SEVENTEEN

Mental Health of Women Warriors: The Power of Belonging

KATE MCGRAW

There is no doubt that the experience of combat, the challenges of war and hostile conflict, and the psychological impacts of these events on combatants of both genders are profound and unforgettable. Many of the experiences of combat can lead to profound shifts in life perspective, unresolved moral and ethical conflicts surrounding actions taken or not taken in the heat of battle, and a re-examination of one’s values, priorities, and goals in life. Some warriors who have had combat exposure may develop mild and brief physical or psychological symptoms related to their experiences, while others may go on to develop severe and lasting symptoms that require professional intervention in order for the warrior to return to healthy functioning. While the experience of war will have permanent impact on all participants, little is known about whether the psychological impacts of these combat experiences may vary based on gender, and if they do, exactly how and why they are not the same.

There are some studies in the current literature where findings seem to suggest that there may be salient factors that influence post-deployment psychological health. Some of these factors may be related to the reported amount, type, or quality of social support perceived by the warrior. The relationship between psychological health and reports of social support appears to vary by gender. These findings raise further questions related to warrior gender, psychological health, and the power of belonging to a group. Is the psychological health of women warriors strengthened or weakened by the amount and type of social support they experience, and if so, is their psychological health influenced by social support factors in ways that are different from male warriors? What about social support in the immediate and larger military work environments? Does the presence or absence of social support for a female in her unit or theater of operations have a different impact on her psychological health than on that of her male peers in similar circumstances?

Currently, there are several significant limitations and barriers in the field that create challenges when looking for gender-related differences in psychological health among warriors. The most obvious challenge to understanding potential gender differences in the psychological impact of combat on military members is the lack of a large enough sample population upon which to draw any valid statistical inference. Because the current sample size of female combat participants is so limited, findings in the extant literature cannot be reliably generalized to all relevant military populations. Recent changes to combat exclusion law will create larger populations to sample from, and will provide new opportunities to study questions about potential gender differences.

Another challenge when studying potential gender differences in the psychological impact of combat is related to the lack of standard constructs in the literature that define sample populations in such a way as to draw easy comparisons among studies. This absence of common understanding related to the terms that researchers used when describing study populations in turn makes it difficult to generalize results of one study of a defined sample population to a larger, more general population. For example, the current literature uses the terms “Veteran” and “Active Duty” in a way that tends to mix subjects of different categories within some studies, and also appears to conflate constructs within other studies. One study that examines the mental health outcomes of a group of females who are no longer on active duty may report findings that are representative of what subjects report they experienced retrospectively. That study may define the construct of the subject as “Veteran” and label the role the subject occupies at the time data is collected for the study, rather than use the label of the role the subjects occupied when the events they report actually had occurred (“Active Duty”). These individuals may at the time of the study be receiving care in the Veterans Health Administration system as Veterans, and yet may be recalling experiences that occurred while on active duty combat several months or years prior. This category of subjects may be labeled “Veterans” in one study, yet in another study researchers may label this same category of subjects “Active Duty.” This may occur because the second group of researchers perceive the content of the retrospective report of study data as belonging in a category that reflects subjects’ active duty experience, rather than the subject’s status at the time the report is made by the subject. In this scenario, even if the statistical outcomes of these two studies with different perspective constructs were the same, the field would have limited ability to conduct comparisons across like-sample populations and subjects, due to the absence of standard constructs and methodologies. These types of challenges are widespread in the relevant body of literature. As a result, we are currently limited in our ability to draw reasonable conclusions about psychological health similarities and differences among combat warriors based on gender.

Some research studies do provide us with important pieces of the puzzle and contribute to our understanding of mental health gender differences in specific military or Veteran sample populations, but most of these studies need to be expanded, further refined, or replicated. There are a few systematic literature reviews that evaluate existing literature, identify and summarize common themes, gaps, and findings, and make recommendations related to future directions in current research. These systematic reviews, including one recently conducted by Department of Defense (DoD) and Department of Veterans Affairs (VA) scientists, help us to better understand the breadth and scope of research findings related to the psychological challenges women face while on active duty, in Veteran status, and while in combat or deployment situations or recollecting those experiences (Bean-Mayberry et al. 2011; Batuman et al., 2011; McGraw et al., 2013; Runnals, et al., 2014). These reviews also underscore that current findings on gender differences in the prevalence of mental health conditions are inconclusive and disparate.

There is an ongoing assessment effort in the Department of Defense that periodically collects data related to psychological health in the combat environment from Army and Marines Service members who are deployed in theater. Since 2003 the Military Health Advisory Team (MHAT) has consisted of teams of 6 to 12 subject matter experts who visit deployed Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) combat locations and conduct surveys and interviews related to the psychological heath of deployed Service members. One important goal of the MHAT is to assess the quality of available resources for those who are struggling with mental health issues while deployed, and to recommend courses of action for improvement to quality of care and access to care for those warriors in theater. While the opportunity to capture meaningful real-time gender differences related to feedback from combat operational military members on these issues while deployed is significant, few MHAT reports have focused on, analyzed, or included gender-based findings.

For example, the MHAT II in 2005 reported no significant differences in the rates of mental health problems between male and female Soldiers deployed to Iraq. The 2006 MHAT IV also reported no differences between the rates of positive screening among male and female Soldiers for anxiety, depression, or acute stress. However, careful analysis of the reported MHAT data indicated that in situations where combat exposure experiences were reported as “low,” female Soldiers were more likely to screen positive for a mental health condition than male Soldiers. Further, in situations where combat exposure experiences were reported as “medium,” no gender differences were noted; the females who reported combat exposure experiences as “high” were reported as too small a group to analyze. Finally, the MHAT V in 2008 reported that ratings of unit morale appear to be influenced by gender, as females reported they perceived lower unit morale than males. No further data were discussed in MHAT V to help us understand what factors played a role in the reported perception of females that unit morale was low. There is a great opportunity for the DoD to use the MHAT in the future to help us shape what data we collect in order to learn more about gender-related psychological health differences of those Service members deployed to combat environments.

Another key finding about gender-related psychological health differences in the combat environment that merits further exploration relates to the work of Vogt et al. (2008). Their team examined nine scales of the Deployment Risk and Resilience Inventory (DRRI) and found that female Service members in this study reported less exposure to combat and the aftermath of combat exposure, felt less prepared for the rigors of battle, perceived a higher sense of threat, and reported mental health issues at higher rates than their male counterparts. This was a retrospective study and as such was not designed for prospective predictive statistical analyses; thus no conclusions can be drawn about why study females reported higher rates of mental health issues, or perceived a higher sense of threat in a combat environment than their male peers.

Some other studies suggest that the psychological health of women who experience combat or deploy into combat operations may be impacted by specific salient factors that differ from factors that have significant impact on the psychological health of men in the same environments. For example, Vogt et al. (2011) studied the relationship between pre-deployment factors and post-deployment mental health among OEF/OIF–era Veterans, as compared to prior result published in Vietnam-era cohorts. Their research team surveyed 579 subjects, who were identified by a Service-stratified randomized sample of OEF/OIF Veterans. Their study sample contained 48.3% active duty, 24.6% Reserve, and 27.1% National Guard subjects, and was oversampled for females; it found an association across genders related to concerns about relationship disruption and posttraumatic stress disorder (PTSD) symptoms. This association appeared to be mediated by the subject’s reports of perceived threats (for example, fear for one’s physical safety and being in a war zone) during his or her deployment. The research team additionally noted that female Veterans who reported greater relationship disruption concerns also were more likely to endorse that they experienced less post-deployment social support, and found what appeared to be a stronger relationship between self-reported poor social support and post-traumatic symptoms among female Veterans, when compared to male Veterans. These findings suggest that social support factors may play a unique and perhaps different role in the psychological health of female combat Veterans as compared to male combat Veterans.

Vogt, Vaughn, et al. (2011) used a national stratified random sample of 2,000 OEF/OIF Service members (50% active duty, 25% National Guard, 25% Reserve) in their study of gender differences in combat-related stressors and the impact of those stressors on psychological health, and ensured that at least 50% of the 595 subjects were females in each study subgroup, based on a power analysis. Results supported previous findings, which indicated that social support appears to be a significant factor in the psychological health of female Service members who had deployed. This team found that females reported slightly higher levels of previous life stressors and sexual harassment during deployment than their male peers, while males versus females reported higher rates of combat-related stressors, such as combat exposure, exposure to the aftermath of battle, and perceived threat. Both males and females in this study reported similar levels of post-deployment post-traumatic stress and mental health symptoms. As compared to their male peers, females did not report elevated post-deployment mental health risks associated with combat-related stressors. Study authors concluded that female Veterans relative to male Veterans of recent conflicts seem to have experienced similar levels of most aspects of combat exposure, and do not appear to demonstrate greater risk for mental health difficulties related to combat exposure. Conclusions of this study, and attempts to generalize the findings, should be interpreted keeping in mind that subjects reported symptoms within one year after their deployment. This limitation means that subject retrospective reports of the psychological health impact of their combat experiences, if made more than one year after their deployment, may differ based on the amount of time elapsed since their deployment or other intervening factors, and these potentially different outcomes may vary by gender as well.

As there appears to be a relationship between the reported pre- and post-deployment social support of female combat warriors and their psychological health, as compared to the reported experiences of their male peers, perhaps the amount of social support that females may or may not find in their military workplace environment might also play a critical role in their psychological health. Women who are working in primarily male career fields—or, as in the military, are breaking into previously closed combat positions currently held by males—may suddenly find themselves part of a social group that has difficulty fully accepting or integrating females. This experience can be painful for the unaccepted female, as well as the unit members who witness or participate in the social exclusion behavior.

This lack of acceptance, or silent setting aside of the female from her group, can have a negative impact on the mental health of not only the individual who is excluded, but also on those members of the unit who either actively exclude her, or those who simply observe her exclusion. The negative impact of this type of behavior may intensify during periods of high stress, such as in combat or deployed locations. The act of exclusion of an individual from a group, through omission, is called ostracism. There is a growing body of literature of the impact of ostracism on the organizational health of the work environment, and on the physical and psychological health of involved individuals.

In order to study situations in which one person is excluded from a social connection with another, especially in the workplace, Robinson et al. (2013) developed a theoretical model. Robinson’s team identified many forms of ostracism in the work environment, to include “linguistic” (which involves exclusion of the target individual from group discussion by use of terms or language that the group understands, but the target doesn’t understand); “missing action” (which includes failure by the group to invite the target to attend social events that the rest of the group is invited to); and “organizational shunning” (whereby a target is eliminated or prevented from participation in group activities due to existing or newly created institutional or organizational policy or practice). Their study emphasized that deliberate acts of omission related to exclusion of an individual from a group can have a significantly negative impact on an individual, because of our fundamental need to belong to a group—a need that appears to be innate and critical to our survival as a species. The ambiguity that often accompanies acts of social omission is typically unsettling, and tends to disrupt both the individual target’s ability to function, as well as the overall functioning of the group. Acts of ostracism can be “purposeful” (to bring about deliberate harm) or “non-purposeful” (harm may result but was not the original intention), and the impact of the act appears to vary according to the intensity of the behaviors, as well as the targeted individual’s perception of the meaning of the acts of ostracism.

Ostracism can produce long-term psychological and physical consequences, in addition to those pragmatic and logistic consequences that arise when a group deliberately leaves a team member out of a critical communication, which may result in a complete communication breakdown and serious degradation of the mission. Several recent studies of the psychological and physical consequences of ostracism illustrate ostracism’s profound impact on the body and mind.

Williams and Jarvis (2006) developed a computer game to study the psychological impact of ostracism on an individual. Their computer game was designed to simulate a social exchange that would trigger the sense of ostracism that occurs when an individual believes that he or she has been excluded by a group. The subjects participated in a pretend game of catch (tossing an object to one another on the computer), with online “confederates” (these confederates were not real people, but the subject believed they were). The subjects were then suddenly excluded from the game (experimental intervention). After the act of ostracism, subjects were asked about their thoughts and feelings related to the game. Responses from the subjects then led the researchers to conclude that social exclusion, even by strangers, can negatively impact an individual’s need to belong to a social group, as well as his or her self-esteem, sense of control, and belief of a meaningful existence. Williams and Jarvis and their team went on to identify the stages that a target is likely to go through in order to fully process their experience of social exclusion. Their computer ostracism simulation is now widely used in studies related to the growing body of research on ostracism.

Williams and Nida (2011) also compared the individual’s reaction of social ostracism to an individual’s experience of actual physical pain, which reflects an important direction for expanded research on the impact of ostracism. There are recent studies that links the mind’s experience of ostracism and the body’s experience of physical pain to a central pain mechanism, which is visible on magnetic resonance imaging (MRI) studies (Eisenberger and Lieberman, 2004; Wesslemann et al., 2003). In fact, the experience of ostracism appears to initiate activity in the dorsal anterior cingulate cortex and the anterior insula, the same areas of the brain that show evidence when a subject experiences physical pain. Further, for those observers who watch a target being ostracized by others, they found evidence that the vicarious experience of the observer appears to activate those same regions of the observer’s brain (dorsal anterior cingulate cortex and the anterior insula), as well as the temporal parietal junction and insula. This brain area activation occurred whether or not the individual target was a person known to the observer.

Finally, Dewall et al. (2010) conducted two experiments in an attempt to show that there are similar behavioral and underlying central neural mechanisms that may overlap when comparing the behavioral and biological evidence of the experience of physical pain, to the behavioral and biological evidence of the psychological pain of social rejection and ostracism.

In the team’s first experiment, 62 patients were given either 1,000 mg of acetaminophen or a placebo twice daily for three weeks, and were assessed using the “Hurt Feelings Scale,” which is a measurement tool that has been accepted by psychologists as a valid instrument to examine the construct of social pain. Hurt feelings, as measured by this self-report scale, and social pain, as reported by the subjects, appeared to decrease during the time of study for those who took the acetaminophen, while no change was observed in subjects who took the placebo. Levels of positive emotions reported by both groups appeared to remain stable during this same time period, with no significant changes observed in either group related to positive emotions. Subjects in this study were also administered functional magnetic resonance imaging (fMRI) to measure their brain activity. Researchers found that subjects who took acetaminophen appeared to have reduced neural responses to social rejection in the same brain regions previously associated with distress caused by social pain, and also in those same regions associated with the affective component of physical pain (the dorsal anterior cingulate cortex, and anterior insula). These results suggest that acetaminophen use may decrease perception or recognition of social pain over time, through an unknown mechanism that impacts the experience of those emotions associated with social pain. Results also suggest that social pain perhaps shares some central pain mechanism pathway with physical pain, and that they each influence one another.

In Dewall’s second experiment, 25 healthy volunteers took 2,000 milligrams daily of either acetaminophen or a placebo. After three weeks, subjects participated in the computer ostracism simulation game, which was rigged to create feelings of social rejection. Functional magnetic resonance imaging (fMRI) used while playing the game suggested that acetaminophen appeared to reduce neural responses to social rejection in those brain regions previously associated both with the distress of social pain and the affective component of physical pain (the dorsal anterior cingulate cortex and anterior insula). In other words, the parts of the brain associated with physical pain were activated in the subjects who received the placebo when they were rejected, while those same parts of the brain displayed significantly less activity in the subjects who were similarly rejected, but who received the acetaminophen. Thus, acetaminophen appeared to reduce both the behavioral and the neural responses that appear to be associated with the pain of social rejection. These experiments, and the expanding literature on this topic, continue to demonstrate existing neural overlaps between social and physical pain, and their interactive influences.

This brings us to important questions for further study: If research findings indicate that female warriors may respond differently from a psychological health standpoint to the presence or absence of social support in their life, and evidence also suggests that ostracism impacts both psychological and physical health, how will female warriors respond to ostracism in their units? If female warriors don’t feel socially included as welcome members as they integrate and deploy alongside their mostly male combat group colleagues, does this lack of inclusion and subsequent diminishment of their sense of belonging to the team impact their sense of safety, their perception of unit morale, and their psychological and physical health? In combat circumstances the individual is heavily dependent for survival upon his or her group. Are female warriors more vigilant or responsive to the presence or absence of social acceptance or ostracism within their unit than their male counterparts? If so, could this potential difference lead to more negative psychological health outcomes in female warriors than in males within units where ostracism is intense or pervasive? Or is this not entirely a gender-related difference, and are there other factors that play a significant role? Is it more about how ostracism impacts any individual in a military unit under combat conditions? Do male warriors who are ostracized from their unit have similar psychological health outcomes as compared to their female warrior buddies? Do female warriors experience more social rejection in their unit than males?

Clearly, further research in the area of psychological health of women warriors is needed. Researchers should work to agree to minimize differences in data collection methods, as well as constructs of study concepts and subject population definitions, in order to optimize cross-study comparisons. Disparities in the types of screening or survey methods and questions used, differences in the actual amount of time subjects are exposed to combat, or the mixture of subjects from different roles into one study are all potential variables that are likely to influence study outcomes and the reliability of findings. Lack of clarity and consistency in these areas across studies results in both obvious and subtle impacts on the interpretation of findings, limits how confident we are in our ability to generalize results from a given study to a larger population, and reduces our ability to compare findings across studies.

More longitudinal and prospective studies are needed to further explore those social and occupational factors that influence the psychological health of female warriors. Future studies should include as study variables those known significant factors from existing literature that have already been shown to influence psychological health outcomes of combat females, as well as be informed by relevant studies in other parallel lines of research in other fields. This will allow scientists to better integrate dynamic theories that tend to emerge in separate but related areas of study on similar topics, and will help us better understand how physical and psychological mechanisms may relate to one another. Additional studies will also help inform combat performance enhancement and organizational health, which are heavily dependent on the psychological health of leaders and individual members, as well as dependent on the way the team functions together as a group. Finally, future research on the unique psychological health needs of our women warriors will ensure that high-quality psychological health services are tailored to the needs of the individual Service member, will help the military health system develop effective psychological health prevention efforts, and will inform high-quality evidence-based care for warriors of both genders who may develop psychological health conditions after combat.

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