Jan/Feb 2008

Trauma and the Military Family: Responses, Resources, and Opportunities for Growth
By Michelle D. Sherman, PhD
Social Work Today
Vol. 8 No. 1 P. 36

How can the families of returning war veterans respond to the posttraumatic issues their loved ones bring home, and how can they use these challenges to grow?

“In the beginning of life, when we are infants, we need others to survive, right? And at the end of life, when you get like me, you need others to survive, right?”
His voice dropped to a whisper. “But here’s the secret: in between, we need others as well.”

— Mitch Albom quoting his aging mentor, Morrie Schwartz, in Tuesdays With Morrie

Trauma can have a wide range of consequences for the survivor, including physical, psychological, and spiritual changes. Recently, more attention has been paid to the considerable effects of trauma on the broader family unit. As Morrie Schwartz wisely reminded his young friend, Mitch Albom, in Tuesdays With Morrie, human beings need each other throughout our lives. It takes strength to ask for and allow others to support us through life’s challenges. Experiencing a traumatic event can increase our sense of vulnerability and provide an opportunity for growth in our close relationships. Survivors can gain strength from their intimate relationships, which can be helpful in healing from trauma. Educating family members about various trauma responses can be therapeutic for the entire family.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) defines trauma as “an event that involves actual or threatened death or serious injury” to which the person responds with fear or helplessness. Using this definition, approximately one half of all people experience a traumatic event at some point in their lives. It’s hard to pick up a newspaper without reading about some sort of trauma, such as military combat, natural and man-made disasters, sexual assault, domestic violence, and other kinds of abuse.

Prevalence of Trauma
Men and women serving in the Global War on Terrorism (GWOT) are being exposed to a wide range of potentially traumatic events. Research by Charles Hoge, MD, of Walter Reed Army Medical Center and colleagues (2004) on 894 Army soldiers who had served in Iraq found that 95% had observed dead bodies or human remains, 93% were shot at or received small-arms fire, 89% were attacked or ambushed, and 65% observed injured or dead Americans. It is practically impossible to be exposed to these kinds of events and not be changed by them.

According to the National Center for Posttraumatic Stress Disorder, 20% to 30% of women and 10% of men experience sexual assault at some point in their lives. Further, 20% to 30% of American women are physically abused by a partner at least once.

Common Responses to Trauma
Most people exposed to a traumatic event experience some posttraumatic stress disorder (PTSD) symptoms afterward, but the symptoms generally decrease and eventually disappear. Human beings are resilient and generally recover well. Trauma is almost always life changing but does not have to be life defining.

However, the struggles continue for some trauma survivors, often resulting in depression, anxiety, relationship problems, substance abuse, and PTSD. In fact, according to the National Center for PTSD, approximately one third of those with PTSD develop a chronic form that persists throughout their lifetime.

With respect to the GWOT, Hoge’s second landmark study examined more than 1,700 Army and Marine soldiers after their deployment to Iraq. He looked at their functioning three to four months after returning home and found that 15% to 17% met the criteria for major depression, generalized anxiety disorder, or PTSD; 24% to 35% admitted to using more alcohol than intended; and approximately one third sought mental health services within the first year of being home (Hoge et al, 2004, 2006).

More recent research by Charles Milliken, MD, and colleagues (2007) found that soldiers reported even higher rates of mental health concerns six months after coming home than they did immediately upon returning. While depression, PTSD, and general mental health concerns showed marked increases, interpersonal conflicts increased four times, attesting to the impact of deployment on military families.

Although the adverse effects of trauma receive the greatest attention, many survivors also experience positive changes, termed posttraumatic growth. For example, they may become more aware of inner strength and courage, build empathy for others, grow spiritually, and feel grateful for an opportunity for a “fresh start.” Mental health professionals can gently challenge and empower their clients to explore the positive outcomes that may emerge when working through painful experiences.

Effects of Trauma on Relationships
The common responses to trauma detailed above potentially affect family relationships, both with intimate partners and children. Research with Vietnam-era veterans found an increased risk of divorce; data are still forthcoming on the divorce rate for GWOT marriages. Overall, three major problem areas in relationships exist for trauma survivors.

First, many trauma survivors experience considerable social anxiety. They often dislike groups, crowds, and busy places such as grocery stores and shopping malls. Survivors often avoid family gatherings, which can result in awkward conversations for family members when asked about the survivor’s whereabouts. Sometimes, family members similarly withdraw from social events, increasing their isolation. Survivors’ children may feel confused and hurt when their parents don’t attend important functions such as athletic events or school activities.

Secondly, anger can pose a significant challenge for survivors. Anger can serve as a protective mask for other vulnerable emotions such as fear and depression. One lieutenant colonel wrote in Down Range: To Iraq and Back about how it takes time for service members to change how they deal with anger and other strong emotions, describing how it’s not as simple or rapid as flipping a “switch”: “The journey home marks the beginning of an internal war for the Marines. Give them the space they require to slowly turn the switch. The switch from violence to gentle. The switch from tension to relaxation. The switch from suspicion to trust. The switch from anger to peace. The switch from hate to love...”

Anger can also function to keep loved ones at a distance, diminishing communication and increasing the loneliness in a relationship. Some research has documented an increase in domestic violence among combat veterans with PTSD (Sherman, Sautter, Jackson, Lyons & Han, 2006), so mental health professionals need to assess the risk of violence in these families.

For significant others and children, living with someone who is explosive and frequently irritable can be difficult. Family members often experience their loved one as unpredictable, hostile, and frightening. The damage caused by these angry outbursts to the survivors, their families, and their relationships can be great.

Thirdly, many survivors become emotionally “numb” to avoid facing the pain associated with the trauma. Although this can be functional at times, being cut off from hurt and pain also typically results in an inability to access positive feelings. Consequently, survivors are sometimes emotionally unavailable to their family.

Family members often say that they feel like they’re living as roommates instead of spouses or partners because emotional intimacy is almost nonexistent. Furthermore, survivors commonly struggle in their role as parents, wanting to be present and available to their children but feeling overwhelmed by their painful memories and feelings. These parents may feel uncomfortable with their children’s playful squeals and active behavior and may withdraw from close, warm interactions with them. Children sometimes personalize this withdrawal, wondering why their parent is distant, and they often question what they did to cause their parent to be so quiet and introverted.

For example, in Down Range a paratrooper home from Iraq said, “Before I deployed down range I was different about my wife and kids. Now that I’m back I can only let them get so close before I have to get away from them. I used to have fun letting my boys jump and crawl all over me. We would spend hours playing like that. Now I can only take a couple of minutes of it before I have to get out. I usually get in my truck and drive back to the base to be with my platoon.”

Family-Based Resources for Mental Health Professionals
Given the impact of trauma on the family, social workers are encouraged to include the entire family unit in treatment. The following three approaches/resources may be useful:

• The Support And Family Education (SAFE) Program: Mental Health Facts for Families Program is an 18-session professional curriculum to support adults caring for someone living with emotional problems, including PTSD. Created in 1999, it is one of the first family education programs written specifically for the Veterans Affairs system and is widely used across the country in the private and public sectors.

The SAFE Program is distinct from other family programs because of its inclusion of information about PTSD and other trauma responses. Furthermore, in contrast to some programs (e.g., the Family to Family Program endorsed by the National Alliance on Mental Illness) that use trained family members as facilitators, SAFE Program sessions are led by mental health professionals.

The entire SAFE Program curriculum is available as a free download on the Internet (w3.ouhsc.edu/safeprogram). Each session can stand alone and contains didactic information, discussion questions, suggested activities, and ready-to-use handouts. Most sessions are not specific to one diagnosis and are applicable to a wide range of issues. Sample session topics include the causes of mental illness, family communication tips, do’s and don’ts for family members, and what to do about displays of anger or violence.

Three- and five-year evaluation data of the SAFE Program show that attendance is positively correlated with participants’ increased understanding of mental illness and increased ability to care for themselves.

• Mental health professionals may find the writings of Susan M. Johnson, PhD, creator of emotion-focused therapy (EFT), useful in working with families dealing with trauma. Johnson’s theory and treatment approach draw from research on attachment theory. The therapy works to strengthen the mutually supportive bond in an intimate relationship to deal effectively with trauma and its consequences. Johnson’s book, Emotionally Focused Couple Therapy With Trauma Survivors: Strengthening Attachment Bonds, outlines the rationale for the couples-level intervention and describes this research-based approach.

• Mental health professionals are urged to support families in looking for the growth that can emerge through trauma. For example, the following questions can spark meaningful reflection and discussions in therapy:

- Have you noticed any positive changes in yourself since the trauma? If so, what have you seen?

- Have you noticed any positive changes in your partner since the trauma? If so, what have you seen?

- Have you noticed any positive changes in your relationship since the trauma? If so, what have you seen?

- Have you shared this with your partner? (He or she would probably like hearing that from you.)

— Michelle D. Sherman, PhD, is a licensed clinical psychologist, director of the Family Mental Health Program at the Oklahoma City Veterans Affairs Medical Center, and a clinical associate professor at the University of Oklahoma Health Sciences Center. She cowrote two books for teens, Finding My Way: A Teen’s Guide to Living With a Parent Who Has Experienced Trauma and I’m Not Alone: A Teen’s Guide to Living With a Parent Who Has a Mental Illness (www.seedsofhopebooks.com).

References
Hoge, C.W., Castro, C.A., Messer, S.C., McGurk, D., Cotting, D.I., et al. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351(1), 13-22.

Hoge, C.W., Auchterlonie, J.L., & Milliken, C.S. (2006). Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan.. Journal of the American Medical Association, 295(9), 1023-1032.

Milliken, C.S. Auchterlonie, J.L. & Hoge, C.W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq War. Journal of the American Medical Association, 298(18), 2141-2148.

Sherman, M.D., Sautter, F., Jackson, H., Lyons, J., & Han, X. (2006). Domestic violence in veterans with posttraumatic stress disorder who seek couples therapy. Journal of Marital and Family Therapy, 32(4), 479-490.