Partners of Veterans with PTSD: Caregiver Burden and Related
Problems
Jennifer L. Price, Ph.D. & Susan P. Stevens,
Psy.D.
Introduction
A number of studies have found that veterans' PTSD symptoms
can negatively impact family relationships and that family
relationships may exacerbate or ameliorate a veteran's PTSD and
comorbid conditions. This fact sheet provides information about
the common problems experienced in relationships in which one (or
both) of the partners has PTSD. This sheet also provides
recommendations for how one can cope with these difficulties. The
majority of this research involved female partners (typically
wives) of male veterans; however, there is much clinical and
anecdotal evidence to suggest that these problems also exist for
couples where the identified PTSD patient is female.
What are common problems in relationships with PTSD-diagnosed
veterans?
Research that has examined the effect of PTSD on intimate
relationships reveals severe and pervasive negative effects on
marital adjustment, general family functioning, and the mental
health of partners. These negative effects result in such
problems as compromised parenting, family violence, divorce,
sexual problems, aggression, and caregiver burden.
1,
2,
3,
4,
5
Marital adjustment and divorce rates
Male veterans with
PTSD are more likely to report marital or relationship problems,
higher levels of parenting problems, and generally poorer family
adjustment than veterans without PTSD.
2,
6,
7 Research has shown that
veterans with PTSD are less self-disclosing and expressive with
their partners than veterans without PTSD.
8 PTSD veterans and their wives have also reported a greater
sense of anxiety around intimacy.
7 Sexual dysfunction also tends to be higher in combat
veterans with PTSD than in veterans without PTSD.
9 It has been posited that diminished sexual interest
contributes to decreased couple satisfaction and adjustment.
10
Related to impaired relationship functioning, a high rate of
separation and divorce exists in the veteran population (those
with PTSD and those without PTSD). Approximately 38% of Vietnam
veteran marriages failed within six months of the veteran's
return from Southeast Asia.
11 The overall divorce rate among Vietnam veterans is
significantly higher than for the general population, and rates
of divorce are even higher for veterans with PTSD. The National
Vietnam Veterans Readjustment Study (NVVRS) found that both male
and female veterans without PTSD tended to have longer-lasting
relationships with their partners than their counterparts with
PTSD.
3 Rates of divorce for veterans with PTSD were two times
greater than for veterans without PTSD. Moreover, veterans with
PTSD were three times more likely than veterans without PTSD to
divorce two or more times.
Interpersonal violence
Studies have found that, in
addition to more general relationship problems, families of
veterans with PTSD have more family violence, more physical and
verbal aggression, and more instances of violence against a
partner.
12,
2,
3 In these studies,
female partners of veterans with PTSD also self-reported higher
rates of perpetrating family violence than did the partners of
veterans without PTSD. In fact, these female partners of veterans
with PTSD reported perpetrating more acts of family violence
during the previous year than did their partner veteran with
PTSD.
2
Similarly, Byrne and Riggs
12 found that 42% of the 50 Vietnam veterans in their study
had engaged in at least one act of violence against their partner
during the preceding year, and 92% had committed at least one act
of verbal aggression in the preceding year. The severity of the
veteran's PTSD symptoms was directly related to the severity of
relationship problems and physical and verbal aggression against
the partner.
Mental health of partners
PTSD can also affect the mental
health and life satisfaction of a veteran's partner. Numerous
studies have found that partners of veterans with PTSD or other
combat stress reactions have a greater likelihood of developing
their own mental health problems compared to partners of veterans
without these stress reactions.
10 For example, wives of Israeli veterans with PTSD have been
found to report more mental health symptoms and more impaired and
unsatisfying social relations compared to wives of veterans
without PTSD.
5 In at least two studies, including the NVVRS study noted
above, partners of Vietnam veterans with PTSD reported lower
levels of happiness, markedly reduced satisfaction in their
lives, and more demoralization compared to partners of Vietnam
veterans not diagnosed with PTSD.
2 About half of the partners of veterans with PTSD indicated
that they had felt "on the verge of a nervous breakdown". In
addition, male partners of female Vietnam veterans with PTSD
reported poorer subjective well being and more social isolation
than partners of female veterans without PTSD.
Nelson and Wright
13 indicate that partners of PTSD-diagnosed veterans often
describe difficulty coping with their partner's PTSD symptoms,
describe stress because their needs are unmet, and describe
experiences of physical and emotional violence. These
difficulties may be explained as secondary traumatization, which
is the indirect impact of trauma on those in close contact with
victims. Alternatively, the partner's mental health symptoms may
be a result of his or her own experiences of trauma, related to
living with a veteran with PTSD (e.g., increased risk of domestic
violence) or related to a prior trauma.
Caregiver burden
Limited empirical research exists that
details the specific relationship challenges that couples must
face when one of the partners has PTSD. However, clinical reports
indicate that significant others are presented with a wide
variety of challenges related to their veteran partner's PTSD.
Wives of PTSD-diagnosed veterans tend to assume greater
responsibility for household tasks (e.g., finances, time
management, house up-keep) and the maintenance of relationships
(e.g., children, extended family).
13,
14 Partners feel
compelled to care for the veteran and to attend closely to the
veteran's problems. Partners are keenly aware of cues that
precipitate symptoms of PTSD, and partners take an active role in
managing and minimizing the effects of these precipitants.
Caregiver burden is one construct used to categorize the
types of difficulties associated with caring for someone with a
chronic illness, such as PTSD. Caregiver burden includes the
objective difficulties of this work (e.g., financial strain) as
well as the subjective problems associated with caregiver demands
(e.g., emotional strain).
Beckham, Lytle, and Feldman
15 examined the relationship between PTSD severity and the
experience of caregiver burden in female partners of Vietnam
veterans with PTSD. As expected, high levels of caregiver burden
included psychological distress, dysphoria, and anxiety. More
recently, Calhoun, Beckham, and Bosworth
1 expanded this understanding of caregiver burden among
partners of veterans with PTSD by including a comparison group of
partners of help-seeking veterans who do not have PTSD. They
reported that partners of veterans with PTSD experienced greater
burden and had poorer psychological adjustment than partners of
veterans without PTSD. Across both studies, caregiver burden
increased with PTSD symptom severity. That is, the worse the
veteran's PTSD symptoms, the more severe the caregiver
burden.
Why are these problems so common?
Because of the dearth of research that examines the connection
between PTSD symptoms and intimate-relationship problems, it is
difficult to discern the exact correspondence between them.
7,
16 Some symptoms, like
anger, irritability, and emotional numbing, may be direct
pathways to relationship dissatisfaction. For example, a veteran
who cannot feel love or happiness (emotional numbing) may have
difficulty feeling lovingly toward a spouse. Alternatively, the
relationship discord itself may facilitate the development or
exacerbate the course of PTSD. Perhaps the lack of communication,
or combative communication, in discordant relationships impedes
self-disclosure and the emotional processing of traumatic
material, which leads to the onset or maintenance of PTSD.
Riggs, Byrne, Weathers, and Litz
7 did examine the connection between PTSD symptom clusters
and the relationship condition. The study examined the connection
between the cluster of avoidance symptoms and the decreased
ability of the person diagnosed with PTSD to express emotion in
the relationship. The results of the study suggest that avoidance
symptoms, specifically emotional numbing, interfere with intimacy
(for which the expression of emotions is required) and contribute
to problems in building and maintaining positive intimate
relationships.
What are the treatment options for partners of veterans with
PTSD?
The first step for partners of veterans with PTSD is to gain a
better understanding of PTSD and the impact on families by
gathering information. Resources on the National Center for PTSD
website and in the reference list for this fact sheet may be
useful. Particularly helpful are the National Center for PTSD
fact sheets listed below under "related fact sheets."
With regard to specific treatment strategies, Nelson and
Wright
13 suggest, 'effective treatment should involve family
psychoeducation, support groups for both partners and veterans,
concurrent individual treatment, and couple or family therapy'
(p. 462). Psychoeducational groups teach coping strategies and
educate veterans and their partners about the effects of trauma
on individuals and families. Often these groups function as
self-help support groups for partners of veterans. Preliminary
research offers encouragement for the use of group treatment for
female partners of Vietnam veterans.
17,
18 Individual therapy
for both the veteran and his or her partner is an important
treatment component, especially when PTSD symptoms are prominent
in both individuals. Couples or family therapy may also be highly
effective treatment for individuals' symptoms and problems within
the family system. Several researchers have begun exploring the
benefits of family or couples therapy for both the veteran and
other family members.
14,
19,20 In light of the recent research on the negative impact of
PTSD on families,
Veterans Affairs PTSD programs and
Vet
Centers
across the country are beginning to offer group, couples, and
individual programs for families of veterans.
Overall, it seems that the most important message for partners
is that relationship difficulties and social and emotional
struggles are common when living with a traumatized veteran. The
treatment options listed above are but a few of the available
approaches that partners may find useful in their search for
improved family relationships and mental health.
Vietnam Veterans Wives (VVW), established in 1996, is an
organization designed to meet the needs of veterans and their
families. The specific and primary purpose of VVW is the
advancement of research and the distribution of information about
PTSD, Agent Orange, and Gulf War diseases. VVW publishes a
variety of literature, including newspapers, magazines, and
brochures. VVW provides PTSD counseling, safe retreats for wives
during times of crisis, a national hotline, and assistance to the
families of incarcerated veterans. Membership is open to all
family members and significant others of anyone that served in
the military during any period.
Matsakis, A. (1988).
Vietnam Wives. Washington, DC: Woodbine House. Aphrodite
Matsakis is a psychotherapist specializing in PTSD. She has
worked extensively with Vietnam veterans and survivors of child
sexual abuse. A new edition of her 1988 book
Vietnam Wives: Facing the Challenges of Life with Veterans
Suffering Post Traumatic Stress (Sidran Press, 1996, $19.95
paper, 1-886968-00-4) deals with the stresses arising from
midlife as well as those stemming from the experience of
combat.
Patience Mason writes from personal experience in
Recovering from the War: A Woman's Guide to Helping Your
Vietnam Vet, Your Family, and Yourself (Viking, 1990, out of
print hard, 0-670-81587-X; Penguin, 1990, out of print paper,
0-14-009912-3; hardcover copies still available from Patience
Press, P.O. Box 2757, High Springs FL 32643 at $27.50 postpaid).
Her husband was a Vietnam helicopter pilot who developed all the
symptoms of PTSD. Mason describes the Vietnam experience and its
impact on veterans and tells what a family needs to do to heal
itself from the lasting wounds of Vietnam.
References
1.
Calhoun, P. S.,
Beckham, J. C., & Bosworth, H. B. (2002). Caregiver burden
and psychological distress in partners of veterans with chronic
posttraumatic stress disorder.
Journal of Traumatic Stress, 15, 205-212.
2.
Jordan,
B. K., Marmar, C. B., Fairbank, J. A., Schlenger, W. E., Kulka,
R. A., Hough, R. L., et al. (1992). Problems in families of male
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Journal of Consulting and Clinical Psychology, 60,
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3.
Kulka,
R. A., Schlenger, W. E., Fairbank, J. A., Hough, R. L., Jordan,
B. K., Marmar, C. R., et al. (1990).
Trauma and the Vietnam War generation:
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5.
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