Contemporary Family Therapy

, Volume 37, Issue 3, pp 281–290 | Cite as

Crisis Management and Conflict Resolution: Using Technology to Support Couples Throughout Deployment

  • Adam M. Farero
  • Paul Springer
  • Cody Hollist
  • Richard Bischoff
Original Paper


The deployment cycle presents unique challenges for military couples. Marital outcomes have been shown to be negatively impacted throughout the deployment process, and at-home stressors can serve as distractions for service members that can compromise their effectiveness and safety. Tele-mental health, specifically the delivery of therapy via videoconferencing, has been shown to be an effective therapy medium, particularly for reaching underserved or isolated populations. A case can be made for the use of tele-mental health as a means of delivering therapy to military couples throughout the deployment process in an effort to strengthen their relationship and enhance service member well-being during deployment. This form of therapy may be particularly valuable to couples experiencing barriers to care due to stigma, rural location, or limited access to military resources (i.e. National Guard service members). Three general recommendations for this form of treatment are first provided, which include (1) work within the military culture, (2) capitalize on existing support structures, and (3) receive training in tele-mental health delivery. Five additional recommendations are provided which are specific to delivering couples therapy while the service member is deployed. These recommendations include (1) tailor treatment to fit the service member’s context, (2) prioritize service member safety, (3) encourage the development of couple skills in therapy, (4) be intentional about session management, and (5) engage the at-home spouse. Legal and ethical considerations, as well as intended benefits for this method of treatment are also discussed.


Tele-mental health Distance therapy Couples therapy Deployment 

The deployment cycle presents unique challenges for service members and their families. Within the first year post-deployment, as many as one-third of veterans utilize mental health services (Hoge et al. 2006). In addition, approximately 20 % of service members returning from deployment meet the risk criteria for mental health concern, which include depression, post-traumatic stress disorder (PTSD), suicide ideation, interpersonal conflict and aggression ideation (Hoge et al. 2006; Milliken et al. 2007). Deployment is also linked with negative mental health outcomes in military spouses and children. Military spouses may demonstrate significant psychological issues during the deployment period, including depressive symptoms and anxiety, along with sleep and adjustment disorders (Jensen et al. 1996; Mansfield et al. 2010). Children with a deployed parent are also at an increased risk for depression, as well as emotional and behavioral problems (Chartrand et al. 2008; Eaton et al. 2008; White et al. 2011).

The National Guard (NG) is a subset of the military that is particularly vulnerable during the post-deployment period, or reintegration. Like their active duty counterparts, NG service members have demonstrated a clear need for mental health services following deployment. One study reported that upon return from deployment, 40 % of NG service members had at least one mental health problem (Gorman et al. 2011). Additionally, suicide has been reported as the third leading cause of death among NG service members (Studenicka 2007).

Substance abuse is also an issue among NG service members during the reintegration period. These service members have been shown to be at an increased risk for alcohol misuse compared to their active duty counterparts, particularly following a deployment (Jacobson et al. 2008). In one study of NG service members that had recently returned from deployment, 29 % were classified as hazardous drinkers (Blow et al. 2013). The impact of the deployment process is also evidenced in the wellbeing of partners of NG service members, with one study reporting 34 % of significant others having one or more mental health problems (Gorman et al. 2011).

Deployment can have a particularly detrimental effect on couples. Marital relationships have been shown to suffer not only during deployment, but throughout the entire deployment cycle (Sahlstein et al. 2009; Caselli and Motta 1995). Both at-home and deployed spouses demonstrate negative marital outcomes associated with deployment (Caselli and Motta 1995; Sahlstein et al. 2009). At-home spouses have raised concern especially over the lack of time spent together and uncertainty regarding the future of their marriage (Sahlstein et al. 2009). The period following deployment has also been linked with higher levels of abuse, including verbal attacks and isolation of the at-home spouse, along with higher rates of domestic violence when compared with veterans not recently deployed (Glenn et al. 2002; McCarroll et al. 2000). Post-deployment PTSD can be particularly trying for married couples, with PTSD being linked to significantly lower marital adjustment, marital satisfaction, and relationship confidence, along with increased marital instability, aggression and hostility between spouses, and reintegration stress reported by both partners (Allen et al. 2010; Caselli and Motta 1995; Glenn et al. 2002; Marek and D’Aniello 2014; Riggs et al. 1998).

Just as deployment impacts relationships, relationship factors are linked to service member mental health and well-being. Marriage and family stressors are frequently reported as the reason service members utilize deployment stress-control clinics. In some locations, relationship stressors even surpass stressors associated with combat as reasons given for seeking treatment (Jenkins and Barry 2007; Warner et al. 2007). In one study, Cigrang et al. (2014) and colleagues found that levels of relationship distress and depression during deployment independently predicted service members’ ratings of impact on duty performance. Furthermore, negative communication with loved ones during deployment is connected to mission distraction, which leads to greater risk of loss of life or limb (Durham 2010; Warner et al. 2007; Wong and Gerras 2006). Service member suicide has been tied to stressors related to marital and familial relationships even for suicides in deployed installations (Warner et al. 2007). Failed and/or failing intimate relationships were the most common stressor preceding suicide (Martin et al. 2009).

While relationship problems have the potential to be a distraction for service members, positive couple communication during deployment has the potential to be a support. Multiple reports have identified the benefits of service members maintaining regular communication with their intimate partner during deployment (Baptist et al. 2011; Merolla 2010; Moelker and van der Kloet 2006). When communication between a deployed service member and their partner is positive, it has the potential to help the couple maintain a sense of closeness, mutual support, and trust, allowing both the deployed and at-home partner to feel supported and to better cope with the deployment process (Baptist et al. 2011; Merolla 2010; Moelker and van der Kloet 2006). Furthermore, couples are then able to develop communication skills that allow them to find solutions to the day to day challenges that emerge during the deployment process (e.g., parenting, disciplining children, financial struggles), without escalating into conflict. Additionally, the risk of PTSD may be reduced by frequent communication with a spouse during deployment when marital satisfaction is high (Carter et al. 2011).

Although there is clear value in and need for couples therapy among service members and their partners impacted by deployment, many are not receiving the help they need. The use of mental health services is highly stigmatized in the military. Studies have indicated that only 40 % of active duty service members and 50 % of NG service members with mental health issues seek treatment (Gorman et al. 2011; Pietrzak et al. 2009). It is a requirement for mental health care providers employed by the military to relay diagnoses and treatment to commanding officers. Consequently, service members have reported avoiding treatment out of concern that it may negatively impact their future military career, including missions, redeployment, and being promoted (Gorman et al. 2011; Green-Shortridge et al. 2007; Hoge et al. 2004). Thus, it is easy to see how service members may face a dilemma when it comes to finding quality treatment that still allows them discretion.

NG service members may be at a particular disadvantage when it comes to accessing mental health services and support in general. In comparison to active duty service members, members of the NG have access to fewer resources during the reintegration process. Due to living off of a military base, NG service members and their families have limited opportunities to receive support from military chaplains and family support programs (Department of Defense Task Force on Mental Health 2007). Unlike active duty members living on-base near unit peers, NG service members tend to live far from other soldiers they served with who could offer an additional source of support. Another implication of living off-base is that many service members must seek medical and mental health treatment at civilian hospitals, rather than travel a long distance to a VA hospital (Gorman et al. 2011). If living in a rural area, NG service members may even have difficulty accessing mental health services at all, let alone service that is sensitive to the military culture. In one study significant others of NG service members echoed the disadvantage of seeking mental health treatment in the NG, reporting that one of multiple barriers to care they experienced was that they did not know where to seek help (Gorman et al. 2011). This limited availability of military resources to NG service members requires them to rely more on support from their local communities (US Department of Defense Task Force on Mental Health 2007), which has led the literature to call for increased community resources (Blow et al. 2012).

Thus, the literature highlights that (1) a strong couple relationship, evidenced by regular positive communication throughout deployment, is a protective factor for relationship distress, marital dissolution, and the development of mental health problems, and (2) there are significant barriers to military couples receiving professional help, particularly in times of deployment. Military programs such as Strong Bonds and Yellow Ribbon have been created to strengthen couple relationships throughout the deployment process. Despite the value of these programs, they are limited to helping couples make plans for effective communication during deployment, or reestablishing good communication following return. Yellow Ribbon events support service members and their families but the structure is designed for information sharing, not relationship treatment. Additionally, these military programs are not available to NG service members and their families who, as previously discussed, are at a disadvantage in terms of resources for the deployment process. Thus, there are gaps that are not filled by these programs. First, they do not actively assist couples in strengthening their relationship during deployment. Second, these programs are not accessible to all service members experiencing deployment, particularly members of the NG. These factors suggest the need for methods of conjoint symptom management during deployment, as well as the accessibility of continued couple therapy following deployment. What is needed is a comprehensive strategy that includes pre-deployment, deployment, and post-deployment support with the purpose of strengthening couple relationships. This paper will focus on highlighting one strategy that can be used to strengthen the couple relationship during deployment.

The Viability of Technology to Deliver Marital Interventions

Despite heightened attention by all branches of the military to improve the well-being of service members throughout the deployment process, additional support is needed for service members experiencing barriers to supportive mental health services both during and post-deployment. NG service members, particularly those in rural locations, are in particular need of accessible couples therapy. During deployment, the physical separation couples experience presents a unique challenge to providing effective therapy. Novel methods for delivery of services are needed that, (1) are accessible to isolated service members and their partners, (2) bridge the physical separation couples experience during deployment, and (3) make use of the methods of communication couples use during deployment. Recent advances in telecommunications, including the ready accessibility of high quality live video, make videoconferencing a viable option for providing ongoing professional couple therapy that will be a protective factor for couples during and after deployment, regardless of location or access to military resources. In this paper, using videoconferencing to deliver couple therapy to service members and spouses will be referred to as tele-mental health.

Tele-mental health is a viable solution for filling the gaps in services available for couples during deployment. Advances in technology have made it possible to bridge barriers created by a lack of physical proximity. Modern videoconferencing technologies allow multiple people in multiple locations to meet in a virtual setting for mental health care. Tele-mental health has been found to be an effective method of delivering psychotherapy (Dunstan and Tooth 2012; Greene et al. 2010). Tele-mental health increases access to care, reduces the indirect costs of treatment, and increases continuity of care for underserved populations (Lexcen et al. 2006; Poon et al. 2005; Ruskin et al. 2004; Singh et al. 2007). It has also been shown to reduce the real costs of providing treatment for those facing access-to-care barriers (Antonacci et al. 2008), with one study showing that the average cost of tele-mental health was 10 % less per patient, and 16 % less per visit, than face-to-face (O’Reilly et al. 2007).

Strong evidence suggests that tele-mental health delivery is effective in significantly reducing symptoms for a variety of mental disorders, including, anxiety, depression, PTSD, and anger problems (Dunstan and Tooth 2012; Greene et al. 2010). Other research has shown that there is very little difference in quality and outcomes of treatment when compared to face-to-face therapy. For example, videoconferencing has been shown to be equally effective as face-to-face psychotherapy, with outcome data suggesting clinically significant reduction in symptomology and gains in general life functioning (Dunstan and Tooth 2012). Several clinical randomized studies have also found that when comparing face-to-face intervention with those occurring through videoconferencing, videoconferencing yields comparable outcomes in symptom severity, treatment adherence, retention and satisfaction (Ruskin et al. 2004; De Las Cuevas et al. 2006; O’Reilly et al. 2007). In fact, the largest randomized controlled study of tele-mental health found that on all measures of clinical outcome, tele-mental health was comparable to face-to-face service delivery, with both groups reporting reduced symptomatic distress and improved mental health (O’Reilly et al. 2007). In the face of few alternatives, patient acceptance of this medium is high (Bischoff et al. 2004). Despite concerns expressed by providers, patients report treatment satisfaction with tele-mental health and the development of a therapeutic alliance comparable to face-to-face mediums (Bischoff et al. 2004; Foster and Whitworth 2005; Singh et al. 2007).

Although the literature suggests tele-mental health as a viable therapy medium, there is a lack of research exploring its efficacy for treating couples, particularly couples who are physically separated. Additional challenges faced by military couples and families include accessibility, cost, and continuity of care (Shore et al. 2014). The Department of Defense (DoD) and the Veterans Administration (VA) have begun to address these challenges by looking for solutions that rely on the use of telecommunications and other technologies (Department of Defense Task Force on Mental Health 2007). For example, the use of mobile and wireless devices to improve health outcomes, health care service and health research is being looked at as a potential solution for meeting the ongoing mental health needs of military service members and their families (Shore et al. 2014). This includes the development of apps for mental health assessments and treatment using cognitive behavioral therapy (Bang et al. 2007). While these applications will soon be widely available to service members and their families in civilian environments and military instillations, they are not currently available in the theaters of war (Shore et al. 2014). The application of tele-mental health care delivery would be the logical solution for addressing marital distress, particularly for couples without access to services on-base, as well as during deployment.

General Clinical Recommendations for Using Tele-Mental Health with Military Couples

The following are three general recommendations to consider when conducting therapy with service members and their partners via tele-mental health. These are appropriate recommendations regardless of the deployed status of the service member. These will be followed by five recommendations specific to working with couples when one or both are deployed. The authors have extensive experience in establishing, providing and supervising the delivery of therapeutic services via distance technology to underserved populations. Within their family therapy training program they have had a program of distance therapy for over 14 years. One of the authors is currently serving as a Chaplain in the National Guard. This has added contextual depth to the approach and suggestions provided.

Recommendation #1: Work Within the Military Culture

Before beginning treatment, it is necessary to understand the military context. A therapist should have a working knowledge of military acronyms and nomenclature in general, along with other customs and values, particularly those associated with rank. An understanding of military culture may provide important insight into family structure and dynamics, and especially the implications of role transitions related to the deployment cycle. Additionally, a therapist should be aware of the distinct challenges that vary depending on a service member’s type of involvement in the military. For example, active duty households are likely to experience multiple relocations, while members of the NG or Reserves, although perhaps more stationary, are at risk due to the separation from military supports (Hall 2008).

Recommendation #2: Capitalize on Existing Support Structures

In addition to becoming familiar in with the military context in general, it will be especially important for the therapist to be aware of the existing military support structures. For example, the military offers the programs Strong Bonds and Yellow Ribbon to aid couples in strengthening their relationship prior to deployment. During deployment service members have Chaplains, a First Sergeant, their chain of command, and at times psychological services at their disposal. The partner also has the support systems of the service member’s unit, the local community, and family members to look to for the emotional support that a partner would otherwise provide during treatment.

Recommendation #3: Receive Training in Tele-Mental Health Delivery

It is recommended that the therapist be trained in how to use this medium effectively. While tele-mental health has been shown to be effective, the delivery of therapy through this medium is different than face-to-face therapy. Accommodations must be made when the therapist is delivering therapy from a location separate from the clients. Consider the scenario in which a couple begins to escalate in-session and there is a need for the therapist to intervene in order to prevent harm. The therapist must do this without the aid of being in the room with the couple. This means that the therapist is unable to reposition the couple in relation to each other. Training will also be important for ensuring that the therapist is prepared to troubleshoot potential difficulties with the technology, such as loss of connection.

Unique Clinical Recommendations for Tele-Mental Health with Couples During Deployment

While there are anecdotal reports of mental health providers conducting therapy with service members in deployed locations, no set of expected standards and criteria have been established. The following are five specific recommendations, in addition to the previous three, for using videoconferencing during deployment as a medium for therapy focused on strengthening couple communication. The deployed environment, especially in combat zones, is such a unique experience that a treatment as usual approach is often unhelpful, and, in some cases, may even be contraindicated.

Recommendation #1: Tailor Treatment to Fit the Service Member’s Context

Before beginning treatment, it is necessary to understand the nature of the deployment context. Some important variables to consider include where the service member is receiving treatment, what the service member will be doing before and after a therapy session and other services available to the service member.

Because the therapist is not able to see the entire setting in which the service member is receiving treatment, it could be easy for a therapist to decontextualize the service member’s setting. Thus, having a working understanding of the service member’s setting is essential.

The therapist should be aware that a service member’s schedule is often erratic, and should be prepared to accommodate. For example, the time of the day when the service member is allowed to use the internet may not fit into a regular schedule of sessions. These times may be morning 1 week and then the evening the next. Session lengths may also vary with therapists needing to be flexible to provide 30-min instead of the regular 50-min session. Scheduling difficulties may also arise due to significant time differences. Sessions ultimately should be tailored to the availability of the service member.

It is also necessary to anticipate being flexible due to potential problems with the connectivity of the technology. As the internet connection is not always predictable in deployed locations, there will be days when the connection is working well and days when it does not work at all. Additionally, complications may arise due to the complexity of coordinating the technology between up to three sites (the service member’s, partner’s, and therapist’s locations). Ultimately, it is important for the therapist to be flexible and to recognize that irregularities in treatment do not suggest lack of investment in treatment, but are more likely the result of situations beyond the control of the service member.

Recommendation #2: Prioritize Service Member Safety

A known risk of mental health treatment, regardless of mode of delivery, is that it can increase emotional and psychological distress, which could distract the service member from performing their job, putting themselves and others at risk. Research has found that when problems at home escalate, service members’ focus and performance is often affected, endangering themselves and other service members (Durham 2010; Warner et al. 2007; Wong and Gerras 2006). Traditional therapy often utilizes techniques that heighten emotions, increase discomfort and unbalance family rules and roles (Minuchin 1974). In the context of deployment, interventions may put the service member at risk, as the therapist may not have enough time to properly work through emotional issues before the service member reports for duty. Each session should have the approach that safety outside of session is tenuous. The therapist should not purposefully elevate the emotion beyond what he or she can help the couple resolve in the session. Care should be taken that by the end of the session the conversation is deescalated and supportive.

Additionally, deployment is not the time to deal with deep psychological scars through couple therapy. Support for service members with deep-seated struggles may be better served, when possible, by psychological services in the deployed location and likewise for the at-home partner. If either of them is experiencing individual psychological distress individual treatment should be indicated. Professionals should use caution when addressing severe emotional stress in the couple framework. If an emergency arises, acute resolution techniques should be used to deescalate the situation and get each member the help they need. Any existing relational issues that are not impacting the couple’s interaction should be set aside for after the service member’s return. It may be necessary to contact the service member’s home station to report a concern if the therapy process brings to light a serious safety concern, such as the service member being suicidal or homicidal.

Consideration should also be given to the service member’s responsibilities and the risk associated with them when determining if he or she is well-suited for this intervention. Involvement in this therapy may be contraindicated for service members working in particularly high-intensity or dangerous roles. It may be necessary to create a screening process that accounts for the service member’s past and current psychological functioning and deployment duties.

Recommendation #3: Focus on the Development of Couple Skills in Therapy

In order to make service member safety a priority, the therapist should help the couple remain focused by guiding them to develop specific skills. One distinction with couple therapy during deployment is that the goal of treatment is to equip the couple with skills to enable them to successfully navigate deployment, rather than resolve serious individual or couple emotional or psychological issues.

The therapist’s goal when working with deployed couples should be to help a couple reduce stress and increase stability. Areas of focus should include crisis resolution, reduction of couple conflict and role strain, while encouraging positive communication skills. It is important to recognize that during deployment both members of the couple experience personal stress and concern for each other (Flake et al. 2009; Warner et al. 2009). Not only is the service member under the constant threat of danger, but the at-home partner takes on significant work loads and family roles, in the absence of their partner (Flake et al. 2009; Warner et al. 2009). The increase of stress, fear and uncertainty among each partner affects the marital relationship (Sahlstein et al. 2009). Magnifying this problem is the fact that the couple’s typical method of problem resolution is often less effective given the distance and technology mediated communication. The therapist is unable to ask the couple to use touch, such as holding hands with one another, as a way to de-escalate. It is therefore important that the therapist focus on ways to help the couple feel emotionally close despite being physically apart. Crisis resolution and problem resolution should be the first priority of couple therapy in order to provide more stability and decrease the couple conflict.

The couple should also be helped to build new positive communication skills. Each service member and partner should be taught that the strategies of responding to distress during deployment are different than those they use when both are home. For example, it is a different experience to try to soothe or comfort a spouse over the phone or through the Internet, rather than face-to-face. As such, new communication skills and ways of connecting must be learned. However, these new skills are valuable, as they can be utilized to work through other stressors the couple experiences throughout deployment.

Recommendation #4: Be Intentional About Session Management

In order to help the couple develop these skills during deployment, the therapist must be intentional about session management. The challenge as a therapist is to vet the conversation topics sufficiently to avoid introducing stress into the couple relationship. More individual meetings may need to take place to ensure that the therapist is monitoring stress levels related to treatment. The therapist should not become complicit in secret keeping but must determine the impact of bringing up every issue either of the individuals is concerned with. Treatment needs to be focused on improving interactional behaviors, rather than delving into the past to deal with unresolved issues.

The therapist should work with the couple to set clear, realistic, measureable, and skills-focused goals in order to help determine appropriate treatment topics. Once the couple and the therapist have identified goals for treatment, the therapist should facilitate a discussion about how addressing those goals during deployment might affect the service member and the partner. It is critical that therapy not increase an already stressful environment. As a result, a discussion about how each partner will talk about these issues is essential. On a session-by-session basis the therapist should check in with each member to see if they feel prepared to address the issues identified for that day; and tailor treatment accordingly. The skill of helping couples learn to recognize their daily level of emotional/psychological strength is an important skill for their everyday communication, as well as for sessions.

Time may need to be spent in individual sessions with each member of the couple to ensure that the therapist does not learn about a traumatic issue at the same time a member of the couple does. If the therapist does find out first, he or she can discuss with one member of the couple how and when is best to tell the other member. This will also enable the therapist to know how to structure the topic of session to ensure time is given for de-escalation, as mentioned above.

Recommendation #5: Engage the At-Home Spouse

Due to the necessity to accommodate many of the aspects of therapy to the deployed service member (i.e. appropriate topics to discuss, when to hold sessions, etc.), it is important to make a point to engage the at-home spouse in the therapy process as well. The demands of deployment may already make the at-home spouse feel invisible or like less of a priority, and therefore the therapist must work not to exacerbate these feelings. In order to help keep the at-home spouse engaged, it may be necessary to meet individually with him/her in the event that the deployed spouse is unable to meet. Doing so could help address any individual concerns the at-home spouse has, while also demonstrating the therapist’s investment in the couple and commitment to their progress. Making consistent efforts to understand and meet the needs of the at-home spouse could increase buy-in from the couple overall and improve the therapeutic alliance.

Legal and Ethical Issues

In addition to accounting for these recommendations when delivering therapy with couples throughout the deployment process, there are certain legal and ethical issues to consider. Currently, states regulate the practice of psychotherapy. There is no national regulation or licensure, let alone regulation of psychotherapy provided to clients residing outside of the United States. This poses a problem in determining the legality of providing services through telecommunications to service members and their spouses who may or may not reside in the state where the therapist is licensed to practice. Neither statutory law nor case law has yet to resolve this issue. Therapists should consult the laws governing the practice of psychotherapy (couple therapy) in both the state in which they are licensed and the state in which one or both spouses reside and are receiving treatment. The DoD has responsibility for the service members, and consequently, has responsibility for determining the legality of the delivery of care through telecommunications to service members in their field of duty during deployment. Telecommunications has made it increasingly possible for service members and their partners to receive couple therapy outside of the military structures, but therapists should be cognizant of the legalities of engaging in this kind of practice and of the consequences, both intended and unintended, of doing so.

Second, couple therapists need to make every effort to ensure that both spouses are giving informed consent to treatment. This includes knowing the potential risks, consequences, and benefits of receiving couple therapy through telecommunication. Given the unique military context, it is particularly important that they know the limits of confidentiality, both in terms of what the therapist is required by law to disclose and what may be disclosed inadvertently due to limitations in the security of the medium or care delivery. It is important to include a statement in the consent form when the therapist would need to break confidentiality and disclose information to military personnel. For example if it is deemed that the service member poses a serious safety risk to themselves (suicidal) or to others (homicidal). At the initial meeting it is important to find out from the service member who should be contacted should any duty to warn issues arise. It is essential that the therapist discuss with the client how electronic information will be stored, used, and made available outside of treatment. It is also critically important that the therapist be upfront with the clients about the risks of technology failure leading to disruptions in sessions, especially given the unpredictability of technology in some deployed locations.

Intended Benefits

Utilizing tele-mental health throughout the deployment process has the potential to help break down the barriers to care that service members often experience. Despite the prevalence of mental health disorders among service members, the stigma associated with seeking mental health services often prevents service members from seeking the help they need (Hoge et al. 2004). However, if service members have already established a relationship with a therapist during deployment, they may be more willing to continue treatment post-deployment while they navigate the reintegration process. Access to a therapist that is sensitive to the military culture, yet unassociated with the military, may also make service members, including those in rural communities such as in the NG, more likely to seek treatment following deployment without concern of it hindering their career. Additionally, as continuity of care has been identified as another barrier to care for service members (Shore et al. 2014), the flexibility of tele-mental health may enable ongoing treatment for service members experiencing frequent relocation due to their military service.

There are added benefits of tele-mental health to consider when using it to support couples during deployment, one of which includes that it allows issues to be addressed sooner, resulting in better long-term outcomes for service members and their families. Early detection and prompt treatment are key factors to improved outcomes among people who struggle with mental health related issues (Moll 2014; Allen et al. 2007). Studies suggest that delays in seeking treatment lead to unnecessary healthcare expenditures, reduction in relational functioning and work productivity as well as poorer treatment outcomes (Van Beijouw et al. 2010). Conversely, other studies demonstrate that early identification and intervention leads to not only reduction of symptomology, but the quality and speed of their recovery (McGorry 2013), including adaptive functioning and the reduction of familial and societal burden. Thus, the use of tele-mental health could mean better outcomes during and following the deployment period.

Directly related to the advantage of addressing issues early is the service member’s improvement in functioning throughout deployment. As previously discussed, couple dynamics have been shown to have a significant impact on the deployed service member functioning, including their stress level, mental health, focus, effectiveness, and safety (Cigrang et al. 2014; Durham 2010; Warner et al. 2007; Wong and Gerras 2006). Thus, improvement in relationship functioning may have a significantly positive impact on the service member’s ability to fulfill their duties more safely and effectively.

A final benefit to consider of utilizing tele-mental health during deployment is specifically the help it provides to the at-home spouse. In addition to aiding in stabilizing the relationship, therapy via tele-mental health offers a source of support for the at-home spouse. This support could be especially important when working with NG couples. National Guard members and their families tend to live off-base and have fewer connections to peers from their unit (Griffith 2005), making military resources that can be a significant form of support of help with adapting unobtainable (Flake et al. 2009). Therefore, at-home spouses, particularly those of National Guard, could benefit from having the additional resource of therapy during deployment.


  1. Allen N.B., Hetrick S.E., Simmons J.G., et al. (2007). Early intervention for depressive disorders in young people: the opportunity and the (lack of) evidence. Medical Journal of Australia, 187, S15–S17. Retrieved from
  2. Allen, E., Rhoades, G., Stanley, S., & Markman, H. (2010). Hitting home: Relationships between recent deployment, posttraumatic stress symptoms, and marital functioning for army couples. Journal of Family Psychology, 24, 280–288. doi:10.1037/a0019405.PubMedCentralCrossRefPubMedGoogle Scholar
  3. Antonacci, D. J., Bloch, R. M., Saeed, S. A., Yildiram, Y., & Talley, J. (2008). Empirical evidence on the use and effectiveness of telepsychiatry via videoconferencing: Implications for forensic and correctional psychiatry. Behavioral Sciences and the Law, 26, 253–269. doi:10.1002/bsl.812.CrossRefPubMedGoogle Scholar
  4. Bang, M., Timpka, T., Erkisson, H., Home, E., & Nordin, C. (2007). Mobile phone computing for in situ cognitive behavioral therapy. Study of Health Technology Information, 129, 1078–1082. Retrieved from
  5. Baptist, J. A., Amanor-Boadu, Y., Garrett, K., Nelson Goff, B. S., Collum, J., Gamble, P., et al. (2011). Military marriages: The aftermath of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) deployments. Contemporary Family Therapy, 33, 199–214. doi:10.1007/s10591-011-9162-6.CrossRefGoogle Scholar
  6. Bischoff, R. J., Hollist, C. S., Smith, C. W., & Flack, P. (2004). Addressing the mental health needs of the rural underserved: Findings from a multiple case study of a behavioral telehealth project. Contemporary Family Therapy, 26, 179–198. doi:10.1023/B:COFT.0000031242.83259.fa.CrossRefGoogle Scholar
  7. Blow, A. J., Gorman, L., Ganoczy, D., Kees, M., Kashy, D. A., Valenstein, M., et al. (2013). Hazardous drinking and family functioning in National Guard veterans and spouses postdeployment. Journal of Family Psychology, 27, 303–313. doi:10.1037/a0031881.CrossRefPubMedGoogle Scholar
  8. Blow, A. J., MacInnes, M. D., Hamel, J., Ames, B., Onaga, E., Holtrop, K., et al. (2012). National Guard service members returning home after deployment: The case for increased community support. Administration and Policy in Mental Health and Mental Health Services Research, 39, 383–393. doi:10.1007/s10488-011-0356-x.CrossRefPubMedGoogle Scholar
  9. Carter, S., Loew, B., Allen, E., Stanley, S., Rhoades, G., et al. (2011). Relationships between soldiers’ PTSD symptoms and spousal communication during deployment. Journal of Traumatic Stress, 24, 352–355. doi:10.1002/jts.20649.PubMedCentralCrossRefPubMedGoogle Scholar
  10. Caselli, L. T., & Motta, R. W. (1995). The effect of PTSD and combat level on Vietnam veterans’ perceptions of child behavior and marital adjustment. Journal of Clinical Psychology, 51, 4–12. doi:10.1002/1097-4679(199501)51:1<4:AID-JCLP2270510102>3.0.CO;2-E.CrossRefPubMedGoogle Scholar
  11. Chartrand, M. M., Frank, D. A., White, L. F., & Shope, T. R. (2008). Effect of parents’ wartime deployment on the behavior of young children in military families. Archives of Pediatric and Adolescent Medicine, 162, 1009–1014. doi:10.1001/archpedi.162.11.1009.CrossRefGoogle Scholar
  12. Cigrang, J. A., Talcott, G. W., Tatum, J., Baker, M., Cassidy, D., Sonnek, S., et al. (2014). Intimate partner communication from the war zone: A prospective study of relationship functioning communication frequency, and combat effectiveness. Journal of Marital and Family Therapy, 40, 332–343. doi:10.1111/jmft.12043.CrossRefPubMedGoogle Scholar
  13. De Las Cuevas, C., Arredondo, M., Cabrera, M., Sulzenbacher, H., & Meise, U. (2006). Randomized clinical trial of telepsychiatry through video conference versus face-to-face conventional psychiatric treatment. Telemedicine and e-Health, 12, 341–350. doi:10.1089/tmj.2006.12.341.CrossRefPubMedGoogle Scholar
  14. Department of Defense Task Force on Mental Health. (2007). An achievable vision: Report of the Department of Defense Task Force on Mental Health. Falls Church, VA: Defense Health Board.
  15. Dunstan, D. A., & Tooth, S. (2012). Treatment via videoconferencing: A pilot study using clinical psychology students. Australian Journal of Rural Health, 20, 88–94. doi:10.1111/j.1440-1584.2012.01260.x.CrossRefPubMedGoogle Scholar
  16. Durham, S. W. (2010). In their own words: Staying connected in a combat environment. Military Medicine, 175, 554–559. doi:10.7205/MILMED-D-09-00235.CrossRefPubMedGoogle Scholar
  17. Eaton, K. M., Hoge, C. W., Messer, S. C., Whitt, A. A., Cabrera, O. A., McGurk, D., et al. (2008). Prevalence of mental health problems, treatment need, and barriers to care among primary care-seeking spouses of military service members involved in Iraq and Afghanistan deployments. Military Medicine, 173, 1051–1056. doi:10.7205/MILMED.173.11.1051.CrossRefPubMedGoogle Scholar
  18. Flake, E. M., Davis, B. E., Johnson, P. L., & Middleton, L. S. (2009). The psychosocial effects of deployment on military children. Journal of Developmental and Behavioral Pediatrics, 30, 271–278. doi:10.1097/DBP.0b013e3181aac6e4.CrossRefPubMedGoogle Scholar
  19. Foster, P. H., & Whitworth, J. M. (2005). The role of nurses in telemedicine and child abuse. Computers, Informatics, Nursing, 23, 127–131. doi:10.1097/00024665-200505000-0007.CrossRefPubMedGoogle Scholar
  20. Glenn, D. M., Beckham, J. C., Feldman, M. E., Kirby, A. C., Hertzberg, M. A., & Moore, S. D. (2002). Violence and hostility among families of Vietnam veterans with combat-related posttraumatic stress disorder. Violence and Victims, 17, 473–489. doi:10.1891/vivi.17.4.473.33685.CrossRefPubMedGoogle Scholar
  21. Gorman, L., Blow, A., Ames, B., & Reed, P. (2011). National Guard families after combat: Mental health, use of mental health services, and perceived treatment barriers. Psychiatric Services, 62, 28–34. doi:10.1176/ Scholar
  22. Greene, C. J., Morland, L. A., Macdonald, A., Frueh, B. C., Grubbs, K. M., & Rosen, C. S. (2010). How does tele-mental health affect group therapy process? Secondary analysis of noninferiority trial. Journal of Consulting and Clinical Psychology, 78, 746–750. doi:10.1037/a0020158.CrossRefPubMedGoogle Scholar
  23. Green-Shortridge, T. M., Britt, T. W., & Castro, C. A. (2007). The stigma of mental health problems in the military. Military Medicine, 172, 157–161. doi:10.7205/MILMED.172.2.157.CrossRefGoogle Scholar
  24. Griffith, J. (2005). The Army National Guard soldier in post-9/11 operations: Perceptions of being prepared for mobilization, deployment, and combat. Journal of Political and Military Sociology, 33, 161–165. Retrieved from
  25. Hall, L. K. (2008). Counseling military families: What mental health professionals need to know. New York, NY: Taylor and Francis Group.Google Scholar
  26. Hoge, C. W., Auchterlonie, J. L., & Milliken, C. S. (2006). Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. Journal of the American Medical Association, 295, 1023–1032. doi:10.1001/jama.295.9.1023.CrossRefPubMedGoogle Scholar
  27. Hoge, C. W., Castro, C. A., Messer, S. C., et al. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 35, 13–22. doi:10.1056/NEJMoa040603.CrossRefGoogle Scholar
  28. Jacobson, I. G., Ryan, M. A., Hooper, T. I., Smith, T. C., Amoroso, P. J., Boyko, E. J., et al. (2008). Alcohol use and alcohol-related problems before and after military combat deployment. Journal of the American Medical Association, 300, 663–675. doi:10.1001/jama.300.6.663.PubMedCentralCrossRefPubMedGoogle Scholar
  29. Jenkins, D.M. & Barry, M.J. (2007). Relationship 101: Couples therapy in theater. Military Medicine, 172, iii–iv. Retrieved from
  30. Jensen, P. S., Martin, D., & Watanabe, H. (1996). Children’s response to parental separation during operation desert storm. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 433–441. doi:10.1097/00004583-199604000-00009-&gt.CrossRefPubMedGoogle Scholar
  31. Lexcen, F. J., Hawk, G. L., Herrick, S., et al. (2006). Use of video conferencing for psychiatric and forensic evaluations. Psychiatric Services (Washington, D.C.), 57, 713–715. doi:10.1176/ps.2006.57.5.713.CrossRefGoogle Scholar
  32. Mansfield, A. J., Kaufman, J. S., Marshall, S. W., Gaynes, B. N., Morrissey, J. P., & Engel, C. C. (2010). Deployment and the use of mental health services among US army wives. New England Journal of Medicine, 362, 101–109. doi:10.1056/NEJMoa0900177-&gt.CrossRefPubMedGoogle Scholar
  33. Marek, L. I., & D’Aniello, C. (2014). Reintegration stress and family mental health: Implications for therapists working with reintegrating military families. Contemporary Family Therapy, 36, 443–451. doi:10.1007/s10591-014-9316-4.CrossRefGoogle Scholar
  34. Martin, J., Ghahramanlou-Holloway, M., Lou K., & Tucciarone, P. (2009). A comparative review of US military and civilian suicide behavior: Implications for OEF/OIF suicide prevention efforts. Journal of Mental Health Counseling, 31(2), 101–118. Retrieved from
  35. McCarroll, J. E., Ursano, R. J., Liu, X., Thayer, L. E., Newby, J. H., et al. (2000). Deployment and the probability of spousal aggression by US. Army Soldiers. Military Medicine, 165, 41–44. doi:10.7205/MILMED-D-10-00048.PubMedGoogle Scholar
  36. McGorry, P. (2013). Prevention, innovation and implementation science in mental health: The next wave of reform. British Journal of Psychiatry, 202, s3–s4. doi:10.1192/bjp.bp.112.119222.CrossRefGoogle Scholar
  37. Merolla, A. J. (2010). Relational maintenance during military deployment: Perspectives of wives of deployed US soldiers. Journal of Applied Communication Research, 38, 4–26. doi:10.1080/00909880903483557.CrossRefGoogle Scholar
  38. Milliken, C., Auchterlonie, J., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq War. Journal of the American Medical Association, 298, 2141–2148. doi:10.1001/jama.298.18.2141.CrossRefPubMedGoogle Scholar
  39. Minuchin, S. (1974). Families and family therapy. Cambridge: Harvard University Press.Google Scholar
  40. Moelker, R., & van der Kloet, I. (2006). Military families and the armed forces. In G. Caforio (Ed.), Handbook of sociology of the military (pp. 201–223). New York: Springer.CrossRefGoogle Scholar
  41. Moll, S. E. (2014). The web of silence: A qualitative case study of early intervention and support for healthcare workers with mental ill-health. BMC Public Health, 14, 138. doi:10.1186/1471-2458-14-138.PubMedCentralCrossRefPubMedGoogle Scholar
  42. O’Reilly, R., Bishop, J., Maddox, K., Hutchinson, L., Fisman, M., & Takhar, J. (2007). Is telepsychiatry equivalent to face-to-face psychiatry? Results from a randomized controlled equivalence trial. Psychiatric Services, 58, 836–843. doi:10.1176/ps.2007.58.6.836.CrossRefPubMedGoogle Scholar
  43. Pietrzak, R. H., Johnson, D. C., Goldstein, M. B., Malley, J. C., & Southwick, S. M. (2009). Perceived stigma and barriers to mental health care utilization among OEF-OIF veterans. Psychiatric Services, 60, 1118–1122. doi:10.1176/ Scholar
  44. Poon, P., Hui, E., Dai, D., Kwok, T., & Woo, J. (2005). Cognitive intervention for community-dwelling older persons with memory problems: Telemedicine versus face-to-face treatment. International Journal of Geriatric Psychiatry, 20, 285–286. doi:10.1002/gps.1282.CrossRefPubMedGoogle Scholar
  45. Riggs, D. S., Byrne, C. A., Weathers, F. W., & Litz, B. T. (1998). The quality of intimate relationships of male Vietnam veterans: Problems associated with posttraumatic stress disorder. Journal of Traumatic Stress, 11, 87–101. doi:10.1023/A:1024409200155.CrossRefPubMedGoogle Scholar
  46. Ruskin, P. E., Silver-Aylaian, M., Kling, M. A., et al. (2004). Treatment outcomes in depression: Comparison of remote treatment through telepsychiatry to in-person treatment. The American Journal of Psychiatry, 161, 1471–1476. doi:10.1176/appi.ajp.161.8.1471.CrossRefPubMedGoogle Scholar
  47. Sahlstein, E., Maguire, K. C., & Timmerman, L. (2009). Contradictions and praxis contextualized by wartime deployment: Wives’ perspectives revealed through relational dialectics. Communication Monographs, 76, 421–442. doi:10.1080/03637750903300239-&gt.CrossRefGoogle Scholar
  48. Shore, J. H., Aldag, M., McVeigh, F. L., Hoover, R. L., Ciulla, R., & Fisher, A. (2014). Review of mobile health technology for military mental health. Military Medicine, 179(8), 865–878. doi:10.7205/MILMED-D-13-00429.CrossRefPubMedGoogle Scholar
  49. Singh, S. P., Arya, D., & Peters, T. (2007). Accuracy of telepsychiatric assessment of new routine outpatient referrals. BMC Psychiatry, 7, 55–68. doi:10.1186/1471-244X-7-55.PubMedCentralCrossRefPubMedGoogle Scholar
  50. Studenicka, E. (2007). Suicide seen as major threat to National Guard. Retrieved February 27, 2015, from
  51. van Beijouw, I. M., Verhaak, P. F., Cuijpers, P., et al. (2010). The course of untreated anxiety and depression, and determinants of poor one-year outcome: A one-year cohort study. BMC Psychiatry, 10, 86. doi:10.1186/1471-244X-10-86.CrossRefGoogle Scholar
  52. Warner, C. H., Appenzeller, G. N., Warner, C. M., & Grieger, T. (2009). Psychological effects of deployments on military families. Psychiatric Annals, 39, 56–63. doi:10.3928/00485713-20090201-11.CrossRefGoogle Scholar
  53. Warner, C. H., Breitbach, J. E., Appenzeller, G. N., Yates, V., Grieger, T., & Webster, W. G. (2007). Division mental health in the new brigade combat team structure: Part I. Predeployment and deployment. Military Medicine, 172, 907–911. Retrieved from
  54. White, C. J., de Burgh, H. T., Fear, N. T., & Iversen, A. C. (2011). The impact of deployment to Iraq or Afghanistan on military children: A review of the literature. International Review of Psychiatry, 23, 210–217. doi:10.3109/09540261.2011.560143.CrossRefPubMedGoogle Scholar
  55. Wong, L. & Gerras, S. (2006). CU@ the FOB: How the forward operating base is changing the life of combat soldiers. Retrieved November 24, 2014, from Strategic Studies Institute, US Army War College website:

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Adam M. Farero
    • 1
  • Paul Springer
    • 2
  • Cody Hollist
    • 2
  • Richard Bischoff
    • 2
  1. 1.Michigan State UniversityEast LansingUSA
  2. 2.Department of Child, Youth, and Family StudiesUniversity of Nebraska-LincolnLincolnUSA

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