfobject transferences potentially stemming from the deployment as a selfobject experience. The themes of “Interconnection Among Relationships” and “Deployment

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and Dear Relationships” illustrate how deployment served as a positive adult selfobject experience and motivated the participants to make changes in their relationships.

In Samantha and Poppy’s accounts, deployment seems to have been internalized as an experience that gave them courage to make changes in their marital relationships. Samantha described a sense of happiness and freedom during her deployment. While she did stay in contact with her spouse and children during that time, her primary focus was on the mission. Samantha emphasized that her experience taught her that she could be independent. However, she returned home to a spouse who had mentally decompensated during her deployment. She explained that she was expected to jump back into various roles post deployment, such as caring for patients, tending to her sons’ needs, and juggling her spouse’s declining mental health. Unfortunately, Samantha stressed that her own mental health started to decline post deployment. However, the independence and freedom she experienced during deployment instilled in her the courage to leave her chaotic marriage. Therefore, this may be interpreted to mean that deployment satisfied Samantha’s self object need for mirroring. Perhaps Samantha recognized the deployment as a powerful selfobject experience that functioned to instill bravery to make necessary relational changes.

Poppy shared how her relationship with her spouse became further strained because of her deployment to Germany. She noted that her spouse expected them to communicate at least 5 to 6 times per day, which impacted her ability to fully immerse herself in the deployment experience. However, Poppy emphasized that her deployment was one of the greatest experiences in her life because she had an opportunity to engage in a mission outside of being an enlisted mental healthcare technician. Poppy stated that her spouse would often question why she did not want to communicate as frequently as he wanted. Perhaps her spouse was exhibiting 153

mirroring selfobject needs within their relational dyad. Poppy described feeling more distant in the relationship post deployment, and the deployment seems to have helped her realize that she did not have to stay in an unhappy marriage. It may have also fulfilled additional twinship selfobject needs by enabling her to establish relationships that provided a sense of likeness with others. Although Poppy ended her marriage post deployment, she felt positive because she would be returning to Korea, where she had formed deep relational bonds in the past.

Gina explained in her story that her deployment experience gave her the space to work as a practicing psychologist without worrying about garrison administrative duties. She deployed with one technician and oversaw the mental healthcare of thousands of service members. Gina highlighted how crucial it was that she deployed with a technician who had prior experience and who she could trust and rely on to take care of service members without oversight. When she returned to her garrison position, she made it her mission to change her relationships with enlisted mental healthcare technicians. Gina saw a deficit in the way enlisted technicians were trained for deployment and began focusing on establishing relationships with her enlisted technicians to develop a better training plan. This demonstrates that deployment may have been a positive selfobject experience that prompted Gina to make changes in her professional relationships.

This finding directly relates to the main research question in this study: •

How might female veteran GWOT military mental healthcare providers and technicians’ experiences with deployment impact their relationships during and after reintegration?

Most of the participants in this study reported that their deployment experience was a positive life event that instilled a great sense of purpose in regard to their career in military

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mental health. A pattern emerged in the results demonstrating that several participants made changes in their relationships post reintegration. As mentioned above, Poppy and Samantha gained self-confidence and a sense of independence during their deployment, which in turn gave them the courage to end their unhealthy marriages post reintegration. Poppy expressed the following in regard to her deployment and marriage: “It kind of helped me make that decision, like, ‘Why am I even here?’ and ‘Why am I still married?’” Samantha disclosed that she couldn’t manage being a provider and a mom, while taking care of her spouse’s mental health needs. She shared, “I couldn’t deal with mental health at work, and I couldn’t be a counselor at home.”

Samantha recalled her deployment as an experience that reminded her, she could be happy, thus providing her with the courage to follow through with a divorce. In contrast, Gina’s deployment appeared to be the catalyst that prompted her to make a change in enlisted/officer relations post deployment.

Finding 3: Empathic Attunement and Mis-Attunement in Relationships The third finding of this study was the potential for an increase in empathic attunement and mis-attunement in relationships post deployment, implying that the deployed experience may impact one’s ability to empathize in their relationships. From a self-psychological lens, empathic introspection is the observational tool used within the analytic dyad (Kohut, 1981). Empathy as a concept has evolved in the world of psychodynamic theory. According to Geist (2009), “Empathy as a methodology is defined as imaginatively feeling and thinking our way into another’s inner life and experiencing that world from the patient’s subjective vantage point” (p.

65). In other words, it is the ability to place oneself in the subjective experience of another.

Kohut (1981) identified “that loss of empathy, the loss of an empathic milieu, the loss of an understanding milieu, not necessarily of the correct action, but the loss of any understanding” as

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disintegration anxiety in the nuclear self (p. 127). The act of empathizing is an intersubjective process occurring within the relational dyads (Rowe & Issac, 1991). The subtheme of “Bidirectional empathy post deployment: It changed me” within the major theme of “Dear relationships” illustrates how the deployed experience appears to have impacted participants’ empathic attunement in their relationships during and after reintegration.

Nikki, Samantha, and Poppy’s accounts highlight that they experienced an initial decline in empathic attunement post deployment, which seems to have negatively affected their relationships for a period post deployment. Nikki reported that when she returned home, everything felt overwhelming. She disclosed how her husband expressed that he needed a break, but that she was initially focused on adjusting to her in-garrison role. She believed that the mission needed her and appears to have struggled to empathize with her spouse’s needs post deployment. Nikki described their relationship as having friction, but it was not until she went on a 2-month TDY that she was able to reflect on her interactions with her spouse and gain empathy for his struggles during her deployment. Samantha also returned from her deployment with what seems to have been an apparent decline in her capacity to empathize with others. She described feeling overwhelmed with the in-garrison role expectations on top of dealing with her spouse’s decline in mental health. She emphasized that during her reintegration, the support for her mental health needs was non-existent. In addition, she shared how treating a family that was terrorized over the holidays, along with other deployment experiences, impacted her capacity to engage with everyday tasks at home. Perhaps, in her eyes, life post deployment seemed less purposeful compared to her deployed experience. However, Samantha shared that because of her deployment, she reached “burnout” and her perspective of her work as a behavioral healthcare provider shifted. She initially believed that she could make systemic changes as a military mental

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healthcare provider, but now seems to focus on making a difference in the life of one individual at a time. Moreover, she shared that when she reached the “burnout” stage, she utilized dark humor to get through it, such as making funny memes with her coworkers to cope with suicidal patients. This coping process seems to have started as result of exposure to secondary traumatic stress during deployment but continues to be utilized in her position as a civilian behavioral healthcare provider for the Air National Guard.

Poppy shared a similar account to Nikki and Samantha in that she seemed to struggle with the ability to empathize with patients as well as her spouse. During deployment, she described feeling pressured by her spouse to communicate excessively and appeared to struggle establishing a connection with him post deployment. Furthermore, she noted that she had difficulty empathizing with drug and alcohol patients post deployment. Her exposure to severely injured patients during deployment may have made dealing with underage drinking difficult and less purposeful after reintegration. Therefore, it can be conceptualized that Samantha, Nikki, and Poppy may have suffered with disintegration anxiety for a time post deployment. While several participants reported a decline in their capacity to empathize with others, some reported that the deployed experience increased their aptitude for empathy in relationships.

Kohut’s early writings on empathy birthed the contemporary two-person centered view of self psychology. Traditionally, Kohut postulated that the analyst engages in empathic immersion for the purpose of entering the intrapsychic world of the analysand (Strozier et. al, 2022).

However, contemporary self psychology views empathy in the analytic dyad as a bidirectional occurrence. Strozier et. al (2022) writes the following: The very act of an empathic gaze alters the landscape of the observed. The field thus created also works both ways. The analyst is themself shaped by empathic interaction

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with the patient, and within this contextual field synergies of profound psychological significance are created. Third, the capacity for empathy is not gender related. Both men and women—and by implication the non-gendered or transsexual—have equal capacity for and potential blocks against empathy. (p. 7) Contemporary self-psychologists have shifted towards a view of self and empathy as a relational achievement (Preston & Shmusky, 2000). This movement towards the relational self in selfpsychology comes from relational theories that perceive human interaction as an intersubjective experience. As a relational achievement, empathy suggests that growth in self stems from the relationship.

Notably, several participants in this study appeared to experience an increase in their capacity to empathize with others as result of exposure to secondary traumatic stress in deployment environments, including Smiley, Puzzles, and Gina. Smiley was deployed to Iraq and would respond to mass casualty calls at the base’s hospital. Prior to deployment, Smiley described having an innate process that helped her treat trauma in service members. She noted that after her exposure to STS during deployment, she was more graceful and patient in her interactions and relationships and was not quick to judge others. Therefore, researchers can postulate that Smiley was empathically immersed with her patients during deployment.

Empathy as a relational achievement, however, is not something that emerges easily or in the moment, but over time. There may well be spontaneously expressed empathy in the moment, which can be quite gratifying for both patient and therapist. But it takes time for empathy to be contextually constrained and sustained over time. (Stozier et. al, 2022, p.

8)

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The empathy she seems to have experienced during the deployment was bidirectional in nature and, thus, potentially contributed to growth of self and an increase in her incapacity to empathize in various relationships post deployment.

Puzzle’s first deployment was described as horrific because of the chaotic relationships she had with her peers. Her commander seemed to engage in splitting her peers, which created a conflictual environment. She noted in her account that she was bullied by her peers because they thought she was medically not fit for deployment. Puzzles also noted an increase in empathy towards soldiers exhibiting suicidal ideations post deployment, particularly the distress these patients experienced because other medical providers did not believe them. She emphasized how other providers appeared to become desensitized to soldiers indicating suicidality. Her own struggle with peers bullying and not believing her during that first deployment may have instilled a strong capacity to empathize with others who were being dismissed and not heard. She recognized the stigma associated with mental health that seems to be innately present in all branches of the military and wanted to help soldiers cope with the possibility of being discharged because of their mental health. She said, “I think that was emotionally difficult for me to have to participate in getting them out. I had to be a part of getting them out, even though that’s not what they wanted.” Puzzle’s deployed experience appears to have helped her develop the capacity for empathic immersion when it came to soldiers facing potential separation due to mental health issues.Based on her descriptions, it seems Puzzles may have been able to enter their intrapsychic world and provide empathic understanding.

Gina provided a detailed account of witnessing an Afghan national catch on fire during her deployment. This experience appears to have significantly influenced the growth in her ability to empathize with others post deployment. Gina described the worst part of that

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experience being the military pushing to have him treated at an Afghan local hospital that did not have the resources to treat his burns. She remembered needing to meet with a chaplain because it felt like this individual was being disregarded by base officials. Upon returning home from deployment, Gina had a greater appreciation for people’s struggles because of what occurred with the Afghan local. She shared in retrospect that decisions are not “black and white” and that this experience helped her recognize that people have different “thresholds of what they can deal and cope with” in her interactions with others and in her relationships. Her own difficulty coping with this deployed experience may have enabled her to engage in empathic immersion with others at a greater level.

This finding is related to the main research and one sub-research question: •

How might female veteran GWOT military mental healthcare providers and technicians’ deployment experiences impact their relationships during and after reintegration? o How might exposure to secondary traumatic stress or development of vicarious trauma affect relationships post reintegration?

Empathic attunement and mis-attunement by their very nature may impact relationships.

A split between those who viewed deployment as a selfobject experience that increased empathic capacity compared to those who believed it decreased was apparent in this study. Some participants noted a decline in empathy for a period post deployment, whereas others endorsed a growth in their capacity to empathize in their relationships. Lack of empathy post deployment seems to create interpersonal conflict in marital relationships. In some participant cases, divorce was the outcome, whereas in other cases, participants recognized their lack of empathy as a sign to work on their marriage. Additionally, several participants reported a decrease in their capacity

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to empathize with patients at their garrison location after returning home, which appears to be related to what they were exposed to during their deployment. However, several participants reported an increase in their ability to empathize with others post deployment, which seems to be related to their exposure to secondary traumatic stress throughout deployment. Perhaps this reported increase in ability to empathize may be related to healthy early selfobject experiences. It is crucial to note that this finding demonstrates that deployed experience, as well as exposure to STS, impacted the participants’ relationships both positively and negatively post reintegration.

Finding 4: Shift in Capacity for Intersubjectivity in Relationships because of Deployment The final finding of this study is the potential for a shift in capacity for intersubjectivity during deployment and post reintegration. This finding suggests that the deployed experience may impact a service members’ capacity for intersubjectivity within the relational dyad. The concept of intersubjectivity theory is rooted in relational theory. Stern (1985) defined intersubjectivity as a “deliberately sought sharing of experiences about events and things” (p.

128). Stolorow’s (1994) theory of intersubjectivity highlights the concept of an intersubjective field, which expands beyond the selfobject experience and into a shared relational space that continues to exist outside of interactions in a relational dyad.

Subjective world is a construct that covers more experiential territory than self. Thus, intersubjective field—the field constituted by the reciprocal interplay between two (or more) subjective worlds—is broader and more inclusive than the self–selfobject relationship; it exists at a higher level of generality. (Stolorow, 1994, p. 36) Benjamin (1990) further expands on the concept of intersubjectivity by going beyond the relationship between self and selfobject experience. She suggests that within a relational dyad, each subject must recognize the other as a separate subject to experience their own subjectivity.

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Intersubjective theory postulates that the other must be recognized as another subject in order for the self to fully experience his or her subjectivity in the other’s presence. This means, first, that we have a need for recognition, and second, that we have a capacity to recognize others in return—mutual recognition. But even when the capacity for recognition is well developed, when the subject can use shared reality and receive the nourishment of "other-than-me substance," the intrapsychic capacities remain. The mind's ability to manipulate, to displace, to reverse, to turn one thing into another is not a mere negation of reality, but the source of mental creativity. (Benjamin, 1990, p. 35 & 43) This study utilizes Benjamin’s conceptualization of intersubjectivity, where within the relational dyad, experiencing one’s subjectivity becomes possible when that subjectivity is acknowledged by another. The next section will discuss how the major themes of “Interconnection Among Self, Relationships, and Deployment” and “Dear Relationships,” along with the sub-themes of “One Boot in Deployment and One Back Home,” “Service Before Self: Coming Back It Felt Like Too Much,” and “Mommy and Me,” demonstrate the way the deployed experience shifted some participants capacity for intersubjectivity in their relationships during and after reintegration.

In Nikki’s lived experience, she struggled to let go of non-military roles during her deployment.

She described her family as non-traditional, identifying herself as the primary decision maker and her spouse as the one who executes the decisions. Nikki noted that she found it difficult to relate to her husband’s need for support in the home once she returned from deployment. Her spouse wanted her to start pitching in by taking care of things in the home. However, her focus was on reintegrating into her garrison mission, and she was seemingly not accustomed to juggling both military and non-military roles. Deployment was an experience that she eventually integrated into and was an environment that was void of non-military role expectations.

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Consequently, when Nikki returned home, she seemed to lack the ability to recognize her spouse’s subjective experience of being a single parent. Researchers It can also be speculated that her spouse grappled with acknowledging Nikki’s subjectivity as an active-duty member returning from a deployment. They both appeared to not be able to mutually recognize what the other needed post deployment, and it took a couple of months of readjustment and reflection for Nikki to regain her capacity to recognize and acknowledge her spouse’s subjectivity in regard to their separation.

Nikki’s experience reuniting with her son after deployment is another example of a potential shift in capacity for intersubjectivity post deployment. She explained that when she returned home, all she wanted was to reconnect with her son. However, she explained that her son was distant and only wanted to share experiences with his father. Initially, she viewed herself as invisible in her son’s eyes, and may have wrestled with connecting to her son’s subjective experience with her absence, creating a barrier to reintegration into the maternal relationship.

Samantha and Poppy both described returning from deployment and experiencing significant marital issues that ultimately resulted in divorce. Samantha noted that her husband’s mental health drastically declined post deployment. However, the deployed experience and her role in this environment appeared to instill in her a sense of independence, freedom, and confidence that she could thrive outside of the marriage. She spoke about having limited contact with her spouse during the deployment, and when she returned from deployment, she lacked the capacity to be a mental healthcare provider at work and in her home. It appears that the independence she attained during deployment contributed to her struggle to recognize her spouse’s subjectivity post deployment, thus prompting her to make an important decision regarding her marriage.

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Similarly, Poppy expressed difficulty reconnecting with her spouse post deployment due to his need to stay in frequent contact during her deployment. She eluded that his need to communicate impacted her ability to fully immerse herself in the deployed mission, seemingly creating a rift in her ability to recognize his subjectivity post deployment. Her spouse may have also struggled with connecting to Poppy’s subjectivity during and after deployment, which may have affected their ability for mutual recognition.

However, Gina, Smiley and Puzzles all appear to have gained a stronger capacity for intersubjectivity due to their experiences during deployment. Moreover, they emphasize having more compassion in their personal and professional relationships, and this growth stems from the struggles and difficulty others encountered in their lives. It’s possible that they were able to connect to the subjectivity of others because of their experiences with STS during their deployments.

This finding is related to the main research and one sub-research question: •

How might the deployed experience of veteran GWOT female military mental healthcare providers and technicians effect their relationships during and after deployment reintegration? o How might military role expectations in the deployed environment affect existing non-military roles?

According to Benjamin (1990), intersubjectivity enables an individual to undergo and

understand their own subjective experiences in life. Therefore, if an individual lacks the ability to engage in intersubjectivity within a relational dyad, one can assume that there is an impact on relationships. Furthermore, if an individual’s capacity to engage intersubjectively with others grows through an experience, there may be a positive shift in their relationships. Some 164

participants reported a pattern demonstrating an inability to connect to and recognize the needs of others post deployment, thus creating a strain on relationships. Nikki, Poppy, Samantha, and Cindy all reported tension and difficulty connecting with their spouses during and after deployment. Three out of the four of them ended up divorcing post deployment. Some participants adjusted to the minimization of non-military roles during deployment, potentially playing a part in increasing or decreasing their capacity for intersubjectivity post deployment.

Furthermore, some participants reported appeared to continue to focus on their deployed mission role post deployment, potentially impacting their ability to engage in intersubjectivity.

Limitations It is vital to explore the limitations of this study to conceptualize and interpret the findings. In addition, it is crucial to note the results of this study are not generalizable to a larger population. However, the goal of IPA as a methodology is not to generalize findings, but rather to explore and understand the lived experience of a homogenous population for the purpose of contributing to a body of research (Smith et. al, 2009). IPA is concerned with the detailed examination of human lived experience. It aims to conduct this examination in a way which as far as possible enables that experience to be expressed in its own terms, rather than according to a predefined category system. (Smith, et. al, 2009) One limitation of this study is that the researcher belonged to this homogenous population. They actively utilized bracketing in the form of journaling throughout this study to ensure credibility and validity, but their interpretive process has its own limitations because of their connection to this study’s population.

A second limitation to this study is the use of technology for data collection. While technology provides researchers with greater access to various populations, it also carries significant limitations. The internet as an advanced technology poses issues for qualitative research. “The

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most affected area of qualitative research has been the collection of data. Data collection methods have fast evolved, along with similar Internet platforms. Thus, Internet interviews can be asynchronous or synchronous, public, or semi-private” (Redlich-Amirav & Higginbottom, 2014, p. 4). In this study, both the first and second interviews were solely conducted over Zoom.

Conducting data collection via communication platforms such as Zoom raises a major ethical concern regarding the potential for privacy issues because of the instability of the internet.

Another problem associated with conducting interviews via Zoom rather than in person is a loss of non-verbal cues during the interview. IPA aims to understand phenomenon, and, by its nature, is an intersubjective methodology among researchers and participants. At times, the sound quality was affected during the interviews due to internet issues. Some questions were asked repeatedly to ensure participant voices were captured, and the researcher repeatedly listened to all interviews and made corrections to transcripts. The potential for confidentiality and privacy issues also existed with storing of data to include informed consent on this my computer.

However, I ensured protocols such as password protection of all data were implemented to ensure that participants felt secure and free to share their stories over Zoom.

The third limitation in this study was racial and military service demographics. Four out of the six participants were White females, whereas the remaining two participants identified as Black and Latina. Consequently, this study did not capture the Black and Latina perspective of the deployed experience. Additionally, participant socioeconomic class was not captured in this study. The potential impact that deployment had on relationships during and after reintegration was primarily captured from the dominant White perspective. This study failed to consider that racism and socioeconomic class may play a role in the impact that deployed experience might have on relationships during and after reintegration. Moreover, this study failed to recruit Navy 166

participants, excluding the unique deployed experience of female GWOT Navy mental healthcare providers and technicians. Lastly, this study was only able to recruit one female enlisted mental healthcare technician, resulting in an unequal representation of officer versus enlisted perspective on the impact that deployed experiences have on relationships during and after reintegration.

A final limitation is the exclusion criteria outlined in this study. Males were not included, which limits an entire gender’s perspective on the impact of deployed experience on relationships. Moreover, participants were only pulled from the GWOT era, limiting the lived experiences of female mental healthcare providers to those from the Vietnam and Persian Gulf Wars. Lastly, this study only captured a small component of the Armed Forces medical personnel that were deployed alongside mental healthcare providers and technicians.

Broader Implications for Social Work There is a lack of quantitative and qualitive research on the impact the deployed experience has on the relationships of female mental healthcare providers and technicians during and post reintegration. Moreover, this topic of study lacks research on other sub-populations serving in the Armed Services who have also experienced multiple deployments and long separations from family and friends. This study offers several implications for the field of social work.

One major contribution to the field of social work that this study offers is enhancement of social work training programs centered on working with military and veteran populations. This study demonstrates the potential for deployed experiences to serve as a positive selfobject experience that may also meet selfobject needs of returning service members. Deployment as a positive selfobject experience can offer insight into ways to treat the readjustment needs of

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returning service members. Many treatment approaches for readjustment and trauma center on the negative impact deployment has on the service member’s intrapsychic and interpersonal world. A treatment approach that explores the positive impact of deployment and overall military career has for service members may be beneficial in treating readjustment issues and trauma symptoms.

Another implication this study provides for the social work field is on the reintegration or post deployment needs of female mental healthcare providers and technicians. . Several participants appeared to experience loss of empathy and lower capacity for intersubjectivity in their relationships during and after deployment. This seems to have impacted their ability to healthily reintegrate with family post deployment. This is an opportunity for social workers to lead the way on readjustment needs as well asimprove family counseling for female service members during and after deployment. Addressing the needs of female service members during and after reintegration may also help retain females in the Armed Forces.

This study demonstrates the unique challenges that female mental healthcare providers and technicians face within their relationships during and after deployment. Several participants in this study voiced the implicit expectation that the military will be their priority over all other roles and the difficultly they had reintegrating into non-military roles post deployment. Many commented on the lack of mental healthcare support available to them post deployment. The military community seemed to acknowledge the challenges participants faced while reintegrating post deployment, as well as the lack of services accessible to them. This is a ripe opportunity for the military social work field to develop and expand on this type of mental healthcare service.

However, this will require a major change in the cultural stigma that exists in the military regarding access to mental healthcare treatment for the individuals providing those very services.

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Suggestions for Future Research Qualitative research methodologies like IPA can enhance further understanding on how the military and deployed experiences may impact the relationships of various sub-groups in the Armed Forces. Further research exploring the potential contrast among the role dichotomy female service members face in and outside of the military is warranted based on this study. Such as study would contribute to examining the pressure and added challenges females face while serving in the military. It can also provide insight into services that will aide in recruitment and retention of female service members.

Future research on examining the lived experience of minority females and their perspectives on the impact deployment has on their relationships during and after reintegration will add to this under studied body of research. A study of this nature would potentially factor in the way racism interplays and effects this population’s perspective on the deployment experiences that may impact relationships during and after reintegration. It may also serve to highlight the impact of racism within a large institutional system like the Armed Forces.

A study comparing different gender perspectives centering on the way deployed experiences impact relationships can add further insight to this body of research. Male participants may offer a different and unique perspective on how deployment may impact relationships during and post reintegration. Moreover, research on the differences among individuals who identify as female, male, and transgender would create a new body of research on the impact deployed experience might have on relationships during and after reintegration.

Research exploring different gender perspectives of this impact has vast implications for social work curriculum, military social workers’ training, and development of services to meet the needs of the different genders that encompass our Armed services.

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This study suggests that there is a need for future research examining deployment as a posttraumatic growth experience for military mental healthcare providers and technicians. A study of this nature could explore the way early attachments might impact deployed experiences and determine whether there is connection between attachment and posttraumatic growth. All participants in this study reported exposure to secondary traumatic stress in their deployed experience. However, not all participants identified that exposure as enhancing their capacity for empathic attunement and intersubjectivity. Future research examining why some experience posttraumatic growth and others do not will enhance the field of social work.

Lastly, while this study did not focus on the military and deployment as an “othering” experience, future research on this will provide a greater understanding of the impact this institution has on the service members’ post military life. Othering is a phenomenon comprised of processes that influence the reflexive capacity and subjectivity of individuals (Krumer-Nevo, 2012). Understanding how the military and deployment may “other” service members may enhance readjustment counseling services at VA hospitals and Vet centers for those struggling to adjust to civilian life.

Summary This research attempted to answer the following question: “How might female veteran GWOT mental healthcare providers and technicians’ deployment experiences impact their relationships during and after reintegration?” Additional sub questions of this study including the following: “How might military role expectations in deployed environments affect existing nonmilitary roles?” and “How might exposure to secondary traumatic stress or development of vicarious trauma in the deployed environment affect relationships post reintegration?”

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In conclusion, in this study suggests that deployed experiences have some impact on the relationships of female mental healthcare providers. Furthermore, this study demonstrates the potential of military role expectations witin deployed environments impacting non-military roles for a period due to a shift in capacity for empathic attunement and intersubjectivity during and after reintegration. Those roles may include mother, daughter, friend, sibling, and friend.

However, this study did not indicate the development of vicarious trauma as result of deployed experience in most participants. Divergent data emerged during this study, with one participant reporting the development of vicarious trauma regarding her perception of her job. It appears her vicarious trauma developed due to her entire career as a military mental healthcare provider, not just the deployment. Furthermore, this study indicates that exposure to secondary traumatic stress in deployed experiences may impact the relationships of female mental healthcare providers post reintegration. It is crucial to note that the impact appears to have been both positive and negative in nature.

Concluding Thoughts It was both an honor and privilege to share the participants’ lived experiences regarding the impact deployment had on their relationships during and after reintegration. It took a vast amount of courage for the participants in this study to share the way their deployed experiences impacted their relationships. I was initially nervous studying a population that I am a member of base on my career in the Air Force However, being considered a part of the study population served to contribute to the interpretation and emergence of themes and findings. I already had a strong passion for providing mental healthcare services to female veterans, but this study ignited a desire to further contribute to healthcare for female veterans by writing academic articles tailored to this population. My hope for the future is that the military, as well as the VA, will

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continue to grow to meet the mental healthcare needs of female veterans, including expanding the services that address growth in their relationships.

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APPENDIX A: INFORMED CONSENT Institute for Clinical Social Work Research Information and Consent for Participation is Social Behavioral Research Title of Study: The Effect of Deployment on Relationships: A Phenomenological Study of Female Global War on Terrorism Mental Healthcare Providers & Technicians I, _____________________________________, acting for myself, agree to take part in the research entitled The Effect of Deployment on Relationships: A Phenomenological Study of Female Global War on Terrorism Mental Healthcare Providers & Technicians This work will be conducted by Julianna Petrone, LCSW under the supervision of Dr. Barbara Berger.

This work is being conducted under the ices of the Institute for Clinical Social Work; At St. Augustine College, 1345 W. Argyle St., Chicago, IL 60640; (773)935-6500.

Purpose The purpose of this interpretive phenomenological study is to explore the impact deployments have on the relationships of veteran female military mental healthcare providers and enlisted mental healthcare technicians during and after reintegration. This study attempts to deepen the understanding of the deployed experience and how that impacts relationships during deployment and post reintegration. This dissertation document will be available online once completed and may be published or presented at professional conferences.

Procedures used in the study and duration After completing the survey and signing consent forms your first interview will be scheduled.

Two semi-structured interviews will be required, lasting no more than 60–90-minutes per interview. Each interview will be audio recorded and transcribed, and all audio recordings will be destroyed after the transcription. Data from these interviews will be secured via password protected files and stored in a password protected computer and locked file cabinets. You will receive a $50.00 gift card for each interview and will be mailed the gift card following completion of each interview.

Benefits

There are many benefits of participation in this study: a) increase in understanding the impact deployments have on the relationships during b) increase of understanding on military roles versus non military roles and how deployment impacts the management of diverse roles c) increased awareness on the deployed experience d) increase of understanding on the relationship between vicarious trauma and maintaining healthy relationships during and post reintegration e) adding to the body of knowledge on pre and post deployment programs for veterans.

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There are benefits to the field of clinical social work which include: a) the research will add to the body of knowledge on the impact deployment has on the relationships of female veterans b) increase understanding on the clinical mental health treatment of female veterans within the civilian and military mental health communities c) contribute to the literature and social work profession by increasing the knowledge about the impact deployments have on female mental healthcare providers and enlisted technicians d) launch further research that would benefit clinical processes and programs for female veterans.

Costs The costs to the study participation will include travel to an interview site determined collaboratively by the researcher and the participant. Costs also include time devoted to two interviews and review of transcription summary data for clarification and feedback.

Possible Risks and/or Side Effects Your safety and comfort are important. There is minimal risk associated with participation in this study. However, there is a possibility that you may experience some psychological discomfort or negative emotional responses when reflecting on or discussing your deployment experiences. If you decide you are no longer comfortable participating in this study, please remember you have the right to withdraw (see section below “Right to Refuse or Withdraw”).

Privacy and Confidentiality Your participation in this study will be kept private and confidential and all identifying information will be protected. In addition, the records of this study will be kept strictly confidential. The e-mail address and computer from which you received your participant information is password protected and accessible only by this researcher. Your contact information will not be connected with any other information you provide during the course of this study. Additionally, your contact information will be immediately deleted upon termination of the data collection phase of this study.

All research materials including recordings, transcriptions, analyses, and consent/assent documents will be stored in a secure location for five years according to federal regulations. In the event that materials are needed beyond this period, they will be kept secured until they are no longer needed, and then destroyed. All electronically stored data will be password protected during the storage period. We will not include any information in any report we may publish that would make it possible to identify you.

Subject Assurances By signing this consent form, you agree to take part in this study. You have not given up any of your rights or released this institution from responsibility for carelessness.

You may cancel your consent and refuse to continue in this study at any time without any loss of benefits (including access to services) to which you are otherwise entitled. Furthermore, other than the initial research recruitment email/information, any interaction regarding this study will occur strictly between you and the researcher and will not be shared with anyone.

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You have the right not to answer any single question, as well as to withdraw from further participation. If you choose to withdraw, you may simply stop your participation and will not receive any more information regarding this study. You understand that you must notify the researcher of the decision to withdraw by email or phone as soon as the decision is made to withdraw to ensure that you no longer receive any additional information from the researcher.

Right to Ask Questions and Report Concerns You have the right to ask questions about this research study and to have those questions answered by me before, during or after the research. If you have any further questions about the study, at any time feel free to contact me, Julianna Petrone at jpetrone@icsw.edu; or Dr. Barbara Berger at bberger@icsw.edu ; 312-493-3023. If you would like a summary of the study results, one will be sent to you once the study is completed.

If you have any questions about your rights as a research subject, you may contact Dr. John Ridings, Chair of Institutional Review Board; the Institute for Clinical Social Work; At St. Augustine College, 1345 W. Argyle St., Chicago, IL 60640; (773)935-6500.; irbchair@icsw.edu.

Signatures For the Participant I have read this consent form and I agree to take part in this study as it is explained in this consent form: Participant Name (please print): ___________________________________ Participant Signature:__________________________________________ Date: _____________ 1. Would you like a summary of the results of this study?

Yes: ____ No: ____ For the Primary Researcher I certify that I have explained the research to _________________________ and believe that they understand and that they have agreed to participate freely. I agree to answer any additional questions when they arise during the research or afterward.

Researcher Name (please print): ___________________________________ Researcher Signature: __________________________________________ Date: ____________ Hello,

Appendix B Recruitment Email

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My name is Julianna Petrone, LCSW and I am a doctoral student at the Institute for Clinical Social Work in Chicago, Illinois. I am emailing you to invite you to participate in my dissertation research project entitled: The Effect of Deployment on Relationships: A Phenomenological Study of Female Global War on Terrorism Mental Health Providers & Technicians. This research study is my final requirement for completion of my doctoral degree at the Institute for Clinical Social Work in Chicago, Illinois. I am interested in researching the impact the deployed experience has on the relationships of female mental healthcare providers/officers and enlisted mental health technicians during and post reintegration. I am recruiting veteran female mental healthcare providers (Social Workers, Psychologists, and Psychiatrists) and enlisted mental healthcare technicians who completed at least one three-month deployment in support of the Global War on Terrorism. All branches of service with medical career fields are welcome to participate in the study. The deployment can be noncombat or combat.

I was an active-duty clinical social worker in the USAF from 2010 to 2017 with one deployment to Qatar in 2012. Military mental healthcare providers and technicians provide a distinct service to the

military community both at their assigned bases and during deployment. A primary mission for military mental health providers and enlisted technicians is to treat and ultimately ensure the emotional stability of all service members from various specialties so that they are fit to deploy and able to carry out duties that support the deployed mission. Female mental health providers and technicians have been uniquely tasked with serving the mission while maintaining various roles outside of the military including but not limited to mother, wife, daughter, friend, and sister. The purpose of this interpretive phenomenological study is to explore the impact deployments have on the relationships of veteran female military mental healthcare providers and enlisted mental healthcare technicians during and after reintegration.

I would like all participants to take part in two 60–90-minute interviews. The interview will be done via Zoom or if you are local to South Florida at my office in Greenacres, Fl. You will be given a $50 Visa gift card for each interview as a thank you. The gift card will be sent to you following the completion of each interview. There are no costs to participating. Your interest in the study, your participation in the study, and all information shared will remain confidential.

I may publish the results of this study; however, I will keep your name and other identifying information private. All participant identifiers will be placed with pseudonyms and all audio files and transcripts will be stored on a locked, password protected computer. Only the primary investigator (me) and my dissertation chairperson, Dr. Barbara Berger will have access to these files and the audio files will be destroyed once they have been transcribed. Data will be used for a dissertation study and will be reviewed only by faculty members of my dissertation committee at the Institute of Clinical Social Work.

If you are interested in participating or gathering more information, please privately message me, email me at jpetrone@icsw.edu or call me at 631-827-1299. Or, if you prefer, provide your contact information and I would be happy to reach out to you. I hope to hear from you.

If you would like to complete the demographic questionnaire you can do so at: https://www.surveymonkey.com/r/76N2V9T

Sincerely, 176

Julianna Petrone, LCSW, BCD Institute for Clinical Social Work License # SW14208

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APPENDIX C: Telephone Interview Script and Questions After a potential participant contacts, me expressing interest in participating I will send them a survey to determine if they meet criteria if it is not yet completed. Once I determine they meet all inclusion criteria, I will call them to conduct a brief telephone interview as the second step in recruitment. Additionally, after they express interest, I will send them informed consent. The purpose of this interview is to ensure that potential participants meet study and eligibility guidelines and criteria and to review the informed consent line by line. The script below is the verbatim language that will be used on this call: “Hello, my name is Julianna Petrone, and I am a doctoral student at the Institute for Clinical Social Work in Chicago, Illinois. I am working on my dissertation as part of the completion of a doctoral degree in Clinical Social Work. My research will explore the impact deployment has on relationships during

and post reintegration. This study attempts to expand understanding of the deployed experience and how that impacts relationships during deployment and post reintegration. This study will focus on the lived experiences of veteran female mental healthcare providers and enlisted mental healthcare technicians who deployed to at least 1 deployment in support of the Global War on Terrorism.

Based on what you have heard so far, does this study sound like something you would be interested in?

[If answered no] I understand and thank you for your time. Goodbye.

[If answered yes] Great and thank you!

Before we move forward, there are a few things I need to confirm about your eligibility for this study.

This information is confidential, and your answers will not be shared with anyone else. There are a few inclusion criterion for this study.

1. Did you serve either active duty, reserve or guard as a mental healthcare provider or enlisted mental healthcare technician?

2. Was your time in service active duty, reserve or guard and what branch did you serve in?

3. Did you serve at least 1 three-month deployment in support of the GWOT? Where and how long were you deployed?

4. Do you agree to be interviewed multiple times and audio-taped each time?

Have you received the informed consent? (If not will email and set up a different time to review). (If yes) Let’s review that informed consent and I would like to give you an opportunity to ask any questions. At the end of our meeting and I would appreciate you signing the consent form via DocuSign.

This study would include two 60-90-minute interviews with you so I can get a thorough understanding of your feelings, thoughts and experiences. You will receive a $50.00 gift card for each interview. The gift card will be issued following the completion of each interview. As a participant, you will have the choice of conducting the interview in-person at my private practice office or by Zoom video conference.

A possible risk to participating in this study is the inconvenience of being interviewed two times and also any emotional difficulties you experienced during your deployment may arise as a result of the interviews. If you experience any discomfort during the interview process, you may choose not to answer 178

the question, end the interview or withdraw participation in the study. I will be asking you questions that pertain to the details of your deployed experience and how that experience impacted your relationships during and post deployment. Those include family, friends, and military relationships at your deployed location and stateside. I will encourage you to describe your thoughts and feelings pertaining to each question in detail. All information that you share will be kept in confidentiality and privacy will be maintained throughout the entire process. Do you have any questions about confidentiality or privacy thus far?

Will you be able to reflect on your deployed experiences?

Based on what you have heard so far, is there anything about this study you feel would make you uncomfortable, unsafe or emotionally vulnerable?

Great, you seem to meet the criteria for participation. The next step is to schedule a meeting to review the informed consent process in detail and begin the interviews. I will email you the informed consent and the demographic survey today so we can begin scheduling the interview.

Do you have any additional questions?” [if answered yes, the interview will continue to answer any further questions] [if answered no, the interview will conclude].

Thank you for your time today and I appreciate your willingness to participate in my study”.

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APPENDIX D: INSTRUMENT Demographic Questionnaire Please answer the following questions about yourself.

1. Name_________________ Email_____________________ Phone_____________________ 2. Do you identify as female?

Yes____ No______ 3.

How old are you? ______

4.

What ethnic/racial identity do you identify with? o African American or Black o Asian American or Asian o European American or White o Hispanic/Latino o Multiethnic or Multiracial o Native American o Pacific Islands American or Pacific Islander o I describe myself in a different way

5.

What is the highest level of education you have achieved? o Middle school o High school o High school equivalent (GED) o Some college o College degree o Graduate degree o PhD o MD

6. What branch of service did you serve with? o Army o Air Force o Navy 7. Did you serve at least 1 three-month GWOT deployment as either a mental healthcare provider/officer or enlisted mental healthcare technician? o Yes, Where___________, Year_________ o No 8. During the deployment were you active, reserve, or guard? o Guard o Active Duty o Reserve 180

9. During your deployment what was your relationship status? o Married o Single o In a relationship 10. How many children did you have during your deployment? o Zero o 1 o 2 o More than 2 11. If you had children during your deployment what was their age range o 0-1year o 2-4years o 5-7years o 8-12 years o 13-17years o 18 years or older

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APPENDIX E: Interview Question Guide

Research Question: • How has the deployed experience of veteran GWOT female military mental healthcare providers and enlisted mental healthcare technicians impacted their relationships during and post deployment reintegration?

Sub research question for this study is: •

How did military role expectations in the deployed environment impact existing garrison roles?

•

Has exposure to secondary traumatic stress or identification of vicarious trauma in the deployed enviroment impact relationships during and post reintegration?

Interview Questions: 1. Opening question on joining the military: •

Tell me about why you decided to join the military and how that decision was received

by family and friends?

•

Prompt: What kind of support or lack of support did you receive from family and friends

once you decided to join?

2. Job Meaning •

Tell me about how you felt about your job before deployment?

Prompt: Tell me about your thoughts and feelings about your job before deployment?

•

Tell me about how you felt about your job during deployment?

•

Prompt: Tell me about your thoughts and feelings about your job during deployment?

•

Tell me about how you felt about your job after deployment?

182

•

Prompt: Tell me about your thoughts and feelings about your job after deployment?

3. Role Expectations •

Describe the explicit and implicit military job/role expectations of a mental health care provider and technician in garrison and at the deployed location?

•

Prompt: Describe what is written regarding job expectations versus what is unspoken?

•

What are some of your nonmilitary role expectations within your family and friendships?

•

Describe any ways you managed the different role expectations (civilian/military) during the deployment.

•

Describe any ways you managed the different role expectations (civilian/military) after the deployment.

•

In general, how did you manage the different role expectations throughout your military career?

•

Prompt: How might these role expectations create conflict?

4. Relationships: •

Describe your relationship with family and friends during your childhood.

•

Prompt for all questions in this section: What was your relationship like with family, friends, leadership, coworkers, and peers during your childhood, before and after deployment. Tell me about any postive or difficult relationships.

•

Describe your relationship with family and friends before the deployment.

•

Describe what kind of relationship you had with family and friends during the 183

deployment?

•

What was your relationship like with your family after the deployment? Did you

notice any changes in your relationships?

•

Describe your relationship with command/ leadership, coworkers, peers at your

garrison location.

•

Describe your relationship with command/leadership, coworker, and peers at the

deployed location.

5. Exposure to Vicarious Trauma Definitions: Vicarious Trauma: “Vicarious trauma (VT) describes the cumulative intrapsychic. and interpersonal transformative effect of working with trauma victims.

Secondary Traumatic Stress: The effects on the mental healthcare providers and other healthcare professionals caused by repeated exposure to the trauma of others is known as Secondary Traumatic Stress (STS) and interchanged with Compassion Fatigue.

•

Describe any of your own experiences with secondary traumatic stress at you garrison location.

•

Describe your experience with any STS at your deployment location.

•

In terms of vicarious trauma as a process. How might bearing witness to other’s pain impact you emotionally and your thoughts about your job and duties in garrison and during deployment?

•

Prompt: Were you impacted by vicarious trauma garrison and at your deployment location.

184

•

Describe how exposure to secondary traumatic stress/or vicarious trauma in the deployed environment might have impacted any of your relationships during and post deployment?

•

Prompt: How did treating service members with mental health issues impact your relationships?

185

Appendix F-Flyer

Are you a Global War on Terrorism female veteran who served in the military as a mental healthcare provider or enlisted mental healthcare technician (Social Worker, Psychologist, or Psychiatrist)?

Did you deploy at least one time and for at least 3 months? (ex: Qatar, Iraq,

Afghanistan, Bharain etc.)

I am a doctoral student at the Institute for Clinical Social Work, ICSW, Chicago, IL. I am looking for female veterans who meet the above criteria and are interested in participating in a qualitative study focused on exploring the impact a deployment has on relationships during and post reintegration.

If you are interested in participating or gathering more information, please email me at jpetrone@icsw.edu or call me at 631-827-1299. Or, if you prefer, provide your contact information and I would be happy to reach out to you.

If you would like to complete the demographic questionnaire you can do so at: https://www.surveymonkey.com/r/76N2V9T THANK YOU and I look forward to hearing from you!

186

References Abraham, K. (1918). Symposium on psychoanalysis and the war neurosis. The International Psychoanalytic Library, (2), 22-29.

Alase, A. (2017). The interpretative phenomenological analysis: A guide to a good qualitative research approach. International Journal of Education and Literacy Studies, 5(2), 9–19.

Barr, K., Campbell, S., Finney, K., Hassan, A. M., Redmond, S. A., & Wilcox, S. L. (2015). A brief introduction to the military workplace. Work, 50(1), 9–20.

Benjamin, J. (1990). An outline of intersubjectivity: The development of recognition.

Psychoanalytic Psychology, 7, 33–46.

Biddle, B. J., (1979). Role theory, expectations, identities, and behaviors. Academic Press.

Bloomberg, D., & Volpe, M. (2019). Completing your qualitative dissertation (4th ed.). SAGE. Breeden, N.C., Welsh, J. A., Olson, J. R., & Perkins, D. F. (2017). The women’s experience: A look at risk and protective factors for deployed female Air Force personnel. Journal of Women’s Health. 00(00). 1-7.

Brenner, L. A., Gutierrez, P. M., Cornette, M. M., Betthauser, L. M., Bahraini, N., & Staves, P. J. (2008). A qualitative study of potential suicide risk factors in returning combat veterans. Journal of Mental Health Counseling, 30, 211–225.

Carr, R. B. (2013). Two war-torn soldiers: Combat-related trauma through an intersubjective lens. American Journal of Psychotherapy, 67(2), 109-133.

Cigrang, J. A., Talcott, W., Tatum, J., Baker, M., Cassidy, D., Sonnek, S., Snyder, D. K., Balderrama-Durbin C., Heyman, R. E., & Smith-Slep, A. M. (2014). Impact of combat deployment on psychological and relationship health: A longitudinal study.

Journal of Traumatic Stress. 27, 58-65.

Chapman, P. L., EInitsky, C. A., Figley, C., Pitts, B. L., Thurman, R. M., & Unwin, B. (2013).

187

Gender differences in combat medic mental health services utilization, barriers, and stigma. Military Medicine, 178(7), 775–784.

Conrad, P, & Scott-Tilley, D. (2015). The lived experience of female veterans deployed to the Gulf War II. Nursing Forum, 50(4), 228–240.

Creech, S. K., Swift, R., Zlotnick, C., & Taft, C. (2016). Combat exposure, mental health, and relationship functioning among women veterans of the Afghanistan and Iraq wars.

Journal of Family Psychology. 30(1), 43-51.

Creswell, J. W., & Creswell, D. J. (2018). Research design: Qualitative, quantitative, and mixed methods approaches (5th ed.). SAGE. Creswell, J. W., & Poth, C. N. (2018). Qualitative inquiry & research design (4th ed.). Sage. https//doi.org/978-1-5063-3020-4 Day, K. W., Lawson, G., & Burge, P. (2017). Clinicians’ experiences of shared trauma after the shootings at Virginia Tech. Journal of Counseling & Development. 95, 269-278.

DeMarni-Cromer, L., & Louie, A. D. (2014). Child attachment during the deployment cycle: Impact on reintegration parenting stress. Professional Psychology: Research and Practice, 45(6), 496–503.

Defense Casualty Analysis System. (n.d.). Conflict casualties. https://www. dcas.dmdc.osd.mil/dcas/pages/casualties_oir.xhtml Didion, M. L., Holohan, D. R., & Voss-Horrell, S. C. (2011). Treating traumatized OEF/OIF veterans: How does trauma treatment affect the clinician? Professional Psychology: Research and Practice, 42(1), 72–96.

Dowling, M. (2004). Hermeneutics: An exploration. Nurse Researcher, 11(4), 30–39.

188

Ferenczi, S., Abraham, K., Simmel, E., & Jones, E. (1923). Psychoanalysis and the war neuroses. The International Psycho Analytic Press.

Ferenczi, S. (1949). Confusion of the tongues between the adults and the child: The language of tenderness and passion. The International Journal of Psychoanalysis,30, 225-230.

Foreman, T. (2018). Wellness, exposure to trauma, and vicarious traumatization: A pilot study.

Journal of Mental Health Counseling. 40(2), 142-155.

Freytes, I. M., LeLaurin, J. H., Zickmund, S. L., Resende, R. D., & Uphold, C. R. (2017).

Exploring the post-deployment reintegration experiences of veterans with PTSD and their significant others. American Journal of Orthopsychiatry. 87(2), 149-156.

Freud, S. (1919). Introduction to psychoanalysis and war neuroses. The standard edition of the complete works of Sigmund Freud, an infantile neurosis and other works, Volume VVII (1917-1919). Vintage Press, 206-215.

Freud, S. (1920). Beyond the Pleasure Principle. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XVIII (1920-1922): Beyond the Pleasure Principle, Group Psychology and Other Works, 1-64.

Gadamer, H. (1965). Elements of a theory of hermeneutic experience. In J. Weinsheimer & D. Marshall (Eds.), Truth and method (2nd ed., pp. 265–369).

Geist, R. A. (2009). Empathic understanding: The foundation of self-psychological psychoanalysis. Self and Systems: Annals of the New York Academy of Sciences, 1159, 63–74.

189

Gutierrez, P. M., Brenner, L. A., Rings, J.A., Devore, M. D, Kelly, P.J., Staves, P. J., Kelly, C.M., & Kaplan, M. S. (2013). A qualitative description of female veterans’ deploymentrelated experiences and potential suicide risk factors. Journal of Clinical Psychology.

69(9), 923-935.

Haddock, L., Hickman, G., & Vincenzes, K. A (2014). The implications of attachment theory for military wives: Effects during a post deployment period. The Professional Counselor, 4(2), 122–128. https:// doi:10.15241/kav.4.2.122 Hallinan, S., Shyiko, M., Volpe, R., & Molnar, B. E. (2020). On the back burner: Challenges experienced by change agents addressing vicarious trauma in first response and victim services agencies. Traumatology, American Psychological Association. 27 (3), 316-325.

Hendin, H. (2017). Psychodynamic treatment of combat veterans with PTSD at risk for suicide.

The Official Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry. 45(2), 217-235.

Hershler, A., Hughes, L., Nguyen, P., & Wall, S. (Ed.) (2021). Looking at trauma: A toolkit for clinicians. Penn State University Press.

Horrell, S. C., Didion, L. M., & Vance, G. T. (2011). Treating traumatized OEF/OIF veterans: How does trauma treatment affect the clinician? Professional Psychology: Research and Practice. 42(1), 79-86.

Klein, M. (1948). A contribution to the theory of anxiety and guilt. International Journal of Psychoanalysis, 29, 114-123.

Kohut, H. (1968). The psychoanalytic treatment of narcissistic personality disorders: Outline of a systematic approach. The Psychoanalytic Study of the Child. 23, 86-113.

190

Kohut, H. (1971). The analysis of the self: A systematic approach to the psychoanalytic treatment of narcissistic personality disorders. The University of Chicago Press.

Kohut, H. (1977). The restoration of the self. The University of Chicago Press.

Kohut, H., & Wolf, E. (1978). The disorders of the self and their treatment: an outline.

International Journal of Psychoanalysis, 59, 413-425.

Kohut, H. (1981). On empathy. International Journal of Psychoanalytic Self Psychology. 5(2), 122–131.

Krumer-Nevo, M. (2012). Writing against othering. Qualitative Inquiry. 18(4), 299-309.

Leung, T., Schmidt, F., & Mushquash, C. (2022). A personal history of trauma and experience of secondary traumatic stress, vicarious trauma, and burnout in mental health workers: A systematic literature review. Psychological Trauma: Theory, Research, Practice, and Policy, American Psychological Association. 1-9. Advance online publication. http://dx.doi.org/10.1037/tra0001277.

Louie, A. D, & DeMarni-Cromer, L. (2014). Parent–child attachment during the deployment cycle: Impact on reintegration parenting stress. Professional Psychology: Research and Practice. 45(6), 496-503.

Lowe, K. N., Adams, K. S., Browne, B. L., & Hinkle, K. T. (2012). Impact of military deployment on family relationships. Journal of Family Studies. 18(1), 17-27.

Mariean, C. & Turliuc, M. N. (2014). Predictors of Vicarious Trauma Beliefs Among Medical Staff. Journal of Loss and Trauma. 18, 414-428.

Moore, B. A., & Barnett, J. E. (E.d). (2015). Military psychologists’ desk reference. Oxford University Press.

191

National Association of Social Workers. (2017). NASW code of ethics. https://www. chhs.unh.edu/sites/default/files/media/2019/02/2018-nasw-code-of-ethics.pdf Nilsson, J., Berkel, L., Kelly. P. J., Trummer, M., Maung, J., & Sukumaran, N. (2015). Women in the national guard: Experiences with children during deployment. Counselling Psychology Quarterly. 28 (2), 113-131.

Ornstein, A. (2015). Why Kohut’s ideas will endure: The contributions of self psychology to the treatment of children and to the practice of psychotherapy. International Journal of Psychoanalytic Self Psychology, 10(2), 128–141.

Pessoa dos Santos, R. & Francisco, R. (2021). Psychological and emotional experiences during a military mission: A longitudinal study with soldiers and spouses. Couple and Family Psychology: Research and Practice. 10(1), 38-53.

Pitts, B. L. & Safer, M. A. (2016). Retrospective appraisals Mediate the effects of combat experiences on PTS and depression symptoms in U.S. Army medics.

Preston, L., & Shumsky, E. (2000). The development of the dyad: A bidirectional revisioning of some self psychological concepts. In A. Goldberg (Ed.), Progress in self psychology: How responsive should we be?, 16, 67–84. Analytic Press.

Pruginin, I., Findley, P., Isralowitz, R., & Reznik, A. (2017). Adaptation and resilience among clinicians under missile attack: Shared traumatic reality. International Journal of Mental Health Addiction. 15, 684-700.

Redlich-Amirav, D., & Higginbottom, G. (2014). New emerging technologies in qualitative research. The Qualitative Report, 19(26), 1–14. https://doi.org/10.46743/21603715/2014.1212

192

Rowe, C. E., & Issac, D. S. M. (1991). Empathic attunement: The “technique” of psychoanalytic self psychology. Rowman & Littlefield Publishers.

Rubin, A., Weiss, E. L., & Coll, J.E. (E.d). (2013). Handbook of military social work. John Wiley & Sons, Inc. Sairsingh, H., Solomon, P., Helstrom, A., & Treglia, D. (2018). Depression in female veterans returning from deployment: The role of social factors. Military Medicine. 183, 133-139.

Saldana, J. (2016). The coding manual for qualitative researchers (2nd ed.). SAGE. Smith, J. A, & Flowers, P. (2009). Interpretive phenomenological analysis: Theory, method, and research. SAGE. Smith, J. A., & Osborn, A. (2015). Interpretative phenomenological analysis as a useful methodology for research on the lived experience of pain. British Journal of Pain, 9(1), 41–42.

Smith, L. E., Bernal, D. R., Schwartz, B. S., Whitt, C. L., Christman, S. T., Donnelly, S., Wheatley, A., Guillaume. C., Nicolas, G., Kish, J., & Kobetz, E. (2014). Journal of Multicultural Counseling & Development. 42, 2-12.

Stern, D. N. (1985). The interpersonal world of the infant: A view from psychoanalysis and developmental psychology. Basic Books.

Stolorow, R. D., Atwood, G. E., & Brandchaft, B. (1994). The intersubjective perspective.

Rowman & Littlefield Publishers.

Strozier, C. B., Pinteris, K., Kelley, K., & Cher, D. (2022). The new world of self: Heinz Kohut’s transformation of psychoanalysis and psychotherapy. Oxford University Press.

193

Vincenzes, K. A., Haddock, L., & Hickman, G. (2014). The implications of attachment theory for military wives: Effects during a post deployment period. The Professional Counselor.

4(2), 122-128.

Welsh, J. A., Olson, J.R., & Perkins, D.F. (2019). Gender differences in post-deployment adjustment of Air Force personnel: The role of wartime experiences, unit cohesion, and self-efficacy. Military Medicine. 184, 229-233.

Wolf, E. (1988). Treating the self. New York, NY: The Guilford Press.

Yaakubov, L., Hoffman, Y., & Risenbloom, T. (2020). Secondary traumatic stress, vicarious posttraumatic growth and their association in emergency room physicians and nurses.

European Journal of Psychotraumatology. 11, 1-9.

194