PTSD: National Center for PTSD

PTSD and the Family

Sadie E. Larsen, PhD

Introduction

When a person has PTSD, the effects can be felt by others in their social network. In turn, the health of one's social network may influence the development or maintenance of PTSD. This article discusses connections between PTSD and the quality of relationships with loved ones. Treatment implications—for individuals and/or couples—and resources for supporting family members are included.

There are 2 limitations of the existing literature that are relevant to note. First, most of the research on this topic has examined how having PTSD affects the romantic partner or children of the person with PTSD. Although the effects of PTSD outlined below likely extend to non-romantic loved ones (e.g., friends, relatives), research on these other relationships is lacking, and so the article generally refers to "partners" below. Second, most of the literature has examined the experience of PTSD in male, heterosexual Veterans and their spouses and children. Further research will help to better understand how trauma type, gender, sexual orientation, and civilian versus military status may impact the following findings. More diversity in sample populations will help us to better understand how PTSD and relationship quality are connected.

How Is PTSD Associated With Relationship Problems?

There are a number of reasons why PTSD might be connected to relationship difficulties, both because PTSD may affect relationships, and because the quality of relationships can in turn influence PTSD maintenance or recovery. The review of key research findings below is based on the proposed directionality of the effects.

PTSD causes relationship problems

On the one hand, PTSD and specific symptoms might cause relationship problems. For instance, avoidance or numbing can foster withdrawal from relationships and a lack of emotional or physical intimacy (1). This can contribute to the feeling that a parent or partner is physically present but emotionally absent (2). At times the partner without PTSD will take up more of the household chores, parenting responsibilities, or emotional labor within a relationship. This "caregiver burden"—the sense that the partner must take care of person with PTSD and take over some extra roles and responsibilities—has in turn been linked to partner distress and relationship dissatisfaction (3). Likewise, some children try to "take care of" the parent with PTSD and feel responsible for how the parent is doing. They may take on a quasi-parental role themselves or over-identify with parents.

Another symptom cluster that may affect relationships is hyperarousal. For example, the effects of difficulty sleeping may affect bed partners and make cohabitation or intimacy more difficult. Knowing that a loved one is anxious or on edge can also lead to partners or children "walking on eggshells" in an effort to keep things calm (2,4). Further, hyperarousal is the symptom cluster that has been most closely linked to irritability or aggression (1). Although the majority of people with PTSD have never engaged in violence, PTSD is associated with an increased risk of violence.

Table 1. Examples of PTSD symptom effects on loved ones

There is some suggestion that the effects of trauma are "passed on" to future generations in the form of higher levels of general distress. Ongoing research on the intergenerational transmission of trauma examines the effects of Holocaust survival, combat trauma, and enslavement on future generations. The mechanisms of such transmission are still under study, and possibly involve both a biological and a social mechanism (5). For instance, if parents with PTSD model avoidance, or conversely share too many graphic details, children may learn to enact their own avoidance or to have their own symptoms in response to the described events.

Finally, research shows that children or partners may experience vicarious trauma via learning excessive distressing details about a person's trauma and then coming to experience some of the symptoms of PTSD themselves (2). And whether through the avoidance/numbing of PTSD or physical separation—such as military deployment—families deal with "ambiguous loss" in which the person with PTSD is either emotionally or physically absent, with uncertainty about whether they will return (6). (Indeed, separate from PTSD, the cycle of military deployment itself can be a source of stress for the whole family, with attendant worries, geographical moves, changes in which parents are present, and general social disruption, all leading to difficulties with parenting (7).)

Relationships affect PTSD symptoms

Research has found that positive social support is an important buffer against the development or severity of PTSD (8). This may be because loved ones can help process or make meaning of traumatic experiences, or simply provide ongoing support and reassurance of safety, care and concern for the trauma survivor. And there is some evidence that having supportive family or friends can make for a more successful course of trauma treatment (9).

There is also evidence that negative responses to disclosure of trauma (especially sexual assault) can harm a trauma survivor—and that such unsupportive experiences have a far stronger effect than any positive responses to disclosure (10). Likewise, one nationally representative sample of African American adults found that higher levels of negative family interaction were associated with higher likelihood of PTSD, except when there was also very close friendship to offset that negative interaction (11). It should also be noted that patterns of disclosure (both trauma-related or more general) may differ based on gender, trauma type and racial background (12).

There is of course, plenty of nuance too. For instance, "partner accommodation" refers to ways in which partners may change their own behaviors to respond to a person's PTSD symptoms (4). This accommodation often is very well-intentioned, as partners want to minimize distress on the part of the person with PTSD. Yet those same behaviors may maintain avoidance symptoms, minimize chances for growth and recovery, decrease opportunities for enjoyable together time, or convey that the partner doesn't think the person with PTSD is capable. Examples of accommodation might include a partner encouraging a person with PTSD to drop out of PTSD treatment if it seems distressing or taking on all grocery shopping so a person with PTSD doesn't have to face crowded places. Such accommodation has been found to be associated with higher levels of PTSD and lower levels of relationship satisfaction (4,13), and there is some evidence that it may make treatment less effective unless directly addressed in therapy (14).

Another nuance within relationships is the idea that it matters how partners make sense of PTSD. When partners perceive that a person has experienced very significant trauma, there is a weaker connection between PTSD symptoms and relationship distress (15). This is potentially because when partners attribute symptoms to the trauma, they are able to feel more empathy and less blame for the person with PTSD. Since many symptoms of PTSD may not be obvious as such to partners, having a shared understanding may help to reinterpret actions such as withdrawal, for instance, from "they don't care about me" to "they are feeling anxious and withdrawn because of PTSD."

Bidirectional links between relationships and PTSD

Several authors have proposed more comprehensive models that incorporate multiple causal influences and levels of analysis, including the Couple Adaptation to Traumatic Stress Model, the Cognitive Behavioral Interpersonal Theory of PTSD, and the Dyadic Responses to Trauma models (see Campbell — Renshaw, 2018 (3), for a review). Each of these emphasize the fact that ultimately PTSD is not only an individual issue, but also a response to an event that both affects and is affected by one's own and one's partner's thoughts, emotions, behaviors, and prior experiences. Beyond this, it is likely that the responses of other friends, loved ones, other more casual relations and even society more broadly impact PTSD, as shown by the significant impact that responses to trauma disclosure can have (10) in the context of ongoing stigma about the experience of trauma and PTSD.

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Partner Relationship Outcomes Associated With PTSD

Because PTSD and relationships affect each other in some of the ways outlined above, PTSD has been linked to negative outcomes related to relationship satisfaction, sexual functioning, partner mental health, and intimate partner violence (IPV).

Relationship functioning and satisfaction

PTSD can affect the relationship satisfaction of partners of those with PTSD. Reviews have consistently found that PTSD in one partner is associated with lower relationship quality in terms of self-reported relationship adjustment or relationship satisfaction (small-to-moderate effect; 16). A more recent meta-analysis found that although all PTSD symptom clusters were associated with relationship problems, the emotional numbing and avoidance symptoms were most closely linked to family functioning problems and intimacy-related issues (1). As suggested above, high levels of accommodation are also associated with distress and relationship dissatisfaction on the part of loved ones (13).

In the 2012 review, 16 of the 22 studies were Veteran or active-duty samples, many focused on male Veterans and their female partners. It will be helpful to study more diverse samples, since findings did differ by gender (16). For instance, although at least some initial studies have found similar relationships between PTSD and family functioning for men and women (17), others have not (18). Likewise, the connection between PTSD and partner support has been shown to vary by sexual orientation (19).

Sexual functioning and satisfaction

Likewise, sexual functioning and satisfaction can be an area of difficulty in intimate relationships for those with PTSD. Although particularly salient for those who have experienced a sexual trauma, it appears that difficulty with sexual functioning can occur after any type of trauma and is most closely linked with PTSD per se, not necessarily trauma exposure alone (20). Sexual functioning may be affected in different ways, from avoidance of sex to sexual compulsivity (21,22) or risky sexual behavior more broadly (23). Within intimate relationships, PTSD has been associated with lower arousal and lubrication (in women Service members; 21) and higher rates of a range of types of sexual dysfunction, including erectile disorder, low desire, and low sexual and relationship satisfaction (among male Veterans, 24). The reasons for this connection are unclear, but likely encompass both biological and psychological factors, e.g., the pairing of fear with sexual arousal, difficulties with attending to the present moment, and challenges with trust and emotional vulnerability.

It is clear that sexual and relationship functioning affect one another, but the directionality of that relationship is not yet established. Finally, antidepressants (SSRIs, SNRIs), which are frequently prescribed for PTSD and for comorbid depression—which is common—can have side effects that exacerbate difficulties with sexual functioning.

Partner mental health and distress

When one partner has PTSD, the other partner is more likely than average to be distressed. For instance, one review found that PTSD in one partner was related to distress in the other partner (small-to-moderate effect), including general distress, secondary traumatic stress and caregiver burden (16). These responses from partners may reflect the accumulated burden and relationship dissatisfaction from living with a person with PTSD. Secondary trauma symptoms may also result when a partner is upset by details of a person's trauma and start to have their own trauma-related responses (e.g., feeling that the world is unsafe). Most studies in this area are limited to male Veterans and their female partners. PTSD and partner distress were more closely linked in military samples than non-military, as well as for those with a more distant (vs recent) trauma. More research to examine gender differences and dynamics among same-sex partners is needed.

Intimate partner violence (IPV)

Finally, PTSD has been linked to a higher likelihood of perpetrating IPV, though again, most people with PTSD have never been violent. Meta-analyses of the link between PTSD and IPV have found small-to-medium effect sizes linking the 2 constructs (5,25), with hyperarousal being the most influential PTSD symptom cluster. This relationship appears stronger in military samples and samples where the male partner has PTSD (which have, again, been the majority of those studied). It has been suggested that, among Veterans and Service members, PTSD may be connected to aggression because of military training that reinforces heightened arousal, a high likelihood of perceiving threat, and a low threshold for responding to threat with aggression (5,25).

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Child and Parenting Effects of PTSD

Review studies have found that parental PTSD has a significant (medium) effect on child distress, PTSD, and behavioral problems (26), regardless of whether only the parent had experienced a trauma (e.g., combat trauma) or whether both parent and child had experienced a trauma together (e.g., natural disaster). This effect was larger for interpersonal traumas. There is also some indication that, for military families, adjusting to the deployment of a parent can be very hard on both the remaining parent and the child; if the partner of the person with PTSD is also negatively affected (as outlined above), that may remove the opportunity for one parent to buffer stress from—or effectively support—the other (27). By contrast, one study found that living in a cohesive neighborhood may buffer the negative effect of PTSD on parenting for single Black parents, indicating that social support across multiple types of relationships may be important to understanding these parenting and PTSD across diverse groups (28).

A review found that links between PTSD and specific parenting practices are inconsistent across studies, so it is not clear exactly what may account for the association between parental PTSD and child distress (29). There is some indication that avoidance and numbing on the part of the parent may have a similar deleterious effect with children as with partners, leading to loss of opportunity for positive interaction or helpful communication between parent and child. Likewise, hyperarousal and attendant anger or emotional reactivity may affect children either directly or indirectly through witnessing parental interaction. In general, when children don't understand why their parents are acting in a certain way (e.g., avoiding their child's activities), they are likely to misinterpret them as parents' not caring about them. Despite these difficulties, parents with PTSD often greatly value their role as parents, which for some can be a motivation to seek treatment (2).

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Treatment Implications

When treating a person with PTSD, it may be productive to assess family and social support at the beginning of and throughout treatment. Even for people only pursuing individual therapy, improving relationships may be a goal of treatment, in which case repeated assessment will help tailor treatment focus. Furthermore, family members may still impact individual treatment through either encouraging or undermining the work of therapy (e.g., through symptom accommodation or advising the patient not to continue with treatment, 30). Since the attitudes and behaviors of family members can have either positive or less helpful impacts on the course of therapy, it may be most productive to proactively discuss at the beginning of treatment whether and how to engage loved ones. Moreover, people seeking PTSD treatment may want their family members to be involved but be unaware that it is an option (31,32). Some individuals with PTSD prefer to not involve a loved one in their treatment initially, but are more open to family engagement at later points; they may feel more ready to discuss their traumatic experience or PTSD symptoms with loved ones once they have made some progress in their individual work.

When partners or other loved ones are involved in treatment, at a minimum it can be helpful to educate them about PTSD and symptoms, and the fact that relationship difficulties are common after trauma and PTSD. If partners can see symptoms as part of PTSD rather than an indication of the person's feelings toward them, this can help with relationship satisfaction. This may be particularly important for symptoms such as numbing, which may not be obvious to the person with PTSD or their partner as a symptom of PTSD. It may also be useful to discuss or facilitate trauma disclosure if desired by the person with PTSD, though this may not be as necessary as disclosing about PTSD diagnosis and symptoms. Skills offered may include improving communication and problem solving more generally. If partners are distressed, they may be encouraged to seek their own support or counseling. Consider utilizing the resources at the end of this article.

Finally, for parents with PTSD, clinicians may want to discuss and provide written information on how to communicate effectively with partners or children (2). Parents can be encouraged to explain to their children the reasons for the parent's difficulties, at a level of detail that is developmentally appropriate. This may or may not involve talking about the trauma itself, again at a level of detail that is appropriate. Clinicians can help parents find a balance between remaining silent about PTSD (in which case children may develop their own inaccurate interpretations of symptoms) and on the other hand sharing too much information for children to be able to handle. It is important to give children a chance to ask questions, and to help them understand that the symptoms are not related to them nor are they at fault or responsible for fixing them. Children may also benefit from their own therapy, from family therapy, or from parents receiving education in positive parenting practices (7).

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Structured Treatments to Involve Families in PTSD Care

For patients who have PTSD and either express an interest in family involvement or are currently experiencing relationship distress, there are various structured options for treatment. The choice of where to start will depend on patient preference, the quality of existing relationships, and provider training and availability.

One option is to provide individual PTSD treatment, since that is identified as the front-line option for treating PTSD. Moreover, as many providers are not trained in couples interventions, individual therapy may be the most available option. There is some initial evidence that both individual and couples-based treatments can help improve relationships, so the choice can be driven by patient preference (33). For patients engaged in Cognitive Processing Therapy (CPT), Prolonged Exposure (PE), Written Exposure Therapy (WET), or Eye Movement Desensitization or Reprocessing (EMDR), clinicians are encouraged to provide the relevant family-focused handouts so that the patient's loved ones can have a better understanding of the treatment approach. (See Resources section below).

When patients are interested in incorporating a partner or loved one into treatment, options range from fully couples-based therapies in which PTSD improvement and relationship improvement are equal goals, to briefly engaging the family to provide them with education.

In terms of fully dyadic treatments, Cognitive Behavioral Conjoint Therapy for PTSD (CBCT for PTSD) involves 15 couple sessions focused on both decreasing the patient's PTSD symptoms and improving relationship functioning for both parties (34). CBCT for PTSD can be conducted with any meaningful person willing to be part of treatment (i.e., it is not limited to romantic couples). The treatment involves psychoeducation, exercises to improve relationship functioning, and cognitive restructuring work focused on trauma-specific and general negative cognitions. Structured Approach Therapy is a 12-session couples' treatment specifically designed for combat Veterans and their partners. It involves psychoeducation, skills training in communication and emotion regulation, and disclosure of trauma memories and emotions in session (35).

A trauma-informed treatment model called Strength at Home has been developed for Veterans specifically. Several variations of this 8-12-session model are available, including treatments tailored for Veterans who have been physically aggressive toward a partner in the past year (Strength at Home—Veterans; SAHV), Veterans who are parents (Strength at Home—Parents; SAHP), or couples who are at risk for IPV or who have used psychological aggression (Strength at Home—Couples; SAHC). Each of these treatments includes psychoeducation on PTSD and how PTSD symptoms may affect relationship functioning and/or parenting. Skills taught include emotion regulation, communication, and time-outs to prevent escalation of arguments. SAHV has been found to prevent IPV; the SAHP intervention has so far demonstrated feasibility but will need further testing to determine efficacy (36-38).

Shorter options exist, such as the newer Brief Family Intervention (BFI), in which family members have 2 individual sessions with a clinician, separate from the patient with PTSD (39,40). Providers offer family members information about PTSD, trauma-focused treatments, and how they can be helpful to their partners as the patient with PTSD goes through individual trauma treatment. The BFI is not a stand-alone treatment, but rather is meant to be delivered to family members of Veterans who are currently engaged in CPT or PE.

All of the above treatments have preliminary support but need more rigorous research to understand their efficacy. Currently, the choice of treatment will depend on patient needs and preferences along with provider training and availability.

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Resources

Many of the resources below were developed for Veterans or VA providers, however the recommendations may be applicable for a broader audience.

Continuing education courses for providers

• Cognitive-Behavioral Conjoint Therapy for PTSD
• The Role of Family Members in PTSD Treatment
• Social Support to Reduce Risk of PTSD and Other Negative Outcomes

VA resources for family members and parents

• The VA Caregiver Support Program (1-855-260-3274) provides services and support to family members who are taking care of a Veteran.
• VA's South Central MIRECC offers a downloadable pamphlet to encourage Veterans with PTSD who have children: A Veteran's Guide to Talking With Kids About PTSD.
• The Oklahoma City VA developed the REACH Program: Reaching Out to Educate and Assist Caring, Healthy Families. The PTSD Manual is a guide for a multifamily group 9-month psychoeducational program for Veterans living with PTSD and their families.

National Center for PTSD materials, apps and videos

• Understanding PTSD: A Guide for Family and Friends (PDF booklet)
• For friends and family members to support a loved one during PTSD treatment, web articles are also available as PDF pamphlets on the pages below or may be ordered for free from the US Government Publishing Office:
  • Helping During Cognitive Processing Therapy (PDF)
  • Helping During Prolonged Exposure (PDF)
  • Helping During Eye Movement Desensitization and Reprocessing (PDF)
  • Helping During Written Exposure Therapy (PDF)
• PTSD Family Coach mobile app
• Couples Coach mobile app
• Cognitive-Behavioral Conjoint Therapy for PTSD animated whiteboard video
• AboutFace: Watch and learn about PTSD and effective treatments from Veterans, family members and clinicians who have been there.
• PTSD Bytes is a podcast free to anyone interested in mental health and technology includes 2 episodes focused on relationships (episode #17) and resources for family members (episode #11).
• Community Reinforcement and Family Training (CRAFT) for PTSD is a self-paced online course for family members of someone working to manage PTSD.

Additional resources for military families:

• Military OneSource is a Department of Defense-funded program offering support for military families and their communities.
• Sesame Street for Military Families is a free, bilingual (English and Spanish) website with age-appropriate content about deployment, homecoming, injury, grief and other relevant topics.

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References

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37. Taft, C. T., Creech, S. K., Gallagher, M. W., Macdonald, A., Murphy, C. M., & Monson, C. M. (2016). Strength at Home Couples program to prevent military partner violence: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 84(11), 935-945. https://doi.org/10.1037/ccp0000129
38. Taft, C. T., Macdonald, A., Creech, S. K., Monson, C. M., & Murphy, C. M. (2016). A randomized controlled clinical trial of the Strength at Home men's program for partner violence in military Veterans. The Journal of Clinical Psychiatry, 77(9), 1168-1175. https://doi.org/10.4088/JCP.15m10020
39. Thompson-Hollands, J., Lee, D. J., & Sloan, D. M. (2021). The use of a brief family intervention to reduce dropout among Veterans in individual trauma-focused treatment: A randomized controlled trial. Journal of Traumatic Stress, 34(4), 829-839. https://doi.org/10.1002/jts.22680
40. Thompson-Hollands, J., Strage, M., DeVoe, E. R., Beidas, R. S., & Sloan, D. M. (2021). Development of a brief adjunctive intervention for family members of Veterans in individual PTSD treatment. Cognitive and Behavioral Practice, 28(2), 193-209. https://doi.org/10.1016/j.cbpra.2020.06.007

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