Partners' motivations for accommodating posttraumatic stress disorder symptoms in service members: The reasons for accommodation of PTSD scale

A Caregiver Perspective for Partners of PTSD Survivors: Understanding the Experiences of Partners

Research affirms that survivors of post-traumatic stress disorder (PTSD) experience psychological distress that affects their romantic partners, and that a bi-directional effect between PTSD symptoms and romantic relationship satisfaction exists, indicating that improvements in the romantic relationship may lead to the improved well-being of the survivor. Indeed, as romantic partners of PTSD survivors are both negatively impacted by the distress of the survivor, and romantic relationship satisfaction can affect the distress of the PTSD survivor, partners are a key stakeholder for mental health. Unfortunately, theoretical models have not adequately captured the experience of this population to properly illuminate their experience and provide appropriate treatment directives. This paper examines the informal caregiving integrative model to determine its applicability to the romantic partners of PTSD survivors with respect to the determinants, mediators, and outcomes. The current literature on romantic partners is used to evaluate the adequacy of fit, as well as to provide the components unique to partners. Future directions, clinical implications, and limitations of current research are explored based on the results of this review.

The significant others' responses to trauma scale (SORTS): applying factor analysis and item response theory to a measure of PTSD symptom accommodation

Background: Symptom accommodation by family members (FMs) of individuals with posttraumatic stress disorder (PTSD) includes FMs' participation in patients' avoidance/safety behaviours and constraining self-expression to minimise conflict, potentially maintaining patients' symptoms. The Significant Others' Responses to Trauma Scale (SORTS) is the only existing measure of accommodation in PTSD but has not been rigorously psychometrically tested.Objective: We aimed to conduct further psychometric analyses to determine the factor structure and overall performance of the SORTS. Method: We conducted exploratory and confirmatory factor analyses using a sample of N = 715 FMs (85.7% female, 62.1% White, 86.7% romantic partners of individuals with elevated PTSD symptoms).Results: After dropping cross-loading items, results indicated good fit for a higher-order model of accommodation with two factors: an anger-related accommodation factor encompassed items related largely to minimising conflict, and an anxiety-related accommodation factor encompassed items related primarily to changes to the FM's activities. Accommodation was positively related to PTSD severity and negatively related to relationship satisfaction, although the factors showed somewhat distinct associations. Item Response Theory analyses indicated that the scale provided good information and robust coverage of different accommodation levels.Conclusions: SORTS data should be analysed as both a single score as well as two factors to explore the factors' potential differential performance across treatment and relationship outcomes.

Stronger together: the longitudinal relations between partner responsiveness, dyadic coping and PTSD recovery

Background: Past research has primarily focused on negative associations between PTSD and relationships. Therefore, this investigation delves into the potential positive role of these relational aspects in aiding PTSD recovery during treatment.Objective: This study aimed to examine the impact of dyadic coping and perceived partner responsiveness on treatment trajectories of PTSD patients.Method: The study included 90 participants, who were requested to complete online questionnaires twice, with a six-month gap between the measures.Results: The results from linear regression analyses indicated that perceived partner responsiveness had a positive effect on PTSD recovery, whereas dyadic coping had the opposite effect: higher levels of dyadic coping were associated with an increase in posttraumatic stress symptoms over time. Additional examination of the subscales indicated that heightened communication between clients and partners regarding stress was related with increased posttraumatic stress symptoms.Conclusions: These findings underscore the importance and complexity of effective and supportive communication between patients with PTSD and their partners. While existing literature supports both perceived partner responsiveness and dyadic coping as beneficial, this study indicates that only perceived partner responsiveness positively impacted PTSD recovery.

Relationship Maintenance among Military Couples

A burgeoning body of research on the relationship maintenance of military couples over the past two decades suggests the time is right to organize, assimilate, and critique the literature. We conducted a systematic review informed by the integrative model of relationship maintenance (Ogolsky et al., 2017) that considered issues of intersectionality (Crenshaw, 1991). Our literature search identified 81 relevant journal articles representing 62 unique samples. With respect to theory, 59.3% of the journal articles employed one or more formal theoretical frameworks. In terms of research design, 88.7% of the studies focused on the U.S. military, 83.9% of the studies recruited convenience samples, 54.8% of the studies utilized quantitative methods, and 30.6% of the studies collected longitudinal data. Among the studies reporting sample demographics, 96.8% of participants were married, 77.2% of participants identified as non-Hispanic White, and only one same-sex relationship was represented. Our narrative synthesis integrated findings about relationship maintenance from studies examining (a) relationship maintenance overtly, (b) communicating to stay connected across the deployment cycle, (c) disclosure and protective buffering, (d) support from a partner, (e) dyadic coping, and (f) caregiving and accommodating a partner's symptoms. We interpret our results with an eye toward advancing theory, research, and practice.

The role of symptom accommodation in trauma-focused treatment engagement and response

Although trauma-focused treatments (TFTs) are generally effective, not all patients improve. Symptom accommodation (i.e., altering one's behavior in response to another's symptoms) by loved ones may be particularly relevant to TFT treatment response and engagement. We examined the role of symptom accommodation by support persons (SPs) in veterans' PTSD treatment response, including the mediating role of treatment engagement and the moderating role of relationship strain. Veterans engaging in prolonged exposure or cognitive processing therapy and a loved one (N = 172 dyads) were sampled at two time points approximately four months apart. Measures of treatment engagement (i.e., highest session completed from the treatment protocol and homework completion) were obtained from hospital records. We found that relationship strain moderated the effect of symptom accommodation on treatment response, ∆R² = .02. Specifically, Time 1 (T1) accommodation predicted poorer treatment response (i.e., Time 2 [T2] PTSD symptom severity, controlling for T1 symptoms) among veterans who reported below-average relationship strain only. Additionally, symptom accommodation was indirectly related to treatment response such that T1 accommodation predicted higher T2 PTSD symptom severity specifically through reduced homework completion, β = .01. The findings suggest that attending to accommodating behaviors of veterans' supportive partners may be an important way to boost both engagement in and response to TFTs for PTSD.

Development of a brief support and education intervention for loved ones of veterans with posttraumatic stress disorder

Clinical practice guidelines for managing posttraumatic stress disorder (PTSD) encourage incorporating loved ones into treatment, and supportive relationships can increase engagement in mental health care for veterans with PTSD. This study describes the iterative refinement, feasibility/acceptability testing, and national dissemination of a brief support and psychoeducation intervention for loved ones of veterans with PTSD. Loved ones (n = 181; range:1-11 per group) attended and qualitatively rated "PTSD 101 for Family and Friends: A Support and Education Workshop." Open-ended questions were used to gather data on suggestions for improvement and descriptions of helpful content, and the workshop was refined following participant and operational partner feedback using a quality improvement framework. Rating quantitative items on a 1-5 scale, participants found the overall quality (M = 4.76) and relevance (M = 4.82) to be excellent, noting they learned substantial new information (M = 4.45). Sense of support (M = 4.95), intentions to use the material (M = 4.87), PTSD self-efficacy (M = 4.41), and understanding of PTSD (M = 4.76) were rated favorably. Common themes among helpful elements were a sense of shared experience and optimism and increased knowledge of treatments/resources. Suggestions for improvement referenced logistics. Following continual stakeholder feedback and refinement, the workshop represents a novel method for providing loved ones with empirically supported psychoeducation, coping skills, and community. It is being disseminated by the Family Services Section of the Veterans Health Administration Office of Mental Health and Suicide Prevention.

Longitudinal Associations Among Service Members' PTSD Symptoms, Partner Accommodation, and Partner Distress

Romantic partners' accommodation of trauma survivors' posttraumatic stress disorder (PTSD) symptoms (e.g., participating in avoidance and safety behaviors, not expressing one's thoughts and feelings) is a putative mechanism linking PTSD symptoms and partner distress, but this hypothesis has never been empirically tested. The current study investigated this proposed within-couple mediation process from service members' PTSD symptoms to partners' depressive symptoms and relationship satisfaction through partner accommodation, as well as between-couple associations among these constructs and the possible moderating role of partners' conflict avoidance and helplessness (CAH) motivations for accommodating service members' PTSD symptoms. We examined these questions in 272 male service member/female civilian couples assessed four times over an 18-month period using the multiple-group version of the random intercept cross-lagged panel model. Within couples, service members' higher levels of PTSD symptoms at one time point significantly predicted partners being more accommodating at the next time point (βs = .14-.19), which, in turn, significantly predicted higher levels of partner depressive symptoms at the subsequent time point (βs = .09-.19) but did not predict partners' subsequent relationship satisfaction. At the between-couple level, partner accommodation was significantly positively associated with partners' depressive symptoms only among those endorsing high CAH motivations for accommodation (r = .50). In addition, accommodation was significantly negatively associated with partners' relationship satisfaction regardless of CAH motivation level (rs = -.43 to -.49). These findings are discussed in light of the potential for couple-based treatments for PTSD to enhance partner individual and relational well-being.

Effectiveness of cognitive behavioral conjoint therapy for posttraumatic stress disorder (PTSD) in a U.S. Veterans Affairs PTSD clinic

Cognitive behavioral conjoint therapy (CBCT) for posttraumatic stress disorder (PTSD) is a 15-session conjoint treatment for PTSD designed to improve PTSD symptoms and enhance intimate relationship functioning. Numerous studies of CBCT for PTSD document improvements in patient PTSD and comorbid symptoms, partner mental health, and relationship adjustment. However, little is known about its effectiveness in real-world clinical settings. Using an intention-to-treat sample of couples who participated in CBCT for PTSD in an outpatient U.S. Veterans Affairs (VA) PTSD clinic (N = 113), trajectories of session-by-session reports of veterans' PTSD symptoms and both partners' relationship happiness were examined. Across sessions, there were significant reductions in veteran-rated PTSD symptoms, d = -0.69, and significant increases in veteran- and partner-rated relationship happiness, ds = 0.36 and 0.35, respectively. Partner ratings of veterans' PTSD symptoms increased before significantly decreasing, d = -0.24. Secondary outcomes of veteran and partner relationship satisfaction, ds = 0.30 and 0.42, respectively; veteran and partner depressive symptoms, ds = -0.75 and -0.29, respectively; and partner accommodation of PTSD symptoms, d = -0.44, also significantly improved from pre- to posttreatment. The findings suggest that CBCT for PTSD was effective for decreasing PTSD and comorbid symptoms in veterans, as well as for improving relationship functioning and partners' mental health, among a sample of real-world couples seeking treatment in a VA PTSD specialty clinic.

A Closer Examination of Relational Outcomes from a Pilot Study of Abbreviated, Intensive, Multi-Couple Group Cognitive-Behavioral Conjoint Therapy for PTSD with Military Dyads

Cognitive-behavioral conjoint therapy for posttraumatic stress disorder (CBCT for PTSD) is associated with improvements in patients' PTSD symptoms, partners' psychological distress, and relationship satisfaction. However, little is known about whether CBCT for PTSD is associated with changes in other relationship domains that have theoretical and clinical relevance to the relational context of PTSD. The current study is a secondary analysis of relational outcomes from an uncontrolled, within-group trial designed to examine whether an abbreviated, intensive, multi-couple group version of CBCT for PTSD (AIM-CBCT for PTSD) delivered in a retreat during a single weekend was associated with improvements in PTSD symptoms and relationship satisfaction. In this investigation, we examined whether AIM-CBCT for PTSD is also associated with improvements in ineffective arguing, supportive dyadic coping by partner, joint dyadic coping, and partners' accommodation of patients' PTSD symptoms. Participants were 24 couples who included a post-9/11 U.S. service member or veteran with PTSD. At 1- and 3-month follow-up, patients reported significant reductions in couples' ineffective arguing (ds = -.71 and -.78, respectively) and increases in supportive dyadic coping by partners relative to baseline (ds = .50 and .44, respectively). By 3-month follow-up, patients also reported significant increases in couples' joint dyadic coping (d = .57), and partners reported significant reductions in their accommodation of patients' PTSD symptoms (d = -.44). Findings suggest that AIM-CBCT for PTSD is associated with improvements in multiple relationship domains beyond relationship satisfaction but that these may be differentially salient for patients and partners.

Associations Between Service Members' Posttraumatic Stress Disorder Symptoms and Partner Accommodation Over Time

When service members manifest symptoms of posttraumatic stress disorder (PTSD), intimate partners may engage in behaviors to accommodate their partners' experiences (e.g., helping service members avoid situations that could make them uncomfortable, not expressing own thoughts and feelings to minimize PTSD-related conflict), which may inadvertently serve to maintain or increase PTSD symptoms over time. In a sample of 274 male service member/female civilian couples, we evaluated hypothesized bidirectional pathways between self-reported service member PTSD symptoms and partner accommodation, assessed four times over an approximately 18-month period. A random-intercept cross-lagged panel model disaggregating between and within effects revealed that, on average, couples in which the service member had higher levels of total PTSD symptoms also scored higher in partner accommodation, between-couple correlation, r = .40. In addition, at time points when service members' PTSD symptoms were higher relative to their own average symptom level, their partners' level of accommodation was also higher than their personal average, within-couple correlation r = .22. Longitudinally, service member PTSD symptom scores higher than their personal average predicted subsequent increases in partner accommodation, β = .19, but not vice versa, β = .03. Overall, the findings indicate both stable and time-specific significant associations between service member PTSD symptoms and partner accommodation and suggest that higher levels of PTSD symptoms are a significant driver of later increases in partner accommodation. These findings add further support for treating PTSD in an interpersonal context to address the disorder and concomitant relational processes that can adversely impact individual and relational well-being.