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Journal of Consulting and Clinical Psychology 1985, Vol53, No. 1,95-102
Social Support in Vietnam Veterans With Posttraumatic Stress Disorder: A Comparative Analysis Terence M. Keane, W. Owen Scott, Gary A. Chavoya, Danuta M. Lamparski, and John A. Fairbank Veterans Administration Medical Center, Jackson, Mississippi and University of Mississippi Medical Center In a cross-sectional study of the social support systems of Vietnam veterans, the following groups were compared: (a) Vietnam veterans who received a diagnosis of posttraumatic stress disorder (PTSD), (b) Vietnam combat veterans who were well adjusted, and (c) Vietnam-era veterans who were not in combat but who were currently hospitalized in a Veterans Administration Medical Center. Retrospective reports of social support were obtained from each group for three adultlife periods: (a) 1-3 months prior to entering the service, (b) 1-3 months following discharge from the service, and (c) at the present time. Indexes of social support included social network size, material support, physical support, sharing, advice, and positive social interactions. Prior to Vietnam, all three groups reported comparable levels of support across all dimensions. For the PTSD veterans, qualitative and quantitative measures of social support systematically declined over time to extremely low levels at the present time period, whereas for the comparison groups, social support was either stable or improved over time.
Reports of psychological distress among Vietnam veterans have increased dramatically during the period following the Vietnam war (cf. Fairbank, Langley, Jarvie, & Keane, 1981). A major epidemiological study by the Center for Policy Research (Egendorf, Kadushin, Laufer, Rothbart, & Sloan, 1981) found that Vietnam veterans exhibited a wide variety of stress-related problems when compared with non-Vietnam-veteran cohorts. The chief complaints among the Vietnam veterans were chronically elevated levels of anxiety, depression, guilt, and sleep disturbance. These symptoms were exhibited in an environment marked by the perceived absence of social support. Specifically, that study found that psychological distress was inversely related to social support (or density) only if veterans lived in nonmetropolitan areas such as me-
dium or small cities and rural areas (Kadushin, 1983). Unfortunately, this study did not provide information about specific diagnostic categories, but rather measured general psychopathology. A significant number of Vietnam veterans were exposed to traumatic combat events during the course of their military service, and some have developed prolonged stress reactions as a function of the specific events. For many of these veterans, the most appropriate diagnostic category describing their symptoms is posttraumatic stress disorder (PTSD). The present research was designed (a) to study social support systems specifically in Vietnam veterans who were requesting psychological treatment and who have been reliably diagnosed as PTSD, (b) to compare directly levels of social support among Vietnam veterans with PTSD with a group of Vietnam combat veterans who were well adjusted (WAV) and with a second group of Vietnam-era veterans who were currently being treated as inpatients in a Veterans Administration Medical Center (VAMC) for medical disorders (MSV), and (c) to compare changes in levels of social support for these individuals over three adult-life periods: prior to military service, following military service, and at the present time.
Portions of these data were presented at the World Congress on Behavior Therapy, Washington, DC, December, 1983. This research was supported by a Veterans Administration Merit Review Award to Terence M. Keane. The authors would like to thank Juesta M. Caddell for her assistance. Requests for reprints should be sent to Terence M. Keane, Vietnam Stress Management Program, Veterans Administration Medical Center, Jackson, Mississippi 39216. 95
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KEANE, SCOTT, CHAVOYA, LAMPARSKI, FAIRBANK
Current information on the social support systems of Vietnam veterans is derived from two sources. The Egendorf et al. (1981) study found low levels of social support among some segments of a non-treatment-seeking sample of Vietnam veterans. In addition, Keane and Fairbank (1983) surveyed more than 1,000 mental health professionals working in VAMCs across the country and found that among those who had the most experience working with PTSD veterans, there was strong sentiment that the presenting disorders of Vietnam veterans were a result of the traumatic events from combat coupled with the lack of social support these veterans experienced when they returned home. However, to date there has been no direct or complete assessment of social support networks in Vietnam veterans with PTSD. The present study also examined the degree to which Vietnam veterans with PTSD perceived changes in their social support systems over time. Specifically, we were interested in the premilitary, postmilitary, and current levels of social support as reported by the veteran. Data on the support systems at these three time periods would provide incremental information on the development and course of combat-related PTSD. Moreover, to draw appropriate conclusions regarding the relationship between PTSD and social support systems, a well-adjusted group of Vietnam combat veterans and a group of medical inpatients from the Vietnam era without PTSD were compared in this study. The inclusion of these groups permitted conclusions to be drawn without concern for the potentially confounding factors of age, race, sex, education (pre-Vietnam), combat experience, veteran status, and the occurrence of a recently stressful (inpatient hospitalization) life event (cf. Keane, Fairbank, Caddell, Zimering, & Bender, in press). There were three hypotheses for the study. First, Vietnam veterans would show a reduction in reported levels of social support, extending from the premilitary period through the postmilitary period and continuing to the present. This decline in social support would be reflected across all dimensions of social support, including support network size. Second, both comparison groups would show stability in support from the premilitary pe-
riod to the postmilitary period to the current time period. The recently hospitalized medical patients might possibly demonstrate a decline in current levels of social support associated with the change in their health. The third hypothesis addressed the premilitary adjustment of Vietnam veterans who develop PTSD. Although some evidence exists that supports the role of predisposing personality factors in the etiology of PTSD (e.g., Worthington, 1977), other studies have been unable to identify any consistent premilitary factors associated with PTSD (Figley, 1978a; Foy, Sipprelle, Rueger, & Carroll, 1984). If differences were found on the social support variables at the premilitary period, then this would support the theory that there is a psychosocial predisposition to the development of combat-related PTSD. Method Subjects A total of 45 male Vietnam-era veterans participated in this study and were divided into three groups. Group I (PTSD) contained 15 patients from the Vietnam Stress Management Program, a program designed to evaluate and treat combat-related PTSD. Group 2 (WVV) consisted of 15 well-adjusted Vietnam combat veterans who were employees recruited from the Jackson, Mississippi, VAMC and who did not report symptoms of PTSD or of any other major psychological disturbance. Group 3 (MSV) included 15 VAMC medical-service inpatients from the Vietnam era without combat exposure and who did not report symptoms of PTSD. Demographic characteristics. There were no betweengroups differences on the following variables: (a) race (31 white, 14 black), (b) branch of service (53% Army, 18% Navy, 20% Air Force, 9% Marines), (c) current age (M = 36.69; SD = 5.36), (d) history of premilitary substance abuse (0%), or (e) history of premilitary psychological treatment (0%). However, there were between-groups differences on other variables (see Table 1). Subject selection procedures. PTSD subjects were all seeking treatment at the PTSD program in the Jackson VAMC. To arrive at the diagnosis of PTSD, two doctorallevel staff members interviewed all patients, using a structured approach that included (a) military history; (b) premilitary history; (c) combat exposure; (d) a structured PTSD symptom checklist derived from the Diagnostic and Statistical Manual of Mental Disorders (DSMIII; American Psychiatric Association, 1980) criteria; (e) the identification of specific traumatic events; (f) a structured, comprehensive mental-status examination; (g) psychometric testing consisting of the Minnesota Multiphasic Personality Inventory (MMPI) and an MMPI PTSD subscale validated on PTSD veterans (Fairbank, Keane, & Malloy. 1983; Keane, Malloy, & Fairbank, 1984); and (h) a laboratory-based psychophysiological
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SOCIAL SUPPORT AND PTSD
Table 1 Demographic Characteristics That Showed Between-Groups Differences Group
Variable Premilitary education (years) Current education (years) Military entrance age No. of jobs since discharge Service-con nected disability
PTSD (n = 15)
MSV (a = 15)
WAV (n - 15)
11.77
11.77
13.70
12.82 20.2
12.82 19.2
16.47 21.2
9.21
2.8
8
3
14.0
7
Note. PTSD = combat veterans with posttraumatic stress disorder, MSV = medical-service inpatients, WAV = welladjusted Vietnam veterans.
administered to screen out patients who were experiencing the symptoms of PTSD from either combat or noncombat events. Both raters agreed that no subjects included in this group met any of the four major criteria for a PTSD diagnosis, and none were taking any psychoactive medications. Subjects who served in Vietnam were excluded from this group, but all subjects did serve in the military during the Vietnam era (1963-1975). The purpose of including the MSV group was to provide a control for age, education, military experience, and combat. We specifically wanted to determine if exposure to combat was an important source of variance in the report of social support systems. Moreover, we were concerned about possible demographic differences between the PTSD and the WAV subjects and that these differences might influence our interpretation of the data. Four of these subjects reported a history of abusive consumption of alcohol. Sixty percent of the veterans using our medical center receive a secondary diagnosis of alcohol abuse, and so it was felt that these subjects were representative of medical inpatients at the facility.
Procedure assessment procedure that has been demonstrated to discriminate PTSD veterans from veterans who do not have PTSD (Malloy, Fairbank, & Keane, 1983). On the basis of the available data, both staff members in the PTSD program independently agreed that all subjects included in the PTSD group presented symptoms consistent with the DSM-III criteria. In addition, subjects with a concurrent diagnosis of psychosis or a personality disorder as determined by the mental-status examination were not included in the sample. In all instances, subjects' data on the psychophysiological assessment (i.e., increased heart rate and skin conductance to combat cues), on the MMPI (Profiles = F, 8-2), and on the PTSD subscale of the MMPI (M - 38) were consistent with data obtained in previous validational studies on Vietnam veterans with PTSD (Fairbank et al., 1983; Keane et al, 1984; Malloy et al., 1983). Only when potential subjects fulfilled all requirements for the diagnosis of PTSD were they included in the study's sample. Subjects in the W\V group were not seeking treatment for any medical or psychological disorders. These individuals were identified by requests for volunteers from medical center technical personnel or support personnel. Again two doctoral-level staff members conjointly interviewed all candidates for this group, using the combat exposure scale to ensure that they had experienced combat and the PTSD checklist to ensure that they did not experience the symptoms of PTSD from either combat or other traumatic events. The two interviewers independently rated all subjects and agreed that no subjects in the WAV group met the four major criteria required for a PTSD diagnosis. Subjects also did not report seeking treatment in the past for psychological problems or taking any psychoactive medication; subjects did not report concerns that would be considered clinically significant. For inclusion in the medical patient group (MSV), subjects were also interviewed joindy by two staff members of the PTSD program. All patients had inpatient status at the time of their participation. The PTSD scale was
The structured interview was designed to assess subjects' social support system at three points in time: (a) 1-3 months prior to entering the military (Time 1), (b) 1-3 months following their discharge from the service (Time 2), and (c) 1-3 months preceding the current interview (Time 3). Social support within one time period was assessed completely before proceeding to the next chronological period. Subjects were first asked a series of specific questions (i.e., Who lived with you at that time? Who were your friends? Who were your neighbors?) to generate a social support network of individuals with whom they had any social/personal contact during a particular time period. Five dimensions of social support were then assessed: (a) material aid (i.e., money and use of possessions); (b) physical assistance (i.e., help working on a project or task); (c) sharing thoughts, feelings, and experiences in conversations; (d) advice, guidance, or information; and (e) positive social contact (i.e., having a good time doing something together). Two measures of each support dimension were then obtained: (a) actual and (b) potential. Subjects were first asked to identify those individuals who actually provided a particular type of support. Then from the remaining people on the list, they were asked to indicate which individuals they thought would have provided that support had they been asked by the subject. The total number of individuals providing actual and potential support within each dimension was used in the data analyses. Two general measures of overall satisfaction with each type of support were then obtained. Subjects were asked to rate on a 1 -7 scale (a) whether each support dimension was important to them during a particular time period and (b) the degree of satisfaction with the amount of support received.
Results Group differences in network size and each dimension of social support (material, phys-
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KEANE, SCOTT, CHAVOYA, LAMPARSK], FAIRBANK
ical, sharing, advice, and positive social support) were analyzed using separate two-factor (Group X Adult-Life Period) analyses of variance (ANOVAS) with repeated measures on the second factor. All statistically significant effects were analyzed using Tukey's honestly significant difference (HSD) test for pair-wise comparisons among the group means at each adult-life period.
PTSD* WAV* MSV-
Social Network Size Illustrated in Figure 1 are changes in network size as a function of time for each of the three groups. Results of the repeated measures ANOVA revealed a significant Group X Time interaction, F(4, 84) = 4.45, p < .003. Pair-wise comparisons between groups revealed significantly fewer support members for the PTSD group versus the MSV group during the postmilitary service period (p < .01) and for the PTSD group versus both the WAV and the MSV groups during the present adult-life period (p < .01). There was no statistically significant betweengroups difference at the premilitary period for reports of social network size. Actual and Potential Social Support Material support. A repeated measures ANOVA performed on the number of people who actually provided material support revealed a significant main effect for groups, F(2, 42) = 4.28, p < .05, indicating that there were fewer people providing material aid for both the PTSD and the WAV groups of Vietnam veterans (PTSD: Time 1 = 11.00, Time 2 = 7.53, and Time 3 = 4.93; WAV: Time 1 = 7.93, Time 2 = 5.93, and Time 3 = 7.20) when compared with veterans in the MSV group (Time 1 = 15.40, Time 2 = 13.60, and Time 3 = 16.26). A similar finding was also observed in a group main effect, f\2,42) = 4.93, p < .05, for potential material support. The means for the three groups were as follows: for PTSD, Time 1 = 8.67, Time 2 = 4.33, and Time 3 = 5.07; for WAV, Time 1 = 9.93, Time 2 = 8.93, and Time 3 = 8.00; for MSV, Time 1 = 12.93, Time 2 = 11.93, and Time 3 = 16.87. The Group X Adult-Life Period interactions for both actual and potential material support failed to reach statistical significance.
Pre-mllKary
Post-military
Present
Figure 1. Changes in social support network size as a function of time for combat veterans with posttraumatic stress disorder (PTSD), well-adjusted Vietnam veterans (WAV), and medical-service inpatients (MSV).
Physical support. Repeated measures analysis of actual physical support revealed a significant Group X Time interaction, P(4, 84) = 3.05, p < .03. Multiple comparison tests performed on the interaction provided evidence for lower levels of actual physical support for veterans in the PTSD group (Time 1 = 9.53, Time 2 = 5.80, and Time 3 = 5.53) versus those in the MSV group (Time 1 = 13.60, Time 2 = 13.33, and Time 3 = 14.53) during the postmilitary service period (p
