The military's hidden mental health crisis: spousal trauma

Army wife Melissa Bourgeois hit her breaking point five years ago when she was living at a U.S. military base in Vicenza, Italy, with her husband, Eric, an infantryman. Eric was just back from a harrowing second deployment to Afghanistan marked by frequent firefights. Filled with an uncontrollable rage, he spent his nights self-medicating at bars with his war buddies.

Eric's anger toward his family had become explosive, and he regularly punched doors, furniture and even a concrete wall that left his hand injured. Melissa, 25 at the time, with their two small children, felt isolated in a new country where she barely spoke the language. She needed to talk to someone about her situation, but she said each time she sought mental-health care on the base, she was given Valium and sent away.

In October 2008, Eric backed Melissa into a corner and started shouting at her in front of the children, the smell of alcohol heavy on his breath. "I was hysterical, screaming," she said. Desperate, she called a friend, who reported him to the military police for domestic abuse. The commanding officer of Eric's company held him in the barracks for 72 hours before releasing him. When Melissa went to her husband's platoon sergeant for help, he told her that if she was so unhappy, maybe he should just send her back home. Soon after that, Eric said, the platoon sergeant told him, "Keep your wife in line."

In a U.S. military psychologically ravaged by 12 years of continuous war, troops' family members, like Melissa, are the victims of a hidden mental-health crisis, missing from the public calculus of the social costs of combat and systematically denied by the institution that placed their partners — and them — in harm's way. Interviews with military doctors, psychologists, social workers and counselors and with service members and spouses suggest that this problem is ubiquitous yet invisible.

"The military just doesn't want to deal with wives," Melissa said. 

Combat post-traumatic stress disorder (PTSD) takes a severe toll on spouses. A New England Journal of Medicine study that analyzed medical records of more than 250,000 spouses of U.S. active duty soldiers from 2003 to 2006 found that the multiple and prolonged deployments typical in Iraq and Afghanistan led to greater risk of "depressive, anxiety, sleep, and acute stress reaction and adjustment disorders" among spouses — among the anxious and depressive symptoms referred to by mental-health providers as secondary traumatic stress. 

While the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) — the bible of psychiatric diagnoses — does not include secondary traumatic stress, it does recognize that PTSD can arise in family members of those exposed to violent trauma. According to peer-reviewed studies on the Vietnam War and the war in Croatia in the 1990s, prolonged caring for and exposure to a partner with PTSD is a strong predictor of developing PTSD symptoms as well.

"When something terrible happens to someone you love, it is going to affect you," explains clinical psychologist Dr. Laurie Pearlman, who played a lead role in identifying the effects of secondary trauma. "The person comes back and your life is completely altered. You live according to their trauma. You imagine what your loved one is going through, and you replay it over and over." 

Military data show rising suicide rates and deteriorating mental health in the ranks — which is tied to a growing epidemic of domestic violence. 

Yet the military does not aggregate data on the mental health of spouses, despite the documented high risk of this population. "We do not track PTSD in spouses. We track PTSD in soldiers," explained Army media-relations specialist Maria Tolleson via email. Catherine Wilkinson, a spokeswoman for the Department of Defense, confirmed that even the numbers of spousal suicides are not collected by the military. "We are not tracking data about spouse death by suicide in the same way that we do for service members," she said.

The Army's attitude to spouses' mental-health struggles is perhaps best captured in the "New Military Spouse Handbook" distributed at family-support centers at the sprawling Fort Campbell Army base on the Kentucky-Tennessee border. The purple pamphlet, with an illustration of a bride and a uniformed groom on the cover, instructs spouses not to get upset about their partners' anger, exhaustion, mood swings or deployments. The handbook offers instructions on how to dress for formal Army functions and write thank-you cards but provides scant information on mental-health problems that families might face or resources that can address these issues. "We are super spouses," the pamphlet reads. "No matter (what) the world throws at us, we can be OK."

Sitting in their Fort Campbell home in a small subdivision of identical houses not far from the barracks, with their toddler daughter playing on the floor, Melissa and Eric Bourgeois describe the toll that his condition has taken on the family. Eric, who comes across as polite and direct, was diagnosed with severe PTSD in 2008. He said combat filled him with overwhelming rage. "When you are over there, the only emotion that keeps itself alive is anger," he said, gesturing with his right hand, his left one in a sling because of a shoulder injury he sustained in Afghanistan. "In the midst of an eight-hour firefight, your only link to survival is the adrenaline that keeps your body moving forward and keeps you fighting for your life … It's not like you're wondering how she's doing back home."

During his second deployment, he would call home in the middle of the night, and if Melissa didn't answer, he would blow up at her the next time they spoke, screaming on the phone.

Eric returned to a wife whose feelings he had learned to disregard and children he no longer seemed to know and who shied from their father's touch. He was unable to turn off his anger; he got blackout drunk just to be able to sleep.

Melissa said her husband's constant explosions and withdrawal and the burden of raising her family practically alone took a profound toll on the family's mental health. The two boys began to mimic their father's behavior. "(The oldest) started acting up when his father was gone. He flooded the house two times, broke eggs on the floor and took off running out the front door," she said. As for herself, "it is like I have absorbed some of his symptoms." Small things upset her, and she started to yell more at the children. She had panic attacks driving on the highway and crying bouts in the bathroom, which she would lock herself in for hours. "I used to be bubbly, a social butterfly," said Melissa, who has an energetic affect and a quick smile. "But with PTSD, you are always waiting for something to set it off."

The Department of Defense said it provides mental-health care to military spouses and families, tasking Tricare with providing "medical services and support to members of the Armed Forces (and) their dependents," which it said includes mental-health care. Eligible spouses (unmarried partners do not qualify) can, ostensibly, access this care directly from military-run facilities on bases, as well as from private providers off-post that are part of the Tricare network.

According to Stacy Rzepka, a public-affairs spokeswoman at Fort Campbell's Blanchfield Army Community Hospital, "Spouses who endure stressors in their role as caregivers to service members ... are entitled to the full range of behavioral health services available in their Tricare medical coverage, whether at an Army medical facility or with one of our network providers off-post."

Yet families who ask for help say they face a mental-health system that is grossly inadequate and inaccessible to them. Even the Department of Defense's own Mental Health Task Force of 2007 acknowledged in a report that it "must expand its capabilities to support the psychological health of its service members and their families" and that the current system is overwhelmed by need and impeded by shortages. Jodi McCullah, whose nonprofit group offers free counseling to service members, veterans and families in the Fort Campbell area, agreed, saying, "We have been at war for 12 years ... There are a lot of people struggling here."

When asked if the military provides adequate mental-health care to families, Dr. Joe Wise, chief of behavioral health at Blanchfield, defended the system, saying, "Dependents have Tricare health insurance, and there are plenty of providers across the country who take Tricare."

But a former Army therapist and psychiatric nurse practitioner and current Tricare mental-health provider who wishes to remain anonymous said that, given the shortage of providers, service members take precedence. "It is kind of harsh, but the family members are not as important as the active-duty members ... because that is what the mission is — to keep the fighting force healthy," he said.

But even troops face long waits for appointments. After Melissa and Eric relocated to Fort Campbell in 2009, Eric was able to see someone only once every six weeks despite being diagnosed with severe PTSD.

His condition escalated last year, with the first of several suicide attempts. Melissa said that since Eric's diagnosis five years ago, it has been nearly impossible for him to get consistent care, with long waits between appointments leaving him and his family vulnerable. "The Army says they care so much about preventing suicide among soldiers, but this is the perfect example of how they don’t really care," she said. 

Spouses who are Tricare recipients are encouraged to first go to their primary-care manager (PCM) — who can be a doctor, physician's assistant or nurse practitioner — Rzepka said. The PCMs, who are generalists and are not required to specialize in mental health, are supposed to refer patients to mental-health specialists when they deem it appropriate, said Rzepka.

Yet numerous spouses complain that they face long waits to see overburdened PCMs who are more likely to prescribe medication than provide timely referrals or meaningful follow-up. The Tricare nurse practitioner who asked to remain anonymous agreed, saying, "When you are talking to a primary-care manager with over 1,500 patients, it is hard to maintain every single patient."

Meanwhile, the adult mental-health facility at Fort Campbell has stopped seeing spouses altogether, said Rzepka, explaining that the system has been overwhelmed by "a lot of soldiers who just need behavioral health right now."

The situation isn't much better for those who go off the base (an option many spouses don't know they have). A U.S. Government Accountability Office report from 2011 finds that national networks of off-post civilian Tricare providers also face dire shortages. 

In a system that cannot handle them, spouses are shunted to nonmedical resources that stand in for medical ones. This includes chaplains, family-readiness groups — command-organized groups run by spouses of service members in a given unit — and military and family life counselors (MFLCs), who provide "short-term, nonmedical counseling," according to program literature. 

MFLCs do not keep written records or track patients in any formal way, and they are not officially empowered to offer medical treatment. Yet they absorb the overflow of a failing system and "treat" spouses facing serious mental-health issues who have nowhere else to turn. Meanwhile, numerous military providers and Army public-affairs representatives said that spouses are encouraged to go to MFLCs for mental-health help, contradicting the program's written guidelines.

But a Fort Campbell MFLC who wished to remain anonymous said, "The military mental-health-care system as a whole is not working for families. (We are) the first line of getting care for families because everyone else is stretched so thin."

When spouses do have serious mental health emergencies, it is not clear where they can seek help.

These structural barriers are compounded by cultural stigma and fear of reprisal from the command, which often prevent spouses from seeking help in the first place. "Here if a wife says too much about PTSD, a soldier gets labeled," said an Army wife based in Fort Hood, Texas, who asked to remain anonymous. "There is fear on the wives' part that they would cause a problem for their husband." 

Assistant professor Colleen Lewy, an Oregon Health and Science University researcher, said that in interviews with more than 500 military wives for a forthcoming study of barriers to mental health, she found that stigma a key deterrent to seeking care. She said interviews revealed that many spouses fear that seeking help through military channels, especially for issues of domestic violence, which could result in an other-than-honorable discharge and strip service members and their families of benefits. "In cases of domestic violence, spouses have an incentive not to seek help," said Lewy.

Melissa Bourgeois said that throughout her attempts to get care for herself, she was encouraged by an Army social worker to visit an MFLC. But the program was totally inadequate, she said. "It is not made to deal with PTSD and things that are real problems beyond my control."

Out of options, she has turned to marriage counselors — who she is able to see only in the context of her relationship with her husband. "It's a loophole" that allows her to talk to someone, she said. Melissa still has no official written mental-health diagnosis, but three marriage counselors have told her she has PTSD.

Efforts to get care for her three kids — now 3, 6 and 10 years old — have also been filled with obstacles. Melissa found that the child and adolescent psychiatry facility — which serves young dependents of soldiers — had long wait times for appointments. And when her oldest was 5, she was told by an Army social worker that his behavioral problems must be dealt with at home, not by mental-health providers. Her middle child was given medications for ADHD and anxiety, but, Melissa said, Army doctors were not willing to provide adequate follow-up talk therapy.

Meanwhile, she continued to seek help for her husband. And it was not until he was transferred to the Warrior Transition Battalion six months ago, where he is stationed as he awaits discharge for his mental and physical wounds, that the military stepped up his treatment and gave him what Melissa considers adequate care. Battalions like this are unique creations of the post-9/11 war on terrorism, used to absorb — and, some say, hide — the high numbers of troops returning with severe injuries, from missing limbs to psychological scars.

While Eric is stable for the time being, Melissa feels she has been left out in the cold. With declining mental health, including increasingly frequent and severe panic attacks, she took another stab at reaching out to on-post doctors for help in early October. But she has been unable to find a doctor who would give her adequate care with meaningful follow-up. "They flat-out deny me," she said.

So for Melissa, survival without support means locking herself in the bathroom and crying for hours, then walking out and pretending everything’s fine so she can take care of her kids. She now regularly sees an Army marriage counselor with her husband but is without hope that she will receive adequate mental-health care for herself anytime soon.

And then there are those who do not survive. Kristina Kaufmann, who was married to a service member for 11 years, tells of three friends, Army wives, who took their own lives, as well as several other suicides she learned of through other spouses. In a military that does not track these deaths, let alone tackle the mental-health problems behind them, it is impossible to measure just how deadly this hidden crisis is.

The military's failure to account for the social effects of war trauma does not start or end with spouses married to active-duty troops. But if this population, which has coverage on paper, is not getting adequate care, what does that mean for everyone else touched by war — from unmarried partners to civilians living in war zones — whom the military doesn't even claim to account for?

"They say you knew what you were getting into when you married him," said Melissa. "But that's not true. The Army didn't educate me. I didn't know. And my kids never chose this."

Research support for this article was provided by The Investigative Fund at The Nation Institute.