Exploring the Experiences of Partners of Veterans with Mental health Difficulties Attending a Group Psychoeducation Support Intervention: A Qualitative Study.

It has long been recognised the challenges military veterans face in terms of physical and mental health difficulties upon their return from conflict. A recent study of veterans who have served in conflict zones suggests the number of veterans in need of support is growing²⁴.

Less attention has been given to the impact of veterans’ partners. However, there is a growing body of literature which suggests veteran’s mental health difficulties to have an enduring impact on partners mental health, caregiving burden and secondary¹³,¹⁵,¹⁶. This implies military stress is experienced both individually and systemically³.

In greater appreciation for the needs of partners and supporting the veteran’s family as a whole, there has been a wide range of psychological support-based interventions developed which incorporate a variety of formats including; individual, group, psycho education couple-based and family-based support interventions. They appear to have promise and have been found to improve partners mental health and relationship satisfaction, veterans’ rates of engagement in therapy and their treatment outcomes¹⁰,²⁷,¹⁴.

The US has taken a leading role in providing group-based support interventions for veterans and their families. Examples of three interventions which have been trialled include SAFE (Support and Family Education)¹⁹, REACH (Reaching Out to Educate and Assist Caring, Healthy Families)²¹,²²and SAH (Strength at Home)⁵,²⁵,²⁶. REACH and SAH share similarities in that they both contain couple-based formats and do not include children whereas the SAFE programme is widely available to all family members living or caring for veterans. The SAFE programme is non-diagnostic specific and is available for any carer of family member living alongside a veteran with mental illness. Although REACH and SAH were not explicitly developed to tackle PTSD, they are sensitive to mental health and relationship difficulties that are likely to have been incurred as a result of the veteran serving in military.

All three programmes vary in length and format from nine to 18 sessions on a weekly or monthly basis. The common components of these interventions are that they strongly feature psychoeducation and include didactic and group exercises, in addition to home activities for the family to complete. All programmes covered the following topics; Communication skills, Problem solving and anger management. However, the SAH programme covers more material on relationship management and the impact of PTSD on the relationship. Self-care is reinforced in the SAFE programme and is achieved through practical skills training.

Findings from evaluations of these programmes are promising with improvements in areas of caregiver burden, knowledge of mental illness/PTSD and ability to self-care¹⁹, relationship satisfaction and conflict management^{2, 5}. Similar findings have been reported for residential based programmes designed to target veterans and their partners and highlight the benefits of incorporating wellbeing activities. For instance, in an intervention whereby meditation was delivered in addition to core aspects like psychoeducation and individual or couple therapy, significant improvements in partners mental health outcomes like depression, anxiety, anger and stress were observed¹¹. Another study which measured clinical levels of PTSD in partners before the intervention also measured a significant drop after completing this lifestyle programme ⁴ .

Few interventions that have been developed are solely designed to support veterans’ partners. Given the evidence reporting the unique challenges military partners face in their role as a caregiver and what barriers they may encounter in accessing support for themselves compared with other caregiving relations¹³, may suggest partners needs are being overlooked in these programmes offering broader support. This evidence highlights some of the complexities that may arise because of the structure and function of the partners intimate relationship with the veteran which may be less problematic or not exist at all in relationships with other family members. This is supported¹ who suggest that partners who are in a family system where there are more rigid rules, may be less receptive to change in therapy. This gap in research has paved the way for the recent development of a UK evidence-based support intervention, TTP. This programme provides partners with understanding of PTSD and mental health strategies to support the veteran partner. It also affords partners the opportunity to develop coping strategies for themselves. The efficacy of this pilot study has been reported elsewhere and suggested improvements in participants symptoms of common mental health difficulties, secondary PTSD symptoms and relationship satisfaction¹⁴.

Overall psychoeducation-based programmes like those described including the TTP have been consistently been well received among the military population and has been found to be effective¹⁵,¹⁹. However, much of the research looking at the effectiveness of family support interventions to date have relied heavily upon quantitative measures²⁰,²⁵. The evidence is limited by the relative lack of qualitative research and therefore little is known about the mechanisms of change which may be experienced as a result of attending interventions of this kind. Of the qualitative studies⁸ which have examined the experiences of US military spouses who were taking part in support- based interventions either group based or online, findings are restricted to the experiences of spouses during military deployments. Therefore, the changes partners experienced may not be comparable to partners of veterans who are no longer serving in the military and are seeking treatment for mental health difficulties. The impact of attending support programmes on a partner’s relationship with the veteran and their interpersonal functioning may not be fully understood. The specific elements of these multifaceted programmes and how partners relate to these are also not known. Literature in this area would benefit from capturing the experiences of partners engaging in these programmes and learning why particular aspects or components are more influential.

In the current study a qualitative methodology of Interpretative Phenomenological Analysis (IPA) was used to gather an in depth understanding of the mechanisms of change and transformation participants may have experienced whilst attending a pilot of a psychoeducation support programme for partners living alongside veteran with mental health difficulties.

The current study recruited participants from those who had completed TTP¹⁵. Participants were included in this study if they had completed TTP (Attended >four out of five weeks). One potential participant was excluded as their partner had dies and it was deemed insensitive to include them

The size of this qualitative study was determined using IPA as a method for analysis. Research indicates small samples of between five and ten to be the most ideal²³ and sufficient for saturation in data and for themes to emerge¹⁷. Initially, a random number was generated for each eligible participant. These random numbers were then ordered numerically, and attempts were made to contact participants down this list. In total, eight participants who had completed TTP were contacted about participating in the qualitative interview. Eight completed in total.

A semi structured interview was developed to allow for flexibility during data collection. The interview schedule was initially developed and then peer reviewed by several military mental health professionals who had experience conducting qualitative research.

Five questions were asked regarding participants experiences of TTP: Did the group have a long-lasting impact on your wellbeing? What things could be improved? What were the main things you would highlight to a friend or another partner? What were the key things you took away from the group? And did you notice a change during the group? Prompts were used like; ‘what do you put this down to?’ and ‘tell me more about that’ to expand meaning of the topics described. Interviews were conducted over the phone and lasted between 20- 40 minutes. Digital recordings were made and transcribed verbatim. Demographic data including age, relationship type and level of education was also collected using a questionnaire administered prior to starting the programme.

IPA²³ was selected as the most appropriate method because the study aims to understand the experiences of participants who engaged in the programme, and what changes there may have been in their intimate relationships. IPA seeks to make sense of individuals experiences by understanding their subjective perspective as opposed to describing their objective account. Therefore, this inductive methodology is well matched for the study’s aims and for researching an area that has not been explored before. Further, IPA has been found to effectively provide insight and in depth understanding of the experiences of partners living alongside veterans with mental health difficulties⁶,¹².

Analysis of the transcripts was conducted using guidelines for IPA²³. This top down approach was used to analyse all eight transcripts and followed the process of six stages; Firstly, the researcher becoming familiar with the transcripts, secondly, re reading the text and noting frequency of words used. The lead author (LS-H) then used these notations to look for repeating themes which emerged from surface text. These sub themes were then labelled. Finally, these sub themes were clustered into groups based on their connections into overarching themes or a super ordinate category. Quotations were extracted from the text to evidence sub themes. Only themes which were grounded in the text were included and those with insufficient evidence were removed.

A number of steps were taken during data analysis to uphold¹⁷ procedures for demonstrating rigor in qualitative research. For example, to ensure themes were accurately derived from the data, sub themes were discussed with co authors (DM & DT) for triangulation.

Approval for this project was granted by the Combat Stress Research Committee. Informed written consent was obtained from each participant prior to the interview. The lead author also discussed with all participants about how their data would be used in accordance with GDPR standards and debriefing would be provided after completing the interview. In addition, guidance around accessing further support was provided.

Three key themes were yielded using IPA analysis (Table 1): self-growth, changing role in relationship and connecting with others. Quotes are presented to illustrate the themes and experiences of participants. (Table 2).

This theme emerged from all interviews where there were positive discussions surrounding the peer support received during sessions and the comfort this brought participants in terms of not feeling alone and knowing support is available.

Many participants spoke about how over the course of the programme they were able to better understand and conceptualise why their partner was behaving in such a way and formulate the maintenance cycle of their symptoms. Being able to rationalise and make sense of why their partner is behaving in a certain way, meant participants were able to cognitively diffuse themselves from self-critical thoughts such as taking things personally. Subsequently, this allowed participants to be more patient, empathic and accepting. This seemed to allow them to adopt more helpful coping strategies derived from Dialectical Behavioural Therapy (DBT) skills like, mindful attention, cognitive reframing and distraction. This suggests teaching participants distress tolerance skills were a core element in facilitating self-growth during TTP. Furthermore, this could translate to other psychoeducational support for partners of veterans.

Veterans appeared to also benefit from the awareness and understanding that participants gained from attending the programme. Participants talked about developing a shared understanding with their veteran partner which previous research has suggested can allow corrections to be made without misunderstanding why people behave in the way they do. It is possible that after the process of being freed from misconceptions about each other, family members could communicate with greater empathy, which fits well with many accounts in this study. Furthermore, many participants described a profound sense of acceptance and non-judgement from other partners within the group. This implies the process of partners modelling acceptance within the group may also help to challenge stigmatising beliefs about themselves.

Participants expressed taking care of their own needs was of greater importance to them after attending the programme. Although participants spoke about difficulty of enduring feelings of guilt in this process, they were able to conceptualise the long-term consequences of being solely focused on their caregiving responsibilities.

Further, participants reported greater confidence in their ability to cope. These findings appear to be linked to participants reporting less avoidance type behaviours and improved self-care which may be indicative of changes in participants locus of control.² veteran spouses with high levels of internal locus control despite not being able to control their husband’s PTSD would be able to recognise they were in control of how they dealt with stress in the marriage. Conversely, the spouse with a high external locus of control is more likely to perceive themselves to be a victim of circumstance and have no control. This theory suggests that participants may have developed greater internal locus control, therefore improving their confidence in their own ability to cope.

The theme describing changes in participants role in their relationship during and after completing the programme was attributed to increased communication and a shift in the way they perceived the journey of caregiving for the veteran. Participants reported feeling more confident to express their own needs and approach their partner to discuss difficulties after completing the programme. These findings are indicative of changes in interpersonal patterns of communication. These findings align with previous research which proposes veteran partners, in their attempt to protect the veteran from further distress, are more likely to collude in their partners avoidance or other safety behaviours²⁸.

The increased dialogue reported by participants in this study also seemed to be aided by a noticeable shift in attitudes around caregiving responsibilities. The majority of participants seemed to adjust their expectations about length of recovery time to accepting the long-term nature of the veteran’s illness. These observations fit with Karp’s’ 4 stages of caregiving experience model⁷ which described carers moving through a series of stages from fear and confusion to recognition that the caregiver cannot control the individual’s illness and thus has greater acceptance of the illness. In view of this model participants at the end of TTP appeared to be more affiliated with the final stage of the caregiving experience model.

A common theme for all participants was ‘knowing I am not alone’. This was a highly valued aspect of the programme. One reason for why participants felt more connected with others and less isolated was because sharing their experiences helped them to discover the challenges they had been facing alone were experienced by others. This seemed like a revelation to most participants and helped to normalise their distress and confusion. Participants spoke about feeling safe to discuss difficult emotions like guilt and frustration which research has found to be natural reactions when feeling helpless in caring for a veteran who is suffering⁹.

After completing the programme, participants reported being able to perceive more hope, knowing support was available to them. Participants commonly described not receiving any support prior to attending the group and being heavily reliant on themselves to source resources and help manage the challenges faced living alongside veterans with PTSD or mental health difficulties. These findings support previous research evidencing prolonged social isolation among military partners in their roles as caregivers¹⁸.

A limitation was participants in this sample were all female and in heterosexual relationships. As such, minority groups within this population (male partners, not in heterosexual relationships) were not included which could limit the generalisability of the findings.

Moreover, only partners’ perspectives about the relationship with the veteran during and after the programme was captured. Thus, in the absence of accounts from partners attending TTP it was not possible to fully explore the couple’s interactions and understand their appraisals and relational responses to the skills and understanding partners may have acquired during the course. Having more information about the couples interacting cognitions and behavioural responses after completing the programme will allow researchers to better understand the impact of the programme on relationship dynamics and thus learn how to adapt the group intervention to be most effective.