Community Mental Health Journal, Vol. 27, No.

3, June 1991

INTERNATIONAL ARTICLE
Treating Post Traumatic
Stress Disorder Couples:
A Psychoeducational Program
Claire Rabi~ D.S.W.
Chen Nardi, M.S.W.

A B S T R A C T : The effects of v e t e r a n s ' w a r - r e l a t e d emotional disorders on wives h a s

received little a t t e n t i o n in t h e l i t e r a t u r e on families a n d f a m i l y t h e r a p y . Clinical
evidence shows d e v a s t a t i n g effects of combat-related psychopathology on t h e m a r r i a g e
relationship. P o s t - t r a u m a t i c stress disorder can r e s u l t in chronic m a r i t a l distress, in
addition to v e t e r a n disabilities. It is contended here t h a t a clinical couples' t h e r a p y
model fails to address the specific needs of this population of couples. A cognitive-
b e h a v i o r a l a n a l y s i s of the effects of p o s t - t r a u m a t i c stress disorder (PTSD) on couple
functioning is p r e s e n t e d as well as a r a t i o n a l e for t r e a t m e n t b a s e d on psychoeduca-
tional, cognitive-behavioral, a n d self-help principles. This p a p e r reviews a n experimen-
t a l p r o g r a m carried out in I s r a e l designed to r e a c h and t r e a t t h e PTSD couple.

Post-Traumatic Stress Disorder (PTSD) involves a variety of symp-

toms, including recurrent dreams, sensitivity to loud noises or colors,
hyperalertness, violence, sleep disturbances, guilt, and memory or
concentration difficulties. With regard to combat-related trauma,
Titchener and Ross (1974) have noted the occurrence of a variety of

Requests for reprints should be sent to: Dr. Claire Rabin, Bob Shapell School of Social Work, Tel
Aviv University, Ramat Aviv, 69978, Israel.
The program described in this paper was carried out under the auspices of the Mental Health
Department, IDF Medical Corps, and was planned and executed by a team headed by Lt. Col. Chen
Nardi and Dr. Yohanan Wozner. The authors wish to thank Major Zehava Solomon, Ph.D.,
Professor Shimon Spire and Col. Moshe Kotler, M.D., Head of Mental Health IDF Medical Corps,
for their contribution to this paper.
209 9 1991 Human Sciences Press, Inc.
210 Community Mental Health J o u r n a l

types of disorders, including symptoms during combat and restoration

of emotional balance afterwards, continuation after the war of disturb-
ing symptoms, or no symptoms during the war but occurrence of PTSD
symptoms afterwards. Solomon (1988) has noted that a set of symptoms
particularly problematic in PTSD for wives includes husbands' numb-
ing of responsiveness and reduced involvement with the external world.
Figley (1978) has noted that constricted affect and feelings of detach-
ment or alienation make it difficult for some veterans to fully reinte-
grate themselves into society.
The response of the family to the returning soldier suffering from
PTSD can greatly influence the outcome of rehabilitation. There is no
doubt that the return home of a traumatized soldier can be a high risk
situation for the family. Veterans' wives report their husbands as
~changed men" (Tarsh and Roystone, 1985). The Center for Policy Re-
search (1979) indicates that the divorce rate among Vietnam veterans
is higher than that of the rest of U.S. population. The President's
Commission on Mental Health (1978) found that 38% of the marriages
of Vietnam veterans broke up within six months of their return from
war.
For those families that stay together, a pattern of avoidance of inti-
macy and lack of involvement in marital and parental roles appears to
be a common veteran response (Figley, 1976; Haley, 1974; Lifton, 1973;
Lumry, et al., 1970; Polner, 1971). Sexual difficulties compound the
avoidance phenomenon, resulting in reduced sexual drive and activity
(Haley, 1978; Williams, 1980). Avoidance of the parental role relates to
wives having taken over many of the parental functions while their
husbands were away, and husbands report of increased sensitivity to
noise (Christenson, et al., 1981; Haley, 1978; Solomon, 1988).
Avoidance behaviors alternate with violent outbursts in many cases
of PTSD. In a study of wives of veterans, Williams (1980) found that
50% of the couples seeking help reported wife abuse. Rosenheck and
Natan (1985) report a high level of aggressiveness towards children,
and have noted that children themselves respond with uncontrolled
rages.
Haley (1974) has found that combat veterans, especially those who
were involved in atrocities, suffer from guilt and fear over their violent
impulses. Horowitz and Solomon (1978) suggest that guilt-provoking as
the violence is, many veterans see violence as a justifiable response to
problems. They conclude that conflicts between aggressive impulses
and the attempt to control them may affect the veteran's functioning as
a spouse and father.
 Claire Rabin, D.S.W. and Chen Nardi, M.S.W. 211

A focus on the wives' role in reinforcing symptoms and their possible

involvement in establishing a chronic and stabilized pattern is impor-
tant. One issue is the wives' attitudes related to PTSD and the other is
sex-role stereotyping and prevalent ideas of what constitutes a good
wife.
There is a great deal of secrecy and shame around the return of a
traumatized soldier in Israel. Unlike victims of accidents and illness,
the soldier has to bear the stigma of failing to live up to social stan-
dards. As a man, the veteran who breaks down has failed to live up to
Israeli ideals for men: bravery under fire, carrying on in a difficult
situation and responsibility to his fellow soldiers. As a husband, the
veteran suffering from PTSD has somehow humiliated the family, and
his return is shameful rather than triumphant. Wives tend to cover up
for their partners. They take over family roles in an attempt to normal-
ize and stabilize the family, while maintaining a facade of normality
toward the outside world (McCubbin, et al., 1976).
In addition, many wives define their feminine role as a nurturing one.
Solomon (1988) has noted that while the wife may have little control
over the changes in her husbands' functioning, she may blame herself
and feel responsible for his well being. She is caught in a "compassion
trap" in which she sacrifices her own needs, leading to frustration that
cannot be directly expressed. Since wives tell themselves that they
'~should" be understanding of the husbands, they passively avoid direct
confrontations. In preliminary study, Solomon (1990) found that long-
term follow-up of PTSD soldiers revealed married vets doing worse t h a n
unmarried vets over time.
Using a cognitive-behavioral model to formulate the couple dynamics
draws on two sources. First, the literature on assertiveness behavior
(Lange & Jakubowski, 1976; Alberti & Emmons, 1978) calls attention
to the interaction between aggressive and passive behavior. Aggressive
behavior as a means of coping with interpersonal stress results in
violent outbursts. Guilt and fear of loss of control results, and the
aggressor attempts to regain control by withdrawal and passive coping.
This results in an increase in unresolved, avoided problems and in-
creased stress. If aggressiveness is the only alternative response to
passivity, the buildup of problems will eventually result in an aggres-
sive outburst. This sets up a cycle moving from aggression to passivity
and back to aggression.
Second, cognitive theories relating to couple functioning (Beck, 1988;
Epstein, et al., 1987), call attention to the way that marital partners
interpret their partners' behavior, their expectations from the partners,
212 Community Mental H e a l t h Journal

and their assumptions about their marriages. Wives of PTSD husbands

appear to blame themselves for their husbands' symptomatology. They
then experience guilt feelings and isolation behaviors.
It may be concluded that both husbands and wives enter into a system
of alternating passiveness and aggressiveness. Aggression leads to
guilt, which may lead to passive avoidance of conflict, which results in
frustration leading to aggressiveness. The result is a couple system in
which the wife overfunctions by avoidance of any areas of conflict or
stress. In addition, overfunctioning in the wife may reinforce under-
functioning in the husband, which increases overfunctioning in the
wife. Stress and conflict increase within the family unit due to its
isolation and secrecy, resulting both in increased use of dysfunctional
patterns of coping, and in distancing the family all the more from
possible helping sources. Increased use of dysfunctional coping patterns
would reinforce wives' sense of failure and guilt, thus increasing their
negative self-attributions and resulting in more self-blame. The higher
the degree of stress and dysfunctioning, the greater the need for isola-
tion and secrecy and the higher the internal stress and conflict. In-
creased conflict continues to reinforce the dysfunctional aggression-
avoidance patterns in both partners.
Using a cognitive behavioral assertiveness model helps in formulat-
ing a treatment program that can be viewed as a psychoeducational
training program rather than a therapy package. One of the central
problems in the treatment of the PTSD couple is their lack of compli-
ance and involvement in treatment, due to isolation behavior (Hogan-
camp & Figley, 1983; Kadushin, 1985; Solomon, 1987; Solomon, et al.,
1987; Tarsh & Roystone, 1985). Fried (1985) reported lack of success in
organizing treatment in Israel for wives and veterans, and noted specif-
ically that the wives were reluctant to participate. Planning of clinical
intervention has to take into account the avoidance behavior that has
stabilized both for husbands and wives, limiting utilization of profes-
sional help.
In addition to the problems relating to involvement in therapy, there
are additional reasons for designing a psychoeducational approach to
PTSD couples. Psychoeducational approaches to families have emerged
from work with schizophrenia (Falloon & Liberman, 1983; Anderson,
1983) and depression (Anderson, 1984). The psychoeducational ap-
proach assumes that the patient has a real illness, much like diabetes,
and thus the family needs to learn how to cope competently with the
illness and its manifestations. Karpel (1986) has cited this approach as
reducing blaming tendencies, decreasing defensiveness, providing in-
 Claire Rabin, D.S.W. and Chen Nardi, M.S.W. 213

formation and support and strengthening family resources. Educa-

tional workshops for family members, a part of psychoeducational pro-
grams, provide concrete understanding of the illness and new ways of
responding. For couples in which husbands suffer from PTSD, a psycho-
educational approach can reduce wives' tendency towards guilt, in-
crease understanding of husbands' symptoms, increase social support
and reduce isolation, and increase self-esteem. This approach would
hopefully break the aggressive-passive behavior cycle between the cou-
ple by activating the partners, decreasing passivity, and increasing
positive coping skills. In addition, the psychoeducational approach ap-
pears to carry less stigma than a clinical therapy model. In the case of
PTSD related to war traumas, feeling of shame and social failure could
be reduced by the more educational model of treatment.
In the Israeli program described below, called ~Ko'ach," treatment of
the avoidance response of husbands was one focus and training of the
couple to break the overfunctioning/underfunctioning pattern was an-
other focus. The need for both a massive intervention with husbands
around their specific psychological disorders and a wife/couples pro-
gram was seen as necessary in light of the severity of psychopathology,
degree of chronicity and stabilization of couples' dysfunctioning over
time. In both aspects of training cognitive-behavioral principles were
implemented in a psychoeducational, rather than a therapy mode of
presentation.

THE KO'ACH P R O G R A M

The "Ko'ach" project proposed and implemented by the Mental Health

Department of the Israel Defense Forces Medical Corps was an innova-
tive program designed to treat veterans of the Lebanon war, who
almost four years after having suffered from post traumatic stress
disorder continued to suffer from residual stress syndromes. Sixty-six
percent of these veterans presented the features characteristic of PTSD
(American Psychiatric Association, 1980). All of them complained of
impaired functioning and disturbed relationships with family, but in
spite of their distress continued to serve as reservists. All of them were
receiving some form of individual therapy, with little evidence of im-
provement.
Underlying "Ko'ach" was a well-articulated behavioral theory about
the development of chronic PTSD, and the manner in which the cycle of
chronicity may be broken. Anxiety reduction through avoidance behav-
214 Community M e n t a l H e a l t h Journal

ior and social environmental non-reinforcement of symptoms directed

the program's interventions. It was viewed as beneficial to remove the
individual temporarily from his environment and place him in a milieu
that would reinforce and teach more competent coping behavior.
~'Ko'ach" was a four week military training camp. The group leaders
were experienced mental health officers, with training and prior experi-
ence in the treatment of PTSD. The 41 soldiers participating in
'~Ko'ach" were called up for a month of reserve duty in the usual Israeli
manner, but only after the program had been explained to them and
they applied for a place in it. The camp was conducted in a military
manner. Soldiers and officers wore uniforms, lived in tents, and spent
much of their day in military training and physical fitness exercises.
The participants were systematically and gradually exposed to stress-
inducing military stimuli, such as noise of firearms. The exposure took
place within a milieu that pressured them to confront their avoidance
behavior and provided them with role models and generous support
from peers and officer-therapists. Soldiers were required and helped to
establish individual change objectives relating to their civilian roles,
and work towards achieving them. They were taught cognitive coping
skills, such as relaxation and '~self talk." This carefully planned regime
was implemented successfully with only minor changes and without
one dropout.
Additional information about work with the veterans can be found in
Solomon, et al. (1987) and in Spiro, et al. (1989).

TRAINING OF WIVES A N D COUPLES

The earlier discussion about dysfunctional couple patterns points to

concrete goals and principles for intervention that could be of benefit to
these wives. Wives need support to break out of their isolation, share
common concerns, ventilate their guilt and express their anger. Wives
also need information about their husband's symptoms and their man-
agement. Specifically, the wives need to know how to respond, how
much daily functioning to request, and how to engage their husband in
active problem solving. Couples need to learn to communicate actively
and openly around problems, to regain their positive identity as a
functioning couple and reduce their isolation and shame.
Group training addresses the isolation and shame issues, and helps
build strengths and natural coping resources. It was assumed that
wives would serve as a source of mutual help and support to each other,
while couples would be able to help each other solve couple problems. In
 Claire Rabin, D.S.W. a n d C h e n Nardi, M.S.W. 215

designing both the wife and the couple components of the training
program, several bodies of knowledge were tapped.
For wives, information wa~ giYen about PTSD symptomatology. So-
cial learning theory with its emphasis on reinforcement of symptoms
was a central focus. Assertiveness theory, with its emphasis on per-
sonal rights, open and direct requests and creating of boundaries, was
an important source of change for wives. Cognitive coping skills (Ellis
& Harper, 1975 & Meichenbam, 1976) and especially ~self-talk," gave
additional coping skills. Since these basic principles were also the basis
of ~'Ko'ach," couple workshops included no new information, but rather
helped the couples apply their assertiveness and cognitive skills to
their own couple interaction.
All the couples were trained as a group in self-help principles so that
they would be able to continue working alone after the end of the camp
experience. Self-help principles were applied to increase maintenance
and generalization of change.

I N T E G R A T I N G I N T E R V E N T I O N WITH WIVES I N KO'ACH:

CONSIDERATIONS A N D I S S U E S

Many wives had developed an antagonism to the Army and their social
services, feeling that years of unsuccessful treatment was the Army's
fault. Thus there was a pressing need to involve the wives both in
seeing their own role in reinforcing symptoms, and in accepting help for
themselves. Efforts toward reaching out to the wives became our cen-
tral focus and remained a major ongoing goal. It could never be taken
for granted that these wives saw themselves as clients.
In addition, wives were already very overburdened, were in charge of
their families and had no extra time. They lived within a wide geo-
graphical range, often far from the project. It was important to be
realistic about how much service wives would be able to use and to
design a program with these limitations in mind.
Another consideration involved integration of skill training for wives
with their husbands' progress. It was seen as important to keep wives
aware of the husbands' progress and to move them at a pace that would
facilitate change. During the four week camp training, veterans re-
turned home during weekends. Wives had to know how to respond
positively to their husbands' change attempts. The program had to
match the wives' skill acquisition and cognitive change to the rate and
type of their husbands' changed behavior.
216 Community M e n t a l H e a l t h Journal

T R A I N I N G MODULES

1. S t a f f Involvement

Prior to the work with wives or with couples, we did role play simula-
tions with the army mental health staff to get feedback, and test out our
model of work. These simulations became an important pathway for
obtaining staff involvement and understanding of the importance of the
couple relationship. During the simulations, we roleplayed four couples
in a therapy group, using the staffto play the couples. This experiential
learning allowed staff to view the high stress that existed between the
partners. Also, discussions with the staff after the simulation generated
a wealth of ideas for how to work with wives and couples.

2. Outreach to the Wives: Introductory Lecture Prior to the ~Ko'ach"

Project

Of the 50 wives invited, only seven wives came to the introductory

lecture. This is indicative of these wives' alienation from the services
provided by the Army. However, the work with these seven women was
the key to our program's success. It was clear that if these women could
be involved, others might join. During this meeting we were struck by
the isolation of the women. They sat far apart from each other initially,
and did not engage in the social "small talk" usual in Israeli society.
Wives received information about the project, including goals, ratio-
nale and program contents. They heard a lecture on war-related
traumas and symptoms. They were given information on family sys-
tems: change, the effects of crisis, role change, chronic rigid patterns of
interaction, and homeostatis. They were told about skills and coping in
dealing with family crisis, with an emphasis on the ability to learn new
skills to communicate better. Finally, they were told what they could
get from the project and what their contribution would be.
It appeared that the women were deeply affected by the psychoeduca-
tional approach. On the one hand, nothing was asked from them at this
point, as they were listening to a lecture. On the other hand, they knew
that the material discussed was central to their lives. By giving them
understanding, we also offered them some hope.
Their immediate response was to "sign up" for the program. In addi-
tion, one of the women suggested that they call the other wives and try
to convince them to come. They divided up the list of women who had
not come and promised to reach out to them.
 Claire R a b i n , D.S.W. and Chen Nardi, M.S.W. 217

3. Group Meeting With Wives Prior to "Ko'ach"

Prior to "Ko'ach," an additional evening meeting for wives was held.
Thirteen wives, including the original seven, attended the meeting.
The two co-leaders began by brainstorming with the wives and listing
all the symptoms of post-war trauma on a blackboard. Participants
were asked which of their husbands' symptoms they experienced as
most disturbing and the ways they typically responded.
As each woman began to share her experience, an atmosphere of
openness and support was gradually created. Some of the wives told
their stories for the first time. Most were surprised at the similarity of
the responses to their husbands' symptoms. In addition, several wives
had experienced some success in decreasing symptoms, and these
women shared their methods. For example, one woman had been consis-
tent in demanding more involvement in childrearing, and had finally
seen changes in her husband. Those women who had not demanded
changes were challenged by several participants to be more confron-
rive.
The evening was concluded with a mini-lecture on the reinforcement
of symptoms by family members. Two concepts were introduced. First,
the women were presented with the notion that attention reinforces
symptoms, and that they could help decrease symptoms by attending to
positive husband behaviors. Second, they were introduced to the notion
of"more of the same" cycles of interaction. For example, nagging on the
part of the wife interacts with withdrawal on the part of the husband, so
the more she nags, the more he withdraws and thus the more she nags.
It appeared that the major outcome of the evening was to decrease
isolation and increase social support. The theoretical material fostered
the belief that they could master new ways of conceptualizing their
problems. Finally, a sense of pride seemed to emerge, evidenced by the
comment of one participant, ~'we deserve a m e d a l - w e are the real
heroines."

4. Assertiveness and Cognitive Coping Skills Workshop for Wives

Before the husbands came home for their first weekend, and during the
first week of ~'Ko'ach," we ran a daylong workshop for the wives.
Eighteen wives came to this meeting. The goals were: to introduce
cognitive coping skills; to teach operant strategies for reinforcing alter-
nate positive husband behavior; and to teach communication tech-
niques for defusing violent interactions. Finally, it seemed important to
prepare the wives concretely for the husbands' visit home, and help
218 Community Mental Health Journal

them begin immediately to apply newly learned strategies. This work-

shop allowed time for practice and application to individual problems.
Five army mental health officers worked together as a team for this
workshop. We began with a group exercise ~'Getting in Touch With Our
Strengths." Each woman was to choose one word that characterized her
special strength (the words were written on a board), say it out loud,
and show how this strength helped her get through the period since the
war. After the entire list was finished, one woman said: ~'I think those
traits are true of all of us!".
In the next stage the group divided into five small groups, using a
written case prepared from the meeting. The case was a fictional ac-
count describing typical patterns heard in the previous sessions.
The small groups were asked to discuss the case and answer the
questions. Later the entire group was presented with cognitive and
operant theory relating to how we increase stress by thoughts (self help)
and reinforce problems. In a sense, the didactic material reinforced
what the small group had already discussed. The entire group was
given the assignment to discuss how the cognitive/operant principles
related to their own lives. The specified three areas: how thoughts
direct behavior; how emotional responses reinforce a problem; and how
shaping and reinforcement principles relate to their reinforcement of
husbands' symptoms. The leaders helped them focus on their own lives
and plan for the coming weekend.
After a break, the group was given a short lecture on alternative
positive coping skills; cognitive coping with positive self-talk, shaping
and ignoring failures. They were taught how social learning occurs, to
expect stress, and how to shape and reinforce all attempts by their
husbands to c h a n g e .
The group again divided into their original small groups and leaders
and worked on two personal goals for the coming weekend. The task
involved translating global complaints into small, constructive
changes. The wives learned to think in terms of successive approxima-
tion of goals, as well as potential reinforcers available in the environ-
ment.
These goals and their shaping programs were shared and discussed
with the entire group. After a break, the group discussed anger escala-
tion and assertive tactics to diffuse violence. The basic skills trained
were: empathy and asking for specific details; non-defensive listening;
finding something to agree with; and stating your way of seeing things
only when you have your partner's attention. These skills were trained
using behavioral modeling, rehearsal and roleplay demonstrations in
 Claire Rabin, D.S.W. a n d C h e n Nardi, M.S.W. 219

front of the group. Volunteers participated in the roleplay of explosive

situations, and tried to react differently using the skills. Finally the
group discussed the upcoming weekend. They were warned that after
the first week of ~Ko'ach," their husbands might be somewhat tense and
there may be potentially explosive interactions.

5. Family Day During "Ko'ach"

During the second week of ~'Ko'ach" the entire staff worked with the
husbands to organize a day for wives and children. Each army unit
decided on its own program and entertained their own families. Pro-
grams included games, watching a judo demonstration, a tour of the
camp, and a picnic organized by the men.
During this day the staff of the project used many different oppor-
tunities for informal conversation to reach out to new wives. There
were informal conversations on the lawn, walking around between
events and during the picnic. Women who appeared in crisis were
approached several times by different members of the staff. In addition,
the wives who had received previous training were asked to approach
new wives and try to involve them in the program. As the day pro-
gressed, wives who had maintained their isolation began to participate.
Even the more resistant women agreed to become involved. We found
that the "trained" wives were extremely effective in reaching out to the
more resistant ones. They understood their hesitancy and fears and
were able to convince these wives that it was worth their while to
become involved.

6. The Couples Group During "Ko'ach"

Three evenings in the 3ra and 4 th week of "Ko'ach" were devoted to
couples groups. Twenty-seven couples participated in four different
groups. Each group, based on the units and geographical location, was
led by a male-female team. These men left for the group meetings and
subsequently returned to camp.
The overall goals of the three meetings were:

1. To share common experiences as a couple and build a supportive

group atmosphere, conducive to problem solving.
2. To focus on specific skill training to improve couples' communica-
tion and problem-solving ability.
3. To strengthen couple functioning, increase hope, and encourage
viewing the partner as a source of support.
220 Community Mental Health J o u r n a l

Staff was trained using a training manual written especially for these
meetings. The manual specified exercises for each session, so that all
groups followed the same format. During each session time was allowed
for discussion of individual couple problems. The training manual can
be obtained from the senior author. Exercises were taken from Gott-
man, et al. (1976).

7. Self-Help Couples Groups After "Ko'ach"

The mental health staff were well aware that a one-month training
experience would need extensive follow-up to maintain results and to
encourage generalization back in real life. None of the professionals
wanted the veterans to return to their previous therapeutic mode, in
which the veteran visited his own therapist for individual sessions in
the Army's Mental Health Unit. The staff had been deeply impressed
with wives' participation, starting with only seven wives and finally
resulting in 27 wives participating in the couples groups, and had been
sensitized to the need for a couples focus in intervention. It was there-
fore decided to base the follow-up work on the couples groups.
Since there was no staff available to lead these groups, and since all
the group members suffered from similar problems, a self-help model
was used. Self-help groups have been used extensively with a wide
variety of mental health problems. However, there has been no report
in the use of self-help for couples in which the husband suffers longterm
and chronic PTSD. The model used here combined structured problem-
solving within a nonprofessional, participant rotating leadership
model.
In a workshop held for all couples immediately after ~Ko'ach," couples
were trained in problem solving group procedures, which then became
the basis for bi-monthly problem solving meetings. Groups meet in
members' homes, rotating a leadership and a secretary function. The
secretary acted as recorder of group decisions, while the leader main-
tained the group focus of problem-solving. The problem solving model
was based on the work of D'Zurilla and Goldfried (1971).
For the nine months following "Ko'ach," 40 veterans took part in four
different groups. Of these 40, 33 had a participating wife in the group,
and 66% of these 33 took part regularly. Only 15% (6) of the 40 veterans
needed personal therapy after the nine months, although 22% (9) had
contacted their previous therapist at some point during this phase. On
several occasions, the individuals' group met on an ad hoc basis to meet
a crisis. Six of the wives received telephone help from mental health
 Claire Rabin, D.S.W. a n d Chert Nardi, M.S.W. 221

Table 1
Participants' Evaluation of Their Current Functioning (9 Months
After Ko'ach)Compared With Their Situation Prior to Ko'ach (n89
Area % Improved % Unchanged % Deteriorated
Military reserve duty 47 32 21
Social relations at 57 26 17
work
Marital relations 68 12 20
Parenthood 68 26 6
Leisure time activities 48 40 12
Self-control 60 25 15
Problem solving ability 67 23 10
Sleep at night 40 45 15
Intrusive thoughts 40 35 35
about war

staff during family crises. Additional workshops were held in the fol-
lowing nine months on anger control, depression, and couple's commu-
nication. The small number of individual professional sessions needed
are an indication of the strength of the couples groups in meeting the
mental health needs of this population.
The veterans were asked to rate their perception of improvement, as
compared to the way they perceived themselves at the start of'~Ko'ach"
and nine months after "Ko'ach." Table one summarizes this data.
It is of interest that of the nine areas assessed, both marital relations
and parenthood received the highest ratings of improvements (68%).
Lowest improvement is evident in questions related to symptomatology
(sleep and intrusive thoughts). Questionnaire, rather than self-report
ratings, did not duplicate these effects. A discussion of the research
findings and their implications for program evaluation can be found in
Spiro, et al. (1989).

DISCUSSION

This paper has focused attention to couple functioning as a major

element in adjustment to Post Traumatic Stress Disorder among com-
bat veterans. A cognitive-behavioral view highlights the potential neg-
222 Community Mental Health Journal

ative interactions (particularly the aggressiveness-avoidance pattern

and self-blaming cognitions), that tend to stabilize husbands' under-
functioning, and wives' overfunctioning. The explanatory model pro-
posed here was developed from observations of PTSD couples with war-
related traumas. Since in Israel shame and isolation appears related to
perceived social inadequacy in this specific situation, it is not known if
the model proposed here is applicable to PTSD couples in which symp-
toms result from other events (accidents, earthquakes, etc.). It appears
useful in situations where traumas are viewed as shameful or blame-
worthy. For example, future work could test out this model of couple
interaction following a rape incident.
It was proposed here t h a t an educational group and self-help model of
work with this population of couples is more appropriate and more
accessible than is couples' therapy. An intensive one-month therapeutic
military camp experience in Israel in which wives of veterans actively
participated is described. Self-help group work was effective in helping
veterans report that they had improved their couple and family func-
tioning. The poor results for individual symptomatology deserves con-
cern considering the massive intervention ~Ko'ach" veterans received
overall. Longterm follow-up research is being carried out to see if
improved couple functioning can be maintained, given the continued
prevalence of symptomatology. These findings highlight the tenacity of
PTSD and the need for continued exploration of its treatment.
Mental health professionals working with veterans should be alert to
the difficulty in involving wives. Wives harbor anger and resentment
which can easily find a target in the often frustrating bureaucracy of
the mental health care system and veterans administration services.
Therefore we would recommend rethinking the treatment of PTSD
using psychoeducational, behavioral, group and self-help principles.
Similar to AA or Alanon, groups of couples with PTSD are able to serve
as a powerful resource for each other and are able to break through the
isolation, shame and secrecy that characterize these couples. We would
like to end this paper with a short vignette, taken from a group meeting
observed soon after the one month military camp:

Dani and his wife Miri were chosen to work on their problem. Miri brought up a
violent fight the couple had just experienced, and reported that Dani was starting
to withdraw again. She said that she was too exhausted to take on the entire
burden of family life again. In the group discussion around defining this couple's
problem, Miri noted how she had not had time away from the house, or any kind
of vacation, since before the war. The group decided that they all needed a
vacation, and that they would go to a resort. Miri was delighted, but Dani, who
 Claire Rabin, D.S.W. and Chen Nardi, M.S.W. 223

r a r e l y leaves the home, was anxious. ~'What if I panic?" or ~'What if I s u d d e n l y find

m y s e l f alone?" After some b r a i n s t o r m i n g , it was decided t h a t t h e couples would
t a k e t u r n s b e i n g w i t h Dani, so t h a t he would feel supported, and so t h a t Miri
would have t i m e alone. Dani reported b e i n g h a p p y w i t h this solution, a l t h o u g h
r a t h e r s u r p r i s e d t h a t t h e group cared so m u c h for him. The next w e e k the group
w e n t a w a y for a weekend, a n d Dani a n d Miri r e p o r t e d enjoying t h e vacation.

In this example the group was able to support this couple concretely,
in a way that a professional could not. Miri, being close to the problem,
was aware of the gradual return of Dani's symptoms early enough to do
something relatively simple. This example demonstrates the need for
more attention to the couple in treating PTSD of war related traumas.
In our program, a military camp was used as a therapeutic milieu to
create rapid change. The principles described here could be applied to
other settings, including day-care or out-patient clinics. However,
thought needs to be given to the theoretical orientation of the service
delivery agency and staff. The behavioral principles underlying this
program are not compatible with all other theoretical orientations, and
conflicts can result. Future evaluations would determine the most ap-
propriate mode of application of this approach.

REFERENCES

Anderson, C. (1983). A psychoeducational program for families of patients with schizophrenia, in

W. McFarlane (Ed.), Family therapy in schizophrenic~ New York: Guilford Press.
Anderson, C. (1984, March). Depression and the family. Paper presented at the Seventh Annual
Family Therapy Network Symposium. Washington, D.C.
Alberti, R., & Emmons, M. (1984). Your perfect right: A guide to assertive behavior. San Luis
Obispo, CA: Impact.
American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders
(DSM-III). Washington, D.C.: American Psychiatric Association.
Bar-Tur, L. (1979). Aggression and guilt feelings of wives of veterans of the I.D.F. who are physically
disabled M.A. Thesis. Tel-Aviv University.'
Beck, A. (1988). Love is never enough. New York: Harper & Row.
Center for Policy Research. (1979). The adjustment of Vietnam veterans to civilian life. New York.
Christenson, R.N., Walker, J.I., Ross, E.R., & Maltbie, A.A. (1981). Reactivation of traumatic
conflicts. American Journal of Psychiatry, 138: 984-984.
D'Zurilla, T., & Goldfried, M. (1971). Problem solving and behavior modification. J. of Abnormal
Psychology, 78, 107-126.
Epstein, N., Prezer, J., Fleming, B. (1987). The role of cognitive appraisal in self-reports of marital
communication. Behavior Therapy, 18, 51-69.
Figley, C.R. (1976, October). Combat-related stress disorders: Family therapy implications. Paper
presented at the Annual Meeting of Marriage and Family Counselors, Philadelphia.
Figley, C.R. (1978). Psychosocial adjustment among Vietnam veterans: An overview of the re-
search. In C.R. Figley (Ed.), Stress disorders among Vietnam veterans- Theory, research and
treatment. (pp. 57-70). New York: BrunnerfMazel.
Gottman, J., Notarius, C., Gonso, J., & Markman, H. (1976). A couple guide to communication.
Champaign, Illinois: Research Press.
224 Community Mental Health Journal

Falloon, I., & Liberman, R. (1983). Behavioral family interventions in the management of chronic
schizophrenia. In W. McFarlane (Ed.), Family therapy in schizophrenic~ New York: Guilford
Press.
Fried, B., (1985). Family therapy for wives of combat stress reaction casualties of the 1982 Lebanon
war. Fieldwork report presented to The School of Social Work, Tel-Aviv University.
Grinker, R.R., & Spiegel, J.P. (1945). Men under stress. Philadelphia: Blakisten.
Haley, S.A. (1974). When the patient reports atrocities. Archives of General Psychiatry, 30:
191-196.
Haley, S.A. (1983). Treatment implications of post-combat stress response syndromes for mental
health professionals. In C.R. Figley (Ed.), Stress disorders among Vietnam veterans- Theory,
research and treatment. (pp. 148-165). New York: Brunner/Mazel.
Hogancamp, V.E., & Figley, C.R. (1983). War: bringing the battle home. In C.R. Figley and H.I.
McCubbin (Eds.), Stress and the family, Vol. II: Coping with catastrophe. (pp. 148-165). New
York: Brunner/Mazel.
Horowitz, M.J., & Solomon, G.F. (1978). Delayed stress response syndromes in Vietnam veterans.
In C.R. Figley (Ed.), Stress disorders among Vietnam veterans-Theory, research and treat-
ment. (pp. 268-280). New York: Brunner/Mazel.
Karpel, M. (1986). Family resources: The hidden partner in family therapy. New York: Guilford
Press.
Kadushin, C. (1985). Social networks, helping networks and Vietnam veterans. In S.M. Sonnen-
berg, A.S. Blank & J.A. Talbott (Eds.), The trauma of war." Stress and recovery in Vietnam
veterans. Washington, D.C.: American Psychiatric Press, Inc.
Lange, A., Jakubowski, P. (1976). Responsible assertive behavior: Cognitive behavioral procedures
for trainers. Champaign, Illinois: Research Press.
Lifton, R.J. (1973). Home from the war. New York: Simon & Schuster.
Lumry, G.K., Cedarleaf, C.B., Wright, M.S., & Braatz, G.A. (1970, April). A further look at the
Vietnam-era veteran. Paper presented at the Fifteenth Annual Conference of the Veterans
Administration Cooperative Studies in Psychiatry, Houston, Texas.
McCubbin, H.I., Dahl, B.B., Lester, G., Benoon, O., & Robertson, M. (1976). Coping repertoires of
families adapting to prolonged war-induced separation. Journal of Marriage and the Family,
38(3), 461-471.
Polner, M. (1971). No victory parades. New York: Holt, Rinehart & Winston.
President's Commission on Mental Health. (1978). Mental health problems of Vietnam-era vet-
erans: Vol. III. (pp. 1321-1328). Washington, D.C.: U.S. Government Printing Office.
Rosenheck, R., & Nathan, P. (1985). Secondary traumatization in the children of Vietnam veterans
with posttraumatic stress disorder. Hospital and Community Psychiatry, 36, 538-539.
Spiro, S., Shalev, A., Solomon, Z., Kotler, M. (1989). Self-reported change, versus self-report:
Contradictory findings of an evaluation of a treatment program for war veterans suffering
from post-traumatic stress disorder. Evaluation Review, 13(5), 533-549.
Solomon, Z. (personal communication), 1990.
Solomon, Z., Schwarzwald, J., & Weisenberg, M. (1985). Mental health sequelae among Israeli
soldiers in the 1982 Lebanon war, Medical Corps, Department of Mental Health, The Israel
Defense Forces. l
Solomon, Z., Weisenberg, M., Schwarzwald, J., & Mikulicer, M. (1987). Post-traumatic stress
disorder among frontline soldiers with combat stress reactions: The 1982 Israeli experience.
American Journal of Psychiatry, 144, 448-454.
Solomon, Z. (1987). Combat-related post-traumatic stress disorder among Israeli soldiers-a two
year follow-up. Bulletin of the Menninger Clinic, 51(1).
Solomon, Z. (1988). The effect of combat-related posttraumatic stress disorder on the family.
Psychiatry, 51, 323-329.
Tarsh, M.J., & Roystone, C. (1985). A follow-up study of accident neurosis. British Journal of
Psychiatry, 146: 18-25.
Titchener, J.L., & Ross, W.D. (1974). Acute or chronic stress as determinants of behavior, charac-
ter and neuroses. In S. Ariety & E.B. Brody (Eds.), American Handbook of Psychiatry, 3(2),
(pp. 36-69). New York: Basic Books.
Williams, C. (1980). The veteran system-with a focus on woman partners: Theoretical considera-
tions, problems and treatment strategies. In T. Williams (Ed.), Post traumatic stress disorders
of Vietnam veterans. (pp. 73-124). Cincinnati, Ohio: Disabled American Veterans.