From front line to home front: a study of secondary traumatization

The adaptation of soldiers to post-service life - the mediating impact of political views on the relationship between violence and adaptation

Introduction

The current research explores the association between political views, combat experiences, and the adaptation of soldiers to post-service life. Violent experiences in military service were explored as contributors to both positive and negative dimensions of adaptation, while political views served as possible mediators.

Methods

Three hundred and twenty Israeli veterans participated in the study.

Results

Political views were correlated with adaptation, especially left-to-right voting and anti-militarism. The results support the mediating role of political beliefs (left-right voting and militarism) in the relationship between combat experience and adaptation to post-service life.

Discussion

We contend that political perceptions affect adaptation through sense-making of the combat experiences and the individual processing of these experiences, and the willingness to continue in reserve service, which allows social support and recognition. In addition, they are linked to a sense of bitterness following the reduction of public participation in military and reserve service.

Post-traumatic stress in war veterans and secondary traumatic stress among parents of war veterans five years after the 2014 Israel-Gaza military conflict

Secondary traumatic stress (STS) has been studied in therapists, spouses, and mainly in children of traumatised individuals. To date, the relationship between children's posttraumatic stress disorder (PTSD) symptoms and their parents' mental health outcomes have been understudied, and specifically, long term STS symptoms of parents of war veterans were not investigated. The current study examined PTSD symptoms among veterans of the 2014 Israel-Gaza war and STS among their parents, five years after the war. The control group consisted of veterans from combat military units who were on active duty at the time of the war but did not actively participate in the war (stand-by units) - providing a natural experiment condition. We found that PTSD symptoms were almost twice as high in the directly active war veterans (DAV, N = 32) group compared to the indirectly active war veterans (IAV, N = 26) group. Results showed that mothers had higher STS symptoms in general, and DAV PTSD symptoms correlated with their fathers STS symptoms. The current study provides novel evidence for: (a) subclinical PTSD symptoms in war veterans 5 years after the war, and (b) transmission of trauma from war veterans to their parents. The overall negative effect of sending a child to war on the parents are also discussed.

Loneliness in Posttraumatic Stress Disorder: A Neglected Factor in Accelerated Aging?

Prior research suggests that people with Posttraumatic Stress Disorder (PTSD) may experience a form of accelerated biological aging. In other populations, loneliness has been shown to elevate risk for many of the same components of accelerated biological aging, and other deleterious outcomes, as seen in people with PTSD. Although standard diagnostic criteria for PTSD include "feelings of detachment or estrangement from others", the relationship of such feelings to the concept of loneliness remains uncertain, in par potentially due to a failure to distinguish between loneliness versus objective social isolation. In order to catalyze wider research attention to loneliness in PTSD, and the potential contribution to accelerated biological aging, the present paper provides three components: (1) a conceptual overview of the relevant constructs and potential interrelationships, (2) a review of the limited extant empirical literature, and (3) suggested directions for future research. The existing empirical literature is too small to support many definitive conclusions, but there is evidence of an association between loneliness and symptoms of PTSD. The nature of this association may be complex, and the causal direction(s) uncertain. Guided by the conceptual overview and review of existing literature, we also highlight key areas for further research. The ultimate goal of this line of work is to elucidate mechanisms underlying any link between loneliness and accelerated aging in PTSD, and to develop, validate, and refine prevention and treatment efforts.

The Aftermath of Trauma and Abuse and the Impact on Family: A Narrative Literature Review

The present narrative review examined quantitative and qualitative research on family members who support survivors of trauma or abuse. Studies included in the present review were found in peer-reviewed journal articles, available in English, published between 1980 and 2019, and focused specifically on the experiences of adult familial supporters of adult trauma and abuse survivors. A search of PsychInfo and Google Scholar identified 136 relevant articles, and analysis of their content generated the following categories: individual-level impacts (i.e., quality of psychological health, burden, secondary traumatic stress, quality of physical health, and positive impacts), interpersonal and environmental level impacts (i.e., quality of relationships with survivors, navigating environment, maltreatment and safety, and social impacts), and other experiences (i.e., social roles, needs, coping strategies, and sociocultural context). Findings indicate that the majority of existing studies examined the experiences of family members of adult survivors of military trauma. Results of the review suggest that family supporters of adult trauma and abuse survivors generally experience physical, emotional, cognitive, behavioral, social, safety, and relational impacts. Implications of review findings and directions for future research are discussed.

Secondary posttraumatic stress symptom trajectories and perceived health among spouses of war veterans: a 12-year longitudinal study

OBJECTIVE

War-related trauma may indirectly affect veterans' spouses both in terms of secondary posttraumatic stress symptoms (PTSS) and negative perceived health. The present study aimed to examine trajectories of secondary PTSS over a twelve-year period and its association with various measures of subjectively perceived health, among spouses of war veterans.

METHODS

Spouses of war veterans (n = 155) were assessed prospectively 30 (T1, 2003), 37 (T2, 2010), and 42 (T3, 2015) years after the 1973 Yom Kippur War. Participants completed self-report questionnaires of PTSS (PTSD inventory) in all three measurement waves, while perceived health measures (Short-Form Health Survey-SF-36) were assessed only at T3.

RESULTS

Most spouses were classified to the 'resilient' trajectory with low and stable secondary PTSS over time, followed by recovered, chronic, and delayed onset PTSS trajectories. Importantly, spouses in the 'chronic' and 'delayed' secondary PTSS trajectories reported a higher severity of general negative subjective health perceptions and health-related social malfunctioning.

CONCLUSION

Veterans' spouses who were grouped in the 'chronic' and 'delayed' PTSS trajectories are to be considered as at-risk populations for both PTSS and negative perceived health perceptions. Mental health professionals as well as family physicians should be aware of the ongoing nature of secondary PTSS which might negatively affect veterans' spouses medical conditions and ability to cope with the aging process.

The Contagion of Psychopathology across Different Psychiatric Disorders: A Comparative Theoretical Analysis

Psychopathology is often studied and treated from an individual-centered approach. However, studies have shown that psychological distress is often best understood from a contextual, environmental perspective. This paper explores the literature on emotional contagion and symptom transmission in psychopathology, i.e., the complex ways in which one person's psychological distress may yield symptoms among others in his/her close environment. We argue that emotions, cognitions, and behaviors often do not stay within the borders of the individual, but rather represent intricate dynamic experiences that are shared by individuals, as well as transmitted between them. While this claim was comprehensively studied in the context of some disorders (e.g., secondary traumatization and the "mimicking" of symptoms among those close to a trauma survivor), it was very scarcely examined in the context of others. We aim to bridge this gap in knowledge by examining the literature on symptom transmission across four distinct psychiatric disorders: PTSD, major depression, OCD, and psychosis. We first review the literature on emotional contagion in each disorder separately, and then we subsequently conduct a comparative analysis highlighting the shared and differential mechanisms underlying these processes in all four disorders. In this era of transdiagnostic conceptualizations of psychopathology, such an examination is timely, and it may carry important clinical implications.

Trajectories of PTSD and secondary traumatization: A longitudinal study

Ever since the publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), there has been a controversy around whether the inclusion of indirect exposure as a potential traumatic event for the diagnosis of posttraumatic stress disorder (PTSD) is justified. The aim of the current study was to examine the validity of PTSD resulting from secondary traumatization by evaluating the longitudinal trajectories and clinical picture of PTSD following both direct exposure and indirect exposure to war trauma. One-hundred-and-fifty-five war veterans of the 1973 Yom Kippur War and their spouses filled out self-report questionnaires assessing PTSD, 30 (T1), 38 (T2), and 42 years (T3) after the war. Findings revealed that although PTSD was more prevalent and intense among veterans, the relative distribution of PTSD trajectories was similar among veterans and spouses. In both groups, the most prevalent was the resilient trajectory (43% and 73%, respectively), followed by the recovered trajectory (28% and 15%, respectively), the chronic trajectory (21% and 7%, respectively), and the delayed trajectory (8% and 6%, respectively). In addition, the composition of PTSD symptoms was similar among veterans and spouses at T1 and T2, but not at T3. These findings demonstrate that although PTSD is more prevalent and intense among individuals who were exposed to traumatic events directly as compared to those who were traumatized secondarily, the similarities in the clinical picture support the inclusion of secondary traumatization in PTSD Criterion A.

What Happens at Work Comes Home

Emergency responders (police, fire, ambulance and defence force personnel) risk exposure to dangerous and traumatic events, and the possible subsequent development of post-traumatic stress disorder. Consequently, partners of these emergency responders risk developing secondary traumatic stress (STS) from vicarious exposure to the trauma through communication and engagement with their responders. A mixed-methods study of the partners of emergency responders in New Zealand examined the extent of such partner-associated STS. This article focuses on two research questions: to what extent were risk factors for STS identified within that population, and what did the participants believe may help them to mitigate the impact of STS. An online anonymous survey was developed and eligible participants completed a 17-item STS scale, a social support measure, and answered several open-ended questions. Of the 646 participants, twenty percent appear to be experiencing intrusion, arousal, and avoidance symptoms related to the trauma experienced by their responder. Almost half stated they have little or no emotional/informational support related to their responder’s work. Thematic analysis of free-text responses identified the need for additional support and more direct communication/engagement from the organisations for partners to navigate their experiences of STS and the level of social support received and required. The authors conclude with recommendations to emergency responder organisations.

Physical and Mental Health and Functioning Among Traumatic Brain Injury Close Relatives: The Role of Posttraumatic Stress Symptoms

Severe Traumatic brain injury (sTBI) often instigates widespread long-lasting disability and is accompanied by extensive rehabilitation. Unsurprisingly, sTBI also holds malignant consequences for patients' close relatives. The burden caused by the injury and its severity explains some of the ramifications for the relatives. Additionally, some findings demonstrate that patients with sTBI and their relatives develop posttraumatic stress (PTS) symptoms. However, although the link between PTS symptoms and physical and mental health is well-documented in literature, the effect of PTS symptoms on relatives of patients with sTBI has barely been examined. This study examines the influence of PTS symptoms of patients with sTBI and their relatives on the physical and mental health and functioning of the relatives. Patients who sustained a severe sTBI (Abbreviated Injury Scale of the head region > 3) and close relatives were included in a multi-center, prospective cohort study (TRAST-MI). One-hundred patients and their relatives were assessed at 2, 6, and 12 months post injury. Outcome variables included health-related quality of life (SF-12) as well as emotional, cognitive, interpersonal, and total functioning (PCRS). Relatives' physical health was predicted by relatives' PTS symptoms (Slope=-1.76; p = .043), and mental health was predicted by both patients' (Slope=-2.77; p = .034) and relatives' (Slope=-6.59; p < .001) PTS symptoms. Functioning level was only predicted by patients' PTS symptoms (Slope=-.25; p_< .001). The findings emphasize that TBI should be considered a comprehensive traumatic experience reaching further than mere physical damage to the brain and its direct consequences, affecting the injured individual and close relatives.

Appreciating the 4 "Ts" of Loneliness When Providing Psychiatric Care for the Lonely Patient

Loneliness can be evaluated from a 4-concept viewpoint of territory, threat, trauma and trust (4 Ts). Territory refers to an area of ownership that is controlled on a daily basis and is fundamental to one's daily life. Lonely individuals often manage boundaries by gaining greater control over their physical environment by territorial behavior. They guard personal territory well as the only area where they can exert dominance and feel safe. Perceptions of social isolation or loneliness increase vigilance for threats, decrease trust, and heighten feelings of vulnerability. Clinical teams caring for the lonely must be especially attentive to a history of prior trauma. Clinicians who ask permission, who pay attention to nonverbal cues, distance, and speed as they enter the lonely person's space, and who respect boundaries may be more successful in gaining trust. Achieving trust diminishes the risk of physical harm, while allowing lonely persons the perceived control they need to permit health care interventions. Veterans are at higher risk for loneliness. Given their military training, they may be particularly attentive to boundaries, protecting the perimeter, watching for threats, and defending their space. In this article, we discuss the successful mental health treatment of a lonely male veteran in a Veterans Affairs Medical Center, by paying attention to the 4 Ts of loneliness. We used a 4-step approach of validation, mentalization, reality testing, and socialization to decrease the sense of threat as we sought acceptance to the patient's territory, followed by building trust and working on past trauma.

Mental health in spouses of U.S. Gulf War veterans

Veterans' spouses are at risk for mental distress and substance use. We examined long term psychological functioning in spouses from a national cohort of 1991 Gulf War era veterans. From clinical interviews, spouses of deployed veterans (n = 488) did not have a greater prevalence of post-war mental disorders compared to spouses of non-deployed veterans (n = 536); however, in couples that were living together since the war, there was an increased risk of anxiety disorders or any one disorder. On questionnaires, the impact varied but was most consistently observed in more severe depression and greater functional impairment in spouses of deployed compared to non-deployed veterans. If a veteran developed post-war anxious/depressive disorders or any one mental disorder, the matched spouse was more likely to develop post-war anxious/depressive disorders or any one mental disorder, respectively. Veteran combat exposure did not similarly increase the risk of spouse post-war mental disorders. Greater spouse self-reported symptomatology was observed in spouses of veterans with anxious/depressive disorders even when controlling for deployment. In summary, the war conferred greater risk for spouse mental disorders and distress for spouses of veterans with mental health disorders, with some increased risk for spouses of deployed veterans, especially in couples together since the war.

Informal caregiving experiences in posttraumatic stress disorder: A content analysis of an online community

This study explored the experiences of individuals who self-identify as providing support to a friend, family member, or significant other with posttraumatic stress disorder (PTSD). We analyzed and coded a total of 345 posts from an online support forum, with reference to 13 categories (finances, life interference, venting/emotional expression, maltreatment, sexual behavior, distress, prevented expression, physical health, communication, no personal space, isolation, and compassion fatigue). Categories for coding were established a priori and based on previous literature about caregiving and supporting. Results suggested that informal PTSD caregivers experience concerns involving interpersonal relations, emotional turmoil, and barriers to care for themselves and the individual they are caring for. This study provides a preliminary examination of the experiences and concerns of PTSD caregivers. Implications and suggestions for future research are discussed.

Is the war really over? A 20-year longitudinal study on trajectories of suicidal ideation and posttraumatic stress symptoms following combat

Combat stress reaction (CSR) has widespread long-term consequences, including profound psychopathology in the form of posttraumatic stress disorder (PTSD). Studies have established the link between combat, PTSD, and suicidality. However, little is known about the temporal course of suicidal ideation (SI) in general, specifically among war veterans. We aimed to trace the trajectories of SI in the aftermath of war and to explore the role of CSR and PTSD in SI trajectories. Israeli veterans with CSR (n=164) and a matched control group (NCSR, n=111) were assessed, using self-report measures at three points over the course of 20 years. Veterans with CSR reported significantly higher levels of SI, compared to the NCSR group at all measurement points. Among veterans with CSR, SI increased 2 years after the war and then decreased 20 years following the war. This pattern was particularly characteristic of veterans with chronic PTSD. The results indicate that CSR is a strong predictor of subsequent PTSD and suicidality. These findings highlight the importance of prevention and treatment efforts for these traumatized veterans, who are at risk for suicide even 20 years after the end of the war.

Symptoms of post-traumatic stress disorder, severe psychological distress, explosive anger and grief amongst partners of survivors of high levels of trauma in post-conflict Timor-Leste

BACKGROUND

Little is known about the mental health of partners of survivors of high levels of trauma in post-conflict countries.

METHOD

We studied 677 spouse dyads (n = 1354) drawn from a community survey (response 82.4%) in post-conflict Timor-Leste. We used culturally adapted measures of post-traumatic stress disorder (PTSD), psychological distress, explosive anger and grief.

RESULTS

Latent class analysis identified three classes of couples: class 1, comprising women with higher trauma events (TEs), men with intermediate TEs (19%); class 2, including men with higher TEs, women with lower TEs (23%); and class 3, comprising couples in which men and women had lower TE exposure (58%) (the reference group). Men and women partners of survivors of higher TE exposure (classes 1 and 2) had increased symptoms of explosive anger and grief compared with the reference class (class 3). Women partners of survivors of higher TE exposure (class 2) had a 20-fold increased rate of PTSD symptoms compared with the reference class, a pattern that was not evident for men living with women exposed to higher levels of trauma (class 1).

CONCLUSIONS

Men and women living with survivors of higher levels of trauma showed an increase in symptoms of grief and explosive anger. The manifold higher rate of PTSD symptoms amongst women living with men exposed to high levels of trauma requires replication. It is important to assess the mental health of partners when treating survivors of high levels of trauma in post-conflict settings.

Keeping a healthy distance: Self-differentiation and perceived health among ex-prisoners-of-war's wives

OBJECTIVE

War captivity may affect spouses of former-prisoners-of-war (ex-POWs) in many ways, including posttraumatic stress symptoms (PTSS) and somatic difficulties manifested in negative perceived health. This is generally known as secondary traumatization. Theory suggests that development of secondary traumatization occurs through the relationship with the primary trauma survivor Figley (1986) , thus implying that the ability to keep balanced emotional distance in the relationship may play a pivotal role. Notwithstanding, the contribution of self-differentiation to secondary somatic disturbances remains largely uninvestigated. The current study fills this gap.

METHODS

Ex-POWs' wives (n=143) and control former-combatants' wives (n=102), were assessed prospectively 30 (T1) and 38 (T2) years after the 1973 Yom Kippur War. Self-differentiation and PTSS were assessed at both time-points, while perceived health measures were assessed at T2.

RESULTS

Wives of ex-POWs endorsed higher PTSS, lower self-differentiation and negative perceived health, compared to control wives. Indirect exposure to war captivity was related to low self-differentiation and elevated PTSS, which predicted negative perceived health. Furthermore, self-differentiation characterized by fusion-with-others fully mediated the relation between indirect exposure to war captivity and perceived health, beyond the effects of PTSS as a mechanism.

CONCLUSION

Results suggest that tendencies towards fusion-with-others within the marital relationship, act as a risk factor not only for psychological distress but also for somatic distress among secondary trauma survivors. Hence, clinical interventions may seek to improve indirect trauma survivor's self-differentiation capacities, thus potentially facilitating the prevention of secondary somatic distress.

Posttraumatic growth among spouses of combat veterans: Adaptive or maladaptive for adjustment?

We examined the relationship between posttraumatic growth (PTG) and distress in spouses of trauma survivors. A sample of spouses of combat veterans of the 1973 Yom Kippur War were assessed using questionnaires pertaining to PTG, depression, anxiety, and posttraumatic stress, in 2004 and 2011. Applying cross-lagged modeling strategy, higher PTG levels predicted higher depression and anxiety levels above and beyond initial distress. Thus, psychological growth in spouses of survivors appears to signify subsequent distress.

Cultural Perspectives on the Aftereffects of Combat Trauma: Review of a Community Study of Bedouin IDF Servicemen and Their Families

Combat trauma may affect servicemen from indigenous, traditional communities in ways that warrant special attention. The Bedouins, who enlist in the Israel Defense Forces (IDF) voluntarily, represent a unique, closed, collectivist cultural minority, potentially in a predicament in light of ongoing sociopolitical events. This paper summarizes findings and lessons learned from a community study of Bedouin IDF servicemen and their families residing in Israel's Western Galilee. This is the only research endeavor to have addressed trauma exposure and posttraumatic reactions in this community. The sampling strategies and interview schedule were designed in consideration of participation barriers typical of hard-to-reach populations. Data collection followed an extended phase of liaising with key informants and building trust. Study limitations are discussed in terms of the challenges presented by this type of research. Interviews conducted with 317 men, 129 wives, and 67 mothers revealed high levels of trauma exposure and posttraumatic stress disorder (PTSD) in the men, and related distress in wives and mothers, but not in the children. The role of aggression in mediating the impact of PTSD and concepts such as shame, the loss of personal resources, and beliefs about retribution are highlighted as key issues for a culturally relevant understanding of traumatized indigenous communities.

Measuring secondary traumatic stress symptoms in military spouses with the posttraumatic stress disorder checklist military version

Little research to date has examined secondary traumatic stress symptoms in spouses of military veterans. This study investigated the presence and severity of posttraumatic stress symptoms in a sample of 227 Army National Guard veterans and secondary traumatic stress symptoms among their spouses. The veterans completed the posttraumatic stress disorder (PTSD) Checklist Military Version (PCL-M) (Weathers et al., 1993) to determine the probable prevalence rate of posttraumatic stress symptoms. A modified version of the PCL-M was used to assess secondary traumatic stress symptoms in the spouses. A confirmatory factor analysis showed that the modified version of the PCL-M used to assess secondary traumatic stress symptoms in spouses fits using the same four-factor PTSD structure as the PCL-M for veterans. This study provides initial evidence on the underlying symptom structure of secondary traumatic stress symptoms among spouses of traumatic event victims.

Long-term trajectories and service needs for military families

The deployment of US military personnel to recent conflicts has been a significant stressor for their families; yet, we know relatively little about the long-term family effects of these deployments. Using data from prior military service eras, we review our current understanding of the long-term functioning and needs of military families. These data suggest that overseas deployment, exposure to combat, experiencing or participating in violence during war deployment, service member injury or disability, and combat-related post-traumatic stress disorder (PTSD) all have profound impacts on the functioning of military families. We offer several recommendations to address these impacts such as the provision of family-centered, trauma-informed resources to families of veterans with PTSD and veterans who experienced high levels of combat and war violence. Recent efforts to address the needs of caregivers of veterans should be evaluated and expanded, as necessary. We should also help military families plan for predictable life events likely to challenge their resilience and coping capacities. Future research should focus on the following: factors that mediate the relationship between PTSD, war atrocities, caregiver burden, and family dysfunction; effective family-centered interventions that can be scaled-up to meet the needs of a dispersed population; and system-level innovations necessary to ensure adequate access to these interventions.

Self-reported emotional and behavioral symptoms, parent-adolescent bonding and family functioning in clinically referred adolescent offspring of Croatian PTSD war veterans

The presence of posttraumatic stress disorder (PTSD) in male war veterans has been linked with family dysfunction and psychopathology in their children [1, 2]. This study aimed to evaluate self-reported emotional and behavioral symptoms, parent-adolescent bonding and family functioning in clinically referred adolescent offspring of Croatian PTSD war veterans and determine the degree that parent-child bonding and family functioning contributed to adolescent behavior problems. Internalizing and externalizing behavior problems, parent-child bonding and family functioning were assessed in a sample of clinically referred Croatian PTSD veterans adolescent offspring (N = 122) and non-PTSD veteran adolescent offspring (N = 122) matched for age, sex, educational level, family income, parental employment status, ethnicity, and residential area. Youth Self-Report, Parental Bonding Instrument, Family Assessment Device were used. Adolescent offspring of PTSD veterans reported having significantly more internalizing and externalizing problems than non-PTSD veteran offspring, and also more difficulties in their family functioning, lower levels of maternal and paternal care, and more impaired mother-child and father-child bonding than control subjects. Internalizing symptoms were associated with family dysfunction, while externalizing symptoms were associated with paternal overcontrol/overprotection, and low maternal and paternal care. In conclusion, the increase in internalizing and externalizing symptoms as well as family and parental dysfunction among clinically referred adolescent offspring of PTSD veterans compared to their non-PTSD veteran counterparts indicates a need for early detection and interventions targeting both adolescent psychopathology and family relationships.

Secondary traumatization and self-rated health among wives of former prisoners of war: The moderating role of marital adjustment

We investigated the relationships between secondary traumatization, marital adjustment, and self-rated health among wives of former prisoners of war. Participants were Israeli wives of former prisoners of war ( N = 116) and a matched control group of wives of combat veterans ( N = 56). Wives of former prisoners of war reported worse self-rated health compared to the control group of wives of combat veterans. Wives of former prisoners of war also reported higher levels of secondary traumatization, and marital adjustment moderated the relationship between wives’ secondary traumatization and their general health. The experience of living with former prisoners of war who might also suffer from posttraumatic stress disorder is associated with wives’ own psychological and self-rated health outcomes.

Using multidimensional grief theory to explore the effects of deployment, reintegration, and death on military youth and families

To date, the US military has made major strides in acknowledging and therapeutically addressing trauma and post-traumatic stress disorder (PTSD) in service members and their families. However, given the nature of warfare and high rates of losses sustained by both military members (e.g., deaths of fellow unit members) and military families (e.g., loss of a young parent who served in the military), as well as the ongoing threat of loss that military families face during deployment, we propose that a similar focus on grief is also needed to properly understand and address many of the challenges encountered by bereaved service members, spouses, and children. In this article, we describe a newly developed theory of grief (multidimensional grief theory) and apply it to the task of exploring major features of military-related experiences during the phases of deployment, reintegration, and the aftermath of combat death--especially as they impact children. We also describe implications for designing preventive interventions during each phase and conclude with recommended avenues for future research. Primary aims are to illustrate: (1) the indispensable role of theory in guiding efforts to describe, explain, predict, prevent, and treat maladaptive grief in military service members, children, and families; (2) the relevance of multidimensional grief theory for addressing both losses due to physical death as well as losses brought about by extended physical separations to which military children and families are exposed during and after deployment; and (3) a focus on military-related grief as a much-needed complement to an already-established focus on military-related PTSD.

Couple and Family Therapy with Five Physical Rehabilitation Populations: A Scoping Review

This article provides a scoping review with a focus on the substantive and methodological issues of the research pertaining to couple and family therapy (CFT) with five physical medical rehabilitation populations. We searched for literature concerned with five populations: spinal cord injury, stroke, multiple sclerosis, traumatic brain injury and amputations. A detailed review of CINAHL, PubMed, and PsycINFO databases identified 14 publications that researched couple/family therapy interventions with these populations. We synthesised the data by outlining and charting the substantive and methodological issues with this research. Findings suggest that individuals who have sustained an injury or are diagnosed with an illness requiring extensive rehabilitation experience increased relationship distress and decreased family functioning. While the literature clearly points to the impact on spouses and families, CFT was primarily used to engage families in efforts to assist health care workers improve physical functioning.

Mechanisms of risk and resilience in military families: theoretical and empirical basis of a family-focused resilience enhancement program

Recent studies have confirmed that repeated wartime deployment of a parent exacts a toll on military children and families and that the quality and functionality of familial relations is linked to force preservation and readiness. As a result, family-centered care has increasingly become a priority across the military health system. FOCUS (Families OverComing Under Stress), a family-centered, resilience-enhancing program developed by a team at UCLA and Harvard Schools of Medicine, is a primary initiative in this movement. In a large-scale implementation project initiated by the Bureau of Navy Medicine, FOCUS has been delivered to thousands of Navy, Marine, Navy Special Warfare, Army, and Air Force families since 2008. This article describes the theoretical and empirical foundation and rationale for FOCUS, which is rooted in a broad conception of family resilience. We review the literature on family resilience, noting that an important next step in building a clinically useful theory of family resilience is to move beyond developing broad "shopping lists" of risk indicators by proposing specific mechanisms of risk and resilience. Based on the literature, we propose five primary risk mechanisms for military families and common negative "chain reaction" pathways through which they undermine the resilience of families contending with wartime deployments and parental injury. In addition, we propose specific mechanisms that mobilize and enhance resilience in military families and that comprise central features of the FOCUS Program. We describe these resilience-enhancing mechanisms in detail, followed by a discussion of the ways in which evaluation data from the program's first 2 years of operation supports the proposed model and the specified mechanisms of action.

Disorganizing experiences in second- and third-generation holocaust survivors

Second-generation Holocaust survivors might not show direct symptoms of posttraumatic stress disorder or attachment disorganization, but are at risk for developing high levels of psychological distress. We present themes of difficult experiences of second-generation Holocaust survivors, arguing that some of these aversive experiences might have disorganizing qualities even though they do not qualify as traumatic. Based on in-depth interviews with 196 second-generation parents and their adolescent children, three themes of disorganizing experiences carried across generations were identified: focus on survival issues, lack of emotional resources, and coercion to please the parents and satisfy their needs. These themes reflect the frustration of three basic needs: competence, relatedness, and autonomy, and this frustration becomes disorganizing when it involves stability, potency, incomprehensibility, and helplessness. The findings shed light on the effect of trauma over the generations and, as such, equip therapists with a greater understanding of the mechanisms involved.

Distress in spouses of service members with symptoms of combat-related PTSD: secondary traumatic stress or general psychological distress?

Combat-related posttraumatic stress disorder (PTSD) is linked with elevated psychological distress in service members'/veterans' spouses. Researchers use a variety of terms to describe this distress, and recently, secondary traumatic stress and secondary traumatic stress disorder (STS/STSD) have become increasingly commonly used. Although STS/STSD connotes a specific set of symptoms that are linked to service members'/veterans' symptoms, researchers often use general measures of distress or generically worded measures of PTSD symptoms to assess STS/STSD. To determine how often scores on such measures appear to be an accurate reflection of STS/STSD, we examined responses to a measure of PTSD symptoms in 190 wives of male service members with elevated levels of PTSD symptoms. Wives rated their own PTSD symptoms, and then answered questions about their attributions for the symptoms they endorsed. Fewer than 20% of wives who endorsed symptoms on the PTSD measure attributed these symptoms completely to their husbands' military experiences. Moreover, compared with wives who attributed symptoms only to events in their own lives, wives who attributed symptoms completely or partially to their husbands' military experiences had a greater overlap between some of their responses on the PTSD measure and their responses to a measure of general psychological distress. These results suggest that most wives of service members/veterans with PTSD experience generic psychological distress that is not conceptually consistent with STS/STSD, although a subset does appear to endorse a reaction consistent with this construct. Implications of these findings for intervention and research with this vulnerable population are discussed.

Trauma and couples: mechanisms in dyadic functioning

Research traditionally has focused on the development of symptoms in those who experienced trauma directly but overlooked the impact of trauma on the families of victims. In recent years, researchers and clinicians have begun to examine how individual exposure to traumatic events affects the spouses/partners, children, and professional helpers of trauma survivors. The current study reports data from a larger mixed-methodology study that includes qualitative interview data from 17 individuals, coded to identify the mechanisms that may affect the couple's interpersonal functioning when there is a history of trauma exposure in one or both partners. The following primary themes were identified: role in the relationship, boundary issues, intimacy problems, triggers, and coping mechanisms. Areas for future research and clinical implications also are identified.

Effect of relocation and parental psychopathology on earthquake survivor-children's mental health

Earthquakes may increase the risk for psychopathology in children because the disaster may disrupt family functioning through causing psychopathology in the parents or disrupting social network through migration, school changes, or socioeconomic status changes caused by the job losses of the parents. This study aimed to investigate the effects of parental psychopathology on the traumatic stress and depression of earthquake survivor-children 4 years after the earthquake. A convenience sample of 104 earthquake survivor-children (43 boys, 61 girls) and their parents were assessed at their homes for earthquake experience and traumatic stress symptoms. The outcome variables were the factor scores of a child/adolescent traumatic stress questionnaire (Traumatic Stress Symptom Checklist for Children and Adolescents). The predictors of child's factor scores were examined using linear regression analyses. The traumatic stress factor score of the children was predicted two variables: the child's reported fear during the earthquake and the father's traumatic stress factor score. The depression factor score, on the other hand, was predicted using the depression factor score of the mother only. Demographic variables or relocation status were not predictive for either of children's factor scores. The results of the present study show that maternal and paternal psychopathologies have differential effects on the psychological status of earthquake survivor-children. Traumatic stress in the child is predicted using the traumatic stress of father, whereas depression in the child is predicted by mother's depression levels. Social network disruption does not seem to have a negative effect on children once parental psychopathology is taken into account.

Posttraumatic stress symptoms among National Guard soldiers deployed to Iraq: associations with parenting behaviors and couple adjustment

OBJECTIVE

In this article, we report findings from a 1-year longitudinal study examining the impact of change in posttraumatic stress disorder (PTSD) symptoms following combat deployment on National Guard soldiers' perceived parenting and couple adjustment 1 year following return from Iraq.

METHOD

Participants were 468 Army National Guard fathers from a brigade combat team (mean age = 36 years; median deployment length = 16 months; 89% European American, 5% African American, 6% Hispanic American). Participants completed an in-theater survey 1 month before returning home from Operation Iraqi Freedom deployment (Time 1) and again 1 year postdeployment (Time 2). The PTSD Checklist-Military Version (PCL-M; Weathers, Litz, Herman, Huska, & Keane, 1993) was gathered at both times, and 2 items assessing social support were gathered at baseline only. At Time 2, participants also completed self-report measures of parenting (Alabama Parenting Questionnaire-Short Form; Elgar, Waschbusch, Dadds, & Sigvaldason, 2007), couple adjustment (Dyadic Adjustment Scale-7; Sharpley & Rogers, 1984; Spanier, 1976), parent-child relationship quality (4 items from the Social Adjustment Scale-Self-Report; Weissman & Bothwell, 1976), alcohol use (Alcohol Use Disorders Identification Test; Babor, Higgins-Biddle, Saunders, & Monteiro, 2001), and items assessing injuries sustained while deployed.

RESULTS

Structural equation modeling analyses showed that increases in PTSD symptoms were associated with poorer couple adjustment and greater perceived parenting challenges at Time 2 (both at p < .001). Furthermore, PTSD symptoms predicted parenting challenges independent of their impact on couple adjustment.

CONCLUSIONS

Findings highlight the importance of investigating and intervening to support parenting and couple adjustment among combat-affected National Guard families.

The Woes of Waiting Wives: Psychosocial Battle at Homefront

Few studies on stress have been carried out in soldiers and other paramilitary forces deployed in operational situations because of the security concerns, practical difficulties of conducting combat psychiatric studies and various other reasons. Studies on their families, who safeguard the family interests, during the period of absence of soldiers, have been even fewer. Significant contributions of researchers in this field were reviewed and suitably interpreted. Analysis revealed various types of stress and the multiple coping methods being practiced. It also highlighted various preventive and remedial measures being undertaken by waiting wives and their children. There is a need to understand and address the psychosocial issues of these families.

Bedouin wives on the home front: living with men serving in the Israel Defense Forces

This community-based study examined emotional and somatic symptoms of 129 Bedouin women whose husbands serve in the Israel Defense Forces. Wives of men diagnosed with posttraumatic stress disorder (PTSD) reported more symptoms than wives of men diagnosed with other disorders and wives of men with no diagnosis. Findings indicate that not only was PTSD in Bedouin servicemen positively associated with their wives' symptoms of posttraumatic stress and depression and somatic complaints, but that this relationship was fully mediated by husbands' aggression. Unraveling the special circumstances of women from traditional backgrounds faced with the devastating effects of husbands' combat-related posttraumatic pathology may inform an approach to the concept of vicarious trauma that is more specific to non-Western societies.

The mental health of partners of Australian Vietnam veterans three decades after the war and its relation to veteran military service, combat, and PTSD

This study assessed psychiatric diagnoses in female partners of Australian Vietnam veterans, compared these with national Australian population statistics, and assessed their relationship with veterans' military service and mental health. Independent assessments of 240 veteran-partner couples used standardized physical and psychiatric diagnostic interviews that permitted comparison with Australian population data. Multivariate regression modeling examined associations of veterans' war service, combat, and psychiatric status with women's mental health. Anxiety disorders and severe recurrent depression were among 11 of 17 psychiatric diagnoses that were significantly in excess of population expectations. Veterans' combat and post-traumatic stress disorder were significant predictors of women's depressive disorder, particularly severe depression. We conclude that veterans' war service and mental health sequelae including post-traumatic stress disorder are associated with higher rates of mental disorder in their female partners 3 decades after the war.

Psychological and marital distress in spouses of Vietnam veterans: importance of spouses' perceptions

Spouses of combat veterans with PTSD have greater psychological and marital distress than spouses of veterans without PTSD; however, few studies have examined how variables related to the spouses (e.g., cognitions) may play a role in their own distress. The current study examined spouses' perceptions of combat veterans' PTSD symptom severity in 465 spouses of veterans from the National Vietnam Veterans Readjustment Study. Spouses' perceptions of veterans' symptom severity were positively associated with spouses' psychological and marital distress; furthermore, spouses' perceptions fully mediated the effects of veterans' self-reported PTSD severity on spouses' distress. Additionally, for spouses who provided complete data with regard to their perceptions of veterans' PTSD, distress was highest when they perceived high levels of symptoms but veterans reported low levels. These results highlight the importance of interpersonal perceptions in intimate relationships and provide preliminary groundwork for future research on cognitions in spouses of combat veterans with PTSD.

Military-related PTSD and intimate relationships: from description to theory-driven research and intervention development

Military operations in Iraq and Afghanistan have brought heightened awareness of military related PTSD, as well as the intimate relationship problems that accompany the disorder and can influence the course of veterans' trauma recovery. In this paper, we review recent research that documents the association between PTSD and intimate relationship problems in the most recent cohort of returning veterans and also synthesize research on prior eras of veterans and their intimate relationships in order to inform future research and treatment efforts with recently returned veterans and their families. We highlight the need for more theoretically-driven research that can account for the likely reciprocally causal association between PTSD and intimate relationship problems to advance understanding and inform prevention and treatment efforts for veterans and their families. Future research directions are offered to advance this field of study.

Psychological and relationship distress among partners of civilian PTSD patients

Significant others of individuals with posttraumatic stress disorder (PTSD) may experience both intrapersonal and interpersonal distress as caregivers. The aim of the present study is 3-fold: (1) to examine symptoms of psychological and relationship distress (anxiety, depression, and dyadic adjustment) among partners of civilian patients with PTSD, (2) to investigate the links between partners' distress and PTSD patients' symptoms (severity; intrusion, avoidance, and arousal subscales), and (3) to explore the perception of mental and physical health, types of trauma and compare partners and PTSD patients' measures. Fifty-seven PTSD patients and their partners filled out 4 questionnaires: Marital Adjustment Test, Beck Anxiety Inventory, Beck Depression Inventory-II, and Medical Outcome Survey-Short Form-12. Results showed that only a minority of partners presented clinical levels of depression (16.7%), anxiety (14.8%), and relationship distress (37%). Pearson correlations analyses revealed an absence of statistically significant relationship between partners' distress and PTSD patients' symptoms. In conclusion, although our study is not a direct validation of the secondary traumatic stress model, our findings fail to provide strong support to the secondary traumatic stress hypothesis among partners of civilian PTSD patients.

Differentiation of the self and posttraumatic symptomatology among ex-POWs and their wives

War captivity is a highly traumatic experience which sometimes has deleterious effects on both ex-POWs and their wives. This study examined the relationships between posttraumatic stress disorder (PTSD) symptoms and differentiation among male ex-prisoners of war (ex-POWs; n = 103), their wives (n = 82), and comparable controls. Results show that ex-POWs and their wives endorsed more PTSD symptoms than controls. Ex-POWs endorsed more cut-off and fusion than controls, while their wives endorsed only more fusion than control wives. Finally, the relationship between differentiation and PTSD was found to be stronger among ex-POW couples than among control couples. The unique characteristics of war captivity and the relationships between avoidance symptoms and cut-off were suggested as possible explanations.

PTSD symptoms, forgiveness, and revenge among Israeli Palestinian and Jewish adolescents

Exposure to political terror and its psychological toll were assessed in 276 Israeli Palestinian and 1,469 Jewish adolescents using self-report questionnaires. Israeli Palestinians displayed more posttraumatic symptoms, higher levels of objective exposure to terror, more negative life events, lower ability to forgive, and a higher need for vengeance than their Jewish counterparts. Although the two groups did not differ in fear levels, Israeli Palestinians expressed more favorable attitudes toward peace. Ethnicity played a major role in explaining the variance of posttraumatic symptomatology. Israeli Palestinians displayed increased vulnerability to mental distress when compared to their Jewish counterparts. The unique roles of subjective fear, attitudes towards peace, forgiveness, and revenge among Israeli Palestinians are discussed.

The contribution of loneliness and posttraumatic stress disorder to marital adjustment following war captivity: a longitudinal study

This prospective study examined the relative contribution of loneliness and posttraumatic stress disorder (PTSD) to marital adjustment among Israeli veterans of the 1973 Yom Kippur war. Specifically, we examined the mediating role of loneliness as measured in 1991 in the association between PTSD as measured in 1991 and marital adjustment as measured in 2003. Our sample consisted of 225 participants divided into 2 groups: ex-prisoners of war (ex-POWs) (N = 122) and a comparison group comprised of veterans who fought in the same war but who had not experienced captivity (N = 103). The findings demonstrate that ex-POWs display lower levels of marital adjustment and higher levels of PTSD than controls. Loneliness was found to mediate the relationship between PTSD as measured in 1991 and marital adjustment as measured in 2003 for both ex-POWs and controls. Further, for ex-POWs, loneliness contributes to marital adjustment above and beyond the contribution of PTSD as measured in 2003. The theoretical implications of loneliness for the marital relationships of traumatized ex-POWs are discussed.