Stories - Blogs

By Brian Ludden, Ed.D., LMHC, LPC

When the world shut down in 2020, I found freedom and healing not in my living room—but in a forgotten forest, as a chaotic hero with a big sword and even bigger self-doubts.

It is early March of 2020, and an unprecedented event is taking place around the world. A global pandemic on a scale that few living today have ever experienced has halted daily life as we know it. The world has shut down and for many of us the way we interact with our jobs has changed drastically.

It was probably about six months into the pandemic that I realized how much the isolation and separation were degrading my mental health. I felt, much like many, a longing for connection, conversation, and to just be with other people. As the pandemic pushed on, my mental health further declined, and my depression became more and more apparent.

In September of 2021, a former colleague and now friend of my partner reached out and asked us if we would like to join a D&D (Dungeons & Dragons) group they host that plays online weekly. Neither of us had ever played D&D, but as fans of the sci-fi and fantasy book and movie genres, it was not a hard sell. We joined our first session, often referred to as Session Zero, where we talked about the type of character we would want to play, picked our class (what type of player we are), and developed back stories. The DM (Dungeon Master also sometimes referred to as a GM or Game Master), gave us a bit of back story for the campaign and walked us through the mechanics of the game.

After that first session, I was hooked. Now four years later, we are playing two times a week, and in three different campaigns (one of which I am the DM for). In D&D I have found an outlet, an escape, and a community that I never expected to find. One of the things that I enjoy the most about D&D is how, as a group, we all craft the story and drive the direction of the campaign. The DM is the guide, but we are all storytellers.

I have no doubts that joining this D&D group and playing weekly is what helped me get through the isolation and sadness that was brought on by the pandemic. This group and this game provided me an outlet for my stress and frustration, a distraction from the responsibilities of daily life. It helped me improve my ability to compartmentalize my life and my day which over time had struggled from a blending of my work and personal lives.

Fast forward to December of 2024, I was attending a Behavioral Health Summit in Manchester, New Hampshire and had the opportunity to sit in a session about TA-RPG (Therapeutically Applied Role-Playing Games), something I had never heard of.

While many are familiar with tabletop games, like Dungeons & Dragons as hobbies, TA-RPGs use these same frameworks within a clinical context to promote therapeutic growth. TA-RPGs are designed to help facilitate social connectedness, explorations of identity and self-concept (through game character development), and practice with coping strategies and mindfulness in a safe and controlled environment. TA-RPG is based on Frame Theory and provides multiple frames for a patient to engage, including the players existing in the real world, the rules and norms of the game, the perspective of the player character, and the ability to see and experience situations from an alternate perspective or roleplaying scenario. 

Frame Theory posits that individuals can interact with a story through multiple lenses—simultaneously navigating reality, game mechanics, and character embodiment. This allows for reflective distance and emotional safety during difficult therapeutic content. For instance, in the two campaigns that I play in, I play two very different characters: one is very confident and sure of himself, he lacks fear, is quick to run in and save the day and he thinks of consequences only after the fact; the other is quite the opposite, she is reserved, quiet, and calculating, often taking time to think about every possible outcome of hers and the group’s decisions and actions. In both characters there are facets of my personality, but each of them embodies something different, something that perhaps I want for myself, or that I try to avoid. When playing these characters, I get to explore life circumstances from a perspective that is different than the way I (Brian) would typically perceive them. There is so much power in being able to change our perspective, especially when cognitive dissonance keeps us stuck in a misinterpretation of the world around us, feeding into our experiences of depression, anxiety, and even trauma.

There has been recent research into TA-RPGs and their associated benefits, specifically with veteran populations as a means of addressing post-traumatic stress in a new and novel way. The Minneapolis VA partnered with a program called “Roll for Growth” which has shown to be effective in reducing depression, aggression, anxiety, and social avoidance after just 12 weeks of gameplay. Another program “Hope for the Warriors” utilized D&D to help combat social isolation during the pandemic to foster camaraderie and connection among veterans struggling with their mental health.

As a clinician, I am always looking for ways to engage clients in therapy and have found the creative and expressive therapies to be particularly good at ‘cracking the shells’ of some of those more resistant clients, especially the military ones. If you're curious about how TA-RPGs might fit into your own clinical toolbox, the best way to start is by sitting down at the table, whether that is virtually or in person. You might look for a local or online D&D group to join to get a feel for the mechanics of the game, character interaction, and collaborative storytelling. D&D groups often welcome beginners, and there's no substitute for firsthand experience. Finding a D&D group can often be accomplished by visiting a local gaming store and comic shop for in-person games, or by searching online forums for virtual groups. You can also watch videos of D&D play from YouTube channels like Critical Role, and Dimension 20 to further familiarize yourself with gameplay and story-telling. Once you’ve immersed yourself in the world of roleplaying, consider pursuing more formalized training through organizations like Game to Grow or Geek Therapeutics. Who knows, you might even find that that your next therapy tool isn't on a bookshelf—but in a dice bag.

Dr. Megan Connell has written an excellent book called “Tabletop Role-Playing Therapy: A Guide for the Clinician Game Master” which is a helpful resource for clinicians that are interested in learning how TTRPGs (Tabletop Role Playing Games) can be used in clinical settings, and how gaming impacts clients’ experiences.

Additionally, Geek Therapeutic offers a 36-hour Therapeutic Game Master Course that teaches you everything you need to know about running Therapeutically Applied Role-Playing Games with clients.

Gone are the days of leather sofas, stuffy offices, and “How does that make you feel?” questions, now is the time for innovation in therapy, and what better way to engage clients in treatment, especially our veteran and service member populations than through game play. Go forth and conquer those dragons, and may all your dice rolls be Natural 20s!

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Brian Ludden, Ed.D., LMHC, LPC, , is a Military Behavioral Health Counselor at the Center for Deployment Psychology (CDP) within the Uniformed Services University of the Health Sciences in Bethesda, Maryland.

Suggested Reading and Resources:
 Baker, I. 1., Turner., I. J., & Kotera, Y. (2022). Role-play games (RPGs) for mental
 health (Why Not?): Roll for initiative. International Journal of Mental Health and
 Addiction, 21, 3901-3909. https://doi.org/10.1007/s11469-022-00832-y
 Connell, M. A. (2023). Tabletop Role-Playing Therapy: A Guide for the Clinician
 Game Master. Norton Professional Books
 Kilmer, E. D., Davis, A. D., Kilmer, J. N., & Johns, A. R. (2023). Therapeutically
 Applied Role-Playing Games: The Games to Grow Method (1st eds.). Routledge
www.GeekTherapeutics.com

• “We offer evidence based certifications to clinicians, social workers, professionals, parents, teachers, and students on how to use Geek Therapy to unlock the best version of your clients and ourselves. We bridge the gap between geeks and therapists to create practical and innovative therapy sessions that anyone can implement in their practice.”

www.GameToGrow.org

• “Game to Grow was originally founded in 2017 by Adam Davis, MAEd, and Adam Johns, LMFT. Davis and Johns met in graduate school at Antioch University Seattle and began using games to improve lives in 2011. They combined their respective training and expertise in family therapy, education, and drama therapy with their years of experience as gamers and facilitators to develop what would become the Game to Grow Method of Therapeutically Applied Role-Playing Games. For several years Davis and Johns ran a small two-person operation serving youth in the greater Seattle area. After four years running these groups, along with their respective other work in public schools and in therapeutic practice, Davis and Johns founded Game to Grow to expand the impact of the game-based methods they had developed.
  
           Game to Grow officially launched via a successful crowdfunding campaign and was able to hire and train new facilitators to expand services. In 2020, as a response to emerging challenges related to COVID, Game to Grow shifted groups virtual. Now no longer confined by geographic regions, group services expanded to meet the need of participants worldwide. Around the same time, demand increased for training in Game to Grow’s unique approach, and our training program was launched. Game to Grow has now provided training and support to over 1,200 professionals..

By Heather Tompkins, Ph.D, MS-ATR, LCMHC

As Month of the Military Child (April) comes to an end and Military Spouse Appreciation (May) begins, I have been reflecting on my experience as a military spouse. The old adage, “it takes a village” comes to mind in relation to these experiences and how “my village” has helped me cope with the challenges of military life. With another pending PCS and not looking forward to the stress of moving, I take pause to appreciate the opportunities for new connections each duty station has brought. Research has shown service member retention is higher when their spouse feels supported, has a sense of belonging within the military community, and is satisfied with military life (Wang, et al., 2015; O’Neal, et a., 2020). From my experience, finding “my village” has become an important part of my military life to provide a sense of belonging and connect with others who understand.

I grew up near a military base and told myself “I would never marry military”. I learned “never to say never”, as I found myself some years later marrying a Marine. I joke that our start was the Marine Corps warning to young Marines of “what not to do”. A nine-month whirlwind of meeting, dating, engagement and marriage. This was accompanied by work-ups prior to our wedding and a departure for deployment roughly a week after we said “I do”. I was left in unfamiliar territory in my new role as a “military spouse” and uncertain how to navigate this first deployment. I not only needed support, but connection to others who understood what I was experiencing. 

Randomly while on base, I overheard someone talking about kickball. I hadn’t played kickball since elementary school, but I was intrigued as to what “SLAKA” (Spouses Lejeune Area Kickball Association) was. I messaged to find out more and was connected to the team affiliated with my spouse’s unit- the Lady Spartans. I can remember showing up to that first practice and immediately feeling welcome. I made it through my first deployment as a military spouse and wore the neon pink and blue jersey for two seasons before we PCS’d. It was through this first encounter with other spouses in the kickball league that I found a sense of belonging within the military life. Five PCS and twelve kickball seasons later, I turned in my coach’s hat and rounded the bases with my “last kick”- still feeling that same sense of belonging as I had started with many years before.

To outsiders, a spouse kickball league may seem like a trivial pastime, but for myself (and most spouses who play), it was more than a pastime. The teams consisted of new and “seasoned” spouses, stay-at-home parents, career-driven individuals, those with/without kids, and active duty; all military spouses and all equally valued. We not only benefitted from having kickball as an outlet, it allowed us to build supportive relationships. These friendships/relationships provided a sense of belonging that extended far beyond the fields. Research on military culture has found that social support can moderate the impact of life stressors on family well-being by offsetting stress/strain (Verdeli, et al., 2011). Whether it was a deployment, planning for an upcoming PCS, or job searching (yet again), my teammates were able to share in these experiences from a place of mutual understanding and support. Both on and off the field my time with these amazing women helped me understand the resiliency developed through this lifestyle, but also how important it is for military spouses to have these relationships and networks to rely on.

Although my kickball days are on pause, I still have my cleats, jerseys and hoodies that serve as reminders of my fun-filled days “kicking balls”. More importantly, I have the memories and relationships that helped me find “my village” in this military life. The sense of belonging and the support I received over the seasons helped me to cope with the unique challenges military life brought. Who knows, I may still have a few more “kicks” in me. For now, I cherish my memories and have a deep appreciation for the military spouses who helped to create them.

*A special thanks to all the military spouses out there who continue to “kick it” and create a sense of belonging both on and off the field for military spouses.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Heather Tompkins, Ph.D, MS-ATR, LCMHC, is a Military Behavioral Health Psychologist with the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. In this role, she provides oversight and fosters collaboration for creative arts related research projects in partnership with the Defense Intrepid Network.

References
 Green, S., Nurius, P., & Lester, P. (2013). Spouse psychological well-being: A keystone to military family
          health. Journal of Human Behavior Social Environment, 23(6).
          doi: 10.1080/10911359.2013.795068.

O’Neal, C., Richardson, E., & Mancini, J. (2020). Community, context, and coping: How social connections
          influence coping and well-being for military members and their spouses. Family Process, 59(1), 158-172. https://doi.org/10.1111/famp.12395.

Verdeli H, Baily C, Vousoura W, Belser A, Singla D, Manos G. (2011). The case for treating depression in
          military spouses. Journal of Family Psychology, 25(4):488–496. doi: 10.1037/a0024525.

Wang, M., Nyutu, P., Tran, K., & Spears, A. (2015). Finding resilience: The mediation effect of sense of
           community on the psychological well-being of military spouses. Journal of Mental Health Counseling, 37(2), 164-174.

By Allison Hannah, MSW, LCSW

I’m a military spouse—a dependent, as we are often referred to in the military community. That word frequently comes with a sting, implying passivity, lack of contribution, and sometimes even entitlement. But my story, like many others, is much more complex than being defined by a label. 

I met my spouse while I was serving on active duty, and for a brief time, we were a dual military couple. When I transitioned out of service, I stepped into a new role—one I thought I understood from years in uniform but quickly learned was far more complex.

I still remember arriving at our first duty station in my new role. Suddenly, it wasn’t my social security number I needed to rattle off at medical appointments or during moving chaos—it was his. The identity shift was subtle yet seismic.

My journey into military spouse life was slightly different because I wasn’t marrying into the unknown—I was already immersed in the military culture. I wasn’t lost in the language of acronyms, and from serving as an officer in the Adjutant General Corps, I had a solid understanding of protocol. Still, no amount of prior knowledge could genuinely prepare me for what it meant to acculturate not as a service member, but as a spouse.

Recently, while conducting the literature review for another project, I came across a 2024 article titled “‘The Culture’ Is Truly the Issue: A Preliminary Exploration of Active Duty Female Spouses’ Acculturation to Military Life” by Amy Preston Page, Abigail M. Ross, and Phyllis Solomon. It struck a chord with me, especially in highlighting the very different, yet equally essential process of military spouse adaptation. Whether you come in with combat boots on or fresh eyes and an open heart, the adjustment to this world—its norms, expectations, and unspoken rules—is real. How we adapt, resist, or reconcile with that culture shapes our experience as spouses and our sense of self.

Never Have I Ever…
 Do you remember playing the game “Never Have I Ever” when you were younger, maybe in high school or college? I usually “won” back then because I lived a relatively tame life. The premise is simple: hold up five fingers, and one by one, say, “Never have I ever…” followed by something you haven’t done. As a participant, if you have done it, put a finger down. It’s fun, sometimes embarrassing, and always revealing.

But here's the thing: as we grow older, the game of life becomes more complex. Our life adventures accumulate, and for military spouses, you realize you have experienced many things that most people wouldn't believe.

So, if you’re ever playing with a mix of civilians and military families, here are a few prompts that might stump the room—or spark some serious bonding. And please, make time to hear our stories—sharing our experiences is truly special to us.

Never have I ever… listed someone I’ve known for less than 48 hours as my child’s emergency contact.
 Constantly moving, a trademark of military life, means filling out school or daycare emergency contact forms before the boxes are even unpacked. Within days of arriving, you’re already asking your brand-new neighbor if they can be your person if there is an emergency with your children. It sounds wild, but it’s also a beautiful example of instant community—something many of us treasure.

A few years back, my family and I were among the first to move into a brand-new neighborhood after a base expansion. Upon arrival, we were one of three families on the block. In those first few days on the base, with two very young children going into daycare the following Monday and myself returning to work, I desperately needed at least one person’s name and number I could share with the daycare staff. After a 15-minute conversation with one of my new neighbors who lived across the street, I said, “I know this is awkward, but my girls are starting daycare on Monday. Would you be comfortable sharing your phone number with me and letting me list you as a contact?” Her gracious answer was, “Of course, and could I get yours to do the same for our girls?” That same neighbor I hesitantly asked for her phone number became one of my dearest friends. That story may sound improbable, but it’s one of the many ways military spouses adapt and thrive—even when dropped into unfamiliar environments. With nearly 80 families arriving in the same summer, it felt like building a village from scratch. We met on sidewalks, shared folding chairs in the driveway, swapped moving tips, and looked out for each other’s kids.

As one spouse commented in the article, “I not only survived but also thrived” (Page et al., 2024, p. 10). That line sums it up perfectly.

Never have I ever… had my driver’s license, car registration, and current address all from different states.
 Military life turns you into a logistics expert—frequently juggling paperwork across state lines. Imagine being at a duty station for a few weeks, running low on gas, standing at the gas station pump, and realizing you can’t remember which zip code is tied to your credit card. Was it the last duty station? Have I already updated it for our new address? Or is this one still tied to that more permanent address that we sometimes use at my husband’s parent’s house? That small moment perfectly captures the “Where even are we right now?” chaos that’s so normal in this life.

When meeting someone new, we often get asked, “Where are you from?” and I usually laugh before launching into: “Well, I was born in Minnesota, my husband is from Texas, we met in South Korea, our oldest was born in Louisiana, our youngest was born in Georgia— I guess we’re really from all over…”

That’s the beauty of military life—it stitches together people from all corners of the world into one community. And with that, we build bridges between cultures, backgrounds, and beliefs.

This idea closely reflects what the article calls the “integration” strategy of acculturation—those of us who learn to navigate both military and civilian life, honoring where we came from while embracing where we are now. As one spouse reflected, “The reality is that I have become half-military... I’m not sorry or resentful. But, I am different” (Page et al., 2024, p. 10). And in many ways, we’re stronger for it.

Never have I ever… had a friend not be frustrated with me for bailing on plans at the last minute.
 When one of my good friends was stationed in Germany, her husband was at a field exercise during her birthday week. She wasn’t sure if he’d make it home in time, so her friend made special birthday plans to celebrate her—knowing full well she might cancel. Although it was unlikely, my friend’s husband returned on her birthday, surprising her by getting home just in time, which often does not happen. She called her friend and apologized for needing to cancel, and instead of frustration, her friend was thrilled for her. There was no guilt, no awkwardness—just joy and understanding.

This is the kind of support that quietly lives in the background of military life. We get it. We’ve all been there. Many of us, in our own ways, have struggled with what the article calls acculturative stress—navigating unfamiliar norms, finding our people, and making peace with a life full of unpredictability (Page et al., 2024). But stories like this remind us that we aren’t doing it alone.

For those outside the military community, these stories may sound fabricated. But for us, they’re just a Thursday. They represent the resilience, flexibility, and strange beauty of a life lived in service—not just by our partners but by all of us.

And maybe that’s the biggest surprise of all. Because somewhere along the way, these weird, exhausting, often lonely moments become shared experiences. They become the things we laugh about at coffee meetups or send memes about late at night with a friend who gets it.

Military culture for spouses isn’t about fitting into a mold. It’s about building your own identity while navigating a culture that doesn’t always make space for you right away. Whether we integrate, resist, adapt, or forge our way, our experiences are valid. They matter. And they shape communities that are stronger, wiser, and deeply compassionate. 

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Sciences or the Department of Defense.

Allison Hannah, MSW, LCSW is a Military Behavioral Health Social Worker at the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.

Reference:
 Page, A. P., Ross, A. M., & Solomon, P. (2024). "The culture" is truly the issue: A preliminary exploration of active duty female spouses' acculturation to military life. Families in Society: The Journal of Contemporary Social Services, 1–16. https://doi.org/10.1177/10443894231211357

By Jessica Strong, Ph.D.

As a military spouse, mother of three extraordinary military children, and researcher on military families, I know military families and children are resilient. Like many other military families, our story includes cross-country and global moves, navigating the emotional terrain of multiple deployments, making friends and moving away from them, and growing through it all. However, personally and through my research, I also know that resilience isn't an innate characteristic; it's a dynamic quality that is carefully cultivated. It hinges on the challenges we face and our ability to overcome them, the strength of our family bonds, and the physical and mental well-being of each member. Crucially, resilience is also profoundly reliant on our access to vital resources, including financial stability, robust social support networks, and dependable healthcare.

Dependable healthcare may be even more important, and challenging to military families with children who have mental health, emotional, developmental, or behavioral (MEDB) concerns. In the U.S., about 22% of children have a disorder of mental health, emotion, development, or behavior (Rethy & Chawla, 2022). More recently, half of military spouses report they have at least one child that has an impairment, disorder, or disability (not restricted to MEDB concerns; Blue Star Families, 2022). I am one of these spouses; I have kids with ADHD and autism.

If we want military families - including military service members - to remain resilient, we must ensure those support systems that undergird their resilience remain strong. One critical area ripe for improvement is the military healthcare system. The recently released Blue Star Families’ 2024 Military Family Lifestyle Survey paints a concerning picture: while healthcare benefits are a significant incentive for families to remain in the military, the struggle to access that very care is a major factor pushing families to consider leaving (Blue Star Families, 2025). In fact, nearly half (49%) of active-duty service members who planned to stay in longer than they originally intended cited healthcare benefits as a key reason they would stay (Blue Star Families, 2025). Yet, a significant portion of active-duty family respondents also identified the inability to access healthcare as a primary driver for potentially leaving the military (Blue Star Families, 2025), although military parents of children with special healthcare needs tend to serve longer than military parents of children with no chronic conditions (Perkins et al., 2023).

Access to healthcare for military families is becoming more challenging. “Healthcare access” is an escalating concern for military families, with the percentage of active-duty families ranking it as a “top concern” doubling from 11% in 2020 to 22% in 2024, though it did drop slightly from 28% in 2023 (Blue Star Families, 2025). While the military provides healthcare through TRICARE and the Defense Health System, the very nature of military life often creates significant barriers to accessing this care, particularly for families with children who have MEDB needs. Each move for these families necessitates finding new providers who accept TRICARE and have availability, navigating different state or regional regulations for special education and support services, and establishing new relationships with therapists, specialists, and support groups. Research comparing TRICARE, commercial, and public insurance found that caregivers utilizing TRICARE were more likely to report needing care coordination and experiencing greater frustration in obtaining necessary services (Hero et al., 2021). The study also highlighted that children who experienced more frequent moves and those with special healthcare needs faced the most significant difficulties in accessing care (Hero et al., 2021).

Several factors contribute to the growing challenges military families face in accessing care. We are seeing a shrinking network of qualified civilian providers, especially those willing to accept TRICARE (National Center for Health Workforce Analysis, 2023), coupled with limited pediatric specialty care availability at military treatment facilities. For families with children with MEDB concerns, this translates to significant difficulties in finding qualified specialists and accessing essential therapies. The 2024 Blue Star Families survey further illuminates the specific struggles in accessing mental health care for children. Among families with children, 20% of active-duty family respondents report their child currently receives mental health care, while 13% report wanting care for their children, but being unable to obtain it (Blue Star Families, 2025). A shocking 42% of those who want mental health care for their children, but cannot access it, cite the inability to find an available provider who will treat them. Even when families can locate a TRICARE provider within a 50-mile radius, nearly half (44%) encounter waitlists or are unable to schedule an appointment. For those placed on a waitlist for their child’s mental health care, a staggering 9 in 10 waited more than three months for care (Blue Star Families, 2025).

Complicating these ongoing issues, TRICARE beneficiaries and providers have faced significant disruptions due to the rollout of new contractors in the East and West regions in early 2025. In the East, a switch in claims processors led to widespread payment delays for healthcare providers, particularly mental health professionals, causing some to consider limiting or ceasing services for TRICARE patients (Kime, 2025). Beneficiaries in the West experienced difficulties with enrollment, payment processing, accessing customer service, and obtaining timely specialty care referrals due to the new contractor, TriWest. These transitions have caused stress, confusion, and potential delays in necessary medical care for beneficiaries, while providers have struggled with unpaid claims and administrative burdens, threatening their ability to serve military members and their families.

These statistics underscore why the work being done here at the Center for Deployment Psychology and within the DoD Child Collaboratory is so important. Through an interdisciplinary, cross-sector collaboration of stakeholders, including researchers, providers, non-profits, and government, the group works to extend and enhance care for military kids, regardless of their geographic location. By implementing strategies such as telementoring and tele-education for providers, expanding telehealth services for families, and providing digital tools and on-demand training, the project works to address the gaps in care and ensure that military children receive the right care at the right time, from the right people.

While the healthcare benefits provided to military families are often cited as a reason to recommend military service or to remain in the military longer (Blue Star Families, 2023), these benefits become meaningless when families cannot access them due to long waitlists, insurance problems, or a lack of qualified providers. That's why the work of the Collaboratory resonates so deeply with me. Our commitment to creating specialized trainings for providers to better understand our military children and their needs, building vital collaborations, and exploring innovative technologies to improve access feels like a direct response to the challenges my own family and countless others have faced.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Jessica Strong, Ph.D., is a military family researcher specializing in the well-being of military and veteran families, serving as a Military Behavioral Health Child Social Worker at the Center for Deployment Psychology (CDP) at the Uniformed Services University for the Health Sciences in Bethesda, Maryland. In this role, she supports the DoD Child Collaboration Study to identify best practices for enhancing and expanding accessibility to care for military-connected children and adolescents.

References:
 Rethy, J., & Chawla, E. (2022). How pediatricians can help mitigate the mental health crisis. Contemporary PEDS Journal, 39(2). https://www.contemporarypediatrics.com/view/how-pediatricians-can-help-mitigate-the-mental-health-crisis
 Blue Star Families. (2022). 2021 Military Family Lifestyle Survey. https://bluestarfam.org/wp-content/uploads/2022/03/BSF_MFLS_Results2021_ComprehensiveReport_3_22.pdf
 Blue Star Families. (2025). 2024 Military Family Lifestyle Survey. https://bluestarfam.org/wp-content/uploads/2025/02/BSF_MFLS24_Comp_Report_Full-v2.pdf
 Perkins, E. M., Sorensen, I., Susi, A., & Hisle-Gorman, E. (2023). The Impact of Having a Child With Special Healthcare Needs on Length of Military Service. Military Medicine, 188(5-6), e1246-e1251. https://doi.org/10.1093/milmed/usab495
 Hero, J. O., Gidengil, C. A., Qureshi, N., Tanielian, T., & Farmer, C. M. (2022). Access to Health Care Among TRICARE-Covered Children. Rand health quarterly, 9(4), 18.
 National Center for Health Workforce Analysis. (2023). Behavioral health workforce, 2023. https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/Behavioral-Health-Workforce-Brief-2023.pdf
 Kime, P. (2025, February 4). Mental health providers in Tricare East go unpaid after claims processor switch. Military.com. https://www.military.com/daily-news/2025/02/04/mental-health-providers-tricare-east-go-unpaid-after-claims-processor-switch.html
 Blue Star Families. (2023). 2022 Military Family Lifestyle Survey. https://bluestarfam.org/wp-content/uploads/2023/03/BSF_MFLS_Spring23_Full_Report_Digital.pdf

By Debra Nofziger, Psy.D.

Culturally, we use the word “tired” to describe so much – being mentally and/or emotionally drained, overly frustrated, sleep deprived, physically spent, and lots of stuff in between. These states are not caused or cured by the same thing. But they can basically be divided into two categories – tiredness/sleepiness and fatigue. This difference isn’t something I had ever considered before being diagnosed with Multiple Sclerosis. But, given one of my most prevalent symptoms of MS is fatigue, I soon realized just how much people don’t understand the difference.

What is the difference? Google’s AI overview actually does a good job describing this: “Tiredness makes you feel sleepy; fatigue makes you feel worn out but not necessarily sleepy.” Tiredness/sleepiness is a temporary state fixed by sleep. Fatigue is a more long-lasting feeling of being drained that persists despite adequate sleep/rest. I explain fatigue as that feeling you get after a cross-country airplane trip, or better yet, transatlantic. You get to your final destination and collapse on the hotel bed, absolutely drained. But you aren’t tired, so you aren’t going to sleep. You simply have absolutely no energy left. Regardless of how much the kids want to go to the Disneyland park immediately upon arrival, they are out of luck!

To make matters more interesting in my particular case, insomnia is also widely prevalent with MS. A recent meta-analysis looking at sleep disorders and MS showed that 1 in 2 adults with MS endorsed poor sleep quality and 1 in 5 were diagnosed with insomnia. Many other neurological disorders, from MS to long covid, have higher rates of insomnia along with fatigue. I am one of the unlucky ones who now has both – random bouts of insomnia and chronic, debilitating fatigue. How do I stay functional through the fatigue? A steady dose of stimulants – something that can rapidly mess with my sleep and trigger insomnia. It is an interesting balance that I manage. And a common conundrum faced by many who have both.

As a clinical psychologist, and one of the CDP instructors who teaches CBT for Insomnia, I find it interesting how little we talk about what to do for patients who experience fatigue but not insomnia, or for patients who have both. Many of our patients have underlying medical conditions, from MS to long Covid, and their fatigue and/or tiredness is enmeshed with their other behavioral health symptoms, like depression and anxiety.

I think a starting place for all of us is making sure our assessment is correct in that we are assessing for both tiredness/sleepiness and fatigue and recognizing that these can be caused by different things. The usual tools can be confusing for this. For example, the Insomnia Severity Index (ISI) is widely used to screen for sleep problems and it does a good job for this in general. But it depends on the patient understanding the difference between sleepiness and fatigue, and I’ve found many do not. If I feel drained of energy all day, I might assume that is because my sleep is not good. That would lead me to answer questions on the ISI, or other measures, expressing my dissatisfaction with my sleep and how much that is impairing my life. This, in turn, could lead to a treatment plan including treatment for insomnia, which isn’t going to help general fatigue at all if it is linked to a medical condition.

It becomes even more convoluted when a patient experiences both insomnia and fatigue. Although they aren’t the same thing, the feelings they produce in the body are incredibly similar, if not the same in some cases. So how do we identify which symptom descriptions are linked more to which problem? For example, if I am physically fatigued I feel similar to when I haven’t slept much – weaker and slower in general. If my insomnia is treated and I sleep well, I am still not going to feel rested upon awakening due to my underlying chronic fatigue, so how do I know if I’m “doing better” with better sleep? I’ve noticed that interview forms often mix fatigue and tiredness questions together which is not helpful. True, fatigue can be a symptom of tiredness, but it can also be something completely separate.

The initial challenge for providers is to educate patients on the difference between tiredness and fatigue while they are in the assessment stage and ensure our assessment tools help us distinguish between the two. We must also ask about any medical conditions that may lead to either or both. It is a challenge. Even as a provider with both fatigue and periodic insomnia, I sometimes find it hard to distinguish with patients. But I think the key is to remember this basic truth – if you are tired/sleepy, you can actually lie down and go to sleep. Your sleep drive is high. If you are only fatigued, you won’t sleep because it isn’t linked to your sleep drive.

Treatment planning for tiredness, fatigue, or both is beyond the space I have for this particular blog. But basically, we know that the plan for tiredness will depend on the specific sleep disorder identified (happily, we have good treatments for many of these). The same is true for fatigue – the treatment is going to depend on the underlying medical condition. That is where it gets tricky because there are so many different conditions involved. Medication is a common answer. Behavioral treatments aimed at maximizing and strategically using available energy are also generally used. Unfortunately, behavioral treatments for fatigue are not widely taught or even known about by general providers. They are more utilized within health specialty clinics.

Our starting point is assessment. You have no idea how much rapport and credibility a provider instantly gets from me when, on their own, they acknowledge that tiredness and fatigue are two different things. I instantly think “yes, they get it!” More often than not, however, I am educating my providers on the difference. So please, be sure you are acknowledging the difference. If your patients don’t seem to understand, educate them. That way both of you can explore how to best approach treatment and how to have realistic expectations on treatment outcomes.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Debra Nofziger, Psy.D., is a Senior Military Behavioral Health Psychologist and certified Cognitive Processing Therapy Trainer with the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.

CITATION:
Zeng, X., Dorstyn, D. S., Edwards, G., & Kneebone, I. (2023). The prevalence of insomnia in multiple sclerosis: A meta-analysis. Sleep Medicine Reviews, 72, Article 101842.
https://doi.org/10.1016/j.smrv.2023.101842

By Diana Dolan, Ph.D., CBSM, DBSM

Recently a case was shared with me in consultation that perked my ears up. He had a number of disruptions related to his sleep, including difficulty staying asleep, nightmares, a diagnosis of obstructive sleep apnea (OSA), and a history of two traumatic incidents. Worse, he had started grinding his teeth to the point of wearing through over the counter mouthguards. He was described as an “extreme case” that had failed prior evidence-based treatment and would not likely benefit from say Cognitive Behavioral Therapy for Insomnia (CBT-I).

SGT B is a married early-40s Army SGT who was screened by a behavioral health provider in primary care after a recent visit with his primary care provider. He reports sleep problems for at least several years, and is currently attempting to use continuous positive airway pressure (CPAP) after a polysomnography or sleep study confirmed a diagnosis of OSA a year ago. He falls asleep for a few hours fairly quickly, then wakes up usually between 0200 to 0300 if not sooner, increasingly, but not solely due to nightmares which also started a year ago and seem to be worsening. As he awakens, he is aware of pulling off his CPAP mask. Some nights he will lay in bed for a bit before he musters the motivation to resume, what he describes as “fighting the fight” with his sleep, putting his mask back on until he eventually returns to sleep, which sometimes doesn’t take long, but other nights is an hour or more. Other nights, he does not put the mask back on at all. Recently, he has started grinding his teeth at night, to the point that his teeth are cracked despite wearing a mouthguard. He notes he’s “tried that behavioral stuff” in the past, and is frustrated that it was not very helpful, so does not feel very interested in CBT-I. Oh, and as the appointment was about to wrap up, he admits that earlier in his career, he witnessed some events that friends have told him could be traumatic, but he was reluctant to share.

SGT B’s provider is recently trained in CBT-I, and is concerned his case is so complex and unusual he will not benefit from the protocol. Besides, even if he otherwise would, he says he has already tried behavioral treatment. His provider wants to know, isn’t this case a lost cause?

Interestingly, while SGT B himself probably feels like a lost cause, hopeless and helpless, his situation is not that atypical from what we often see with military-connected patients who have co-morbid OSA, insomnia, and trauma. Let’s unpack everything, starting with OSA as that has been previously diagnosed. He dislikes the CPAP, but denies purposefully removing it as he is half-asleep. It’s not surprising that since he’s not able to use his CPAP regularly, he would still have the associated symptoms, like excessive daytime sleepiness, attention and memory difficulties, and reduced productivity at work. There seems to be a relationship between untreated OSA and nightmares, so his report of increasing nightmares over time, despite what he believes is sufficient CPAP use isn’t too surprising. There also may be a relationship between untreated OSA and bruxism, or detrimental teeth grinding. Mostly, the challenge for SGT B is going to be using his CPAP for more time during the night – which admittedly, is a challenge, if he does not fully realize he isn't doing it.

Next, SGT B clearly has evidence of impaired sleep ability, as even on nights without using his CPAP, he has difficulty, and he will wake during the night at times even without nightmares. Although he says he has tried behavioral treatment, it turns out, he completed a sleep log for a few weeks, but did not get out of bed, as recommended by his previous therapist more than a few nights, and did not stick with a sleep schedule. It is likely his sleep inability, or insomnia, is contributing to taking his mask off as he becomes more aware of it on awakening, as well as contributing to his nightmares as we may remember nightmares more so if we awaken from them.

It also seems SGT B has a strong potential for screening positive for PTSD. Of course, sleep disruption can exacerbate symptoms of PTSD, and PTSD would, in turn, contribute to further sleep disruption and nightmares.

Take a moment to pause here before reading on. What do you think now that you know more details – is SGT B’s case treatable with behavioral interventions? What would you recommend as next steps?

Read on from here if you would like my take. In short, I don’t think SGT B is really an extreme case, even though it probably feels that way to him. He is not alone in the presence of these comorbidities. If he feels up to it, I might recommend a trial of CBT-I with motivational enhancement strategies, clearly assisting him in differentiating this from his prior attempt. I would anticipate if he can sleep more solidly, he will have fewer awakenings and thus fewer instances of pulling off his mask and nightmares. At the same time, I would encourage him to speak with his sleep medicine physician to perhaps find a more comfortable mask and setting option. After CBT-I and optimizing his CPAP comfort, his bruxism may also improve. Once his sleep is improved, he may feel he has the energy and mental resources to explore his trauma history and complete treatment for PTSD, if diagnosed. On the other hand, if he does not feel up to starting with CBT-I, he might be open to starting with a discussion of trauma; evidence-based PTSD treatment would be expected to decrease nightmare frequency, which would reduce associated awakenings and again decrease pulling off his mask. If insomnia is still clearly present, which will likely be the case, as it is one of the most common post-PTSD treatment residual symptoms, he could revisit CBT-I as an option then. Or, he could even start with addressing either the insomnia or potential PTSD and while he is working with sleep medicine, he could set up a mask desensitization protocol with his therapist and decide whether to address insomnia or potential PTSD directly down the road.

It would be easy in a case like this to worry there is too much going on for a behavioral health provider to play a role. However, in looking at the options above, behavioral interventions play a key role in all of them! SGT B’s provider felt more confident with potential options and reassurance that he would likely improve to some extent, and ultimately he chose to tackle CBT-I first. As providers, and especially if we are feeling uncertain or even overwhelmed, it can be very helpful to take a step back and think through our case conceptualization with a colleague or consultant. At CDP, we have consultation tools and resources for you. Feel free to reach out to us!

For more information about consultation options, vist the "Consultation Services" section here.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Diana Dolan, Ph.D., CBSM, DBSM, is a clinical psychologist serving as an Assistant Director of Training & Education with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland..

By Adria Williams, Ph.D.

Quick question for my military couples: “How did you make it through the pandemic?” Answers range from “It brought us closer” to “We didn’t.” For me and my husband, the answer was couples counseling.

As a therapist, I wish I could say that I share this response with pride. I do say it openly—to model healthy behavior for clients, friends, family, and the public—but inside, I’ve felt a twinge of discomfort. Call it fear (of judgment), doubt (about whether it’ll work for us), or embarrassment (about exposing marital imperfections). Whatever the label, these emotions are worth examining because if I, as a mental health professional, feel them, imagine how someone with little to no exposure to therapy must feel. Those feelings create tremendous barriers to seeking help.

Yet, when I schedule a doctor’s appointment for myself or my husband, I don’t feel fear, shame, or embarrassment. In fact, I might even feel responsible, proactive—maybe even a little proud. And when it comes to preventative care!? Woo wee!! I’m nailing this adulting thing! I just know these actions are improving my health and quality of life.

So What’s the Difference?
 The gap between seeking medical care and seeking couples’ therapy stems from two key factors: lack of information and stigma. Social norms tell us that needing therapy signals weakness or failure. Add in the common misconception that “it won’t make a difference,” and many people are discouraged from seeking help. But the research tells a different story. Long-term partnership with high relationship satisfaction is good for your health (Rhoades & Stanley, 2014)!

The Solution: A Logical Application of the Transitive Property
 Bear with me, it’s about to get a little “mathy”. The transitive property states that if “B” leads to “C” and “A” leads to “B” then “A” leads to “C” and vice versa. I am going to apply this logic as a way to overcome the barriers above.

B Leads to C
 Marital/relationship satisfaction is linked to far-reaching positive health and quality of life outcomes, such as overall better health, lower rates of disease, and lower mortality rates (Robles et. al., 2014). It is also linked to improved mental health (Downward et al., 2022) and financial communication (Saxey, et. al., 2023). Conversely, marital/relationship distress is consistently linked to mood disorders, anxiety disorders, substance use disorders, and increased physical health problems (Lebow, 2019). According to the DoD’s Annual Report on Suicide in the Military, the top psychosocial stressor associated with both suicide deaths and attempts is intimate relationship problems (Department of Defense, 2024). Additionally, the adverse impact it has on children is so noteworthy that it is now its own condition according to the DSM-5 (Bernet et.al., 2016). Thus, high relationship satisfaction (B) leads to improved physical and mental health (C).

Marital Health by the Numbers
 Since we’ve established that healthy relationships lead to better health and longevity and that relationship distress leads to increased health problems and poorer outcomes, let’s take a look at marital health. In the general population, divorce rates remain between 40-50% for first marriages (U.S. Census Bureau, 2001). According to the CDC (2002), the median length of marriages that end in divorce is 7-8 years—meaning couples endure years of marital dissatisfaction and distress before ending the relationship. That is a long time to be miserable.

On top of the stressors that lead to these outcomes for civilian couples, military couples face unique stressors. Deployments, PCS moves, unpredictable schedules, limited family and social support, and high-pressure work environments put additional strain on marriages.

On average, service members marry younger and at higher rates than civilians. More than 50% of married service members do so before age 25. One of the strongest predictors of divorce is age at first marriage, which likely contributes to divorce rates in the military being higher than in the general population (Hogan & Seifert, 2010).

A Leads to B
 The good news? Couples counseling works!

Research shows that 60-80% of distressed couples benefit from behavioral and emotion-focused therapies (Bradbury & Bodenmann, 2020). The average person receiving couples therapy fares better than 70-80% of individuals who don’t (Bradbury & Bodenmann, 2020). Emotionally Focused Therapy (EFT) helps 70% of couples become symptom-free by the end of treatment (Spengler, et. al., 2024)

That said, couples therapy isn’t a magic fix. Anywhere from 35-50% married couples who engage in therapy still divorce—but that’s lower than the rate for couples with similar issues who never seek help (Snyder & Balderrama-Durbin, 2020). A critical factor? Timing.

Both military and civilian couples wait anywhere from 2 and a half to 7 years after issues begin before seeking therapy (Doherty, 2021; Jarnecke, 2020). Earlier engagement could significantly improve outcomes.

Thus, couples counseling (A) leads to increased relationship satisfaction (B).

A Leads to C
 What if we treated couples counseling like dental checkups? We don’t wait until we have cavities or gum disease before seeing a dentist. Regular teeth cleanings prevent major dental issues and even reduce risks for heart disease, diabetes, and other systemic conditions.

What if we applied the same approach to relationships? Preventative couples counseling—regularly scheduled, even when things are “fine”—could prevent major breakdowns and improve long-term relationship health, leading to better overall physical and mental health. Plus we are addressing stigma by normalizing and establishing preventative relationship health as a priority.

Couples Counseling as an Essential Component to Mission Readiness
 Strong, satisfying marriages aren’t just good for our well-being—they’re critical to overall health and thus, mission readiness. High relationship satisfaction is linked to lower rates of disease and lower mortality rates. According to Kornblum and colleagues (2021), it’s also associated with improved mental resilience, financial stability, and success in attaining career goals —key factors for military personnel and their families. Service members undergo medical, dental, and readiness screenings before deployments, sea time, or PCS moves. These transitions are some of the most stressful events a military couple can face—so why isn’t relationship health part of the checklist?

Including couples counseling in pre-deployment training, PCS preparation, and reintegration programs could set military families up for success. Imagine how much we could improve overall health and military readiness if we routinely strengthened relationships before high-stress periods instead of waiting until things fall apart.

BOTTOM LINE: Couples counseling leads to improved physical and mental health or, A leads to C.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Adria Williams, Ph.D., is a Military Behavioral Health Psychologist at the Center for Deployment Psychology (CDP) with the Uniformed Services University of the Health Sciences. Dr. Williams is a suicide prevention subject matter expert and trainer.

References
 Bernet, W., Wamboldt, M. Z. & Narrow, W. E. (2016). Child Affected by Parental Relationship Distress. Journal of the American Academy of Child & Adolescent Psychiatry, 55, (7), 571 - 579. https://doi.org/10.1016/j.jaac.2016.04.018

Bradbury, T. N. & Bodenmann, G. (2020). Interventions for Couples. Annual review of clinical psychology, 16 (1), 99 - 123. https://doi.org/10.1146/annurev-clinpsy-071519-020546

Centers for Disease Control and Prevention (2002). Cohabitation, marriage, divorce, and remarriage in the United States (Vital and Health Statistics Series 23, No. 22). https://www.cdc.gov/nchs/data/series/sr_23/sr23_022.pdf

Department of Defense. (2024). Annual report on suicide in the military for 2023. https://www.defense.gov/News/Releases/Release/Article/3964785/department-of-defense-releases-its-annual-report-on-suicide-in-the-military-for/.

Doherty, W.J., Harris, S.M., Hall, E.L. and Hubbard, A.K. (2021). How long do people wait before seeking couples therapy? A research note. J Marital Fam Ther, 47: 882-890. https://doi.org/10.1111/jmft.12479

Downward, P., Rasciute, S. & Kumar, H. Mental health and satisfaction with partners: a longitudinal analysis in the UK. BMC Psychol 10, 15 (2022). https://doi.org/10.1186/s40359-022-00723-w.

Hogan, P. F., & Furst Seifert, R. (2010). Marriage and the Military: Evidence That Those Who Serve Marry Earlier and Divorce Earlier. Armed Forces & Society, 36(3), 420-438. https://doi.org/10.1177/0095327X09351228

Jarnecke, A. M., Ridings, L. E., Teves, J. B., Petty, K., Bhatia, V., & Libet, J. (2020). The path to couples therapy: A descriptive analysis on a veteran sample. Couple and Family Psychology: Research and Practice, 9(2), 73–89. https://doi.org/10.1037/cfp0000135

Kornblum, A., Unger, D., and Grote, G (2021). How romantic relationships affect individual career goal attainment: A transactive goal dynamics perspective. Journal of Vocational Behavior, 125, 103523. https://doi.org/10.1016/j.jvb.2020.103523

Lebow, J. L. (2019). Divorce today. In J. L. Lebow, Treating the difficult divorce: A practical guide for psychotherapists (pp. 35–55). American Psychological Association. https://doi.org/10.1037/0000116-003

Robles, T. F., Slatcher, R. B., Trombello, J. M., & McGinn, M. M. (2014). Marital quality and health: A meta-analytic review. Psychological Bulletin, 140(1), 140–187. https://doi.org/10.1037/a0031859

Saxey, M. T., LeBaron-Black, A. B., Dew, J. P., Yorgason, J. B., James, S. L., & Holmes, E. K. (2023). Money to Marriage, or Marriage to Money? Examining the Directionality Between Financial Processes and Marital Processes Among Newlywed Couples. Journal of Social and Personal Relationships, 40(8), 2445-2465. https://doi.org/10.1177/02654075221149967

Snyder, D.K. and Balderrama-Durbin, C.M. (2020). Current Status and Challenges in Systemic Family Therapy with Couples. In The Handbook of Systemic Family Therapy (eds K.S. Wampler and A.J. Blow). https://doi.org/10.1002/9781119790945.ch1

Spengler, P. M., Lee, N. A., Wiebe, S. A., & Wittenborn, A. K. (2024). A comprehensive meta-analysis on the efficacy of emotionally focused couple therapy. Couple and Family Psychology: Research and Practice, 13(2), 81–99. https://doi.org/10.1037/cfp0000233

United States Census Bureau (2001). Number, Timing, and Duration of Marriages and Divorces: 2001. https://www.census.gov/library/publications/2005/demo/p70-097.html

By Kristyn Heins, Ph.D.,

When you’ve decided to officially share a life with someone, maybe through marriage, civil union, common law, or any other way, you may go into it with the assumption this is 50/50. This is a partnership where together we will put effort into building a life we love. Few of us have an outright conversation about expectations and roles, we just think, “I love this person and they love me and we will figure out our own way”. For a while it probably works well, little issues may arise, but everything is manageable. But after a period of time you may start to think “why am I doing the dishes all the time?” or “when is the last time they made dinner”. Slowly we may start keeping score of the inequities in the union. The give and take may look like who is doing more house work? Who’s career are we more focused on? Who gets to accept a job out of state, and who has to follow? Who’s paying more bills? Who’s taking care of the kids? When children are brought into the relationship there is even more compromise needed. Who is doing drop off? Who picks up? Who makes sure school projects are taken care of? Who’s getting snacks for soccer on Saturday? Military spouses know this world of give and take better than most. As I write this I think of a friend of mine who has a masters degree but never was able to obtain a job where she used it due to her husband’s frequent relocation.

There are times that we are close to 50/50, but it might never feel like an even split. Someone is giving 40, the other 60, the work is divided and everyone is feeling fulfilled. But also, in more difficult circumstances it may be a 90/10 split and someone is carrying the majority of the weight. Isn’t this the “for better or worse”? The “in sickness and in health”? Why didn’t vows include “when my career takes precedence over yours” or “when my tee time overrules your plans”. Are we ever prepared for this shift in responsibility and effort? If not appropriately addressed, this compromise crossroad can lead to discord. Enter Gottman’s famed four horsemen of the apocalypse- criticism, contempt, defensiveness, and stonewalling (Gottman.com). Ultimately these can bring couples to break up or divorce when not addressed in therapy.

As providers, especially those working with the active duty population, addressing this even split myth can be beneficial in therapy. There is opportunity for great understanding and growth when couples are able to openly discuss expectations and roles. Starting with identifying thoughts can allow for the discussion for change. Working with couples on communication styles and effective interpersonal communication is another way to address this. When someone has reached the point of resentment, they are likely communicating in an aggressive manner. Helping people to understand assertive communication skills may lead to more effective exchanges. Along with couples counseling, working to dispel this myth of the even split relationship is another way providers can help. This can be done professionally, maybe through workshops and therapy. 

As educators and professors, this can be discussed in the classroom with future mental health professionals. As people ourselves, we can discuss this relationship myth with people in our own lives. On a personal level this is a conversation I have had with many of my friends, the reality of the scales being unbalanced. Supporting our friends and family, and discussing the fact that relationships are not 50/50 can help normalize our experiences and give perspective. We can help with adjusting expectations in therapy, but as mental health professionals let's also work on dispelling this myth and not allowing it to continue, because we know partnership is never an even split.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Kristyn Heins, Ph.D., is a Licensed Professional Counselor serving as a Military Behavioral Health Counselor for the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. In this role, she supports the CDP’s efforts of training clinicians in evidenced-based practice focused on suicide prevention.

By Amanda McCabe, Psy.D.

As a continuation of last week's blog about readiness assessments, we now attempt to answer questions about the civilian providers' role within these assessments. For example, do civilian providers need to make a readiness determination? What does it mean if a civilian provider does make a readiness determination? What if a civilian provider doesn’t want to provide readiness feedback?!

These are all great questions! The biggest expectation of providers in the community is that they conduct good, ethical, effective care for service members. There is no expectation that network providers would be making decisions on readiness. However, there are times when a service member may get flagged in the system, necessitating a readiness assessment. These flags may be due to a pending large-scale training exercise, a deployment, or the service member themselves endorsing behavioral health symptoms at their yearly physical. At these times, a military provider should reach out to the service member, and let them know that they are flagged, requiring a behavioral health evaluation to determine their individual readiness status (no duty limitations vs duty limitations). If this is the case, the service member and the evaluator will likely want to hear from you, the network behavioral health provider, to hear your perspective as it relates to the client’s case (such as the service member’s stability, prognosis, and ongoing treatment needs). You may be wondering what this process looks like and if it is ethical and/or legal for you to communicate your patient’s healthcare status. Before discussing a step by step plan, it is important to discuss HIPAA compliance. There is a military clause under HIPAA that permits communications on certain topics with a service member’s command team. It does not necessitate disclosure and its incredibly important to verify to whom the information is disclosed, in order to protect the patient. Please check out the resources below to learn more about this clause. Now, here are some definitive steps on how to respond when someone wants to hear from you about your service member patient.

1. Talk to the service member. What event initiated this request? Is there a pending training exercise? Is there an upcoming deployment? Is the assessment due to a profile that was initiated after a yearly physical? The implications are different depending on what is the cause of this recent request for information.

2. How does the service member feel about this initiating event? It is good to know the concerns for the service member, their motivations, and thoughts. While this is not the only consideration to be used in determining readiness, it is important to know.

a. If it’s a field exercise, do they want to go? Do they feel ready to go? Do they have the coping skills to be effective during this exercise? Do they have the resources they need? Do we expect their symptoms to worsen if they are in an extended training event? How long will this event be? How do they see themselves coping?

b. If it’s a pending deployment, the same questions above apply. This time though, think about a longer timeline (e.g., 3-9 months) and how it impacts all of the above questions.

c. If they have a profile that was initiated after a physical, what does the service member think of the profile? Do they want it? Do they want to stay in the military? Do they think they cannot sustain and want out? Are they bothered by the thought of having a profile?

3. Who is the information going to? Do they want it to go to a medical provider, a nurse, a case manager or do they want it to go to command, or all of the above?

4. What information does the patient want released? What information does the patient not want to be released? How do they want it released? Do they want to be present in the room during conversations when you release information or do they want a copy of what is being released?

5. What potential repercussions does the service member anticipate from the release of this information? Patients do not always have an accurate read on this! Sometimes they do, and sometimes they do not because this is a complex process. Communicating with military providers can really help service members achieve their military goals. Occasionally, service members are kept on duty limitations because it is unclear the status of their treatment progress from their network provider; consistent communication can help alleviate any treatment questions. Finally, it could be beneficial to consult someone familiar with the military system if there are any outstanding questions. Find a military specialist to contact.

6. Finally, how do YOU as the provider feel about releasing information? If you are not comfortable, releasing the bare minimum required, a treatment summary or just your notes is sufficient and a step in the right direction for establishing what the next steps for your patient will be. Also, there are many people you can consult with, generally speaking, to help you gain more comfort in working with military personnel.

7. When you are ready to release information, ensure that you have a signed release from the service member!

Once a Network Provider has been able to communicate the current status of their patient in terms of diagnosis, stability, and risk, a provider within the DoD will then most likely meet with that patient and help determine that service members’ readiness, ie, the need for any duty limitations. This is a complex evaluation that considers a variety of issues and information, as well as regulations and policies.

Again, providing ethical, effective care is the most important consideration when working with military members. We are lucky to have providers in the community helping our military personnel every day! If someone from the military ever reaches out about one of your patients, following these guidelines is an effective way to steer you and your patient in the right direction.

Resources:
DHA Privacy and Civil Liberties Office Fact Sheet: The Military Command Exception and Disclosing PHI of Armed Forces Personnel

Health.mil: Military Command Exception

US Army Ft. Bliss Legal Assistance Office: The Military Command Exception to the Health Insurance Portability and Accountability Act

Look for upcoming webinar through the CDP-P on Wednesday, July 9th.
Title: Assessing Readiness for Service Members Receiving Private-Sector Behavioral Health Care: Insights from a Recent RAND Report
Presenters: Jessica Sousa, MPH, MSW and Kimberly Hepner, Ph.D.

For Questions about this blog please reach out to: cdp-tpr-ggg@usuhs.edu

Click here for Part 1: "What is Readiness and Why is it So Important?"

Click here for Part 2: "Overview of Military Readiness Assessments"

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Amanda McCabe, Psy.D., is a Military Behavioral Health Psychologist with the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. In this capacity, she develops and delivers training on a variety of evidence-based therapies. Prior to the CDP, Dr. McCabe served as a clinical psychologist in the Army from 2013 to 2024.

By Amanda McCabe, Psy.D.

Military readiness is a critical measure to ensure that service members are both physically and
mentally prepared to carry out their duties. As was highlighted in last week’s blog, readiness
assessments are vital for maintaining operational effectiveness and helping to ensure that the
military is taking care of its service members by identifying problems early and ensuring access
to treatment. These evaluations consider both physical and behavioral health; however, today’s
post will focus on the behavioral health portion and what specific domains are assessed. 

Readiness evaluations are conducted by providers within the DoD due to ever-changing rules
and regulations.  If you are a civilian network provider, know that these assessments will not be
demanded of you; however, your input is imperative to ensure the relevant factors are considered
when making a readiness determination. Therefore, it is good to have background knowledge of
these assessments if you are a provider working with service members.

The current guideline that regulates Military Readiness assessments is the Department of
Defense Instruction (DoDI) 6130.03 Vol 2. This specifies the criteria for all readiness
evaluations within the Department of Defense, in other words, each branch of service. It outlines
three main domains within the Behavioral Health section of a readiness evaluation that will be
reviewed today, as well as one additional topic: psychotropic medications. These domains are
safety, symptom severity, and specific diagnoses. Once the assessment has been completed
providers will establish if any duty limitations are needed.

One thing to note, before the readiness assessment domains are reviewed, are the options for the
final disposition. Readiness assessments conclude with a decision about the need for duty
restrictions for service members. Sometimes during treatment, duty limitations are initiated to
help the service member focus on treatment and recovery. Upon the conclusion of readiness
assessments, providers will notate one of three dispositions: no temporary duty limitations,
temporary duty limitations, or permanent duty limitations which would require a medical
evaluation board. Temporary duty limitations would mean that the service member is put on a
profile, if they are in the Army or Air Force, or put on Limited Duty (LIMDU) if they are in the
Navy or Marines. To ensure clarity, it is important to state that if a service member is on profile
or LIMDU they most likely are considered temporarily non-deployable. This status would also
warrant a discussion with the service member’s Command team (see our next article in the blog
series for further information). Your role is to provide the necessary treatment to the service
member with the ultimate goal of being returned to duty with no limitations; however, that will
be determined by a military provider following the completion of treatment or potentially at a
midpoint in treatment. Now that the conclusions of readiness assessments have been reviewed,
the next step is to discuss the domains evaluated within these assessments.

1. Safety: To Self and Others
Service members are often placed in high-stress, dangerous, and complex situations, therefore,
safety is paramount. The evaluation of safety includes two important facets: safety for the
individual service member and safety of others.  These are complex assessments with multiple
factors considered, the scope of which is beyond this blog for today, but a summary will be
given.

Self-Safety: The first domain to be evaluated in readiness assessments is the risk of suicide.
Suicide risk assessments are vital for all behavioral health patients, but within the military, they
have a different lens due to patients having consistent access to lethal weapons as part of their
daily jobs. Service members who are considered higher risk for suicide (please see DHA AI
6025.06 for break down of appropriate risk levels within the Defense Health Agency care) are
given temporary duty limitations that would limit their access to weapons for work and allow
them to access treatment consistently (helping minimize any occupational barriers that might
prevent this) as well as, access multiple levels of resources (intensive outpatient programs,
inpatient care, residential care) until their risk of suicide consistently decreases. With temporary
duty limitations, such as a profile or LIMDU, due to high risk for suicide, patients are able to
access treatment on a routine basis, have access to case managers, and higher levels of
consultation and review, as well as any other required care.

Safety to Others: Equally important to assess for in readiness evaluations, is the risk of harm to
others. If a service member’s current mental health symptoms manifest as wanting to hurt or kill
others, then that person will be evaluated to see if duty restrictions are warranted. This evaluation
would help determine if limiting access to their occupational weapons is needed as well as
inpatient services or if legal action would be required at that time. Individuals who may exhibit
impulsive, unpredictable, or violent behavior pose a risk to the safety of those around them.
In summary, providers assessing for readiness are examining risk factors of harm to self or
others to determine if duty limitations are necessary.

2. Symptom Severity
Beyond ensuring safety, military readiness assessments focus heavily on the severity of
symptoms related to mental health conditions. Providers within the DoD system assess for
symptom severity because it can directly affect service members' ability to perform their duties. 
Mild to Moderate Symptoms: Service members with mild symptoms of conditions, like anxiety
or depression, will likely not require any change of duties since their symptoms are manageable
and do not significantly impair their work. Counseling or other forms of treatment can be
prescribed to help them cope with the stresses of military life while maintaining their duties. A
moderate symptom presentation does not always require duty limitations either. A moderate
symptom presentation that would require duty limitations would be determined based on the type
of impairment experienced, symptoms manifested, service member occupational demands, and if
any safety concerns are present.

There is one exception to the rule for moderate symptoms. Substance use that rises to the level of
diagnosis, and has demonstrated any type of impairment, does lead to temporary duty limitations
to help the service member start and work through a substance treatment protocol.
 Severe Symptoms: Service members with severe symptoms that cause significant impairment
socially and/or occupationally can be viewed as warranting temporary duty restrictions. These
duty restrictions limit what the individual can do occupationally, temporarily, while facilitating
consistent access to care. For example, if a service member is in the middle of treatment for
Major Depressive Disorder while their unit comes on orders for a month-long training exercise,
that is away from home, these duty limitations allow the service member to remain at their
normal duty location (at home), and continue to receive their needed treatment. 

In summary, during brief readiness assessments, service members in treatment often have mild
to moderate symptoms requiring no need for duty restrictions.  When conditions result in
significant impairment, then temporary duty limitations are placed.  Finally, if any of these
conditions require a year or more of treatment (or they have been in treatment for a long time and
expect treatment to continue for a long time), a permanent profile may be issued. The permanent
profile would initiate a medical review board, which would determine if a service member can be
rehabilitated in the near future or would need a medical retirement due to their conditions.
 
3. Specific Diagnoses: Psychotic Disorders and Bipolar I Disorder
The nature of being in the military and having access to weapons make for an environment that
is unsustainable for certain diagnoses. Psychotic disorders, like Schizophrenia and
Schizoaffective disorder, as well as Bipolar I Disorder, require permanent duty limitations and
service member’s will be referred for a medical review board upon initial diagnosis. The nature
of these diagnoses and their treatment requirements are beyond the scope of the Active Duty
component (however, it is very much integral to the Veteran Affairs medical which is not limited
to medicine, but also housing assistance and career assistance). These diagnoses often warrant
long-term treatment with medication, therapy, and case management services that are not
available in all geographic locations and specifically within an austere environment of a
deployed setting or long training mission. This would significantly impact the training, location,
and job abilities of the service member, therefore permanent duty limitations are placed and a
medical evaluation board is initiated.  
 
4. Specific Medications: Antipsychotics and Mood Stabilizers
Each military branch has its own regulations on specific types of psychotropic medications,
especially those prescribed for long-term mental health management, such as antipsychotics and
mood stabilizers. The differing regulations stem from the different constraints placed on various
occupations and the availability of medications and services. An example of differing medication
requirements can be seen when looking at the occupational requirements for a pilot versus a
supply specialist. With that said, psychotropic medications are frequently used within the
military services. Service Members, once having established there are no significant side effects

upon initial use, oftentimes do not require duty limitations and can work as usual. When
considering a deployment, different geographic locations have different mandates on
medications due to the availability of services in that region. Prior to deployments, service
members undergo readiness screeners to ensure that their medications fall within the parameters
of that region or see if there is a possibility to obtain a waiver for those medications. 
A good rule of thumb for any military service is if antipsychotics and mood stabilizers are
required for stabilization and long-term care, then permanent duty limitations would be placed
and a medical retirement is likely warranted. These medications carry potentially significant side
effects, require consistent monitoring, and would be difficult to store and dispense in austere
environments.

In summary, each military branch has its own regulations governing medication use within their
services. Also, psychotropic medications are commonly used within the DoD’s Behavioral
Health system. Screeners are therefore conducted by their behavioral health personnel to help
determine if duty limitations are required due to the service member’s specific job constraints
and deployment needs. 
 

Conclusion
Military readiness assessments occur consistently throughout the DoD/DHA Health Services.
These evaluations help determine if service members require temporary or permanent duty
limitations, which impacts overall mission readiness for commanders. The behavioral health
aspect of these evaluations considers safety, symptom severity, diagnoses, and medications as
crucial pieces for determining duty limitations. These evaluations not only protect the individual
service member but also ensure the safety of their peers and the overall success of the mission.
By carefully balancing the need for mental health treatment with the demands of military service,
the Armed Forces strive to maintain a force that is both healthy and ready for the challenges they
may face.

Click here for Part 1: "What is Readiness and Why is it So Important?"

Click here for Part 3: "Private Sector Providers and Readiness"

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Amanda McCabe, Psy.D., is a Military Behavioral Health Psychologist with the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. In this capacity, she develops and delivers training on a variety of evidence-based therapies. Prior to the CDP, Dr. McCabe served as a clinical psychologist in the Army from 2013 to 2024.