Stories - Blogs

By Shantel Fernandez Lopez, Ph.D.

I recall evaluating and treating an adolescent from a military-connected family who had moved frequently over several years. Each relocation meant adjusting to new schools, routines, and peer environments, changes the family navigated with resilience but that made consistency difficult to maintain. He had engaged in treatment with several providers over time, had several diagnoses, and his caregiver continued searching for support as progress felt limited.

During routine screening for sleep, a different picture began to emerge. He was averaging about four hours of sleep per night, napping for long periods after school, relying on energy drinks, and staying up past midnight playing video games. These patterns contributed to tension at home and difficulty adjusting academically after another move.

As we explored how sleep affected his energy, mood, and relationships, he became open to small, realistic changes, refraining from naps, replacing energy drinks with caffeine free alternatives, adjusting his sleep schedule, and decreasing late-night gaming. These adjustments were made collaboratively with his mother. Over time, sleep improved, family conflict decreased, friendships began strengthening, and his school functioning began to shift. Experiences like this remind me and highlight how meaningful clinical change can begin with routine sleep screening and understanding how sleep influences multiple areas of functioning.

An estimated 20–30% of children and adolescents experience sleep problems, yet sleep remains frequently under assessed in clinical care (Owens, 2020). For providers working with military-connected youth, sleep can be an especially meaningful clinical entry point. Within military-connected youth and family systems, contextual factors associated with military life including relocations, changing school environments, shifting caregiver roles, and ongoing adjustment to new communities may shape daily structure, emotional regulation, and family rhythms in ways that influence sleep consistency, even among highly resilient families.

Rather than viewing sleep as secondary to treatment, many providers recognize it as a foundation that supports regulation, learning, and engagement in care.

Why Sleep Matters
 Military-connected families bring strong adaptability and structure, yet transitions such as time zone changes, reintegration periods, or shifting household roles can unintentionally disrupt routines that support sleep (Lester et al., 2016). These disruptions are understandable responses to changing environments. When sleep difficulties persist, providers may notice irritability, concentration challenges, or increased stress responses. When treatment progress slows, sleep is often an important area to revisit.

Common Sleep Concerns
 Sleep difficulties vary developmentally but commonly include:

• Difficulty falling or staying asleep
• Bedtime resistance or delayed schedules
• Nightmares or nighttime fears
• Insufficient sleep duration
• Circadian rhythm shifts during adolescence

Chronic insufficient sleep is associated with challenges in emotional regulation, attention, learning, and behavior (Gregory & Sadeh, 2016; Shochat et al., 2014). Because these concerns overlap with anxiety, mood changes, and trauma-related stress, integrating sleep assessment into routine care can provide valuable clinical insight.

Taking a Systems Approach to Sleep
 Sleep reflects the interaction of developmental factors, family routines, physiological arousal, environmental conditions, and emotional stress (Owens et al., 2014). Within military-connected families, frequent moves or schedule variability may influence sleep patterns, but they do not determine outcomes. Clinically, sleep disruption often maintains existing challenges rather than causes them outright, making it a meaningful target for intervention.

Evidence-Based Strategies
 Behavioral and cognitive-behavioral approaches remain first-line treatments for pediatric sleep concerns (Meltzer et al., 2014; Mindell et al., 2006). Here are some examples of sleep-focused strategies providers can integrate into practice:

• Supporting consistent bedtime routines
• Encouraging predictable sleep and wake schedules
• Teaching relaxation skills
• Addressing bedtime worries or fears
• Using CBT-informed strategies for insomnia and nightmares

A Practical Takeaway for Providers
 For providers working with military-connected youth, sleep may be one of the most helpful places to begin. Integrating brief sleep screening and targeted intervention can improve engagement, reduce caregiver stress, and support resilience across the family system. Sometimes the most impactful clinical shifts come from strengthening routines that help children feel regulated, supported, and ready to grow.

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 War.

Shantel Fernandez Lopez, Ph.D., is a clinical psychologist serving as a Military Behavioral Health Child Psychologist at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. In this role, she supports a study focused on the identification and enhancement of evidence-based treatment delivery to youth with neurodevelopmental and behavioral health needs via telehealth and tele-education.

By Jennifer Nevers, MSW, LCSW

“You feel pretty safe.”

It’s a simple statement, but it carries a great deal of meaning and purpose when shared by a military kid reflecting on what it means for them to have a parent in the military.

In honor of the April's Month of the Military Child, I interviewed my son and stepchildren about their experiences being military-connected. These interviews helped me see how my children relate to military culture and the routines of military life. While their views differ, common themes emerged, including meaning, safety, and loss.

Pre-Deployment: The Notification

“I was pretty chill.”

“I was confused why you were leaving.”

“I was like- three straight months! And then you were gone for another two and a half months”.

Telling the kids I was leaving was an achingly difficult moment for my husband and me. It made our path painfully clear, and there was no turning back. I recall our daughter, the oldest, exclaiming, “You can’t leave! I don’t want to eat cereal for breakfast every day!” Her honesty was raw, and the daily impact stood out in that moment.

Her reaction became my guiding light for what I could focus on with her before I left. Leading up to my departure, she learned how to use the oven, determined to bake crescent rolls with chocolate chips in the middle the way I did. This was the most-requested breakfast I made for the kids a couple of times per week, and living without this routine was a step too far. Navigating my departure was a new experience for her and her brother, as they haven’t always been part of a military family.

For my son, our middle child with Autism, he had a very pragmatic response reflecting on his experience during pre-deployment. He described his reaction as shaped by the predictable patterns of a military kid,

“I was pretty fine because sometimes you do that.” As a concrete thinker, it didn’t seem odd for me to leave. “You’re usually gone for three days.” Even though this was months, not days, he felt prepared for the challenge due to practice effects. Having experienced many separations and reunifications, he’s come to see this rhythm as normal. So, while he often struggles with transitions and change, this felt expected and typical for him.

Deployment: Navigating Separation

“I thought I liked being a military kid, but I care when you leave.”

“You missed my birthday.”

For my stepchildren, navigating this separation was their first time really feeling the reality of what it means to be a military family. Another series of missed birthdays, extracurricular activities, and important events. Being in the National Guard, the periodic days away every month were common. Even the occasional two-week obligations were manageable. But the reality of a long separation meant not only time away from me, but also from my son. Our co-parenting routine and schedule were quite different compared to what they were used to.

For our daughter, that meant she was the only girl in the house, and she very seriously suggested that other deploying parents avoid this dynamic by adopting another child. For our youngest son, it was significant because he didn’t get to see his stepbrother as often as he would have liked. “I like playing with my brother, and that was not cool”. He was careful not to hurt my feelings with his words, but it was clear that what felt most disruptive to him was time away from his stepbrother, whom he’s grown so close to. Blended families often face unique challenges during normative military experiences, such as deployment and other separations. For example, in a local family, the mother's deployment means the stepfather struggles to get time with their stepson, even for significant family events. These challenges can disrupt the home environment for other children, affect the parent-child connection, and undermine the deployed parent's family dynamic.

Deployment: Maintaining Connection

My son would probably be shocked to learn that he’s the one I worried about the most. Would he struggle once the reality set in? How would we connect effectively while I was away? My anxieties informed my questions to him, and I wanted to know what was helpful during my deployment that might be helpful for other parents. He had a quick answer: “Play a game with them.” This is very on- brand for him and reflects how we connected while I was away. We had a video-calling app we used that also let us play games and read books together. He shared that this was helpful and wanted other parents to know it might help their kids, too.

What stood out to me most in these conversations wasn’t the exact experiences but, more so, how they so clearly reflected on what mattered. For them, connection looked like small moments of playing games, reading books, and finding creative ways to spend time together from a distance. It wasn’t the trinkets I brought home, or the sharing of stories and pictures about my experiences. Connection was rooted in the normal joys of childhood. My kids reminded me from notification to reintegration with the family, it’s not about perfection. It’s not about leaving behind the perfect gift or saying just the right words on a recording within a doll, but about those small, deliberate opportunities to share an experience, even from afar.

The most meaningful perspectives from these interviews come directly from the kids themselves. Here are some parting thoughts that my children wanted every child preparing for a parent’s deployment to hear:

“Don’t worry, they’ll be back. It’s ok, you can get through it. It might be hard, but it will be just fine.”

“Be calm, because they’re pretty much going to be ok.”

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.

Jennifer Nevers, MSW, LCSW, is the Subject Matter Expert Office Lead for the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.

By Amanda McCabe, Psy.D.

Service members, including Active Duty (Army, Navy, Air Force, Marines, Space Force), Reserve Units, and National Guard members, are referred to network providers for a wide range of medical care, including behavioral health services. Receiving care outside of a military treatment facility can be more complex than typical civilian healthcare. This is due to the unique demands of military service, such as strict physical fitness standards, operational responsibilities, and the need to handle weapons and sensitive equipment. As a result, service members must consistently demonstrate fitness for duty through regular readiness evaluations. These assessments are often part of routine medical appointments, though they may also occur separately.

When care is provided outside of the military system, periodic check-ins are required to assess whether the service member can meet military retention standards. These evaluations determine if the service member can continue full duties, requires temporary duty restrictions, or may need permanent restrictions, potentially leading to medical retirement.

This process differs from civilian healthcare practices, even though it shares some similarities with evaluations for pilots or law enforcement officers. To help civilian providers better understand military medical requirements, we have developed a set of tools to clarify these expectations and processes.

We have developed a new frequently asked questions (FAQ) handout for community providers, outlining the process of readiness evaluations, sometimes called Fitness for Duty evaluations, for service members who are seeking behavioral health care in the community.

In addition to our FAQ, we also have two videos (Military Readiness & Military Readiness and Behavioral Health) that walk providers through the background of the assessments, as well as the process of a request for information, and what it might look like for a behavioral health provider.

Finally, there are three blog posts (What is Readiness and Why is it so Important; Overview of Military Readiness Assessments; Private Sector Providers and Readiness) that describe this process in detail, as well as include a step-by-step guide if and when a provider finds that a military official is requesting information about your patient, in the name of a readiness evaluation or fitness for duty.

Again, these can seem like a foreign process if you are working outside a military hospital, military treatment facility, or MTF; however, these are all typical processes within the military medical system, and hopefully, these resources can help clear up some of the ambiguity, mitigate anxiety, and guide providers through this process.

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 presents trainings 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 Jaime Rodden

The Rise of Wearable Health Technology
 Wearables have become increasingly popular over the last few years, and chances are high that you own one yourself, or someone in your close circle does. In fact, over one-third of U.S. adults report using a wearable device, with significant continued growth reported annually. Wearable devices, which include smartwatches, biosensors, and activity trackers, collect physiological data to inform our understanding of health and well-being. Not only can this help individuals better understand their daily health habits and set goals for improvements (cue me immediately Googling ‘walking treadmills’ after seeing my step count following an eight-hour day at my desk), but these devices also possess significant potential for real-time health monitoring and tracking of physical and mental health conditions such as cardiovascular disease, chronic respiratory conditions, anxiety, stress, and insomnia.

Wearables for Sleep Monitoring
 Sleep wearables have gained particular traction in recent years, appealing to those focused on optimizing their physical and cognitive performance from the likes of athletes and service members, and individuals navigating mental health challenges, such as insomnia and anxiety. These devices claim to detect light, deep, and REM sleep phases, and measure sleep metrics such as sleep onset latency, to compile the dataset into a “sleep score” reflecting nightly and average sleep quality. This information can be genuinely useful for understanding sleep habits and making informed changes to optimize health. The potential benefits are promising and initial validation studies show promise, but further exploration into the reliability of these metrics is still needed.

When Data Becomes a Detriment
 The surge in sleep wearable device popularity has also surfaced some potential downsides worth considering. A new term has emerged, orthosomnia, defined as a preoccupation with perfecting one’s wearable sleep data. Initial research suggests that for a subgroup of users, regularly fixating on sleep metrics may actually backfire, exacerbating insomnia and reinforcing their sleep-related anxiety, rather than relieving it. One proposed explanation is that people may feel compelled to spend extended periods of time in bed in order to boost their numbers, but since devices tend to overestimate time spent asleep, this can be counterproductive, leading some people to believe they have a sleep problem when they are, in fact, getting adequate rest.

Wearable Data in the Clinical Setting
 For providers, wearables can serve as a useful tool for objectively understanding patients’ sleep habits when coupled with evidence-based psychotherapy treatment such as Cognitive Behavioral Therapy for Insomnia (CBT-I). That said, it’s crucial to keep in mind that patients may arrive with firmly held beliefs about what their device data means, and those beliefs can be resistant to change. The decision to incorporate wearable feedback into treatment should be individualized, guided by each patient’s relationship with their device and whether engaging with that data seems likely to help or hinder progress. Some patients may even resist traditional treatment altogether, preferring to rely on their wearable data instead. As the science behind sleep wearable accuracy continues to evolve, providers are encouraged to be intentional about positioning wearable data as a supplemental resource for raising awareness, rather than a driver of treatment decisions. For those who are open to it, providers can use the opportunity creatively, for example, having patients track subjective sleep quality and daily functioning both with and without their device, turning it into a meaningful behavioral experiment.

Looking Ahead: Maximizing Benefits While Minimizing Harm
 Overall, wearable technology brings exciting possibilities for physical and mental health monitoring and optimizing. As the market continues to expand rapidly, it’s important that we thoroughly weigh both the benefits and potential drawbacks of weaving these devices into our daily lives and clinical care practices.

CDP’s Research
 The themes explored in this post are ones our CDP team is actively investigating in collaboration with Walter Reed Army Institute of Research-West, Malcolm Grow Medical Clinics and Surgery Center, and Tripler Army Medical Center. The clinical trial study evaluates the effectiveness of an mHealth application and group-based Cognitive Behavioral Therapy for Insomnia (CBT-I) across various provider levels and objectively measures sleep using a Fitbit device. To learn more about the study, visit the one-pager 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.

Jaime Rodden is a Clinical Research Manager for the Center for Deployment Psychology (CDP). In her role she works to advance the center's research portfolio, providing management for clinical studies through supervision, administrative oversight, and coordination of research protocols.

By Linda Thompson, Ph.D.

Although drinking alcohol can serve many purposes in everyday life, from social and to traditions, its connection with sleep often stems from underlying motivations: are we trying to cope to escape negative emotions, or are we directly seeking a shortcut to slumber? Unpacking these "whys" is essential for understanding risk-related usage patterns and their relationship with sleep health.

Not getting enough sleep affects much more than just feeling tired. Over time, poor sleep can increase stress, anxiety, and even symptoms of depression (Basta et al; 2007; Watling et al., 2017). When people worry about another restless night, those feelings of frustration and fear can make things worse. It’s common for someone struggling to fall asleep to look for a quick solution, whether that’s an over-the-counter sleep aid, prescription medication, or even alcohol (Khantzian, 2003). The grind of daily life, whether it’s intense work deadlines or personal setbacks can directly contribute to sleep issues and the temptation to use alcohol as a quick fix. Drinking alcohol can make you feel sleepy (Roehrs & Roth, 2001), so it might seem like a fast way to fall asleep. But the reasons people turn to these substances are often more complicated than just wanting to rest. It’s usually a mix of trying to finally get some sleep and managing the stress or difficult emotions that are keeping them awake in the first place.

No matter the motivation, it’s no secret that the use of alcohol often interferes with a good night's rest. Even though a drink might seem like it helps you fall asleep faster, research shows that if you’ve had any alcohol during the day, you’re likely to sleep longer but also have more restless, interrupted sleep that night (Roehrs & Roth, 2001; Thompson et al., 2024). On a deeper level, drinking alcohol can disrupt rapid eye movement sleep, which is a stage critical for emotional regulation and restoration (Ebrahim et al., 2013). As a result, you may wake up feeling more fatigued and irritable the next day. Keep in mind that alcohol’s effects also vary depending on the type and amount of alcohol you drink and may look different for different people. The problem is, that the short-term feeling of relief these substances provide can easily turn into a habit, making it harder to address the root causes of sleep problems. This cycle can quietly undermine sleep health over time, even if it feels like a helpful solution at the moment.

Although current research has helped clarify the relationship between alcohol use and sleep, there’s still so much to learn especially when it comes to real world use and individual motivations such as how and why people use substances like alcohol to manage sleep and distress. These dynamics are important to consider, especially because the short-term effects of alcohol use can mask underlying issues that contribute to long-term difficulties. These consequences are amplified for anyone with existing sleep disorders. Drinking alcohol to manage insomnia, for example, often leads to unintended negative outcomes which not only derail treatment efforts, but may also worsen the condition over time. Recognizing these patterns when alcohol is used as a coping mechanism and a sleep aid can provide valuable context for understanding these difficulties. This knowledge allows for a more targeted approach, helping to identify the root emotional or behavioral factors, rather than focusing solely on the sleep symptoms. It encourages a broader perspective that considers how daily habits and coping strategies impact sleep health, which can ultimately inform more effective support and resources.

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.

Linda Thompson, Ph.D., is a Postdoctoral Fellow with the Center for Deployment Psychology. Dr. Thompson earned her doctorate in Behavioral Science, Psychology from the University of North Texas and a master’s degree in Psychology from San Diego State University.

References
 Basta, M., Chrousos, G. P., Vela-Bueno, A., & Vgontzas, A. N. (2007). Chronic insomnia and the
 stress system. Sleep medicine clinics, 2(2), 279-291.

Ebrahim, I. O., Shapiro, C. M., Williams, A. J., & Fenwick, P. B. (2013). Alcohol and sleep I: effects
 on normal sleep. Alcoholism: Clinical and Experimental Research, 37(4), 539-549.

Khantzian, E. J. (2003). The self-medication hypothesis revisited: The dually diagnosed patient.
Primary psychiatry, 10(9), 47-54.

Roehrs, T., & Roth, T. (2001). Sleep, sleepiness, and alcohol use. Alcohol Research & Health,
 25(2), 101.

Thompson, L. M., Slavish, D. C., Messman, B. A., Dietch, J. R., Kelly, K., Ruggero, C., ... &
 Blumenthal, H. (2024). Alcohol Use Predicts Longer But More Fragmented Sleep: A Daily Diary
 Study of Alcohol, Sleep, and PTSD in Nurses. International Journal of Behavioral Medicine, 1-12.

Watling, J., Pawlik, B., Scott, K., Booth, S., & Short, M. A. (2017). Sleep loss and affective
 functioning: more than just mood. Behavioral sleep medicine, 15(5), 394-409.

By Jennifer Nevers, MSW, LCSW

I thought I had more time.

I’m so tired, but I can’t go to sleep. I’m fully packed. I’ve double and triple-checked that I have all of my essential items. I’m in the eleventh hour now, and whatever I don’t have in my house isn’t going into my duffel bags. Even after staying up all night, I’m not sure I will be able to get everything done that I need to. But I have to get these gifts ready for the kids. I can’t leave without them having something from me to hold close while I’m gone.

I really hadn’t thought this part through. I had planned and prepared for transitioning all of my work obligations and spent the last five weeks doing as much as I could around the house. I didn’t want my husband to be left with a mountain of housework after I left. But here I am, still awake in the middle of the night, just hours before heading to the airport, and I still don’t feel ready.

I ordered dolls for the kids- you know the ones that you can record your voice inside, and when you squeeze them, they hear your personalized message. For some reason, even with all of my planning, I hadn’t considered what I would say to them.

As I record and re-record each message, trying to make them all different while also conveying the same theme—I love them, I will miss them, and I want them to make lots of new memories while I’m gone— I can’t help but get tearful. For some of the recordings—truthfully, most of the recordings—I have to stop in the middle and start again because my emotions are just too raw.

I knew this moment would happen. I train providers about these moments and teach service members ways to help prepare for them. And yet, it doesn’t make living it any easier. Knowing that this is normal only reassures me that I will get through it—that our family will get through it—but it doesn’t take the hurt and sadness away of leaving them for the next several months.

In true Army fashion, my flight leaves at 6 AM, so we have to leave the house by 4 AM to make sure I make it on time. Our kids are still completely asleep, in their pajamas, as we load them into the car and head for the airport.

I hope I have everything.

The longing for my family has already begun—my husband and I quietly hold hands, aware these are our last moments together before I leave. It’s surreal.

Everything moves fairly normally when we arrive at the airport. I travel a lot, so this process isn’t new for us- we’ve had a lot of practice. After my husband unloads my bags onto the curb, I have a moment of panic. I frantically search my wallet and bag for an item I have to bring with me. I can’t find it. The pressure is mounting, and the pace of our farewell changes suddenly. Eventually, I find what I’m looking for, but we can’t turn back the clock on how this moment feels.

I have to go.

My attention quickly shifts to getting my bags checked so I don’t miss my flight. My husband and I embrace quickly, and tears start to come for both of us.

This isn’t the moment I’d thought we would have. I thought we’d have more time.

The kids are half asleep, but we manage to say our goodbyes. No amount of hugs or I love you could ever feel like enough at this moment. I volunteered to support this deployment. To fill a critical vacancy and ensure my fellow service members are cared for. We talked about it endlessly and, as a family, agreed it was the right thing to do. And yet, it feels like an impossible task to leave the people I love the most, knowing it will be months before I see them again.

My story is not all that different from the millions of service members who came before me as they navigated the final moments before deployment. While we each have our own unique rituals, expectations, and responsibilities to navigate, we share the emotional complexities of excitement, anxiety, sadness, and anticipation. The pre-deployment period is a crucial time in a service member's career that brings together all of the training and preparation they have spent years cultivating.

For mental health providers supporting the military community, this period presents a unique opportunity to support service members and their loved ones in successfully navigating what can be a complex time.

For me, peace of mind came from those already supporting the mission and through loved ones at home who helped with intentional preparation. I worked to understand the practical realities of my new environment: What will my housing look like? Where will I eat? Who will I work with? Meanwhile, my family and I prepared for my absence by organizing bill payments, childcare schedules, arranging additional family support, and even setting communication expectations for times when I might be unreachable.

Gathering this information (and more) was critical in helping my family and me feel solidly grounded for my departure and can serve as a starting point for clinicians when working with service members preparing for deployment.

To learn more about ways to better support service members, veterans, and their families across the military life cycle, consider joining Star Behavioral Health Providers for their military-cultural competency training: Tier One: Introduction to Military Culture and the Military-Connected Experience.

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.

Jennifer Nevers, MSW, LCSW, is the Subject Matter Expert Office Lead for the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.

By Kelly Chrestman, Ph.D.

I “knew” Edna Foa before I met Edna Foa, as one does when the person you are talking about is as renowned, as scholarly, as influential in one’s field of study as she was and will remain even after her passing. Her work, of course, is foundational in understanding the impact of trauma and in the treatment of PTSD, but she is equally respected as an international expert in OCD. She developed the most efficacious treatments for both PTSD and OCD, and continued to refine our understanding of these disorders and their treatment throughout her life. At the same time, she worked to make evidence-based treatment more widely available by leading initiatives to disseminate treatment across the globe.

I have read many obituaries and tributes to her since I learned of her passing, and they all speak of her scientific rigor, her intellectual brilliance, and her commitment to alleviating suffering. They speak of her tireless work ethic and her relentless pursuit of more: more knowledge, more understanding, more effectiveness, greater impact. That impact is not only evident in the hundreds of published articles, numerous books, and over 10 million dollars in grants, but in the power of her mentorship, and truly, she was a mentor to many of the current luminaries in the study of anxiety, PTSD, and OCD. Even so these tributes do not fully describe the tremendous impact of her legacy.

I finally met her for real when I interviewed for a position at the Center for the Treatment and Study of Anxiety. I was to be a clinician in many of the studies of Prolonged Exposure Therapy. To my profound surprise and delight, I was hired, and began one of the most demanding and richly rewarding experiences of my professional career. She was a brilliant researcher, an insightful and compassionate clinician, and an inspiring leader. In my time at CTSA she consulted on nearly every case from her large faculty of clinicians and researchers. Her consultation was direct and unrestrained. When errors occurred, she provided precise feedback on their nature and causes. Her approval was equally discerning, and was prized, though less frequent.

Beyond her groundbreaking work, her personal passions revealed a vibrant side that enriched those around her. As I came to know her personally, I learned that she also loved the symphony and collected art. She was a curious and penetrating conversationalist and did not shy away from controversial topics. She was interested in fashion, but not “high” fashion. Her style was unique, sometimes eccentric (her word, not mine) in her signature black with splashes of color and the ubiquitous cape or shawl that could be dramatically tossed over the shoulder. She and her late husband Charles loved to gather her CTSA family at her home several times a year for dinner or a picnic, and she delighted in hosting the international groups who came to CTSA to train several times a year. She was creative as well. I learned she designed most of her unique dresses and had them made in Israel on her many visits. She was also a knitter; a fact I discovered when she saw me knitting and offered to teach me a new technique!

In my mind, she is always busy. Busy writing, creating, going to the symphony, traveling, teaching, learning something new, telling someone else about it… I miss her already, even though we weren’t in frequent contact. I still hear her voice when I teach or write, admonishing, encouraging me to get it exactly right. I feel her absence knowing that we won’t meet at a conference or share an email any longer. I am profoundly grateful for her mentorship and teaching, and for her friendship. May her memory be a blessing to all who knew her and to those who feel connected to her through her work and her legacy.

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.

Kelly Chrestman, Ph.D., is a Senior Military Behavioral Health Psychologist at the Center for Deployment Psychology (CDP). She provides training, support and consultation in Cognitive Behavioral Therapy and in the Assessment and Treatment of PTSD.

By Shealyn Clinger, MA, MSW, LCSW

Over the years, working with service members, veterans, and their families, I’ve learned that some forms of distress can feel confusing and overwhelming until someone finally gives them a name. For many people, moral injury is one of those experiences.

Many trauma reactions are rooted in fear and survival. Moral injury is different. It occurs when what we have seen, done, or been unable to prevent conflicts with our deeply held values—our sense of what is right and who we believe ourselves to be.

As a neurodiversity-affirming therapist, I’ve also noticed that when we talk about moral injury, we often miss an important piece of the picture: neurodiversity.

Neurodiversity refers to the natural variation in how human minds think, process, and make sense of experience. It includes ADHD, autism, specific learning differences such as dyslexia and dyscalculia, as well as motor and communication differences. In simple terms, it recognizes that people think, learn, and experience the world in different ways.

For some people, those differences can shape how moral wounds are experienced.

What Research Says About Moral Injury
 The Center for Deployment Psychology has highlighted that moral injury and moral distress are still evolving concepts and are not yet defined in exactly the same way across research and clinical settings.

A recent CDP Staff Perspective explains that moral injury often occurs when someone is exposed to events that violate deeply held moral beliefs or values. This may happen through:

• their own actions
• the actions of others
• or perceived betrayal by leaders, institutions, or systems in high-pressure situations

Researchers are also developing ways to better measure moral injury. Tools such as the Moral Injury Outcomes Scale (MIOS) and the Moral Injury and Distress Scale (MIDS) help clinicians understand both exposure to potentially morally injurious events and the impact those experiences can have on a person’s functioning. Having clearer language helps describe experiences that many people have felt for years but struggled to explain.

Readers interested in learning more can explore additional CDP research, staff perspectives, and clinical resources on moral injury through the Center for Deployment Psychology’s publications.

Why Neurodiversity Matters
 Neurodiversity can influence how people perceive, interpret, and emotionally process events. For some neurodivergent individuals, certain aspects of moral injury may feel especially significant.

Pattern awareness: Some people naturally notice patterns, details, and inconsistencies. This can make unresolved moral conflicts harder to ignore.

Values tied to identity: For some individuals, values are deeply connected to identity. When those values are violated, the impact may feel deeply personal.

Sensitivity to betrayal: Many definitions of moral injury involve betrayal by leaders, institutions, or trusted peers. People who strongly value rules, structure, or fairness may feel betrayal more intensely.

Meaning-focused thinking: Instead of avoiding the issue, everyday events may repeatedly bring someone back to the moral meaning of what happened.

In other words, neurodiversity does not necessarily make someone more vulnerable. It may simply mean that someone processes moral meaning more deeply or differently. That depth can be a strength. But without the right support, it can also make resolution more difficult.

A Personal Reflection
 I’ve sat with people in therapy rooms and support groups who describe moral injury not as fear, but as a break in how they see themselves. It can feel like something important inside them changed in a way they cannot easily make sense of. For some people, this shows up as shame or remorse. For others, it feels like a painful conflict between what they believe is right and what they have witnessed, done, or been unable to prevent.

In many trauma models, the goal is to help someone return to a sense of safety. With moral injury, the goal can be different. It may involve helping someone build a new understanding of their story, where meaning can exist alongside what happened. Not erasing the experience—but making room for it. Recognizing this difference can help validate experiences that might otherwise feel chaotic, unresolved, or misunderstood.

Where Neurodiversity and Moral Injury Intersect
 This intersection does not mean all neurodivergent people experience moral injury differently. But it does suggest that:

• Some people may need more space to talk through moral events in detail.
• Some may feel more impacted by conflicts between values and actions.
• Some may feel a strong drive to make meaning of what happened rather than avoid it.

These responses are not weaknesses. They are simply different ways of processing experience. Understanding this can help us distinguish between exposure to morally challenging events and the lasting psychological effects that may follow.

Final Thoughts
 Moral injury is not about dysfunction. It is about meaning. And for people whose minds naturally search for meaning deeply and carefully, the hidden weight of moral injury may not always be fear. Sometimes it is the persistent pull of unresolved questions about values, responsibility, and identity. Recognizing neurodiversity as a lens rather than a problem can deepen our understanding of moral injury and broaden the ways we talk about it—in therapy, research, and public conversation.

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.

Shealyn Clinger, MA, MSW, LCSW, is a licensed clinical social worker and senior behavioral health leader with more than 15 years of experience advancing evidence-based wellness, prevention, and health promotion initiatives across federal, military, clinical, and community settings

By Timothy Rogers, Ph.D.

We all know that sleep is important. A 2021 congressional report by the Department of Defense (DOD) described sleep as the most important biological factor determining health and combat readiness. 

The report was based on a study required by the National Defense Authorization Act (NDAA) for Fiscal Year 2020 (Public Law 116-92).

The study had four objectives:

1. Provide a standardized definition of sleep deprivation.
2. Conduct an assessment of the prevalence of sleep deprivation among members of the Armed Forces.
3. Assess the relationship between sleep deprivation and medical conditions such as traumatic brain injury (TBI), post-traumatic stress disorder (PTSD), and depression.
4. Provide recommendations on efforts to mitigate sleep deprivation based on the study's findings.

The report defines sleep deprivation as “inadequate sleep that negatively impacts a service member’s military effectiveness, evidenced by a reduced ability to execute complex cognitive tasks, communicate effectively, quickly make appropriate decisions, maintain vigilance, and sustain a level of alertness required to carry out assigned duties” (Department of Defense, 2021). A recent review by Rodden et al. (2026) on the impact of sleep deprivation on combat readiness supports the DoD’s definition and created an infographic to summarize key findings from the literature (See figure 1). Prevalence estimates for sleep deprivation among service members were roughly twice as high compared to civilian populations, with 64% reporting getting less than seven hours of sleep per night.

The report notes multiple challenges to obtaining adequate sleep, often related to operational demands. It provides supporting evidence that sleep deprivation is significantly related to mental health conditions such as TBI, PTSD, depression, as well as suicide risk, with 23% of deployed service members screening positive for a mental health disorder when getting four or less hours of sleep per night (Department of Defense, 2021). To address these findings, the report made several recommendations, including adopting duty schedules that ensure eight hours of sleep, implementing sleep-related training for both service members and leadership, the importance of brief interventions, research focused on circadian rhythm issues, and establishing a clearinghouse for military sleep-related resources.

However, a Government Accountability Office (GAO) report in 2024 found that the DoD had no formal plans to implement or monitor the recommendations from that 2021 study. The GAO report noted that between 2015 and 2019, there were 489 reported instances of fatigued-driving related fatalities. Additionally, fatigue has contributed to hundreds of millions of dollars in damage to ships, vehicles, and aircraft (Government Accountability Office, 2024).

Citing the need to address military culture factors that negatively affect sleep and to improve the coordination of research and training, the GAO report serves as a call to action to convene a summit that focuses on addressing sleep and fatigue issues within the Department of War. The Uniformed Services University and its Center for Deployment Psychology, Consortium for Health and Military Performance, Center for the Study of Traumatic Stress, Department of Neurology and Rehabilitative Medicine, along with the Walter Reed Army Institute of Research, and United States Air Force are hosting a 2-day summit for researchers, policy makers, and other key stakeholders to address:

1. Sleep and fatigue challenges in military operations
2. The role of research in advancing sleep intel to support mission readiness
3. Dissemination and implementation strategies to optimize sleep and fatigue management

For more information about the sleep summit, please contact dod-sleep-summit-ggg@usuhs.edu or visit https://sites.google.com/usuhs.edu/sleep-and-fatigue-management/home

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.

Timothy Rogers, Ph.D., is an Assistant Director of Online Training, Technology and Telehealth for the Center for Deployment Psychology (CDP) at the Uniformed Services University for the Health Sciences in Bethesda, Maryland.

References:
 Department of Defense (2021). Study on the effects of sleep deprivation on the readiness of members of the Armed Forces.
https://assets.documentcloud.org/documents/20495233/study-on-effects-of-sleep- deprivation-on-readiness-of-members-of-the-armed-forces-final-report.pdf

Government Accountability Office. (2024) Military readiness: Comprehensive approach needed to address service member fatigue and mange related efforts. (Report No. GAO-24-105917). https://www.gao.gov/products/gao-24-105917

Rodden, J., Rogers, T., Dolan, D., & Paxton Willing, M. M. (2026). Sleep isn’t Optional, it’s
      Operational: The biopsychosocial toll of sleep deprivation in the armed
      forces [Manuscript accepted]. Military Medicine.

By Khristine Heflin, MSW, LCSW-C, LCSW, LICSW

I have served on the Military Child and Family Collaboratory, here at the Center for Deployment Psychology for almost four years now. A part of that work has been the valuable insights that I have gained from, providers, policy makers, advocates and families at our bi-annual convening events. One common theme is that our military families are often described as resilient, even as military youth face unique circumstances and navigate settings and situations marked by constant change. Hearing this theme repeated led me to look more closely at how resilience is supported and defined within military families.

Although there has not been a consensus on the definition of resilience, we can conclude that there are both individual factors and external circumstances that interplay to foster resilience (Skomorovsky & Dursun, 2022). Family resilience research emphasizes that risk and protective factors operate together and the balance of these factors influences a family's ability to be resilient (Sullivan et al., 2020). This framework also underscores how resilience can only fully be understood when providers consider the interaction between a family's stressors, strengths and access to resources (Sullivan et al., 2020).

To bring this framework to life, I want to share some reflections of a recent conversation with my cousin on what sustains her family’s resilience.

Before we get started can you please tell us a little about your family?
 We are the Johnsons. Andrew is 39 and has served on active duty in the U.S. Air Force for 15 years, and I’m Liz, 36, his spouse. We’ve been married for 11 years and are raising two kids—Dylan, our 9-year-old soccer enthusiast, and Amaya, who is 7 and proudly claims the title of gymnastics queen, along with Jefe, our forever puppy, who is either 10 or 70 depending on how you count dog years.

Andrew and I met at his first duty station in Washington, D.C., and since then our family has completed six permanent changes of station and experienced two full deployments. Dylan has already lived through five PCS moves, Amaya four, and Jefe five, each move adding another chapter to our family’s military journey.

-When you think about the term resilience, what does it mean for you in your day-to day life and what is needed to ensure that families maintain resilience?
 Definitely going with the flow and having to be okay with it. With Andrew being active duty, every so often, he’ll get his call-to-duty email and that’s when everything shifts gears with the quickness. When Andrew leaves, I try my best to keep our schedule the same or I may have to add more guidelines to our schedule. My saying for when he’s gone is “we’re all on the same team, we need to 'play' in harmony so that we can make this work”. I try to make sure the kids don’t miss out on their activities and maintain a sense of normalcy. Sometimes, I feel like I’m overcompensating to fill the absence of dad.

It sounds like flexibility is an important component of your family’s ability to maintain resilience. I know your family recently PCS’d. Can you tell us a little about that? How has military life such as deployments, trainings, frequent moves, or changes in routine impacted your family’s sense of connection, adaptability or staying steady during change and what helps your family stay cohesive during these transitions?
PSC-ing is very hard. This particular PSC came with a lot of anxiety for me and sadness for the kids. Andrew and I have open conversations about the upcoming PCS so we can prepare the kids and ourselves. I would schedule more playdates or try to squeeze in that last family vacation to make the idea of leaving less dreadful. We lived overseas and loved every minute of it. Living in Okinawa, I felt safe. My children got to be children (go outside and play without me standing feet away from them, walk alone, not have to worry about active shooters or even having to participate in the drills). I was able to let my guard down and feel human. Once we got the news we were coming back, I started to become stressed, stressed about money, the political climate and not having a job. For the kids, now that they’re older, they’ve expressed sadness because of them having to their friends, schools and teams.

We are a very tight knit family, Dylan and Amaya are each others best friends, they play extremely well together. I’ve had to have a lot of heart-to-hearts with them and remind them that they are always going to be there for each other no matter what. It’s funny to see how they are so different when they interact with their friends. Dylan is more reserved and will have maybe 1 or 2 solid buddies and then there Amaya, she had everyone and their family as a friend. Watching them say goodbye to their friends was hard for me. Amaya and her “besties” cried the whole day and hugged. Dylan gives a quick high-five and a “bye guys” and goes on about his business. Once we landed in the U.S. I saw the excitement and the calmness leave him and he became very sad for a few days. It took him a while to say the words “I’m sad” “I miss my life in Okinawa” “I want to go back”.

Because we PCS-ed during the holiday and the kids weren’t enrolled in school, our schedules were all out of whack, going to bed late, eating out, sleeping in. We talked about how this Christmas didn’t feel like Christmas. Typically right after Thanksgiving, we’re gearing up for Christmas, this year we were gearing up for a move. Dylan reminded me that this year we did not have our traditional movie nights or hot chocolate dance parties. Hearing that made me extremely sad because I am “Mother Christmas" and I feel like as a mom, it’s my duty to help create these traditions and memories.

It’s clear that a move can bring on both excitement and stress, can you share what helps your family maintain stability and a sense of belongingness?
 I try my hardest to keep connections with our family members, cousins and friends to maintain normalcy and consistency for the kids. Thank God for technology, the kids have been able to chat or Facetime their friends and family whenever they want. I try to show them that they don’t have to forget anyone just because we aren’t physically close to them.

What supports, resources, or change within schools, health care, or military systems would support greater resiliency for you and your family?
The process of transferring schools might have be the most nerve wracking for me. During our most recent move, the school we were transferring to needed all of these reports and forms that the kids' current school was not able to give to us until the semester finished, which was bringing us too close for comfort. Having the kids transition right into school was a big goal for me, so that they didn’t have such a big break in their routine, but in true PCS fashion, things just didn’t go as planned. I wish the military would allow/pay for one family member to travel with us during a PCS. This would take a lot off of our minds when we are trying to do our last minute packing or bag check ins. This time around, when we arrived in San Antonio, we had eight large totes, three big suitcases two kids and one dog with a very large travel crate. Having to wrangle everything up, and not have it in the way of the other travelers and keep the kids put, was very hard, especially when we had to walk the entire airport to go to retrieve a rental. Thank God I ran into a longtime friend in the baggage claim, he was willing to sit with our bags and the kids while we got our rental. If we had someone already there with us, we would have gotten out of that airport a lot quicker. Another option might be to have a sponsor ready and waiting for us with a large vehicle to pick us up from the airport and drive us to the hotel. In Okinawa, we drive on the opposite side of the road and car. Coming back and having to immediately remembering how to drive in a state where the minimum speed limit is 80 MPH and it was night (I don’t do well with night driving) was scary. I was terrified, and I kept it 100% honest with my kids, mom was scared. So we drove in silence to help me concentrate. We have a good laugh about it now, but if we could have something like a shuttle service, that would alleviate a lot of stress and added anxiety.

Why are periods of rest or stability important for your family’s resilience?
 This PCS we had a longer period of rest because of the holidays, which for the kids was great, for me, I was burnt out with “Mommmmmm” “Can you charge my ipad?” “Where’s my chargerrrrrr?” “Can I have a snaaaackkkk?”. I think by 12/31 the kids were ready to go back to school and I definitely started that countdown lol. I do, however, like having those moments of rest because it gives us an opportunity to sit with our feelings, good or bad and recalibrate.

Military families and youth experience various risk factors that contribute to challenges, including deployments, reintegration following deployment and frequent moves but their outcomes are shaped not only by these challenges (Sullian et al., 2020). Protective factors like family cohesion, access to resources and support and connection to community serve as a buffer against negative outcomes and contribute to resilience (Sullian et al., 2020).

These experiences of the Johnson family show the work of resilience emerges through the steady and often forgotten moments of connection, flexibility and rest. Sustaining families means not only acknowledging the demands of military life but fostering an environment that promotes coordinated systems of support and opportunities for families to connect, rest and reset.

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.

Khristine Heflin, MSW, LCSW-C, LCSW, LICSW, is a licensed Clinical Social Worker and has been practicing since 2006. Currently, she serves as a Military Child Social Worker with the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences located in Bethesda, MD.

References:
 Skomorovsky, A., & Dursun, S. (2022). Introduction: Resilience in military families. Military Behavioral Health, 10(2), 71–73. https://doi.org/10.1080/21635781.2022.2098886
 Sullivan, K. S., Hawkins, S. A., Gilreath, T. D., & Castro, C. A. (2021). Mental health outcomes associated with risk and resilience among military-connected youth. Family Process, 60(2), 507–522. https://doi.org/10.1111/famp.12596