Mental Health Concerns in Military Dependents

It important to keep in mind that military dependents (i.e., children and spouses) are also at a heightened risk for mental health problems including anxiety, depression, behavioral problems, and psychological stress (Esposito-Smythcrs et al., 2011). Military families experience unique challenges associated with the deployment cycle. For this reason, group counseling formats may be especially helpful for some clients to help them build connections with others who have shared experiences. Military children and teenagers benefit most from approaches that focus on building support and coping skills (Esposito-Smythers, 2011). Additionally, spouses and children of servicemembers with PTSD may be at risk of developing secondary traumatic stress (Dichlc, Brooks, & Greenberg, 2017) or child behavior problems (DeVoe, Kritikos, Emmert-Aronson, Kantor, & Paris, 2018). The REPC approach’s focus on the relationship with the equine can enable children to experience a greater sense of support and acceptance through this relationship. The child has the opportunity to practice a wide range of skills in working with the equine, such as problem-solving, communication, conflict resolution, and calming to help manage stressors and mental health problems associated with the deployment cycle. Finally, it is important to consider that surviving spouses and children of deceased sendeemembers arc more likely to experience complex grief and have unique needs that differ from other types of grieving clients, especially in the case of loss due to combat (Cozza et al., 2017) or suicide (Harrington-LaMorie, Jordan, Ruocco, & Cerci, 2018).

Mental Health Concerns Related to COVID-19

At the time of writing this section (May 2020), restrictions in the United States arc becoming increasingly relaxed while projected cases of and deaths from COVID-19 continue to rise. Pandemics have much in common with other types of disasters such as impacting entire communities, being unpredictable, resulting in fatalities, and continuing effects after the immediate danger has passed. However, unlike other disasters that encourage communities to physically come together for support and rebuilding, pandemic response is marked by separation and isolation (Sprang & Silman, 2013). COVID-19 is a global pandemic impacting individuals across ethnicity and socioeconomic status worldwide. It is crucial that attention to mental health needs is not overlooked. It is likely that the mental health impacts will be both acute and also long-lasting after life begins to normalize again (Galea, Merchant, & Lurie, 2020).

There is currently a limited amount of literature on the mental health needs of people experiencing a pandemic than other types of disaster-related mental health research and resources. Previous epidemics have been correlated to increases in posttraumatic stress disorder, stress, anxiety, and psychological distress (Galea et al., 2020). Individuals with preexisting mental health conditions are especially vulnerable to increased emotional distress and maladaptive behaviors (Cullen, Gulati, & Kelly, 2020). Societies are also at risk of increases in substance abuse, domestic violence, and child abuse (Galea et al., 2020). Loneliness is another significant threat to mental health and may be especially pronounced in older adults who practice social distancing more stringently (Galea et al., 2020). It is likely that many clients will also experience grief and loss not only from the death of and separation from loved ones but also for the loss of daily life and routines during times in which local restrictions and social distancing measures arc in place. However, even after these measures are relaxed or lifted, life may not return to the way it previously was and many clients will grieve this loss as well.

The impact of quarantine itself can lead to stress, depression, difficulty sleeping, fear, and confusion among children, adolescents, and adults (Golber-stein, Wen, & Miller, 2020; Pfeffcrbaum & North, 2020; Wang, Zhang, Zhao, Zhang, & Jiang, 2020). These effects may be more pronounced due to prolonged quarantine periods, financial stress, and fear of not having adequate supplies to meet basic needs. Finally, it is important to note that the secondary’ effects of social distancing may influence an increased rate of suicide. Reger, Stanley, and Joiner (2020) identified factors influencing risk of suicide as economic stress, social isolation, decreased access to community' and religious support, barriers to mental health treatment, illness and medical problems, national experience of anxiety, and an increase in firearms sales.

Individuals most at risk for the psychological distress related to the pandemic include those who contract the disease, older and/or immunocompromised individuals, individuals with preexisting mental health conditions, and essential workers (Pfeffcrbaum & North, 2020). Individuals who contract and recover from pandemic diseases are at greater risk of developing PTSD. Survivors with pandemic-related PTSD are also more likely to experience psychological distress and impaired social functioning years after receiving treatment (Hong et al., 2009).

Healthcare professionals, especially' those working in emergency or critical care facilities, are especially vulnerable to negative impacts on mental health due to anxiety and fear of contracting the virus or passing it on to significant others, feeling stigmatized, negative feelings about their job, and high stress (Cullen et al., 2020; Lai et al., 2020). Nurses may' be at an even higher risk given that they tend to have the most frequent close contact with patients. These healthcare professionals are also at risk of experiencing moral injury (MI). As described in the section on military clients, MI results from experiences or actions that violate an individual’s sense of their moral code and places these professionals at an even higher risk of depression, PTSD, and suicide (Greenberg, Docherty, Gnanapragasam, & Wessely, 2020). These professionals may experience profound feelings of sadness, guilt, shame, and anger. It is critical that therapists working with frontline healthcare professionals are experienced in identifying and treating trauma. Based on research on military families, it is likely that family members of healthcare and other essential workers are at a heighted risk for secondary' trauma based on the essential worker’s exposure to stressful experiences (Dirkzwager, Bramscn, Ader, & van dcr Ploeg, 2005; Herzog, Everson, & Whitworth, 2011). In the case of a pandemic and associated quarantine, these effects may be magnified due to lessened social support for both essential workers and their families.

As COVID-19 has impacted people worldwide, it would be prudent for all therapists practicing EACP to be trained in trauma-informed approaches.

All clients should be screened for presence of PTSD due to COVID-19. UCLA (2020) released a free screening tool to evaluate the presence of COVID-19-rclatcd PTSD in children and adolescents. Assuming it can be provided safely with proper sanitizing and social distancing procedures in place as needed (see Chapter 12), EACP may provide a less risky alternative to receiving office-based counseling as EACP sessions take place outdoors with greater opportunities for social distancing. Facilitating opportunities for clients to build connection with the equines can increase perceived social support and reduce loneliness. In addition, EACP can help clients to develop coping skills and providing opportunities for self-care (Pfefferbaum & North, 2020). For children, interventions focused on encouraging expression of feelings and strengthening the parentchild relationship can best support child clients and reduce the risk of developing or worsening serious mental health issues (WHO, 2020).

Finally, therapists should be aware of the potential for impacts on the session itself. For example, clients may feel more on edge or anxious while onsite if they are worried about contracting a disease. As many organizations highly recommend wearing masks when providing in-person services, the therapist should consider how restricting facial expressions may impede the counseling process as the client cannot read the therapist’s facial expressions and the therapist cannot read the client’s as accurately The result may be increased misunderstandings and frustration on the part of both the client and therapist. However, as pointed out to me by an intern, wearing a mask may have a silver lining in that it may encourage some clients to verbalize their thoughts and feelings more directly in order to be understood.

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