Staff Perspective: A Dynamic Relationship Model for Couples Experiencing PTSD

Staff Perspective: A Dynamic Relationship Model for Couples Experiencing PTSD

Posttraumatic Stress Disorder (PTSD) does not happen in a bubble – it impacts everyone around that individual, especially close family members living with them. Although various treatments for PTSD exist, there is not much research to determine if individual treatment significantly helps the family problems that can happen in the wake of PTSD. There is a lot of research over the past few decades which supports that Veterans of combat deployments are at a higher risk of engaging in aggression and intimate partner violence (IPV). But more information is clearly needed to determine how to recognize increased risk in specific families and determine how to best mitigate this risk.

In July 2014, Dr. April A. Gerlock and colleagues published their more recent work looking at relationships between couples where one of them have combat related PTSD, titled “Military-related posttraumatic stress disorder and intimate relationship behaviors: A developing dyadic relationship model” (see below for reference). This study specifically looks at the relationship dynamics between male Veterans with PTSD and their partners. By taking their research from a larger study looking at IPV among Veterans, their findings reflect on how these dynamics impact IPV. A theoretical model for relationships where one partner has PTSD is developed that helps clinicians see the relationship dynamics in a multi-dimensional way. We start to see how some couples are able to mitigate the impact of the PTSD symptoms while other couples have difficulty.

This current study was designed to specifically look at the impact of PTSD symptoms on relationship behaviors and to see how these couples handled conflict and how this has changed over time. Interviews and data gathered from the overall Relationship and PTSD Study: Detection of Intimate Partner Violence (NRI: 04-040) was used. Out of the original 441 subjects, 23 couples were identified to use in this study. These couples included a male Veteran having deployments from WWII through Operation Enduring Freedom, with the majority having their first war experience in Vietnam. These Veterans were already in PTSD treatment in various VA and Vet Centers when the parent study was conducted. The 23 couples were selected based on the clarity of the interview recordings and amount of information available in order to make good qualitative analyses. This final selection consisted of 13 couples who met the parent study definition of IPV and 10 which did not.

Qualitative analysis of the relationship dynamics was achieved by analyzing the couple’s interviews. These interviews were done separately in a semi-structured format. Topics covered a range of issues, including family demographics, length of relationships, if the Veterans shared war experiences, how they handled conflict, substance abuse, general violence, caretaking issues, etc. Modified grounded theory was used to look for symbolic interactions and categorized interaction styles, focusing on the perspectives of the participants. A significant goal of the analysis was to identify relationship aspects, or dimensions, that attribute to how couples are impacted by and cope with PTSD, including aspects that could lead to relationship violence and abuse.

After in-depth analysis, the researchers identified multiple relationship dimensions both impacted by and impacting the experience of PTSD. Two specific categories of relationship aspects were developed, Relationship Axes and Relationship Qualities. Relationship Axes are defines as “intertwined areas in which PTSD emerged as impacting relationship functioning” (349) and Relationship Qualities are qualities that affect the degree the PTSD is felt and impact the axes. In other words, Axes are qualities within the relationship that fall along a continuum and are impacted by PTSD symptoms, such as communication. The Qualities impact where on the continuum between distressed and non-distressed each axis falls. The following are the various dimensions found in this study.

                Relationship Axes: specific relationship interactions and aspects impacted by PTSD

  • Caregiving – this is a common theme for PTSD couples, with the partner feeling the need to care for and protect the Veteran from triggers and distress in general. The Veteran can feel both the need for this and appreciation as well as resentment and threatened by the reminder of their inability to take care of themselves and manage their symptoms. Couples can have good communication around this, or the caregiving aspects can lead to couples losing themselves in the roles and tension.
  • Communication – depression, avoidance, need for control, and emotional numbing, all common in PTSD, can lead to significant communication challenges. Couples range from being able to develop strong communication skills around problems and symptoms to feeling like they are completely shut off from each other.
  • Community – interactions with people outside of the family unit can be both essential for support as well as threatening and something to protect the Veteran from. Difficulties in this area can be exacerbated by the differences in military vs. civilian cultures and the Veterans’ ability to navigate between these.
  • Responsibility – interestingly, both the Veteran and partner expressed the belief that the partner is responsible for taking care of the Veteran, to include daily living needs, protection from triggers, and the emotional state of the Veteran. While the Veteran can see their partner as being caring and supportive in these areas, there can also be resentment and feeling overly controlled. Blame can also occur when the partner “fails” to keep the Veteran’s symptoms from being triggered.
  • Trauma – the concept of trauma focused on how the Veteran continued to experience the trauma, not just in terms of memories but in how they felt about and interpreted their experiences. For example, some Veterans have a strong sense of entitlement given what they have experienced.
  • Disability – topics around disability were found throughout the interviews. Disability types included physical issues, cognitive difficulties, and emotional distress. Substance use was discussed in this category given it can be viewed as self-medication to avoid PTSD memories/triggers and numb the Veteran’s experiences. Disability problems can both add to a couples issues with caretaking and responsibility, as well as inhibit their ability to interact with others.          

Relationship Qualities:  these are qualities that affect the degree the PTSD is felt and impact the different axes.

  • Mutuality – defined as “the bidirectional movement of feelings, thoughts and activity between persons” (352). This is reflected with how well the couple communicates, mutually enjoys each other’s company and engaging in activities, and attends to the emotional state of the other.
  • Locus of Control – this reflects how much the person perceives life events as being within their control our outside of their control/ controlled by factors external to them. The goal is for there to be a balanced locus of control.
  • Weakness Tolerance – Veterans in this study described weakness tolerance as the ability to accept limitations and assistance from others. On the other hand, Veterans may be intolerant of their perceived weaknesses and reject those who try to assist them.

Overall, the inter-relatedness of these categories can lead to complex couple dynamics. They may feel distressed in some aspects and do relatively well in others. But the more distress they feel throughout, the more difficulties the couple will have and the likelihood of aggression increases.

While there is not room in this blog to go in to detail about the dimensions above, it is compelling information that I encourage every provider working with Veterans to review. The article diagrams the dimensions together in a way that is very understandable and can help clinicians see the deep impact that these issues have on the experience of PTSD. Excerpts from the interviews are also used to demonstrate ways that both distressed and non-distressed couples may talk about the various dimensions.

Overall, I found this to be an outstanding article outlining the intertwined aspects of relationships and how they are impacted by a partner with PTSD. Clinicians will definitely start to see the multi-dimensional challenges involved in PTSD relationships. After reading this article, I found myself thinking about it during interviews and work with Veterans. It has added more depth on how I see and question them about their relationships, how I view their PTSD impacting them and their family, and how I see their relationships also impacting their experience of PTSD. I am looking forward to future articles by these authors and hope they will begin to identify ways to use this relationship model to better help those impacted by trauma.

Dr. Debra Nofziger is a Deployment Behavioral Health Psychologist with the Center for Deployment Psychology. She currently holds the position at Brooke Army Medical Center in San Antonio Texas.