Family Reintegration Experiences of Soldiers with Combat-Related Mild Traumatic Brain Injury

Sunday, 27 July 2014: 3:15 PM

Kyong S. Hyatt, PhD, FNP, RN
Department of Research, Walter Reed National Military Medical Center, Bethesda, MD

Purpose:  Approximately 12% to 22% of service members (more than 325,000) returning from Iraq and Afghanistan are estimated to have sustained some level of mild traumatic brain injury (mTBI) and it is among the most widespread and undertreated injury of the conflicts. Mild traumatic brain injury (mTBI) affects not only the injured individuals, but also their families. A major gap in the current literature on family reintegration/adjustment following an mTBI is the absence of an empirically derived framework for describing and understanding family reintegration experiences and coping processes. Clearly, there is a compelling need to understand the unique family reintegration process in order to help researchers and clinicians develop more effective support programs and devise outcome measurements of their effectiveness. Therefore, the purpose of this study is to explore the problems and challenges of military family reintegration following a combat-related mTBI.  This study is one of the first to examine reintegration experiences of both injured soldiers and their spouses.

Methods:   Participants were recruited by self-referral, healthcare provider referral from the TBI clinic at a large Army Medical Center, or direct approach in the clinic. If prospective dyads met the study inclusion criteria, the spouse was contacted by phone to get verbal consent and scheduled a face-to-face meeting. Participants were active duty soldiers with deployment-related mTBI and their legally married civilian spouses who spoke English. All soldiers were between 2 and 24 months post-deployment.  Strauss and Corbin’s grounded theory methodology was used to collect and analyze the data. Sampling was directed by theoretical sampling methods, which means that recruitment of study participants was guided by emerging and theoretically relevant constructs drawn from analysis of collected data. This sampling strategy allowed the investigator to broaden and refine emerging categories during the theory building phase.

This study received approval from the Institutional Review Board of a large Southeastern university. The primary method for data collection was face-to-face, semi-structured interviews. Conjoint interviews were conducted first to determine each dyad’s shared views of family reintegration. These shared views were further explored during separate individual interviews. Nine dyads yielded a total of 27 interviews (9 conjoint soldier-spouse interviews, 9 spouse interviews, and 9 soldier interviews). During the first part of each interview, the investigator used broad, open-ended queries, such as: Tell me about your family’s experiences of being reunited after deployment.Separate face-to-face interviews, first with the soldier and then with the spouse, were conducted approximately 1 week after the initial joint interview.

In both joint and separate individual interviews, the open-ended questions were influenced by the ongoing analysis, and the direction of subsequent interviews was guided by the emerging theory. Participants were recruited and interviewed until data saturation was reached, that is, until no new themes of family reintegration challenges or coping strategies were identified. Quality control and rigor of data collection was maintained through the use of mentor-guided interview techniques and established data collection protocols. These included independent coding corroboration with colleagues and 100% auditing of the first five joint interview transcripts by two expert mentors. Dependability of the data was assured through participant validation of the key points of the interview at its conclusion and explicit procedures for data selection, analysis, and synthesis.

Results: Majority of soldier participants (n=8) were male. More than 50% of the soldiers (n=5) and 75% of the spouses (n=7) were White. The soldiers’ rank ranged from specialist to field grade officers. More than 65% of couples (n=6) had 1 or 3 children at home. Fifty-six percent (n=5) and 44% (n=4) of soldiers reported clinically significant depression and anxiety symptoms, defined as a score 11 or greater of each of the depression and anxiety subscales of the Hospital Anxiety and Depression Scale (HADS). Ten percent (n=1) of spouses disclosed clinically significant anxiety symptoms based on the HADS subscale score. Fifty-six percent (n=5) of soldiers reported unsatisfactory marital relationship, as indicated by a score of less than 100 on Marital Adjustment Test (MAT); whereas, 22% of the spouses (n=2) reported dissatisfaction with their marriage. Sixty-seven percent of soldiers revealed clinically significant Posttraumatic Stress Disorder (PTSD) symptomotology on the PCL-M scale, represented by a score of 50 or above.

Overarching theme of reintegration experience was finding the new normal. A new normal was defined by participants as the couple’s new, post-mTBI expectation of the family unit or family routine. The idea of a new normal is supported by the following themes: facing up to the soldier’s unexpected homecoming, managing unexpected changes in the family routine, experiencing mismatched expectations, and adjusting to new expectations for the family. First, when the soldier returned home with an mTBI, the couples encountered unexpected changes from their normal family routines and often indicated that these changes were unlike any past experiences. This finding may be unique to these study participants since, unlike civilians with mTBI, these soldiers sustained their mTBI while they were separated from their families, thus presenting them and their spouses with a series of delayed (and unexpected) changes upon their return. Second, couples were required to manage the challenges of day-to-day life and somehow try to fit the injury-related changes into their daily family routine. This finding was congruent with findings of both Naalt and Miles, who suggest there is significant post-mTBI impact on the marital relationship as married couples go through a process of adjustment. Third, couples needed to resolve mismatched expectations of the soldiers’ post-mTBI functional capabilities, which created family conflict. Finally, couples who successfully negotiated household roles and responsibilities accepted post-mTBI changes and recognized limitations with the soldiers’ functional capabilities. These couples looked toward rebuilding a new normal for their family.

Almost all couples indicated that post-mTBI symptoms had impacted their marital relationship. This study supports findings from previous studies indicating that after mTBI, both partners have to adapt to new life situations and renegotiate their roles and responsibilities. In particular, this study shows how changes in a soldier’s mood and short-term memory loss can impact a couple’s communication and relationship. These findings support Blais and Boisvert’s research findings showing that spousal perceptions of the injured individual’s communication skills have significant effects on both psychological and marital satisfaction. In the present study, the post-injury alterations in couple communication resulted in the uninjured spouse avoiding communication and the soldier blaming him or her for the problems, which caused further deterioration in the relationship.

The way couples managed unexpected changes in the soldier and post-mTBI family reintegration appears to have been influenced by the spouse’s prior reintegration experiences and the soldier’s length of service in the military. Soldiers with more years of service and who were senior ranking appeared to accept the post-mTBI changes as being one of the risks or costs of serving in the military, whereas soldiers with fewer than 10 years of service viewed the post-injury changes as a loss of their career and of the lifelong dream of being a career soldier.  In general, soldiers with more time in the Army and longer marriages adjusted to the new normal better than soldiers whose Army careers had just begun and/or who had newer marriages. Couples with more mature marriages (marriages of at least 10 years) adjusted to post-injury changes faster and better than couples with more recent marriages (less than 10 years). All spouses who had been married longer than 10 years indicated that they did not have clear boundaries about family roles or responsibilities; instead, these couples worked as a team and shared whatever tasks that needed to be done. These spouses appeared to be experienced homemakers who maintained their homes independently while their soldier spouses were gone. At the same time, they were willing to give up part of their independence upon the soldier's return.

The study findings suggest that the process of post-mTBI family reintegration—finding a new normal—is an evolving process that includes facing reality and accepting changes. This study provides a basic understanding of the needs of soldiers and their spouses following mTBI. Unlike other studies that focused exclusively on the view of the spouse, this study offers views of both injured individuals and their spouses, thus providing a more comprehensive understanding of how married couples manage the challenges of post-mTBI changes.

Conclusion: Individuals with mTBI and their families may benefit from interventions that directly address mismatched expectations and promote the acceptance of new normal. Due to mTBI’s lack of visible injury, soldiers may confuse their mTBI symptoms with those of other deployment-related injuries and therefore delaying treatment. Future studies with longitudinal designs that examine mTBI symptoms as they evolve over time may provide a deeper understanding of how injured individuals and their uninjured spouses experience the variable nature of mTBI. These studies may illuminate how couples can achieve a successful recovery over time and can thus provide a basis for creating effective rehabilitation and support programs.  In addition, future research that explores individual and family coping post mTBI could provide a foundation for developing interventions that are tailored to family post-injury adjustment challenges.