Mental Health Therapy for Veterans with PTSD as a Family Affair: A Qualitative Inquiry into How Family Support and Social Norms Influence Veteran Engagement in Care

Abstract

Social support is important for PTSD recovery and emerging literature indicate that social support could increase engagement in PTSD therapy. However, there is a need to understand how and why family-involvement can increase treatment engagement to inform strategies used in clinical practice. This study explores how individuals with PTSD and family members of individuals with PTSD experience therapy and how social interactions help or hinder therapy engagement. We interviewed 18 US military veterans who had been referred for psychotherapy for PTSD in the Veterans Health Administration and 13 family members and used rapid content analysis to identify themes. We found that engaging in therapy was a family-level decision that participants expected to improve family life. Veterans were motivated to seek treatment to protect their relationships with loved ones. Family members generally encouraged veterans to seek treatment. Specifically, family members who viewed PTSD as a treatable illness versus a static aspect of the veteran’s personality expressed positive attitudes about the effectiveness of therapy for reducing symptoms. Veterans whose social networks included individuals with prior military or trauma-related experiences reported that their loved ones possessed more understanding of PTSD and described positive subjective norms around therapy. Family members are often embedded in the therapy process because PTSD has a profound impact on the family. Positive subjective norms for therapy are created by family encouragement and may influence veteran perceptions about the value of treatment. Family members should be engaged early in mental health therapy and to the extent desired by the patient and family member.

Introduction

The development of posttraumatic stress disorder (PTSD) and its sequelae is inherently social (Maercker & Horn, 2013). It has profound negative implications for multiple domains of life that require a high degree of interpersonal interaction, including social relationships, work, and community participation. PTSD can manifest in distorted beliefs about safety, trust, control, and intimacy (Foa et al., 2007) and can lead to emotional numbing, withdrawal, and anger that are especially detrimental for close social connections, such as relationships with family and friends (King et al., 2006; Ray & Vanstone, 2009; Sautter et al., 2009). Negative family outcomes can include increased distress in the family unit and individual family members (Papero, 2017), withdrawal of family members, reduced social support for the person who experienced the trauma (King et al., 2006; Ray & Vanstone, 2009), and ultimately family separation (Galovski & Lyons, 2004). On the other hand, positive social support reduces the likelihood of developing PTSD after a traumatic event and, for individuals who develop PTSD, social support can reduce symptoms (King et al., 2006) and improve PTSD therapy outcomes (Spoont et al., 2014).

The Bowen Family Systems Theory is particularly relevant for understanding how the sequelae of PTSD ripple across the family unit. Through this theory, it is posited that a family unit exists as a complex emotional system in which individual members experience interconnected emotional states, feelings, and patterns of reactivity (Kerr & Bowen, 1988). PTSD symptoms expressed by one individual, including emotional numbing, avoidance, and heightened reactivity, negatively impact the connection between that individual and other members of the family unit leading to dysfunction within that unit (Figley & Kiser, 2013; Papero, 2017). Furthermore, the ways in which non-PTSD afflicted family members react to the symptomatic individual can either increase or decrease the intensity of PTSD symptoms (Charuvastra & Cloitre, 2008; MacKay, 2012; Markowitz et al., 2009). For example, if family members are able to stay emotionally connected to one another while maintaining healthy individual-level boundaries, this should promote positive functioning within the family unit (Priest, 2015) and reduce symptoms in the individual with PTSD (Papero, 2017). In fact, social support and disclosure of the trauma experience to close family members and friends have been found to be protective for PTSD, while blaming and ostracizing the individual who experienced the trauma are risk factors for PTSD onset and symptom severity (Maercker & Horn, 2013).

The way in which PTSD symptoms impact and are affected by reactions in the family unit suggests that care and treatment for PTSD should incorporate family systems approaches. For example, couples-based, trauma-informed therapies are associated with robust improvements in PTSD symptoms, while also enhancing relationship satisfaction (Macdonald et al., 2016; Monson et al., 2012). Yet only in the last few years have family-based approaches been leveraged to increase engagement in PTSD therapy generally or evidenced-based PTSD psychotherapies (EBP), specifically Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) (Meis et al., 2022; Shepherd-Banigan et al., 2022; Thompson-Hollands, Lee, Sloan, 2021). Limited engagement in PTSD therapy is a major barrier to promoting recovery for veterans with PTSD at a population level. Within VA, fewer than 23% of veterans with a PTSD diagnosis started an EBP and of those who initiated at least one session, only 9% completed an adequate dose (Maguen et al., 2019). Data about use of general therapy for PTSD is only slightly better. Just 39% of veterans received at least one therapy visit within 6 months of a PTSD diagnosis and of those only 24% completed an adequate dose (Spoont et al., 2010).

Family-involved approaches to increase engagement in PTSD therapy may be promising. For example, one randomized pilot study showed a 50% decrease in veteran drop-out of an EBP following a brief 2-session intervention that targeted support partners (Thompson-Hollands, Lee, Sloan, 2021). However, evidence is needed to understand why and how family-involved approaches could work. Theoretical frameworks propose individual and interpersonal processes that might underlie mechanisms between family-involved approaches and PTSD therapy engagement. For example, the Theory of Planned Behavior (Ajzen, 2002) acknowledges that individual-level attitudes towards treatment are influenced by subjective norms—or the beliefs of the individual with PTSD about whether others in the family system and social networks approve or disapprove of a behavior, such as attending therapy (Meis et al., 2019; Meis et al., 2020). Similar to family systems theory, the Theory of Planned Behavior posits that these beliefs are likely influenced by the expressed attitudes of others in the family or social network towards the efficacy of therapy. Therefore, cultivating positive attitudes among people in the individual with PTSD’s social network may be an important pathway to promoting engagement in mental health care. While not explicitly linked to these theories, work by Meis and colleagues has started to examine mechanisms linking the family system and adherence outcomes. This research shows that family encouragement to face distress and family knowledge of PTSD and treatment may be important to prevent drop-out (Meis et al., 2019; Thompson-Hollands, et al., 2021). These studies provide initial support for the usefulness of family systems theory and the Theory of Planned Behavior for family-involved interventions to promote engagement in PTSD therapy.

Current Study

Evidence about social support buffers and stressors that underlie the post-trauma experience builds support for the assumptions that increasing family member buy-in of treatment may promote better engagement in PTSD therapy (Meis et al., 2019; Spoont et al., 2014). However, to our knowledge there are no existing qualitative studies of Veterans and their family members that examine how and why family members¹ encourage veterans to seek and engage in PTSD therapy and how these interactions influence Veteran perspectives of PTSD therapy. Specifically, we aim to explore how family-level considerations influence why and when individuals with PTSD decide to initiate therapy, how family members engage with the individual with PTSD who is seeking therapy, and how these interactions help or hinder the therapy process. The overall goal of this study is to learn about the mechanisms underpinning family-involvement in mental health care seeking and engagement from the distinct perspectives of veterans and family members and grounded in family systems and health behavior theory. We apply a theoretical lens to focus our investigation on family interactions and behavior change mechanisms that can be translated into clinical strategies. With this information, we will build a theory-driven evidence base to guide efforts to develop and refine family-involved interventions that can be implemented in clinical care.

This paper presents findings from a qualitative study of US military veterans with PTSD who were referred to therapy and their family members to explore how and in what ways these interpersonal relationships influence care seeking and therapy engagement.

Materials and Methods

Sample and Recruitment

Our sample represents a national population of veterans from medical centers across the VA Healthcare System with an ICD-10 PTSD diagnosis who were referred for mental health therapy and their family members that had applied to the Veterans Affairs (VA) Program of Comprehensive Assistance for Family Caregivers (PCAFC) (Collins et al., 2016). We chose to limit eligibility to veterans with family members who had applied to PCAFC to increase the efficiency and specificity of our recruitment efforts because these veterans were more likely to have a support person in their lives. We identified patient PTSD diagnosis through electronic medical records, but medical records do not contain reliable information about family members. By using research-approved administrative data sources that included electronic health data and PCAFC administrative data, we were better able to target veterans with a family member. The family member was the individual who was 18 years or older and was associated with the most recent application to PCAFC between May 1, 2010, and May 7, 2019; in one case the family member chosen by the veteran was not the person who applied to PCAFC but was the veteran’s spouse. We sampled veterans who had a referral for a VA mental health visit in their medical records because we were interested in interviewing veterans who had and had not engaged in therapy. Referrals were limited to those that had occurred 18 months prior to December 2019. To be included in the sample, during eligibility screening veterans also needed to recall having received the referral and report being in touch with the family member who applied with them to PCAFC. Referrals for mental health therapy were identified using VA electronic health records and PCAFC application information was derived from Caregiver Support Program administrative data.

Out of 373 veteran records reviewed, our study team contacted 276 veterans. We randomly selected eligible veterans to receive letters with study details and an opt-out number. Study staff contacted potential participants who did not opt-out within 10 days by telephone to explain the purpose of the research, convey the risks and benefits of study participation, and assess eligibility using a telephone-based screening tool. Then, we sent a letter was sent to their support person (n=169) who was also contacted by telephone and screened for eligibility. Veterans who were eligible and interested (n=27) were consented and scheduled for an interview; 17 veterans participated in the interview. Ultimately, we consented 20 family members into the study and 13 participated in the interviews. All individuals who participated in the interviews provided verbal consent and received $25 for their participation. The unit of observation was the dyad because we were interested in the phenomenon of the family experience of mental health therapy for PTSD. Therefore, when one member of the dyad was consented, we considered the dyad to be enrolled in the study even if we were unsuccessful in enrolling and/or collecting data from the other member of the dyad. Reasons for not interviewing both members of the dyad varied including not being able to reach the family member to consent them, the veteran or family member not showing up for or cancelling the interview and then not rescheduling, and reaching saturation on family member perspectives around therapy (see Figure 1, Study Flow).

Figure 1.

Study Flow

Note: SP=support partner

Table 1 displays sample characteristics. Fifty percent of veterans in our sample identified as male and 17% identified as Hispanic. Thirty percent identified as white, 30% identified as Black, and the remaining 40% self-identified as belonging to other racial categories. Among the family members, 60% identified as women and a higher proportion identified as Black (39%) and Hispanic (39%) than among the veterans. Nine of the 11 dyads in our sample were married or partnered with one another. One family member was the mother of an interviewed veteran, and one was the veteran’s adult daughter. The team interviewed two family members without an associated veteran – one described herself as the veteran’s “life partner” and the other was a neighbor and close friend. We interviewed seven veterans without an associated family member and all identified their family member as their spouse.

Table 1:

Participant Characteristics (N= 31)

Characteristic	Total
	Veterans (n = 18)	Family Members (n = 13)
	n (%)
Sex
Male	9 (50.0)	5 (38.5)
Female	9 (50.0)	8 (61.5)
Race
White/Caucasian	5 (27.8)	4 (30.8)
Black/African American	5 (27.8)	5 (38.5)
Asian	1 (5.6)	0 (0.0)
Native American/Pacific Islander	3 (16.7)	0 (0.0)
Mixed	2 (11.1)	2 (15.4)
Other	1 (5.5)	2 (15.4)
Prefer not to answer	1 (5.5)	0 (0.0)
Ethnicity
Hispanic, Latino(a)	3 (16.7)	5 (38.5)
Age, median (minimum – maximum)	46 (31–57)	41 (28–72)
Veteran/Family member Relationship	Dyads* n = 11
Spouse	8 (72.7)
Significant Other	2 (27.3)
Parent/Child	1 (9.1)

^*both individuals in a dyad were interviewed

Study procedures were approved by the Durham VA Institutional Review Board (Protocol #02227).

Data Collection

We interviewed veterans and family members separately. The team developed interview guides using input from a literature review. Guides were revised after review by a veteran and caregiver stakeholder engagement group and then piloted through five interviews. We linked the design of the interview process and scripts to existing theoretical frameworks. For example, per the Bowen Family Systems Theory, we intentionally aligned the interview scripts for the veteran and family member to triangulate information about the emotional interdependence of family members and close friends related to PTSD and therapy. To understand the specific interpersonal processes underlying family-level attitudes towards PTSD therapy we asked how family members were supportive of and helpful during the therapy process. To link these theoretical constructs with care seeking behaviors, we explored constructs from the Theory of Planned Behavior, including veteran treatment attitudes, intentions to engage in therapy, and their perceptions about subjective norms related to therapy (i.e., individual’s beliefs about opinions of others about PTSD therapy).

The interview guides explored barriers and facilitators to engaging in therapy for PTSD after the most recent referral the veteran had received. Specifically, we explored the role that family members could play in the veteran’s treatment and improving engagement in treatment. In some cases, veterans were not engaged in the therapy for which they had been referred and so we explored barriers to beginning that episode of therapy. However, all veterans in the sample had prior experience with mental health therapy and were therefore able to speak about these topics in relation to past treatment for PTSD and other mental health and behavioral conditions. Other topics covered during the interviews included: 1) how veterans came to learn they had PTSD, 2) a review of the veteran’s PTSD treatment history including where the veteran received therapy (i.e., VA vs. community care), 3) why they believed that they were referred for the most recent round of therapy, 4) whether therapy would be helpful or not for them now, 5) why they did or did not follow through on the most recent referral for therapy, 6) whether they intended to continue to seek access to or to engage in therapy, 7) whether individuals in their support network were aware that they had PTSD and had been referred for treatment, 8) whether these individuals were supportive of therapy and if their opinions about therapy influenced the veteran to engage in therapy, and 9) in what ways these individuals were helpful or not as the veteran sought therapy for PTSD and what support these individuals might need from VA. We asked core questions of all participants and discussed each topic with probes that may or may not have been used based on their relevance to topics discussed during the interview. We asked family members a parallel set of questions that prompted them to describe their understanding of and perspective on the veteran’s mental health treatment and to detail their role as a family member in the veteran’s past and current mental health therapy.

Trained interviewers collected data via telephone interviews between February 2020 and February 2021. We paused participant recruitment between April-August 2020 due to challenges related to the COVID-19 pandemic. Interviews (n=31) were semi-structured and lasted on average 32 minutes. Participants included veterans (n=18) and family members (n=13), of which 11 were dyads. Interviews were digitally recorded and transcribed (n=26) or documented through detailed notes of the recordings (n=4) and interviews (n=1). The team conducted interviews until variation in perspectives decreased and new data became redundant (Saunders et al., 2018).

Analysis

The study team reviewed and summarized transcripts and interview notes. We used Hamilton’s rapid content analysis approach (Hamilton, 2013) to structure the qualitative inquiry. The qualitative analyst (AS) created a summary template for each dyad (or individual if only one member of the dyad was interviewed) that identified structural codes from the questions in the interview script. Examples of structural codes include: “reasons for treatment”, “helpfulness of treatment”, “family member functions”, “family member influence on treatment decisions”, and “opinions of family member about PTSD therapy”. We aligned the matrices with the theoretical frameworks to ensure that relevant constructs were identified when present. One of three members of the qualitative team (AS, ME, TL) summarized each transcript/interview notes into this template and another member reviewed each summary for accuracy and completeness. The team met weekly to discuss emerging themes and reactions to the data using a value adding analysis approach to identify and ultimately summarize themes (Eakin & Gladstone, 2020). Then, the data from each summary template was transferred into a single matrix and, using matrix analysis (Averill, 2002) coders summarized the information by structural code across dyads/cases and within dyads across structural code. We considered dyads to be the unit of analysis. Cases where we only interviewed the veteran or family member were considered to be a dyad with missing data. We analyzed dyads as cases to attempt to capture the experience of therapy at the family level. Two qualitative team members reviewed each summary. The team also summarized stories about treatment engagement within dyads. The team met to compare summaries and then met again to review all summaries, refine themes, discuss interpretations of the data, and to reflect on their own position as non-veteran researchers and how those positions interfaced with their understanding of the data. Once the team developed written narrative of the themes, they reviewed data in the matrices and transcripts again to ensure that the selected themes reflected participants’ reporting. Table S1 shows theoretical constructs/definitions and how the constructs map onto interview question domains, codes, and broad themes.

Results

Theme 1. Getting into therapy was often a family affair.

For many veterans their family members were integral to their decision—and in some cases propelled them—to begin therapy. One family member recounted how she persuaded the veteran to engage in therapy and said,

“I even told him, you know— ‘We want to see you happy. The kids want to see you happy. Everybody wants to see you happy. And we know you can get to be where you were, and you just need to go in and get the help that you need’—And so I know it took a couple conversations until he decided to [go to therapy].” (family member (F), dyad 1)

Veterans were often encouraged by family members, friends, supervisors, or work colleagues to seek therapy for their symptoms. Several veterans reported that the realization that they needed treatment came from interactions in the workplace; as one veteran described, “One day, one of my office workers said that I might need to go to mental health and talk to someone. … And I didn’t realize what was going on. The people around made me aware of what was going on and what I was doing.” (veteran (V), dyad 4)

A few veterans described how they made the decision to participate in therapy together with family members. As one veteran said, “She would see issues I was having, but I wasn’t seeing it. So, with her help, pushing me to go get seen and go into the VA and turning myself in and saying, ‘Hey, I have issues,’ she had a lot to do with it.” (V, dyad 2). One family member described a conversation he had with the veteran about getting into treatment and their decision about whether or not to pursue therapy at a location that was not near their home,

“We had been talking about needing to get some form of help and they [mental health providers] always talk about these places where you can go and get help, and there’s a couple of places around us where you go away. Well, going away is not always the easiest thing to do.” (F, dyad 3)

Participants portrayed improving PTSD-related symptoms through therapy as a shared goal. In fact, several family members described anticipated treatment outcomes in terms of “we,” “us” and “our” outcomes. One family member described their veteran’s therapy as, “something that’s going to help not only you as a person but us as a family.” This outlook conveyed a high level of confidence in the value and efficacy of therapy for PTSD which seemed to underlie positive attitudes towards therapy.

Family member decisions about therapy did not just target the veteran as the individual needing therapy. Instead, participants described this as a bi-directional process where the veteran also encouraged other family members, particularly spouses, to participate in therapy to improve the quality of family life. One veteran talked about how she shared what she learned through treatment with her spouse who also had PTSD,

“I believe that he [spouse with PTSD] needs to do a treatment like I’ve done, and so does he. It’s just hard finding that time to do the treatment…So I’m very encouraging about it, and I do bring a lot of the stuff I do home, and he processes it with me, he’s very understanding about some of the tools I brought home and he will practice a lot of those tools. But I believe that if he had somebody to work with him with those tools, it would be even better.” (V, dyad 3)

Theme 2. A desire to protect and maintain relationships with loved ones motivated veterans’ drive to seek therapy.

Many veterans in the sample had been living with PTSD for many years and they described negative impacts of PTSD symptoms on their daily lives. Veterans described how the first step underlying their drive to begin therapy was when they recognized that behavioral symptoms related to PTSD were interfering in key life domains, including family, work, and participating in life events in public, such as attending a child’s sports games. Motivation to seek therapy was rooted in a desire to strengthen and protect family relationships, particularly with children and spouses. One veteran described that he sought treatment “due to the symptoms, because it was actually wrecking my life, wrecking my marriage. And once I said to myself—’Man, goodness, why am I like this? Why have I changed so much?’—That’s when I [sought] counseling and mental health assistance.” (V, dyad 1) Some veterans and family members described the veteran’s engagement in make-or-break terms regarding family relationships. As one family member stated,

“There were times there that I had to kind of tell him— ‘If you don’t get help, this [our marriage] might not be working out, so you have to try. Try and tell. If you can’t talk to me, you need to talk to somebody that can help you.’— So I think that, and with the grandchildren and the children, that he kind of pushes himself, that he has to do it for them.” (F, dyad 2)

Theme 3. Family members viewed PTSD as symptoms of a treatable illness.

During interviews family members conveyed an expressed assumption that PTSD symptoms were external to the veteran—not an inherent part of the veteran’s personality—and were treatable. Family members shared sentiments like the following, that therapy for PTSD was “not so much to fix herself, because she’s not really broken, but to move on with some of the things that she hasn’t been able to get through.” (F, dyad 3) Another family member described that this perspective was learned through her education on PTSD as part of their veteran’s therapy,

“I think at one time I told her—I felt like she was just more weak than anything, so it was just me not really, truly understanding PTSD. … Because I didn’t understand, you know? Really wasn’t educated on PTSD. … But I mean, I’ve come to learn—I mean, I don’t think of her as being weak.” (F, dyad 6)

Family members described PTSD as problem to be addressed and in general did not place blame on the veteran for difficult behaviors. One family member described the effects of their veteran’s therapy,

“It allowed some of the things that are stuck in, she’s able to get it out, and she don’t have to hold on to that anymore. So it was like releasing some of those. I’m not going to say inner demons, but inner secrets, I’ll say. That need to get up—they need to come up and be released so that she can—you know, don’t have to hold them in anymore. Those feelings, you know?” (F, dyad 6)

Theme 4. Family support for therapy existed on a gradient from general encouragement and interest to more intensive engagement, and it matched veterans’ expectations for support.

Veterans in the sample described how they had been engaged in treatment—either therapy or medication—in the past. They had sought therapy for multiple mental health conditions, including PTSD, depression, anxiety, and substance use. Therefore, participants in our sample were not new to trying to manage the veteran’s mental health symptoms. Both veterans and family members generally reported that individuals who were currently in the veterans’ social networks were supportive of therapy for PTSD. veterans expressed broad appreciation for family support. Support from family members for therapy ranged in intensity from giving the veteran space during the treatment process to being more purposefully involved. Several veterans expressed that the support they needed or wanted did not include the expectation that the veteran would discuss the specifics of their therapy or trauma with their family member, but instead they needed their family member to give them space during the therapy process. As one veteran described,

“What helps me with my wife is her understanding that this who I am, and this is something I have to step through for my betterment before it’s our betterment, her respect for that. She doesn’t push me for specifics, but does ask, ‘Hey how’d your appointment go?’ She is there to listen, assist [me] getting there.” (V, dyad 7)

One family member, who had encouraged her husband to enroll in PTSD therapy described purposefully remaining unaware of specifics, “Honestly, I’m not sure what he was referred for. … Because while he and I do our best to communicate with each other, sometimes I know he would probably feel more comfortable talking to someone else.” (SP, dyad 11) This perception was corroborated by the veteran, who stated, “I told her I had just regular appointments, because I was doing a lot of appointments checking up on my [physical health condition]… so I didn’t have to talk about it when I got home.” (V, dyad 11)

Examples of how family members were involved in more intense ways with the veteran’s therapy included, improving veteran access to therapy by getting the veteran on the family member’s health insurance, handling appointment-related communications for the veteran’s therapy, transporting the veteran to therapy appointments, attending appointments, and taking the initiative to find a pathway to therapy.

Theme 5. Having family and friends with military or trauma experiences provided especially meaningful social support and positive subjective norms around therapy for PTSD for veterans with PTSD

Veterans reported that a highly salient attribute contributing to helpful support was receiving that support from spouses, friends, family, and therapists who had been in the military themselves or who had also experienced PTSD. One veteran talked about how her sister, also a veteran with PTSD, supported her,

“And she suffers from PTSD herself. Veterans know veterans will take care of each other. So she knows. We’ll go shopping, we’ll go do something that I enjoy. Or when she’s having problems, I know what she likes. We go shopping or just try to calm down or just maybe have a margarita.” (V, dyad 4)

This perceived helpfulness related to the previously mentioned theme about family member perceptions of PTSD as symptoms of a treatable illness and not as features of the veteran’s personality. Specifically, the veterans perceived that family members and friends who were in the military possessed more empathy for and awareness of PTSD behavioral symptoms and this may have led to a greater degree of understanding of PTSD and explicit support for therapy. One veteran, whose spouse was also a veteran with PTSD stated,

“I don’t think that our marriage would work if we didn’t have a lot of the same things going on, so he can recognize when I might be going into a mental state where I shouldn’t be, and he also can take the kids or help me through it and understand what I’m going through is a true thing. He doesn’t get angry at me, and he’s very patient sometimes because he goes through the same situations.” (V, dyad 3)

One veteran shared that she felt misunderstood by other people who did not have personal experiences of trauma.

“ … And then we had some friends that weren’t military at all and they don’t get it. It’s a different mindset, and you look like you are just mean. People would think I was a bitch. People would think I was just mean or rude. … If you don’t have anybody around you that understands that there’s more to your emotions than everyday things, it comes off as you’re mean, or you’re not connected with them, or you don’t care. They just don’t get it. It affects relationships.” (V, dyad 8)

Veterans who described having a larger network of family and friends with personal experience of trauma and positive experiences/perceptions of therapy conveyed enthusiasm for therapy and the potential for therapy to improve symptoms. Through interactions with these larger networks, these veterans described how they were exposed to social norms that favored therapy. As one veteran described,

“My husband and I have other family members that’s in the military as well, that also have PTSD, so they were diagnosed. I have two brothers that served in the Iraqi war and then I had one that was in Vietnam. So with all of us coming together and I have three that was diagnosed with PTSD and we talk a lot, you know, about the programs and stuff and I could see that it had helped some of them out as well.” (V, dyad 9)

Discussion

Our findings suggest that family members may be embedded in the therapy experience because PTSD has such a profound impact on how family units function (Papero, 2017). Participants in our study described family involvement as a dynamic, bi-directional process in which veterans and their family members made treatment decisions together and encouraged and enabled each other to participate in therapy. In this way, engaging in PTSD treatment became a shared family goal.

Veteran and family member participants generally reported a high degree of support for therapy among others in their social networks, and these positive attitudes coincided with veterans’ own perceptions about the value of therapy for veterans with PTSD. In fact, our findings suggest that family members and friends may influence the veteran’s enthusiasm for therapy by conveying positive attitudes towards treatment (Ajzen, 2002; Meis et al., 2019; Sayer et al., 2009; Wisdom & Agnor, 2007). Positive subjective norms about the value of therapy may be even more influential when individuals in the social network have first-hand experience of military service and PTSD (Hundt et al., 2015; Spoont et al., 2014) because these individuals may engage with the veterans in ways that feel more understanding and authentic and less judgmental. Veterans who are surrounded by a large network of individuals with first-hand experiences might also have more opportunities to learn about positive therapy experiences.

Positive attitudes towards therapy held by family members and friends may influence veteran beliefs because the ways in which these loved ones talked about PTSD and therapy with the veteran can be important. The perception that PTSD symptoms were external to the veteran allowed the family to talk about PTSD and therapy in an objective way and avoid placing blame on the veteran. This perspective may have been important in moving the veteran from symptom recognition to seeking out therapy. Interactions that are encouraging promote a sense of safety for individuals with PTSD (Charuvastra & Cloitre, 2008) and could help to provide a solid foundation upon which they feel that they can engage in emotionally challenging therapies (Thompson-Hollands, 2021).

Our findings partly contrast with findings from another qualitative study by Thompson-Hollands et al., (2021) that interviewed support partners of veterans with poor treatment adherence, most of whom were unsuccessful in completing evidenced-based therapy for PTSD (Thompson-Hollands, 2021). Support partners in that study did not report a high level of involvement in veterans’ decisions to engage or drop out of therapy and conveyed little understanding of the treatment process generally. The study samples may have been different in that we recruited veterans who had been referred for mental health therapy rather than veterans with poor adherence to treatment. Avoidance symptoms may be related to treatment dropout (Bryant et al., 2007) and these symptoms could have extended into veteran desire to involve family members in their treatment. The prior study also found that support partners would be enthusiastic about participating in the veteran’s treatment more extensively in the future (Thompson-Hollands, et al., 2021) which is aligned with our findings suggesting that support partners are eager to support veterans when possible.

Research Implications

Our findings provide preliminary support for the underlying theoretical constructs and suggest that these theories, when used together, may help to explain how and why social connections are a critical foundation for PTSD care seeking and treatment engagement. In accordance with the Bowen Theory of Family Systems, veterans and their family members in our study were emotionally intertwined as were their attitudes towards therapy for PTSD which was generally expected to have benefits for members of the family and improve the function of the family unit as a whole. For example, we observed that positive social interactions, as opposed to blaming the veteran for their symptoms, co-occurred with positive veteran attitudes towards treatment. Our findings also align with the Theory of Planned Behavior in that when family members and friends promoted an understanding of PTSD as a treatable illness and therapy as effective for treating symptoms (i.e., positive subjective norms), veteran respondents conveyed positive attitudes towards therapy and an inclination to engage in therapy. Our study suggests that future research efforts to address PTSD treatment and recovery should incorporate a family systems perspective. While not examined in this study, additional theories might also prove useful for future research. For example, the way in which veterans and their family members in our sample described family-level experiences of PTSD and treatment aligns with the communal coping approach. This theory offers additional constructs that intervention developers and clinicians can use to select intervention strategies that improve the well-being of the dyad (Helgeson et al., 2018).

Clinical Implications

For individuals in our sample, treatment for PTSD was a journey that had played out through multiple episodes of care and involved different treatments and modalities. Given the importance of family and friends in mental health recovery (Maercker & Horn, 2013), health systems need to engage family members early in the treatment process so that they can provide on-going support. However, success likely depends on how encouraging and positive veteran and family member interactions are. Our findings suggest that family involvement can take many forms. Therefore, clinicians need to ensure that family member involvement meets the needs of the veteran and the desires of the family member and that treatment goals are aligned for both individuals in the dyad. Building knowledge among family members about PTSD, therapy, and the veteran’s treatment goals may augment the ability of family members to provide authentic social support. Leveraging the support of family members and friends with first-hand experiences of the military and mental illness might also prove to be a useful strategy. These efforts will likely pay dividends in cultivating and protecting the social support that is essential for individuals to recover from PTSD and that we found motivated veterans to engage in care in the first place.

Limitations

While our study provides a rich understanding of dynamics between veterans with PTSD and their loved ones around therapy, our results are exploratory. Additional quantitative research is needed to assess the generalizability of our findings to the population of veterans with PTSD. Our sampling frame, inclusion criteria, and recruitment rate may further inhibit how generalizable our findings are to subsets of individuals with PTSD. First, veterans in our study likely already had a supportive partner because family members had applied to PCAFC and most agreed to participate in this study. For example, family members enrolled in PCAFC may have access to resources that augmented their understanding of PTSD, mental illness, and mental health therapy, resulting in more supportive attitudes and a greater level of knowledge. Relatedly, a few veterans described that their PTSD-related behaviors had alienated family members and friends—these people were no longer in their social networks—suggesting that people who elected to remain in the veteran’s current network were more likely to have the emotional resources to be supportive and/or were tied to the veteran in other ways (e.g., spouse who might be financially or emotionally dependent on the veteran). Therefore, individuals who had less social support may have elected not to participate in our study such that our sample might not reflect the perspectives of individuals who may have fewer social interactions and more interpersonal conflict due to their PTSD behaviors. As a result, we might be missing the perspectives of Veterans who had more negative attitudes towards family involvement in treatment or family members who had more negative attitudes towards PTSD and treatment. These missing perspectives may limit our ability to fully evaluate constructs of our theories for Veterans with varying levels of social support. Our sample size was also relatively small with data from 11 dyads that included both the veteran and family member. Finally, despite our attempt to recruit veterans who had not used treatment in the past, all veterans in our sample had used some sort of mental health pharmacological or behavioral treatment in the past and therefore our results do not reflect the perspectives of individuals who are treatment naïve. As a result, these individuals may have already had positive views of treatment and may have been more willing to engage their family members.

Conclusions

These findings provide preliminary evidence in support the use of family systems approaches in mental health service delivery for PTSD, especially for individuals who have supportive loved ones in their lives. Our findings may help clinicians understand why and how to engage supportive partners and how to assess the types of interpersonal processes that promote authentic social support for treatment. However, there is likely no one-size-fits-all approach to leverage family and friend support to promote positive attitudes towards therapy and treatment engagement. More work is needed to understand the feasibility and perceived value of various approaches ranging from couples therapy for PTSD (Macdonald et al., 2016) to lighter-touch approaches that focus on the family member only (Thompson-Hollands et al., 2020). Given the social nature of PTSD (Papero, 2017). Future research is also needed to understand how to engage family members from distressed relationships because successfully engaging these types of dyads will extend the application of these findings to the larger group of individuals with PTSD with family members who wish to support their treatment and recovery.

Impact statement.

Family-based strategies are a promising approach to increase low-levels of engagement in PTSD therapy. However, the field needs theory-driven evidence about the mechanisms linking family-based approaches and veteran treatment engagement to guide decisions about intervention development and refinement, and ultimately clinical practice. This qualitative study is one of the first studies to integrate family-oriented and health services theoretical frameworks to explore mechanisms underlying family-involvement and veteran initiation and engagement in therapy for PTSD.