Partners of Veterans with PTSD:
Caregiver Burden and Related Problems
A National Center for PTSD Fact Sheet
By 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 Riggs12 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 Wright13 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 Feldman15 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 Bosworth1 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 Litz7 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 Wright13 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 (http://www.va.gov)
and Vet Centers (http://www.va.gov/rcs/)
across the country are beginning to offer group, couples, and individual
programs for families of veterans.
Overall, it seems that the most important message for partners is that
relationship difficulties and social and emotional struggles are common when living
with a traumatized veteran. The treatment options listed above are but a few of
the available approaches that partners may find useful in their search for
improved family relationships and mental health.
Additional Resources
http://www.vietnamveteranwives.com/
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.
Related Fact Sheets
FAQ
about PTSD
Answers to common questions such as: What is the best way to manage stress
related to terrorist events? Who is vulnerable to developing PTSD? How can
you tell when a person needs professional help?
PTSD
and relationships
Describes how trauma and PTSD can have significant effects on relationships
with others
Symptoms of
PTSD
Learn about how traumatic experiences affect people, what survivors need
to know, and the common symptoms of PTSD
The effect
of PTSD on families
Provides information about the effects of PTSD on family members, and how
to cope with the effects
What
is PTSD?
Answers basic questions about the signs and symptoms
of PTSD, who gets it, how common it is, and what treatments are available
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B. K., Marmar, C. B., Fairbank, J. A., Schlenger, W. E., Kulka, R. A., Hough,
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