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IIR 08-308 – HSR&D Study

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IIR 08-308
Complicated Family Reintegration in OEF-OIF Veterans
Steven L. Sayers PhD
Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
Philadelphia, PA
Funding Period: June 2010 - September 2015

BACKGROUND/RATIONALE:
There is extensive evidence that PTSD, Depression, and other psychiatric complications of combat trauma can have a negative impact on marital and family functioning. It is not clear, however, the pathway or mechanism by which the sequelae of combat exert this impact. Most of the existing models of trauma applied to the understanding of combat veterans and their family members do not take into account the family reintegration processes that these families experience.


OBJECTIVE(S):
The purpose of this research project was to understand better how war-related psychiatric symptoms of OEF/OIF veterans may interfere with family reintegration and negatively affect family functioning. This study sought to test whether difficulties with family reintegration account for the impact of psychiatric symptoms on overall family functioning over time.

METHODS:
The study planned a sequential mixed methods design with the qualitative aspect secondary to the quantitative aspect. The quantitative aspect of the study was planned as a non-treatment two-wave (Baseline and 12-month follow-up) clinical assessment of military veterans with a target N=220 and their family members recruited within 2 years of their return from OEF-OIF deployments. We hypothesized that psychiatric symptoms, namely, depressive mood, trauma-related avoidance, and emotional numbing will be associated with reintegration problems. The qualitative aspect of the study consisted of semi-structured interviews, administered separately to each spouse. Qualitative interviews were conducted after entry into the study with a purposive-subsample of veterans and their spouses (target N= 40 dyads). Interview data were generated from open-ended and interviewer follow-up questions, with data analysis following the grounded theory approach.

Recruitment was through evaluation referrals, primary care, and the Women's Clinic providers, and in addition, area military reserve and National Guard units were sought to participate in recruitment. Assessments were conducted with the veteran, his/her spouse by interview at the VA Medical Center, or by telephone using a structured set of interview assessments, conducted separately for each spouse. Due to the difficulty in recruiting OEF-OIF veterans who were married/partnered, returned from deployment within the last two years, we expanded the study entry criteria tied to military discharge within 3 years prior to study entry, and we recognized were unlikely to obtain an adequate sample to evaluate the quantitative goals of the study. The interviews assessed anxiety, depressive and other psychiatric symptoms, family reintegration, overall family functioning, and a range of demographic and military service covariates. Baseline interview took approximately 55 - 65 minutes for each member of the couple and the qualitative interviews extended for 45-75 minutes. Each spouse was paid from $60 to $80 for each interview for their participation. Follow-up interviews were conducted with a portion of the sample

FINDINGS/RESULTS:
Qualitative data analyses have been conducted on interviews of Veterans (N=30) and non Veteran spouses (N=24), including a same-sex, dual-career, and female Veteran couples. A minority of Veterans (40%) and their spouses (30%) were maritally dissatisfied, and 47% of Veterans had clinically significant PTSD. There was an insufficient sample to evaluate the quantitative hypotheses planned for the study.

The findings indicated that the degree and type of relationship commitment emerged as an important factor in relationship success and satisfaction after deployment. Spouses who made an 'a priori' commitment to relationship success appeared to be significantly strengthened in the post-deployment period, whereas those with tentative and 'wishful' thoughts about relationship commitment were less successful and satisfied. Those most satisfied and committed also were able to gain greater post-deployment relationship growth, confidence and meaning after the trauma of combat deployment. Finally, regarding divisions of labor, nondeployed spouses relinquished household responsibilities to returning combat Veterans reluctantly, especially for those Veterans with PTSD.

Additional analyses demonstrated that communication during a combat deployment is important tool for helping couples manage stress and maintaining their relationship, with several caveats. First, deployment communication can be highly unpredictable, within and across deployments. Deployment conditions and thus communication with spouses are highly variable and communication blackouts lead to increased unpredictability and anxiety. Second, the content and depth of what couples discuss both influence the impact of the communications. Deployed service members likely withhold information to protect their spouses from unneeded anxiety and themselves from emotional vulnerability--spouses often sense the service members' emotional unavailability. When everyday family problems are discussed electronically, this can be stressful for deployed service members, particularly for unhappy couples. Yet it may be difficult for couples to avoid discussing important family issues when the spouse is experiencing critical situations at home. Planning for the desired degree and type of deployment communication prior to the deployment was accomplished by a few couples and likely led to better outcomes.

IMPACT:
These findings suggest that couples who plan deliberately in advance of a combat deployment for changes they may experience, and discuss their preferences for deployment communication, may fare better following the deployment. In addition, the findings suggest that there are the following opportunities for intervention development with couples following deployment: 1) helping couples renew or reconsider factors in their relationship following deployment, rather than trying to return to the status quo from prior to the deployment, and 2) helping couples in which the Veteran has significant PTSD or other injury with reintegration so that the Veteran's couple and family role can be maximized, rather than minimized, which is likely the more common tendency.

PUBLICATIONS:

Journal Articles

  1. Sayers SL, Barg FK, Mavandadi S, Hess TH, Crauciuc A. Deployment communication: Underlying processes and outcomes. Journal of family psychology : JFP : journal of the Division of Family Psychology of the American Psychological Association (Division 43). 2018 Feb 1; 32(1):3-11.
  2. Sayers SL, Rhoades GK. Recent advances in the understanding of relationship communication during military deployment. Journal of family psychology : JFP : journal of the Division of Family Psychology of the American Psychological Association (Division 43). 2018 Feb 1; 32(1):1-2.
  3. Hershenberg R, Mavandadi S, Klaus JR, Oslin DW, Sayers SL. Veteran preferences for romantic partner involvement in depression treatment. General hospital psychiatry. 2014 Nov 1; 36(6):757-9.
  4. Dausch BM, Cohen AN, Glynn SM, McCutcheon S, Perlick DA, Rotondi AJ, Sautter FJ, Sayers SL, Sherman MD, Dixon L. An intervention framework for family involvement in the care of persons with psychiatric illness: further guidance from Family Forum II. American Journal of Psychiatric Rehabilitation. 2012 Mar 9; 15(1):5-25.
  5. Sayers SL. Family reintegration difficulties and couples therapy for military Veterans and their spouses. Cognitive and behavioral practice. 2011 Feb 1; 18(1):108-119.
  6. Adler DA, Possemato K, Mavandadi S, Lerner D, Chang H, Klaus J, Tew JD, Barrett D, Ingram E, Oslin DW. Psychiatric status and work performance of veterans of Operations Enduring Freedom and Iraqi Freedom. Psychiatric services (Washington, D.C.). 2011 Jan 1; 62(1):39-46.
  7. Pomerantz AS, Sayers SL. Primary care-mental health integration in healthcare in the Department of Veterans Affairs. Families, systems & health : the journal of collaborative family healthcare. 2010 Jun 1; 28(2):78-82.
VA Cyberseminars

  1. Sayers SL. Success and failure in family research: trial and tribulations of involving Veterans’ intimate partners. [Cyberseminar]. 2014 Jul 21.
Conference Presentations

  1. Sayers SL. Challenges faced by military families during and post deployment. Paper presented at: North Carolina Division of Mental Health, Development Disabilities, and Substance Abuse Practice Improvement Collaborative Highlighting Military Conference; 2015 Mar 10; Raleigh, NC.
  2. Sayers SL. Reintegration, PTSD and couple functioning of military Veterans of the Iraq and Afghanistan wars. Paper presented at: Uniformed Services University of the Health Sciences Research Week Annual Meeting; 2015 Feb 12; Bethesda, MD.
  3. Sayers S, Barg F, Mavandadi S, Hess T, Stanely S, Erbes CR, Polusny MA, Arbisi P, Curry J, Kiser L, Ventimiglia A, Dowling L, Carter P, Renshaw K. Pre- and post-deployment prediction of complicated family reintegration: findings from two samples of National Guard Veteran/partner dyads. Paper presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2014 Nov 21; Philadelphia, PA.
  4. Sayers SL. Treating military and Veteran couples: clinical approaches and treatment considerations. Paper presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2013 Nov 23; Nashville, TN.
  5. Sayers SL, Mavandadi S. Outreach to family member of Veterans not engaged in mental health care: adventures in public health messaging. Poster session presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2013 Nov 22; Nashville, TN.
  6. Sayers SL, Mavandadi S. Couple reintegration and resilience of military Veterans of the Iraq and Afghanistan wars. Paper presented at: International Society for Traumatic Stress Studies Annual Meeting; 2013 Nov 7; Philadelphia, PA.
  7. Schmitz TM, Haywood JL, Layton WB, Cooper EB, Sayers SL. Dyadic resilience: a new construct in Veteran couples. Poster session presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2012 Nov 18; National Harbor, MD.
  8. Sayers SL, Schmitz TM, Mavandadi S, Barg F, Hess T, McCabe A, Hoedeman A. Couple and family reintegration problems of military Veterans of the Iraq and Afghanistan Wars. Paper presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2012 Nov 17; National Harbor, MD.
  9. Mann-Wrobel M, Hess T, Straits-Tröster K, Glynn S, Close J, Ventimiglia A, Wong M, Sayers SL. PTSD, co-occurring symptoms, and targeted coaching interventions provided to family member callers seeking to engage Veterans in care: data from Coaching Into Care’s first year as a national service. Paper presented at: International Society for Traumatic Stress Studies Annual Meeting; 2012 Nov 2; Los Angeles CA.
  10. Sayers SL. Military and Civilian Partnerships: Extending the Bridge to Meet the Short- and Long-Term Needs of Military Families and Their Young Children. Paper presented at: National Training Institute Annual Conference; 2011 Dec 8; National Harbor, MD.
  11. Sayers SL, Whitted P, Straits-Troster K, Hess T, Fairbank J. Families At Ease: A National Veterans Health Administration Service for Family Members of Veterans to Increase Veteran Engagement in Care. Paper presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2011 Nov 13; Toronto, Canada.
  12. Sayers SL. Coaching into care: a pilot program to enhance outreach to military Veterans and their family members. Paper presented at: VA Mental Health Annual Conference; 2011 Aug 23; Baltimore, MD.
  13. Sayers SL. Families-at-ease: a pilot program to enhance outreach to military Veterans and their family members. Paper presented at: American Psychological Association Annual Convention; 2011 Aug 7; Orlando, FL.
  14. Sayers SL. Can't you just make him go to treatment? Coaching family members as a means of increasing Veteran engagement in care. Paper presented at: American Psychological Association Annual Convention; 2011 Aug 7; Orlando, FL.
  15. Sayers SL. Families-at-ease: a pilot program to enhance outreach to military Veterans and the family members. Paper presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2010 Nov 19; San Francisco, CA.
  16. Clark L, Sayers SL, Starver K, Tew J, Good CB, Peters J, Burke T, Haas GL, Pasquale A, Ehman K, Klaus J. Improving access and safety of varenicline for smoking cessation using telephone care management. Poster session presented at: VA Implementing a Public Health Model for Meeting the Mental Health Needs of Veterans Annual Mental Health Conference; 2010 Jul 28; Baltimore, MD.
  17. Schmitz T, McCabe A, Barron A, Dichter ME, Sayers SL. Impact of fear related to domestic violence on treatment seeking in a sample of recently returned military veterans (OEF/OIF). Poster session presented at: VA Implementing a Public Health Model for Meeting the Mental Health Needs of Veterans Annual Mental Health Conference; 2010 Jul 28; Baltimore, MD.


DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders
DRE: Treatment - Observational
Keywords: Anxiety Disorders, Caregiving, Deployment, Depression, Family, Gender Differences, Operation Enduring Freedom, Operation Iraqi Freedom, Reintegration Post-Deployment
MeSH Terms: none

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