Introduction

“Secondary traumatization” refers to the traumatization of persons in close proximity to victims of traumatic events, who suffer from a range of emotional symptoms although they themselves were not directly exposed [14]. Under a variety of names, such indirect traumatization has been documented among children of Holocaust survivors [10], wives of combat soldiers [2], and even therapists who treat trauma victims [30]. Nonetheless, it is still a much less widely researched phenomenon than direct traumatization [17].

The present paper presents a study of the secondary traumatization of wives of former prisoners of war (POWs). As is well known, war captivity is a traumatogenic experience that is associated with posttraumatic stress disorder (PTSD) and other symptoms of distress (e.g., [13, 39]), including work, sexual, and marital problems (e.g., [7]). Nonetheless, only a handful of studies have been carried out on the wives of former POWs, and, in most of them, the wives' emotional condition was not the focus. McCubin et al. [24] and Hunter [21] studied the wives of POWs of the Vietnam War in an effort to identify variables in marriage and in the wife that predicted better marital adjustment after the husband's return. Dent et al. [11] compared Australian Vietnam POWs and their wives with non-POW combat veterans and their wives. Although they found no difference in the marital intimacy of the two groups, they found a significant association between the wives' and husbands' depression and, moreover, that the association was stronger in the POW- than in the non-POW couples. Bernstein [4], based on interviews with World War II POWs and their wives, reports that the couples experienced emotional distance. Only Hall and Williams [18] focused directly on the wives' emotional condition after their husbands' return. Using a clinical sample, they found that POWs' wives experienced feelings of abandonment, role ambiguity, and suppressed anger and suffered from severe psychosomatic symptoms.

Moreover, none of the studies distinguished between the wives of POWs who did and did not have PTSD, making it impossible to know how much of their distress stemmed from their husband's war imprisonment itself and how much from his PTSD. The distinction is important because studies of war veterans consistently show that wives of veterans with PTSD have more emotional problems [22, 32, 40], marital problems [25, 41], and exposed to more spousal aggression [16, 22] than wives of war veterans without PTSD. However, whether or not the findings could be generalized to the wives of former POWs remain unknown.

Not much is known about the contributors to the distress of the wives of former POWs'. One possible contributor, of course, would be the husband's PTSD. Several literatures on the wives of war veterans indicate that the more severe the husband's PTSD, the more severe the wife's distress [2, 29].

Another contributor may be the husband's aggression against the wife. Findings consistently show a significant association between husbands' aggression and their wives' emotional distress, both among general samples [9, 42] and war veterans [6].

Conversely, there may be variables that help to temper the distress of women married to traumatized men. Among these, one possibility is the woman's tendency to self-disclosure—that is her tendency to share her feelings and thoughts with her partner [15]. Self-disclosure may serve as a resource that helps to alleviate the wives' secondary traumatization: by enabling her to discuss her distress with her husband, by ameliorating the husband's PTSD symptoms, and by improving the quality of the marriage. Studies of couples show that disclosure provides partners with the opportunity to maintain intimacy, openness, and trust [5, 15] and is related to greater emotional involvement and relationship satisfaction.

The first aim of this paper is to examine secondary traumatization among the wives of former POWs. In keeping with the literature, it examines both specific trauma symptoms (nightmares, intrusive thoughts, and flashbacks) and other manifestations of distress, namely, general psychiatric symptoms and marital difficulties, that are not specifically trauma related, but may be augmented by direct or indirect exposure to traumatic events [17]. To identify the source of the wives' secondary traumatization, the study compared three groups of wives: wives of POWs with PTSD, wives of POWs without PTSD, and wives of non-POW combat soldiers.

The second aim of the study is to examine variables that may contribute to the wives' secondary traumatization: the husband's PTSD, the level of his verbal and physical aggression against his wife, and the wife's level of self-disclosure.

Methods

Procedure and participants

Israeli wives (including cohabiting girlfriends) were located through their husbands who were veterans of the 1973 Yom Kippur War and had participated in a previous study by our research group [34]. Using updated Israel Defense Forces (IDF) files, we phoned those participants and their spouses. After we explained the purpose of the present study, the wives who agreed to participate were offered the option of filling out the research questionnaires either in their homes or in a location of their choice. Before filling out the questionnaires, they signed informed consent form. The data were collected in 2003.

Ex-POWs' wives

Of the 124 ex-POWs who had participated in the study, 111 were married or had a partner at the time of the study. Eighty-two of their wives participated in the present study. Eighteen (22%) were married to ex-POWs with PTSD, 64 (78%) were married to ex-POWs without PTSD. Husbands' PTSD was diagnosed based on a self-report questionnaire they filled out (more details, [31]).

Control group

Of the 106 combat veterans who had participated in the previous study, 102 were married or had a partner. The control group consisted of the 74 wives who agreed to be interviewed. Of these, two were excluded from the analyses because their husbands met PTSD criteria, leaving a total of 72.

Examining the differences in background variables of the wives revealed no significant differences between the three groups in age, years of education, number of marriage years, number of children, and work status. Age of the women in the research ranged from 22 to 72 (M=50.51, SD=6.29), mean years of education was 14.18. Marriage years ranged from 3 to 53 (M=27.82, SD=6.54), mean number of children was 3.13 (SD=1.18). Fifty-two percent of the women in both groups worked in full-time job, 26% had part-time job, and the rest did not work.

Measures

  1. 1.

    Posttraumatic stress symptoms [33]. The women's PTSD symptoms were assessed using a self-report scale that consists of 17 statements corresponding to the 17 core PTSD symptoms listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition DSM-IV [1]. For each statement, the women were asked to indicate whether or not they had the symptom in the previous month. Instead of referring to a traumatic experience of their own, however, they were asked about their husband's experiences of combat or captivity. Example of their answer was “I have recurrent pictures or thoughts about my husband's captivity.” The intensity of their secondary traumatization was assessed by the number of symptoms they endorsed. Internal consistency among the 17 items in the current sample was high (Cronbach's α=0.91).

  2. 2.

    Brief symptom inventory (BSI). This is a self-report measure that inquires about 53 psychiatric symptoms during the 2 weeks preceding the assessment [12]. This scale allows for the assessment both of overall distress [Global severity index (GSI)] and nine symptoms' categories. Each item of the BSI is rated on a 5-point scale of perceived distress, ranging from 1 (not at all) to 5 (to a great extent). The scale has been used widely with various groups of Israeli populations (e.g., [26]). Internal consistency for the current sample was 0.97 for the GSI and ranged from 0.86 to 0.94 for the subscales.

  3. 3.

    Dyadic adjustment scale (DAS) by Spanier [35]. DAS is a 32-item measure consisting of four subscales: consensus, cohesion, satisfaction, and affectional expression. Participants were asked to indicate the extent to which each item described their current marital interaction. The dyadic adjustment score was calculated by summing up the ratings on the 32 items. High scores reflect better adjustment. Heyman et al. [19] reported that the scale had very good convergent validity and discriminant validity. The scale has been widely used with Israeli populations, including couples undergoing treatment for infertility [27] and patients with severe affective disorders [20].

  4. 4.

    Self-disclosure index (SDI). The SDI [28] measures the extent and content of self-disclosure. The inventory consists of ten questions that can be posed with regard to five target figures: mother, father, same-sex close friend, opposite-sex close friend, and partner. In the current study, we chose to ask only about the husband (“I tell my husband my most horrifying fears”, “I tell my husband about traits I like and dislike in myself”). Respondents are asked to rate the degree to which the statement is applicable to them on a scale of 1 (not at all) to 6 (very applicable). Each participant's score was the mean of her 10 ratings. The higher the score, the greater the self-disclosure. Internal consistency for the current sample was 0.94.

  5. 5.

    Conflict tactics scale (CTS) [36]. It is an 18-item self-report scale tapping multiple forms of aggression in marriage: verbal aggression (e.g., insults or swearing, yelling) and physical aggression (e.g., throwing things, pushing, grabbing or shoving, and attacks with a knife or gun). Participants were asked to indicate on a 6-point scale (1=never to 6=everyday) how often their husbands had perpetrated the behavior in the previous year. Two indices reflecting the frequencies of verbally and physically aggressive acts were computed.

The CTS has established internal consistency ranging from 0.88 to 0.95 in samples of husbands and wives. Its construct validity is supported by the large number of studies that have obtained consistent and theoretically meaningful findings using it [37].

Results

PTSD symptoms

An ANOVA with mean number of PTSD symptoms as the dependent variable revealed a significant difference among the three groups of wives [F(2,151)=18.55, p<0.001]. Post hoc Scheffe analysis showed an incremental pattern, with wives of combat controls having the fewest symptoms (M=1.50 SD=0.40), wives of POWs without PTSD having more symptoms (M=1.92 SD=0.68), and wives of POWs with PTSD having the most symptoms (M=2.30 SD=0.65).

General psychiatric symptoms

The wives' general psychiatric symptoms were compared using an ANOVA with the GSI total score as the dependent variable and a multivariate ANOVA (MANOVA) with the nine subscales as the dependent variables. Table 1 presents means, SD, and the F results of these analyses.

Table 1 Means and SD of distress measures according to research group
Full size table

As can be seen, the wives of POWs with PTSD have significantly higher levels of general distress than both the controls and the wives of POWs without PTSD. They also had more obsessive compulsive symptoms, interpersonal sensitivity, depression, hostility, and paranoia than the women in the other two groups. Moreover, they had significantly more symptoms of anxiety, phobia, somatization, and psychoticism than the wives of the controls, although not of the wives of the non-PTSD POWs.

Marital adjustment

As can be seen in Table 1, the wives of the PTSD POWs reported significantly poorer marital adjustment and significantly more physical aggression than the wives of both the controls and the non-PTSD POWs. No significant group differences were found in their self-disclosure or in the verbal aggression they suffered.

Contribution of self-disclosure and spousal aggression to secondary traumatization

Three three-step hierarchical regressions were conducted to examine the contributions of the husband's PTSD, his verbal and physical aggression, and the wife's self-disclosure to her secondary traumatization, as manifested in her PTSD symptoms, general psychiatric symptoms, and marital adjustment. In the first step, demographic variables (number of years of marriage, years of education, and work status) were entered. In the second step, we entered group affiliation, aggression, and self-disclosure. Group affiliation was entered as two demi-variables. The first was wives of PTSD POWs vs the two other groups. The second was wives of non-PTSD POWs vs the other two groups. The men's verbal and physical aggression and the wives' self-disclosure were entered as Z scores. In the third step, we entered two interactions: each of the demi-variables with self-disclosure. Table 2 presents the beta coefficients.

Table 2 Multivariate model predicting PTSD, GSI, and marital adjustment
Full size table

PTSD symptoms

Together, the variables explained 40.2% of the variance in the wives' PTSD symptoms [F(14,141)=6.10, p<0.001]. The demographic variables explained 13.2% of the variance, with years of education and work status making significant contribution. More education and working out of home were associated with fewer PTSD symptoms. The second step explained another 20.7% of the variance, with the most substantial contribution made by group affiliation, a smaller contribution made by the husband's physical aggression and no contribution by the wife's self-disclosure. Consistent with the earlier findings, wives of POWs with PTSD had the most PTSD symptoms. In addition, exposure to physical aggression is associated with more distress. The third step added another 6.3% to the explanation of the variance. Of the two interactions, the one whose contribution was significant was that between demi 1 (wives of PTSD POWs vs others) and self-disclosure. To determine the source of this interaction, we calculated the b coefficient of self-disclosure predicting number of PTSD symptoms separately for the wives of POWs with PTSD and the wives in the other two groups combined. Results revealed that the b coefficient correlation between self-disclosure and PTSD symptoms among the wives of ex-POWs with PTSD was b=−0.34, while that of the wives in the other two groups was almost 0 (0.07), pointing to the moderating effect of group on the relations between self-disclosure and PTSD symptoms. In other words, self-disclosure tempered the distress of the wives of the ex-POWs with PTSD.

Global severity index

Together, the variables explained 37.1% of the variance in the wives' PTSD symptoms [F(14,140)=5.30, p<0.001]. The first step explained 4.1% of the variance in the wives' distress. However, none of the demographic variables made a significant contribution on its own. The second step explained 22.8% of the variance. Wives of POWs with PTSD had the highest level of psychiatric symptoms. Higher self-disclosure was associated with less psychiatric symptoms, and physical aggression is associated with more psychiatric symptoms. The third step added another 10.2% to the explanation of the variance. Of the interactions, the one between demi 1 (wives of PTSD POWs vs others) and self-disclosure was once again the one to reach statistical significance. The b coefficient correlation between self-disclosure and GSI among the wives of ex-POWs with PTSD was strongly negative (b=−0.46), while that of the wives in the other two groups was insignificant (0.02).

Marital adjustment

Together, the variables explained 56.7% of the variance in the wives' marital adjustment scores [F(14,135)=13.18, p<0.001]. None of the demographic variables in the first step made a significant contribution on its own. The second step explained all the variance. POWs with PTSD have less marital adjustment than the two other groups. The greatest contribution was made by self-disclosure: higher self-disclosure was associated with higher self-adjustment. In addition, exposure to verbal aggression is associated with lower marital adjustment. None of the interactions made a significant contribution.

Discussion

The first aim of the study was to compare the distress of wives of former POWs with PTSD, of former POWs without PTSD, and of non-PTSD combat veterans who had never been in captivity. The comparison was undertaken to determine the degree to which their distress was rooted in their husband's captivity and/or in his PTSD. The findings in all three measures of secondary traumatization show that the highest measure of distress was endorsed by the wives of former POWs with PTSD. They had significantly more PTSD symptoms (although relatively low), more general psychiatric symptomatology (higher total score and significantly higher scores than both groups on five of the nine symptoms categories), and poorer marital adjustment than the wives in the other two groups. The current study also found that wives of PTSD veterans reported more frequent physical aggression than the wives of both the former POWs without PTSD and the non-PTSD combat controls.

These findings are consistent with the findings on the wives of PTSD veterans that are presented in the “Introduction” (e.g., [3, 22]). They are also consistent with Galovski and Lyons' [17] observation that secondary traumatization is a multifaceted phenomenon, manifested both in specific PTSD symptoms and nontrauma-specific forms of distress.

The findings that wives of POWs with PTSD showed more distress than the wives of the men in the other two groups highlight the role of the ex-POWs' PTSD in their wives' distress. The findings of the regression analyses, in which the man's PTSD was shown to contribute significantly to all the measures of distress, reinforce this conclusion.

The findings of the study also show, however, that the man's captivity is implicated in his wife's secondary traumatization as well. It is significantly associated with his wife's PTSD symptoms. Although the wives of the former POWs without PTSD had significantly fewer PTSD symptoms than those of the wives of the POWs with PTSD, they had significantly more PTSD symptoms than the wives of the combat veterans who had not been captives. The man's captivity also seems to have contributed to his wife's general psychiatric symptoms, albeit somewhat less strongly. Although the difference did not reach statistical significance, they endorsed more general psychiatric symptomatology than the wives of the combat controls. The only area in which the men's captivity alone was not associated with the wives' distress was in their marital adjustment.

Nonetheless, the findings show that the husbands' PTSD was more strongly associated with the wives' secondary traumatization than their captivity. Given the lack of other studies, we cannot know whether or not this difference is unique to the particular captivity. As is widely noted in the literature, war captivity varies greatly in length and severity from one situation to another. The Israeli prisoners examined in this study were held for a relatively short period: between 6 weeks and 8 months in comparison to the American POWs in the Far East, who were held for several years. We know that such differences lead to different PTSD rates among different groups of captives. We cannot rule out that they may lead to differences in the role of the captivity itself in family members' secondary traumatization.

The second aim of the study was to examine potential contributors to the wives' distress, beyond the husband's PTSD and captivity. The findings show that, in addition to these factors, both the man's aggression and the wife's self-disclosure play a role in the wife's level of distress. More specifically, the more frequent her husband's aggression, the more PTSD and general psychiatric symptoms the wife reported. The more frequent his verbal aggression, the lower her marital satisfaction. The finding that wives of physically aggressive men reported more psychiatric symptomatology is consistent with the extensive literature documenting somatization, depression, and PTSD among wives of physically aggressive husbands [9, 42].

Self-disclosure has a direct contribution to GSI and martial adjustment manifestations of secondary traumatization and a moderating effect on wives' PTSD and GSI symptoms. The salutary effect of their self-disclosure is particularly striking in view of the fact that there was no significant difference in the self-disclosure levels of the women in the three groups. We might expect that women married to men with PTSD, who tend to be closed and withdrawn by definition, would close off and withdraw in response. It is not only that this does not seem to have happened, it is also that the women who were remained open and sharing seem to have been able to compensate somewhat for their husband's emotional deficiencies. Part of the explanation may lie in the importance of verbal intimacy to women [8]. It cannot be ruled out that self-disclosing women encourage their husbands with PTSD to come out of their shell.

This study suffers from several limitations. The husbands' mental status was assessed using self-report questionnaires filled out by the husbands themselves, with no psychiatric diagnosis. It may be pointed out, however, that such self-reports have been found to be consistent with clinical diagnoses [33]. The wives' PTSD symptoms were assessed using a modified version of a questionnaire that was developed to assess the PTSD of direct victims. Unfortunately, the development of instruments to assess spouses' secondary traumatization is still in its infancy [38]. Finally, the study focused solely on the pathogenic aspects of living with former POWs. Recent literature shows that traumatogenic experiences may also be growth inducing, not only for the persons who undergo it but also for those close to them [23].

Notwithstanding these limitations, the study contributes to our knowledge of a little-studied population who, as the findings show, are victims of their husbands' traumatization. Further study is urged to identify coping resources, develop and evaluate treatment approaches, and explore possible salutogenic effects of living with traumatized veterans in general and former POWs in particular.