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Post Traumatic Stress And The Military Family

Studies indicate that soldiers serving in a combat zone are three times more likely to develop symptoms of PTSD (Basham, 2008). Veterans who are returning home from Operation Iraqi Freedom/Operation Enduring Freedom are experiencing symptoms of PTSD at alarming rates. According to Hodge et al. (2004), between 12-20% of soldiers returning from Operation Iraqi Freedom are treated for moderate to severe issues of PTSD, and 6-11% of those returning from Operation Enduring Freedom (Afghanistan) also experience such symptoms. Not since Vietnam has the United States seen such high rates of PTSD. The Veteran’s Administration and Vet Centers are striving to meet the needs of returning soldiers with issues of PTSD. As these organizations become overwhelmed with requests for services, social workers are being called in to assist (Knox & Price, 1995).

In addition to the burden of PTSD on soldiers and their families, family members are displaying high levels of secondary traumatic stress due to these deployments. As little is known about secondary traumatic stress, family members are less likely to receive services for this issue as they are not yet available. It is yet to be determined if PTSD contributes to STS, or if it is an issue that develops separately, due to the fact that these family members are prone to higher levels of anxiety regardless of deployment status.

Problem Statement

For the first time since the Vietnam era, soldiers returning home from combat zones such as Iraq and Afghanistan are experiencing higher levels of post traumatic stress disorder. In some cases, the symptoms are apparent right away, while with others, symptoms are not appearing for months or even years following the deployment. In addition, family members are displaying high levels of secondary traumatic stress due to these deployments. As less is known about secondary traumatic stress, family members are less likely to receive services for this issue. It is yet to be determined if PTSD contributes to STS, or if it is an issue that develops separately, due to the fact that these family members are prone to higher levels of anxiety regardless of deployment status.

Questions to be researched:

1. What is the cause of STS?

2. Are family members of soldiers with PTSD more likely to develop STS?

3. How is STS diagnosed?

4. What treatment options are currently available?

5. Does the military recognize this issue among family members of soldiers?

6. Is the military taking any steps to increase the awareness of STS?

7. Does the military offer counseling services for family members?

8. What steps are being taken to address this issue prior to deployments?

9. is STS a direct result of deployment, or is there another underlying reason?

Personal Experience

The author of this paper is a military wife of nineteen years. In the last seven years, her husband, a reservist, has been called to deploy twice; one in 2003 at the start of the Iraq War, and again in 2007, in support of Operation Iraqi Freedom. The first deployment came about very suddenly. The unit had not been deployed since WW II and was completely unprepared. The soldiers were given 2 weeks to prepare. Family members were not prepared with the necessary information, IDs, etc. The author still recalls the day she dropped her husband off at the reserve center, not knowing if she would ever see him again and still recalls how she drove away screaming and crying. Certain songs, scents, and personal items will trigger recollections of that painful time. The author finds herself avoiding these songs, scents and personal items so that she does not have to re-live that painful time in her family’s life.

The second deployment was different in that the soldiers had been placed on alert and were prepared for the deployment. The author served as the battalion family readiness group coordinator and it was her

job to prepare the families for the days and months ahead. Using her experience from the first deployment, the author strived to ensure that every family member was fully prepared and didn’t experience the same difficulty as with the first deployment. Although the author placed her focus on helping the other family members, she still experienced a great deal of anxiety knowing that her husband was in Iraq. She experienced sleeplessness, depression, anxiety, weight loss, followed by weight gain, and fatigue. In addition, she often found herself angry with her husband, as he had left her twice to run the entire household and to carry on alone. She recalls the many arguments on the telephone when her husband called from Iraq. The author was angry for being left behind, but even more so because she feared for her husband’s life each and every day. The author kept her feelings of anger to herself, as she feared that she would be judged harshly by her family and friends if she disclosed that she was angry. After all, during deployments to a combat zone, it is the soldier who receives all of the focus and concern.

Analysis of Methodological Structures

A study to Determine the Effects of PTSD and STS

Ein-Dor, Doron, Solomon, Mikulincer and Shaver (2010) examined the associations among attachment-related dyadic processes, PTSD among war veterans and secondary traumatic stress in their wives (Ein-dor et al., 2010). They hypothesize that the level of attachment anxiety among wives whose husbands have higher levels of PTSD and further hypothesize that the husbands with these high levels of PTSD will form attachment anxiety which will contribute to higher levels of secondary traumatic stress in the wives.

The authors used a sample of 157 Israeli soldiers. 85 soldiers who were held in captivity as prisoners of war and their wives were compared to a group of 72 veterans who had not been captured, along with their wives. Each group completed self reported scales which assessed attachment insecurities such as anxiety, avoidance and symptoms of PTSD. The control group for the study consisted of the 72 veterans that had not been held in captivity. The control participants were chosen based upon their similarities to the ex-pows based upon their age, rank, and exposure to combat. All participants in the study were married.

The levels of attachment and anxiety were assessed by using the 10 item Adult Attachment Styles scale that was developed by Mikulincer and colleagues (1990). The authors contend that this scale “decomposed Hazan and Shaver's (1987) descriptions of avoidant and anxious attachment styles and constructed five items for each dimension. The five anxiety items (e.g., “I worry about being abandoned”) corresponded to items in Brennan and colleagues' (1998) anxiety subscale of the Experiences in Close Relationships (ECR) measure, and the five avoidance items (e.g., “I feel uncomfortable when others get close to me”) corresponded to items in Brennan and colleagues' avoidance subscale. The participants rated the extent to which an item described them using a 7-point scale ranging from 1 (not at all) to 7 (very much) (Ein-dor et al., 2010). PTSD symptoms were also measured by the Post Traumatic Stress Inventory (PTSDI; Solomon et al., 1994), which is based upon the 17 core symptoms stated in the DSM-IV (APA, 1994). For the wives, secondary stress was determined by the level of PTSD symptoms related to their husbands’ traumatic experiences.

The authors concluded that the group of soldiers with severe symptoms of PTSD had wives who experienced elevated levels of secondary traumatic stress when compared to the control group. Those who scored higher on attachment anxiety also reported more severe war-related PTSD than did their less attachment-anxious counterparts (Ein-dor et al., 2010).

The authors provide a valid study of Israeli combat soldiers and their spouses following the Yom Kippur War of 1973 as part of a long term study of PTSD among combat veterans who were held captive. The authors contend that “no previous study has examined these associations at the dyadic level or the contribution of ex-POWs' and their wives' attachment insecurities to increasing the associations of avoidant attachment with PTSD and STS” (Ein-Dor et al., 2010). They further contend that “no previous publications based on this project have examined the unique and interactive contributions of study group (ex-POW, control) and trauma status (primary/husband, secondary/wife) on the links between attachment insecurities and PTSD.”

Reunification

The reunification process can be exceptionally difficult. Both the soldier and the spouse have developed different lifestyle habits and often expect to return to life as it was prior to the deployment. Such expectations are rarely feasible. The soldier has experienced a great deal of trauma, which rarely is discussed with the spouse. The spouse has also suffered a certain degree of trauma, whether it is personal stress from being the sole caregiver, or stress based upon constant worry about the wellbeing of the soldier. Both parties worry about the other and often repress their own feelings. The marital relationship often suffers, as communication is minimal.

Figley (1998) has discussed the term secondary traumatic stress as “the natural consequent behaviors and emotions resulting from knowledge about a stressful event experienced by a significant other” (p. 7). An article authored by Dirkzwager, Bramsen, Ader, and van der Ploeg (2004) entitled Secondary Traumatization in Partners and Parents of Dutch Peacekeeping Soldiers examines whether secondary traumatic stress reactions exist among the family members of former peacekeepers (Dirkzwager et al., 2004). The authors studied the differences between the family members of these former peacekeepers who had various levels of post traumatic stress disorder. In this particular study, spouses of one subgroup were compared to the parents in the remaining subgroup. Dirkzwager et al., (2004) state “we hypothesized that the partners of peacekeepers with higher levels of posttraumatic stress would appraise the quality of the marital relationship as less favorable and would experience more problems in social contacts than partners of peacekeepers with lower levels of PTSD symptoms” (para.8). They further hypothesized that the parents of these former peacekeepers with higher levels of PTSD would report more of these symptoms themselves; i.e. more somatic issues, sleeping difficulties, and more social difficulties than those parents of peacekeepers with lower levels of PTSD.

The total number of participants was 1,476. The average age of the participants was 32 years (range = 19–71 years, SD = 9.7), and one third of them were single. The average amount of time that was served by the peacekeepers was 5.7 months abroad (range = 1–23 months; SD = 3.9), and the peacekeepers were studied an average of 6.6 years following their deployment (range = < 1 year to 20 years; SD = 5.6) (Dirkzwager et al., 2004). Partners and parents of the peacekeepers were given questionnaires for PTSD, somatic complaints, sleeping problems, and social support, while only the partners were given questionnaires regarding the quality of the relationship.

The Self-Rating Inventory for PTSD (SRIP) was used to measure current PTSD symptoms of both the peacekeepers and the family members (Hovens et al., 1994, as cited in Dirkzwager et al., 2004). The SRIP contains 22 items that meet the criteria for PTSD in the DSM-IV (APA, 1994). Hovens, Bramsen, & Van der Ploeg, 2000; Hovens et al., 1994, as cited in Dirkzwager, et al., 2004) determined that the SRIP is valid and reliable and that the test-retest reliability correlation coefficient was.92, and the internal consistency alpha coefficient was.92.

Dirkzwager et al., (2004) concluded from their study that the partners of the said peacekeepers with elevated levels of PTSD also experienced higher levels of PTSD, sleeplessness, somatic complaints, diminished social support, and a decline in the overall satisfaction of the relationship. Their study also determined that there was minimal differences were found among the parents of these peacekeepers, regardless of their level of PTSD. The authors concluded that the higher levels of PTSD and other symptoms for partners of the peacekeepers was based upon the fact that there is more of an intimate relationship with couples, and the fact that the peacekeeper is often the primary source of support. In regard to the parents, in many cases, the peacekeepers have likely moved out of their parents’ home at the time that the study was conducted. The authors contend that their study is consistent with the results of other studies conducted regarding military veterans. The authors state “These findings may indicate secondary traumatization; however, because the data were collected retrospectively by means of self-reported data, other alternative explanations must be considered. For instance, we cannot rule out the

possibility that the PTSD symptoms of the partner predated the peacekeeper's PTSD symptoms and hence influenced the peacekeeper's likelihood of developing PTSD symptoms (Dirkzwager et al., 2004, para.33). They further contend that peacekeepers with higher levels of PTSD are likely to develop marital difficulties. On the other hand, peacekeepers with marital difficulties prior to the deployment are more likely to develop PTSD.

Effects on Relationships

It is often stated that during deployment, strong relationships become stronger, while those who were experiencing relationship strife prior to the deployment will probably experience greater difficulty within their relationship. This statement may have some level of truth, but fails to consider the effects of PTSD and STS on a relationship. No matter how strong one’s relationship is prior to deployment, both parties will change significantly. The spouse becomes stronger because she (or he) has no alternative. Routines have changed. Couples must become reacquainted all over again and must learn to exist as a couple. Both parties may have experienced their own levels of anxiety, anger, depression, sleep disturbances, somatization, substance abuse, dissociation, and sexual problems. When PTSD and/or STS is added to the equation, even the strongest relationships may face troubled times ahead.

Goff, Crow, Reisbig and Hamilton (2007) address the interpersonal impact of trauma upon the combat veteran. The authors conducted a study of 45 male soldiers (Army) from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) and their spouses/partners. They contend that trauma symptoms such as sleep disorders, dissociation and sexual issues on the part of the soldier resulted in decreased levels of satisfaction within the relationship. They hypothesize that “Greater trauma history and trauma symptoms of soldiers will predict lower relationship satisfaction for soldiers and for their female spouses/partners” (Goff et al., 2007).

The study was conducted near Ft Riley, Kansas and included 45 couples from this military installation. 56 couples initially agreed to participate in the study; however, 11 couples either cancelled or failed to appear, resulting in a response rate of 80.36%. 95.6% (n = 43) were married, In order to participate in the study, the soldier must have deployed in support of OIF or OEF. 95.6% (n = 43) served in OIF, and 4.4% (n = 2) served in OEF. All participants were over the age of 18, had been in their relationship for a minimum of one year and indicated that they were not experiencing any substance abuse or domestic violence.

The Traumatic Effects Questionnaire (Vrana & Lauterbach, 1994) was utilized to determine any past history of trauma and the types of trauma experienced. The purpose for this was to have a background of any previous trauma which could result in PTSD symptoms. Questions regarding combat exposure included ““Did you ever serve in a war zone where you received hostile incoming fire from small arms, artillery, rockets, mortars, or bombs?” (Goff et al., 2007). Two additional questions regarding past trauma included: “As a child, were you the victim of physical abuse?” and nine other questions regarding past trauma such as being a victim of a violent crime, rape, etc.(Goff et al., 2007). Of the traumatic events reported by the soldiers, 82% indicated that their deployment to a combat zone was their most traumatic event, and 24% of their partners reported the same. The Traumatic Events Questionnaire was reported to be reliable with test–retest reliability coefficients ranging from .72 to 1.00 (Vrana & Lauterbach, 1994, as cited in Goff et al., 2007).

The Purdue Post Traumatic Stress Disorder Scale-Revised (PPTSD-R) was also utilized in the study and meets the criteria indicated in the DSM-IV (APA, 1994) for symptoms of PTSD. The mean for this study was reported as soldiers = 35.79 for the PPTSD–R, while female partners reported a mean of 34.77. According to Lauterbach & Vrana, 1996, as cited in Goff et al., 2007) “The PPTSD–R has been shown to have adequate internal consistency, with coefficient alpha for the total score at .91 (para.19). Test-retest reliability was also considered good with a report of a score of .72. In regards to the study conducted by the authors, Cronbach's alpha estimates for the total scale scores were adequate for soldiers (.92) and female partners (.95).

The results of their study contended that “Significant negative correlations were found between soldiers' DAS and soldiers' PPTSD–R (r = –.45, p < .01) and TSC–40 scores (r = –.58, p < .001), but not for soldiers' TEQ total scores (r = –.19)” (Goff et al., 2007, para.23). The females’ DAS scores compared with soldiers' TSC–40 scores (r = –.32, p < .05). Per these results, the authors concluded that that the soldiers’ emotional status played a profound role in their relationship dissatisfaction. They further concluded that they can no longer consider trauma as merely an individual event.

Those who are Left Behind

There is a great deal of focus upon the soldier as he returns home from combat. Family members and friends are excited to see that the soldier has returned home safely and worry about his physical and mental condition. They worry that the soldier has experienced extreme traumatic events and worry about how he will adjust to life at home once again. Little focus is placed upon the spouse, who in many ways has suffered an equal amount of trauma. As previously stated, the spouse must carry on alone by becoming the sole caretaker, the accountant, and various other roles of which she is not accustomed. In addition, she constantly worries about the wellbeing of her soldier; particularly if she does not hear from him for days or weeks upon end. She jumps when the phone rings, when someone is at the door, or when there is an unfamiliar car parked outside. There is always that fear that she will receive notification that her soldier has been injured or killed.

Goff, Crow, Reisbig and Hamilton (2009) discuss the fact that research has often overlooked the impact that the soldiers’ trauma affects family members. The results of their study strongly indicates that increased trauma on the part of the soldier significantly affects the symptoms of traumatic stress in family members; particularly female partners when addressing soldiers’ avoidance issues.

A study was conducted using 45 couples in two small cities in the Midwest that neighbor Army posts in close proximity to the university where the research was conducted. The participants were recruited using several methods such as public flyers, newspaper ads and referrals from family readiness groups. The participants were not recruited by contacting soldiers and their families directly. The total sample included 45 male soldiers and 45 female partners. Although female soldiers were not excluded from the sample, no female soldiers elected to participate (Nelson-Goff et al., 2009). Their hypothesis supports the current the theory of secondary post traumatic stress disorder and increased individual symptomatology in female spouses/partners. They also hypothesized that avoidance symptoms in the soldiers significantly accounted for 13% of the individual trauma symptoms in the female partners. Nelson-Goff et al., (2009) state “The stress of war deployment impacts not only the soldiers, but also their spouses/partners, who serve the nation by maintaining their lives while waiting for the safe return of their soldiers” (p.12).

As with the previous study conducted by these authors, in order to participate in the study, the soldiers must have served as part of OIF or OEF. They must be over the age of 18, had been in their current relationship for at least one year, and denied current substance abuse or domestic violence. 91.1% (n= 41) were recruited from the Post 1 area and 9.9% (n = 4) were recruited from the Post 2 area. The average length of deployment was 10.03 months (SD = 3.98), with an average of 5.10 months (SD = 3.39) (Goff et al., 2009). The average age of the soldier was 31.18 (SD=6.90) and the average age of the female partner was 29.36 (SD=6.27). 95.6% (n = 43) were married. The average length of the relationship was 5.31 years (SD = 5.47).

Similar to that of the aforementioned study conducted by the authors, the Traumatic Events Questionnaire was utilized in order to determine if the participants had suffered from past traumatic events. In addition to this questionnaire, the Purdue Post-Traumatic Stress Disorder Scale-Revised was used once again, along with the Trauma Symptom Checklist-40 (TSC-40). This checklist is used to evaluate the symptoms in adults who have previously experienced trauma. The TSC-40 is a 40 item checklist that ranges from 0-3, 0 indicating “never” and 3 indicating “often”. The scale also contains 6 subscales which includes 9 questions regarding anxiety, 9 items regarding depression,6 items regarding dissociation, 7 items for Sexual Abuse Trauma index, 8 items regarding sexual problems and 6 items regarding sleep disturbances (Goff et al., 2009). The checklist is scored from 0-120, with the higher number indicating greater trauma. Goff et al., (2009) indicate that they included this checklist in their study because it provides broader information regarding traumatic systems that succeed PTSD.

The authors’ hypothesis was partially supported, as the PTSD symptoms from the soldiers “best predicted the female partners’ current trauma symptoms” (Goff et al., 2009, para. 20). They further state that “The most significant predictor of the female partners’ trauma symptoms was the soldiers’ PPTSD-R scores, R2 = 0.21, Adj R2 = 0.19; F (1,42) = 11.04, p < .01” (para.20). Finally, they contend that the avoidance symptoms demonstrated by the soldiers accounted for 13% of the traumatic symptoms demonstrated by their female partners.

The Military Spouse and PTSD

Being the spouse of a soldier who is suffering from symptoms of PTSD can be extremely difficult. Without extensive knowledge of the topic, particularly knowing the symptoms, triggers and best manner in which to help the soldier, living with a spouse with PTSD is a daily challenge. In addition, soldiers with PTSD may develop other issues such as alcohol and substance abuse, domestic violence, failure to maintain employment and suicide ideations.

Denkel, Goldblatt, Keidar, Solomon and Polliack (2005) address the challenges faced by the military spouse. They experience issues of constant tension with their soldiers, and often struggle to maintain their own sense of identity and independence. They suffer a heavy burden, depression, anxiety, low self-esteem, somatic symptoms, and often blame themselves for their current circumstances.

The authors conducted a study using qualitative methods to examine the manner in which military spouses of soldiers with PTSD discuss their lives. The study was conducted with 9 wives of Israeli soldiers who were suffering from PTSD. Their ages ranged from 36-57 years old (M = 45.2, SD = 11.04). Eight of the participants were married with children and one participant had cohabitated with her soldier for many years. Although this participant is not married, she is referred to in the study as a spouse.

The study was conducted with an in-depth 2 hour group interview which was led by two therapists, both social workers and researchers. They ensured that each participant was given an equal opportunity to speak. The participants were asked to describe their lives as being married to a combat veteran. The researchers each completed their own summaries based upon the discussions. The researchers compared their analyses, discussed their differences and came to an agreement. Their comparisons addressed both the content of the themes and their interpretations. The analyses were conducted in the following stages:

1. Open coding: The researchers thoroughly read the transcripts of the discussion while taking notes. The purpose was to identify similar themes based upon the discussion. Emerging themes gathered from the data included “‘‘the reactions of the husband, the wife and the family to the injury,’’ ‘‘the husband’s injury as expressed in the wife’s emotions and behavior,’’ and ‘‘how the wife perceives her role in relation to her husband’ (Deckel et al., 2005).

2. Axial coding: Upon reading the transcript for the second time, the researchers were able to determine among categories and subcategories related by context and content. They determined that ‘‘how the wife perceives her role in relation to her husband’’ was determined to be a primary category, as opposed to “the wife as a caregiver”, which was determined to be a subcategory (Deckel et al., 2005). Following the conclusion of these two stages, a profile was created for each participant.

3. Integration: Themes were determined and placed in context in terms of the meaning of being the wife of a veteran with PTSD (p.27).

Based upon the determinations of the researchers, the following categories were established:

1. ‘The illness as navigating living.’’ This category depicts how their husbands’ illness affected the wives physically and emotionally, as well as their daily functioning outside of the home.

2. ‘‘Between merging and individuation’’ determined the struggle in which to maintain control of their own personal space (Deckel et al., 2005, p. 27).

3. ‘‘The partners as present-absent’’ depicts the difficulty and the loneliness experienced by the wives as their husbands were physically present, yet psychologically absent.

4. ‘‘Separation and divorce—the impossible path’’ depicts the commitment that the wives had to their husbands.

5. ‘‘The partners as empowering’’ depicts the positive aspects of the marriages of the participants.

Based upon their findings, it was determined that the participants struggled with the daily tension with their husbands, experienced loneliness due to the psychological absence of their spouse, and had difficulty maintaining their own sense of self and personal space. In spite of this, each participant expressed a moral obligation to maintain the marriage and was fully committed to their spouse, despite having to bear the burden of caring for the family. Despite the difficulties that they experience, each participant expressed many positive aspects of their marriage.

Evaluation of Data Analysis Techniques

Criterion for PTSD

The Diagnostic and Statistical Manual of Mental Disorders (APA, 2000) specifies the criteria for Post Traumatic Stress Disorder (PTSD) as follows:

“ Criterion A: stressor: The person has been exposed to a traumatic event in which both of the following have been present:

1. The person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others.

2.The person's response involved intense fear, helplessness, or horror. Note: in children, it may be expressed instead by disorganized or agitated behavior.

Criterion B: intrusive recollection: The traumatic event is persistently re-experienced in at least one of the following ways:

1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: in young children, repetitive play may occur in which themes or aspects of the trauma are expressed.

2. Recurrent distressing dreams of the event. Note: in children, there may be frightening dreams without recognizable content

3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated). Note: in children, trauma-specific reenactment may occur.

4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

5. Physiologic reactivity upon exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

Criterion C: avoidant/numbing

Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by at least three of the following:

1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma

2. Efforts to avoid activities, places, or people that arouse recollections of the trauma

3. Inability to recall an important aspect of the trauma

4. Markedly diminished interest or participation in significant activities

5. Feeling of detachment or estrangement from others

6. Restricted range of affect (e.g., unable to have loving feelings)

7. Sense of foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

Criterion D: hyper-arousal

Persistent symptoms of increasing arousal (not present before the trauma), indicated by at least two of the following:

1. Difficulty falling or staying asleep

2. Irritability or outbursts of anger

3 . Difficulty concentrating

4. Hyper-vigilance

5 .Exaggerated startle response

Criterion E: duration of the disturbance (symptoms in B, C, and D) is more than one month.

Criterion F: functional significance

The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning” (APA, 2000, pp 467-468).

Table 1. Annual New Post-Traumatic Stress Disorder Diagnoses in All Services

As of September 7, 2010

Year Not Deployed Deployed

2000 1,614 0

2001 1,703 0

2002 1,709 138

2003 1,524 1,169

2004 1,577 3,901

2005 1,648 6,788

2006 1,714 7,762

2007 2,069 11,660

2008 2,371 14,183

2009 2,432 13,595

2010 1,423 7,739

Total 21,784 66,935

Source: Personal communication with Dr. Michael Carino, Army Office of the Surgeon General, September 21, 2010. Data source is the Defense Medical Surveillance System (DMSS).

Soldiers are not the only ones who suffer from the emotional difficulties that result from combat experiences. Family members, particularly spouses, suffer many of the same difficulties as the soldier. They may experience high levels of anxiety, depression, somatic complaints, sleeplessness, etc... These family members often face what is known as secondary traumatic stress (STS). Figley (1998) has discussed the term secondary traumatic stress as “the natural consequent behaviors and emotions resulting from knowledge about a stressful event experienced by a significant other” (p. 7). Ein-Dor, Doron, Solomon, Mikulincer and Shaver (2010) conducted a study to determine the associations among attachment-related dyadic processes, PTSD among war veterans and secondary traumatic stress in their wives (Ein-dor et al., 2010). They hypothesize that the level of attachment anxiety among wives whose husbands have higher levels of PTSD and further hypothesize that the husbands with these high levels of PTSD will form attachment anxiety which will contribute to higher levels of secondary traumatic stress in the wives. Based upon their study, the authors concluded that the group of soldiers with severe symptoms of PTSD had wives who experienced elevated levels of secondary traumatic stress when compared to the control group. Those who scored higher on attachment anxiety also reported more severe war-related PTSD than did their less attachment-anxious counterparts (Ein-dor et al., 2010).

Marital satisfaction is at risk with veterans with PTSD and/or spouses with STS. Dirkzwager, Bramsen, Ader, and van der Ploeg (2004) conducted a study of 1,476 Dutch former peacekeepers. They state “we hypothesized that the partners of peacekeepers with higher levels of posttraumatic stress would appraise the quality of the marital relationship as less favorable and would experience more problems in social contacts than partners of peacekeepers with lower levels of PTSD symptoms” (para.8).

Relationships may deeply suffer due to the deployment, symptoms of PTSD, and STS. Both parties may have experienced their own levels of anxiety, anger, depression, sleep disturbances, somatization, substance abuse, dissociation, and sexual problems. When PTSD and/or STS is added to the equation, even the strongest relationships may face troubled times ahead. Goff, Crow, Reisbig and Hamilton (2007) conducted a study of 45 male soldiers (Army) from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) and their spouses/partners. They concluded that that the soldiers’ emotional status played a profound role in their relationship dissatisfaction. They further concluded that they can no longer consider trauma as merely an individual event.

When a soldier returns from a combat zone, there is a great deal of concern regarding his wellbeing, both mental and physical, and even more concern is focused upon the level of trauma that he may have experienced. Little emphasis is placed upon the family members who have suffered their own form of trauma. Goff, Crow, Reisbig and Hamilton (2009) discuss the fact that research has often overlooked the impact that the soldiers’ trauma affects family members. The results of their study strongly indicates that increased trauma on the part of the soldier significantly affects the symptoms of traumatic stress in family members; particularly female partners when addressing soldiers’ avoidance issues. Based upon their study, they contend that the avoidance symptoms demonstrated by the soldiers accounted for 13% of the traumatic symptoms demonstrated by their female partners.

Life as a military spouse of one who suffers from PTSD can be exceptionally challenging. In addition, soldiers with PTSD may develop other issues such as alcohol and substance abuse, domestic violence, failure to maintain employment and suicide ideations. Denkel, Goldblatt, Keidar, Solomon and Polliack (2005) address the challenges faced by the military spouse. They experience issues of constant tension with their soldiers, and often struggle to maintain their own sense of identity and independence. They suffer a heavy burden, depression, anxiety, low self-esteem, somatic symptoms, and often blame themselves for their current circumstances. The authors conducted a study using qualitative methods to examine the manner in which military spouses of soldiers with PTSD discuss their lives.

Limitations

The concept of PTSD in combat veterans is a familiar topic. It is common knowledge that soldiers returning from combat zones often experience symptoms of PTSD. Little is acknowledged regarding the suffering that is endured by the military spouse. Although the resources for treating soldiers are plentiful, minimal services are offered for family members presenting symptoms of secondary traumatic stress. Few organizations acknowledge a connection between PTSD symptoms in combat veterans and STS symptoms among their spouses. Until military installations offer services for the entire family, it is likely that symptoms of STS are going to increase among military spouses and emulate those of the soldiers suffering from PTSD.

Application to Counseling Field

Recommendations

Increasing awareness of STS in spouses of combat veterans is crucial to helping this population. In order for this to occur, it might be helpful to conduct a study of soldiers and their spouses prior to deployment (pretest) based upon their previous experiences with stress to determine the likelihood of STS. Following the deployment, this group of soldiers and their spouses should be tested once again (posttest) to evaluate the levels of PTSD and STS. The current research suggests that spouses who have experienced previous personal trauma or experience elevated levels of anxiety have an increased likelihood of developing secondary traumatic stress. Having this knowledge prior to the deployment could be extremely beneficial to spouses, as they may be able to receive services in advance that could help diminish the severity of their symptoms before, during and following the deployment.

Application to Culturally Diverse Groups

The military is considered to be a culture in and of itself. Although the United States is a country that is comprised of many colors, religions and ethnicities, life in the military means relinquishing diversity in order to assume a whole new identity. Conformity is expected and nothing less is acceptable. Upon joining the military, individuality becomes suppressed. Uniforms and haircuts are the same. Soldiers are addressed by their last names, and few even know the first name of their fellow soldiers. Officers do not fraternize with enlisted personnel, even if the wives become friendly.

Family members are considered to be a subculture in the military. The mission at hand becomes priority for the soldier and their families become secondary, thus the need for family readiness groups. It is often difficult for family members to make friends due to the frequent deployments and transfers to other military installations. Family members are expected to conform to the expectations that are established for them, otherwise the soldier is held accountable for their behavior.

Although the military is comprised of people of many different cultures, religion and ethnicity, because of the expected uniformity, PTDS appears to affect everyone in the same capacity. Symptoms appear to be the same, although each individual may react differently to the said symptoms. Culture, religion or ethnicity does not determine who will develop PTSD symptoms and who will not. One’s perception of the events that have occurred will determine who develops PTSD.

Conclusion

Combat veterans suffering from post traumatic stress disorder do not suffer alone. Their illness equally affects their loved ones. It has been determined that those spouses whose soldier is experiencing higher levels of PTSD are likely to develop symptoms of secondary stress. With the wars in Afghanistan and Iraq continuing at full force, Post Traumatic Stress Disorder for soldiers and Secondary Traumatic Stress for family members is likely to become unsystematic and overwhelming for the Veteran’s Administration, Vet Centers, mental health professionals and social workers. In order to avoid this serious problem, it is important to increase the level of awareness not only for issues of PTSD, but also for STS. As stated by D.W Winnicot (1958) “There is no soldier without a family. When a soldier deploys, the whole family serves. When a soldier returns from combat, the whole family is affected”. Professionals must educate themselves not only regarding PTSD and treatment options, but they must also become more aware of those who suffer from issues of STS.

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