The Psychological Adjustment Experience of Reintegration Following Discharge from Military Service: A Systematic Review

M Romaniuk, C Kidd

Abstract

Background: Previous literature has noted a substantial proportion of veterans experience difficulty reintegrating into civilian society following discharge from military service, which may have a significant impact on their psychosocial functioning.

Purpose: This review aimed to identify, describe and thematically synthesise literature on veteran reintegration following discharge from military service, focusing on psychological adjustment experiences.

Material and methods: A systematic multi-database text word search incorporating search results from the databases PsycINFO, Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Military and Government Collection, Scopus and Web of Science. Consolidated criteria for reporting qualitative research (COREQ) was used to assess the quality of included studies, and thematic synthesis was used to review the studies and identify common themes.

Results: The review identified 18 qualitative and mixed methods studies that met inclusion and exclusion criteria. Synthesis of studies revealed that veterans experience significant and multiple losses following discharge from military service. Overall, veterans’ transition experiences were impacted by the loss of military culture and community, a loss of identity, and the loss of purpose. These findings were consistent across countries and contexts. This review also identified a number of limitations and gaps in the current literature and outlined strategies to address such limitations in future research.

Conclusion: These findings establish the importance of addressing the experience of loss for transitioning military veterans.

Keywords: veterans, reintegration, transition, psychological adjustment, loss

Conflicts of interest: The authors declare no conflicts of interest.

In a military context, the term ‘reintegration’ refers to the dynamic process and outcome of resuming a civilian ‘role’ following completion of military service.¹ Extant empirical literature notes a considerable proportion of veterans report some form of reintegration difficulty when transitioning to civilian society following military service.^2-4 This difficulty has been associated with poor social and family relationships,^2,4,5 unemployment,^3,4, financial strain,³ homelessness,⁶ and poor physical and mental health.⁷ Due to such negative outcomes associated with reintegration difficulty, it is imperative to understand the factors that influence the transition period.

A number of reviews have summarised literature pertaining to post-deployment reintegration.^1,8,9 This reviewed literature has focused on adapting back to life following the immersive experience of operational deployment, rather than the reintegration experience of transitioning to civilian life following permanent discharge from military service. To the authors’ knowledge, a systematic review on the reintegration experience following discharge (unrelated to deployment) has not been conducted. Given not all service personnel will operationally deploy, but all will experience transitioning out of the military, this is an important gap to address.

Further, previous research has primarily investigated the impact of psychiatric disorders, traumatic brain injury and other physical conditions on veteran reintegration.^4,7,10-13 However, recent research has noted that even in the absence of clinical conditions, a considerable proportion of veterans may still experience adjustment difficulty,¹⁴ suggesting other factors may be impacting their transition from military to civilian life. The differences between military and civilian culture,^15,16 the experience of ‘identity crises’,^17-19 as well as disconnection and separation from the military community^20,21 have been identified in past studies as possibly contributing to problematic reintegration. While this research highlights a variety of factors (distinct from psychiatric and physical conditions) that may influence adjustment from military service to civilian life, a systematic review of the psychological adjustment experience of reintegration has not been conducted.

The aim of this study was to conduct a systematic review and thematically synthesise published research describing the psychological adjustment experiences of veterans reintegrating into civilian life following permanent discharge from military service. In this study, the term ‘veteran’ refers to all service personnel who have previously served in the military, regardless of deployment experience, and have discharged from military service.

Methods

The systematic review aimed to include all published and peer-reviewed research investigating the psychological adjustment experience following discharge from military service. To ensure quality and transparency, this review adhered to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines.²²

Search strategy

EBSCO host was used to access the PsycINFO, Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Military and Government Collection databases. Scopus and Web of Science databases were also accessed. Initially, searches were conducted using a combination of the following key search terms: ‘(veteran OR retired soldier OR ex-service*) AND (reintegrat* OR transition* OR *adjust* OR community integrat* OR adapt*)’. However, these search terms returned excessive results (5131, 1029, 4956, 20093, 3895 and 5867, respectively). To narrow the search results, additional search terms cultur*, loss, belong* and identity were added to the original search terms. These terms were chosen based upon an initial scan of the literature which indicated these were common concepts in the literature that related to psychological adjustment. Upon review of the new search results, the authors concluded the search terms cultur* and loss were sufficient to capture the broad range of psychological adjustment experiences associated with discharge from the military and reintegration. The inclusion of belong* and identity did not return any additional results not captured by cultur* and loss searches. Consequently, where possible, All Text searches of the databases were completed with a combination of the following search terms: ‘(veteran OR retired soldier OR ex-service*) AND (reintegrat* OR transition* OR *adjust* OR community integrat* OR adapt*) AND (culture) OR (loss NOT weight NOT hear*)’. Database searches were finalised on 23 November 2017. To extend the search further, reference lists of eligible full texts were also screened for potentially relevant articles.

Inclusion and exclusion criteria

Articles included in this review met the following inclusion criteria: (1) published in a peer-reviewed journal; (2) military veteran participants; and (3) reported quantitative or qualitative analysis of psychological adjustment related to reintegrating into civilian life after discharge from the military. Exclusion criteria included: (1) study unavailable in English; (2) focused on post-deployment reintegration rather than reintegration following permanent discharge from the military; (3) adjustment experiences described were exclusively related to a psychiatric or medical condition (e.g. a diagnosis of post-traumatic stress disorder or traumatic brain injury); or (4) grey literature. There were no restrictions placed on publication dates and no preference was given to studies that emphasized qualitative or quantitative methodology.

Thematic synthesis

For the purposes of this review, data were considered to be all text in the Results and Discussion sections of included studies. As all included articles were qualitative or mixed methods, thematic synthesis methods²³ were chosen to analyse these data. Thematic synthesis methods are similar to thematic analysis of primary qualitative data; however, thematic synthesis is used to summarise qualitative data from multiple studies to produce overarching themes present across the literature.²³ In accordance with these methods, coding was conducted in three stages: (1) line-by-line coding of primary (participants’ quotes) and secondary (authors’ interpretations) data; (2) codes organised into descriptive themes; and (3) descriptive themes used to generate analytical themes to produce an interpretation beyond the original data. Coding and themes were discussed in depth and agreed upon by both authors. The qualitative data analysis program NVivo 11 was used during the coding stage.²⁴

Results

Article selection

Database searches returned 7,133 articles in total. After removing duplicates, 5,150 articles remained. One author screened titles and abstracts for relevance and further excluded 5,113 articles. An additional nine articles were identified from reference lists. Forty-six full texts were assessed for eligibility separately by both authors in accordance with inclusion and exclusion criteria and aims of this review. Articles were included if both authors agreed on eligibility; however, there was no disagreement on eligibility between the authors. A total of 18 articles were included for review. Figure 1 presents the search and selection process according to PRISMA guidelines.

Characteristics of included studies

Data were systematically extracted by one author. Table 1 details the sample, design and methodological characteristics of the included studies. All studies were published within the past 4 years and predominately originated from the United States.^20,25-35 Three articles originated from the United Kingdom,^17,36,39 two from Sweden^37,38 and one from Africa.⁴⁰ Sixteen studies were qualitative^{17,20,25-30,32,33,35-40} and two studies reported a mixed methods design.31,34 The primary focus of all included studies was the reintegration of veterans into civilian life.

The number of participants recruited varied from one to 29 (N = 285), with 14 studies recruiting 10 or more participants. Samples were mostly homogeneous, consisting predominantly or entirely of male veteran participants from a range of conflict eras. Three studies exclusively recruited female participants.^25-27 Nine studies did not report the length of time since participants were discharged.^{17,25,26,28,30-33,40} Across the remaining studies, participants were discharged between 3 months and 38 years prior to study participation.

Semi-structured interviews were the most common method of data collection, used exclusively in 14 studies.^{17,20,25,27-31,33-35,37-39} Two studies used a combination of semi-structured interviews and focus groups^26,40 while one study used only focus groups.³² Finally, one study reported using interviews but did not describe the technique used.³⁶ Along with qualitative methodology, two studies collected quantitative data with self-report Likert scale questionnaires. Questionnaires related to perceived work barriers³¹ and accessing support in an education context;34 however, the findings from these measures were not directly related to psychological adjustment and, as such, were not included in the results of this review.

Comprehensiveness of reporting

As all of the included studies were qualitative or mixed method designs, the studies were systematically assessed using the consolidated criteria for reporting qualitative research (COREQ) framework.⁴¹ This 32-item checklist provides readers with information on the comprehensiveness, trustworthiness and quality of findings in included studies.⁴¹ This checklist also identifies limitations of included studies. Inclusion of studies was not weighted according to this assessment. Table 2 outlines each COREQ item and the overall comprehensiveness of reporting in this literature. In addition, Table 1 lists the items each study reported. The studies captured between six and 26 items, with 14 studies reporting over half of the items (M = 18.83, SD = 4.94). Most studies identified the interviewer but many failed to provide the interviewer’s characteristics or consider their relationship with participants. Theoretical frameworks, sampling methods and approach were reported in the majority of studies. Few studies reported reasons for non-participation, the setting of data collection, or presence of non-participants at data collection. Most studies gave details about the interview procedures including an interview guide, duration details, and audio/video recording. Data analysis was well described in most studies; however, participant checking and details of software used for the analysis were infrequently reported. All studies provided a description of their sample including sample size, reported participants’ quotations, presented data that were consistent with their findings, and demonstrated clarity of major themes.

Themes

Analysis revealed the psychological adjustment experiences of veterans discharging from military service were characterised by extensive and multiple losses. This unifying theme of loss emerged in three central interrelated domains: culture and community, identity, and purpose. Table 3 provides quotations that illustrate these themes from participants (italicised) as well as authors of the included studies.

Loss of culture and community. The first descriptive theme demonstrated that difficulties experienced by veterans during their transition into civilian society could be attributed to feelings of loss of their military culture and community. Despite participants originating from varying military organisations during different conflict eras, descriptions of military culture were consistent. Overall, military culture was described as a collectivist social institution that emphasises hierarchy, structure, conformity and comradery. Once enlisted, participants described the acculturation process ‘wherein their appearance, behaviours, and thoughts are remodelled’^33(p40) and conformity was enforced.⁴⁰ The structured military culture provided participants with ‘clarity’ and direction,^20(p5) as one participant described: ‘I’m told exactly what to do, when to do it, how to do it, and I just completely surrender.’^26(p498) In addition, the military was described as an organisation that cares for its members^20,27 providing them with ‘safety’ and ‘comfort’.^20(p5)

In comparison, civilian culture was described as considerably less structured and less supportive.^{20,25,27,29,30,35} Burkhart et al.,sup>25 described the transition from military to civilian culture as ‘bridging these two worlds’ where veterans must learn to navigate ‘different psychological and social rules’. ^(p121) Authors described this reintegration experience as ‘cultural shock’,^{25(p119),27(p113)} where participants were ‘unprepared’ to handle requirements of civilian life.^25(p119) Participants reported difficulty reorganizing their lives,²⁰ managing their health care,²⁵ obtaining employment,^27,31,40 and establishing new routines.²⁸ Furthermore, the loss of military structure triggered emotional distress as participants described feeling overwhelmed,³⁰ in addition to feeling angry³⁵ and frustrated.²⁰ Alternatively, authors noted that when participants transitioned into a similarly structured culture such as university^29,33 or similar workplace,³¹ they appeared to experience an easier reintegration process.

Additionally, military members were described as ‘family’ in terms of support, closeness and shared experiences.^{20(p4),33(p44)} According to participants’ descriptions and authors’ interpretations, the team-oriented culture of the military breeds strong comradery and interdependence among its members.^{20,33,37,39,40} Members are encouraged to ‘de-individuate’ and work towards a collective goal.^33(p40) The strength and importance of the interpersonal relationships between military personnel was described frequently throughout the studies^{17,20,33,36,39,40} and appears to be one of the most important and influential components of military culture. As summarised by one participant: ‘They say there is no stronger and better friendship than the one made in the army.’^40(p129) For many participants, discharging from the military resulted in significant loss of community.^33,36,37,40

This loss of community was further perpetuated by difficulties forming and maintaining relationships with civilians following discharge.^{25,28,29,32-34,40} Some participants expressed that their relationships with civilians could never be as close as the ones they had during their military service.^33,37,40 Participants frequently commented that civilians cannot truly understand their military experience or the consequences of their service.^{20,26,28,31-34} In turn, participants regularly reported difficulty relating to civilians.^{25,28,29,32,34,40} Overall, findings revealed participants of included studies experienced significant loss of culture and community upon discharge from the military and reintegration into civilian society. Veterans appeared particularly vulnerable to the perceived lack of structure, support and comradery in civilian culture.

Loss of identity. The second theme encompasses participants’ descriptions and authors’ interpretations of the military identity and a loss of this identity upon discharge. Initially, participants provided detailed descriptions of their military identity which was followed by reports of identity crises upon discharge. Their military selves were described as ‘competent, motivated, efficient’,^38(p257) ‘creative, dedicated, passionate’,^37(p214) ‘mission driven’,^27(p1379) ‘focused … task-orientated’,^30(p115) and ‘assertive’.^25(p119) These military identities were formed through military training and service experience and reinforced by the structured, collectivist-oriented military culture.^{17,31,36,38-40} This identity construction was summarised by one participant as: ‘[The military] organisation changes you completely, the person that you were as a civilian, you are no longer that person, it changes you completely.’^40(p128) In addition to the above descriptions, one study described their participants’ military ranks as ‘deeply embedded within their self-perception’.^27(p1379) In line with this statement, participants across studies inferred their role and rank in the military was so intrinsic that it became their identity.^31,33,36,39 For example, one participant noted their identity was their military occupation: ‘’Cause it’s like it’s not just part of your life; it’s who you are. It’s not just an occupation.’^33(p42)

As a consequence of forming an identity shaped by military culture and dependent on their military role, the process of discharge subsequently triggered an experience of identity loss which evoked significant distress among participants.^{17,26-28,36-38} Brunger et al.¹⁷ described participants as having a ‘fractured sense of self’ where during the reintegration process, they had ‘lost everything that epitomised and reinforced this identity’.^(p93) One participant recounted the grief they had felt over their lost identity: ‘the big wrench of course … is I was no longer somebody. ’^36(p47) In addition to losing their military identity, participants appeared to face the dynamic process of reconstructing their civilian identity following discharge: ‘In the civilian world, it’s like, who am I? What do I dress like? How do I talk? Where do I go? What do I do?’ ^26(p503) During this reconstruction process, participants’ military identities were challenged by civilian expectations, values and rules,^25,28 which created conflict between identities, described by one participant as a ‘tug of war’.^38(p263) Alongside the grief of losing their military identity, participants recounted the process of determining their civilian self-concept as challenging: ‘It’s challenging to have to figure out who exactly I am.’ ^26(p503)

Others reported difficulty letting go of their military identity: ‘No longer being able to say that … that’s who I was, was probably the hardest part.’^28(p4) Overall, analysis of the included studies indicated that military culture and military work roles were central components of participants’ identity prior to discharge. Upon discharge, participants appeared to grieve the loss of this identity and experience difficulties forming a new civilian identity.

Loss of purpose. Finally, analysis of the included studies revealed the common experience of loss of purpose upon discharge.^{20,28,31,33,36-38,40} Derived from participants’ accounts of their military work experiences, serving in the military provided them with a powerful sense of purpose. During their service, participants felt they were part of something bigger than themselves.^38,40 They held ‘responsibility’,^33(p42) and felt accomplished,^32,33 ‘successful’^31(p484) and empowered,⁴⁰ and by serving, participants had ‘made a meaningful contribution to a worthy and noble cause’.^31(p484) Additionally, Kramm and Heinecken40 reported some participants became ‘reliant’ on military structure to provide them with ‘purpose and direction’.^(p130)

In line with these accounts, upon reintegration into civilian society, participants frequently reported losing purpose and meaning.^{20,28,31,33,36-38} It became apparent that after discharge, many felt that they were no longer contributing to something as important as the collective effort of military service.^20,27,31,33 One participant summarised this as follows:

It’s really hard to put in words but I just miss the environment. I miss the common goals … the way people put aside their own personal [agendas] … I used to run a lot and [the] feeling is just like that … ‘yeah man, let’s go do it!’ I’ve never really gotten the same thing on the civilian side, even though I try and pour my heart into things.^20(pp6-7)

Additionally, lost purpose resulted in some participants having difficulty finding motivation to complete their civilian duties such as work or study.^20,37,38

Discussion

This was the first known systematic review to investigate the psychological adjustment experiences of veterans reintegrating into civilian life following discharge. A total of 18 qualitative and mixed methods studies, representing four countries, were identified. Overall, analysis revealed military veterans’ psychological adjustment experiences during reintegration were characterised by significant losses. Veterans appeared particularly vulnerable to the loss of important facets prominent in military culture including structure, support and community. Additionally, many experienced identity loss which was further compounded by difficulty reconstructing their self-concept as a civilian. Finally, many veterans experienced a significant loss of purpose and meaning upon return to civilian life. This perceived ‘void’ of not contributing to an important, collective cause appeared to subsequently impact motivation to engage fully in civilian settings.

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In addition to these findings, this review identified a number of limitations in the current literature. Firstly, the overall quality and comprehensiveness of the qualitative research methods of the studies was moderate with some studies using methods that may introduce bias. Tong et al.⁴¹ recommended good qualitative research should report the characteristics, experience and training of the researchers and interviewers and advise participants of this. This is termed ‘reflexivity’. Reflexivity reduces personal bias from influencing the study and improves credibility and transparency of the findings.⁴¹ Despite the importance of reflexivity in qualitative research, few studies reported these criteria. To improve the quality and comprehensiveness of future qualitative research, COREQ41 or similar criteria should be considered when designing and implementing qualitative studies and publishing research findings.

Secondly, it was noted over half of the included studies failed to report participants’ length of military service. Length of service may be an important consideration in understanding transition and reintegration experiences through the influence it may have on veterans’ construction of military identity and acculturation into the military system. Furthermore, half of the included studies failed to report the length of time since participants had discharged. This makes it difficult to ascertain how veteran reintegration difficulties may change over time. Increased rigour when reporting demographic characteristics of participants would benefit future research and may help determine if length of service has an influence on experiences of loss following discharge from military service. In addition, longitudinal research may be beneficial to ascertain how, and if, reintegration difficulties change over time. Two studies included in this review were longitudinal;^37,38 however, more longitudinal research needs to be conducted to support and extend the findings of these studies.

Thirdly, during the search and selection process it became evident that the current reintegration literature predominantly focuses on adapting back to civilian life following an operational deployment, rather than the reintegration experience following permanent discharge. Further, while participants of these studies may have discharged from military service upon returning from the deployment, this distinction was rarely provided. Future research should overcome this limitation by explicitly differentiating between post-deployment and post-discharge populations. Additionally, extensive literature has highlighted the impact of psychiatric disorders and physical conditions following deployment.^4,7,11-13 As these factors were outside the scope of this review, future research should consider extending the findings of this review to investigate how these difficulties may relate to, and further perpetuate, the experience of loss following discharge.

Finally, the majority of research studies investigating reintegration following discharge from military service are qualitative. As this is a relatively new area of research, with particular complexities, it is not unexpected that studies would use qualitative methodology to investigate this topic. However, future research should consider developing quantitative measures to enable assessment of factors that contribute to a difficult reintegration experience post-discharge, to extend the current research literature and allow for quantitative investigations.

Strengths and limitations of the review

A key strength of this review was the rigorous scientific methods used to identify, critique and synthesise the literature. PRISMA search and selection criteria ensured quality and transparent reporting of findings22 and thematic synthesis provided an in-depth analysis of these findings beyond a standard review of the literature.²³

Quality and comprehensiveness of included studies were also evaluated using standardised criteria used in previous systematic reviews of qualitative literature.^42,43 Despite these strengths, the quality and comprehensiveness of reporting varied across the included studies which may affect the reliability of the findings. In addition, combining and summarising qualitative data has been criticized by some researchers who argue that these data are specific to the context, time and group of participants they were gathered from and therefore should not be generalised beyond this.²³ In particular, participants originated from different military organisations (e.g. United States, United Kingdom, Sweden) and served in a variety of service branches and conflict eras and, as such, generalising their reintegration experience could be inaccurate. However, regardless of these limitations, the findings from this review indicated the experience of loss was consistent across countries and contexts, signifying this finding is stable and unlikely to be affected by these limitations.

Conclusions

This systematic review of 18 qualitative and mixed methods studies revealed the psychological adjustment experiences of veterans reintegrating into civilian life following discharge from military service are characterised by extensive and multiple losses. Veterans in the included studies reported they were impacted by the loss of military culture and community, identity and purpose which contributed to a difficult reintegration experience. These findings were consistent across countries and contexts, and establish the importance of addressing the experience of loss for transitioning military veterans.