Military Spouse Mental Health Outcomes After Receiving Short-Term Counseling Services

Mental Health Symptoms Among Military Spouses

Researchers have drawn attention to the mental health needs of military spouses. In particular, military spouses reported the imposed demands of deployment often lead to neglecting self-care (Mailey et al., 2018). Although, deployment is not the only time of mental health distress for military spouses. For example, Peck and Parcell (2021) found that counseling services are needed in the reintegration (post-deployment) time as well. In a cohort of Army spouses, Sullivan, Hawkins et al. (2021) noted that 15.5% received a mental health diagnosis within the year following the research study. Researchers continue to explore how the military lifestyle impacts the mental health of military spouses. Some scholars have found that among non-treatment-seeking military spouses, rates of depression and anxiety are not disproportionate to civilians (Steenkamp et al., 2018). Although, anxiety and depressive symptoms remain at the forefront of mental health outcomes explored by researchers among military spouse populations.

Researchers reported rates of anxiety symptoms among military spouses ranging from 6.5% to 12.1% (Mailey et al., 2018; Steenkamp et al., 2018; Sullivan, Park, & Riviere, 2021). Scholars have investigated military-related stressors in relationship to anxiety among military spouses, such as the combat injury of the service member (Cozza et al., 2022) and transitions to overseas duty stations (Elliott, 2020). During deployments, some military spouses carry an invisible labor of limiting sharing of distressful information with the service member (Carter et al., 2020), which perpetuates distress. Ponder (2021) explained the transition from closed-ranks communication, which is adaptive during deployment, to open-ranks communication at reunification can be difficult for couples. Additionally, Fields et al. (2012) found heightened anxiety among military spouses associated with worsened overall health. In their sample of spouses (N = 68), over half screened positive for generalized anxiety disorder and reported few social supports, a common mediator of anxiety among this population. While there are certainly additional stressors to the operational tempo and risk associated with military lifestyle, researchers cautioned to overgeneralize the experiences. Indeed, in a burgeoning line of studies, researchers are considering non-military-related factors associated with spousal mental health. For example, Sullivan, Park, and Riviere (2021) described how anxiety is not always a direct response to military stressors, and that contextual factors of an individual's history and ecological environment are additive, such as self-reported adverse childhood experiences and relationship concerns.

In addition to anxiety, researchers often explore depressive symptoms in mental health studies among military spouses. Researchers reported prevalence rates of depressive symptoms among military spouses ranged between 6.05% and 10.7% (Steenkamp et al., 2018; Sullivan, Park, & Riviere, 2021), and probable diagnosis of Major Depressive Disorder at 4.9% (Donoho et al., 2018). These rates are congruent with active-duty military spouses’ reported loneliness during deployments (OPA, 2020). In a study of military couples in which the service member had posttraumatic stress disorder cluster symptoms, Walter et al. (2021) found that 14.4% of spouses met the criteria for new-onset depression, and limited communication about the service members’ symptoms exacerbated depressive symptoms. Similar to anxiety, researchers have considered non-military factors correlated to depressive symptoms. For example, Donoho et al. (2018) found unemployment and less education achievement associated with depressive symptoms among military spouses. Although, some researchers argued that education and employment limitations may be influenced by military lifestyle (OPA, 2020). Additionally, family factors, such as having more children, positively correlated with more depressive symptoms (Donoho et al., 2018; Walter et al., 2021).

Depression during the deployment cycle does remain at the forefront of research among military spouses, and Erbes et al. (2017) created depression trajectories, noting 83% of National Guard spouses aligned with the resilient trajectory. Such evidence brings to light that military spouses with significant mental health needs remain a small overall proportion of the population. However, the factors remain worthy for exploration. For example, Mooney (2019) purported that depression and anxiety among military spouses served as risk factors to their resilience. In military communities, resilience is a core element of military ethos and is considered a significant protective factor for both service members and their families (Burgin & Prosek, 2021).

Resilience and Military Families

A consensus study report conducted by the National Academies of Sciences, Engineering, and Medicine (NASEM, 2019) defined resilience among military families as “positive adjustment in the aftermath of adversity” (p. 3). The NASEM report benchmarked a new wave of focus on military families in terms of wellness and resilience. Prior to discharge, resilience programming in the military often positioned the spouse in service to the military personnel (Anderson et al., 2013). Researchers observed that resilience may look different between service members and spouses. For example, Pflieger et al. (2020) found that while deployments demonstrated positive outcomes for service members (e.g., social support, self-mastery), the same was not true for spouses during that time, in which they reported loneliness and disconnection. Najera et al. (2017) suggested that stakeholders attend to the resilience of the family similarly to the resilience of the service member. Coupled with the NASEM report, researchers began exploring family resilience, such as the family systems concept espoused by Sullivan, Hawkins et al. (2021), who framed resilience as associated with risk and protective factors across the individual, family, and community levels in military populations.

At the individual level, protective factors supported in research include self-efficacy in household management during deployment (Walker O’Neal et al., 2018), satisfaction with the military lifestyle, and education (Pflieger et al., 2020). Whereas risk factors to resilience included mental health symptoms (Pflieger et al., 2020). At the family level, researchers identified relationship satisfaction as a risk factor and suggested the coping skills of military couple develop across time, such that newer military couples seemed to disproportionality express this stress (Pflieger et al., 2020). Finally, at the community level networks of social support, including religious affiliation and living on a military installation were considered protective factors of resilience (Sullivan, Park, Cleland, et al., 2021). Indeed, participants in their study who demonstrated protective coping skills and trait resilience found those individual factors were not sufficient to mitigate effects of risk; thus external and internal protective factors seem essential to build resilience among military families.

Purpose of the Study

Mailey et al. (2018) found that military culture influenced the felt sense of spouses that they need to take care of everyone, which influenced hesitations to seek support or their own care. On rare occasions, spouses reframed that getting help was essential and not a sign of weakness. The hesitation to receive services is paralleled in the limited research on military spouses’ clinical outcomes in counseling. Steenkamp et al. (2018) noted in comparison to the service member and veteran mental health, spouses have rarely received the same attention in the literature. However, researchers have established the prevalence of depression and anxiety (Steenkamp et al., 2018; Sullivan, Park, & Riviere, 2021) among military spouses. Additionally, resilience is central to the military ethos (NASEM, 2019) and researchers have correlated depressive symptoms, anxiety, and resilience among military spouses (Mooney, 2019). Therefore, in our sample of military spouses accessing counseling services, we positioned two research questions: (a) do depressive and anxiety symptoms predict resilience among military spouses accessing mental health care? And (b) does a six-session dose of counseling contribute to the increase of resilience and decrease of depressive and anxiety symptoms among military spouses?

Procedure and Intervention

The setting for the current study was a nonprofit organization serving military service members, first responders, frontline health care workers, and their families, situated in the southwestern United States. The clinical staff conduct assessments with clients at intake and every six sessions. Given the data were de-identified and archival in nature, the first author's Institutional Review Board (IRB) determined an exemption for the post hoc analysis. For inclusion in this study, participants needed to be military spouses, aged 18 or older with completed assessments at intake and session 6. Data included in this review were collected between 2015 and 2021. The counselors at the agency have the autonomy to practice talk therapy from their respective guiding frameworks. On average, there are 15 counselors and staff with caseloads of 30 clients. Military spouses represent a smaller portion of the total clientele served at the agency. Services are provided free of charge to clients. A power analysis using G*Power (Faul et al., 2009) indicated a sample of 68 participants was required to conduct a hierarchical regression analysis with a medium effect size (ƒ² = .15), a power of .80, an alpha level of .05, and two tested predictors.

Participants

The military spouse participants (N = 71) reported an average age of 39.79 years (SD = 11.32). The participants self-identified as women (97.2%, n = 69) and men (2.8%, n = 2). They also reported race and ethnicity: 64.8% White (n = 46), 16.9% (n = 12) African American/Black, 12.7% (n = 9) Hispanic/Latinx, 2.8% (n = 2) multiracial, 1.4% (n = 1) Asian American, and 1.4% (n = 1) Hawaiian Native/Pacific Islander. The majority of participants were married (78.9%, n = 56) and employed full-time (53.5%, n = 38). Given the majority of the sample was married, we used the term military spouse for readability. Participants reported level of education: 23.9% (n = 17) high school diploma, 21.1% (n = 15) associates degree, 16.9% (n = 12) some college, 16.9% (n = 12) bachelor's degree, 14.1% (n = 10) did not report, 4.2% (n = 3) master's degree, and 2.8% (n = 2) doctoral degree. Many participants (52.1%, n = 37) disclosed previous participation in counseling, 35.2% (n = 25) reported this was their first counseling experience, and 12.7% (n = 9) did not respond to the item. The military spouses reported their branch affiliation as follows: 42.3% (n = 30) Army, 23.9% (n = 17) Marines, 16.9% (n = 12) Navy, 14.1% (n = 10) Air Force, and 2.8% (n = 2) multiple branches. All demographics were collected from the intake paperwork associated with the agency.

Measures

Data Analysis

Prior to analysis, we assessed the multicollinearity of the study variables by reviewing correlations. We found a statistically significant relationship between depressive symptoms and resilience at intake, but it fell below .80 (Field, 2018; Table 1). We reviewed the data for assumptions of multivariate analysis. The Durbin–Watson test was in expected range (1.69) to establish independence, visual inspection of plots confirms linearity, and skewness and kurtosis fell within acceptable range (Field, 2018).

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Table 1.

Correlation Matrix of Study Variables at Intake Assessment.

Variable	1	2	3
1. RSES	–
2. PHQ-9	−.347*	–
3. GAD-7	−.218	.678	–

Note. Each study variable at intake among the total sample (N = 71)

RSES = Response to Stressful Experiences Scale; PHQ-9 = Patient Health

Questionnaire-9; GAD-7 = Generalized Anxiety Disorder-7.

*p < .05

Implications for Counseling

Rates of accessing mental health services among military spouses have consistently risen over the years (OPA, 2020) despite barriers to care such as geographical location (Brown et al., 2015), or prioritizing the caregiving needs of service members (Ramchand et al., 2014) and children over oneself (Ross et al., 2021). Specific populations of military spouses, such as those in Special Operations Forces, reported counseling as a central element to maintaining their wellness (Richer et al., 2022), thus there is optimism to reach populations of military spouses in the clinical setting. Data derived from the Millennium Cohort Family Study noted that military couples rarely endorsed having the same mental health concern (Steenkamp et al., 2018). It may be that counselors need to develop clinical interventions attuned to spouses, rather than as adjacent to the evidence-based practices for service members. This assertation aligns with previous researchers who reported that more attention is needed to develop culturally and developmentally responsive services for military spouses (Burgin & Prosek, 2021; NASEM, 2019).

To build resilience, many researchers point to increasing social support network for military spouses (NASEM, 2019; Sullivan, Hawkins et al., 2021). Thus, a 6-week dose of individual counseling may not be sufficient in increasing resilience. Counseling agencies serving this population may want to consider multi-modal services, such as group counseling for military spouses. HomeFront Strong, an 8-week community-based group intervention aimed at building resilience for military spouses, demonstrated promising results in terms of reducing anxiety and stress (Kees & Rosenblum, 2015), and although not immediate, at the 3-month follow-up reported improvements with depressive symptoms (Kees et al., 2015). Given our findings that lower levels of depression predicted more resilience among military spouses entering counseling, there may be continued support for navigating how the risk and protective factors come together. Another clinical modality to consider could be couples counseling. Lucier-Greer et al. (2022) found that marital quality was a protective factor of mental health outcomes among both partners; therefore, couples counseling may be an adjunct service worth exploring as counselors assess the needs of their individual clients.

Limitations and Directions for Future Studies

The results of the current study need to be considered in the scope of limitations. The participants in the current study were derived from one agency in the southwestern United States, limiting generalizability. More specifically, they represented white, employed, educated females. Additionally, the spouses represented heterosexual couples, nearly all wives, which limits the application of results in terms of sexual orientation and gender diversity. We did not have sufficient sampling for comparative analyses among spouses currently experiencing a deployment. Prosek (2020) described inherent limitations when researching programs in community settings. We experienced several of those factors, such as sampling, choice of assessments, and compliance with assessment completion, which limited the analyses and clinical variables available. Finally, the sample of military spouses represented those receiving clinical services and may not be generalizable to spouses not entering mental health care.

There are several opportunities for counseling researchers to develop studies that would support the clinical conceptualization and outcomes of military spouses accessing mental health care. With a cautious interpretation of the current study, further exploration of length of services and modality is warranted. Previous researchers demonstrated mixed findings on the importance of deployment as an impacting factor of focus for military spouse mental health research. For example, a growing body of literature suggested deployment may not be as impactful on spousal mental health as once presumed (Meadows et al., 2016; Steenkamp et al., 2018); therefore, developing more clinical studies that consider other ecological conditions may be beneficial. Researchers noted education attainment (Donoho et al., 2018), employment (Gribble et al., 2019), and social supports (Corry et al., 2019) are all impactful in the mental health of military spouses, which may offer a reasonable agenda for future research projects. However, other scholars, even some drawing from the same Millennium Cohort Family Study data, indicated the impact of deployments, specifically combat experiences, on military spouses and families (Pflieger et al., 2020); additionally, researchers emphasized the need to strengthen mental health services during reintegration (Peck & Parcell, 2021). The conclusion may be more aligned with an and-both situation; meaning, that although the high-risk factors of deployment remain important, it may also be one variable in a constellation of life experiences that researchers need to explore to fully understand the complexity and impact of military lifestyle on spouses. Finally, Sullivan, Park, and Riviere (2021) described how the nature of protective and risk factors for resilience could be considered cumulative, which may offer further insight into the nuances of how the strengths are developed and sustained among military spouses. Future clinical studies that can capture more demographic and contextual variables may be better situated to help explain the mental health and resilience outcomes of military spouses receiving counseling services.