Items filtered by date: July 2016

Jennifer L. Price, PhD & Susan P. Stevens, PsyD

Introduction

A number of studies have found that Veterans' PTSD symptoms can negatively impact family relationships and that family relationships may exacerbate or ameliorate a veteran's PTSD and comorbid conditions. This fact sheet provides information about the common problems experienced in relationships in which one (or both) of the partners has PTSD. This sheet also provides recommendations for how one can cope with these difficulties. The majority of this research involved female partners (typically wives) of male Veterans; however, there is much clinical and anecdotal evidence to suggest that these problems also exist for couples where the identified PTSD patient is female.

What are common problems in relationships with PTSD-diagnosed Veterans?

Research that has examined the effect of PTSD on intimate relationships reveals severe and pervasive negative effects on marital adjustment, general family functioning, and the mental health of partners. These negative effects result in such problems as compromised parenting, family violence, divorce, sexual problems, aggression, and caregiver burden. (1,2,3,4,5)

Marital adjustment and divorce rates

Male Veterans with PTSD are more likely to report marital or relationship problems, higher levels of parenting problems, and generally poorer family adjustment than Veterans without PTSD. (2,6,7) Research has shown that Veterans with PTSD are less self-disclosing and expressive with their partners than Veterans without PTSD. (8) PTSD Veterans and their wives have also reported a greater sense of anxiety around intimacy. (7) Sexual dysfunction also tends to be higher in combat Veterans with PTSD than in Veterans without PTSD. (9) It has been posited that diminished sexual interest contributes to decreased couple satisfaction and adjustment. (10)

Related to impaired relationship functioning, a high rate of separation and divorce exists in the veteran population (those with PTSD and those without PTSD). Approximately 38% of Vietnam veteran marriages failed within six months of the veteran's return from Southeast Asia. (11) The overall divorce rate among Vietnam Veterans is significantly higher than for the general population, and rates of divorce are even higher for Veterans with PTSD. The National Vietnam Veterans Readjustment Study (NVVRS) found that both male and female Veterans without PTSD tended to have longer-lasting relationships with their partners than their counterparts with PTSD. (3) Rates of divorce for Veterans with PTSD were two times greater than for Veterans without PTSD. Moreover, Veterans with PTSD were three times more likely than Veterans without PTSD to divorce two or more times.

Interpersonal violence

Studies have found that, in addition to more general relationship problems, families of Veterans with PTSD have more family violence, more physical and verbal aggression, and more instances of violence against a partner. (12,2,3) In these studies, female partners of Veterans with PTSD also self-reported higher rates of perpetrating family violence than did the partners of Veterans without PTSD. In fact, these female partners of Veterans with PTSD reported perpetrating more acts of family violence during the previous year than did their partner veteran with PTSD. (2)

Similarly, Byrne and Riggs (12) found that 42% of the 50 Vietnam Veterans in their study had engaged in at least one act of violence against their partner during the preceding year, and 92% had committed at least one act of verbal aggression in the preceding year. The severity of the veteran's PTSD symptoms was directly related to the severity of relationship problems and physical and verbal aggression against the partner.

Mental health of partners

PTSD can also affect the mental health and life satisfaction of a veteran's partner. Numerous studies have found that partners of Veterans with PTSD or other combat stress reactions have a greater likelihood of developing their own mental health problems compared to partners of Veterans without these stress reactions. (10) For example, wives of Israeli Veterans with PTSD have been found to report more mental health symptoms and more impaired and unsatisfying social relations compared to wives of Veterans without PTSD. (5) In at least two studies, including the NVVRS study noted above, partners of Vietnam Veterans with PTSD reported lower levels of happiness, markedly reduced satisfaction in their lives, and more demoralization compared to partners of Vietnam Veterans not diagnosed with PTSD. (2) About half of the partners of Veterans with PTSD indicated that they had felt "on the verge of a nervous breakdown". In addition, male partners of female Vietnam Veterans with PTSD reported poorer subjective well being and more social isolation than partners of female Veterans without PTSD.

Nelson and Wright (13) indicate that partners of PTSD-diagnosed Veterans often describe difficulty coping with their partner's PTSD symptoms, describe stress because their needs are unmet, and describe experiences of physical and emotional violence. These difficulties may be explained as secondary traumatization, which is the indirect impact of trauma on those in close contact with victims. Alternatively, the partner's mental health symptoms may be a result of his or her own experiences of trauma, related to living with a veteran with PTSD (e.g., increased risk of domestic violence) or related to a prior trauma.

Caregiver burden

Limited empirical research exists that details the specific relationship challenges that couples must face when one of the partners has PTSD. However, clinical reports indicate that significant others are presented with a wide variety of challenges related to their veteran partner's PTSD. Wives of PTSD-diagnosed Veterans tend to assume greater responsibility for household tasks (e.g., finances, time management, house up-keep) and the maintenance of relationships (e.g., children, extended family). (13, 14) Partners feel compelled to care for the veteran and to attend closely to the veteran's problems. Partners are keenly aware of cues that precipitate symptoms of PTSD, and partners take an active role in managing and minimizing the effects of these precipitants. Caregiver burden is one construct used to categorize the types of difficulties associated with caring for someone with a chronic illness, such as PTSD. Caregiver burden includes the objective difficulties of this work (e.g., financial strain) as well as the subjective problems associated with caregiver demands (e.g., emotional strain).

Beckham, Lytle, and Feldman (15) examined the relationship between PTSD severity and the experience of caregiver burden in female partners of Vietnam Veterans with PTSD. As expected, high levels of caregiver burden included psychological distress, dysphoria, and anxiety. More recently, Calhoun, Beckham, and Bosworth (1) expanded this understanding of caregiver burden among partners of Veterans with PTSD by including a comparison group of partners of help-seeking Veterans who do not have PTSD. They reported that partners of Veterans with PTSD experienced greater burden and had poorer psychological adjustment than partners of Veterans without PTSD. Across both studies, caregiver burden increased with PTSD symptom severity. That is, the worse the veteran's PTSD symptoms, the more severe the caregiver burden.

Why are these problems so common?

Because of the dearth of research that examines the connection between PTSD symptoms and intimate-relationship problems, it is difficult to discern the exact correspondence between them. (7,16) Some symptoms, like anger, irritability, and emotional numbing, may be direct pathways to relationship dissatisfaction. For example, a veteran who cannot feel love or happiness (emotional numbing) may have difficulty feeling lovingly toward a spouse. Alternatively, the relationship discord itself may facilitate the development or exacerbate the course of PTSD. Perhaps the lack of communication, or combative communication, in discordant relationships impedes self-disclosure and the emotional processing of traumatic material, which leads to the onset or maintenance of PTSD.

Riggs, Byrne, Weathers, and Litz (7) did examine the connection between PTSD symptom clusters and the relationship condition. The study examined the connection between the cluster of avoidance symptoms and the decreased ability of the person diagnosed with PTSD to express emotion in the relationship. The results of the study suggest that avoidance symptoms, specifically emotional numbing, interfere with intimacy (for which the expression of emotions is required) and contribute to problems in building and maintaining positive intimate relationships.

What are the treatment options for partners of Veterans with PTSD?

The first step for partners of Veterans with PTSD is to gain a better understanding of PTSD and the impact on families by gathering information. Resources on the National Center for PTSD website may be useful.

With regard to specific treatment strategies, Nelson and Wright (13) suggest, "effective treatment should involve family psychoeducation, support groups for both partners and Veterans, concurrent individual treatment, and couple or family therapy" (p. 462). Psychoeducational groups teach coping strategies and educate Veterans and their partners about the effects of trauma on individuals and families. Often these groups function as self-help support groups for partners of Veterans. Preliminary research offers encouragement for the use of group treatment for female partners of Vietnam Veterans. (17, 18) Individual therapy for both the veteran and his or her partner is an important treatment component, especially when PTSD symptoms are prominent in both individuals. Couples or family therapy may also be highly effective treatment for individuals' symptoms and problems within the family system. Several researchers have begun exploring the benefits of family or couples therapy for both the veteran and other family members. (14, 19, 20) In light of the recent research on the negative impact of PTSD on families, Veterans Affairs PTSD programs and Vet Centers across the country are beginning to offer group, couples, and individual programs for families of Veterans.

Overall, it seems that the most important message for partners is that relationship difficulties and social and emotional struggles are common when living with a traumatized veteran. The treatment options listed above are but a few of the available approaches that partners may find useful in their search for improved family relationships and mental health.

Additional resources

VA Caregiver Support: The VA Caregiver Support Line (1-855-260-3274) provides services and support to family members who are taking care of a Veteran.

Coaching Into Care: This VA program works with family members who become aware of their Veteran's post-deployment difficulties--and supports their efforts to find help for the Veteran. Contact them at 1-888-823-7458 This email address is being protected from spambots. You need JavaScript enabled to view it..

Matsakis, A. (2007). (Sidran Press, paperback, ISBN 1886968187). Back from the Front: Combat Trauma, Love, and the Family. Aphrodite Matsakis is a psychotherapist with a special interest in PTSD. Her book aims to help partners and Veterans understand the effects of combat trauma on relationships and family life. It also includes resources to help every member of the family.

Slone, L.B. & Friedman, M.J. (2008) (Da Capo Press, paperback, ISBN 1600940544). After the War Zone: A Practical Guide for Returning Troops and Their Families. Laurie Slone and Matt Friedman are in the leadership of the National Center for PTSD. Their book is a guide to homecoming for returning Veterans and their families. The book suggests ways families can cope with the effects of trauma.

References

1. Calhoun, P. S., Beckham, J. C., & Bosworth, H. B. (2002). Caregiver burden and psychological distress in partners of Veterans with chronic posttraumatic stress disorder. Journal of Traumatic Stress, 15, 205-212.
2. Jordan, B. K., Marmar, C. B., Fairbank, J. A., Schlenger, W. E., Kulka, R. A., Hough, R. L., et al. (1992). Problems in families of male Vietnam Veterans with posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 60, 916-926.
3. Kulka, R. A., Schlenger, W. E., Fairbank, J. A., Hough, R. L., Jordan, B. K., Marmar, C. R., et al. (1990). Trauma and the Vietnam War generation: Report of findings from the National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel.
4. Silverstein, R. F. (1996). Combat-related trauma as measured by ego developmental indices of defenses and identity achievement. Journal of Genetic Psychology, 157, 169-179.
5. Waysman, M., Mikulincer, M., Solomon, Z., & Weisenberg, M. (1993). Secondary traumatization among wives of posttraumatic combat Veterans: A family typology. Journal of Family Psychology, 7, 104-118.
6. Mikulincer, M., Florian, V., & Solomon, Z. (1995). Marital intimacy, family support, and secondary traumatization: A study of wives of Veterans with combat stress reaction. Anxiety, Stress, and Coping, 8, 203-213.
7. Riggs, D. S., Byrne, C. A., Weathers, F. W., & Litz, B. T. (1998). The quality of the intimate relationships of male Vietnam Veterans: Problems associated with posttraumatic stress disorder. Journal of Traumatic Stress, 11, 87-101.
8. Carroll, E. M., Rueger, D. B., Foy, D. W., & Donahoe, C. P. (1985). Vietnam combat Veterans with posttraumatic stress disorder: Analysis of marital and cohabitating adjustment. Journal of Abnormal Psychology, 94, 329-337.
9. Cosgrove, D. J., Gordon, Z., Bernie, J. E., Hami, S., Montoya, D., Stein, M. B., et al. (2002). Sexual dysfunction in combat Veterans with post-traumatic stress disorder. Urology, 60, 881-884.
10. Solomon, Z., Waysman, M., Avitzur, E., & Enoch, D. (1991). Psychiatric symptomatology among wives of soldiers following combat stress reaction: The role of the social network and marital relations. Anxiety Research, 4, 213-223
11. President's Commission on Mental Health. (1978). Mental health problems of Vietnam era Veterans (Vol. 3), pp. 1321-1328. Washington, DC: U.S. Government Printing Office.
12. Byrne, C. A., & Riggs, D. S. (1996). The cycle of trauma: Relationship aggression in male Vietnam Veterans with symptoms of posttraumatic stress disorder. Violence and Victims, 11, 213-225.
13. Nelson, B. S., & Wright, D. W. (1996). Understanding and treating post-traumatic stress disorder symptoms in female partners of Veterans with PTSD. Journal of Marital and Family Therapy, 22, 455-467.
14. Verbosky, S. J., & Ryan, D. A. (1988). Female partners of Vietnam Veterans: Stress by proximity. Issues in Mental Health Nursing, 9, 95-104.
15. Williams, C. M., & Williams, T. (1987). Family therapy and Vietnam Veterans. In T. Williams (Ed.), Post-traumatic stress disorders: A handbook for clinicians (pp. 221-231). Cincinnati, Ohio: Disabled American Veterans.
16. Beckham, J. C., Lytle, B. L., & Feldman, M. E. (1996). Caregiver burden in partners of Vietnam War Veterans with posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 64, 1068-1072.
17. Ruscio, A. M., Weathers, F. W., King, L. A., & King, D. W. (2002). Male war-zone Veterans' perceived relationships with their children: The importance of emotional numbing. Journal of Traumatic Stress, 15, 351-357.
18. Harris, M. J., & Fisher, B. S. (1985). Group therapy in the treatment of female partners of Vietnam Veterans. Journal for Specialists in Group Work, 10, 44-50.
19. Williams, C. (1987). The veteran system with a focus on women partners. In T. Williams (Ed.), Post-traumatic stress disorders: A handbook for clinicians (pp. 169-192). Cincinnati, Ohio: Disabled American Veterans.
20. Johnson, S. M. (2002). Emotionally focused couple therapy with trauma survivors: Strengthening attachment bonds. New York: Guilford.
21. Monson, C.M., Guthrie, K.A., & Stevens, S. (2003) . Cognitive-behavioral couple's treatment for posttraumatic stress disorder. Behavior Therapist, 26, 393-401.

Taken from http://www.ptsd.va.gov/professional/treatment/family/partners_of_vets_research_findings.asp