Insights on How to Serve Military and Veteran Populations

Service Members

Among active-duty service members, 82.4% are enlisted members while 17.6% serve as officers (U.S. Department of Defense 2020). Most active-duty members (82.8%) are male. Of these, 17.2% are Hispanic or Latino and 31.1% belong to racial minority groups. The average age among enlisted service members is 27 while officers have an average age of 34.4 (U.S. Department of Defense 2020). Marriage is also prevalent, with more than half of active-duty service members married during their enlistment.

While not all service members develop complications such as post-traumatic stress disorder (PTSD), a large portion of the population, especially Afghanistan and Iraq veterans, experience the disorder during service because of the trauma they have faced during deployment. Other challenges faced by service members typically include more complex health conditions than those faced by the general population, including psychological, cognitive, physical, and behavioral issues (Hull et al. 2015). Much of this stems from traumatic brain injury (TBI) resulting from combat injury or training. TBI is associated with adverse conditions such as memory loss, dizziness, headaches, and sleep deprivation (Nworah et al. 2014).

Frequent separations from family are another challenge for service members. These separations occur due to training, schooling, and deployments and on average last between 10 to 18 months total (Wenger, O’Connell, and Cottrell 2018). Half of all soldiers deployed since 2001 were married and half of those had children (Wenger, O’Connell, and Cottrell 2018. Separations can impact bonding with children and affect partner intimacy, among other issues. These circumstances can add stress for the entire family while service members are serving away from home or when they return.

Veterans

Veterans, numbering some 20 million in the United States, are women and men who have served in the U.S. Armed Forces for any length of time. Veterans make up less than 10% of the U.S. civilian population, with just 7% of adults in 2016 having served (Bialik 2017). This number is expected to decrease in coming years, however, the number of female veterans is set to double from 9% to 18% by 2045 (Bialik 2017). The veteran population is also expected to become more racially and ethnically diverse, with the number of African American and Hispanic members anticipated to increase by 4% and 6%, respectively, by 2045.

Studies on veterans show increasing rates of mental health disorders, including bipolar disorders, drug and alcohol dependence, anxiety, PTSD, TBI, and adjustment disorders (Hunt et al. 2015). The largest increases were in PTSD and depression. Rates for mental health issues among veterans are significantly higher than for the general U.S. population which could be partially attributed to increased screening rates and efforts to de-stigmatize mental health services among veterans and increase access to services (Hunt et al. 2015). However, research shows an increased need for services for veterans within the Veterans Health Administration and in community-based organizations.

National Guard & Reserve

National Guard and Reserve service members include all branches of service with the Army National Guard representing the largest portion. Guard and Reserve personnel serve in one of three categories: the Standby Reserve, the Ready Reserve, and the Retired Reserve. The Ready Reserve is comprised of service members who served Active Duty or as Selected Reserve members, has 1,021,613 members (U.S. Department of Defense 2020), and is increasingly diverse, reflecting changes in service member demographics. National Guard and Reserve members live as civilians until they are called for deployment, and for the last 20 years have increasingly been deployed overseas in combat areas. They face challenges transitioning back and forth between military and civilian life, in addition to experiencing long separations from family. National Guard and Reserve members have higher suicide rates than the general U.S. population (U.S. Department of Defense 2019). National Guard and Reservists report that civilian support agencies are not equipped to effectively address their needs (Sonethavilay et al. 2019).

Women Veterans & Service Members

Millions of veterans and service members identify as women and/or LGBTQIA. And despite progress towards a more diverse military, service members and veterans from these populations face many challenges and stigma associated with their identities. These difficulties cover almost every facet of life, from discrimination faced in VA hospitals based on sexual orientation or sexual identity to a lack of targeted healthcare designed to address their unique experiences while serving or transitioning to civilian life.

Nearly 20% of service members are women, and due to policy changes since the 1990s the number of women who are combat veterans has increased to 10% nationally (Maury et al. 2018).  Still, women are underrepresented in the literature, programming, and research around the military community, which obscures their gender-specific needs (Hawkins and Crowe 2018). As a result, they often find it difficult to access services and programs even while serving. Further, transitioning to civilian culture presents challenges for women. Women service members face greater financial challenges and depression compared to male service members. Women take longer to find employment than male veterans. Women transitioning from military to civilian life find their identity is also in transition. They must find a new sense of purpose which may contribute to feelings of anxiety, frustration, fear, and loss. They also struggle more with social isolation than their male counterparts, especially over the long- term (Maury et al. 2020) and find that civilian culture places gender-specific misrepresentations on female veteran experiences.

Military sexual trauma (MST) is a significant concern for female service members, with one in five veterans between 55 and 64 years of age reporting experiences of MST and one in ten veterans ages 65 and above reporting the same (Gibson et al. 2020). MST has been linked to increased instances of PTSD, something female service members are already more likely to experience yet less likely to be diagnosed than men (Heineman 2017). They are also more likely than men to experience depression, sleep disorders, suicidal ideation, and pain conditions (Gibson et al. 2020).

LGBTQ+ Veterans & Service Members

Between 66,000 and 75,000 service members belong to the LGBTQIA community, and the transgender military population is two to three times higher than the transgender civilian population. More than one million veterans identify as LGBTQIA (Ahlin and Douds 2018). LGBTQIA service members experience unique challenges, such as concealing their sexual orientation and gender identity, concerns over being discharged because of their gender identity or sexuality, and harassment from fellow service members (Ahlin and Douds 2018). The former challenge has been tied to an increase in mental health concerns post-discharge (Cochran et al. 2013). LGBTQIA service members are at an increased risk of experiencing MST, as well as sexually transmitted diseases, substance abuse, and smoking (Ahlin and Douds 2018; Ruben et al. 2019).

The stigma surrounding mental health and seeking services presents unique challenges to service members, veterans, and National Guard and Reserve. Military culture emphasizes self-reliance and an ethic of strength that deters service members and veterans from seeking services because they do not want to look weak (Teeters et al. 2017). In addition, concerns over how mental health needs may impact their military career also prevent many military personnel and veterans from seeking services.

LGBTQIA service members face unique challenges when seeking physical and mental healthcare due to discrimination in healthcare settings (Ruben et al. 2019) and fear their sexuality will not be accepted. Transgender service members and veterans are particularly at risk for this type of discrimination (Chen et al. 2017), and face higher rates of biased hiring and firing, police harassment, incarceration, and eviction. Often LGBTQIA service members and veterans delay seeking services because of these challenges, and fear of being discharged from the military. This puts them at increased risk for mental health issues, anxiety, and suicidal ideation.

Transitioning to civilian life presents many challenges for departing service members, as well as sometimes ongoing difficulty for veterans. This transition from military structure to civilian life is sometimes referred to as cultural transition, shifting from one culture (the military) to another (civilian life) and the cultural loss that comes with the change (DeLucia 2015).

This transition affects multiple aspects of life such as social, financial, familial, occupational, and personal identity. Adjusting expectations in personal relationships, both from the service member as well as their partners, is often necessary to reestablish close relationships in the wake of active service.   Veterans depart from the values, rules, traditions, and supports to which they have become accustomed while serving. This renegotiation can sometimes be a slow process, potentially leading to disillusionment about transitioning back to civilian life.

Transitions can be especially difficult for service members who joined the military while they were young. Many of them are accustomed to a highly structured environment including housing, medical care, a stable income, and even educational benefits. Moving from this predictable schedule into the more chaotic routines civilians experience can be especially jarring when all the service members have known as an adult is rigid order.

Veterans and service members might also find their values in direct contrast with those embraced by civilians. The emphasis on personal performance and distinction, for example, is at odds with the importance service members place on acting for the benefit of the group, not the individual. The loss of group values and the identity service members had within that community—identities that are often tied to specific tasks, duties, or station—can lead to difficulty establishing personal identity outside of the military.

Veterans and enlisted service members may also face challenges relating to more practical matters such as transportation, housing security, health care, and financial difficulties. These challenges can negatively impact their quality of life.

One of the most common strengths of service members and veterans is their pride in their work. This combines with other prevalent strengths relating to their desire to work collaboratively, learn and improve new skills, and build strong communities. Social connections and social support are critical components of resiliency, including support gained from family cohesion.

Early outreach to service members and veterans facing a transition—a post-military civilian life or a return home after a deployment—can significantly ease the cultural loss many feel during that transition. A common barrier to arts participation is difficulty finding information about available programs. Close collaboration with other service and arts providers in the community is therefore recommended so that proposed arts programming will be well aligned and complementary to other arts and non-arts engagement opportunities offered in the community. Ideally, arts providers should:

• Help educate service members and veterans about the different arts programs available.
• Enable organizations to better create programs that combine seamlessly with other initiatives to offer comprehensive services.  
• Develop programs and resources that meet the needs of veterans in the community in a way that complements existing resources.

Equally important is incorporating veteran strengths, such as those described above, into the basis of community arts programs. Holistic services that emphasize new skill acquisition, reinforcement, and collaborative work, and educating staff and teaching artists about military culture are two approaches that can be used to incorporate veteran strengths into these programs.

Community is another critical component to include in programming. Veterans often face isolation as they transition back into civilian life, and group art sessions can offer them a valuable physical space in which they can offer and receive social support. This supportive environment also frees veterans to express their struggles and desires for the future through their artwork. Feeling safe enough to “get lost” in the process of creating art while allowing participants to take “safe” risks with their projects in ways they might not be able to do in their everyday lives has been tied with positive results.

Arts providers should build organizational skills in the following areas:

• Using evidence-based practices and evaluating programs.
• Increasing understanding of military culture.
• Collaborating with existing veteran or military serving organizations, and other community-based organizations.
• Conduct continuous outreach to military-connected participants and family members.

When working with veterans and service members, Creative Arts Therapists should consider:

• Working from a strengths-focused approach. Engaging people in a strengths-focused approach can help to build upon existing successes and strengths.
• Involving the full family whenever possible. Full family engagement in programming is important to consider as the family is also affected when a service member is preparing for deployment, is deployed, or transitions out of the military.
• Developing opportunities for peer-to-peer mentorship. Consider creating opportunities for veterans to mentor other veterans by giving back through advocacy, volunteering, and engaging in programming in support of other transitioning veterans.

Using engagement with creative arts therapies to help break through barriers to treatment. Engagement with creative arts therapies can help veterans and service members begin to talk about their experiences. Creative arts-based interventions can provide an approach to therapy that reduces barriers to engagement.

Deployments and Separations

Separations happen due to training, schooling or deployments for service members, including National Guard and Reserves. On average, service members are deployed for between 10 to 18 months at a time (Wenger, O’Connell, and Cottrell 2018). Frequent and lengthy separations mean spouses must assume both parental roles and shoulder family responsibilities on their own. Children experience these separations as a loss with older children often assuming more responsibilities and taking on parental-like responsibilities (Hooper, Moore, and Smith 2014).

Transitioning to Civilian Life

While civilian life often means less moving and fewer separations for military families, the transition can be challenging. As service members transition to civilian life, they may lose access to military services, communities, and support systems that lessened burdens and stress during active service, including health care, easy access to fellow military families, and housing support (Karney and Crown 2011). The transition process can be more complicated if the service member or veteran was injured, suffers from post-traumatic stress (PTSD), or traumatic brain injury (TBI). In these cases, spouses often assume a caregiver role (Renshaw, Rodrigues, and Jones 2008).

Military policy and programs define ‘family’ narrowly and exclude unmarried partners, multigenerational family members (such as grandparents), or LGBTQ+ families and spouses. This narrow definition does not match the lived experience of military families (NASEM 2019). Although these family members may reside with the service member (or veteran) they are not entitled to military benefits and military programs do not serve these family members.

Service Member Military Families

Few programs are specifically designed for military families and their unique challenges and strengths. Military life includes frequent transitions and moves, family separation, unpredictable work schedules, and a significant amount of paperwork for families. These factors create additional stress due to lack of stability, continuous changes in schools, lack of childcare, and the worry that comes with a family member deployed to another part of the world. Military families report that social isolation and loneliness are major stressors. Families living off-base may be ‘hidden’ within the civilian community creating social isolation and a lack of connection and belonging to civilian communities and neighbors (Shiffer et al. 2017). The military lifestyle may move families away from grandparents and other family support networks, adding to social isolation (Shiffer et al. 2017).

Dual Service Military Families

Dual-service military families are families in which both parents and/or spouses are service members. This kind of relationship faces unique challenges, especially if children are involved. Some dual-service couples are separated for long periods of time due to deployments or training, and parents must decide where children should live during these times. Parental gender norms often deviate from traditional roles for military families, and these along with work-family conflicts can sometimes cause one spouse (typically the female spouse) to leave the military before retirement.

Single Parent Military Families

Female service members are more likely to be single parents than their male counterparts and single parents are less likely to be officers (Clever and Segal, 2013). While research on the specific needs of single parent military families is scarce, it is thought that single parents in the military experience decreased social support and increased stress when compared to their civilian counterparts, especially where deployments are concerned (Kelley 2006; Vaughn-Coaxum et al. 2015).

Veteran Families

Veteran families include those with a partner, spouse, child, sibling, or parent of a veteran. Veteran families face several challenges. After transitioning to civilian life, veterans often face under and unemployment once they leave the military regardless of health status. This creates financial challenges for families who are now without the housing and other support once provided by the military. After years of deployments with spouses and possibly older children managing both parental roles, veterans and their spouses must renegotiate their family roles. Nearly half of veterans surveyed felt like guests in their homes and 37% were unsure of their role within the family (Sayers et al. 2009). Once out of the military, family members lose access to health care, as the Veteran’s Administration does not serve family members.

Military Spouses

Spouses of service members often struggle with social isolation and feel that they lack an identity. Moving to new duty stations often takes spouses and families far from their home communities and family support networks. Frequent moves and transitions mean spouses are chronically under or unemployed, though often highly educated. Unemployment can increase feelings of social isolation and loss of self-identity (Sonethavilay et al. 2020). These challenges can be felt more acutely by partners who are not recognized as family members by the military and thus do not receive any services. The transition out of the military exacerbates many of these challenges for spouses. They continue to navigate under and unemployment, seek additional education, and address gaps in resumes. Out of the military, they must find access to community and VA services, health care, and benefits. Like their service member spouse, military spouses experience the loss of military community and a loss of identity (Keeling et al. 2020). Unlike their service member spouse, there are few resources, supports, or programs that target spouse experiences (Keeling et al. 2020). Spouses that must take on the caregiver role face additional challenges.

Shared experiences help alleviate some of the stressors for military families and reinforce the type of communication that serves as a source of relief. Programs that focus on resilience can also strengthen bonds between spouses and families, and community connection is tied to increased resilience (Blaisure et al. 2012).

Few programs target military spouses and families. Programs should focus on the strengths and resilience of military families, such as shared experiences, openness to change and ‘new adventures’, and the values of service and selflessness. Programs for families should consider:

• Taking a holistic family-based approach and using a strengths-based approach. 
• Helping families make meaning of challenges.
• Building social connections with other families.
• Enhancing family communication and reconnecting after deployments.

Military spouses are less commonly included in programs. Possible program elements should consider:

• Programs that increase social connections.
• Programs that support affirming and building self-identity.
• Programs for veteran spouses, as well as spouses of service members.

Arts providers should build organizational skills in the following areas:

• Using evidence-based practices and evaluating programs.
• Increasing understanding of military culture.
• Collaborating with existing veteran or military serving organizations, and other community-based organizations.
• Conduct continuous outreach to military-connected participants and family members.

When working with military spouses and families, Creative Arts Therapists should consider:

• Offering a holistic approach in serving the whole family. In addition to serving veterans and service members, include spouses, children, and other family members in the services offered.
• Using a strengths-based approach. Operating from a strengths-based perspective puts the focus on building or enhancing skills, strengths, and relationships, which is often more engaging and more beneficial.
• Embedding evidence-based practice and evaluation in programming. Research and evaluation allows for programs to be more effective and engaging.
• Using a multidisciplinary approach. Multiple treatment options and providers address varying needs (e.g., physical health, mental health, and community engagement) and promote collaboration and coordination among service providers.

Transitions

There are many transitions throughout military service, including relocations and frequent moves (sometimes overseas), adjusting to new schools and communities, family reintegration, and transitioning to civilian life after military service. Many military children adapt to the lifestyle well but navigating new schools and resources along with financial difficulties and a variety of additional stressors can be a challenge. Studies have found negative impacts from military-related mobility such as mental health issues like anger, poor adjustment, anxiety, and behavioral problems (Cramm et al. 2019). These issues can be compounded by other factors of military life. Family members returning home after deployment and the changing family dynamics that result can be particularly difficult for children (Siegel and Davis 2013).

Separations

Most military children have been separated from their service member parent at some point. While this does not always result in behavioral or emotional challenges, it serves as a significant stressor that can sometimes be perceived as a loss by children (Siegel and Davis 2013). This is true of both deployment separations as well as other military-related separations, such as training. Research into preschool aged military children has indicated an increased need for mental health services during separation. Behavior issues such as disturbed sleep, increased crying, attachment issues, and toileting problems such as wetting the bed and other accidents (Cramm et al. 2019) are also common.

Research has found many military children to be kind and mature with exceptional adaptability and openness, all of which are strengths that may help them rebound from stressors. Quality interaction with their communities, including developing relationships at school, is another factor that is sometimes linked to improved adjustment and functioning in the population (Huebner 2019).

Military children sometimes feel “invisible” while at school or in community care. Improving their sense of connection can help them to draw strength from the community through social support, friendships, and resources set aside for service members’ children (Rossiter et al. 2016). However, these benefits are not always extended to children of Reserve and National Guard members (Kudler and Porter 2013). Still, most military children adjust well to the experiences and challenges of the military lifestyle.

The arts can allow military children, including children of veterans, to discover and use their voice as well as serve as a tool to make friends or express emotions. When focused on strength building, arts programs can also help children improve resiliency (Collie et al. 2006).

Designing arts programs for military children that focus on their strengths, experiences, and challenges can maximize the benefits that military children gain from them. Other suggestions include:

• Creating a family-based approach that includes community members to increase familial and community ties.
• Providing flexibility and choice for children that is developmentally, or age, appropriate.
• Activities that reinforce their unique strengths while allowing them to interact with the broader community.
• Incorporating a group or team element to strengthen peer relationships.

To effectively interact with military children, community arts providers should build organizational skills in the following areas:

• Using evidence-based practices and evaluating programs.
• Increasing understanding of military culture.
• Collaborating with existing veteran or military serving organizations, and other community-based organizations.
• Conduct continuous outreach to military-connected participants and family members.

When working with children of service members and veterans, Creative Arts Therapists should consider:

• Offering a holistic approach in serving the whole family. In addition to serving the children of service members and veterans, include parents, grandparents, siblings, and other family members in activities, services, or events. Creative arts therapists should consider treating the family as a system in order to address and enhance parenting skills, parent-child relationships, sibling relationships, family dynamics, and other variables within the family context.
• Using a strengths-based approach. Programs that focus on building or enhancing skills, strengths, and relationships are often more engaging and more beneficial.
• Using a multidisciplinary approach. Multiple treatment options and providers address varying needs (e.g., physical health, mental health, and community engagement) and promote collaboration and coordination among service providers.
• Using developmentally appropriate practice. The needs and experiences of military children vary widely, and programs should take a developmental and contextual approach to caring for military-connected children and youth.

Caregivers

Advances in battlefield medicine have led to more survivors from traumatic brain injury (TBI) and amputation, creating a need for veterans and their caregivers to adapt to and live with life-altering conditions. Veterans receive care for a variety of physical and mental conditions such as depression, anxiety, or post-traumatic stress disorder (PTSD), as well as traumatic brain injury, diabetes, and paralysis or spinal cord injury (National Alliance for Caregiving and United Health Foundation 2010). Post-9/11 veterans also receive care for back pain as well as mental health and substance abuse disorders (Ramchand et al. 2014).

Military caregivers are at risk for neglecting their own health as caregiving activities often take priority. This neglect often manifests as disturbed sleep, physical strain, a higher incidence of illness than non-caregivers, and high blood pressure (National Alliance for Caregiving and United Health Foundation 2010; Ramchand et al. 2014). Preventative health care and unaddressed medical needs are a major population need for caregivers.

Caregivers have increased rates of anxiety and depression when compared with non-caregivers due to daily life challenges, such as financial issues, spousal relationships, physical health, whether they have children to care for, and even their gender (Ramchand et al. 2014; Stevens et al. 2015).

A loss of personal identity and independence are also common challenges for military caregivers. Because they spend so much time caring for others, their personal life, including personal relationships, often suffer, which may increase feelings of social isolation. This is especially true for caregivers caring for their spouse. Shifts in intimacy and friendship with the service member occur when caregivers take on a parental role with a spouse or partner, putting these couples at an increased risk of divorce (National Alliance for Caregiving and United Health Foundation 2010; Ramchand et al. 2014).

Grief is another experience and contributor to poor health and social isolation. Caregivers, especially spouses, often grieve because the life they planned has been altered due to the changes in the veteran from TBI or other life-altering conditions (Saban et al. 2016). They also experience increased depressive symptoms and stress when care recipients have marked cognitive challenges due to TBI. Secondary traumatic stress (STS), a condition related to caring for someone exposed to traumatic events, also contributes to poor mental health for caregivers (Bride and Figley 2009; Strong 2018). All these issues may increase feelings of burnout and a desire to leave the caregiver role.

Children

Caregiving can impact children as well as the adult caregiver. In 2010, the National Alliance for Caregiving reported that three out of ten veteran caregivers have children under the age of 18 in the household. Sometimes children themselves are pulled into the caregiving relationship and provide care to the veteran.

To learn more about the impact of caregiving on children growing up in military caregiving homes, click here

Caregivers cope with many adverse outcomes of caregiving, however, by overcoming these stressors they also build resiliency. In fact, caregivers have many factors that help them experience resilient outcomes including their health, social support, religiosity, and caregiving networks with friends and extended family (Smith-Osborne and Felderhoff).

Arts programs should focus on holistic health, ideally including the care recipient in the program when appropriate. Flexibility in scheduling is an important factor to weigh, as caregivers might not be able to participate during traditional business hours. Offering programs in different formats, such as the following, can also ease barriers to access:

• Online programs.
• One-on-one classes (both online and in-person).
• Community classes with other caregivers to foster social connection, stress reduction, and self-care.

Community connection is an important element of successful community arts engagement programs. Caregivers connecting with each other can help reduce isolation and improve mental health.

Arts organizations should build organizational skills in the following areas:

• Using evidence-based practices and evaluating programs.
• Increasing understanding of military culture.
• Collaborating with existing veteran or military serving organizations, and other community-based organizations.
• Conduct continuous outreach to military-connected participants and family members.

When working with military caregivers, Creative Arts Therapists should consider:

• Offering a holistic approach to serving the military-connected population by serving caregivers, spouses, and children in addition to serving veterans and other military family members, when possible.
• Utilizing a multidisciplinary approach that can include several different types of therapies (e.g., music therapy, art therapy, and mental health counseling) and services (e.g., peer-to-peer support groups, activities, and engagement in the community) to promote engagement.
• Orienting programming around opportunities for self-care, meaningful engagement, and connection to other caregivers. Creative arts therapy services can address needs associated with mental health, identity, stress management, and the caregiver/care recipient relationship.
• Providing flexibility in appointment scheduling, hours of operation, and format of service delivery to reduce barriers to engagement.

First, the authors conducted a data and literature review covering the various stressors, challenges, and experiences of service members, veterans, military and veteran family members (including children), and caregivers. In this step, the research team sought out existing peer-reviewed journal articles, white papers, and reports to gather key findings specific to these military-connected subgroups on topics related to health and wellness, mental health, and other population needs, as well as existing clinical and community-based arts and non-arts programs and interventions.

Second, together with key leaders from within Creative Forces, the project team codeveloped a selection matrix of key organizations and individuals across different service delivery settings (e.g., clinical, community, government), target subgroups (e.g., service member, veteran, family member, caregiver, youth), and intervention type (e.g., visual art, music, theater, creative writing, etc.).

Third, the authors held confidential semi-structured interviews with nineteen subject matter experts, purposely elected to represent diverse perspectives about personalizing service and support to the target subgroups. Finally, the project team synthesized and grouped findings from the literature review and expert interviews by target subgroup to summarize existing needs, approaches, gaps, and opportunities for Creative Forces service providers representing arts organizations and creative arts therapists