Daily Posttraumatic Stress Disorder Symptom Accommodation and Relationship Functioning in Military Couples

Abstract

Romantic partners’ accommodation of trauma survivors’ posttraumatic stress disorder (PTSD) symptoms (e.g., taking on tasks, survivors avoid participating in social withdrawal) is associated with lower relationship satisfaction for both partners and survivors. Little is known about associations of partner accommodation with other aspects of relationship functioning, like intimacy. Sixty-four male military veterans with at least subclinical PTSD and their partners participated in α 2-week daily diary study. Veterans completed nightly measures of PTSD symptoms, while female partners completed nightly measures of accommodating behaviors performed that day. Both partners reported feelings of intimacy each night. Multilevel models revealed that accommodation was significantly, negatively associated with feelings of intimacy, with stronger effects for partners (t = −8.70) than for veterans (t = −5.40), and stronger effects when veterans had lower (t = −7.43) rather than higher (t = −5.20) levels of daily PTSD symptoms. Therapists should consider accommodating behaviors as a potential impediment to relationship intimacy, particularly when veterans have less severe symptoms of PTSD. Accommodating behaviors are an ideal treatment target in behavioral couple therapies.

INTRODUCTION

Posttraumatic stress disorder (PTSD) is associated with poorer relationship functioning for both trauma survivors and their partners (Lambert, Engh, Hasbun, & Holzer, 2012; Taft, Watkins, Stafford, Street, & Monson, 2011). Researchers have identified survivors’ increased irritability and conflict, emotional withdrawal, and impaired communication as potential contributors to these associations (review by Campbell & Renshaw, 2016). More recently, researchers have begun to examine partners’ behaviors in this context, with particular attention to partners’ behavioral accommodation of survivors’ PTSD symptoms.

Accommodation is defined as modifying activities, emotional responses, or behaviors in response to another’s PTSD symptoms, to alleviate or prevent PTSD-related or relationship distress (Fredman, Vorstenbosch, Wagner, Macdonald, & Monson, 2014). It is hypothesized to have the potential to maintain PTSD symptoms, with recent evidence that it is associated with maintenance of situational avoidance over time (Campbell, Renshaw, Kashdan, Curby, & Carter, 2017). Accommodation has other likely effects, as well. In particular, it has been linked with lower relationship satisfaction (Fredman et al., 2014, 2016). Due to its relative novelty in the empirical literature, however, little else is known about potential effects of accommodation.

One mechanism through which accommodation could influence relationship satisfaction is reduced relationship intimacy. Intimacy is related to but conceptually distinct from satisfaction (e.g., Schaefer & Olson, 1981). Intimacy is typically operationalized as a “feeling of closeness and connection” to a significant other (Laurenceau, Feldman Barrett, & Rovine, 2005, p. 314), whereas relationship satisfaction tends to include a wide collection of constructs, such as agreement about handling major issues, frequency of arguments, and perceived happiness (e.g., Spanier, 1976). Low levels of relationship intimacy have been associated with poorer psychological health and relationship dysfunction in a variety of contexts (review by Van den Broucke, Vandereycken, & Vertommen, 1995), and intimacy may be a particularly important component of relationship functioning for trauma survivors. Individuals with PTSD demonstrate generally low levels of intimacy, with numbing/avoidance symptoms exerting the strongest influence on intimacy (Campbell & Renshaw, 2016). Moreover, intimacy is linked with greater self-disclosure (Reis, 2017), and greater self-disclosure is linked with reduced PTSD symptoms in veterans (Hoyt & Renshaw, 2014). At the same time, some research suggests that perceived intimacy may enhance negative momentary reactivity of those with PTSD (Leifker, White, Blandon, & Marshall, 2015). Thus, intimacy appears to be essential to healthy relationship functioning and an important but complex factor in the relationships of individuals with PTSD.

Although the link of accommodation with intimacy has not yet been studied in the context of PTSD, accommodation-like behaviors in other conditions demonstrate an association with lower relationship intimacy. For instance, avoidance of discussing cancer-related relationship issues was associated with reduced intimacy in couples in which one partner has cancer (Manne, Badr, Zaider, Nelson, & Kissane, 2010). Moreover, relationships in which partners accommodate OCD symptoms by engaging in rituals and providing reassurance are also characterized by low levels of intimacy (Walseth, Haaland, Launes, Himle, & Håland, 2017). Despite these straightforward findings, the association of accommodation with intimacy may be dependent on the severity of symptoms that are accommodated. For example, for veterans with high levels of PTSD symptoms, accommodation may feel warranted and, thus, be perceived as supportive and less likely to be linked with intimacy for both veterans and their partners (e.g., Renshaw, Allen, Fredman, Giff, & Kern, 2018). Conversely, accommodating low levels of PTSD symptoms may feel unwarranted or intrusive, and the behaviors may mimic behaviors that interfere with intimacy and closeness in nonclinical couples. Alternatively, intimacy may already be at low levels when a partner suffers from severe PTSD, and accommodation behaviors may, thus, not be strongly linked to already low relationship intimacy. To date, however, no studies have explored these associations in romantic relationships in which one member has PTSD.

It may also be important to consider these constructs in a more ecologically valid timeframe than is provided in global self-reports. Assessing constructs daily may enable more accurate recall of behaviors. Indeed, prior research has demonstrated that short-term recall is more accurate than long-term recall (Robinson & Clore, 2002). To date, only one other study has assessed accommodation on a daily basis (Campbell et al., 2017), and this study did not explore the association of accommodation with relationship outcomes.

Finally, although progress has been made in recent years to include reports from both members of a dyad in which one member has PTSD (Campbell & Renshaw, 2016), the majority of research on relationship processes in PTSD uses data from only one couple member. Dyadic data collection is necessary to fully understand the complex picture of relationship processes affected by PTSD. As prior research shows some discrepancies in the impact of accommodation on trauma survivors and partners (e.g., Kenny, Allen, Fredman, & Renshaw, 2015), outcome data from both partners may reveal distinct experiences of accommodation within the same relationship.

In light of the above, our aims were to: (i) evaluate the daily associations of partners’ accommodation of veterans’ PTSD symptoms with both partners’ relationship intimacy; and (ii) evaluate the degree to which veterans’ PTSD symptom severity moderates the association of daily accommodation with daily intimacy. First, we hypothesized that partners’ daily accommodation of PTSD symptoms would be negatively associated with both partners’ daily intimacy. Second, we hypothesized that veterans’ daily PTSD symptoms would moderate the association of partners’ daily accommodation with both members’ daily intimacy, such that the association between accommodation and daily intimacy would be less negative at higher levels of PTSD.

METHOD

Participants

Participants included 64 heterosexual romantic couples in which the male partner was an active-duty military service member or veteran (hereafter referred to as veterans), and the female partner was a civilian. Veterans were mostly non-Hispanic White (79.7%; 4.7% Latino; 4.7% African American; 1.6% American Indian/Alaska Native; 1.6% Native Hawaiian/Pacific Islander; 6.3% Bi/Multi-racial; 1.6% Other), with a mean age of 34.94 years (SD = 7.53). Over half (78.1%) had completed some college, and most (81.3%) were members of the Army. Veterans had an average of 2.30 (SD = 1.18) OIF/OEF-era deployments and 1.17 (SD = 1.62) other deployments. Slightly less than half of the male sample reported military veteran status (46.9%), with the remainder reporting activity duty (35.9%) and National Guard/Reserves (NG/R) status (17.2%). Partners were mostly White (76.6%; 7.8% Latina, 7.8% African American, 3.1% American Indian/Alaska Native, 3.1% Asian American, 1.6% Bi-racial), had a mean age of 34.14 years (SD = 7.48), and most (90.7%) had completed some college. Slightly less than half of the sample (48.4%) had an annual household income of less than $50,000. Nearly, all (95.3%) couples reported that they were married (the remainder reported cohabitation for at least 3 months), and the sample’s mean relationship length was 9.45 years (SD = 5.86). The majority (78.1%) of veterans had sought psychological treatment at the time of the baseline assessments, with 62.5% receiving medication and 59.4% participating in therapy. Veterans who reported seeking treatment for co-occurring psychological disorders primarily listed depression, anxiety, and insomnia. Notably, only a quarter of partners reported having undergone any kind of treatment for a psychological disorder.

Procedure

All procedures were approved by the George Mason University Institutional Review Board and the NIH office of Human Subjects Research Protections. Participants were recruited primarily through an in-person presentation to a Family Readiness Group Battalion, online advertisements in military community and social media sites, military psychology listservs, and blog posts/social media announcements by military/veteran research organizations. Interested participants answered screening questions on the study website. Couples were eligible if they were in a committed romantic relationship for ≥6 months, currently cohabiting, both ≥18 years old, fluent in English, and had daily Internet access. Veterans needed to be male, active duty or veteran status, have had at least one deployment since November 9, 2001, and demonstrate significant symptoms of PTSD via a score of 35 or higher on the PTSD Checklist for DSM-IV-Military Version (see below for more information). Partners needed to be female, with no current or former military service. Due to the expected sample size prohibiting subgroup analyses and limitations of data collection skip logic, same-sex and dual-military couples were excluded from this study. Multiple checks verified eligibility and validity of respondents, including consent comprehension questions, checks of IP addresses indicating unanticipated locations outside of the United States, checks for repeat IP addresses, and questions designed to verify veterans’ military service (e.g., UIC, permanent duty station, MOS). After screening and consenting, eligible participants provided the name and email address of their romantic partner, indicating whether the study staff could contact the partner for invitation to the study if the partner had not yet completed the screening/consent procedure. Names and emails addresses were matched for couples, and individual and couple IDs were assigned to paired couples.

Each member of the couple then independently completed a baseline questionnaire, for which they were compensated $25 per couple. Couple members then received independent emails with personalized links to nightly diaries and specific diary start dates selected for when the couple would be able to complete 14 consecutive diaries. Couple members were instructed to complete diaries within 1 hour of going to sleep, and to answer questions about the previous 24 hours. Study staff assessed diary accuracy by examining time stamps and communicated with participants following missed days or incorrectly completed entries in order to improve compliance. Couples were paid $70 for their diaries, with a $15 bonus per participant if at least 5 diary days were completed per week.

In total, 670 individuals clicked on the study link. Most individuals failed to complete the screener. In total, 226 partners and 156 veterans passed the eligibility and consent screen. Twenty-three veterans had appropriate military information but insufficiently elevated PTSD symptoms. An additional four veterans had suspicious entries (e.g., multiple entries, mismatching military information). From the remaining individuals, we matched and identified 96 couples, 70 of which had partners who both provided baseline questionnaire data. These 70 couples were invited into the daily diary portion, but six couples opted to withdraw from the study due to unanticipated life events that interfered with their ability to complete nightly diaries, leaving a final sample of 64 couples. Diary compliance was high, with 88% of veterans and 89% of partners completing at least 10 of 14 possible entries. Veterans provided 785 total days of data, and partners provided 792 total days of data.

Measures

Demographics

Data on age, gender, marital status, and other demographic variables were collected in a standard demographic questionnaire.

Significant Others’ Responses to Trauma Scale

Partners completed a shortened version of the Significant Others’ Responses to Trauma Scale (SORTS; Fredman et al., 2014), which, in its original form, is a 14-item measure of accommodation of trauma survivors’ PTSD symptoms over the past month. Each item asks respondents how frequently they performed a particular behavior, from 0 (Not at all) to 4 (Daily), and how distressing they found the behavior from 0 (Not at all) to 4 (Extremely). The SORTS demonstrates strong psychometric qualities (Fredman et al., 2014). For our daily measure of accommodation, we selected eight items that had the highest item-total correlations in the development study (Fredman et al., 2014), to create an abbreviated version to reduce participant burden. This daily version of the SORTS used the same 0-4 Likert scale as the full version, with questions focused only on frequency of accommodation over the previous 24 hours (questions on distress or intensity were not included). Items selected for the abbreviated version and their individual item-means are shown in Table 1. As reported elsewhere, the daily SORTS shows good convergent validity with the baseline version of the SORTS (converted r = .57), good construct validity regarding associations with veterans’ PTSD symptoms, and excellent within-person (R_C = .90) and between-person reliability (R_1F = .88) (Campbell et al., 2017). Of note, the ICC for the daily SORTS was .41, suggesting that 41% of daily accommodating behaviors are attributable to differences between partners (Bolger & Laurenceau, 2013).

Table 1.

Items Selected for Daily Measure of Accommodation and Daily Item Means

Item	M (SD)
1. How often do you avoid veteran because of his irritable or angry mood?	0.85 (1.11)
2. How often do you “bite your tongue” or hold back from trying to discuss any relationship issues with veteran?	1.05 (1.14)
3. How often do you help veteran with a task because he was having difficulty concentrating?	0.92 (1.11)
4. How often do you make excuses to others for veteran’s behavior or try to manage his relationships with other people?	0.64 (0.99)
5. How often do you “tiptoe” around veteran so as not to anger him?	0.92 (1.08)
6. How often do you not share your own feelings or concerns with veteran due to concerns that he would become upset?	1.12 (1.15)
7. How often do you change your routine due to veteran’s difficulties?	0.86 (1.11)
8. How much have you modified your leisure activities due to veteran’s difficulties?	0.89 (1.17)

PTSD Checklist for DSM-IV—Military Version

Veterans completed the PTSD Checklist for DSM-IV (PCL-M; Weathers, Litze, Herman, Huska, & Keane, 1993) at baseline. The PCL-M is a 17-item self-report measure assessing prior-month distress from military-related PTSD symptoms on a 1 (Not at all) to 5 (Extremely) Likert scale. Items correspond to PTSD symptoms as presented in the DSM-IV (American Psychiatric Association, 1994), and a total score is created by summing all items. Clinical cutoff scores on the PCL-M for DSM-IV range from 30–34 in military/veteran primary care clinics (Bliese et al., 2008) to 50 in military prevalence studies (Weathers et al., 1993). One eligibility criterion for the current study was a PCL-M score greater than 35, and the mean PCL-M score at baseline (63.55, SD = 13.07) represents a highly symptomatic sample, with 79.7% of the sample scoring above 50 on the PCL-M. Internal consistency reliability for the present sample was excellent (α = .93).

We also assessed daily PTSD symptoms using a modified PCL-M, with instructions amended to refer to the current day, consistent with Naragon-Gainey, Simpson, Moore, Varra, and Kaysen’s (2012) use of a daily version of the PCL-Civilian. Our daily PCL-M demonstrated acceptable to good within-person reliability (.88) and very high between-person reliability for the total scale (.98), consistent with prior daily measures of PTSD (e.g., Naragon-Gainey et al., 2012).

Daily intimacy measure

Both members of the couple completed a measure of felt intimacy (Laurenceau et al., 2005) as part of the nightly diary. The measure consists of a single item derived from measures used in prior dyadic daily diary research and designed to minimize participant burden (e.g., Belcher et al., 2011; Laurenceau, Feldman Barrett, & Pietromonaco, 1998; Laurenceau et al., 2005). The item asked “How much intimacy did you feel with your spouse/ partner today across all of your interactions?” Participants rated their relationship intimacy from 1 (Very little) to 5 (A great deal). Couples reported a moderate amount of intimacy (veterans’ aggregate mean daily intimacy = 2.63, SD = 0.90; partners’ aggregate mean daily intimacy = 2.56, SD = 0.73).

Analytic Plan

To evaluate the daily associations of accommodation with both partners’ relationship intimacy (aim 1) and the degree to which veteran’s PTSD moderated these associations (aim 2), we conducted a multilevel model using HLM Version 7.0 (Raudenbush, Bryk, & Congdon, 2011), with day (Level 1) nested within individual (Level 2) nested within couple (Level 3), modeling daily intimacy as the outcome. Only partners completed measures of daily accommodation and only veterans completed measures of daily PTSD. Thus, partner accommodation and veteran PTSD were recorded as Level 1 variables for both partners and veterans. The Level 1 model was as follows: Y (INTIMACY)_ijk = (b₁Days_ik + b₂Accom_ik + b₃PTSD_ik + b₄Accom*PTSD_ik + e_ijk) where Days_ik was the number of days in the study, Accom_ik was partners’ daily accommodation, PTSD_ik was veterans’ daily PTSD, Accom*PTSD_ik was the interaction of accommodation with daily PTSD, and e_ijk was Level 1 error. Accommodation and PTSD were both grand mean centered for analyses. Although we did not expect linear trends of time on daily intimacy for either partner, Days_ik was included to ascertain whether intimacy changed as a function of time in the study, given the repeated measures of this variable across time. The Level 2 model included role (veteran or partner) as a predictor of each Level 1 parameter, including both fixed and random effects. After running an initial model with all effects, we subsequently removed all nonsignificant same-level and cross-level interactions to streamline the model and produce more readily interpretable associations to probe. Finally, any significant interactions were probed per recommendations of Aiken and West (1991). Namely, for interactions with PTSD, we ran individual models with high (+1 SD) and low (−1 SD) levels of veteran PTSD. For interactions with role, we ran individual models with a variable in which veterans were coded 0 and partners were coded 1, and then vice versa.

Of note, although we had the capacity to conduct analyses of how same-day accommodation predicted next-day intimacy, the general stability of intimacy over the course of the study led to only same-day intimacy significantly predicting next-day intimacy in all such analyses. Thus, we focused only on same-day analyses. Additionally, we replicated the results of our main analyses using the baseline version of the PTSD measure as a Level-3 moderator of the association of daily accommodation with daily intimacy, rather than daily PTSD with a Level-1 interaction term. Results mirrored those reported for daily PTSD. Full results of these analyses are available from the first author upon request.

RESULTS

The results of the initial full multilevel model are shown in Table 2. There were no significant effects of PTSD, Role, or PTSD × Role on the intercept, indicating that daily intimacy was similar across veterans and partners, regardless of levels of PTSD. In addition, there was no significant effect of role on any variable except accommodation. When these effects were dropped, the pattern of results of the trimmed model was unchanged from the original full model (see Table 2). Thus, we probed this trimmed model, for ease of interpretation of results.

Table 2.

Parameter Estimates for Multilevel Models of Daily Intimacy

	Initial model		Trimmed model
	B (SE)	t	B (SE)	t
Intercept (L1)	2.709 (0.096)	28.32***	2.710 (0.096)	28.30***
Role (L2)	−0.021 (0.103)	−0.20	—	—
Diary day (L1)	−0.018 (0.008)	−2.39*	−0.018 (0.008)	−2.39*
Role (L2)	0.009 (0.011)	−0.78	—	—
Accommodation (L1)	−0.055 (0.005)	−8.13***	−0.054 (0.007)	−8.16***
Role (L2)	−0.025 (0.008)	−2.92**	−0.026 (0.008)	−3.36***
PTSD (L1)	−0.004 (0.004)	−0.93	−0.004 (0.004)	−0.94
Role (L2)	−0.004 (0.004)	1.01	—	—
PTSD*accommodation (L1)	0.001 (0.000)	2.27*	0.001 (0.000)	2.30*
Role (L2)	−0.000 (0.000)	−0.73	—	—

Note. PTSD = Posttraumatic Stress Disorder.

^***p <.001

^**p <. 01

^*p < .05

The results for diary day indicated that ratings of intimacy decreased over the course of the study. The results for accommodation revealed that, overall, greater daily accommodation was associated with lower daily intimacy. Moreover, as hypothesized, this effect was moderated by PTSD (see Figure 1). Probes indicated that the association was weaker at higher levels of PTSD (B = −0.041, SE = 0.008, t = −5.21, p < .001) as compared to lower levels (B = −0.069, SE = 0.009, t = −7.43, p < .001). Finally, this association was also moderated by Role (see Figure 1). The probes of this moderation showed that the association was weaker for veterans’ intimacy (B = −0.041, SE = 0.008, t = −5.40, p < .001) as compared to partners’ intimacy (B = −0.067, SE = 0.008, t = −8.70, p < .001).

Figure 1.

Associations of Daily Accommodation with Daily Intimacy, as Moderated by Levels of Daily Posttraumatic Stress Disorder Symptoms and by Role.

DISCUSSION

This was the first study to explore daily associations of PTSD symptom accommodation and relationship intimacy in couples coping with PTSD. In our multilevel model, daily PTSD was not significantly associated with daily reports of intimacy by either veterans or partners. This finding suggests that intimacy, when measured with a shorter recall period, is less associated with levels of PTSD (when accommodation is accounted for). In contrast, partners’ daily accommodation was significantly, negatively associated with daily intimacy, suggesting a generally negative influence of accommodation on intimacy for both veterans and partners. Importantly, given same-day associations, intimacy levels could also influence levels of accommodation. More complex associations emerged when accounting for PTSD and role in the couple.

First, accommodation and intimacy were more strongly negatively associated in partners of veterans. It is noteworthy that even veterans’ intimacy was lower on days when partners’ accommodation was higher. These results suggest that partners’ accommodation behaviors play an important role in relationship intimacy even for veterans who are experiencing significant, intimacy-impairing symptoms. Not surprisingly, however, this effect is stronger for partners’ intimacy than for veterans’ intimacy. If partners have to engage in substantial levels of accommodating behavior, it may breed resentment, or it may simply detract from the capacity to connect with a partner. Alternatively, it may also be that veterans who elicit greater accommodation on a given day are concurrently less able to generate intimacy. A third possibility is that shared method variance (e.g., both reports of accommodation and intimacy coming from the same source) contributed to the stronger association among partners.

Second, the association of accommodation with intimacy was weaker when veterans reported higher levels of PTSD that day. In prior research, partners reported perceiving that accommodation of situational avoidance is beneficial or an appropriate means of fulfilling one’s duty to the relationship (Renshaw et al., 2018). Partners may also see themselves in a “caregiving” role when veterans have higher levels of symptoms. Although problematic in other ways, such as maintaining situational avoidance symptoms, accommodating may be perceived as more necessary or helpful when veterans are experiencing high levels of PTSD symptoms. Such a perception may reduce the negative association of accommodation with intimacy. However, we did not explicitly measure reasons for accommodating in this study; thus, this explanation is speculative. Importantly, the association of accommodation with intimacy was still negative even at high levels of PTSD, suggesting that accommodation is still associated with reduced intimacy in such a context.

Conversely, the negative association of partners’ symptom accommodation with both members’ intimacy was even more pronounced when veterans reported lower levels of PTSD. It is possible that engaging in accommodating behaviors when the need for such behaviors is less prominent is associated with greater resentment or disconnection in partners. Also, when PTSD symptoms are less severe, accommodation behaviors may be less linked to specific PTSD symptoms. Indeed, the two most highly endorsed accommodation behaviors were not discussing relationship issues and not sharing feelings. In such instances, accommodating behaviors such as withholding personal disclosure or canceling leisure activities might create greater emotional distance for both veterans and partners, as they more closely resemble behaviors that would impair intimacy more generally.

Existing couple therapies for PTSD commonly teach couples to resist avoiding distressing topics or emotions and, instead, to communicate empathically and collectively approach trauma-related thought and feelings (e.g., Monson & Fredman, 2012; Sautter, Glynn, Cretu, Senturk, & Vaught, 2015). In so doing, these treatments directly counter the patterns of mutual avoidance and behavioral accommodation that may emerge in couples such as those seen in the present study, and indeed, research suggests dyadic treatment of PTSD does reduce accommodation (e.g., Pukay-Martin et al., 2015). These practices have the added effect of enhancing intimacy by encouraging self-disclosure. Although such communication strategies and awareness of self-censoring impulses are fundamental to general couple therapies (e.g., Jacobson & Christensen, 1996), the present study suggests that they may be particularly appropriate within the context of couples in which one member has PTSD. In these couples, the present research suggests, daily patterns of collective avoidance emerge and have negative cumulative associations with the relationship intimacy of both partners. Indeed, this mirrors the research on the effects of mutual avoidance on intimacy in community couples (Van den Broucke et al., 1995). Of course, any PTSD-focused treatments would focus primarily on PTSD symptoms. Accommodation has been shown to have negative effects on such symptoms, as well (Campbell et al., 2017). Our current findings add another layer of potential effects to consider when addressing accommodation in couples in which one member suffers from PTSD.

Of note, gathering data from both members of the couple and at the daily level allowed for investigation of these phenomena with greater nuance and ecological validity and less recall bias. Additionally, the multilevel models appropriately account for missing data by using maximum likelihood estimate and adjusting the standard errors (Singer & Willett, 2003). These features allow analyses to potentially present a more accurate pattern of results than traditional retrospective analyses.

Limitations and Future Directions

Although the present study illuminates new information about the role of PTSD symptom accommodation in relationship intimacy, there are important limitations to consider. First, PTSD symptoms were self-reported and not confirmed by clinical interview. Nonetheless, prior research has demonstrated significant convergent validity between the PCL-M and clinician ratings of PTSD (Monson et al., 2008). Second, our sample was homogenous, with a preponderance of White, heterosexual participants. Although Latino/a and African American participants were only slightly underrepresented in our sample compared to the general composition of OIF/OEF-era service members (IOM, 2010), our largely Internet-based recruitment strategy may have oversampled White participants (Gosling, Vazire, Srivastava, & John, 2004). Additionally, the effects of PTSD symptoms on relationship outcomes tend to be stronger for female partners of male trauma survivors than vice versa (e.g., Lambert et al., 2012), so effects may be attenuated or reversed in female-survivor couples. Moreover, same-sex couples of female veterans and service members may have comparable rates of symptom accommodation, but potentially different associations with intimacy than those found in the present study, particularly if accommodation of anger/irritation is less pronounced in those samples (Blount, Peterson, & Monson, 2017). Finally, although this is the most intensive study of this population to date, the assessment period of 14 consecutive nights was relatively brief. Measurement-burst designs, in which intensive assessments are captured repeatedly over a longer period (e.g., 2 weeks of nightly surveys every 5 years), might illuminate the longer-term effects of accommodation (e.g., Sliwinski, 2008).

Future research should assess the degree to which these findings are generalizable to samples of female veterans, same sex couples, dual-trauma couples, veterans from other service eras, and civilian couples. Also, longer follow-up periods, as discussed above, would be useful for determining the degree to which effects stabilize versus intensify over time, and their longer-term impacts on PTSD symptoms and relationship status/functioning.

The current findings advocate for increasing psychoeducation for couples about the implications of accommodation not only for PTSD symptoms, but also for relationship functioning and intimacy. As accommodation is generally associated with worse psychiatric and relationship health, it should always be addressed in treatment. Working conjointly with veterans and their partners may provide opportunities for addressing accommodation at more subclinical levels of PTSD, where it may be more reflective of poor relationship behaviors than of direct responses to PTSD symptoms. In contrast, both accommodation behaviors and more severe PTSD symptoms should be addressed concurrently in couples in which higher levels of PTSD are a concern. Here, the accommodation behaviors may play more of a role in maintaining PTSD symptoms and should be addressed accordingly. In sum, the present study suggests the importance of promoting intimacy-enhancing and adaptive support behaviors in treatment, and working to break the cycle of avoidance that families can reinforce in the context of PTSD.