Session # H2a
October 11, 2013
1:30pm-2:00pm
Biopsychosocial Health of
Military Couples
Angela Lamson, PhD
East Carolina University
Melissa Lewis, PhD
University of Minnesota-Duluth
Meghan Lacks, MS
East Carolina University
Amelia Muse, MS
Texas Tech University
Lisa Buchner, MS
University of Minnesota
Collaborative Family Healthcare Association 15th Annual Conference
October 10-13, 2013 Bolder, CO U.S.A.
Faculty Disclosure
• “This research and development project was conducted by East
Carolina University and is made possible by a cooperative
agreement that was awarded and administered by the U.S. Army
Medical Research & Materiel Command (USAMRMC) and the
Telemedicine & Advanced Technology Research Center (TATRC), at
Fort Detrick, MD, under Contract Number: W81XWH1120221.”
• “The views, opinions and/or findings contained in this presentation
are those of the author(s)/East Carolina University and do not
necessarily reflect the views of the Department of Defense and
should not be construed as an official DoD/Army position, policy or
decision unless so designated by other documentation. No official
endorsement should be made.”
Need/Practice Gap & Supporting Resources
Most mental health concerns are seen in a physical
healthcare context. Therefore, mental health screenings
should be a mandatory part of treatment within
healthcare systems that treat service personnel and
veterans AND spouse.
Mental health problems are more likely to occur at the 3
month assessment versus the later 6 month assessment.
However at 6 months, cases that were missed at 3
months were identified. Therefore, we should assess the
mental health of service personnel EVERY 3 months
after deployment (at least 9-12 months).
Abstract
• This presentation will be comprised of 1) a review of the biopsychosocial
health of military couples, 2) results of the research that has been
conducted with 100 military couples and 3) assessment and intervention
recommendations for clinicians and researchers. The first section will be a
review of current literature of the biopsychosocial state of military couples
today. This information will familiarize the participants with the strengths
and risks to the health of military couples, whereby both partners were
involved in the research. Section two is a presentation of study results.
Data collection, methodology and statistics will be briefly presented. Next,
the presenters will discuss study results and implications for military
couples with an emphasis on the systemic and dynamic health trends (i.e.,
depression, substance use, PTSD, BMI, blood pressure, stress response,
relational quality) in military marriages. The third section will focus on
implications for future practice or research. Finally, some time will be left
at the end for audience members to ask questions and complete their
evaluation forms.
Learning Objectives
Learning
Objective
#1 *
Learning
Objective
#2 *
1. Participants will learn health risk and
resiliency factors for military couples.
2. Session participants will gain an
understanding of the dynamic nature of both
military and marital health on military couple’s
overall health functioning.
Learning
Objective 3. Participants will learn outcomes related to
assessment and interventions with military
#3 *
couples in the healthcare system.
Military Marriages
• Risks to marriage are higher in military
couples
• 3.6% of officers sought divorce in 2009.
• Probability of divorce greater for those who
have served 2 or more years in active duty
• Those who marry early have higher rates of
divorce than civilians
Department of Defense. (2010). Demographics 2009: Profile of the military community. Washington, D.C.:
Department of Defense.
Hogan, P. F., & Seifert, R. F. (2010). Marriage and the military: Evidence that those who serve marry earlier and
divorce earlier. Armed Forces & Society (0095327X), 36, 420-438.
Military Marriages
• Military couple life is complex
–
–
–
–
–
Regular relocation
Challenges to both partners’ emotional health
Trauma and secondary-trauma
Apart on significant occasions
Interpersonal violence and abuse by partner or on
duty
– Divorce
Eran-Jona, M. (2011) Married to the military: Military-family relations in the Israel defense forces. Armed Forces and Society, 37, 19-41. doi
10.1177/0095327X10379729
Figley, C. R. (1988). A five-phase treatment of post-traumatic stress disorder in families. Journal of Traumatic Stress, 1, 127-141. doi:10.1002/jts.2490010109
Goff, B. S. N., Crow, J. R., Reisbig, A. M. J., & Hamilton, S. (2007). The impact of individual trauma symptoms of deployed soldiers on relationship satisfaction. Journal
of Family Psychology, 21, 344-353. doi:10.1037/0893-3200.21.3.344
Hogan, P. F., & Seifert, R. F. (2010). Marriage and the military: Evidence that those who serve marry earlier and divorce earlier. Armed Forces & Society (0095327X),
36, 420-438.
Mansfield, A. J., Kaufman, J. S., Marshall, S. W., Gaynes, B. N., Morrissey, J. P., & Engel, C. C. (2010). Deployment and the use of mental health services among U.S.
army wives. The New England Journal of Medicine, 362(2), 101-109.
Renshaw, K. D., Rodrigues, C. S., & Jones, D. H. (2008). Psychological symptoms and marital satisfaction in spouses of operation Iraqi freedom veterans: Relationships
with spouses’ perceptions of veterans’ experiences and symptoms. Journal of Family Psychology, 22, 586-594. doi:10.1037/0893-3200.22.3.586
Sayers, S. L., Farrows, V. A., Ross, J., & Oslin, D. W. (2009). Family problems among recently returned military veterans referred for a mental health evaluation. Journal
of Clinical Psychiatry,70, 163-170. doi:10.4088/JCP.07m03863
Warner, C. H., Appenzeller, G. N., Warner, C. M., Grieger, T. (2009). Psychological effects of deployments on military families. Psychiatric Annals, 39, 56-63.
doi:10.3928/00485713-20090201-11
Military Marriages
• Military couple life is complex (Continued)
– Division of labor and roles
– Marital strengths and challenges
– Unpredictability of deployment
– Exposure to combat and secondary trauma
Allen, E. S., Rhoades, G. K., Stanley, S. M., & Markman, H. J. (2010). Hitting home: Relationships between recent deployment,
posttraumatic stress symptoms, and marital functioning for army couples. Journal of Family Psychology, 24, 280-288.
doi:10.1037/a0019405
Eran-Jona, M. (2011) Married to the military: Military-family relations in the Israel defense forces. Armed Forces and Society, 37,
19-41. doi 10.1177/0095327X10379729
Mattson, R. E., Paldino, D., & Johnson, M. D. (2007). The increased construct validity and clinical utility of assessing relationship
quality using separate positive and negative dimensions. Journal of Psychological Assessment, 19, 146-151.
doi:10.1037/1040-3590.19.1.146
Sayers, S. L., Farrows, V. A., Ross, J., & Oslin, D. W. (2009). Family problems among recently returned military veterans referred
for a mental health evaluation. Journal of Clinical Psychiatry,70, 163-170. doi:10.4088/JCP.07m03863
Health risks for military personnel
Physical
•
•
•
•
Obesity
Hypertension
Amputation
TBI
Psychological
Relational
• Conflict
• Inter-partner violence
• Reduced trust and
intimacy
• Stress
• Post Traumatic Stress
• Depression
• Suicide
• Alcohol, cigarette, drug
use
AFHSC. (2010). Mental health issue. Medical Surveillance Monthly Report, 17(1), 1-32.
Associated Press. (2007). Military divorce rates studied. Retrieved March 5, 2010 http://www.military.com.
Bobo, W. V., Hoge, C. W., Messina, M. A., Pavlovcic, F., Levandowski, D., & Grieger, T. (2004). Characteristics of repeat users of an Inpatient psychiatry service at a large military
tertiarycare hospital. Military Medicine, 169(8), 648-653. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=14080893&site=ehost-live
-See Reference page for full list
Deployment & Mental Health
• 19% of military personal who returned for deployment
reported a mental health problem
– Only 35% of these accessed mental health services within a year
of returning home
• Diagnoses of depression was significantly higher 120 days
after returning from deployment than directly after
returning home
• Complex presentations may complicate depression
– Marital distress
– Alcohol abuse
– Family problems
Bliese, P. D., Wright, K. M., Adler, A. B., Thomas, J. L., & Hoge, C. W. (2007). Timing of postcombat mental health assessments. Journal of Psychological Services, 4, 141148. doi:10.1037/1541-1559.4.3.141
Felker, B., Hawkins, E., Dobie, D., Gutierrez, J., & McFall, M. (2008). Characteristics of deployed operation Iraqi freedom military personnel who seek mental health care.
Military Medicine, 173, 155-158.
Iverson, A. C., Staden, L. V., Hughes, J. H., Browne, T., Hull, L., Hall, J., Greenberg, N., Rona, R. J., Hotopf, M., Wessely, S., & Fear, N. T. (2009). The prevalence of
common medical disorders and PTSD in the UK military: Using data from a clinical interview-based study. Journal of BMC Psychiatry, 9, 1-2. doi:10.1186/1471244X-9-68
Renshaw, K. D., Rodrigues, C. S., & Jones, D. H. (2008). Psychological symptoms and marital satisfaction in spouses of Operation Iraqi Freedom veterans: Relationships
with spouses' perceptions of veterans' experiences and symptoms. Journal of Family Psychology, 22(4), 586-594. doi:10.1037/0893-3200.22.3.586
Sayers, S. L., Farrows, V. A., Ross, J., & Oslin, D. W. (2009). Family problems among recently returned military veterans referred for a mental health evaluation. Journal
of Clinical Psychiatry,70, 163-170. doi:10.4088/JCP.07m03863
Verdeli, H., Baily, C., Vousoura, Belser, A., E., Singla, D., & Manos, G. (2011). The case for treating depression in military spouses. American Psychological Association, 25,
488-496. doi: 10.1037/a0024525
Military Wives’ Emotional Health
• Military wives have been shown to struggle with physical
and emotional health concerns:
– Physiological distress
– Depression
– Caregiver burden
– Psychological distress
Allen, E. S., Rhoades, G. K., Stanley, S. M., & Markman, H. J. (2010). Hitting home: Relationships between recent
deployment, posttraumatic stress symptoms, and marital functioning for army couples. Journal of Family Psychology,
24, 280-288. doi:10.1037/a0019405
Eaton, K. M., Hoge, C. W., Messer, S. C., Whitt, A. A., & Cabrora, O. A. (2008). Prevalence of mental health problems,
treatment needed, and barriers to care among primary care-seeking spouses of military service members involved in
Iraq and Afghanistan deployments. Journal of Military Medicine, 173, 1051-1056
Smith, T. W., Cribbet, M. R., Nealey-Moore, J., Uchino, B. N., Williams, P. G., MacKenzie, J., & Thayer, J. F. (2011). Matters of
the variable heart: Respiratory sinus arrhythmia response to marital interaction and associations with marital quality.
Journal of Personality and Social Psychology, 100(1), 103-119. doi:10.1037/a0021136
Warner, C. H., Appenzeller, G. N., Warner, C. M., Grieger, T. (2009). Psychological effects of deployments on military families.
Psychiatric Annals, 39, 56-63. doi:10.3928/00485713-20090201-11
Physiological Arousal & Marital Quality
• Physiological arousal is related to marital quality.
– Wives experience changes in physiology when discussing
problem areas
– These physiological changes are related to women’s
judgments' of the negativity of their marriages
– Thus, arousal might impact how wives think about their
marriages when interacting with their husbands
Menchaca, D., & Dehle, C. (2005). Marital quality and physiological arousal: How do I love thee? Let my heartbeat count the
ways. The American Journal of Family Therapy, 33, 117-130. doi:10.1080/01926180590915897
Research questions
1. What is the state of dyadic data collection in
research on military couples?
2. What is the state of dyadic analysis in
research on military couples?
 How do researchers employ methodology in an
effort to gather data from both members of a
dyad?
3. Which dyadic interventions are effective in
treating military couples?
Lewis, M. E., Lamson, A. L., & White, M. B. A systematic review of interventions for military couples. Under review by Family Process.
Constructing a BPR study with Couples
Relational
Psychological
Biological
• Marital:
• Satisfaction
• Quality
• Adjustment
• Alcohol Use
• Depression
• Distress
• PTSD
• BMI
• BP
• HRV
How is stress measured?
• In order to quantify stress, psychophysiological or
biological markers can be used to measure the
amount of stress that someone is experiencing
(i.e., increased respiration, blood pressure, sweat,
brain wave activity, etc.).
• Heart Rate Variability (HRV) is a measure of the
autonomic nervous system that assesses
sympathetic and parasympathetic responses
(relaxation and stress response).
• HRV has been used to detect biopsychorelational
health concerns including cardiovascular disease,
diabetes, PTSD, as well as marital quality.
Boysen, A., Lewin, M. A., Hecker, W., Leichter, H. E., & Uhlemann, F. (2007). Autonomic function testing in children and adolescents with diabetes mellitus. Pediatric Diabetes, 8(5), 261264.
Cohen, H., Benjamin, J., Geva, A. B., Matar, M. A., Kaplan, Z., & Kotler, M. (2000). Autonomic dysregulation in panic disorder and in post-traumatic stress disorder: Application of power
spectrum analysis of heart rate variability at rest and in response to recollection of trauma or panic attacks. Psychiatry Research, 96(1), 1-13.
Smith, T. W., Cribbet, M. R., Nealey-Moore, J., Uchino, B. N., Williams, P. G., MacKenzie, J., & Thayer, J. F. (2011). Matters of the variable heart: Respiratory sinus arrhythmia response to
marital interaction and associations with marital quality. Journal of Personality and Social Psychology, 100(1), 103-119. doi:10.1037/a0021136
Thayer, J. F., & Lane, R. D. (2007). The role of vagal function in the risk for cardiovascular disease and mortality. Biological Psychology, 74(2), 224-242. doi:10.1016/j.biopsycho.2005.11.013
Physiological Reactivity and PTSD
• For those persons who have experienced
traumatic events, those diagnosed with PTSD
had worse physical outcomes than those who did
not have PTSD
– The ‘active ingredient’ is not just the PTSD diagnosis
but the actual sympathetic nervous system activity
which is associated with worsening biopsychosocial
health
 PTSD is usually accompanied by other physical
symptoms
Beckham, J. C., Taft, C. T., Vrana, S. R., Feldman, M. E., Barefoot, J. C., Moore, S. D., . . . Calhoun, P. S. (2003). Ambulatory monitoring and physical
health report in Vietnam veterans with and without chronic posttraumatic stress disorder. Journal of Traumatic Stress, 16(4), 329-335.
doi:10.1023/A:1024457700599
Schnurr, P. P., & Jankowski, M. K. (1999). Physical health and post-traumatic stress disorder: Review and synthesis. Seminars in Clinical
Neuropsychiatry, 4(4), 295-304.
Schnurr, P. P., Spiro,Avron, I.,II, & Paris, A. H. (2000). Physician-diagnosed medical disorders in relation to PTSD symptoms in older male military
veterans. Health Psychology, 19(1), 91-97. doi:10.1037/0278-6133.19.1.91
Summary of Outcomes
•
•
•
•
•
Lewis, Lamson, et al. 2012, 2013
Buchner, Lamson et al 2013
Lacks, Lamson et al. 2013
Lamson, Meadors et al 2013
Muse, Lamson et al. 2013
Policy Recommendation 1
• Ask about partners and encourage clients/patients
to bring their spouse to healthcare visits
1. Military experiences such as occupational stress,
deployment, and PTSD can pose serious threats to marital
relationships, yet medical professionals do not routinely
assess both members of a couple during medical visits.
•
The most common mental health concern for returning military
personnel with PTSD is marital disruption
2. Mental health assessments of spouses of PTSD victims are
also necessary due to the reciprocal and shared
relationship of PTSD for couples.
Bowen, G. L., & Orthner, D. K. (Eds.). (1989). Organization family: Work & family linkages in the U.S. military. Organization Family: Work & Family Linkages in the U.S. Military. Ipswich, MA: Praeger Publishers.
Dirkzwager, A. J. E., Bramsen, I., Adèr, H., & van der ploeg, H. M. (2005). Secondary traumatization in partners and parents of Dutch peacekeeping soldiers. Journal of Family Psychology, 19(2), 217-226.
doi:10.1037/0893-3200.19.2.217
Faber, A. J., Willerton, E., Clymer, S. R., MacDermid, S. M., & Weiss, H. M. (2008). Ambiguous absence, ambiguous presence: A qualitative study of military reserve families in wartime. Journal of Family Psychology,
22(2), 222-230. doi:10.1037/0893-3200.22.2.222
Figley, C. R. (1988). A five-phase treatment of post-traumatic stress disorder in families. Journal of Traumatic Stress, 1(1), 127-141. doi:10.1002/jts.2490010109
Hourani, L. L., Williams, T. V., & Kress, A. M. (2006). Stress, mental health, and job performance among active duty military personnel: Findings from the 2002 department of defense health-related behaviors survey.
Military Medicine, 171(9), 849-856.
Lewis, M., Lamson, A., & Leseuer, B. (2012). Health Dynamics of Military and Veteran Couples: A Biopsychorelational Overview. Contemporary Family Therapy: An International Journal, 34(2), 259-276.
doi:10.1007/s10591-012-9193-7
Mansfield, A. J., Kaufman, J. S., Marshall, S. W., Gaynes, B. N., Morrissey, J. P., & Engel, C. C. (2010). Deployment and the use of mental health services among U.S. Army wives. The New England Journal of Medicine,
362(2), 101-109.
Orthner, D. K., & Rose, R. (2009). Work separation demands and spouse psychological well-being. Family Relations, 58(4), 392-403. doi:10.1111/j.1741-3729.2009.00561.x
Riggs, D. S., Byrne, C. A., Weathers, F. W., & Litz, B. T. (1998). The quality of the intimate relationships of male Vietnam veterans: Problems associated with posttraumatic stress disorder. Journal of Traumatic Stress,
11(1), 87-101. doi:10.1023/A:1024409200155
Romanoff, M. R. (2006). Assessing military veterans for posttraumatic stress disorder: A guide for primary care clinicians. Journal of the American Academy of Nurse Practitioners, 18(9), 409-413. doi:10.1111/j.17457599.2006.00147.x
Recommendation #2
• Conceptualize PTSD relationally, as opposed
to individually.
• PTSD severity is moderated by the social
system of the sufferer and those closest to the
victim of PTSD are equally at risk for health
concerns
More support for familial
intervention…
• Family Support with healthcare decisions should be
encouraged
– The support system of a patient has numerous positive effects on
the patient’s health outcomes provide and provide needed support
with recovery that results in better symptom and cost management
than when receiving care alone.
• Many people prefer to involve family in their healthcare needs
– The majority of all military personnel prefer family-focused
interventions to treat mental health needs.
• The presence of a spouse at a medical visit has been found to
decrease partner symptomology by 21% and relate to reduced
medical visits by both partners.
• Further, marital status and familial support are related to
higher incidence of adherence to the medical treatment plan.
DiMatteo, M. (2004). Social support and patient adherence to medical treatment: A meta-analysis. Health Psychology, 23(2), 207-218. doi:10.1037/0278-6133.23.2.207
DeSimone, K. L. (2000). Is a single oral dose of amiodarone safe and effective in converting new-onset atrial fibrillation (AF) to sinus rhythm? The Journal of Family Practice, 49(6), 493-494.
Khaylis, A., Polusny, M. A., Erbes, C. R., Gewirtz, A., & Rath, M. (2011). Posttraumatic stress, family adjustment, and treatment preferences among national guard soldiers deployed to
OEF/OIF. Military Medicine, 176(2), 126-131.
Law, D. D., & Crane, D. R. (2000). The influence of marital and family therapy on health care utilization in a health-maintenance organization. Journal of Marital & Family Therapy, 26(3),
281-291.
Sayers, S. L., White, T., Zubritsky, C., & Oslin, D. W. (2006). Family involvement in the care of healthy medical outpatients. Family Practice, 23(3), 317-324. doi:10.1093/fampra/cmi114
Resources
• The Alliance of Military and Veteran Family Behavioral Health
Providers: http://www.ecu.edu/che/alliance/
• Integrated Care Models:
http://www.integration.samhsa.gov/integrated-care-models
• Collaborative Family Healthcare
Association: http://www.cfha.net/
• Naval Center for Combat & Operational Stress Control:
http://www.med.navy.mil/sites/nmcsd/nccosc/Pages/welcome
.aspx
• SAMHSA Military Families:
http://www.samhsa.gov/MilitaryFamilies/
• Database for Veteran and Military Health (Medline Plus):
• http://www.nlm.nih.gov/medlineplus/veteransandmilitaryheal
th.html
Contact Information
Angela Lamson, PhD, LMFT, CFLE
112 Redditt House
Greenville, NC 27858
East Carolina University
(252)737-2042
lamsona@ecu.edu
Melissa Lewis, PhD
University of Minnesota Medical School - Duluth Dept of Biobehavioral Health &
Population Sciences
1035 University Drive
Duluth, MN 55812-3031
218-726-6569
218-726-7559 (fax)
melewis@d.umn.edu
Session Evaluation
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!