Vol. 15, n. 1, febbraio 2022
STUDI E RICERCHE
Counseling Militare
Una review narrativa
Lorenzo Antichi1, Marco Giannini1 e Yura Loscalzo1
Sommario
Questa review narrativa ha l’obiettivo di illustrare i tipi di counseling presenti nella letteratura scientifica e applicabili ai militari e ai loro familiari, con particolare riferimento al counseling clinico, al career counseling e al counseling familiare. Viene evidenziato come il counseling clinico possa essere un importante strumento per la prevenzione di disturbi psicologici nei militari e nei loro familiari. Il career counseling, invece, mira a favorire il reinserimento lavorativo del militare una volta avvenuto il ritiro dall’esercito e a modificare eventuali pensieri disfunzionali. Il counseling familiare rappresenta uno strumento per supportare la famiglia nel processo di reinserimento del militare all’interno del nucleo di appartenenza. Infine, viene presentata la sandplay therapy come trattamento per i militari affetti da Disturbo Post-Traumatico da Stress. La sandplay therapy, in quanto intervento efficace nell’elaborazione del trauma, rappresenta infatti una possibilità di trattamento per il militare che ha bisogno di elaborare aspetti traumatici. Tuttavia, in letteratura sono presenti pochi studi relativi alla valutazione di efficacia di questi interventi per i militari. Quindi, sono necessari ulteriori ricerche per dimostrarne l’efficacia nella popolazione militare. Inoltre, è fondamentale implementare interventi volti a ridurre lo stigma associato alla richiesta di aiuto agli specialisti della salute mentale.
Parole chiave
Carreer Counseling, Counseling Clinico, Counseling Familiare, Counseling Militare, Psicologia Militare, Salute dei Militari, Sandplay therapy, Stigma.
STUDIES AND RESEARCHES
Counseling for the military
A narrative review
Lorenzo Antichi2, Marco Giannini1 and Yura Loscalzo1
Abstract
This narrative review aims to illustrate the types of counseling present in scientific literature applicable to soldiers and to their families, with particular reference to clinical counseling, career counseling and family counseling. The fact that clinical counseling can be an essential tool for preventing psychological disorders in the military and their families is highlighted. Career counseling, instead, aims to facilitate the soldier’s reintegration into the work force once retirement from the army has taken place and to modify any dysfunctional thoughts. Family counseling is a tool used to support the family in reintegrating the soldier into the family unit. Finally, we present sandplay therapy as a treatment for soldiers with Post-Traumatic Stress Disorder. Sandplay therapy, as an effective intervention in trauma processing, represents indeed a treatment possibility for soldiers who need to process traumatic aspects. However, few studies in literature have evaluated the effectiveness of these interventions for military personnel. Hence, more research is needed to demonstrate its effectiveness in the military population. Additionally, it is critical to implement interventions to reduce the stigma associated with seeking help from mental health specialists.
Keywords
Career counseling, Clinical counseling, Family counseling, Military counseling, Military health, Military psychology, Sandplay therapy, Stigma.
Introduction
In literature, there are few studies investigating military distress during war or missions, as well as after the end of the conflict. However, although soldiers might have good resources — even greater ones compared to the civilian population — they might also face many psychological downsides. More specifically, Loscalzo et al. (2018) showed that Italian blue helmets (i.e., soldiers engaged in missions organised by the United Nations) had fewer internalising symptoms, a better quality of life and higher psychological resources than the control group. However, other studies showed that soldiers are also at risk of experiencing distress or developing psychopathology due to the greater likelihood of being exposed to stressful events during war missions (Hoge et al., 2004). In line with this, Castro et al. (1999) found that a higher number of days spent on missions predicted an increase in the incidence of Post-Traumatic Stress Disorder (PTSD) among the military. Moreover, Schlenger et al. (1992) reported that at least 30% of soldiers who participated in the Vietnam War developed PTSD. Other studies showed a percentage of soldiers diagnosed with PTSD ranging between 8% and 17% (Hoge et al., 2004; Litz et al., 1997; Wolfe et al., 1999). There is also a significant prevalence of depressive disorders among soldiers. For example, Lapierre et al. (2007) found that 44% of soldiers returning from Afghanistan and Iraq experienced depression, PTSD, or both. Other widespread symptoms in this population are anxiety, dissociation, somatisation, and substance addiction (Armenta et al., 2018). Furthermore, there might be suicide attempts due to feelings of guilt about having killed or injured other humans (Blinka & Harris, 2016). In summary, despite some evidence for good resources in the military (Loscalzo et al., 2018), there are also studies highlighting the widespread psychopathology issues in this population. Moreover, it should be considered that the prevalence estimates of mental disorders in soldiers might be biased by the stigma associated with mental illness. For example, Britt (2000) showed that American blue helmets had more difficulties in disclosing their psychological problems than medical conditions (Britt, 2000). Consequently, soldiers have issues asking for psychological help (Wolfe-Clark & Bryan, 2017). A qualitative content analysis highlighted that 33% of the US military who participated in the study did not ask for psychological support, even if needed, because they were afraid of a negative impact on their careers (Johnston et al., 2017). Moreover, Rae Olmsted et al. (2011) showed that soldiers perceived themselves as more stigmatised if they benefited from a psychological intervention than those who did not use mental health services.
Even retirement from missions might be associated with psychological issues. Retirement is a critical moment: soldiers can reunite with their family (Gibbs et al., 2012) and they may feel more mature and have higher levels of self-confidence (Pew Research Center, 2011). However, retirement is also associated with increased levels of distress for both the soldier and their family (Castaneda et al., 2008). Once back home, veterans often report feelings of guilt, shame, fear, and loneliness (Esposito-Smythers et al., 2011). Furthermore, retirement is associated with high levels of marital distress (Gewirtz et al., 2010; Jordan et al., 1992). Soldiers experiencing distress or suffering from psychological disorders are more likely to divorce and to report less marital satisfaction, less intimacy with partners, greater difficulties in exercising parental functions and a lower level of family integration (Allen et al., 2010; de Burgh et al. 2011; Gibbs et al., 2012). Also, they might commit acts of violence towards their partner or children (Sherman et al., 2006; Taft et al., 2007). In line with this, some studies reported high stress and anxiety levels in children at reunions with their father (Chandra et al., 2010; Pexton et al., 2018; Sayers et al., 2009). Also, Cozza et al. (2010) showed that more than two thirds of children experience distress when their fathers return home from war or missions.
About families, it should also be mentioned that they face many challenges during soldiers’ missions. Soldiers are often absent for their children and partner, due to their work commitments, which lead them to stay away from home for a long time. Furthermore, they may be called to serve in dangerous areas and the soldier’s salary can be scarce or perceived as insufficient. For these reasons, family members could see military absence as avoidable if they were employed in a different job (Black, 1993). Women awaiting the return of their partners often complain about being alone and feeling indecisive (Garrett et al., 1978; McCubbin & Dahl, 1976). Children’s education and lack of money are other typical issues (Barnes et al., 2007). Moreover, women often have the perception that their partners care little about their health condition (Garrett et al., 1978; McCubbin & Dahl, 1976). Among male adolescents whose father is not present in the family due to a military career, substance abuse, high levels of perceived stress, and lower school performances are common (Barnes et al., 2007; Nicosia et al., 2016). Also, eating disorders are more frequent in adolescent females whose fathers are soldiers (Waasdorp et al., 2007).
Finally, it should be mentioned that when soldiers retire from a mission, they might abandon their military career. However, returning to ordinary work can be difficult, and unemployment can further aggravate their distress (Bullock et al., 2009). In addition, they sometimes return from missions with disabilities, which might prove an obstacle for getting back to their previous job. For example, mild traumatic brain injuries are common in veterans, and they are associated with neuro-behavioural problems (Porter et al., 2018). Furthermore, low levels of self-efficacy and cognitive distortions can be a substantial obstacle to job reintegration. For example, Bullock et al. (2009) found that 15% of US military personnel believed they would not be hired because of their physical impairments, while 16% believed their appearance would compromise the job interview.
Given the importance of addressing mental health issues in the military, this narrative review will present counseling interventions that might be implemented in this population. In fact, given the spread of psychological disorders in the military, it is essential to provide them with interventions aimed both at preventing and treating psychopathology. Counseling can be a valuable instrument for these purposes (Di Fabio, 2017). Therefore, we will present below the application of clinical counseling, career counseling, and family counseling. Finally, we will present sandplay therapy as an available treatment for those soldiers who need an intervention for processing trauma-related experiences.
Clinical Counseling
Clinical counseling can be used to prevent mental disorders or decrease levels of distress. It might be delivered during missions by adequately trained psychologists for this type of intervention. Also, it might be used for other purposes, such as increasing motivation in the soldier. For example, Hartjen (1986) found that a 4-week counseling programme increased the soldier’s motivation to participate in war missions. Counseling can also effectively increase military adherence to medical treatments, which is often neglected during missions. For instance, Cayetano and Loquias (2020) showed that counseling improved soldiers’ attitudes, dedication, and knowledge regarding interventions to reduce hypertension. Finally, counseling interventions are critical for identifying those soldiers needing clinical intervention. In fact, if the counselors find evidence for mental disorders, they will refer the soldier to psychotherapists who have experience with this population. The referral is important since there is support for the efficacy of various types of psychotherapy addressed to soldiers, such as trauma-focused psychotherapy (Foa et al., 2018; Reger et al., 2011), person-centred psychotherapy (Foa et al., 2018; Resick et al., 2015), cognitive-behavioural psychotherapy (Schnurr et al., 2007) and interpersonal psychotherapy (Markowitz et al., 2015). Here follows a description of some counseling interventions, a few of which have been tested for efficacy in the military.
The ABC 2.0 intervention (Moyer et al., 2002) is an individual, patient-centred short-structured protocol for the prevention of mental disorders. It requires a minimum of one session and a maximum of four sessions. It was originally coded to reduce drug use and prevent the onset of substance-use disorders in the civilian population. However, in 2008, the US Air Force adapted it for soldiers (Sirratt et al., 2012). More specifically, the counselor and the client draw up a plan of change, where they set the objectives to be achieved to improve the client’s quality of life. Next, having clarified the modalities of substance use, the counselor provides a psychoeducational module about the risks associated with the use of drugs, such as body damage and negative social consequences. Sometimes, the counselor highlights the incompatibility and discrepancy between the consumption of substances and military values. If the soldier explicitly requests it or the counselor deems it necessary, coping strategies for anger and stress management can also be taught. Other objectives addressed by ABC 2.0 are the learning of techniques for optimising sleep and the development of skills to communicate assertively with others. Even if this intervention has been adapted to the military, there are no studies analysing its efficacy on this population.
Cognitive-behavioural and acceptance and commitment counseling proved to be effective (after 12 sessions) in decreasing both behavioural problems and internalising and externalising symptoms in soldiers (Cho et al., 2020). Cognitive-behavioural counseling is based upon educating soldiers about automatic thoughts and cognitive errors that might characterise them, aiming to improve their ability to identify them in everyday life and in interpersonal relationships. The dysfunctional aspects of core and middle beliefs are explained to soldiers to introduce the ABC (Activating event, Beliefs, Consequences) task. Specifically, core beliefs are nuclear beliefs about the Self, the world, and the future (e.g., I am wrong). Instead, middle beliefs are more specific, and are attitudes, rules, and assumptions (e.g., I do not want to disappoint anyone). These beliefs activate automatic thoughts (e.g., I deserved to be criticised). Hence, participants monitor and try to modify their automatic thoughts, middle and core beliefs to change their responses to activating events. In acceptance and commitment counseling, instead, soldiers must recognise their experiences (e.g., thoughts and emotions). Participants are then helped by the counselor to detect experience avoidance — in other words, the attempt to avoid or suppress thoughts, emotions, and memories — and use instead cognitive defusion — in other words, emotionally detaching from these experiences — as a way of coping with their negative thoughts and emotions.
In conclusion, since friends and family’s social support is associated with better well-being in soldiers (Wang et al., 2015), we suggest that clinical counseling interventions should also include suggestions for reducing social isolation, such as setting up video calls between the client and significant others or trying, as far as possible, to organise meetings with colleagues to develop a sense of community.
Career Counseling
Career counseling is helpful in preventing post-retirement distress and it is sought by soldiers themselves. For example, Covert (2002) found that soldiers often ask for counseling help about their self-efficacy and motivation levels, finding a new job, or enrolling in a new course of study. Given the importance of career counseling, Prosek et al. (2018) developed some guidelines that they suggest should be used by any career counselor that works with veterans. First, the counselor should try to understand the military culture, in other words, the veterans’ values and moral code. These values usually are sacrifice, honour, and humility. Second, the counselor should investigate how the soldier’s professional and personal life interact (e.g., how the values of military service influence the veteran’s life once the service is finished). Third, the career counselor must assess how military service influences their family and relationships between family members. Finally, the counselor should also investigate the concerns that prompted the veteran to seek psychological help. Hence, the treatment will be organised based on these evaluations. To address the veteran’s problems, the counselor will teach them strategies and skills (e.g., how to behave in job interviews or how to write a covering letter or a CV) to increase the likelihood of finding a new job. Finally, Prosek et al. (2018) highlighted that counselors should always evaluate whether they are able to carry out a treatment with a veteran and if they have sufficient experience in this field.
Despite the importance of career counseling, to the best of our knowledge, there are no studies in literature demonstrating its effectiveness for the military. In fact, Prosek and Burgin (2020), analysing scientific literature on career counseling published between 1998 and 2018, highlighted that researchers’ contributions are purely theoretical. Hence, we will present some military career interventions, without being able to provide evidence for their effectiveness.
Sampson et al. (2004) developed the Cognitive Information Processing (CIP) approach. This programme identifies negative thoughts about job placement, such as concerns about impairments, outward appearance, and fear of being discriminated because of ethnicity. They suggested that soldiers must be helped by the counselor to become aware of their cognitive distortions. Next, the counselor tries to contest these distorted thoughts. At the same time, the soldier must increase their decision-making skills and try to understand what their job interests might be. Some behavioural prescriptions may also be given, such as visiting job centres, trying to enrol in training courses on using computers, or talking to veterans who have already found work.
The Communication, Analysis, Synthesis, Valuing and Execution (CASVE) cycle is another type of career counseling approach (Sampson et al., 1992). The first step (Communication) is to ask the soldier to communicate their issues with job placements. Then, the counselor analyses the soldiers’ self-knowledge about their job aspirations and work preferences (Analysis). Synthesis corresponds to the stage where soldiers’ work preferences are strengthened, even if other new job alternatives are explored. After each option is evaluated, the counselor formulates an action plan to increase the veteran’s chances of being accepted for the desired job position (Valuing). At the end of career counseling, veterans should be more aware of their aspirations and abilities and be ready to execute their plan (Execution). At the end of the cycle, the soldier is asked to give the counselor feedback about the process of execution, to enable the latter to make plans for potential problems (Peterson et al., 2002; Sampson et al., 1992).
Finally, Strength-Based Cognitive Counseling (SBCC; Hayden & Buzzetta, 2014) has been proposed for those soldiers suffering from brain damage. After establishing a good therapeutic alliance, the counselor and the client analyse the extent of the injury, aiming to determine the soldier’s strengths and weaknesses. Then, the counselor assesses the client’s job aspirations. At the end, the soldier will develop problem-solving and decision-making skills to facilitate job placement.
Family Counseling
Family counseling is critical for the prevention of both marital dissatisfaction and the deterioration of family relationships. Moreover, it might support the family in the moment of reunion. Unfortunately, there is only one study that analyses the effectiveness of this type of counseling, and it did not reveal any increase in marriage satisfaction after couples counseling (Schumm et al., 2000). Hence, we will review the family counseling proposals without providing evidence for their efficacy.
Black (1993) designed a counseling intervention for women who have partners in military missions. According to Black (1993), the intervention must be performed in female groups. Participating with other members with similar problems is, in fact, a protective factor from social isolation. Moreover, it aims to teach adaptive coping strategies: the focus is on personal resources and growth opportunities rather than on psychopathology. Through this intervention, women learn how to communicate effectively with their children about their emotions. They can also encourage their children to write letters to their father, or contact him through other media, to maintain a connection.
Hirono (2019) instead set up a counseling intervention for preventing distress in the moment of reunification between the military and his family. This intervention aims to promote clear and effective communication between family members regarding their needs and desires. Specifically, negotiation is a technique that allows the family to define an agreement about the values to which every member should conform, and it is taught through counseling to avoid conflicts.
Sandplay therapy
Dora Kalff (1980) introduced sandplay therapy as a development of the work by Margaret Lowenfeld, who already used sand, water, and miniatures for processing psychological issues. As Kosanke et al. (2016) explained, Kalff believed that sandplay therapy might help establish contact with the unconscious and, most importantly, allow healing to occur. In brief, sandplay therapists usually provide two sand trays (dry sand and wet sand), with the bottoms and sides coloured blue, representing the water and the sky. Moreover, the client has many different miniatures available, including people, animals, vegetation, buildings and symbolic objects.
Castellana and Donfrancesco (2005) highlighted that sandplay, even if initially used with children and adolescents, has also been used with adults. Also, Carey (2006) showed that sandplay therapy is effective in undoing the neurobiological effects of trauma. In line with this, Kosanke et al. (2016), through a thematic analysis of the scant literature concerning the use of sand tray work with adult trauma survivors, concluded that sandplay is helpful as it fosters communication of the experience of trauma, which is often hard to express using words. Moreover, it facilitates healing from traumatic experiences thanks to the person’s empowerment. Trauma memories are usually implicit memories; hence, they are stored in the oldest part of the brain (i.e., the limbic system and brain stem), namely, in non-verbal sections. As a result, these memories might not be accessed through cognitive processing (Goodwin & Attias, 1999; Homeyer & Sweeney, 2011). Sandplay, being non-verbal, could enable us instead to access these implicit memories.
Therefore, we speculate that sandplay therapy might be used for those soldiers whom clinical counselors reveal as being affected by PTSD. However, sand tray work should be implemented by adequately trained therapists. Hence, we suggest that counselors working with the military, in the event of a diagnosis of PTSD, refer the person to a therapist with experience in sandplay therapy for treating adult trauma survivors.
Conclusion
Scientific literature highlights that military personnel might face many mental health issues, such as depression, anxiety, PTSD, substance abuse and suicide. Furthermore, once back home, soldiers might experience the challenges of retirement and of finding a new job. Finally, also the wife and children of the soldier might experience distress. Hence, it is fundamental to implement interventions to prevent distress or restore well-being, both in soldiers and their families.
Counseling offers various possibilities of intervention with soldiers and their families. More specifically, we presented clinical counseling (ABC 2.0 intervention, cognitive-behavioural counseling, and acceptance and commitment counseling), career counseling (Cognitive Information Processing counseling; Communication, Analysis, Synthesis, Valuing and Execution counseling; and Strength-Based Cognitive counseling), and family counseling (focused on women’s coping and focused on the reunion). Finally, we presented sandplay therapy as a treatment for soldiers with PTSD. However, there are few studies in literature concerning their efficacy. This may be due to the difficulty of recruiting this type of population, also because of the stigma associated with asking for psychological help among soldiers. Hence, aiming to design studies about the efficacy of counseling interventions among the military would be helpful first to implement stigma-reduction interventions. These might consist in organising awareness campaigns or setting up groups where both soldiers and individuals with psychological disorders participate (Corrigan & Penn, 1999).
In conclusion, the main limitation of this review concerns the fact that it is based on scant literature, especially about the efficacy of the interventions. However, providing a narrative review of counseling interventions that might be applied in this population could help prompt scholars to deepen analysis of their efficacy. We suggest that future studies should address this gap in literature, by possibly designing quasi-experimental or randomised controlled studies.
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Vol. 15, Issue 1, February 2022
