BACKGROUND/RATIONALE:
Post-traumatic stress disorder (PTSD), prevalent among returning OEF/OIF/OND Veterans, has a powerful impact on family functioning. Good family relationships appear to moderate its impact; stressful relationships may reduce the benefits of treatment. A program that assists both Veteran and family in coping with the Veteran's PTSD could directly improve the Veteran's re-adjustment and well-being and indirectly improve his/her social and occupational functioning.

OBJECTIVE(S):
The specific aim of this project is to describe the needs and preferences of OIF/OEF service-era veterans with PTSD and their families relevant to family involvement in care.

METHODS:
This two-site study was conducted at the Central Arkansas Veterans Healthcare System (CAVHS, Little Rock, AR) and Oklahoma City (OKC) VAMCs. Qualitative (focus-group or individual) interviews were conducted with 47 Veterans (33 CAVHS/14 OKC) and 36 Veteran-designated family members (19 CAVHS/17 OKC). Veterans were eligible if they were 18-65 years of age, had served in Iraq or Afghanistan since October 2001, had received treatment for PTSD at the CAVHS or OKC VAMCs in the previous 12 months, and had an adult family member who might be willing to participate in an interview. Family was defined broadly to include relatives, significant others, and friends the Veteran considered "as close as family." Separate focus groups were conducted for male Veterans, female Veterans, and family members. Interviews addressed perceived needs related to the Veteran's readjustment to civilian life, desires for family involvement in treatment, types of services that were/would have been helpful and attractive during readjustment, and logistical considerations (e.g., frequency of meetings). Qualitative data were analyzed using the techniques of constant comparison and content analysis. Demographic data, deployment data, and data on preferred program structure and format were collected via a brief anonymous pencil-and-paper questionnaire administered following the qualitative interview.

FINDINGS/RESULTS:
Participating Veterans ranged in age from 21-60 (median: 36 years), were predominantly male (70%), and married/living as married (57%). 40% reported being non-Hispanic Black; 38%, non-Hispanic White; 22%, Hispanic or Other. Most (60%) had deployed at least twice in the preceding 7 years and 98% had seen combat in Iraq or Afghanistan. Participating family members were predominantly female (75%), and the spouse or significant other of a participating Veteran (61%). They ranged in age from 18-66 (median: 37.5 years). The majority reported being non-Hispanic White (53%) or non-Hispanic Black (33%). A quarter of family participants were themselves Veterans; five (14%) had deployed to Iraq or Afghanistan.

It should be noted that participants were asked about the things that had helped or hindered the Veteran's readjustment as well as things they thought would have helped. Thus, a comment about a needed service does NOT necessarily mean the service was unavailable; it may have been used and valued.

A consistent, overarching theme raised by participants was that preparation and support for post-deployment readjustment should begin before deployment, be sustained during deployment, and continue for a substantial period post-deployment. That approach would necessarily involve Department of Defense as well as VA; involvement of other sectors of the community such as schools, civilian primary-care providers, and employers, was also desired.

In the specific context of post-deployment care/programs for Veterans with PTSD, Veterans and family participants uniformly supported involvement of adult family members. Opinions on involvement of children and adolescents in educational and informational (vs. recreational) activities ranged from excluding minors entirely (n=1) to establishing a minimum age for their involvement in selected activities.

Not surprisingly, when asked about the reintegration issues with which they needed/had needed help, the most frequent response from both Veterans and family participants was information for family members about PTSD, its cause, symptoms and course, especially the behaviors/behavioral changes to expect in a Veteran with PTSD. Veterans frequently raised the need for easily accessible information about the VA services available to them and help in navigating the VA system. They also emphasized information and skills for family members to help them cope supportively while living with a person with PTSD, e.g., information to help family understand what deployment was like; skills in communicating, listening, not "triggering," and joint problem-solving in the context of PTSD. While family members emphasized the need for help in supporting the Veteran through readjustment, they were as or more likely to speak compellingly of their own need for support (skills, information, advice) and for support groups for family members, including children and adolescents. Notable among the unanticipated issues raised was help/support for the Veteran in re-learning how to structure and organize his/her own life after years of being told what to do and when to do it.

The most frequently cited obstacles to Veteran or family involvement in a post-deployment program were the time and costs associated with it (travel costs, costs of child-care), the competing demands of work and child-care, and individual attitudes (denial, stigma, apathy). Participants suggested a wide variety of creative approaches to make a program appealing enough to overcome the obstacles to involvement in it. Contrary to expectations about this technologically experienced generation, questionnaire responses from both Veterans and family members showed a strong preference for a program with in-person meetings only (68%-71%) or combined with telephone, e-mail, or internet-based contact (11%) in contradistinction to one that met primarily via video-conferencing, internet or tele-conferencing. This was consistent with a theme that often arose during interviews - the desire for a safe/understanding environment in which they could re-connect, share experiences, share coping tips, and have fun.

IMPACT:
This study addressed critical gaps in knowledge about readjustment-relevant needs and preferences of OEF/OIF/OND Veterans and families, and how best to involve families in treatment. Disseminated with greater detail, findings should contribute to improving quality and outcomes of care by helping VA address two priorities: increasing sustained engagement of OEF/OIF/OND Veterans in mental healthcare and assuring required family programming addresses the needs of this service-era. Findings also reinforce the importance of ongoing VA-DoD efforts to create an effective, seamless transition in mental health programming for soldiers/Veterans.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Fischer EP, Sherman MD, McSweeney JC, Pyne JM, Owen RR, Dixon LB. Perspectives of family and veterans on family programs to support reintegration of returning veterans with posttraumatic stress disorder. Psychological Services. 2015 Aug 1; 12(3):187-98. [view]

Online News Media Articles

1. Fischer EP, Sherman MD, Mcsweeney J, Pyne JM, Owen RR, Dixon LB. Engaging Family Members in Post-Deployment Programs for Iraq and Afghanistan Veterans With PTSD. APA Journals Article Spotlight [Internet]. 2016 Dec 20. Available from: http://www.apa.org/pubs/highlights/spotlight/issue-86.aspx. [view]

DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders, Health Systems
DRE: Treatment - Observational, Prevention
Keywords: Caregivers – not professionals, Deployment Related, PTSD
MeSH Terms: none