RE-INTEGRATION OF MILITARY SOLDIERS TO A NON WAR ENVIRONMENT AND THE COPING SKILLS THEY EMPLOY, AS OBSERVED BY THEIR WIVES

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1 RE-INTEGRATION OF MILITARY SOLDIERS TO A NON WAR ENVIRONMENT AND THE COPING SKILLS THEY EMPLOY, AS OBSERVED BY THEIR WIVES A Thesis Presented to the Faculty of California State University, Stanislaus In Partial Fulfillment of the Requirements for the Degree of Master of Social Work By Pamela Short December 2014

2 CERTIFICATION OF APPROVAL RE-INTEGRATION OF MILITARY SOLDIERS TO A NON WAR ENVIRONMENT AND THE COPING SKILLS THEY EMPLOY, AS OBSERVED BY THEIR WIVES by Pamela Short Signed Certification of Approval page is on file with the University Library Dr. Robin Ringstad Professor of Social Work Date Dr. Valerie Leyva Associate Professor of Social Work Date

3 2014 Pamela Short ALL RIGHTS RESERVED

4 DEDICATION To Keith Warren Cottom I, my father, who always believed in me and never gave up on me. My only wish was that I finished before you left this earth. To my daughters; Krystal, Megan and Courtney, who are strong and wonderful women and have supported me in everything I do. To my son-in-law, Bradley Sensibaugh, your 10 years of service in the army inspired this research. To his wife, my daughter, Megan Sensibaugh, the best army wife ever. To all of my grandchildren; Nathan, Brandon, Ashley, Noah, Emily, Mason, Isiah and Warren. To the many soldiers who sacrifice for all citizens - All gave some, some gave all. To the wives and families of soldiers - for their support and sacrifice so that soldiers can protect us. iv

5 ACKNOWLEDGEMENTS To the soldiers wives and husband that participated in this study: I am grateful for your willingness to share your private lives with me. To my classmates and instructors who supported and helped me to keep on track with projects and include me in activities.. I would like to most thank Dr. Ringstad for continuing to help me pick up every time I fell short of completion. You have gone above and beyond to help me complete my degree. Without your support I may not have made it. To Barbara Dimberg for getting me on track, keeping me on track and always knowing what I needed to do to stay connected. v

6 TABLE OF CONTENTS PAGE Dedication... Acknowledgements... iv v Abstract... viii CHAPTER I. Introduction... 1 Statement of the Problem... 4 Statement of Purpose... 5 Significance of the Study... 5 II. Literature Review... 7 Changes After Deployment... 7 PTSD Symptoms and Family Distress... 9 Family Relationships After Deployment Suicide Concerns Treatment for Soldiers and Their Families Conclusion III. Methodology Sample Instrumentation Data Collection Data Analysis Protection of Human Subjects IV. Results Sample Overview Guiding Questions Research Question #1: What is Different? Research Question #2: Symptoms Observed Research Question #3: Coping Skills Research Question #4: Effectiveness of Coping Skills Summary vi

7 V. Discussion Major Findings in the Context of Existing Knowledge Implications for Policy and Practice Implications for Future Research Conclusion References Appendices A. Survey/Focus Group Guiding Questions B. Informed Consent vii

8 ABSTRACT This study explored the changes, symptoms, and coping skills that a soldier with wartime involvements experienced. The study focused on the observations of the soldiers spouses after the soldiers returned from war-time service. Seven soldiers spouses completed a survey and participated in a focus group to discuss their observations of the effect of war on the soldier and their families and on coping skills soldiers used to deal with their symptoms. The study uncovered that the soldiers were changed by their experiences and those changes made adjusting to returning from war difficult for not only the soldier but their families as well. Changes, symptoms, and coping skills identified in this study were consistent with the findings in prior studies. This suggest that future research is needed to identify and implement early interventions or treatments for the soldiers that includes their families. viii

9 CHAPTER I INTRODUCTION More than 1,600,000 U.S. military service personnel have served in the wars in Iraq and Afghanistan (Erbes, Polusny, MacDermid, & Compton, 2008, p. 972). Many of these individuals will return with unresolved issues from their time in the war zone. More than 1,300 soldiers have died to date in these wars. The RAND Corporation conducted a survey in 2008 of 1,965 military individuals returning from the war zone, and estimated that 300,000 individuals returning from Afghanistan and Iraq suffer from Post Traumatic Stress Disorder (PTSD) or major depression and 320,000 may suffer from some form of Traumatic Brain Injury (TBI) (Tanielian & Jaycox, 2008). For many soldiers experiencing trauma, TBI s, PTSD, and other psychological issues, re-entry into a non-combative environment may become a daunting task. The issues they face when re-establishing their role in the family unit are multiple. The soldiers must redefine their roles as a parent, spouse, child, and friend to family and friends they left behind at deployment. If the soldier was a parent, often a spouse or civilian parent was left behind to continue raising the child or children as a single parent until the soldier returned. Even without suffering physical or mental injuries, the soldier will have some type of re-adjustment issues due to the long absence of an 18 month tour at war. Little is known about what coping skills these soldiers utilize to 1

10 2 transition from the vastly different experience of the stress of war to the stress of civilian family life. This transition can be exasperated by physical injuries, serious or minor, which require physical healing, possibly surgeries, physical therapy, or acceptance of permanent disabilities due to the injury. Soldiers are returning with loss of limbs, loss of hearing, damage to their core body, traumatic brain injuries, and other injuries. The extent of the injury adds to the stress of returning to relationships the individual established before deployment. The spouse may have sent off a healthy young soldier who returns with serious injuries that changes the spouse s role to caregiver. Approximately 20,000 soldiers have returned with TBI; some believe this figure is closer to 150,000 (Hallinan & Bloice, 2008). Individuals with TBI can experience cognitive, physical and emotional difficulties. TBIs can be penetrating, when an object penetrates the lining of the brain, or closed, without any penetration. The individual may have symptoms such as stomach pain, constipation, lack of empathy for others, chest and back pain, hearing and vision damage, short term memory problems, personality changes, depression, or social difficulties, and have problems with equilibria, decision making, and impulse control (Hallinan & Bloice, 2008). With instances of minor TBIs, the soldier may not be aware there has been a brain injury. Without this knowledge the spouse may be confused about the changes in his or her soldier. Without knowledge or treatment, the difficulties with reentry are augmented.

11 3 Symptoms of TBI can linger and be severe enough to interfere with the individual s ability to manage day to day life and work. These individuals may have difficulty re-entering work, home, and their lives in the community (Trudel, Nidifer, & Barth, 2007). TBI symptoms for the most part fall into three categories (French, & Parkinson, 2008). The first category is somatic consequences; headache, sleep disturbances, vision problems, fatigue, seizures, or balance dysfunction. The second category, cognitive dysfunction, can include attentional impairment, reduced processing speed, memory dysfunction, or difficulties with language. Also included in this category is motivation, ability to initiate behaviors, and self-monitoring. In the third category is emotion and behavior. The symptoms include depression, anxiety, irritability, impulsivity, disinhibition, and on rare occasions mania or psychosis (French, & Parkinson, 2008). Post Traumatic Stress Disorder is another common obstacle to an individual s reentry to a non-war environment. Due to their experiences in the war, individuals can experience flashbacks, nightmares, numbing, avoidance, depression, alcohol abuse, drug abuse, headaches, and panic attacks (Bliese,Wright, Adler, Cabrera, Castro, & Hoge, 2008). There is a high rate of suicide with this current war. Research shows that an estimated soldiers are committing suicide each month (Gilbertson, 2008). The symptomology of PTSD has a large impact on the individual and the family. In a recent and highly publicized study, (Tanielian & Jaycox, 2008), conducted a survey of over 1,900 service members and veterans. They estimated that 14% of respondents screened positive for posttraumatic stress disorder (PTSD) and

12 4 another 14% for major depression. Additionally, 19% may have experienced a traumatic brain injury while deployed. Estimates from these data are that 300,000 service members and veterans may have diagnoses of PTSD or depression and that 320,000 have experienced a possible TBI (Sammons, & Batten 2008). Statement of the Problem With soldiers returning from the war zone suffering from symptoms of physical injury, TBI, PTSD, and major depression, it is likely that families will be affected by the soldiers symptoms. The returning soldier may develop coping skills that are not conducive to a family system. A common thread in most of the research on soldiers and symptoms they face is alcohol abuse (Sammons, & Batten 2008). The soldier may not want to talk about the symptoms they face or to appear weak to commanding officers and fellow soldiers by asking for help. This resistance may lead to dysfunctional coping mechanisms, which the soldier may not recognize. With the soldier struggling with these issues, the re-integration in a non-war environment would create stress for the family as well. Often the family is happy to welcome their soldier home and relieved that he or she escaped injury or death. The wounds the soldier sustained may not be visible to the family; however the symptoms could be devastating to the family as well as the returning soldier. There does not appear to be much research on how families cope with the stress of these symptoms. The soldiers spouses have a unique opportunity to observe these coping mechanisms used by reintegrating soldiers and to evaluate their effectiveness in stabilizing family functioning.

13 5 Statement of Purpose This study explored issues surrounding soldiers re-integrating to a non-war environment, and how this re-integration is effected by physical, mental, and psychological trauma the soldiers experienced during their tour at war. How these individuals re-integrate with their families was explored by looking at a seldom consulted member of their families, the military spouses. Although woman are soldiers and also deploy to war zones leaving family members behind to manage family life alone in their absence, this study focused primarily on the male soldier deploying. The military spouse was consulted during a focus group to obtain his or her thoughts on these questions. The study primarily included female spouses (wives). One male spouse (husband) was included, however, as he was part of the participants group and he wished to participate in the study. The purpose of this study was to examine symptomology and coping skills from the perspective of the soldiers spouse. This study focused on the following questions: (a) What is different in the soldiers family role after the return from the war zone than before deployment? (b) What symptoms are the soldiers experiencing? (c) What coping skills are the soldiers employing to manage symptomology? And (d) which coping skills appear to be most effective? Significance of the Study The military family functions together as a unit with each member having primary roles before the soldier deploys to the war zone. Each member of the family unit has roles and responsibilities which they must fulfill in the family. When a

14 6 husband deploys, the wife must take on all the responsibilities the husband held before deployment. The soldier must leave the family behind and focus on the job he has been trained to do, while constantly being on guard for attacks against the individual and the unit. When the soldier returns, there may be differences in how he was before deployment. The family unit may also be affected by the differences in the soldier. The returning individual may experience difficulties separating the role as soldier and that of husband and father. Those who had previously been patient and calm may become easily frustrated with their own children, responding with anger to minor insults. An individual may isolate from family members and avoid family functions, resulting in further alienation. Some returning individuals may abuse alcohol and drugs in attempt to cope with the difficulties of re-integration and escape from painful memories of traumatizing things they may have done or seen while in the war zone. This study looked at what coping skills the soldiers used which helped them with their re-integration. This study hoped to identify which coping skills were not helpful. Spouses may have observed some of these coping skills and differences in the soldiers roles in the family. Results can inform intervention efforts such as couples counseling, individual therapy, programs such as wounded warriors, and medical treatment within the military system. The study also attempted to identify what resources the soldiers and their families were utilizing, and with what success.

15 CHAPTER II LITERATURE REVIEW This literature review focuses on how a soldier may be changed by the experience of war and what researchers have found regarding symptoms the soldier might experience, the importance of coping skills for a soldier to re-integrate into family systems and the community, and the rate of suicide among soldiers. The review also discusses the common mental health diagnoses of returning soldiers, the high rate of suicide among soldiers with a mental health diagnosis, and the benefits of treatment to reduce symptoms and assist the soldier to return and reintegrate into the family system. Most of the research found has focused on studying male soldiers and their wives. There would appear to be a need for further study into female soldiers and their partners. This review, also, focuses primarily on the male soldier and his female significant other being female, but includes some information for a female soldier and male significant other when it applies. Changes After Deployment Prior literature has identified how a soldier may be different after the experience of war (Ray & Vanstone, 2009). According to Ray and Vanstone soldiers and family members report soldiers not being the same persons they were before deployment. The soldier can become hyper-vigilant with their families and especially with their children. Soldiers have reported feeling like they are on guard, and watching the area when they are out in the community with their children (Ray & 7

16 8 Vanstone, 2009). Ray and Vanstone looked at the symptoms soldiers experienced after war and how it affected their families. They analyzed the interviews of 10 veterans of war talking about their symptoms, coping skills, and family interactions. One of the soldiers in the study stated that after his experience at war, he became the body guard for his children. Another soldier shared that his wife told him he was changed and different since his return from war. The symptoms returning soldiers experience often suggest that the returning soldier is different than before the war experience, and returning soldiers are often found to suffer from symptoms of post-traumatic stress disorder (PTSD). Amdur and Liberzon (2011) conducted research on the clusters of symptoms soldiers with a diagnosis of PTSD experience. Their research specifically looked at how PTSD symptoms are clustered. Often soldiers experienced some degree of symptoms such as avoidance, emotional numbing, and sleep disturbances as well as intrusive memories of their experiences. The experience of war would likely result in trauma for the soldier even if the soldier was able to process the experience and was not diagnosed with mental illness. Returning soldiers sometimes also engage in risky behaviors. They may misuse alcohol, exhibit anger and aggression, and engage in risky and daring behaviors such as driving fast and not wearing a helmet when riding a motorcycle (Kelly, Athy, & Cho, 2012). Kelly et al. (2012) suggested that soldiers were more likely to engage in risky behaviors post-deployment than prior to being deployed. They reported that not wearing a helmet while riding a motorcycle, increasing

17 9 frequency and intensity of alcohol use, perceived invincibility, more aggression, and increased thrill seeking behavior were all more likely post-deployment. Kelly et al. (2012) reported an increase in confidence among returning soldiers, and stated this may be due to the soldier preferring dangerous situations or that hostile situations may strengthen the individuals. When the soldier returns from deployment, he or she may seek out risky situations, possibly looking for a sense of control Kelly et. al.(2012) also found that in regards to risk-taking behaviors, the soldiers personalities changed after deployment. Although traditionally personality is thought to be fairly stable once an individual reaches adulthood, Kelly et al. (2012) research suggests that some parts of personality may change during deployment in a combat zone. Another interesting discovery in the research by Kelly et al.(2012) was that a control group and a group diagnosed with traumatic brain injury (TBI) both scored lower on anxiety post-deployment than those diagnosed with PTSD or with PTSD and TBI. It appears that the symptomology associated with a diagnosis of PTSD is particularly debilitating to the soldiers ability to cope after they return from deployment. PTSD Symptoms and Family Distress Prior literature seems to identify the symptoms of Post Traumatic Stress Disorder (PTSD) as being one of the most damaging set of symptoms to family systems and the most likely to alienate the support systems needed for the soldier to be successful with treatment. Galovski and Lyons (2003) conducted research into the impact of PTSD on soldiers and their families. One conclusion of their study was that

18 10 soldiers diagnosed with PTSD were consistently identified as the critical element regarding the family distress. Riggs, Byne, and Weathers (1998) examined 50 couples and explored the level of distress in their relationships. They found that 70% of the couples with a soldier diagnosed with PTSD reported relationship distress compared to only 30% of the non-ptsd couples reporting relationship distress. A majority of the literature reviewed indicated there was increased difficulty for a soldier to acclimate to civilian life while experiencing symptoms of PTSD. Often the most challenging symptoms impacting family relationships are the soldiers avoidance and emotional numbing. When a soldier is experiencing these symptoms the result may be that the family support, which has been found to be beneficial in treatment, may be reduced or eliminated by the avoidance and emotional numbing. Ray and Vanstone (2009) found that the symptoms of PTSD, specifically emotional numbing, avoidance, and anger, had a negative effect on the family. They reported that the cycles of emotional withdrawal for the soldier and the family create more challenges for healing from the trauma. A study conducted by Hunt (2004) supports this finding as well. There appears to be consistency within the literature regarding soldiers with PTSD having more challenges processing their trauma experiences than soldiers without PTSD. PTSD among soldiers is most likely the result of battlefield trauma. Stein, Tran, Lund, Haji, Dashevsky, Baker, (2005), however, found that soldiers who had experienced childhood trauma were more likely to develop PTSD after military deployment. Stein s research was based on secondary analysis from prior research.

19 11 Stein reported that the greater the exposure to combat trauma, the greater the likelihood of the soldier developing PTSD, and that the development of PTSD was sometimes related to prior experiences. After reviewing prior research, Stein et al.(2005) also concluded that there was a relationship between combat exposure, higher symptoms of PTSD, and the coping skills used by soldiers. Soldiers who used avoidance as a coping skill and who had experienced longer deployments reported more PTSD symptoms than soldiers who did not use avoidance as a coping skill (Stein et al. 2005). Stein indicated that these findings suggest that while the use of avoidance as a coping skill allows the soldier to focus resources on other activities, it also prevents the individual from processing their experiences fully to cope with the war time stress. Therefore, the prolonged overuse of avoidance to deal with consistent and excessive stress is more likely to lead to pathology (Stein et al. 2005). Such findings suggest that when working with soldiers with PTSD, it is important to consider the number of deployments the soldier experienced and length of each deployment. Also, if the soldier is using avoidance as a coping skill the PTSD symptoms could be higher because the soldier is not processing the experience. A soldier who uses problem solving as a coping skill could process his or her experiences more effectively and feel more control over his or her own experience and self. Another challenge for the soldier diagnosed with PTSD is a higher likelihood of increased health risk behaviors such as substance misuse, aggression, risky driving behaviors, and thrill seeking behaviors after the soldier has returned from the war

20 12 experience (Kelly et al. 2012). This study investigated behaviors of post-deployment soldiers, and compared behaviors of a groups of individuals diagnosed with PTSD, a group diagnosed with Traumatic Brain Injuries (TBI), a group diagnosed with PTSD and TBI, and a control group without any of the previous diagnoses. Kelly et al. found that the soldiers diagnosed with PTSD and soldiers diagnosed with PTSD and TBI reported engaging in far more risky behaviors. These groups reported more episodes of drinking with higher consumption than the other groups. Also, these two groups scored higher on aggression, thrill seeking, feelings that they needed to cut down on drinking, and using more alcohol than they intended than the other groups. When considering the challenges experienced by soldiers after returning from the war experience, specifically, the challenges for those diagnosed with PTSD, the issue of the soldiers quality of life may be considered as well. It seems consistently clear that the soldier dealing with symptoms of PTSD has challenges in most areas of his or her life. It would seem that because of the discomfort of the symptoms, the soldier would experience a reduced quality of life. If the soldier is struggling with his or her family relationships and with difficulties in social situations to the point of avoiding them and engaging in increased alcohol use, the soldier would not have a stable quality of life (Schnurr, et al.2009). Schnurr et al.(2009) used social-material conditions, functioning, and satisfaction as indicators of quality of life. Prior research has shown that soldiers with PTSD have higher rates of unemployment, relationship distress, and divorce and homelessness than soldiers without PTSD (Tanielian & Jaycox, 2008). This

21 13 information would suggest that a soldier diagnosed with PTSD, experiencing even one of the issues above, would experience a lower quality of life. Although there is a large amount of research exploring the effects of war experience on the soldier, Schnurr et al.(2009) found very little research measuring the effects of PTSD symptoms on each area of quality of life. Schnurr suggested a need for more research specifically on PTSD and the quality of life, and indicated that it may be possible to reverse or even prevent a downward spiral of interaction between poor quality of life and PTSD by effectively treating PTSD. Schnurr went on to state that improved quality of life should be prioritized as a goal of treatment. Family Relationships After Deployment Little research has been completed about family relationships after deployment. What is available, however, consistently discusses the importance of family support for the veteran with PTSD to be successful with treatment. Challenges for the family begin immediately when the veteran with PTSD returns home (Mikulincer, Florian, & Solomon, 1995). Soldiers who return home to their families after a deployment may experience a period of reunion and re-adjustment with their families. The lengthy period of stress and worry for the family will have undoubtedly changed both the soldier and spouse during deployment. The couple will need to make adjustments for how they communicate and how decisions are made in regard to finances, tasks, and raising children (Erbes et al. 2008). While a soldier is deployed, the soldier s partner often must adjust to being the only parent in the household, caring for children, managing the household, making independent

22 14 decisions, and dealing with life stressors without the aid of the soldier (Erbes et al., 2008). When the soldier returns the family system is disrupted once again. Soldiers with PTSD seem to have the most challenges with readjustment as seen by research results depicting the higher likeliness of reports of reduced couple satisfaction, divorce, difficulties with co-parenting, and contemplating divorce among soldiers diagnosed with PTSD than among soldiers without the diagnosis (Galovski & Lyons, 2003). Riggs et al.(1998) found that 70% of couples with a veteran diagnosed with PTSD reported relationship distress as compared to only 30% of couples with a veteran without a PTSD diagnosis. Emotional withdrawal from family support creates a struggle with healing from trauma (Ray & Vanstone, 2009, p. 841). Wives of soldiers with PTSD also present relationship distress and mental health concerns. Wives of soldiers with PTSD present with more psychiatric impairment and psychopathology than wives of soldiers without a diagnosis of PTSD (Galovski & Lyons, 2003). Wives of soldiers diagnosed with PTSD report increased marital problems, violence on the soldiers part, increased violence for themselves, lower life satisfaction, and increased feelings of demoralization than the other groups of wives (Galovski & Lyons, 2003). Wives of soldiers with PTSD are more likely to experience spousal abuse than wives of soldiers without PTSD. Sherman, Zanetti, and Jones (2005) identified the difficulty for the wives of soldiers returning from war with PTSD as greater than that of wives of soldiers returning without PTSD. The strain on the wife to hold the family system together and manage children and household responsibilities without the

23 15 soldier s assistance can create trauma for the wife. If support for the soldier is diminished due to the wife s trauma, the soldier with PTSD may have a poor outcome with treatment (Sherman et al., 2005). Children of the soldier returning from a war experience also often experience trauma. Research conducted with families of soldiers returning from deployment found that children may experience difficulty with the soldier being over-protective and hyper-vigilant of the child or leaving the care and responsibility to the wife (Ray & Vanstone, 2009). The child may feel confused about the soldier s role in his or her life post-deployment. While the soldier was away from the home the wife was the sole parent and disciplinarian for the child and often the child will continue to look to the mother for confirmation when the soldier gives the child direction. This can further leave the soldier feeling alienated from the family (Ray & Vanstone, 2009). Unfortunately, soldiers may see avoidance and emotional numbing as ways to protect their families from the symptoms they are experiencing. This can create a larger problem for the child because the soldier is not being a good role model for how the child can learn good behaviors and methods for dealing with problems. This can also result in further estrangement for the child and the soldier (Ray & Vanstone, 2009). Adult children of soldiers with PTSD have reported that they were aware of the soldier s symptoms, however the symptoms were mostly not explained to them and they had very little understanding of why their fathers exhibited such symptoms (Galovski & Lyons, 2003). Children may not understand why their parent displays

24 16 symptoms and feel as if they are always on edge and unsure of what is happening (Galovski & Lyons, 2003). Children of a father with PTSD from war trauma appear to have more emotional and behavioral problems and higher rates of psychiatric treatment than children of soldiers without PTSD. When this population of children was observed in group therapy, the children exhibited aggressive behavior and were unable to relate to their peers socially or to ask for assistance from caregivers to manage their stress, resulting in regression when faced with social stressors (Galovski & Lyons, 2003). Galovski and Lyons (2003) reported that soldiers traumatic experiences may be transmitted to the child by 1) the parent s behavior, 2) the child identifies with the parent, and 3) as a result of non-specific dysfunction in the family. Research paints a picture of children not only suffering from the symptoms of the soldier, but also having developmental problems that can carry on through adulthood. One theory regarding how the wife and children are affected by the soldier s symptoms is secondary traumatization. One explanation of secondary traumatization is that an individual living closely to victims of violent trauma can become victims of indirect trauma. The individual can experience secondary traumatization resulting in nightmares, flashbacks, and intrusive thoughts after hearing about the trauma from the initial victim. Another way an individual can experience secondary traumatization is through the disruptive behaviors of the initially traumatized individual. The anger, violence, avoidance, and emotional numbing can cause the secondary trauma. Wives may suffer from battering and emotional detachment from the soldier as well as being

25 17 responsible for the children, household, finances, the husband s care and psychological health, and a lack of sexual intimacy. Wives of soldiers with PTSD present with more psychiatric impairment and psychopathology than wives of soldiers without PTSD (Galovski & Lyons, 2003). Suicide Concerns The literature on suicide rates for post-deployed soldiers seems to point to an increase in suicides in the last 10 years. There have been many studies to attempt to identify solders at risk of suicide and to better help identify signs that a solider may be struggling with suicidal ideations (Lemaire & Graham, 2011). Soldiers with PTSD are at risk for suicide as well as comorbidity of substance abuse issues and prior mental health issues (Jakupcak & Varra, 2011). Other noteworthy patterns related to a risk of suicide are those of soldiers who felt guilty about combat actions or about surviving combat (Maguen, Luxton, & Skopp 2011). A history of mental diagnosis and medication use were also associated with a high risk of suicide (Jakupcak & Varra, 2011) as was a diagnosis of depression (Kelly et al., 2012). Childhood trauma has also been identified as a risk factor and, specifically, the PTSD symptoms of emotional numbing and avoidance were identified as related to this condition (Amdur & Liberian, 2011). With all the concerns for soldiers who have experienced war found in the research, this is an area in need of more study to identify effective treatment methods to help our soldiers and their families to gain relief from the many challenges they face post-deployment.

26 18 Treatment for Soldiers and Their Families In researching the extensive material available regarding post-deployment issues for soldiers and treatment that has been used, Cognitive Behavioral Therapy (CBT) seems to top the list of most effective treatment for the soldier and the family (Schnurr, et al. 2009). The effectiveness of Cognitive Behavioral Therapy to improve the relationships that the soldiers are involved in was identified to have positive outcomes in treatment (Monson, Taft, & Fredman, 2009). Soldiers reported improved family relations, decreased symptoms of PTSD, and improved coping skills after participating in CBT treatment (Monson et al., 2009). Soldiers diagnosed with PTSD also reported improved couple functioning with CBT, although not improved social functioning (Schnurr et al., 2009). Treatment should include an emphasis on the importance of family involvement and providing information for the family to understand what the soldier is experiencing and how best to support the soldier.. Coping skills are also important aspects of the soldier s treatment, specifically problem-solving coping skills (Stein et al. 2005). Positive coping skills are correlated with the soldier feeling more of a sense of control with their experience of war and processing that experience (Stein et al., 2005). There is also seems to be some recent research related to Eye Movement Desensitization and Reprocessing (EMDR) having positive outcomes with PTSD and, specifically, with symptoms of reliving the trauma (Sammons & Batten, 2008). Galovski and Lynos (2003) reviewed the literature and reported on effective treatment methods for soldiers and their families. Systematic Treatments were listed

27 19 as effective for reducing distress to the family from the trauma of PTSD, suggesting traditional marital and family therapy). This therapy uses an agreement within the family about what the traumatic event is and how they will deal with issues that come from it when they occur. The family can be strengthened as a whole to improve communication skills around the trauma and symptoms. At the time of their study, Galovski & Lyons (2003) found no published studies on systematic therapy to validate the effectiveness. Support Treatment, which focused on education for families about the nature and treatment of PTSD was also identified as an effective treatment by Galovski and Lyons (2003). This method can include training to help the family understand and cope with the soldier s symptoms of PTSD. Support Treatment often included family day treatments, couple s therapy, and group therapy focused on developing problemsolving strategies. Consideration of male norms (Jakupcak & Varra, 2011) seems to be an issue that affects for soldiers seeking support. Often the soldier does not want to appear weak by seeking help for symptoms they are experiencing. Jakupcak and Varra (2011) recommended that therapists use careful assessment and frank discussions about the symptoms the soldier is experiencing, and emphasize the strengths and tools the soldier already possesses. They also recommend that frank discussions about suicidal thoughts and actions be discussed openly with the soldier, and report that no increase in suicidal ideations has been found due to frank discussion.

28 20 Conclusion Examination of prior literature leads to recognition of the importance of treatment for soldiers post-deployment to better help them to re-integrate into their family systems and the community. The research shows that many soldiers return with war trauma that is debilitating to their lives, families, and ability to work and maintain a stable household. The research shows that the symptoms of the soldier can result in homelessness, substance misuse, unemployment, divorce, poor parenting skills, and an overall reduction in the soldiers quality of life. With this information it would seem that treatment outcomes need to be further studied, and identification of soldiers in need of treatment screening needs to be improved. The quality of soldiers lives, as well as the lives of their family members, can be affected by the soldier s symptoms. The research leads to an understanding that the soldiers symptoms do affect the family as a unit and as individuals. The results of untreated symptoms seems to show that the children of soldiers with PTSD and other diagnoses suffer not just in the current family system but as they grow up and begin families of their own. The studies of children of soldiers with PTSD found that children exhibit behavioral issues and social dysfunction. There is no doubt that further studies of treatment for soldiers symptoms needs to be conducted and screening methods for soldiers returning from deployment needs to be improved. There should be a better understanding for military personal that treatment is an important aspect of the soldiers experience and more encouragement for soldiers to request support.

29 CHAPTER III METHODOLOGY The purpose of this study was to examine how wives described what symptoms soldiers returning from the war zone were experiencing as they attempted to re-integrate into a non-war environment. Along with what symptoms the soldiers were experiencing, this study looked at what coping skills their spouses reported soldiers were utilizing. The study attempted to explore symptoms and coping skills from the perspective of soldiers spouses, most typically wives, as they have a unique opportunity to observe firsthand the daily functioning of the returning soldier. It was anticipated that soldiers would incorporate some type of coping skills, whether they were negative or positive to manage the emotional and psychological issues they faced as a result of their war-time experiences. The soldiers wives were likely to have intimate knowledge of these coping skills and how effective they were. This study examined symptomology and coping from the perspective of the soldiers spouses. This study focused on the following questions: (a) What is different in the soldiers family role after the return from the war zone than before deployment? (b) What symptoms are the soldiers experiencing? (c) What coping skills are the soldiers employing to manage the symptomology? And (d) which coping skills appear to be the most effective? This study utilized a qualitative design. An open-ended survey was administered to spouses of returning soldiers. After the spouses completed the survey, 21

30 22 some of them participated in a focus group to discuss and expand on the content areas of the survey. Sample The participants for this exploratory study include six wives of soldiers and one husband of a female soldier for a total of seven participants. All soldiers had been deployed to a war zone. A form of snowball sampling was used to gather participants. One source was known to the researcher and agreed to recruit participants. This source was a wife and active member of the Family Readiness Group (FRG) which helps to prepare soldiers and their families for deployment, welcome deployed soldiers back, and provides support to the families while the soldier is deployed. This source had access to other wives who were her friends and military wives. The initial source enlisted her friends to encourage other friends to participate in a focus group. Through word of mouth a sample for the focus group was obtained. The advantage for the focus group was that the participants were familiar with each other and were relatively comfortable sharing personal information with each other. The wives often socialized and supported each other with personal issues and coping skills of their own when their husbands were deployed. Instrumentation The survey consisted of ten open-ended questions regarding any differences in the soldiers the spouses had observed post-deployment, symptomology of their soldier spouses, coping skills employed, and the effectiveness of these coping skills. The surveys were distributed to the spouses approximately one week prior to the

31 23 focus group. Each participant completed the survey and brought it to the researcher on the day of the focus group. The surveys were confidential and were put into a manila envelope until the researcher reviewed the responses after the completion of the focus group. The focus group covered the same basic questions as the survey allowing for the participants to elaborate on their experiences. The purpose of a survey and a focus group was that participants would be more candid on the survey as opposed to the focus group. The survey allowed the participants to answer the questions as truthfully as possible without concern for their friends knowing intimate details of their soldiers issues from war. The focus group allowed the participants to be as open as they were willing to be with other wives, and provide support to each other. Data Collection Participants completed the survey independently and anonymously approximately one week prior to participating in a focus group. The surveys were returned to the researcher prior to focus group in a manila envelope which was sealed until a later date to analyze the information. The focus group was conducted in the home of one military wife where the discussion was guided by the survey questions. Participants were encouraged to discuss how their soldier spouses were different than before deployment, symptoms and behaviors which were different, coping skills utilized, how effective these coping skills had been, and participants feelings about these issues. The focus group was audio recorded and the participants were encouraged to use first names only.

32 24 Participants from the focus group also provided surveys to other army wives who were unable to attend the focus group. These surveys were added to the data for analysis. Data Analysis After the focus group, the researcher transcribed the recorded focus group and compared the commonality of experiences expressed by the participants. Data were reviewed by organizing the data by research question. All responses were then reviewed to identify commonalities. The researcher looked for common themes regarding the soldier, symptoms, coping skills, and effectiveness of these coping skills. The researcher also analyzed the responses to the written survey for commonality of responses related to each research question. The analyses of the written survey and the focus group were compared, and ultimately combined, by the researcher. The results showed common symptoms the soldiers were experiencing and the many similarities in the coping skills used. Protection of Human Subjects All participants in this study were provided with an informed consent form. The participants were instructed not to write their names on the survey. Each survey was placed in a manila envelope by the participant. After all surveys were collected the envelope was sealed until the researcher later analyzed the information. Once the data were analyzed, the surveys were locked in a file cabinet to be maintained until the completion of the thesis.

33 25 The focus group was audio recorded. The participants were instructed to use first names only during the focus group. After the researcher analyzed the audio recording, the tape was placed in the manila envelope with the surveys and locked in a file cabinet for maintenance until after the completion of the thesis. At no time was any identifying information collected, and the data were only shared with a university professor (the Thesis Chair) for analysis purposes. Participants were advised that all data would be protected from all inappropriate disclosure under the law. They were also advised that their participation was completely voluntary and that they could withdraw from participation at any time without penalty or loss of benefits. All participants in the focus group were asked to maintain the confidentiality of what fellow focus group participants reported, but all participants were advised that complete confidentiality by group members could not be guaranteed and they should be aware of this prior to their participation. It was possible that during the focus group some of the soldiers spouses could become upset discussing the sensitive issues they faced with their spouses. While sharing this sensitive information a spouse could become overwhelmed by the emotions experienced due to the problems the family faced with re-integration, or could become angry about the circumstances that had led to the family s issues with re-integration. A participant could feel anger because of his or her perceived helplessness with the symptoms his or her spouse was experiencing or could become angry with other military wives and the opinion they expressed during the focus group. To assist with these feelings the researcher did have resource contact

34 26 information available to refer any of the participants that requested or appeared to require further assistance. Two resources were readily available. One was the Army Chaplain, who could have been contacted during the focus group with an immediate response time. The other resource was the Service Assistant Agency, which was available on the base where participants lived. An Army dependent may have six sessions with a contracted clinician before any issues must be reported to an Army official.

35 CHAPTER IV RESULTS Soldiers with war-time experience return to family and community systems on a regular basis in the United States. Since 2002, American soldiers have been deployed to Southwest Asia, and many have served multiple tours of duty across Afghanistan, Iraq,and Pakistan. Many Americans are proud of soldiers service and exhibit respect and gratitude through welcome home parties and parades when the soldiers return from deployment. Once the dust settles, individual soldiers and their families attempt to re-establish their family system, possibly hoping that their lives can go back to the way it was before the soldier was deployed. Many soldiers return, however, with trauma experiences that can result in symptoms which disrupt the process of re-integrating into family and community systems. If the soldier uses dysfunctional coping skills such as alcohol misuse, detachment, and anger the soldier s challenges with family systems can be increased. This researcher wanted to explore whether soldiers were different after their war experiences, what symptoms they experienced, what coping skills they used, and what coping skills were most effective for them. Sample Overview This research was qualitative in nature and included a survey of ten open ended questions presented to soldiers' spouses or significant others. This researcher received seven completed surveys for review. A focus group was also conducted with 27

36 28 three wives and one husband of soldiers. All but one of the participants lived at the same military base and knew each other in some capacity, either as friends or acquaintances. The participant of the last survey did not live on base and was the wife of a Vietnam veteran. The participants completed the survey on their own time and returned them in a confidential manila envelope to this researcher. The individuals who completed the survey were either married to a soldier or in a significant relationship with a soldier before the soldier deployed to war. Several of the individuals experienced their soldier and other family member soldiers deploying to war more than one time. Most of the individuals completing the survey lived on the same base, knew each other, and seemed to be part of a community within the military system. One individual was a male soldier married to a female soldier. Both this male participant and his female spouse had deployed to war more than once. Guiding Questions The results of the survey were organized into one document for comparison of the responses to each question. All the surveys were completed in their entirety with the exception of one survey, which was partially completed by leaving several answers blank. Information gleaned from the focus group participants was also included, and was organized similarly to survey responses. The purpose of the research was to answer the questions; what is different about the soldiers after their war experience, what symptoms have been observed, what coping skills have the

37 29 soldiers used, and which coping skills are most effective. Results are organized and reported by research question. Research Question #1: What is Different? Much of the literature regarding soldiers returning from war deployments discusses common symptoms reported by soldiers returning with PTSD. Participants in the current study reported many of these same symptoms present among the returning soldiers in their families. The soldiers spouses reported the differences they had observed in their soldiers since they returned from the war experience. Some of the differences the spouses observed were that the soldiers were quieter than before, more task oriented, and needed to stay busy. They also indicated the soldiers were angrier and short tempered, more stressed, and experienced bad dreams, increased violence during relational intimacy, increased aggression, mood swings, hypervigilance, and increased drug and alcohol misuse. One of the participants in the focus group was a male soldier married to a female soldier. Both had been deployed at different times to a war zone. The male spouse was able to share his experiences both as a soldier who had experienced a war zone and returned from a war zone, and as a spouse observing the changes and challenges of his soldier spouse after her war experience. When the discussion began, the first topic was about how the soldier was different after returning from the war experience. The male spouse immediately stated: I m psychotic now to the point of taking medication and I wasn t before. This participant did not elaborate on his psychotic symptoms, however he added: I was a pretty laid back guy. Now if you