"My Scar": Posttraumatic Loneliness as a Source of Pain and Resource for Coping.

Contemporary understanding of combat trauma's psychological effects emphasizes the interpersonal ways survivors process their experiences. Yet cases of incongruence between survivors who want to share their traumatic experience and close others who are not ready to take part in this challenging task are common. Hence, many trauma survivors are compelled to cope with the posttraumatic consequences mostly alone. The present study followed the interpretive phenomenological approach to examine the experience of loneliness, as described by 15 male combat veterans dealing with posttraumatic stress. Participants completed semistructured qualitative interviews in which they shared their knowledge regarding postservice distress, loneliness, coping, and growth. Two main themes emerged: "The Loneliness Complex," highlighting this phenomenon's multifaceted, layered, and cyclical nature; and "Emotional Growth after Loneliness," presenting the positive potential of loneliness. These findings emphasize the importance of interpersonal relations in trauma survivors' recovery process. Participants described how experiences with peers can serve as a pivotal point for coping with postservice distress and how internalization of positive interpersonal interactions seems to be a crucial psychological resource for further rehabilitation and growth. Being a multilayered and cyclical condition, loneliness might serve trauma survivors in their search of safety, while also bearing the potential to motivate them to act upon their condition and promote emotional growth. Clinicians should acknowledge the risks trauma survivors take by leaving their lonely yet safe place, as they are encouraged to process their traumatic experiences and share their inner world with others.

Parent-child triangles and family loyalties as psychological arenas of grief manifestation among adults who lost a parent at a young age.

The current qualitative interpretative phenomenological study explored the intricate experiences of Israeli adults who lost a parent during childhood and subsequently navigated the challenges of adapting to a stepfamily dynamic. Through semistructured interviews, nine participants revealed three key themes: "Unbreakable Bonds: Loyalty to the Deceased Parent," illustrating efforts to preserve the original family structure amid changes; "Replacement Bonds: Loyalty to the New Parent," depicting the loyalty conflicts arising when connecting with a stepparent; and "Harmonic Bonds: Loyalties to All Three Parents," showcasing instances in which bereaved children successfully maintained connections with their deceased parent while forming meaningful relationships with their stepparent and living biological parent. The study findings informed a model elucidating the dialectical stance family members may adopt in response to such complexities. The model emphasizes the prioritization of orphaned children's emotional needs in a pyramid-shaped family structure, in which the psychological presence of the deceased parent remains integral.

"Remarried military widows" grief in light of social policy upheavals.

Military widows' remarriages and their consequences have scarcely been studied. We examined how legal changes enacted on behalf of remarried war widows, who regained their official rights after many years without them, impacted their life experience. Based upon 29 qualitative interviews, we found that the reinstatement of official recognition of widowhood validated participants' personal longitudinal grief but also revived painful loss-related feelings, which were expressed in interpersonal spheres. Policy changes allowed some widows a higher measure of independence, alongside upsetting the current couple's power balance. Social and clinical implications of such interruptions in the longitudinal grief course are discussed.

Living with spousal loss: Continuing bonds and boundaries in remarried widows' marital relationships.

The grief literature emphasizes widows' continuing bonds with their deceased spouses as a significant part of their grief process. Yet, little is known about what happens to those bonds when a widow remarries and there is a second spouse, and how these bonds are dealt with by the new family members. This study explored the continuing bonds of remarried Israeli widows, the role the second spouse plays in these processes, and the ambiguity and permeability of the boundaries between the first and the second marital relationships. Semi-structured interviews were conducted with 29 Israeli remarried military widows, over three decades after their first husbands' deaths. Data were analyzed by using thematic content analysis. Findings revealed that most of the women maintained continuing bonds with their deceased husbands, whereas a few of them severed these bonds. In all of the scenarios, however, the second husband played a major role, resulting in different levels of boundaries, from strict to blurred, between the first and the second marriages. These findings suggest that in order to obtain a full understanding of grief's impact on the second marital relationship, grief should be considered a couple-hood process in which the boundaries between the relationships are dynamic. The association between these patterns and personal and marital adjustment should be further explored.

En las publicaciones sobre el duelo se hace hincapié en que las viudas continúen los vínculos con sus cónyuges fallecidos como una parte importante de su proceso de duelo. Sin embargo, se sabe poco acerca de lo que sucede con esos vínculos cuando una viuda vuelve a casarse y hay un segundo cónyuge, y acerca de cómo los nuevos miembros de la familia manejan estos vínculos. En este estudio se analizó la continuidad de los vínculos de viudas israelíes que volvieron a casarse, el papel que desempeña el segundo cónyuge en estos procesos y la ambigüedad y la permeabilidad de los límites entre la primera y la segunda relación conyugal. Se realizaron entrevistas semiestructuradas con 29 viudas de militares israelíes que volvieron a casarse durante tres décadas después de la muerte de su primer marido. Los datos se analizaron usando el análisis de contenido temático. Los resultados revelaron que la mayoría de las mujeres mantuvieron la continuidad de los vínculos con los familiares de sus maridos fallecidos, mientras que algunas los cortaron. Sin embargo, en todas las situaciones, el segundo marido desempeñó un papel importante y hubo diferentes niveles de límites, desde definidos hasta desdibujados, entre el primer matrimonio y el segundo. Estos resultados indican que, con el fin de comprender completamente el efecto del duelo en la segunda relación conyugal, el duelo debe considerarse un proceso de pareja en el cual los límites entre las relaciones sean dinámicos. Deberá analizarse más profundamente la asociación entre estos patrones y la adaptación personal y conyugal.

Treating posttraumatic stress disorder across cultures: A systematic review of cultural adaptations of trauma-focused cognitive behavioral therapies.

OBJECTIVE: Although trauma-focused cognitive-behavioral therapies (CBTs) for posttraumatic stress disorder (PTSD) have been applied worldwide, the nature of how these Western-based interventions are applied in diverse settings has varied. This paper systematically reviewed the literature on how trauma-focused CBTs have been applied and adapted cross-culturally. METHOD: A systematic review of studies that discuss the process of cultural adaptation of trauma-focused CBTs. RESULTS: Seventeen papers were included and varied in the comprehensiveness of the adaptation process. Two studies stated that a theoretical framework was followed. Almost one-third of the studies did not report whether local stakeholders were involved in the process of application. Fifteen studies examined the efficacy of the adaptations and the results were positive, but the methodology and quality varied. CONCLUSION: There are inconsistencies in how trauma-focused CBTs are culturally adapted. A systematic approach to the transportation of such therapies would enable greater investigation into the necessity and efficacy of such adaptations.

Culture as a Double-Edged Sword: The Posttraumatic Experience of Indigenous Ethnic Minority Veterans.

The applicability of Western concepts regarding the treatment of trauma in soldiers from indigenous ethnic minority backgrounds has scarcely been researched. This study explored the subjective meaning of living with chronic posttraumatic stress disorder (PTSD) among indigenous Bedouin veterans of the Israel Defense Forces (IDF), who are of Arab ethnicity and Muslim faith. In-depth, semistructured qualitative interviews were conducted with 10 Bedouin veterans suffering from PTSD and three Bedouin mental health clinicians working with this population. Two themes emerged: "I wanted to be like everyone else," referring to participants' experiences during their military service, and "Fluctuating between belonging and abandonment," referring to veterans' experiences of living with mental health problems in a traditional minority community. These findings highlight the importance of conducting a comprehensive inquiry into the complex cultural and social backgrounds of indigenous minority veterans suffering from PTSD, and the interplay between the conflicted identities and multiple "realities" they experience.

Emotional processing is not enough: relations among resilience, emotional approach coping, and posttraumatic stress symptoms among combat veterans.

Combat soldiers are exposed to various potentially traumatic events and face high risk of developing military-related psychopathology, such as depression, posttraumatic stress and grief (PTSS). However, a strong body of research shows that resilience is the default in the aftermath of trauma and indeed, many veterans do not develop high symptomatic levels. To explicate this inconsistency, the current study examined the associations among PTSS, resilience, and patterns of emotional-approach coping. A sample of 595 male combat veterans filled out questionnaires on trauma exposure, PTSS, depressive symptoms, resilience, and emotional-approach coping. Their data were analyzed using structural equation modeling path analysis. Participants reported high exposure to potentially traumatic events during service. Mean scores were high for resilience and relatively low for PTSS and depressive symptoms; 13% had a clinical level of posttraumatic stress disorder. Structural equation modeling revealed that emotional-approach coping strategies mediated the relationship between resilience and PTSS. However, emotional expression was associated with lower PTSS levels, whereas emotional processing was associated with higher PTSS levels. These results suggest that although emotional-approach coping was related to higher resilience, emotional expression (an intrapersonal coping strategy) might have a more positive effect than self-oriented emotional coping strategies. Providing veterans with supportive opportunities and a wider repertoire of emotional coping skills might enhance their well-being, reduce postservice emotional distress while not harming veterans' resilience levels.

Combat military service and male depression: The relationship between social support, PTSD, and male depression following combat military service.

BACKGROUND: Soldiers in military service are at risk of exposure to traumatic and stressful experiences, which can lead to symptoms of posttraumatic stress disorder (PTSD) and symptoms of depression. In the context of veterans' PTSD and depression, social support has been shown to be a very significant resource. However, while general depression has been examined among veterans and although combat soldiers are often men, male depression has been rarely examined. Therefore, the present study aimed to examine the relationships between social support, PTSD symptoms, and male depression among veterans. METHODS: Five hundred and ninety-five male combat veterans completed a demographic questionnaire and measures of social support, PTSD, and male depression, including the specific symptoms of anger, substance use, social withdrawal, and restricted emotions. RESULTS: Structural-equation-model analyses showed that social support was negatively associated with both PTSD symptoms and depression symptoms. Specifically, social support showed lower trends of associations with substance use and anger; whereas there were higher associations with social withdrawal and restricted emotions. PTSD showed the strongest association with anger. Thus, we can see that social support is a key resource for coping with PTSD and different symptoms of male depression. CONCLUSION: Greater attention to social support, PTSD, and aspects of male depression could assist the development of intervention and therapeutic programs and also help to prevent the misdiagnosis of depression among military veterans.

Bedouin wives on the home front: living with men serving in the Israel Defense Forces.

This community-based study examined emotional and somatic symptoms of 129 Bedouin women whose husbands serve in the Israel Defense Forces. Wives of men diagnosed with posttraumatic stress disorder (PTSD) reported more symptoms than wives of men diagnosed with other disorders and wives of men with no diagnosis. Findings indicate that not only was PTSD in Bedouin servicemen positively associated with their wives' symptoms of posttraumatic stress and depression and somatic complaints, but that this relationship was fully mediated by husbands' aggression. Unraveling the special circumstances of women from traditional backgrounds faced with the devastating effects of husbands' combat-related posttraumatic pathology may inform an approach to the concept of vicarious trauma that is more specific to non-Western societies.

Long-term grief and sharing courses among military widows who remarried.

OBJECTIVE: The long-term consequences of military spousal grief have not been adequately studied. Although the literature emphasizes the widow's connection with the deceased as part of the grief process, the importance of the sharing patterns of such grief has been overlooked. This study aimed to add to the understanding of remarried military widows' long-term grief, via 2 main processes: The first was to explore their grief processes, and the second was to reveal whether and how their grief processes were shared with others. METHOD: Semistructured interviews were conducted with 29 Israeli remarried military widows, more than 3 decades after their husbands' deaths. Data were analyzed by using thematic content analysis. RESULTS: Findings revealed 2 continuums, 1 for each process. The first continuum was the grief process timeline, which covered a spectrum going from time- and emotionally limited processes to prolonged mourning processes. The second continuum was the sharing process, which covered a spectrum ranging from solitary grief to shared grief. Consequently, we suggest that widows can be viewed as occupying shifting points, over the years, on these intersecting continuums. CONCLUSIONS: The findings illuminate varied courses of coping and sharing of grief among older remarried military widows. IMPLICATIONS: An integration of loss, aging, and family relations theories for clinical work is suggested. (PsycINFO Database Record (c) 2019 APA, all rights reserved).