Military culture

Military enculturation presides over not just the serving person but also the family. The complexities imposed by military culture and the frustrations of military life felt by all involved are well documented [7–11]. Whilst military families face the same challenges that civilian families endure, they also must contend with a range of unique situations that other (civilian) families will never, or seldom face such as deployment, extended separations frequent relocations and inflexible work regimes [12]. Consequently, for military families, military life creates a culture that is unique to them.

Much of the extant research [2,13–15] have depicted military culture as hierarchical, disciplined, male-dominant and competitive, where dominance prevails and an expectation that ‘duty was meant to override love’ [16]. There is a growing consensus that suggests the military family (or family unit) is viewed as an integral part of the overall military community given that their private family life is synonymous with, and not separate to, military life. Values and beliefs underlain by stoicism, hierarchy, marriage, expectations, and mental health stigma of a military spouse have preceded to embody what military enculturation is today [1,17,18].

Mental health within the military

Recent decades have seen an exponential growth of interest both politically and publicly regarding military conflicts, humanitarian operations and the resultant mental health of serving personnel [19–21]. For serving personnel and veterans alike, military studies recognise a range of mental health issues arising from combat and trauma exposure. For example, greater exposure to combat correlates with a deterioration of mental health and increased risk of suicide [22,23] and psychosocial stressors may also be associated with subsequent mental health issues. Previous research suggests that, irrespective of age, gender, rank, family/relationship troubles, and occupational problems, were the leading causes of depression in the armed forces [24]. Depression prevalence within military personnel is noticeably greater (23–26%) than that of the general population which is estimated at 13–15% [25,26]. Regardless, it is estimated that less than 40% of military personnel and veterans with a mental health issue will seek help [27] but may well require help from their family members and spouse.

Mental health and military spouses

Limited evidence surrounds military spouses and their experiences of living alongside their serving partner with a mental health issue. There could be numerous reasons for this, including (but not limited to) global austerity measures, worldwide underfunding for the armed forces, and limited healthcare management models [26] have led to family members predominantly providing care to their military partner with a mental health condition [28]. Consequently, this may cause various and far-reaching psychological/adverse effects on those family members, especially the spouse [29] including divorce [30,31], care burden and impacts on health such as physical exhaustion, increased stress, anxiety and depression [32,33]. All of these are further compounded when considering the military context such as overseas deployments, working patterns, and military culture [34–36].

Feminist vision, values and spirit

Compelled by the sentiments of empowerment, equality and for the relationship to be one reciprocity, the collection of data in the present study aligned to feminist vision, values, and spirit [39,42]. The driving force was to understand the oppression of women, provide opportunities and voice to untold stories, to generate knowledge, to ‘make a difference’ and ‘create change’ [56; p.1]. In contrast to the notions of interview detachment, the interviewer-interviewee relationship is, first and foremost, the basis of the research with the presence of the researcher, as a person, acknowledged [42,51]. By doing so allows for more conversation (e.g., interactions and rapport building), which is fundamental when researching difficult and/or sensitive topics [57].

The preponderance of feminist research is that it is by women and for women [42]. In the present study, and understanding the military community, it was expected that female participants would predominate, however, it was accepted that all participants, regardless of gender, would share cultural commonality with one another [58].

Researcher positionality

As a member of the military community (previous healthcare practitioner role with military and a military spouse) acknowledging the insider role was paramount [42,59], so that the conceptual thinking and the lenses in which we view the world highlight the standpoint of the researcher. The 1st author’s conceptual thinking identified three differing lenses as the foundation of making sense of the data: (i) the story; (ii) military culture, and (iii) feminism (Fig 1).

Recruitment

A purposive strategy was adopted, and the recruitment strategy necessitated two approaches as it was recognised that there was a hard-to-reach element arising from ‘military culture, stoicism and stigma surrounding the sensitive topic. Initial recruitment employed a ‘non-invasive sampling strategy’ (n=4) using posters and postcards with study details and a contact email address. These were shared nationally with Community development workers who worked in collaboration with Military welfare teams. Service federations were contacted, and an article was published in the Army Families Federation magazine as well as a study promotion blog included on their social media feeds. Other military connected groups which included NSPCC mother and toddler groups, Military wives’ choirs, and coffee morning groups were approached to display posters and hold postcards for people to take away. This was followed by a purposive snowballing recruitment method (n = 6), common in hard-to-reach populations where participants referred new participants to the study [59]. The criteria for inclusion required participants who were a military spouse (inclusive of wife, girlfriend, husband, boyfriend, partner) of serving personnel of any rank across the tri-services, Army, Navy or RAF and that their serving partner had during their serving career experienced a mental health issue; namely, common mental health disorders (depression, anxiety), adjustment disorder, or post-traumatic stress disorder. Ten participants meeting the inclusion criteria came forward. Nine military spouses from across England and Northern Ireland participated in this study; one further participant referred through snowballing, on consideration declined to take part.

The interview space

Data was collected between March 2018 and November 2019, over two separate in-person interviews at a venue and time of the participants choosing. The starting point of any biographical study is to engage participants either through sharing stories or joining alongside them as they live out their stories [60]. At the heart of the life story interview is the collaborative process of storytelling and listening facilitated by time spent together. Initiated from a broad, single narrative question ‘Tell me your story?’ the first interview provided a ‘biographical self-presentation’ [40]. With no starting point stipulated, for most participants, the stories began when they met their partners. Reiterating a sense of agency within the process, participants talked freely and without prompts or interruptions allowing them as much time as they wanted to talk about their experience [61].

To allow for follow-up and focused participant self-reflection, a second interview whilst more conversational in nature, was structured around four open-ended questions. This afforded greater focus specific to the study area namely: the participants own experiences thoughts and feelings. Opportunities for participants to revisit what they had said, occurred concurrently throughout both interviews by seeking clarification through pen portraits and summarising points made during the interviews [60,61]. To close the interviews, participants were invited to ask questions.

Participant information was issued ahead of the first interview, assurances of confidentiality and anonymity throughout the study were given and written consent was obtained from all participants prior to each audio-taped interview. Given the sensitive nature of topic, a debrief document and support document, identifying key agencies available for referral and support was given [42]. All the interviews were transcribed verbatim and stored in accordance with General Data Protection Regulations (2018).

Ethical approval

Ethical approval was granted by the University Ethics Committee (Submission Ref: 2879). This study is reported following the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist (see supplementary information 1).

Data analysis

The study adopted more than one analytical approach to allow different perspectives to arise from the data. Lieblich et al.’s (1998) framework was adopted for analytical pluralism whereby the completeness of the story and the generation of categories or themes are embodied. The framework offers two independent dimensions: ‘holistic versus categorical’ and ‘content versus form’ and assumes four potential avenues of data analysis however, it is noted that analysis need not simply fit into one [62; p12-13].

Generating stories

Producing an authentic depiction of the participant and generate the final story a combination of ‘Holistic-Form’ and ‘Holistic-Content’ analytical approaches were executed. The transcripts were read and re-read prior to manually analysing the data for the stories. Whilst culturally and thematically different to this study, the three stages of the two-stage life story analytical approach was reflected within the participant stories and therefore adopted for this study. When asked to tell me their stories, a conjoined story about themselves, their serving partner and their relationship was shared, providing a context or rationale for their current situation. On analysis, the participants themselves were not always easy to locate in the story; the emphasis was very much focused on telling their serving partner’s story.

Generated initially from the stories was a collection of years and events which set the scene about their relationship. These events were collapsed into one and therefore were indicative of ‘the beginning’ stage and named as such. The second part of the story telling was shorter yet more detailed specifically focused on ‘changing times’ with the emergence and the duration of the mental health issue. ‘This is me’ is the final stage of the story, illustrating the participants’ ‘self’ in this journey and current circumstances. The body of the story was then captured by applying a holistic-content analytical approach; a five-stage reading process allowing a temporally ordered description involving events, actions and interpersonal interactions within each stage. The final story was created by using raw data elements which were depicted in italics throughout the stories and narrative linkages drawn together from the data collected over two interviews. The couple’s story was captured from the participant’s viewpoint and as such, presents only a part of the overall picture. This was acknowledged through writing in the third person to differentiate from the stage ‘this is me’ where the data referred to the participant themselves. This was an important part of the analysis and is illustrated in the first person, ensuring the emphasis is on them and that they were not invisible within their partners’ stories.

Generating categories

Generating the stories, meant that a deep familiarity with each of the transcripts. Unlike the manual strategy of analysis used for the stories, due to the amount of data collected NVIVO (version 12) was used to revisit the original transcripts. Within the framework, the ‘Categorical-Content’ elements are used to analyse and emphasize the interactions between insights arising from the individual stories and the themes emerging collectively.

The approach exercised was subjective and involved the complex process of interpretation [62]. Unlike holistic individualistic analysis, categorical-content analysis collates and details the patterns from across the collective data set allowing for the comparison of structural elements along with identification of difference or similarities across the data [63]. The analysis began without any preconceived thoughts of what or how the subcategories would look like. In this study, the identification of utterances led to the subcategories (21) and then broader categories (6) (see Fig 2), which once identified by the first author, were critically discussed by the team.

Prior to any identification of words and texts, the aim of the study was revisited. The references made to any aspect of the experience of living alongside a mental health issue that captured something important such as a description of a behaviour, a feeling or response regardless of size or prevalence were highlighted. Such references materialised both spontaneously during the first interview and in response to the narrative generated questions used to deduce the participants’ experiences during interview two: ‘On a good day, what is it like for you?’

The stories

The final stories originated from the data collected in both interviews; they give a nuanced in-depth insight into the experiences and are too vast for inclusion in this paper. Table 2 provides a vignette of each participant’s story. Each story shares an initial joint story where predominance was given to their serving partner and/or to provide context. These are represented in two stages: ‘in the beginning’ and ‘changing times’. The final stage of the story illustrated by a vignette and representational quote in Table 2 focused on the participant themselves and was titled ‘this is me’.

The categories

Illustrated in Fig 2 are the final categories (6) and sub-categories (21) generated following the application of Lieblich et al.’s (1998) categorical- content analysis.

Living with disruption highlights the experiences of military spouses as they navigate the prolonged disruption in their relationships due to their partners’ mental health issues. Three subcategories emerge from this experience. Noticing illustrates the initial recognition of changes in behaviour. These changes varied from withdrawal and silence to anger and aggression. Some spouses observed these signs early on, while others, struggled to identify the changes due to their own emotional challenges. Responses to these changes ranged from confusion and paradoxical laughter to a gradual realization of the severity of the situation.

…at first it was obviously quite funny, and I’d be laughing, but I would think to myself after, ‘ee god, what on earth is going on?” I didn’t really know at first. [Sara]

The spouses described various emotional and physical manifestations of their partners’ mental health struggles, including night terrors, increased alcohol consumption, and hypervigilance. These behaviours often disrupted family life and created a tense atmosphere at home leaving participants feeling helplessness, lonely, and exhausted as they dealt with the unpredictability of their partners’ moods.

He couldn’t function in a normal manner at all and then, it was more when he got back. He would wake me up in the middle of the night and his eyes would be open, but he would be asleep, and I remember him shouting at me; like ‘we need two helmets, we need them, we need them now’ and I’d be thinking ‘what the hell?’ [Sara]

The emotional disconnect that arose from the partners’ mental health issues led some spouses to feel as though they were living with an “empty shell.” Communication difficulties and withdrawal from emotional engagement became pronounced, resulting in a sense of ambiguous loss for the spouses, who felt their partners were physically present but emotionally absent.

“It was nothing obvious about Adrian, it was only that he never showed any form of any emotion from anything... I always knew that when he was with us that he would generally just sit and watch a lot, it was almost like, he needed to see everything, but for me I don’t know, it just felt a bit uncomfortable”. [Cathy]

Living in the midst of it all captures the ongoing nature of these challenges, emphasizing the emotional rollercoaster experienced by spouses as they adapt to their partners’ fluctuating mental health.

“I feel really gutted when I see that he’s in one of those, I don’t think it’s an episode, it’s a mood or whatever...gets that turmoil of emotion, that’s how I know when it’s coming and then I just sort of go in auto-drive…” [Christina]

The themes of frustration, anger, and worry permeate their narratives, as they navigate the impact of their partners’ mental health on their own well-being and family dynamics.

“It’s like when you are just at work and hear on the news about a train incident knowing what mood you have left them in and stuff like that, you don’t know if it is them or not. If they are that way and then they turn round and sort of say I would never be that stupid to do it, but you just don’t know do you?” [Vikki]

It isn’t enough illustrates the point at which the participants realised their limits as well as their efforts to seek and receive help. The findings are categorized into three main themes. Participants often felt an inherent need to ‘fix’ their partners’ mental health issues, which stemmed from a blend of emotional commitment and a lack of knowledge. They expressed feelings of inadequacy regarding their ability to help, leading to a sense of frustration.

[I said] ‘Well, just tell me what’s wrong?’ ‘I can’t fix it if you can’t tell me’. [Sophie]

Many participants acknowledged their lack of understanding of mental health issues, which contributed to feelings of helplessness.

“I thought, ‘I’m not trained in that, I don’t know’ and yet I knew there was something not right with him… This is the thing; I don’t understand it enough to be like ‘oh I understand why you are in a mood” [Lauren]

This was sometimes overcome by the serving partner trying to reach out,

“James showed me this video and he was ‘just like have a look at this’… he said, ‘just have a look at this video of this guy’. Eventually, this guy did kill himself ‘cos he just couldn’t cope anymore and he [James] said, ‘that’s how I feel, but that’s like how I feel’ and he had to do it through a video to show me” [Simone]

However, there was also feelings of inadequacy after a prolonged period of trying to help. Some participants felt they had exhausted their resources, leading to tensions in their marriages. This prompted some to consider leaving their partners if they did not seek help, which in turn was often the motivation that led to the serving partners to seek external help.

“I thought we were over… at the point now where I feel like I’ve done as much as I can do in the whole relationship, I wanted him to go to welfare, say that he is struggling mentally, I wanted him… and obviously eventually, he went to the doctor and sorted all that out” [Christina]

Seeking support exemplifies the expressed frustration over the limited support available and reflected on their experiences with both informal and formal avenues of assistance, including consultations and treatments, and the varying degrees of involvement of military spouses in these processes.

Formal Support included medical and welfare services provided by the military. While some participants reported positive experiences,

“The army have been good, they have supported him... he saw somebody and he had to go through like a decompression stage and then they do so many meetings after and I think they picked up something wasn’t quite right ‘erm and it was when I disclosed and said ‘look like he is having the bad dreams, like things aren’t quite right, like we have gone to the cinema and he’s cowering in the aisles’, ‘you gonna have to do something’, I said, ‘like this isn’t normal?” [Sara]

Many felt that the military services focused solely on the serving personnel, often neglecting the needs of military spouses.

“They all say like they are family orientated but they are not, they don’t think anything about families I don’t think, it’s all about them [serving personnel]” [Sophie]

Once the serving partner had sought help, the participants faced challenges in being heard by the formal support systems. While some had positive interactions, many felt their concerns were overlooked or dismissed.

“From a wife’s perspective, I don’t find them approachable, the whole system is not approachable ‘cos you have to, I can’t just rock up into camp, knock on welfare and say, ‘there’s an issue’, you know I can’t do that, it’s usually the serving member that has to go in and say, ‘there’s an issue”. [Cathy]

Informal support systems were also evident; while some participants highlighted the strength they found from friends and family,

“I don’t think I would have got through half of it, if it hadn’t have been for my mum and dad ‘cos I would just tip up at the door or ring them to say, ‘I’m coming over with the kids’ and they were like ‘yep that’s fine, not a problem’, you know” [Vikki]

Whereas others were reluctant to share for fear of being judged.

“The only people that you have to vent to, is friends but you can’t vent the real extent to them ‘cos you don’t want them to think that everything is rocky at home, ‘cos you don’t want them to think that, you want everything to seem ok, ‘yeah it’s not as good as what it was’ you can say but you don’t want to be ‘oh my god, they’re on the verge of divorce’ like you know, that’s a lot of it. It’s the same with family, you don’t want to tell them the true extent of it because otherwise, everyone’s very judgy, aren’t they?” [Lauren]

Diagnosis and treatment of mental health issues often came later in the journey, after participants had already been living with the challenges for some time. Stigma both internalised and external along with the perceived hierarchy of mental health against physical health were all factors in this delay to seek help.

“I’m talking relatively recently but we have recently experienced it [post-natal depression] but, if you go back, it wasn’t really talked about, really. I think we have friends that have got problems, that have proper injuries; I say proper, I mean physical types of injuries and things and then had to deal with those... I’d say from any officer, a lot of times, they don’t want everybody knowing about it and, there’s it going to welfare, the more people that find out it becomes a thing”. [Harry]

The treatment varied, with many partners receiving counselling and medication. Participants noted varying levels of engagement from their partners in treatment, with some seeking external help independently.

Couples therapy... “he’s just lying again and if he did it to me, that’s the biggest sin but then if you did it in therapy then your kinda not using it really (pause) and he has started doing to the therapist what he has done to me really, cancelling sessions because he would have work and he would do it at the last minute. At first, she did accommodate him and kinda did what I did and made excuses for him and then after a while, she stopped doing that” [Lindy]

There was a notable lack of inclusion of military spouses in their partners’ treatment processes, which many participants felt could have aided their understanding and ability to support their partners.

“I was quite surprised there was no kind of, [not] even one chat…I was surprised, I was surprised. I think I said to her at one point, and I was very surprised that I’ve had no formal involvement at all, absolutely nothing…The connection to the military wise, there’s been nothing really…” [Harry]

Living alongside symbolizes the fluctuating journey between periods of their partner’s mental wellness and relapse, recognizing that the mental health issue was a constant presence. Strategies for coping varied among participants, with some focusing on accommodating their partner’s behaviours while others adapted their own responses to manage the relationship. Key themes emerged in the participants’ experiences, categorized into resilience and reflection on their journey.

“You have to completely change your relationship anyway and you just have to either adapt or walk away…. he is not the person I met; he’s a lot different to who I originally, see ‘cos when I first met him, he’d never done a tour, but I was never gonna walk away because of my kids” [Cathy]

Many participants developed protective interpersonal strategies, such as avoidance and accommodation, to cope with their partner’s mood swings and behaviours.

“I suppose in order to survive it; I have had to adjust quickly all of the time, and I have become quite good at that... You have to have certain mentality ‘cos I think most people would just go…… I have accommodated him, and I suppose I am quite good at that” [Lindy]

Over time, some participants noted personal growth and resilience, with changes in their own behaviour leading to improved relationship dynamics. For example, some shifted from merely accommodating their partner’s outbursts to actively challenging them, illustrating their development.

“I don’t think Daniel’s changed at all since his initial treatment, I think I’ve changed, I think I’ve changed how I interact with him” [Christina]

Participants also reflected on their experiences, often expressing feelings of heartache, resentment, and invisibility within their relationships.

“I lived my whole life miserable so really, it’s been seven years of all that heartache and pain wouldn’t have been there” [Cathy]

They acknowledged the toll that their partner’s mental health issues took on their own identity and sense of self.

“I would say I am with this empty shell, and I have become more of an empty shell because of it” [Lindy]

Despite these challenges, some participants recognized the strength gained from their experiences and the importance of their support networks.

“You sacrifice a lot but then you gain a lot, the people I’ve met the network of the people I’ve got across the country is unreal, I’m really, really like I would never change that” [Christina]

Both the stories and the categories indicate that living with a serving partner who has mental health issues is a complex journey marked by both struggle and growth. While participants faced emotional detachment and feelings of invisibility, they also identified gains in resilience and strengthened relationships.

Relationship trajectory model

Fig 3 illustrates the Relationship Trajectory model which conceptualises the coming together of the holistic and the categorical analysis. The data was not only interrogated separately but analysed together following the generation of stories and categories. While individual journeys varied, the majority followed the same trajectory, with military culture interwoven throughout. This led to the conceptualisation of the relationship trajectory model during one episode of a mental health issue. A predominant U-curve trajectory illustrates the participants’ experiences throughout the course of their partner’s mental health challenges; positive, early relational strength, followed by relationship decline and then a move to relationship reinvention during times of remission or effective treatment (see Fig 3). It was noted that this U-curve trajectory also applied during recurring episodes of mental health issues.

Strengths and limitations

A key strength is the diversity in ranks of the serving partners and their geographical spread, although the study is limited to only army spouses, therefore excluding the experiences of those from the Navy or Royal Air Force. Adopting a biographical approach and conducting in-depth life story interviews, is an original and novel approach which has facilitated the often marginalised, unheard voices of military spouses to be heard.

It is worth noting that the study’s small sample size and lack of diversity among participants—primarily female (n = 8) and all participants were married to opposite-sex partners—limit the scope of the findings. A broader and more heterogeneous sample, including more male and some same-sex spouses, could have provided additional insights into the experiences of all significant others of serving military personnel.

Recommendations

The findings suggest a need for further qualitative research to explore common experiences among military spouses, emphasising their crucial role as informal support for serving personnel. They also emphasise the necessity for investigating support avenues for military spouses, such as peer-led education and information sharing, which are often sought informally rather than through structured support groups.