Can Veterans Experience Acculturative Stress?

Presently, the bulk of research and theory on the veteran population has remained narrowly focused on correlates of psychopathology associated with posttraumatic stress disorder (PTSD). To date, inadequate research has explored understanding the broader category of transitional difficulties (including intercultural interactions, individual cultural identity, societal cultural values, social support loss, and cultural language fluency) and possible heterogeneity of outcome variables associated with both PTSD and acculturative stress. In this paper, I attempt to address this deficit by blending qualitative thematic analysis with first-person reflections associated with acculturation and acculturative stress. This approach is intended to offer the reader a contextually rich understanding of concepts that may be new, unfamiliar, or vague. Thematic analysis examines three aspects of acculturative stress impacting the lives of military veterans when returning back to civilian society: military and civilian cultural differences, perceptions of being stereotyped due to their differences, and adopting a new self-identity. Personal reflections on identical aspects of acculturative stress, draw upon my firsthand experiences going through the acculturation process between military and civilian societies. The conclusion offers implications based on this new understanding, which includes future lines of research needed to further our understanding and support of this community.

The bulk of research and theory on the veteran population has remained narrowly focused on correlates of psychopathology associated with posttraumatic stress disorder (PTSD) (Berntsen et al., 2012;Bonanno, 2004;Schultz et al., 2014), despite the fact that empirical evidence indicates that PTSD occurs in a small percentage of returning veterans (Donoho et al., 2017;Magruder & Yeager, 2009;McNally, 2012).To date, sparse research has explored understanding the broader category of transitional difficulties (including intercultural interactions, individual cultural identity, societal cultural values, social support loss, and cultural language fluency; (Kleykamp, 2013;Knight, 2014;Moore, 2017;Sontag & Alvarez, 2008) and possible heterogeneity of outcome variables associated with both PTSD and acculturation stress experienced during their return to civilian society.
Popular press and media offer a variety of sources discussing the transition from military to civilian life (Horton, 2011;Miller, 2019), but this is not reflective of empirical evidence or theoretical frameworks.This results in few resources available to address cognitive, emotional, behavioral, or psychological impacts of their transitional experience.The goal of this manuscript is to transform popular press conversations into theoretical constructs, thus supporting a better understanding of the complex experience of the military-to-civilian transition.This manuscript attempts to perform this through provision of personal reflections associated with this transition, then connecting these reflections with qualitative thematic analysis examining three dimensions of acculturative stress and associated sub-dimensions (Caplan, 2007).

LITERATURE REVIEW
The US Department of Veterans Affairs (VA) has developed a number of programs in the areas of education and employment to support veterans' transition back to civilian society.Five Federal-level programs, stemming from the Servicemen's Readjustment Act (SRA) of 1944, focus on veterans employment and education benefits and services: Transitions Assistance Program (TAPS)/Transition Goals, Plans, Successes (GPS); G.I. Bill Educational Benefits; Vocational Rehabilitation and Employment (VR&E); Small Business Administration Veterans Programs (SBA); Local Veterans Employment Representatives (LVER) and Disabled Veterans Outreach Programs (DVOP); and Veterans Upward Bound (VUB).Despite these programs, the VA recognizes that veterans' employment, education, and health outcome measures lag behind those of their civilian peers (Council of Adult Experiential Learning, 2010;Kleykamp, 2013;Lemos, 2013;Smith, 2015).
Additional VA programs focus on psychological support, mainly Post Traumatic Stress Disorder (PTSD) treatment (V. A. DoD, 2010;Yehuda & Hoge, 2016).Available outcome evidence of credible treatments, namely prolonged exposure (PE) and cognitive processing therapy (CPT), indicate that a majority of veterans who participate in these treatments continue to suffer elevated symptoms (Steenkamp, 2016;Steenkamp et al., 2015).This manuscript offers an argument that broadening the lens of research and practice is needed to provide improved services and outcomes for the wide range of experiences of transitioning veterans by focusing on broadening the discussion on veterans' transition and substantiating this line of literature through rooting in a legitimate theoretical framework connected to acculturation and acculturative stress.

ACCULTURATION
Acculturation is the process of learning and incorporating the values, beliefs, language, customs, and mannerisms of a new culture an individual is living in, including behaviors that affect health such as dietary habits, activity levels, and substance use (Berry, 2004).Formative acculturation literature focused on better understanding native tribal languages and culture (Powell, 1880), and remained focused on understanding connections between communication and acculturation for a century (Adler, 1975(Adler, , 1977;;Furnham & Bochner, 1986/1994;Zaharna, 1989).
Subsequent research broadens to examine psychological and sociological impacts and challenges acculturation present (Austin, 1983(Austin, , 1986;;Caplan, 2007;Céspedes & Huey, 2008;Finch & Vega, 1999;Ward et al., 1998).Austin (1983Austin ( , 1986) ) found cultural reentry to be a more challenging experience than experiencing a new culture for the first time (culture shock).Immigrant acculturation research highlights the sense of adriftness between two worlds (cultures).Adriftness caused by high degrees of uncertainty due to separation from their own culture's values and way of life (Caplan, 2007, Céspedes & Huey, 2008;Finch & Vega, 1999).
There are significant studies addressing veterans' experiences returning to civilian society.These literatures acknowledge the lack of an adequate conceptual framework to better understand and explain the soldierto-civilian transition (Jenkins, 2014;Junger, 2010Junger, , 2016;;Mobbs & Bonanno, 2018;Rose, 2017).Studies explore the concept of veterans' transition stress, containing overlapping findings to acculturation stress literature, yet stop short of connecting the two concepts.This manuscript attempts to connect these two concepts by highlighting related findings and establishing an adequate conceptual framework as a foundation for future lines of research.For brevity's sake, I recognize bodies of literature associated with veterans' self-identity, military culture, and stereotyping (among others).These foundational studies lend to the continuation of this discussion.

ACCULTURATIVE STRESS
Acculturative stress, the impact of psychological adjustment to a new culture, tends to be observed in immigrant and ethnic minority communities (Mena et al., 1987).Acculturative stress literature identifies a variety of instrumental and environmental stressors, including increased frequency of headaches, increased alcohol consumption, and reduced ability to express environmental needs (Barry & Kronk, 1993;Berry et al., 1972;Larson & McQuiston, 2008).Berry and Kim (1988) found that the process of acculturation can alter the mental health state of those living through the experience.
Caplan (2007) developed a taxonomy of common stressors experienced during the acculturation process (see Table 1 below).Social and interpersonal stressors include higher levels of depression and suicide ideation, particularly among first-generation immigrants (Hovey, 2000).Mui and Kang (2006) identified that family values also had a tendency to diminish due to acculturation stress, specifically leading to domestic violence.Both dimensions and sub-dimensions of acculturative stress have been linked to negative health outcomes (Cespedes & Huey, 2008;Finch & Vega, 2003).
Social and interpersonal stressors include higher levels of depression and suicide ideation, particularly among firstgeneration immigrants (Hovey, 2000).Those who reached out to family when facing acculturation stressors benefited from their support (Rivera, 2007).Yet, additional complexity includes social support potentially acting as a stressor brought about by intergenerational conflict (Céspedes & Huey, 2008).Finch and Vega (2003) found discrimination to be a key factor impacting acculturation stress.Immigrants who perceive experiencing discrimination during migration report higher levels of acculturation, a reduced sense of belonging, and increased separation from the dominant culture (Mena et al., 1987).

CULTURAL TRANSITION
A number of studies recognize the military-to-civilian transition to be challenging (Interian et al., 2014;Lieberman et al., 2014;Morin, 2011;Pew Research Center, 2011;Shepherd et al., 2019).Mobbs and Bonanno (2018) indicated the lack of a theoretical framework is a significant limitation in understanding which factors may be impacting veterans' long-term adjustment back to civilian society.This body of literature suggests a need for empirical evidence to begin identification of factors impacting this transition.According to Mobbs and Bonanno (2018), "at present almost no resources are available to address the cognitive, emotional, behavioral, or psychological impacts of the soldier-tocivilian transition" (p.2).The acculturative career planning theoretical framework (see Figure 2 below) is an initial effort to provide resources to support the solider-tocivilian transition and future studies.
There are links between existing veterans' transition literature and emerging veterans' acculturation literature.Both recognize discrimination and stigma, self-identity, and social support as factors leading to negative outcomes.The difference is transition literature stops short of providing a theoretical framework.Smith (2021) confirmed the existence of acculturation stress in undergraduate veterans.Acculturation stress literature is connected to, among others, three contemporary theories associated with intercultural interaction: Stress and Coping (Cuellar et al., 1980;Lazarus & Folkman, 1984), Culture Learning (Argyle, 1969), and Social Identification (Deaux, 1996).(Caplan, 2007).
CONCEPTUAL FRAMEWORK Ward (2001) and Zhou et al. (2008) have described how minority populations experience and make decisions about engagement with civilian society, engagement in higher education, and make decisions about civilian careers.Their models suggest that individual and societal level variables are present and impact the outcomes of individuals going through higher education as a conduit to civilian employment outcomes.This study predicts that military veterans have similar experiences to other cultural minority populations, and these perceptions impact veterans' transitional experience, including college and employment outcomes.The model of this study (see    (Berry, 1992).

METHODS
In order to address the above hypothesis, this manuscript blends qualitative thematic analysis with topical personal narratives in order to provide a deeper understanding of an emerging line of research (Ellis, 2004;Holman, 2005).Thematic qualitative analysis was performed on openended responses (N = 32) to questions associated with cultural differences between military and civilian societies.Purposive sampling was used to collect participant responses through formal organizations focused on serving student veterans (Patton, 2002;Poorman, 2002;Teddlie, 2005).Anonymous undergraduate student veterans sampled for this study met two important inclusion criteria: (a) stated identification as a military veteran, any discharge status; and (b) enrolled in a part-time or full-time undergraduate degree program at a variety of colleges and universities.Formal organizations focused on serving student veterans included Student Veterans of America (SVA) chapters and National Association of Veteran Program Administrators (NAVPA).Participants were provided informed consent materials and voluntarily participated in the study.

STUDY DESIGN
Three-open ended questions were designed specifically to allow veterans the ability to describe their experience transitioning back to civilian society, without leading respondents or narrowing their response categories.These questions were: 1. How would you describe differences between military and civilian culture? 2. Veterans sometimes feel misunderstood when returning to civilian society.Have you had any experiences like that?What happened, how did you deal with the situation?3. Veterans sometimes wonder whether college really prepares them for a career.Do you agree or disagree with this statement?Why?
Open-ended questions, developed during a pilot study, were intentionally designed to further explore sub-dimensions of acculturative stress (Table 1).Deductive thematic analysis connected participants responses to the three acculturative stress sub-dimensions of discrimination stigma, loss of social status, language barriers, and political affiliation.The resulting themes address the above hypothesis and subhypotheses.

BIAS
To increase trustworthiness of research findings, I implemented strategies recommended by Glesne (2010), including peer review and expression of personal bias.Peer review ensures external reflection and validation of research data through the review by other researchers (Glesne, 2010).
Stating bias upfront encourages the researcher to reflect upon their own subjective view (Glesne, 2010).Reflection on subjectivity prior to performing analysis allows the researcher to develop strategies to mitigate the impact of bias.My lived experience includes enlisting in the US Army for four years, including a combat deployment.My experiences of involvement in the military may have created bias in creation of the study design and could have influenced analysis.

RESULTS
The results section addresses three themes associated with acculturative stress.This section includes topical personal narratives associated with respective themes (Caplan, 2007).This analysis delves into the topic of acculturative stress through the blending of story and identified thematic patterns.These three themes are identity and acculturation, cultural differences, and being stereotyped.

PERSONAL NARRATIVES IDENTITY AND ACCULTURATION
I enlisted in the US Army in 2005 with two intended goals: eliminate undergraduate student debt and complete a graduate degree.I was intrinsically motivated by financial insecurity that I experienced during my formative years in a lower-middle class family.While I do recognize that I served in the military, I do not see this as my primary selfidentity.This may sound confusing or even heretical: Why would someone not be proud of their military service?Why would someone not want to identify as a military veteran?
Simply, I find it to be easier to connect with others through a civilian self-identity.I am the type of veteran who prefers not to wear military or veteran clothing or constantly reminisce about my military experiences.I am open to talk about military service, but I am much more interested in discussing other topics and experiences.A growth mindset perspective keeps me living in the moment and focusing on my future self.My self-identity will remain rooted in prior life experiences, yet I choose not to stagnate.

CULTURAL DIFFERENCES
I have heard the phrase suffering comes from our own resistance to being our true selves.I wonder how it applies to those who have gone through acculturation experiences.It brings up existential questions of self, do our true selves exist within a cultural context or can we maintain this true identity across cultures?When reflecting on my cultural re-entry and considering cultural differences, I felt out of place most of the time during the first couple of years returning home.Re-entry was lonely, I didn't have a mentor or guidebook offering insight into the "right" way to think or act.In the military, I felt grounded in my role, rank, company, battalion, skills, group of friends, training schedule, and promotional goals.These external connectors went away as I drove off the military base for the last time.The lack of a road map left me feeling aimless and somewhat helpless despite my achievements: job promotion, combat deployment survival, received meritorious awards for my actions, and completed a graduate degree.
I can see iterative indications of my desire for integration (Figure 1), yet this strategy was unknown to me at the time.My preference to identify more as a civilian than as a military veteran may sound confusing to civilians, professionals working with veterans, and those in the veteran community.

STEREOTYPED
When I introduce myself in a public or private setting, I avoid talking about my military service.I hide this part of my identity to avoid the potential of being stereotyped.Unproductive discussion or ignorant comments can lead to strong emotions, thus hiding part of my identity is a strategy for self-protection.On occasion, people comment that I don't act or sound like I was in the military (i.e., I can pass).I wonder if this is what people from other minority cultures experience when they are told, "you don't act like you are ________".
My own lived experience has changed how I engage with others.I am intentional and try hard not to make assumptions about personal identity, based on my own limited understanding of them.I find this to be freeing and often leads to deeper relationships, beyond the surface.

THEMATIC ANALYSIS SELF-IDENTITY AND ACCULTURATION
Veterans express their need to conform to societal norms in effort to be accepted back to society, which includes learning and adopting civilian behavior, language, and other traits.This fits within the social/interpersonal dimension of acculturation stress, veterans are changing their behavior in part to avoid conflict.
• "Yes, I tried to conform to their type of behavior." • "I had to learn to communicate differently, the military has its own language so I had to relearn how to talk as a civilian.I stopped swearing as much as I used to."• "I conformed.I kept the things that worked and canned the things that didn't.If it didn't directly benefit me, I tossed it aside."• "Some people are very uncomfortable with direct communication.I have learned that I have to be less direct, otherwise I'm seen as being too aggressive." Veterans experience identity confusion when re-entering civilian society.To address their loss of identity, individual strategies include seeking support: from others, through faith, and through education respectively.
• "Joining the military at 18 and exiting at 24, I had a massive identity crisis.My cultural identity was wrapped up in being a soldier.That made it very difficult to connect with anyone who wasn't military.What helped me in my transition and figuring out who I was outside of the uniform was my Christian faith.I feel that embracing my spiritual identity, which I had already done in the military, gave me something to hold onto when I wasn't understood by civilians."• "I did not know what to do or how to define myself when I got out.I was lucky enough to have a great support system that helped me through this rough time."• "Yes.I spent a few years job hopping until finally deciding to pursue a BA in psychology in order to better understand myself and others, and to research these same issues veterans are having with transition."Some veterans expressed dismay and difficulty relating to civilians.These veterans voiced a tendency to keep to themselves in order to reduce stigma producing situations based on past experiences.Veterans are expressing acculturative stress sub-dimensions within environmental and social/interpersonal dimensions.They may feel as though they do not belong due to their inability to naturally connect with civilians: • "People don't understand my humor or outlook on life.I have difficulty relating to people who have never been in the military."• "Being in the civilian society I keep to myself and only share what I need to, the bare minimum because I don't feel like I can make good connections with people."

CULTURAL DIFFERENCES
Veterans express moral criticism for the American societal construct of individualism.As they re-enter society, it appears common for veterans to vocalize their displeasure for this aspect of civilian society, starkly contrasted with the collaborative culture they experienced during military service.A common military phrase, "got your six" meaning "I've got your back," is used to express the military value of collaboration and communal support.This phrase instills confidence that someone is always looking out for your best interest because it will strengthen the community as a whole.In contrast, the civilian world tends to be dog eat dog, or the devil takes the hindmost.Veterans in this study were asked to respond to the question, "how does military culture differ from civilian culture", one response theme that emerged was the value of community: • "In the military, my team succeeded and failed together.We were only as strong as our weakest link.
The strong supported the weak.Civilian society seems to take advantage of the weak at every turn."• "Military gives you a solid path to follow for advancement, and those around you will help.Civilians expect you to know the path and how to get on it, stay on it, and figure out all of your faults and you are on your own to solve everything with no help at all." • "Military culture is centered around relationships and mentoring.Military training and operations are performed together as units.People spend a lot of time together and grow to become family.Civilian culture is very different, most people don't know each other, and tend to only look out for themselves."• "As a civilian I am on my own, there is nobody to watch my back and no clear way to find help.The civilian institutions like the VA are filled with people who mean well but don't understand the people they are supposed to help."

STEREOTYPED
Veterans expressed that they have experienced being negatively stereotyped by civilians.These stereotypes include the perception that those who serve in the military are of lower intelligence and all have the same political affiliations.
• "I was told by Ivy League faculty and students that they were amazed at my intelligence because they thought only people with no other prospects served in the military.That happened on five or six separate occasions." • "Liberal students apologized to me for originally stereotyping me as a racist alt right veteran when they took the time they learned I am open minded and I value diversity because of the diverse type of people I worked with in the military." Respondents also believe that civilians stereotype veterans due to their lack of cultural awareness and low comprehension of military service.This offers an opportunity for industries to intervene through research and education of their civilian employees.It also offers an opportunity to prepare those reentering society for what they might experience.Inclusion of veterans within mandatory stereotype training would help address issues faced by veterans within these statements: • "Many times as a veteran you are welcomed warmly, however, there are often times you are met with pure hate when it is discovered you are a veteran.I think many civilians think every member of the military is a stereotypical frontline infantryman who is a crazy war criminal, when that is not the reality.Civilians are drastically uneducated when it comes to the functions of the military, and often are hated just for the idea of supporting the government."

DISCUSSION
Although US military veterans have been experiencing transitional difficulties back to civilian society for decades, the research is sparse on factors leading to transitional difficulties.This manuscript is intended to highlight a few factors leading to transitional difficulty thus contributing to research literature in the following ways: (a) It provides evidence that veterans perceive acculturative stress during their transition, (b) it provides evidence that veterans experience social/interpersonal difficulties to include loss of social status, and (c) it provides evidence that veterans experience societal difficulties to include discrimination.
Veterans come back to society looking for acceptance and understanding.The results of this study showcase evidence that veterans express perceiving acculturative stress.It is known that marginalization, an acculturation orientation where segregated members of society also don't keep their own culture, is associated with the highest levels of acculturative stress (Berry, 2006).

SELF-IDENTITY AND ACCULTURATION
Similar to the findings in transitional stress literature (Papa & Maitoza, 2013;Schulz et al., 2006), self-identity difficulty was found to be a primary theme in thematic analysis of this study.Transitional stress meta-analysis finds significant decreases in well-being, loss of self-esteem, and reduction of self-efficacy (Creed et al., 2009;Papa & Maitoza, 2013).These findings are consistent with acculturative stress literature that find connections between stress and wellbeing including increased medical concerns, such as mental health issues (Castillo et al., 2008;Jenkins, 2014;Ward & Kennedy, 1994;Ward & Rana-Deuba, 1999).

CULTURAL DIFFERENCES
This study agrees with transitional stress literature; cultural differences exist between military and civilian societies (Lieberman et al., 2014;McGurk et al., 2006.Literature exploring military organization and culture highlight three distinct cultural attributes: communal lifestyle, hierarchical structure, and discipline orientation (Feaver & Kohn, 2000;Holsti, 1998;Lang, 1965;Moskos, 1977;Soeters et al., 2003).According to Lang (1965), communal lifestyle showcases one of the clearest cultural differences between military and civilian societies.Within military organizations, employees tend to be fully oriented toward the goal of the institution (Moskos, 1977;Soeters et al., 2003).Military institutions have control over leisure time and activities, family matters, salary and promotions, and living conditions.In contrast, civilian institutions tend to emphasize private life, incentivize leisure time, and offer performance-based bonuses or salary increases (Soeters, 1997).
This study finds that veterans express their need to conform to societal norms in effort to be accepted back to society, which includes learning and adopting civilian behavior, language, and other traits.This fits within the social/interpersonal dimension of acculturation stress.

STEREOTYPED
Similar to transitional stress findings related to stereotype threat (Hoit, 2012;Schmader, 2002;Steele & Aronson, 1995), this study finds that it is common for veterans to feel stereotyped by civilians.These experiences have led some veterans to hide aspects of themselves, essentially not feeling comfortable sharing this part of their identity for fear of rejection or judgment.It is known that marginalization, an acculturation orientation where segregated members of society don't keep their own culture, is associated with the highest levels of acculturative stress and lowest health outcomes (Berry, 2006).As previously mentioned, Finch and Vega (2003) found discrimination/stereotyping to be a key factor impacting acculturation stress, commonly resulting in negative employment, education, and health outcomes (Ward & Kennedy, 1994;Ward & Rana-Deuba, 1999).

PRACTICAL IMPLICATIONS AND FUTURE RESEARCH
Emerging research finds that a majority of undergraduate veterans express experiencing acculturation stress (Smith, 2021).Acculturation and acculturative stress literature find asset-based cross-cultural interventions to be effective for international travelers and immigrant populations (Caplan, 2007;Castillo et al., 2008;Finch & Vega, 2003;Hou et al., 2018).Increased understanding of veterans' acculturative stress experiences may prove to be valuable, offering service providers with a new understanding of the acculturation process and factors leading to acculturative stress for military veterans.Preparation, orientation, and cultural skills acquisition training before entering a new culture empowers international students with proper tools to effectively engage with the dominant culture (Zhou et al., 2008).It may be the case that asset-based approaches to acculturation would benefit transitioning veterans as well.This type of intervention training should seek to include self-identity reframing, which may help veterans step out of the role of martyr and find which role(s) may best fit their individual identity.Conceptualizing veterans as active agents in their journeys back to society will likely increase their sense of resilience and confidence that they belong and are able to move forward.
Future research should attempt to replicate acculturative stress and health outcome studies performed on other populations.This includes first understanding which acculturation strategy veterans choose when encountering civilian society (Zhou et al., 2008).It is also recommended that future studies measure potential differences in cultural values between civilian and military societies (Hofstede, 2001).
As stated within other studies (Mobbs & Bonanno, 2018), this manuscript recommends longitudinal studies following individuals from basic training, through military service, and into their return to civilian society collecting data pertaining to pre-military culture, military acculturation, and civilian society re-entry acculturation.These types of studies would increase the collective understanding of the complex experiences of this distinct, minority population.There is precedence these types of study designs (Bernsten et al., 2012;Engelhard et al., 2007;Smith et al., 2008).Leveraging existing study designs with the inclusion of prospective measurements to capture individual experiences, stressors, and responses may lead to the ability to predict future outcomes and identify effective interventions to best support the military-tocivilian transition.
The military-to-civilian transition is complex.The intention of this study was not to fully explain or understand all factors contributing to the difficulties experienced by veterans; rather to connect existing transitional stress literature to existing acculturative stress literature.Thus providing a conceptual theoretical framework as a foundation for future research.The goal of this manuscript is to offer a new understanding, which may lead to improved interventions and support for current and future generations of veterans.

Figure 2 )
is adapted from Ward et al.'s (2001) interactive acculturation model.The lack of acculturative stress empirical research connected to a theoretical framework highlighted an opportunity to connect veterans' lived experience to existing factors and framework.This research is an attempt to move the conversation beyond anecdotal examples of the "veterans' experience."Hypothesis 1: Transitioning veterans have difficulty adjusting to civilian life, in part, due to perceptions of acculturative stress.Hypothesis 1a: Transitioning veterans have difficulty adjusting to civilian life, in part, due to experiencing social/interpersonal acculturative stress.Hypothesis 1b: Transitioning veterans have difficulty adjusting to civilian life, in part, due to experiencing societal acculturative stress.

Table 1
Dimensions of Acculturation Stress • "Of course once everyone finds out that I am a Marine they want to talk about war and "how many people I have killed".They think that they know what goes on in the military based[on]the movies that they see."•"People seem to have an idea of what veterans are like based on movies or news stories."