PTSD Discussion

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"Helping Vets with PTSD" --

"CNN: Some Women Return from War with PTSD" --

"Female Veterans Coping with PTSD" --

M13DB - DB Group 3

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Background

In this module we've learned that a condition like PTSD may have effects that range beyond those symptoms exhibited by the affected person and that with any physical or mental health condition our identities play a role in how symptoms manifest and in how amenable we are to treatment.

Instructions

Using only the material in this module, discuss how at least three different identities or statuses (e.g., sex, veteran, age) might interact to make a condition like PTSD either more complicated or perhaps more navigable (that is, harder or easier to live with and treat) and to affect family and loved ones. You may reference characters in ODAAT or you may think more generally. Your post should include responses to the following prompts in three paragraphs.

  • Identify the three identities/statuses and define each of them.
  • Describe how the three identities/statuses might interact to make a condition like PTSD more complicated or perhaps more navigable for the affected person.
  • Describe how that same interaction of identities/statuses might affect family and loved ones.

Tips for Success

  • For some ideas, go back to the "What We'll Do in This Module" section and consider the examples I provided related to ODAAT.

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CLINICAL SCHOLARSHIP Experiences of Military Spouses of Veterans With Combat-Related Posttraumatic Stress Disorder Teresa W. Yambo, PhD, MSN Ed, RN1 , Mary E. Johnson, PhD, RN, PMHCNS-BC, FAAN2 , Kathleen R. Delaney, PhD, PMHNP-BC, FAAN3 , Rebekah Hamilton, PhD, RN, FAAN4 , Arlene Michaels Miller, PhD, RN, FAAN5 , & Janet A. York, PhD, PMHCNS, BC, FAAN6 1 Gamma Phi, Instructor, Spouse Employment Program, Air Force Aid Society, Osan Air Base, South Korea 2 Gamma Phi, Assistant Dean for Specialty Education, Professor, Department of Community Systems and Mental Health Nursing, Rush University, Chicago, IL, USA 3 Gamma Phi, Professor and Program Director, PMH-NP program, Project Director, Graduate Nursing Education Demonstration, Rush University, Chicago, IL, USA 4 Gamma Phi, Assistant Dean for Specialty Education, Professor, Women, Children and Family Health Nursing, Rush University, Chicago, IL, USA 5 Gamma Phi & Alpha Lambda, Professor, Community, Systems, and Mental Health Nursing, Rush University, Rush University, Chicago, IL, USA 6 Beta Lota, Director, PMHNP Residency Program, Mental Health Service Line, Ralph H. Johnson VAMC, and Adjunct Research Professor of Nursing, Medical University of South Carolina, Charleston, SC, USA Key words Spouse, posttraumatic stress disorder, phenomenology, military, Colaizzi Correspondence Dr. Teresa W. Yambo, Rush University, College of Nursing, 600 S. Paulina St., Chicago, IL 60612. E-mail: Teresa w yambo@rush.edu Accepted July 17, 2016 doi: 10.1111/jnu.12237 Abstract Purpose: To explore the experiences of military spouses living with veterans with combat-related posttraumatic stress disorder (PTSD). Design: Husserlian phenomenology was chosen as the theoretical framework because it allowed a deeper understanding of the unfolding of the spouses’ daily experience. Methods: A purposive sample of 14 spouses living with veterans with symptoms of PTSD participated in unstructured interviews. Data were analyzed using a modification of the Colaizzi phenomenological method. Findings: Spouses recognized that the veteran was no longer the same person, with life becoming one of living with the unpredictability of PTSD. The spouses bore the burden to maintain normalcy in the family and eventually created a new life. Conclusions: Military spouses endure psychological stress and strain, while living with a veteran with PTSD. There is a need for more programs to support the resilience of military spouses. Clinical Relevance: Life for military spouses of veterans with PTSD is everchanging and unpredictable. Practitioners need to be aware of the stress that spouses experience and develop programs and interventions that bolster the resilience of military families. Spouses are a major support to married veterans who are experiencing symptoms of combat-related posttraumatic stress disorder (PTSD; Dekel, Goldblatt, Keidar, Solomon, & Polliack, 2005). Symptoms of PTSD may occur after exposure to a traumatic event, such as threatened death to oneself or others, the death of others, serious or threatened injury to oneself, or actual or threatened physical or sexual violence (U.S. Department of Veterans Affairs, 2015). Although there have been international studies (Ahmadi, Azampoor-Afshar, Karami, & Mokhtari, 2011; Dekel et al., 2005; Dirkzwager, Bramsen, Adèr, & Journal of Nursing Scholarship, 2016; 48:6, 543–551.  C 2016 Sigma Theta Tau International van der Ploeg, 2005; Franciskovié et al., 2007; McLean, 2006; Westerink & Giarratano, 1999; Woods, 2010) in spouses of veterans from previous combat operations, a recent review of the literature (Yambo & Johnson, 2014) revealed no published studies of the essence of the experience in U.S. spouses living with veterans who developed symptoms of PTSD from post-9/11 overseas contingency operations (OCO). Veterans who supported OCO had unique experiences when compared to veterans from previous combat. What makes OCO unique is that they are the first sustained 543 PTSD Experiences of Spouses of Veterans ground combat, since the Vietnam War (Hoge et al., 2004), with 75% of veterans wounded by explosive devices (Helwick, 2011), more married veterans in families with more children, and accessible cutting-edge medical care (Glasser, 2011). Further what makes OCO different from previous operations for the spouses is that more military families are negatively impacted by PTSD, which contributes to weakened family bonds and hostility toward partners and military children (Peterson, Lester, Calohan, & Azad, 2014). To fill this gap in knowledge, the purpose of this study was to describe the experiences of military spouses living with a veteran with PTSD from OCO. According to the World Health Organization (WHO, 2013a), it is critical to not only meet the mental health needs of individuals, but to employ integrated strategies to coordinate holistic care to support mental well-being. Understanding the spouses’ perspective will be useful to international clinicians and researchers who are funding, developing, and testing interventions that could potentially prevent mental health problems among military families. Further, this study may benefit mental health practitioners who care for veterans and their spouses as they manage the symptoms of PTSD. Background Globally, PTSD prevalence rates span from 0.3% to 6.1% in the general population and 15.4% in conflictaffected populations (WHO, 2013b). In the United States, PTSD impacts about11% to 20% of the 2 million veterans returning from OCO (U.S. Department of Veterans Affairs, 2015) and almost 1.1 million military caregivers provide care to post-9/11 veterans (RAND Corporation, 2013). Living with a veteran with PTSD can have a negative impact on the mental health of military partners. Secondary traumatic stress, psychological distress, burden (Yambo & Johnson, 2014), marital and relationship dis-satisfaction, difficulty coping (Hamilton, Nelson Goff, Crow, & Reisbig, 2009), and domestic violence (Dekel et al., 2005) have been documented. Despite the emerging evidence in family resiliency (Peterson et al., 2014), most research is limited to investigations on the impact of trauma on the primary victim—the veteran with symptoms of PTSD. However, the spouse’s perspective is critical to enhance family resiliency. Philosophical Framework To investigate the phenomenon of interest, Husserlian phenomenology was employed. Phenomenology is a research methodology that is used to understand the essence of a phenomenon (Munhall, 2007), in this case, 544 Yambo et al. the participant’s perspective of living with a veteran with PTSD. This philosophical framework stems from Husserl’s posit that consciousness is connected to human experiences. Thus, phenomenology refers to the study of the participant’s perspective of their lived experience. The researcher must therefore strive to set aside his or her personal preconceptions, partialities, and beliefs to acquire consciousness of the experience (Munhall, 2007). Developing consciousness of the phenomenon as one who does not know is referred to as existential interaction. Existential interaction requires the researcher to participate in transcendental subjectivity (Wojnar & Swanson, 2007). When a researcher participates in transcendental subjectivity, he or she must make endeavors to relinquish presumptions and portray the genuine consciousness of the phenomenon. To achieve transcendental subjectivity, bracketing must occur. Bracketing is defined as purposefully surrendering previous encounters, beliefs, and prejudices to prevent obstruction of the phenomenon (Tymieniecka, 2003). Previous encounters, beliefs, and prejudices must be exposed by the researcher. Intentionally setting aside preconceptions is referred to as decentering, which allows the researcher to become an authentic and effective instrument of research. These concepts are essential for the researcher to acknowledge the essence of the participant’s experience (Munhall, 2007). Methods Recruitment Procedures and Participants Participants included in the study were married to Active Duty, Guard, Reserve, retired, or medically discharged veterans. The participants reported that their husbands had a presence of PTSD symptoms or were diagnosed with PTSD as a result of deployment to an OCO. Additionally, the inclusion criteria were (a) between the ages of 21 and 60 years, (b) English-speaking, and (c) having the capacity to reflect upon and discuss their personal experiences. Exclusion criteria included individuals who were unable to participate due to mental or physical illness, hospitalization, inability to communicate, residing outside of the United States, or unmarried partners. A pilot study was conducted to refine the methodological issues (Yambo, Hamilton, & Johnson, 2014). Participants were recruited through purposive sampling. Further recruitment was conducted through social networking and participant referral. Each participant was asked to pass along the information to other spouses living with veterans with PTSD until the investigator reached study saturation. Recruitment ended when, via Journal of Nursing Scholarship, 2016; 48:6, 543–551.  C 2016 Sigma Theta Tau International PTSD Experiences of Spouses of Veterans Yambo et al. Table 1. Participants’ Sociodemographic Characteristics (N = 14) Variable n (%) Age (years) 21–29 30–39 40–49 50–56 4 (29) 6 (43) 3 (21) 1 (7) Ethnicity Caucasian Caucasian-Hispanic Hispanic Employment Caregiver Employed∗ Homemaker Volunteer Children None 1–5 6–10 Current health Fair Good Very good Excellent 10 (71) 2 (14) 2 (14) 3 (21) 8 (57) 3 (21) 1 (7) 2 (14) 11 (79) 1 (7) 3 (21) 4 (29) 3 (21) 4 (29) Variable Length of marriage (years) 10 n (%) 2 (14) 6 (43) 6 (43) Number of deployments 1 2 3 4 PTSD symptoms Diagnosed Undiagnosed 12 (86) 2 (14) Traumatic brain injury Diagnosis No diagnosis 7 (50) 7 (50) PTSD symptoms (years) 5 2 (14) 9 (64) 3 (21) Relationship status Married Divorcing 6 (43) 3 (21) 4 (29) 1 (7) 11 (79) 3 (21) Note. Caregiver = recognized as provider of personal care to the veteran. PTSD = posttraumatic stress disorder. ∗ One caregiver worked outside the home. coding and examination of the interviews, it was determined that redundancy had been achieved (Morse, 2006). The purposive sample (N = 14) included 2 spouses of veterans with PTSD symptoms (without formal diagnosis) and 12 spouses married to a veteran with a diagnosis of PTSD. In this study, participants (n = 7) reported living with a veteran with a codiagnosis of PTSD and traumatic brain injury (TBI). The TBI, as reported by the spouses, was the result of a traumatic event that occurred during the veteran’s deployment. Table 1 includes additional sample demographic characteristics. The participants felt that their participation in the study might aid others living with veterans with PTSD. Ethical Considerations and Data Collection Rush University Institutional Review Board approval was obtained for this dissertational study. Before the interviews took place, each participant gave written informed consent. Data collection took place from Journal of Nursing Scholarship, 2016; 48:6, 543–551.  C 2016 Sigma Theta Tau International September 2013 to December 2014 until redundancy and data saturation were achieved after the 14th interview. Data were collected through interviews with each participant individually at a mutually agreed upon time. Twelve participants were interviewed face to face. Per their request, two participants were interviewed via telephone. Interviews were unstructured with openended questions that began by asking the participants to describe an experience that exemplified what it was like to live with a veteran with PTSD symptoms. For parts of the story that needed clarification, more detail, or deeper exploration, probing questions, such as, “Can you say more about that?” were utilized. Individual questions were used to further explore what makes living with someone with PTSD symptoms either more difficult or easier. The interviews were audio-taped and field notes were written following each interview. Recordings were transcribed verbatim by a professional transcription service. Each transcript was quality checked for accuracy by the first author. Data Analysis The transcripts were uploaded into the qualitative data management program, ATLAS.ti (Scientific Software Development, Berlin, Germany). Data were analyzed using a modification of Colaizzi’s phenomenological analysis (Colaizzi, 1978). The modification included contacting three participants for validation of the findings, rather than all participants, to ensure that their words had the same meaning as the investigator understood. The Colaizzi (1978) analytical steps involved (a) reading each participant’s description of the experience, (b) formulating the meaning of each significant statement, (c) organizing the formulated meaning into clusters of themes, (d) integrating the results into a description of the phenomenon, (e) validating the findings by revisiting three participants, and (f) integrating modifications provided by the participants into the final description. Three participants compared their experience with a summary of the findings of the study. Participants reviewed the findings separately and expressed agreement that the findings accurately described their experiences. To preserve confidentiality, each participant was assigned a pseudonym. Findings Four major themes emerged. A description of the themes along with supporting quotes follows to reflect the essence of the spouses’ experience. Military spouses living with veterans with PTSD described the experience of reintegration, a period of time immediately following the deployment, as a time 545 PTSD Experiences of Spouses of Veterans of noticing changes in their husbands. Outwardly, their husbands looked the same, but their reactions and behaviors were different. For instance, Sara, spouse of a veteran with PTSD and TBI, recalled how she initially noticed the change in her husband’s behavior but only later realized that it was a symptom of PTSD. She stated, “We had a lot of fights over him just being self-absorbed with video games all the time. Now I know that that’s a common symptom of PTSD, the isolating and withdrawal. It’s still a struggle.” The spouses struggled to understand the change in their husbands’ behavior and attitudes. These changes were often observed, but sometimes they were simply hunches that something about their husband was different. Over a period of time, the spouses began to realize that certain conditions or events triggered a memory of a traumatic experience from their husband’s deployment. Alice, a spouse of a veteran with symptoms of PTSD, shared that the subtle changes in her husband’s behavior made her aware that he was no longer the same. She said, It started clicking to me, um, that he was having some PTSD because just like the locking of the doors. And later he told me that was because he felt like he was being followed or, you know, he got paranoid that people were after him. When their husbands returned from deployment, the spouses expected their husbands to resume their previous roles and responsibilities and that life would return to “normal.” However, the more time the spouses spent with their husbands, the more they recognized that their husbands were no longer the same. Recognizing their husbands were no longer the same made many of them realize that they, not their husbands, needed to readjust. Living With Unpredictability Living with their veteran spouse was turning into a life of unpredictability. The spouses often referred to the predictability of unpredictability as “walking on egg shells.” In other words, they knew their husband would react, but they did not know when or where the reaction would occur. Not knowing what new experience was going to trigger a reaction coupled with the uncertainty of their husbands’ reactions was stressful to the spouses. Isabelle reflected on the unpredictability. She explained, “Sometimes, it feels like walking on eggshells. You don’t know if he’s having a good day or not. Small things could trigger him.” All of the spouses were trying to become more attuned to their husbands’ moods and triggers. Although the spouses were feeling stressed from the continual 546 Yambo et al. exposure to PTSD symptoms, this stress was compounded by the loss of predictability in their lives. Leah shared her viewpoint on the impact of unpredictability on her life. She explained, It’s very unpredictable because you don’t know. We could be shopping and be fine and then somethin’ catches his eye. Like I know crying children and women in balaclava or whatever the headdress. Certain things if he catches it, it puts him back there in whatever happened; the aggression comes out or whatever he needs to do to get out of the situation. It’s a daily stress, unpredictable. The spouses dealt with the daily challenges of unpredictability. Many of them recognized that their husbands would have good days that made everyone feel good. However, when their husbands had bad days, they felt the loss of predictability in their lives. The loss of predictability created an emotionally unstable environment that left the spouses wanting to recreate peace in their homes. Bearing the Burden The spouses perceived two types of burdens, a tangible one from assuming the duties and responsibilities of their relationship, and an invisible psychological burden. With regards to the tangible burden, the spouses felt that it was their responsibility to manage the changes in their lives that were sparked by their husbands’ medical condition. For example, shifting roles, assuming their husbands’ chores, or reintegrating their husbands into the family became part of their responsibility. Megan, whose spouse had symptoms of PTSD, reflected on how shifting roles helped her to support her husband. She stated, “That sense of you’re dealing with—you know that this person can’t deal with the regular stuff. You step in. You take care of it for them. Cleaning, the dishes, all these little things. Even filling up the car.” In addition, three spouses bore the psychological burden of guilt for their husbands’ traumatic deployment experience, the impact of PTSD on their life, or for starting a new life without their husband. Cassie, a spouse of a veteran with PTSD and traumatic injuries expressed her guilt for encouraging her husband to take the place of another military member when it was not his turn to deploy. She was feeling guilty for her husband’s traumatic experience that resulted in PTSD and a traumatic injury. She shared, “I asked my husband to volunteer to go this third time to Afghanistan. I guess I feel guilty because he did go and 3 months later came home with 45% burns to his body, you know, PTSD.” Journal of Nursing Scholarship, 2016; 48:6, 543–551.  C 2016 Sigma Theta Tau International Yambo et al. Maintaining the peace. Ten of the spouses felt responsible for maintaining peace in the family. They tried to avoid conflict, but often felt unsuccessful in their endeavors. For those spouses with children, maintaining peace between their husbands and their children was emotionally exhausting because their husbands angered easily and quickly. One tactic they used to maintain the peace was to help the children understand their father’s medical condition. The spouses also tried to model behavior for their children. Yet, keeping the peace was an ongoing challenge for them. Lily expressed concern about the emotional fragility of her family. She said, I feel like I’m the peacemaker in our home and it gets exhausting. Sometimes you just want to lock yourself in the room and really just want to run away, but you can’t because if you do then he might hurt himself or the kids will be scared. Dealing with spouse’s emotions. The spouses experienced a myriad of emotions as they tried to navigate the journey of PTSD with their husbands. Six of the spouses shared that they were struggling with dealing with their husbands’ coexisting mental health concerns. Three spouses reported struggling with their husband’s plan to commit suicide. To keep their husbands safe, each spouse described encouraging their husbands to seek mental health treatment. All three of these spouses discussed intervening at times to prevent their husband’s suicide attempt. Maria was feeling afraid that she might not be able to keep her husband safe. She said, “I’m terrified of the snap. There’s been a couple of times he’s had to take himself to the [hospital] because he’s suicidal. ‘Cause he’s suicidal and he snaps; things make him so angry that I can’t calm him down.” Many of the spouses were dealing with their husband’s volatile emotions without seeking assistance from external sources. In other words, they were silently struggling with their own emotional needs, while tending to their husband’s emotions. Protecting the children. Twelve of the spouses had children and many of them expressed concern about how PTSD symptoms were impacting their children. Therefore, they were taking measures to shield their children from hostility and to prevent the children from triggering a symptom of PTSD. The mothers were also attempting to nurture the father–child bond. Six spouses noticed that their husbands were unable to relate to them or the children during a flashback. A flashback, the mothers expressed, posed a significant fear for their children’s safety and their own. Thea, a spouse of a veteran with PTSD and TBI, recalled protecting herself and their children when her husband experienced a Journal of Nursing Scholarship, 2016; 48:6, 543–551.  C 2016 Sigma Theta Tau International PTSD Experiences of Spouses of Veterans flashback. She stated, “You had to clear all the kids to one room, and lock yourself in the room ‘cuz your husband has a knife and he’s trying to kill you, but he doesn’t know that he’s in that mind frame.” Creating a New Life The return to life before the deployment was not happening the way the spouses anticipated it would when their husbands returned home. Therefore, each spouse created new ways to function around the veteran’s PTSD symptoms. Bree described how she altered the way she tended errands. She said, “We have to change our shopping schedule around a lot. He doesn’t like to be where there’s a lot of people. When we do, he just—he has anxiety.” Kathy reflected on the changes in their social life. She recalled, “We could never go out, ever. We couldn’t go out to crowded places. We couldn’t go to restaurants or couldn’t go even grocery shopping. Couldn’t go anywhere where there were crying kids and babies because that set him off, too.” Not seeing old friends; creating new friends. Despite having a network of friends, six of the spouses described feeling alone in dealing with their husband’s symptoms of PTSD. Lily described why she sought support from like-minded spouses. She remarked, I enjoyed being around other spouses that were experiencing similar situations because they understood. They didn’t judge and they didn’t look down on you. They understood exactly what you were going through, and sometimes you’d hear their stories and you’re like, “Oh, my day wasn’t that bad today then.” As silly as it sounds, it helps you get through. All of the spouses were gravitating towards individuals who accepted their experience. The spouses cultivated relationships with individuals who shared ongoing emotional encouragement. Receiving emotional encouragement became a lifeline, linking them to those who understood their plight. Making sense of the relationship. Restructuring ways of thinking and reacting was important to the spouses. Two spouses talked about structuring their “new normal.” However, their new normal was not a destination, but rather an ongoing journey. Michelle, a spouse of a veteran with PTSD and TBI, recalled how she was able to accept her new way of living. She remarked, “Seeing that MRI made me realize there’s no way he’s ever coming back. We started our new normal that day that I was in [treatment facility]. He cannot multitask anymore. He can only do one thing at a time.” Because 547 PTSD Experiences of Spouses of Veterans of the impact of PTSD symptoms on their marriage and family, the spouses altered their lifestyle to cultivate a way of living that fit their relationships. Three spouses shared that they were contemplating divorce as their way of creating a new life. Megan described how struggling with her husband’s medical condition impacted her decision. She commented, “I’ve actually filed for divorce just this month because it’s something I’ve had to do. ‘Cause I’m at the point with after many struggles with his PTSD and all the problems that have come with it.” The three women perceived that their new normal was to be without their husbands. In spite of filing for divorce, two spouses felt that they would reconsider the divorce, if their husbands were willing to engage in treatment and make progress towards reducing self-destructive behaviors. Adjusting the environment. As their lives unfolded, the spouses were learning to adapt their surroundings to their husband’s condition. For instance, Isabelle, a spouse of a veteran with PTSD, discussed how she was creating structure for her husband. She mentioned, I have a dry erase board to write everything down. If I’m gonna be working, I make sure to write it on there. I even text him reminders. I always have to keep reminding him about certain things, so he doesn’t forget. One spouse established rapport with her husband’s medical practitioners to become active in her husband’s treatment. Several women became advocates for their husband’s care; they were helpful in creating processes to ensure their husbands were compliant with their medical treatment. Hence, spouses were finding ways to adjust the environment for their husbands. Understanding PTSD and TBI. The spouses whose husbands were diagnosed with PTSD and TBI described feeling unprepared to deal with their husbands’ dual medical disorders. Michelle shared her difficulty with understanding her husband’s dual diagnosis. She said, “I wish, [my husband], I could have tattooed on your forehead ‘PTSD’ and ‘TBI’ because you look the same, but you do not act the same.” Because the spouses were limited in their knowledge of how to deal with the veteran’s dual diagnosis, they were experiencing difficulty with the complexity of PTSD and TBI symptoms and communicating with their husbands. 548 Yambo et al. Discussion The essence of the experience of living with veterans with symptoms of PTSD is that spouses are struggling to find balance. Finding balance is a primary concern in postdeployment resiliency for spouses, because prolonged exposure to PTSD symptoms is a predictive factor of secondary traumatic stress (Ahmadi et al., 2011). The findings reported here highlight military spouses’ perspective of their daily life with a veteran with PTSD symptoms. Further, this study adds to earlier descriptions of the experiences of military spouses living with veterans with PTSD (Dekel et al., 2005; Lyons, 2001; Maloney, 1988; McLean, 2006; Ray & Vanstone, 2009; Woods, 2010); supports marital adjustment findings revealed in PTSD research conducted with Vietnam veterans’ partners (Evans, McHugh, Hopwood, & Watt, 2003; Jordan et al., 1992; Koenen, Stellman, Sommer, & Stellman, 2008; Riggs, Byrne, Weathers, & Litz, 1998), ex–World War II Prisoners of War (POWs; Cook, Riggs, Thompson, Coyne, & Sheikh, 2004), and former Israeli POWs (Dekel & Solomon, 2006); and provides a deeper understanding of the impact of combat-related traumatic stress on family relationships (Canfield, 2014; Frederikson, Chamberlain, & Long, 1996; Maguen, Stalnaker, McCaslin, & Litz, 2009; Ray & Vanstone, 2009). The findings of this study support the evidence that spouses struggle to balance their day-to-day life due to the symptoms of PTSD (Mansfield, Schaper, Rosen, & Yanagida, 2014). Often, the military spouses struggle alone in silence. It is little surprise that many of the participants expressed loneliness amid the mental health resources that are available to them. Moreover, these findings are consistent with findings from research with U.S. Vietnam veteran spouses (Lyons, 2001) and Canadian peacekeepers’ spouses (McLean, 2006). Researchers found that spouses readjust their lives around the veteran’s symptoms without regard to their own personal physical and emotional well-being, and little is known about the cost of such resiliency. This study is one of the few qualitative studies conducted to explore the essence of the experience of U.S. military spouses living with a veteran with PTSD symptoms from OCOs. In this investigation, the themes and significant statements described were comparable to the themes of previous research: feelings of anger, confusion, fear, and loneliness; thoughts of confusion to understanding PTSD symptoms; and descriptions of the complexity of their relationship with their husband (Woods, 2010). Furthermore, they were consistent with themes identified by Dekel and associates (2005) in wives of Israeli veterans: the illness as navigating living, between Journal of Nursing Scholarship, 2016; 48:6, 543–551.  C 2016 Sigma Theta Tau International PTSD Experiences of Spouses of Veterans Yambo et al. merging and individuation, partners as present-absent, separation and divorce, and partners as empowers. The themes revealed that spouses perceived that navigating their husband’s illness made it difficult to maintain their individuality, which created emotional dissonance in their relationship that led to thoughts of separation and divorce. However, despite the emotional dissonance, partners remained in their relationship. Remaining in the relationship meant assuming the responsibility of making household decisions on their husbands’ behalf. Hence, the partners felt empowered when they made decisions that impacted the well-being of their family, while their husbands dealt with PTSD symptoms. This study, which focused on these women’s lived experiences, detailed the myriad adjustments they make on many fronts to keep themselves and their children safe, to regulate their husband’s emotions and affect and to preserve the threads of their relationships. This research also provided insight to the spouses’ perception of PTSD as ever-changing, unpredictable, and stressful to their family dynamics and relationships. According to the Substance Abuse and Mental Health Services Administration (2014), enhanced behavioral health clinical policy is necessary for families to receive tailored care to help them cope with the complexities of PTSD. Although, each spouse felt that living with a veteran with PTSD was an individual experience, their lives were interwoven in commonalities that cut across all the spouses, regardless of the veteran’s PTSD symptom severity. The findings indicate that living with a veteran with PTSD is stressful for the spouses due to the complexity of the condition. On a positive note, five spouses reported gaining insight on how other spouses coped with a difficult situation and working to “normalize” their experience through the experiences of others. In other words, when the spouses connected with other individuals, they were able to make sense of their situation. When spouses made sense of their situation, they were able to identify common stressors and utilized their awareness of others’ ways of coping to cultivate their own coping strategies. Unfortunately, two spouses, who were unable to connect with others, were feeling exceedingly stressed and lonely in their efforts to cope. Although programs such as Families Overcoming under Stress (FOCUS project) are underway to address family resilience enhancement, most of the emphasis has been on deployment and has not targeted PTSD and spouse resilience (Saltzman, Bartoletti, Lester, & Beardslee, 2014). However, even when there are collaborative efforts like the FOCUS project, military spouses lack the tools to effectively cope with the stress of PTSD symptoms. Thus, it is paramount for community and Journal of Nursing Scholarship, 2016; 48:6, 543–551.  C 2016 Sigma Theta Tau International private organizations to link the spouses with resilience services early in the military separation process. Limitations of the study include the absence of a male spouse in the sample. Although community organizations supported male and female spouses, we were unsuccessful with the recruitment of a male spouse. One male spouse intended to participate; however, his veteran wife had a co-occurring, incurable illness that prevented his participation. Therefore, findings cannot be generalizable beyond female spouses. In addition, it is not possible to control for the interaction of PTSD and the impact of multiple deployments. Conclusions The experiences of these military spouses draw attention to the tremendous stress of spouses of veterans who suffer with PTSD and traumatic injuries. Community organizations are crucial to offering resources and connecting spouses to appropriate referral services. Yet, there remains a need to nudge collaboration among civilian, military, and federal components to support the health and well-being of military spouses. Respect and understanding of the spouses’ unique position in the treatment of PTSD warrants the unveiling of obscure systematic processes to provide continual support for military families. Reintegrating is a challenge for military families. Future studies are needed to understand the impact of traumatic stress on the spouse and military family. Clearly, we are on the cusp of transforming health care to acknowledge and care for the unsung heroes of military families—military spouses. It is our hope to keep military families together through educational efforts to increase awareness of their plight. Acknowledgments We appreciate the Jonas Center for Nursing and Veterans Healthcare, Bob Woodruff Foundation, and the National Military Family Association, which partially funded this research. Clinical Resources r r Rand Corporation. (2014). Supporting military caregivers: The role of health providers. http:// www.rand.org/pubs/research_briefs/RB9764z3.html World Health Organization. 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PTSD DISCUSSION

1

PTSD DISCUSSION

Name

Institution

Date

PTSD DISCUSSION


2

Identify the three identities/statuses and define each of them.

Veterans; a veteran is defined as a person who have previously worked in the military or
offered public service eg, at war and who was put at hold from working further due to a
disease or condition. In our cases, the condition is PTSD.

Age; Refers to the number of years that one is in existence. It identifies whether a person
is young or old. Terms such as young, middle or late adulthood will be used.

Sex; Determined by gender on whether male or female.


Describe how the three identities/statuses might interact to make a condi...


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