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Session Thirteen - PTSD and its impact on the family
Resources Related to OIF/OEF Soldiers & Their Families

Materials Needed
Handout W: “PTSD and its Impact on the Family”
Handout X: “What We'd Like our Family Members and Friends to Know about Living with PTSD”

Brochures on local treatment options for patients with symptoms of PTSD
  1. Review of the diagnosis of PTSD

    1. The diagnosis of PTSD (Post-Traumatic Stress Disorder) is only made when very specific criteria are met. One patient who has been diagnosed with PTSD may look very different from another patient with the same disorder. The specific traumatic experience and the resultant impact on the patient and his/her loved ones are unique to each family. The diagnosis can only be made by a trained mental health professional (preferably one with experience in working with PTSD).

    2. PTSD falls in the diagnostic category of anxiety disorders. Rather than outlining all of the specific criteria, the major clusters of symptoms will be reviewed (DSM-IV, 1994).

    3. First, the patient experienced or witnessed an event that involved actual or threatened death or serious injury, and the patient felt very afraid or helpless.

      • Traumatic events can include a wide variety of different experiences, including (but not limited to):
      • military troops involved in combat
      • victims and rescue workers involved in natural disasters (e.g., earthquakes, floods, hurricanes)
      • victims and rescue workers involved in man-made disasters (e.g., Oklahoma City Bombing in April 1995)
      • sexual assault or other violent crimes
      • domestic violence
      • physical and/or sexual abuse
      • immigrants fleeing violence in their homeland
      • torture


    4. Patients may RE-EXPERIENCE the event in a variety of ways:

      1. May have distressing dreams or nightmares of the event.
      2. May feel very uncomfortable when confronted with a reminder of the event (e.g., war movie).


    5. Patients may AVOID certain triggers or reminders of the trauma (e.g., conversations, places, and thoughts associated with the event). For example, many veterans have strong reactions to the sound of helicopters, firework displays, thunderstorms, humid weather, and sand.

    6. Patients may report feeling NUMB:

      1. May feel emotionally distant from other people.
      2. May engage in previously enjoyed activities less often.


    7. Patients may experience INCREASED AROUSAL:

      1. May be irritable and/or have angry outbursts.
      2. May experience insomnia (problems falling or staying asleep).
      3. May be hypervigilant (e.g., the veteran may sit with his back to the wall in public places so as to be aware of all that is occurring around him).
      4. May startle easily

  2. Background information on PTSD

    1. Community-based research has revealed a lifetime prevalence of PTSD in the United States today ranging from 1-14%.

    2. Although not formally labeled PTSD until recently, the symptoms have been recorded throughout history (Khouzam, 1999):


      1. Biblical accounts describe PTSD symptoms in Job, Joseph and David
      2. Egyptian, Greek and Roman mythology refer to similar symptoms
      3. Shakespeare describes nightmares and intrusive thoughts in Henry IV
      4. WWI: phenomenon was called "shell shock" or "soldier's heart"
      5. WWII: symptoms were called "combat neurosis" or "operational fatigue"
      6. The formal diagnosis of "PTSD" first emerged in 1980 in the American Psychological Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III)


    3. Most people who are exposed to a traumatic event experience some PTSD symptoms following the event…but the symptoms generally decrease over time and eventually disappear. Approximately 8% of men and 20% of women go on to develop PTSD. For both men and women, rape is the most common trigger of PTSD. (National Center for PTSD)

    4. Although symptoms of PTSD usually emerge within 3 months of the trauma (DSM-IV), some individuals have a delayed onset. Some individuals avoid facing the painful emotional residue from the trauma for many years, often using substance abuse or other addictive behaviors to distract him/herself from the feelings. When the patient begins to exhibit symptoms of PTSD many years after the event, caregivers may feel confused.

    5. The course of the disorder is quite variable, as some symptoms may diminish rapidly while others may fluctuate in intensity throughout the individual's life. Approximately 30% of those who have PTSD develop a chronic form that persists throughout their lifetime (National Center for PTSD).

    6. Who develops chronic PTSD? Several variables can be considered, including: (DSM-IV, 1994)
      1. severity of the trauma
      2. duration of exposure
      3. level of involvement
      4. premorbid functioning
      5. extent of social support
      6. repertoire of coping skills

    7. Research has documented that 20% of men wounded in Vietnam meet the criteria for PTSD (Helzer, Robins & McEnvoy, 1987; DSM-IV). The Veterans Health Administration was the first institution to develop treatment programs for PTSD. Much-needed treatment programs began to emerge in the mid-1970s in response to pressure from Vietnam veterans.

    8. The rates of comorbidity of PTSD and other psychiatric diagnoses strikingly are high. If a patient has PTSD, he/she is at greater risk for also having another diagnosis. For patients diagnosed with PTSD, the lifetime prevalence rates of other disorders include: (Khouzam, 1999)


      1. Alcohol dependence 75%
      2. Drug abuse 23%
      3. Major depression 30%
      4. Generalized anxiety disorder 53% (Davidson, 1997)

  3. Effects of combat veterans’ PTSD on relationships and families
    • PTSD can result from a variety of different traumatic events; the intensity and duration of patients’ reactions differ depending on many factors (e.g., nature of the trauma, extent of social support, level of premorbid functioning, participation in treatment, repertoire of coping skills).

    • The specific consequences of traumatic experiences will be addressed in this section, with an emphasis on the sequelae of military combat. The potentially disruptive effects of these symptoms on relationships will also be reviewed.

            Discussion Questions:

    • What is the toughest issue for you and your family in living with a veteran with PTSD?

    • How do you cope?


    1. Social anxiety:

            Discussion Questions:
      • How has the veteran’s social anxiety affected your family life?

      1. Families may become isolated due to the social anxiety many veterans experience. As veterans often feel very uncomfortable in large groups and crowds, the family may be quite limited in their activities.

      2. The veteran may pressure the family members (directly and/or indirectly) to stay home with him, thereby narrowing caregivers’ social contacts and limiting their ability to obtain support. Family members often feel guilty for pursuing independent activities.

    2. Angry outbursts:

            Discussion Questions:

      • How have your loved one’s anger management problems affected your relationship?
      • Your family?
      • Any concerns for the children?

      1. Anger is often a “weapon” in the veteran’s arsenal of protection against painful feelings, memories, and thoughts. Anger can function as a barrier and further isolate the veteran, as other people often pull away from the frightening hostility and rage.

      2. Due to the veteran’s difficulty in managing his anger, the family may live in an atmosphere of constant chaos. This lack of emotional and sometimes physical safety can be damaging to the mental health and development of all family members.

      3. Family members may be at greater risk for being exposed to verbal abuse (e.g., yelling, name calling) and physical abuse (e.g., throwing things, aggression). Both veterans with PTSD and their spouses / partners engage in higher levels of physical violence than do comparable family members when the veteran does not have PTSD (Jordan et al., 1992). These repeated negative interactions damage the trust and cohesion within the family.

      4. Children may acquire maladaptive patterns for the expression of anger. A large nation-wide survey revealed that the children of Vietnam veterans with PTSD are more apt to have behavioral problems than children of Vietnam veterans who do not have this disorder (Jordan et al., 1992).

      5. Wives are often torn between caring for the acting-out veteran and protecting the children from his angry outbursts (Glynn, 1997).

      6. The rage exhibited publicly may further alienate the family from their social network.

    3. Emotional unavailability:

            Discussion Questions:

      • How does it feel to live with a spouse / significant other with whom you do not feel connected?
      • Or to have an emotionally distant relationship?
      • How else do you get your needs for emotional intimacy met?


      1. Patients with PTSD may be emotionally unavailable due to preoccupation with managing mental stress. The emotional distance in the relationship may also stem from the higher levels of fear of intimacy experienced by both veterans with PTSD and their partners (in comparison to couples in which the veteran does not have PTSD) (Riggs, Byrne, Weathers, & Litz, 1998).

      2. The veteran may be reluctant or unwilling to share his feelings with his wife and children (Matsakis, 1989). Consequently, family members may feel rejected and lonely, and they may blame themselves for their loved one’s emotional distance.

      3. The individual may struggle with experiencing and expressing positive emotions. He may be unavailable to his children and unable to meet their emotional needs (Curran, 1997)

    4. Sleep disturbance:

      1. Given the difficulties many veterans with PTSD have with sleep (including insomnia, frequent wakings, nightmares, etc.), many couples choose to sleep in separate beds (and rooms). This physical separation can parallel the emotional distance experienced in the relationship. Physical intimacy can also be adversely affected by this sleeping arrangement.

      2. In addition, the veteran’s behavior during a nightmare can be very frightening for the spouse and family. In the midst of a nightmare or flashback, some patients become physically aggressive, thinking that their wife/partner is the enemy in a combat situation. Wives often report extreme terror and confusion about these experiences, as they do not understand the out of control behavior.

    5. Difficulty managing family roles and responsibilities

            Discussion Questions:
      • What challenges have you faced in negotiating family roles and responsibilities?

      1. Given the veteran’s emotional instability, the wife may assume some traditionally-male roles, such as primary breadwinner, “head of the household,” manager of family finances, and chief disciplinarian. The wives may feel overwhelmed by all of the demands in their lives, and wives may resent the veteran’s withdrawal from familial responsibilities (Peterson, 1997).

      2. Given that the wife has taken over many of the veteran’s tasks, she may be unable to pursue her own goals (Matsakis, 1989), which can breed further bitterness.

      3. Children may acquire adult responsibilities at an earlier age, resulting in their maturing quickly and sometimes taking on the role of a “parentified child” (Catherall, 1997).

      4. Individuals with PTSD often have difficulty keeping their jobs, thereby creating financial duress on the family.
    6. Given these potentially difficult family issues, the fact that Vietnam veterans with PTSD and their partners experience greater levels of marital conflict (Riggs et al., 1998) and less marital satisfaction (Jordan et al., 1992) than do comparison families without PTSD is not surprising. Veterans with PTSD are twice as likely to have been divorced (in comparison to veterans without PTSD) and almost three times as likely to have had multiple divorces (Jordan et al., 1992).


  4. Treatment options for PTSD

    1. Participating in treatment for PTSD can be challenging, as patients are invited to directly face memories and feelings that they may have avoided for many years. Patients are much more likely to succeed in treatment if the following pre-requisites are in place:

      1. Patient is not abusing alcohol or using any street drugs. As stated earlier, substance abuse is often an issue for patients with PTSD. Patients need to learn skills (such as through a substance abuse treatment program) to cope with strong emotions such that they can directly face the traumatic memories without numbing themselves with substances.

      2. Patient has adequate coping skills (patient is not suicidal or homicidal).

      3. Patient has sufficient social support.

      4. Patient has a safe living situation (not homeless or in an abusive environment).

    2. Although each patient’s individualized treatment plan is unique, the following goals are often important aspects of therapy:


      1. Examine and learn how to deal with strong feelings (such as anger, shame, depression, fear or guilt).

      2. Learn how to cope with memories, reminders, reactions, and feelings without becoming overwhelmed or emotionally numb. Trauma memories usually do not go away entirely as a result of therapy, but become less frequent and less intense.

      3. Discover ways to relax (possibly including physical exercise).

      4. Increase the frequency of patient’s pleasant activities.

      5. Re-invest energy in positive relationships with family and/or friends.

      6. . Enhance sense of personal power and control in his/her environment


    3. Components of treatment for PTSD

      Most treatment programs involve a comprehensive approach, including several modalities:
      • Psychiatric medications
      • Education for client and family
      • Group therapy
      • Cognitive behavioral therapy
      • Writing exercises

      1. Psychiatric Medications

        1. Choice of medication(s) depends on the patient’s specific symptoms and any co-morbid difficulties (e.g., depression, panic attacks)
        2. In general, medications can decrease the severity of the depression, anxiety and insomnia. However, there is no “cure” for PTSD.
        3. Medications may be prescribed by the patient’s primary care provider or psychiatrist.

      2. Education for patient and family about PTSD

        1. Education is very important, both for the patient and the family. It typically addresses the nature of PTSD (e.g., symptoms, course, triggers), communication skills, problem-solving skills, and anger management.
        2. . The education may occur in a variety of modalities, such as couples/family therapy, psychoeducational programs, support groups, etc.

      3. Group Therapy

        1. In general, groups “counter the profound sense of isolation, social withdrawal, mistrust, and loss of control. The acknowledgment by victims that they are not alone, can support others, and can safely share their traumatic experiences within a responsive social context provides an opportunity for healing.” (Hadar Lubin, MD, 1996).
        2. Groups have a variety of formats, including: process oriented, trauma oriented (e.g., telling one’s story), present-day focused (e.g., coping skills), and/or psychoeducational (e.g., anger management)

      4. Cognitive/behavioral therapy

        1. Cognitive therapy involves inviting patients to examine their thinking processes and replace irrational thoughts with more realistic thoughts. This form of therapy has received strong research support. Cognitive restructuring is a cognitive therapy approach used with PTSD.
        2. Behavioral therapy involves inviting patients to change their behaviors, which results in a shift in their mood / mental state. Behavioral interventions may include teaching relaxation techniques, imagery, and breathing techniques.
        3. Anger management training may involve both cognitive and behavioral skills.
        4. Exposure based therapy (e.g., flooding, desensitization) involves helping the patient to repeatedly “re-tell” the traumatic experience in great detail, such that the memory becomes less upsetting. Researchers have found this approach to be very effective in decreasing symptoms of PTSD.

      5. Writing Exercises

        1. A psychologist, James Pennebaker, Ph.D, at the University of Texas at Austin has performed extensive research over the past 15 years on the power of writing. He has studied many survivors of trauma and discovered interesting results about the healing potential of writing.
        2. Pennebaker reports that people who write about traumatic events have many positive outcomes (e.g., fewer doctor appointments, decreased pain for arthritic patients, lower blood pressure, happier mood, increased lung capacity for asthmatics, etc.) (Pennebaker, 1997).
        3. Why might writing be associated with such positive outcomes? Pennebaker suggests that writing helps people to:
          • Feel a greater sense of control over their lives
          • Gain greater understanding of their feelings
          • Break the situation into smaller pieces
          • Pay more attention to their feelings


  5. Tips for family members and friends on being in a relationship with someone who has PTSD


    1. Educate yourself about PTSD through reading, lectures, talking to others in similar situations, etc.

      Good Books on PTSD:
      Catherall, D. (1992). Back from the brink: A family guide to overcoming traumatic stress. Bantam Books.
      Mason, P. (1990). Recovering after the war. New York: Penguin Books.
      Mason, P. (1990). Why is Daddy like he is? A book for kids about PTSD. Patience Press.
      Matsakis, A. (1996) Vietnam wives, 2nd ed. Lutherville, MD: Sudran Press.
      Matsakis, A. (1998). Trust after trauma: A guide for relationships for survivors and those who love them. Oakland, CA: New Harbinger Press.
      Parkinson, F. (2000). Post-trauma stress. Tucson: Fisher Publishing.
      Sherman, M.D., & Sherman, D.M. (2005). Finding my way: A teen’s guide to living with a parent who has experienced trauma. Edina, MN: Beaver’s Pond Press. Available at www.seedsofhopebooks.com


      Interesting Movies about PTSD and its Effects on the Family:

      The Great Santini Ordinary People Saving Private Ryan
      Born on the 4th of July In Country Fearless
      Prince of Tides Copy Cat  
      Coming Home The Accused  


      Relevant Web Sites:

      www.patiencepress.com [site with examples of the “Post-Traumatic Gazette”]
      www.adaa.org [Anxiety Disorders Association of America]
      www.ncptsd.org [National Center for PTSD]
      www.sidran.org [Sidran Traumatic Stress Foundation]
      www.trauma-pages.com [David Baldwin’s Trauma Information Pages]

    2. Do not push or force your loved one to talk about the details of his/her upsetting memories. Try to avoid feeling jealous if your loved one shares more with other survivors of similar traumas or to his/her therapist than to you. Rather, be pleased for them that they have a confidant with whom they feel comfortable.

    3. Do not pressure your loved one to talk about what he/she is working on in therapy. Also, avoid trying to be his/her therapist.

    4. Attempt to identify (with your loved one) and anticipate some of his/her triggers (e.g., helicopters, war movies, thunderstorms, violence). Learn and anticipate some of his/her anniversary dates (e.g., Tet offensive, especially painful events)

    5. Recognize that the social and/or emotional withdrawal may be due to their own issues and have nothing to do with you or your relationship.

    6. Do not tolerate abuse of any kind – financial, emotional, physical, or sexual. Individuals with PTSD sometimes try to justify their behavior (e.g. angry outbursts, destroying property, lying) and “blame” their wrongdoing on having this psychiatric disorder. Patients may try to rationalize their behavior by stating that they were “not themselves” or “not in control” or “in another world.” However, patients should always be held responsible for their behavior.

    7. Pay attention to your own needs.

    8. Take any comments that your loved one makes about suicide very seriously and seek professional help immediately.

    9. Do not tell your loved one to just “forget about the past” or just “get over it.”

    10. Explore the available treatment options in your community, and encourage your loved one to seek professional help. However, respect that they know if/when they are ready to take this courageous step, and do not pressure them excessively.

  6. Local Treatment Options for Veterans with Symptoms of PTSD

    Example: Oklahoma City VA Medical Center

    1. PTS Recovery Program
      • This six-week intensive outpatient program focuses on unresolved feelings about combat experiences as well as present day coping skills. Specific groups address issues of anger management, communication skills, dealing with emotions, insomnia management, etc.
    2. Women/Men of Courage Programs
      • This 12-week weekly 90-minute psychotherapy group focuses on healing from a sexual trauma (experienced in childhood and/or in the military). Specific sessions address issues of safety, self-esteem, telling one’s story, and empowerment.
    3. Some other VA facilities (including Little Rock, AK; Topeka, KS) offer time-limited inpatient programs for veterans with combat-related PTSD. Some also offer time-limited inpatient programs for veterans with sexual-assault related PTSD.