PTSD and Marriage/Family Keith Armstrong, LCSW Clinical Professor, UCSF Director, Couples/Family Clinic SFVA Victoria Tichenor, Ph.D. Associate Clinical Professor, UCSF Director of Training, PTSD Clinic SFVA

PTSD and Marriage/Family Experience at SFVA z Research on Families and PTSD z Expression of PTSD within the Couples System z Treatment z

• Vietnam Veterans • Newly Returning Veterans

Experience at SFVA Couples z Male Vietnam Veterans z Heterosexual z Remote Trauma—established symptoms z Modern Deployments z

Experience at SFVA 1.6 Million newly returning Veterans z Treatment z

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Private/Public Hospitals Community Mental Health VA Private Practice

Research on Couples/Family and PTSD z z

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Nationally representative sample of Vietnam veterans and families Assessed female partner of veterans diagnosed with PTSD and female partner of veterans not diagnosed with PTSD Reported lower levels of happiness and life satisfaction, higher demoralization scores when vet diagnosed with PTSD

NVVRS; Jordan et al; 1992

Research on Couples/Family and PTSD z

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Veterans diagnosed with PTSD and their partners reported more marital, parental and family adjustment problems than veterans not diagnosed with PTSD and their partners 60% of veterans diagnosed with PTSD and their partners report medium to high levels of marital problems More reports of violence in “PTSD families”

NVVRS; Jordan et al; 1992

Research on Couples/Family and PTSD z

Children of veterans diagnosed with PTSD are more likely to have behavioral problems than children of veterans without PTSD

NVVRS; Jordan et al; 1992

Research on Couples/Family and PTSD z

Subjects: Male veterans of the 1982 Arab-Israeli War and their partners

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When veterans’ partners indicated veteran had PTSD and combined with a prior stress reaction diagnosis, partner reported more psychiatric problems than did partners of veterans without stress-related problems

Solomon et al, Family Process, 1992

Research on Couples/Family and PTSD z

Partners’ Problems Included: » Depression, obsessive-compulsive problems, anxiety, paranoid ideation, interpersonal sensitivity, hostility, and somatic complaints » Inner feelings of loneliness » Impaired marital and family relations » Lack of satisfaction with the wider social network

Solomon et al, Family Process, 1992

Research on Couples/Family and PTSD z

One year after war married soldiers diagnosed with CSR reported a higher number of symptoms and higher rates of PTSD than unmarried soldiers diagnosed with CSR

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Higher rates of PTSD among married soldiers are associated with low expressiveness (openness of expression), low cohesion (the degree to which family members feel committed to each other), and high conflict (anger, violence, and struggle)

WHY?

Research on Couples/Family and PTSD z z z z z z

Marriage is inherently stressful Depletion of coping resources make it difficult to handle marital demands CSR casualties may have a greater difficulty in reassuming roles as father and husband Roles change while away which can increase tension at home Did not measure marital satisfaction Did not examine having children

Solomon et al, Family Process, 1987

Research on Couples and PTSD z z z

50 Vietnam veterans with and without PTSD and their partners 70% of Vietnam veterans with PTSD and their partners report relationship distress 30% of Vietnam veterans without PTSD and their partners report relationship distress

Riggs et, al, JTS, 1998

Research on Couples and PTSD z z

Relationship distress correlated with severity of PTSD symptoms Emotional numbing appears to be the most problematic symptom in couples with male veteran diagnosed with PTSD

Riggs et, al, JTS, 1998

Expression of PTSD Symptoms within the Couple System

Expression of PTSD Symptoms within the Couple System z

Intrusions Appearing self absorbed, disconnected Feeling different, toxic Often leads to avoidance (emotional withdrawal) and arousal

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Result Anger, Fear, Rejection, Self Blame Lack of discussion Incorrect attributions

Expression of PTSD Symptoms within the Couple System z

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Avoidance Feeling deadened-- Lack of intimacy or difficulty sustaining Withdrawal during times of emotional intensity Desire to avoid overstimulation Result Emotional distance Social Isolation, limited activities Difficulty investing in relationship, life

Expression of PTSD Symptoms within the Couple System z

Arousal Irritability and/or Explosive anger Sleep difficulties Safety Issues

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Result Avoidance of Conflict Difficulty Negotiating Desire to protect—tight boundaries

Expression of PTSD Symptoms within the Couple System z

Survivor Guilt Feelings of not deserving happiness and good quality of life in a relationship Focus on the past

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Result Inability to relax, have fun, enjoy the moment Partner may become resentful, depressed, overprotective

Expression of PTSD Symptoms within the Couple System Control Issues Emotions Environment Others z Result Undercontrol: Overcontrol: z

lack of investment overcritical mistakes kill

Systems and PTSD Participation in various systems affect symptoms of PTSD z Couples’ interactional patterns can increase, decrease, or maintain PTSD symptoms z Couples’ interactional patterns can affect the couples’ well being in their larger family and community z

Developmental Issues Length/Number of Marriage Distance from Trauma Trauma in Partner Age of Partners Children

Focus on Family Strengths Encourage/ mobilize adaptive coping Discourage negative view of family Engender hope for change

Treatment of Couples and PTSD

Ground Rules for Treatment in Couples Therapy Confidentiality Explicit Treatment Contract No Violence No Threats of Divorce No Retaliation

Assessment for Couples Therapy Relationship history Family of origin history Substance abuse history Traumatic Events history Role functioning Distribution of power in the relationship

Assessment for Couples Therapy Affect Tolerance Communication Skills Investment in Relationship Ideas about the Problem, Change Responsibility

Interventions with Couples z z z

Obtain an agreed upon problem focus Clarify Couple’s goals Educate the couple / family about PTSD • • • •

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Diagnosis Biology Social Impacts Treatment

Use of homework

Discussion of Traumatic Event z z z

Couples therapy does not have to involve discussion of Trauma Choice not to discuss: does not preclude a general discussion Choice to discuss: • • •

Establish Safety Small Parts Groundrules

When to Refer Violence Substance Abuse Stabilization Medication Trauma work Partners treatment Suicidality Psychosis

OEF/OIF Couples Which relationships are we talking about? z Met before hand and had a relationship prior to deployment (maybe children) z Met before hand and have little to no history of relationship (don’t really know each other) The impact of multiple deployments z Met after the war

OEF/OIF video Met after war z Confidential material z Session 5 z 15 minute clip z

OEF/OIF video Couple dealing with practical problem z Informal PTSD education z Partner’s dilemma z Developing a plan for the future z Strengthening the “we-ness” of the couple z

OEF/OIF vets and their partners z z z z z z z z

Arousal heightened in OEF/OIF veterans Impulsivity more prominent Substance use Hopeful about relationship Have not yet experienced demoralization Willing to try How to help if they fail? Engender and maintain hope

OEF/OIF vets and their partners z z

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Interacting with the world- going out more, dealing with work and social problems Couples’ interactional cycles are more fluid in younger relationships and with younger people Education regarding relationships and regarding specific PTSD symptoms is more extensive with OEF/OIF couples Family of origin issues are typically more predominant (obtain detailed genogram)

OEF/OIF z

Therapist seen as wise (read old) with OEF/OIF veterans QuickTime™ and a decompressor are needed to see this picture.

Vietnam vets and their partners z z z z z z

Numbing more predominant Physiological arousal (reactivity) has decreased in Vietnam vets and partners Want to get it right this time with their relationship Maturity about relationships that can come with age Interaction patterns more rigidified in their response to stress Helping the couple move toward acceptance of the role of PTSD in their lives

When OEF/OIF vet has recently returned to family z z z z z

Helping the couple share their day to day lives together again Parents resuming co-parenting together Adult children maintaining relationships with their parents and siblings Decision making Vet feeling like an outsider

Curran, 2007

When OEF/OIF vet has recently returned to family z z z

Has the couple been able to resume routines, or develop new equally satisfying ones? Did the returning family member miss any significant family events? Did the family put anything on hold during the family member’s absence that now needs attention?

Curran, 2007

When OEF/OIF vet has recently returned to family z

Has anyone who helped the family still feel like more a “part of the family” than couple would ordinarily want them to be? »

If so, couple could benefit from coaching about how to “uninvite” a helper from their family – “We sure appreciate your having helped us out while ____ was away. We’re really glad and relieved to be back together again so we can take care of our family ourselves. It feels great that we know we can always turn to you if we need help again.”

Curran, 2007

OEF/OIF Interventions for Couples Define the interactional cycle and make sure the couple understands their own participation in the cycle z Education about: Relationships Impact of war z

OEF/OIF Interventions for Couples z z

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Work toward de-escalation of interactional cycle (Johnson et al, 2005) Reframe problem in terms of the cycle, emotions, and underlying attachment needs (Johnson et al, 2005) Make sure the non veteran partner’s concerns are addressed. Vet’s concerns/issues can take up a great deal of space

OEF/OIF interventions Changing interactional positions Promote identification with disowned attachment needs Promote acceptance by each partner of the other’s experience Facilitate the expression of needs and wants to restructure the interaction based on new understanding of self and partner z

Johnson, et al, 2005

OEF/OIF interventions Consolidation and integration Facilitate new solutions to old problems Consolidate new positions and cycles of attachment behaviors

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Johnson et al, 2005

OEF/OIF Interventions Intrusions Help to develop and communicate plan of action with partner Grounding etc. z

“Other soothing” strategies “I am here and you are safe”.

Sherman, 2004

OEF/OIF Interventions Avoidance Reframing avoidance as being “concerned or worried” Emphasize how much vet cares about partner

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OEF/OIF Interventions Arousal Negative affect reciprocity Working to slow down interactions so that behaviors are better understood by both members of the couple Careful use of time outs

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For families facing additional deployments

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Making the most of the time they have together without engaging in reckless behavior (spending too much etc.) Preparing for future separations Parents helping children anticipate further absence of the parent

Curran, 2007

National Center for PTSD Handouts NCPTSD.org z z z z z

Talking to children about going to war Coping when a family member has been called to war War related stress reactions: What families need to know Homecoming after deployment: Dealing with changes and expectations Effects of going to war on family members of active duty personnel

Curran, 2007

Resources for vets and families z

Websites Places to obtain useful websites: NCPTSD.org Courageafterfire.com

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Books – for adults While They’re at War: The True Story of American Families on the Homefront,” by Henderson Courage After Fire: Coping Strategies for Returning Soldiers and Their Families, by Armstrong, Best and Domenici

For Families with young kids Sesame Street video z PTSD and the Family: For Parents of Young Children – Canadian VA z Articles on line about coping with babies crying z

Curran, 2007

Thanks