Mental Health Concerns of Servicemembers
Military sendeemembers of all eras have a heightened risk of mental health issues, especially posttraumatic stress, depression, suicidality and traumatic brain injury Many more senicemembers, ranging from 27% to 44%, encounter significant transitional and reintegration stress when returning to civilian life or leaving the military. Such issues may be related to employment, housing, health, and self-concept (Atucl & Castro, 2018; Morin, 2011).
Many military sendeemembers that do not respond to or avoid traditional office-based therapies seek EACP. As pointed out by Mobbs and Bonanno
(2017), senicemembers may face barriers that limit treatment such as perceived stigma, difficulty accessing quality care, and discomfort with treatment approaches available from the Department of Veterans Affairs (VA) or other military installations. An alternative approach, such as EACP, can minimize these barriers. Many of my military clients report choosing EACP because it did not “feel” like therapy. These clients often feel discomfort sitting in an office that can feel sterile and artificial. Servicemembers report preference for EACP due to it being outdoors and feelings of peace and calm generated by being with the equines.
Social connectedness is an important protective factor in recovery for all servicemembers with mental health issues. Servicemembers who report loneliness reported more severe depression symptoms, increased suicidality, and decreased help-seeking behaviors (Teo et al., 2018). In my clinical experience using REPC, many of the servicemembers I have worked with have reported strong feelings of disconnection, detachment, or distrust in others. Facilitating the servicemember’s connection with their chosen equine can be a crucial first step in supporting recovery from depression and reducing risk of suicidality. These clients often form strong bonds and attachments with their chosen equine. Over time, this bond helps them feel safe to process distressing thoughts and feelings (including trauma) and take risks to initiate connections with other people. As I discuss mental health conditions commonly experienced by servicemembers in the following sections, I will follow the discussion with mention of benefits of EACP in treating such conditions.
Posttraumatic Stress (PTSD)
Posttraumatic stress disorder (PTSD) is considered to be one of the signature wounds of war for servicemembers who have deployed to locations in the Middle East such as Iraq and Afghanistan. The prevalence of PTSD in these servicemembers varies widely across different studies, ranging from 4% to 30% (Hepner et al., 2017a; Hepner et al., 2017b; Reisman, 2016). The prevalence of PTSD in Gulf War veterans is estimated to be 10.1% (Kang, Natelson, Mahan, Lee, & Murphy, 2003). In a recent study on PTSD prevalence in Vietnam veterans, Marmar and colleagues (2015) found the current prevalence of PTSD to be 4.8%, current plus threshold rate to be 10.8%, and lifetime prevalence to be 17.0%. It is important to keep in mind that there are likely many servicemembers who do not meet full criteria for PTSD but experience subthreshold PTSD (in which they meet some criteria for most symptom clusters and experience emotional distress and/or functional impairment comparable to other servicemembers who do meet the full criteria) (Marmar et al., 2015). There arc several mental health conditions that often co-occur with PTSD in military clients including depression, mild traumatic brain injury, anxiety, and substance use disorder (Reisman, 2016).
In working with servicemembers, I have found that REPC and the associated bond formed between the equine and servicemember can be beneficial in reducing intrusion symptoms, especially physiological distress; reducing avoidance of distressing thoughts and feelings; reducing symptoms relating to negative alterations in cognitions and mood, especially in reduction of negative feelings and detachment and increases in interest and positive feelings; and reducing symptoms related to arousal and reactivity, especially irritable and aggressive behavior, hypervigilance, and sleep problems (Shcade, 2015).
Moral Injury (Ml)
Many servicemembers with PTSD also experience moral injury (MI). However, many therapists are unaware that servicemembers can experience a MI without experiencing PTS or PTSD. A client suffering from a MI may experience feelings of guilt, betrayal, grief, shame, sense of meaningless, or spiritual struggle (Koenig, Youssef, & Pearce, 2019). Although distinct from PTSD, the presence of MI can interfere with treatment of PTSD if undetected. Koenig, Ames, and Blissing (2019) described the role of loss of trust, spirituality, and meaning in the treatment of MI. Through interaction with the equine, a servicemember has the opportunity to not only express and process thoughts and feelings directly related to the MI, they can also explore themes related to building trust. Furthermore, the spiritual domain of the REPC approach for EACP allows for exploration of the client’s spiritual identity and challenges within the client’s own spiritual framework while also enabling the client to connect with a sense of meaning or purpose through experiences with the equine.
Frank’s experience with Grande illustrates the power of the human-equine relationship in promoting healing from MI. Frank was a Navy SEAL who had completed numerous deployments during the Gulf War. He presented for EACP after experiencing debilitating symptoms of PTSD and depression that had culminated in a suicide attempt. Frank reported that he no longer knew who he was, and was unable to make even simple decisions such as which cereal to eat for breakfast. Frank had few personal connections with friends or family. He stated that he trusted no one, not even himself. During his first visit to the pasture, Grande approached Frank from across the pasture. He stopped a few feet away from Frank, and reached his nose out to smell Frank. Frank started to reach to pct Grande but stopped himself. He said he did not know if that would be the right decision even though he wanted to touch Grande. Frank was paralyzed by his own indecision and lack of trust in himself. When asked if he wanted to work with Grande again the next week, Frank said he didn’t know. During the next session, Grande once again approached Frank from across the pasture. Frank said that although he couldn’t trust himself, he wanted to trust Grande’s judgment and agreed to work with him. Over time, Frank began to take risks to initiate physical contact and later structured activities with Grande. Frank struggled to stay present during the sessions, as his mind raced with thoughts and worries about how to manage his daily life. Grande responded to Frank’s agitation by becoming restless and disengaged himself. Frank and Grande spent weeks working together to help Frank become present. On one particularly challenging day, Frank suddenly stopped and turned to Grande. He said “I heard him! I don’t know how but I feel like I just heard Grande’s voice telling me that I can do this”. Frank reported feeling comforted and encouraged by this experience and that he felt a new level of closeness with Grande. After this experience, Frank turned a corner in EACP and reported a significant decrease in negative thoughts and feelings about himself and worked towards the creation of a new meaning and narrative for all of his deployment-related experiences.
Depression is another significant mental health concern for servicemembers. Estimates of depression range from 1 % up to 60% in servicemembers presenting with post-deployment health concerns (Hepner et al., 2017b). Furthermore, approximately 55% of servicemembers with PTSD also experience depression. Regarding suicidality, servicemembers who have deployed to Iraq and Afghanistan have a heightened risk compared to the U.S. general population, with deployed servicemembers having a 41 % higher suicide risk of suicide than the general population and non-deployed servicemembers having a 61 % higher suicide risk (Kang et al., 2018). The number of servicemembers who die by suicide each day has increased since 2005. According to the U.S. Department of Veterans Affairs (2019), 16.8 servicemembers died by suicide each day in 2017. Servicemembers who experience moral injury may have a heightened suicide risk (Koenig et al., 2019b). The presence of the equines can enable the clients to feel safe when processing distressing thoughts, feelings, and experiences. The relationship with their chosen equine can enable the client to feel safe and accepted while working to create new meaning and self-identity.
Mild Traumatic Brain Injury (mTBI)
Mild traumatic brain injury (mTBI) is also considered to be a signature wound for Iraq an Afghanistan veterans, with 15-25% sustaining an mTBI (Davenport, 2016). The majority of mTBIs are sustained following exposure to an explosive blast. However, as many symptoms of mTBI overlap with that of PTSD, accurate diagnosis can be difficult (Hayes, 2019). Clients who experience comorbid PTSD and mTBI can experience compounding of symptoms and impairment, especially in areas related to daily functioning and self-concept. Interventions in EACP that focus on promoting cognitive skills (e.g., decision-making, social skills, and problem-solving) while also addressing client identity and self-concept arc especially helpful. In working with clients with service-connected mTBI, I have found the equines to be particularly helpful in assisting these clients in relearning facial cues and social skills, building confidence and decision-making skills, and making connections between bodily sensations and emotional experiences. For many such servicemember clients, the equine’s accepting, empathic, and authentic way of being enables these clients to feel a sense of worthiness in navigating life’s new challenges and redefining self-identity.
Military Sexual Assault (MST)
Military sexual assault (MST) is defined as “both sexual harassment and sexual assault that occurs in military settings” (Street & Stafford, n.d.). Clients who have experienced MST arc more likely to experience mental health concerns such as PTSD, eating disorders, dissociative disorders, personality’ disorders, anxiety, and depression (Kimerling, Gima, Smith, Street, & Frayne, 2007). The prevalence of MST is difficult to identify, but it is estimated that between 23.6% to 52.5% of female servicemembers and between 1.9% to 8.9% of male servicemembers have been the victims of MST (Wilson, 2018). Survivors of MST face unique challenges such as not being believed or blamed by others, and/or having to continue working in proximity to their perpetrator. Furthermore, MST survivors may feel a heightened sense of betrayal, especially if they worked closely with or perceived the perpetrator as family. This experience can lead to numerous interpersonal difficulties with trust, feeling safe, and setting boundaries. MST survivors often experience self-blame, shame, low self-worth, difficulty with decision-making, and guilt. The primary needs of an MST survivor are to experience safety, feel in control, and find meaning (Foynes, 2016).
The relational focus of the REPC approach makes this a useful intervention in meeting many of the needs of MST survivors. For many MST clients, the presence of the equine can enable the client to experience a sense of safety’ and protection. In fact, many of my clients with MST have deliberately chosen the largest equine in the herd, citing an increased feeling of protection. Additionally, interaction with their chosen equine can provide opportunities for the client to practice relational skills, such as building trust and setting boundaries, leading to a sense of empowerment and control by being able to communicate with and gain cooperation from such a large animal. The equine’s interest in and acceptance of the client can challenge negative self-perceptions and strengthen the client’s self-concept.