Posttraumatic Stress, Family Adjustment, and Treatment Preferences ...

ORIGINAL ARTICLES Authors alone are responsible for opinions expressed in the contribution and for its clearance through their federal health agency, if required.

MILITARY MEDICINE, 176, 2:126, 2011

Posttraumatic Stress, Family Adjustment, and Treatment Preferences Among National Guard Soldiers Deployed to OEF/OIF Anna Khaylis, PhD*; Melissa A. Polusny, PhD*tt; Christopher R. Erbes, PhD*t; Abigail Gewirtz, PhD§; COL Michael Rath\\ ABSTRACT We used an anonymous self-reported questionnaire to assess posttraumatic stress disorder symptoms, relationship concerns, and treatment preferences including interest in family-focused interventions among 100 National Guard Soldiers who were recently redeployed from Iraq or Afghanistan. We found that the majority of married or partnered soldiers were concerned about getting along with their partners, while the majority of parents were concerned about their child-rearing practices. Posttraumatic stress disorder symptoms were significantly associated with the degree of relationship concerns. Soldiers showed a striking preference for family-based interventions over individual treatment, highlighting the importance of developing family-based interventions tailored to address post-deployment mental health and co-occurring family problems.

INTRODUCTION As cotiflicts iti Afghanistati (Operatioti Enduring Freedom [OEF]) atid Iraq (Operatioti Iraqi Freedotn [OIF]) contitiue, the Departmetits of Defetise atid Veterans Affairs (VA) face the challenge of meeting the deployment-related mental health needs of a growing number of military service personnel returning from combat duty. To date, over 1,8 million troops have served in OEF or OIF, with nearly half of these troops activated from the National Guard and Reserve (NGR) component. With the historically unprec*Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN 55417. tCenter for Chronic Disease Outcomes Research, One Veterans Drive, Minneapolis, MN 55417. ^University of Minnesota Medical School, 420 Delaware Street SE, Minneapolis, MN 55455. §Department of Family Social Science and Institute of Child Development, University of Minnesota, 290 McNeal Hall, 1985 Buford Avenue, St. Paul, MN 55108. llMinnesota Army National Guard, 445 North Minnesota Street, St. Paul, MN 55101. The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of Veterans Affairs, Department of the Army, or Department of Defense. None of the authors report current or future competing interests or disclosures of financial interests and relationships.

126

edented deployment of NGR troops who tend to be older and more likely to be married with families, over 2,7 million family members have been affected by their service members' deployments to OEF or OIF' All OEF or OIF veterans, including those from NGR, are eligible to receive military service-related VA health care at no cost for 5 years following separation from active duty,' In light of the negative influence of combat-related posttraumatic stress disorder (PTSD) on family relationships and the potential for families to provide an important source of social support for combat veterans, there is a pressing need for the VA to address the family concerns of this newest generation of combat veterans. However, there are relatively few empirically validated interventions for addressing the combination of family functioning and individual posttraumatic distress within veteran populations. Moreover, less research has examined whether family-based interventions may be more acceptable or preferable to OEF or OIF combat veterans over individual interventions. This study begins to address this gap in the literature. As with previous eras of combat veterans, OEF or OIF veterans seeking VA health care frequently report post-deployment mental health concerns. Analysis of VA administrative data from over 100,000 OEF or OIF veterans shows that PTSD was the most common mental health diagnosis among those

MILITARY MEDICINE, Vol. 176, February 2011

Treatment Preferences among OEF/OIF Soldiers

veterans seeking help at VA health care facilities.^ Specifically, 26% of OEF or OIF veterans treated at VA were diagnosed with mental disorders, with PTSD diagnosed in 10% of treated veterans.' Compared with OEF or OIF veterans from the active duty component, NGR troops report higher rates of PTSD and other mental health problems initially after returning from deployment. These problems appear to escalate further during the months of réintégration following deployment." At the same time, a significant number of OEF or OIF veterans may not readily seek needed mental health treatment because of concerns about stigma and other barriers to care.'' Moreover, rates of drop-out from PTSD treatments are twice as high among OEF or OIF veterans as among combat veterans from the Vietnam War.' Without effective treatment, chronic PTSD can be disabling, with high rates of co-morbidity," unemployment, and social impairments.' In particular, the negative influence of PTSD symptoms on romantic partner and parent-child relationships has been well documented and may lead to poor outcomes for both the family and the individual with PTSD.'" Research has shown that PTSD symptoms among veterans are associated with greater marital distress," higher rates of intimate partner violence,'^ and higher rates of divorce.' Veterans with PTSD and their partners report significantly more relationship distress, difficulties with intimacy, and relationship problems. Additionally, veterans' symptoms of emotional numbing are particularly associated with relationship distress." A related line of research has shown that increased PTSD symptoms in veterans are also related to higher rates of psychological difficulties and marital distress among their partners." A recent study found that wives of recently returned OEF or OIF National Guard Soldiers exhibited elevated levels of depression and PTSD compared with community samples.'" Interestingly, spousal symptoms of depression and PTSD correlated much more strongly with spouses' perception of soldiers' symptoms than with soldiers' self-reported symptoms. Moreover, marital satisfaction was negatively related to soldiers' self-reported symptoms only when spouses perceived low levels of combat exposure in their soldier husbands, highlighting the importance of communication, attribution of symptoms, and marital functioning among veteran couples.'"* PTSD symptoms in veterans also have a significant negative influence on their children and parenting styles. Children of veterans with PTSD tend to experience greater rates of behavioral problems, academic difficulties, and social impairment.""' In addition, research has suggested that veterans with PTSD symptoms experience difficulties with parenting satisfaction and a decreased quality of parent-child relationships.'^•"' Several studies have shown that severity of PTSD and emotional numbing symptoms are associated with various aspects of the father-child relationship and poorer satisfaction with parenting."'" Symptoms of PTSD in veterans may lead to greater disruptions in their family relationships, which may in turn worsen

MILITARY MEDICINE, Vol. 176, February 2011

the PTSD symptoms through the mechanism of social support, a posttrauma factor that may play a significant role in the trajectory of PTSD symptoms. A high level of social support post-deployment can serve as a crucial protective factor against worsening of PTSD symptoms.''^"" A primary source of social support for veterans is marital and family relationships^"" and, if lacking, may contribute to worsening of PTSD symptoms. It is also possible that conflict within families, either between partners or with children, may serve as a source of stress for veterans with PTSD, leading to greater withdrawal or otherwise increased symptoms. To stabilize social support and minimize symptoms, it is crucial to address relationship functioning in the context of PTSD treatment. Veterans with PTSD and their families face an array of challenges, with implications for the veterans, their partners, and their children. Efforts to provide treatment that bolsters family functioning for veterans with PTSD and simultaneously addresses the symptoms of PTSD are relatively new and under-studied.^*" As such treatments are developed, investigated, and implemented, it is also important to consider the willingness of OEF or OIF veterans to engage in familybased interventions. One anonymous survey of 114 veterans receiving treatment from a specialized PTSD clinic found that nearly 80% of veterans reported interest in increasing family involvement in their VA treatment.^" However, given the brevity of the survey, the combat era of veterans (e.g., Vietnam War, OEF or OIF) was not assessed, limiting the utility of findings to understanding the treatment preferences of OEF or OIF veterans. Although there is clearly a need for familybased interventions for combat veterans, it is unclear whether or not recently returned OEF or OIF veterans perceive such need or express interest in family-based interventions. Given the high drop-out rate among OEF or OIF veterans,' it may be necessary to tailor services for the specific needs and interests of this generation of veterans. This study examines the needs and interests of a sample of OEF and OIF deployed Army National Guard Soldiers pertaining to their relationship functioning and family-based interventions. METHODS Procedures One hundred National Guard Soldiers were invited to participate in a paper-and-pencil survey conducted during a postdeployment Soldier Readiness Program over 2 weekends of consecutive months. Soldiers received a cover letter and a self-report questionnaire (response rate = 97%). The cover letter detailed the purpose of the study and described the risks and benefits of participating. Written informed consent was waived, returning a completed survey-implied consent. The 5-page survey assessed demographics, PTSD symptoms, relationship satisfaction, concerns about relationships and mental health care, and likeliness of accessing various types of mental health care services. This study was approved by the human

127

Treatment Preferences among OEF/OIF Soldiers

subjects research review committees of the Minneapolis VA Medical Center, and all study procedures were approved by National Guard command. Per military regulations, no incentives were provided for participation. Participation was voluntary and anonymous. We assessed PTSD symptoms using the Primary CarePTSD Screen (PC-PTSD),^' a 4-item screening questionnaire designed for use in primary care and other medical settings. The measure cues respondents to a traumatic event and asks if they have had nightmares or intrusive thoughts about the event, avoided reminders or thoughts about the event, were hypervigilant or easily startled, and felt numb or detached. Prior research has established a cutoff score of 2 or more positive responses as a positive screen for PTSD symptoms, yielding a sensitivity of 0.91 and a specificity of 0.72 compared with the Clinician-Administered Scale for PTSD'" for diagnosing PTSD.2' We assessed relationship satisfaction using the global item from the Dyadic Adjustment Scale.^' Respondents rated their degree of happiness with their marriage or primary relationship (1 = "extremely unhappy," 2 = "fairly unhappy," 3 == "a little unhappy," 4 = "happy," 5 - "very happy," and 6 - "extremely happy"). Research has shown that this item correlates highly with the total Dyadic Adjustment Scale score.'^ We also asked participants in a marital or romantic relationship to rate how concerned they were about their family adjustment in terms of getting along well or communicating with their partner (1 = "not at all concerned," 2 = "mildly concerned," 3 = "concerned," and 4 = "very concerned"). We asked parents to rate how concerned they were about childrearing or getting along well with their children (1 = "not at all concerned," 2 = "mildly concerned," 3 = "concerned," and 4 = "very concerned"). We also asked them to rate if parenting was more stressful after returning from deployment (1 - "strongly disagree," 2 = "somewhat disagree," 3 - "neither agree nor disagree," 4 = "somewhat agree," and 5 - "strongly agree"). Finally, we asked all participants about the extent to which they would consider accessing various forms of mental health treatment, such as individual, group, or couple/family therapy (1 = "would not use," 2 - "might consider using," 3 - "would strongly consider using," and 4 - "would definitely use").

Participants Participants were 97 (90 male and 7 female) Army National Guard Soldiers who had been previously deployed to OEF or OIF. They were recruited to participate in the survey as part of a Soldier Readiness Training Program. As illustrated in Table I, the majority of participants were identified as Caucasians, which is consistent with the National Guard population of the state. Most participants reported completing at least some college degree. Less than half were married or living with a romantic partner, and over one-third reported being parents or caregivers of children. Mean age ofthe participants was 28.5 years (SD = 6.3). Participants on average reported 1 deployment to OEF or OIF (SD = 1 ).

128

TABLE 1.

Demographic Characteristics {N=91)

Variables

n

Percentage (%)

Gender (% Male) Race White/Caucasian Black/African-American Hispanic/Latino Pacific Islander/Asian-American American Indian/Alaska Natives Others Education High School Diploma/General Educational Development (GED) Diploma Some College/Associate of Arts (AA) Degree 4-year College Degree Graduate Degree Employment Full-time Part-time Unemployed Marital Status (% Married/Co-habitating) Parental Status (% Parents of Children)

90

92.8

87 2 3 3 1 1

89.7 2.1 3.1 3.1 1.0 1.0

20

20.6

65

67.0

10 2

10.3 2.1

55 15 27 42 36

56.7 15.5 27.8 43.3 37.1

RESULTS Frequencies of soldiers' reports of PTSD symptoms and other post-deployment mental health concerns are shown in Table II. Overall, nearly half of the sample screened positive for PTSD symptoms based on the recommended cutoff score of 2 or more on the PC-PTSD. Over one-quarter reported experiencing nightmares or intrusive thoughts, avoiding trauma-related thoughts and situations, and almost half reported feeling numb and/or emotionally detached and being on guard, watchful, or easily startled. A substantial number of soldiers reported feeling that it was difficult to move on with life as usual after deployment, and the majority was concerned about their ability to manage emotions and reactions in the past year. Among the subsample of participants {n = 42) who reported being married or living with a romantic partner, more than half screened positive for PTSD, agreed that it was difficult to move on with life as usual after deployment, and were concerned about their perceived ability to manage emotions and reactions in the past year. A quarter of partnered soldiers reported that they were unhappy in their relationship, and over three-fourths of partnered soldiers reported that they were concerned about getting along well with and communicating with their romantic partner. Relationship satisfaction was significantly associated with PTSD symptoms, with those soldiers reporting greater relationship dissatisfaction endorsing more PTSD symptoms (Spearman's rho -0.3\,p< 0.05). The percentage of partnered soldiers willing to consider couple counseling (76%) was significantly greater than the percentage willing to consider individual counseling (64%), x^ (l,n = 41) = 0.13;p