PTSD has a significant impact upon physical health (Pacella et al., 2013), substance misuse (Reynolds et al., 2005), interpersonal relationships (Taft et al., 2011) and development of other comorbid psychiatric disorders (Kessler, 1995). Existing research primarily focuses on individuals experiencing PTSD, with less attention given to the impact on partners and loved ones; understanding the wider effects is crucial as poor interpersonal relationships can negatively influence the onset and maintenance of the symptoms (Brewin et al., 2000). Additionally, the onset of PTSD can lead to psychological distress in partners, due to difficulties including caregiver burden and secondary trauma (Lambert et al., 2012).
In their recent study, Powling et al. (2024) aim to add to the literature regarding partners’ experiences of PTSD. Notably, the researchers gathered in-depth accounts of partners that fall outside of high-risk occupations, like those in law enforcement roles or health care workers, where research is typically focused. The study qualitatively explored the interpretative accounts of partners as they give meaning to their experiences.
The research aims are as follows: ‘what are the experiences and views of people who have a partner with a history of trauma and diagnosis of PTSD?’ (Powling et al., 2024, p. 3).
Previous studies have focused on the individual experiencing PTSD, yet limited focus has been given to partners’ perspectives.
Methods
This qualitative study, set in a specialist NHS UK trauma service, used semi-structured interviews to explore the experiences of partners of people with PTSD. The interview schedule was developed in relation to existing literature and the lived experience of the lead author. The interview questions explored the context of the traumatic event, the experience of the relationship before the event, the present status of the relationship, access to services, and future expectations. The interviews were audio-recorded.
Participants were eligible to contribute if their partner was a service user, diagnosed with PTSD, and waiting for, or receiving, psychological treatment for PTSD. A purposive sampling strategy was used to recruit participants into the study. Some participants were known to the clinician, and some were not. For the former, single layer consent was gained by the clinician directly approaching the partner, and for the latter, double layer consent was gained from both the service user and the partner. All potential participants received an information sheet about the research and were invited to participate. Before the interviews, all participants provided written informed consent.
To enhance the credibility of the qualitative research undertaken, the authors adhered to the guidelines set by Yardley (2000). These guidelines included ensuring sensitivity to context, commitment and rigour, and transparency and cohesiveness. These guidelines were met through practices including supervision, attendance of qualitative research groups, and through using verbatim extracts for reader clarity. The first author also kept a reflective diary throughout to ensure reflections on biases and assumptions. Other members of the research team also independently read sections of the transcripts.
To analyse the data, an idiographic approach was employed through Interpretive Phenomenological Analysis (IPA), to explore individual meaning-making for participants after experiencing significant life events.
Results
The study explored the experiences of six partners of people diagnosed with PTSD, with a mean age of 51. All participants in the study were white British. The traumas experienced varied, some included physical and sexual assault, combat related traumas and healthcare related traumas. A primary trauma was identified and explored for participants who had experienced more than one traumatic event.
The overarching theme observed from the interviews was “an ongoing journey of loss and gain” (p.5). For the participants, their partners’ PTSD journey was a path of wins and losses paved by sense-making, shifting individual and relational identities, and support from the outside world. The researchers identified three superordinate themes to further evidence this journey of loss and gain.
“Making sense of the trauma and ensuing consequences”
- Striving and struggling to understand. For some, their partners’ diagnosis of PTSD provided relief and validation. Participants made sense of their partners’ diagnosis through the media, which appeared unfruitful at times. Others used literature to enhance their understanding. Making sense of the trauma proved difficult as many faced other consequences, such as financial difficulties, depression and a lack of understanding of PTSD from loved ones and the wider public.
- Entering a new perceived reality. The PTSD diagnosis significantly altered expectations and perceptions of the participants’ life course. The harsh reality of the omnipotence of PTSD is highlighted by the authors in this theme, as it is described as an “evil witch” (Powling et al., 2024, p. 6) that infiltrates their future wider social lives.
- Looking backwards: reflecting and reminiscing. Many reflected backwards on the changes in their relationship and the contrasts pre-and post-trauma. Some cited negative changes, but two cited positive relationship changes, like improved communication.
- Looking forwards: hope versus uncertainty. Participants spoke about their journey in contradicting terms, citing both hope and hopelessness about the future. The participants highlight the link between PTSD and suicidality here, fearing the worst if the “evil witch” takes hold.
“Shifting identities”
- Adapting to new responsibilities and roles. Participants explained the changing roles that came with new responsibilities, such as having to adapt and change parenting styles.
- Subordinated in the relationship. Participants felt that their relationship equality had changed, and their role had been somewhat diminished because of the increased needs of their partner.
- The emotional journey. Participants experienced many differing emotions, all throughout the journey, with all participants citing guilt as a strong emotion. Some participants found mirroring symptoms of their partners’ PTSD, such as anxiety and sleeplessness.
“Accessing and experiencing outside resources”
- Support from others. Participants explained how utilising support networks provided space to receive sympathy. Some reported finding it difficult to use personal support networks, due to differences in understanding of PTSD, which left them feeling alone.
- Professional support. Participant experiences with accessing professional support were diverse; some expressed appreciation for assistance, others reported increased stress when seeking external support, and some felt disconnected from the care process.
Partners of individuals with PTSD navigate a complex landscape, marked by a juxtaposition of losses and gains.
Conclusions
The study participants demonstrated how their experience of their partners’ PTSD was a continual journey of losses and gains. The experiences were a juxtaposition of striving and struggling to make sense of the trauma, shifting identities and relationships, and accessing personal and professional support.
The authors concluded that a range of different emotions were experienced by participants in the study in relation to their partners PTSD.
Strengths and limitations
The study provided a rich insight into the experiences of individuals whose partners have PTSD. The authors contribute important findings to the literature regarding the wider impact of PTSD, especially for partners who do not work in high-risk occupations. The authors’ findings are important and will have implications for practice.
Additionally, the authors did well to ensure credibility and safeguard against the bias and subjectivity that can be present in qualitative research (Hammarberg et al., 2016). The authors followed specific guidelines for qualitative research, to ensure sensitivity to context, commitment and rigor and transparency and coherence (Yardley, 2000). To adhere to these guidelines, the first author employed methods including maintaining a reflective journal, attending research groups, presenting verbatim extracts and utilising supervision.
Although the authors took steps to reduce the impact of bias, it is possible that bias may have been present. Bias may have been common amongst the sample, as the study did not include relationships that have ended. Within the context of the study, the inclusion of broken relationships may have revealed more about specific stressors that may lead to the dissolution of a relationship, and provide different insights into other preventative and supportive measures.
Reliance on memory may have led to recall memory biases. Some authors are attempting to alter the psychological narrative regarding the unreliability of memory (Brewin et al., 2020). Nevertheless, there is an abundance of literature noting the malleability of memory (Clifasefi et al., 2007); one study found that the nature of transgression recall in romantic relationships was mediated by trust level (Luchies et al., 2013), suggesting there may be confounding variables impacting recall. Further longitudinal research may be beneficial here, to explore how meaning making varies over time, enhancing the accuracy of accounts.
A further limitation relates to generalisability. The six participants were all white British, and only one couple were in a same-sex relationship. UK mental health services are accessed by people from a diversity of backgrounds. Evidence demonstrates the experience of PTSD varies culturally (Jobson & O’Kearney, 2008); the lack of diversity amongst the sample limits the real terms applicability to UK clinical settings. More research is needed to capture a broader range of experiences.
The study highlights the experiences of romantic partners’ of individuals with PTSD, but further qualitative research could employ an ethnically diverse sample.
Implications for practice
The implications for practice from this study are important and relevant for all levels of mental health services in the UK.
Studies have noted the positive impact that a PTSD diagnosis can have (Hundt et al., 2019), and this present study has demonstrated that this impact can also translate to loved ones, as participants reported how diagnosis brought relief. Within secondary care, quick and accurate diagnosis of PTSD should be ensured without delay, to aid in fostering understanding.
Studies also note the importance of ensuring that diagnosis is not the end point, as this can be detrimental, and lead to increased stigma and feelings of hopelessness (Perkins et al., 2018). Participants in this study highlighted the detrimental effects of receiving either no support or unsuitable support. Secondary care must ensure that swift diagnosis is aligned with treatment plans that include partners. A randomised controlled trial found cognitive-behavioural conjoint therapy for PTSD to be effective for a reduction in PTSD symptom severity and increased relationship satisfaction (Monson et al., 2012). Secondary care services may be best placed to provide such support, due to the availability of appropriately qualified clinicians, however, with training, it is not beyond the scope of primary care, as primary care services already provide couples therapies and therapies for PTSD.
Primary care mental health services, like NHS Talking Therapies, may already be well placed to support partners. Routine, self-referred assessments can provide a space for partners to access signposting to services like PTSD UK, which provides education for loved ones, or substance misuse support. These are simple processes that can improve the journey for loved ones, as mirrored by one of the participants in the study, who stated that informational material would have been helpful regarding their expectations.
Talking Therapies services can also support partners by providing individual support for mental health problems that they may go on to develop due to the change in lifestyle, like depression, or by developing psychoeducational groups exploring the impact of caring and its relationship to anxiety and depression. However, as services are often extremely busy, enhancing clinician awareness via training is crucial to ensure clinicians understand the impact of PTSD on partners and the importance of identifying this.
Primary care services are well established to provide this level of support, so it is unlikely that this would provide much increased burden on clinicians and services. However, further research is likely needed to explore the development and expansion of couples-based therapies for PTSD, to ensure its efficacy and economic viability.
The expansion of Talking Therapies services could support couples-based therapies for PTSD or family therapy.
Statement of interests
Amelia is a clinician in primary care services. No conflicts of interest to declare.
Links
Primary paper
Powling, R., Brown, D., Tekin, S., & Billings, J. (2024). Partners’ experiences of their loved ones’ trauma and PTSD: An ongoing journey of loss and gain. PLOS ONE, 19(2), e0292315. https://doi.org/10.1371/journal.pone.0292315
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