Associations between distress tolerance and posttraumatic stress symptoms among combat veterans and their parents: The mediating role of parents’ accommodation

Abstract

Objective: Combat-related posttraumatic stress disorder (PTSD) might negatively impact the mental health of veterans’ family members. Nevertheless, nearly no research has examined secondary PTSD symptoms (PTSS) in veterans’ parents, and still to be explored are the mechanisms by which distress tolerance (DT) contributes to veterans’ PTSS and parents’ secondary PTSS (SPTSS). In the present study, we aimed to use a dyadic approach to explore the association between veterans’ and parents’ DT and their PTSS/SPTSS, as well as to examine the mediating role of parents’ accommodation of veterans’ behaviors in these associations. Method: A volunteer sample of 102 dyads of Israeli combat veterans and their parents responded to online validated self-report questionnaires in a cross-sectional study. Analysis included actor–partner interdependence modeling (APIM) and mediation analyses. Results: Veterans’ PTSS was positively correlated with parents’ SPTSS. Moreover, veterans’ DT and parents’ DT negatively predicted their own PTSS and SPTSS, respectively. Furthermore, veterans’ DT negatively predicted their parents’ SPTSS. Importantly, parents’ accommodation mediated the links between veterans’ DT and both veterans’ PTSS and parents’ SPTSS, as well as between parents’ DT and veterans’ PTSS with parents’ SPTSS. Conclusion: Parents of combat veterans might be indirectly traumatized by their offspring’s military experiences and suffer from secondary PTSS. Among both veterans and parents, low DT is associated with higher levels of parents’ accommodation, which in turn is related to more posttraumatic symptoms.

Keywords

Posttraumatic stress symptoms veterans parents distress tolerance secondary posttraumatic stress symptoms war

Introduction

Combat-related trauma and posttraumatic stress disorder symptoms (PTSS) might negatively impact veterans’ family relations and the mental health of their family members, who are known to be at risk for secondary PTSS (SPTSS; Solomon et al., 2021). However, most studies have focused primarily on veterans’ spouses or offspring, and information regarding parents of traumatized veterans and service members is scant (Biton et al., 2017). Moreover, a few studies have found low distress tolerance (DT) associated with higher levels of family members’ behavioral accommodation and higher veterans’ PTSS (e.g., Akbari et al., 2021; Allen et al., 2021). Nevertheless, associations between veterans’ and parents’ DT and their PTSS/SPTSS, as well as the possible mediating role of parents’ accommodation in these links, have never been explored. The present study aims to use a dyadic approach to assess the relationships between DT, PTSS, and SPTSS and the mediating role of parents’ accommodation between combat veterans and their parents. As positive familial relations are known to be important for veterans’ adaptation to traumatic residues (Monson et al., 2009) and family members’ accommodation might be modifiable through treatment (Reuman & Thompson-Hollands, 2020), this study is of theoretical and clinical importance.

The quality of the parent–offspring bond, a crucial agent for offspring’s mental health and well-being, is known to change its nature during the transition to adulthood (Mesman et al., 2012). During this period, between the ages of 18 and 30, offspring are characterized by stabilization of personality traits and maturation in intimacy, identity, and work characteristics (Yau et al., 2021). Nevertheless, while offspring are becoming more independent and self-sufficient, parents still play significant, yet evolving, roles in their lives (Tanner & Arnett, 2016). Thus, on the one hand, parents act as “scaffolding” by temporarily giving their offspring support and tools to advance their lives, achieve their goals and settle into adult roles and responsibilities. On the other hand, most parents also function as a “safety net” for young people to return to in times of crisis and to be provided with temporary, intermittent help to minimize setbacks in their transition to adulthood (Inguglia et al., 2015). During this “emerging adulthood” period—the transition into adulthood—the parent–child tie develops into a more mutual, reciprocal relationship between two separate, yet connected, adults (Bucx et al., 2012). Importantly, while the average age of military service in the United States is 27, Israel’s mandatory military service, at the ages 18–21, is intertwined with various aspects of the life-course of its service members and their families, such as gaining mature identity and enhancing human capital and socioeconomic stability (Wilmoth & London, 2013).

The naturally developing parent–child relationship is sometimes dramatically challenged by experiences of potentially traumatic events and chronic physical or mental illness over the course of offspring’s life (Zerach et al., 2016). However, most studies have focused on parents of young children who are adapting to their children’s severe medical conditions, such as cancer or surgery (e.g., Chardon et al., 2021). On the one hand, parents might experience significant distress associated with their children’s clinical condition and treatment, due to their caregiving burden, fear of children’s death, or identification with their children’s suffering (e.g., Norberg et al., 2012). On the other hand, high parental stress due to their children’s medical conditions, such surgical hospitalization, is associated with higher levels of children’s emotional distress (Ben-Ari et al., 2020).

Specifically, families of military service members and veterans also face hardships due to stressors associated with deployment and reintegration, as well as the interpersonal effects of distress (Monk et al., 2018). In family systems theory, individuals exist in the context of interconnected family units where members mutually influence the thoughts, emotions, and behaviors of one another (e.g., Bowen, 1978). Thus, according to this perspective, neither veterans nor their parents can be fully understood and treated in isolation. However, although parents are known to play an important role in military family life, much less scientific focus has been aimed at parents of deployed service members and veterans (Basinger & Knobloch, 2018). For example, in a qualitative study of parents of deployed adult-children veterans, themes such as intense worries about children, frustration regarding communication with them, coping mechanisms, and impact on their own marriages were reported (Crow & Myers-Bowman, 2011). However, quantitative dyadic exploration of possible negative outcomes following indirect exposure of parents to their adult offspring’s combat trauma and PTSS, and the psychological and familial mechanisms that may contribute to it, have been relatively unexamined.

The most common sequela of exposure to potentially traumatic events during military service is PTSD (Yehuda et al., 2015). PTSD is characterized by four distinct symptom clusters: intrusive re-experiencing of the traumatic event(s), avoidance of trauma reminders, hyperarousal, and persistent negative alterations in cognitions and mood (APA, 2013). The prevalence of combat-related PTSD is estimated at 6–25% and is dependent on the intensity of combat exposure and differences in war theaters and eras (e.g., Fulton et al., 2015). Specifically, recent studies have reported about 21% of Israeli Defense Forces (IDF) combat veterans—the target population of this study—cope with self-reported probable PTSD following military combat service (Zerach & Levi-Belz, 2021,Zerach & Levi-Belz, 2021). Many veterans may also experience a symptom intensity range below the threshold required to establish a diagnosis, although still experiencing PTSS.

Exposure to combat-related trauma, and particularly experiencing PTSS, are known to be associated with impairments of veterans’ relationship functioning, and may also entail detrimental consequences for the mental health of their family members (e.g., Campbell & Renshaw, 2016; Waddell et al., 2020). Specifically, a repeated or extreme indirect exposure to aversive details of a traumatic event by veterans’ family members—also known as “secondary traumatization” (Figley, 1995)—can bring about emotional distress and even secondary PTSS (SPTSS), similar to posttraumatic symptoms of the primary trauma survivor (APA, 2013). Indeed, a persistent pattern of positive associations has been found between veterans’ PTSS and family members’ general emotional distress (Lambert et al., 2014) and specific SPTSS (O’Toole, 2021; Zerach & Milevsky, 2020). It should be noted that some studies (e.g., Renshaw et al., 2011) show that family members’ distress is rather general and does not specifically refer to the traumatized veterans’ PTSS.

Only a few studies have directly assessed SPTSS among parents of veterans. Two studies among Dutch peacekeepers (Dirkzwager et al., 2005) and Bedouin IDF servicemen (Caspi & Klein, 2012) found that parents of combat veterans reported PTSS, which were associated with their offspring’s traumatization or PTSS. Nevertheless, these studies used measurements that assessed general traumatic event criteria for PTSS but did not directly refer to offsprings’ combat experiences. Recently, Bitton et al. (2017) examined parents of Israeli active-duty combatants during a military operation and found that 20.2% of the parents reported PTSS. However, this study lacked a direct assessment of veterans’ PTSS and their associations with their parents’ SPTSS. The present study aims to overcome these limitations, with a dyadic approach to examination of the reciprocal associations between veterans’ PTSS and their parents’ SPTSS, which refer to their offspring’s military service.

Over the years, a number of theoretical models have tried to explain the possible reciprocal links between veterans’ PTSS and their family members’ SPTSS (e.g., Nelson-Goff et al., 2020). For example, Monson et al. (2010) provided a systemic description of the interactions between veteran’s and partner’s reactions to trauma. Their cognitive-behavioral interpersonal model suggested overlapping behavioral (e.g., conditioning processes), cognitive (e.g., disrupted schemas), and emotional (e.g., guilt, shame, and anger) mechanisms which affect PTSD and relationship adjustment. While the outcomes of this hypothetic systemic process are sometimes adaptive and promote recovery, at other times, they can be maladaptive and influence the chronicity of an individual’s PTSD and the possibility of partners’ psychopathology. An extension of their model may possibly suggest that overlapping behavioral, cognitive, and emotional mechanisms affect both veterans’ PTSS and their parents’ SPTSS reciprocally, as well as the parent–child relationship. Two possible factors that may maintain and even increase both veterans’ PTSS and their parents’ SPTSS over time are their ability to tolerate distress, and parents’ accommodation process.

Distress tolerance (DT) has been defined as the perceived ability or objective capacity to withstand exposure to negative psychological or physical experiences (Simons & Gaher, 2005). DT is known to impact perception of aversive or threatening states, such as uncertainty and physical discomfort (Brown et al., 2005). Specifically, individuals with low DT tend to expect distress to be unbearable to handle, to perceive distress as shameful, to experience overwhelming negative emotions, and to regulate distress by its avoidance. Although DT is a relatively stable construct, it might be modified through psychological interventions (e.g., Boffa et al., 2018).

DT has been treated as a transdiagnostic, cognitive-affective factor associated with development and maintenance of varied psychiatric disorders such as depression, anxiety, substance abuse, and personality disorders (e.g., Vujanovic & Zegel, 2020). DT has recently gained increased attention in the traumatic stress literature due to its relevance for understanding and treatment of PTSD (Ranney et al., 2020). For example, recent meta-analysis results show negative associations between DT and PTSD symptoms, such that lower DT was associated with higher PTSS, particularly following a high number of traumatic events (e.g., Akbari et al., 2021). It has been hypothesized that low DT impacts one’s ability to handle the emotional pain associated with exposure to trauma and thus increases proneness to avoid aversive stimuli as well as general avoidance behavior, which represent a crucial component in the development and maintenance of PTSD (e.g., Marshall-Berenz et al., 2010). It should be noted that higher PTSS might also be associated with reductions in DT (Vujanovic & Zegel, 2020). To date, only a few studies have examined the role that DT plays in a dyadic context—mostly in marital interpersonal relationships (Dorrley et al., 2019)—and to the best of our knowledge, no studies have examined the possible relationships between DT, PTSS, and SPTSS among dyads of veterans and their parents.

Beyond the hypothesized direct associations between veterans’ and parents’ DT and PTSS/SPTSS, in the present study, we also aimed to examine indirect associations with these links through parents’ accommodation. Although causality cannot be established in cross-sectional data, we aimed to explore a theoretical prediction in which low ability to tolerate distress by veterans and their parents would be associated with higher levels of parents’ accommodation, which in turn would relate to more PTSS/SPTSS. The process of accommodation refers to behavioral actions taken by family members in order to manage or reduce the anxiety or distress of their loved one, who is coping with a psychiatric disorder (Calvocoressi et al., 1995). In the same vein, accommodation can aim to regulate family members’ own negative emotions and tension in their household (Timko et al., 2015). Although family members’ intentions mostly tend to support and help their loved ones, in the long run, their behavioral changes negatively reinforce avoidance and maintain posttraumatic symptoms (Reuman & Thompson-Hollands, 2020).

Although family members’ accommodation has been studied thoroughly among psychiatric disorders such as the obsessive-compulsive disorder, its empirical study in the context of PTSD is relatively in its infancy and has focused primarily on female partners of traumatized veterans (e.g., Allen et al., 2021). As delineated in the cognitive-behavioral interpersonal model (Monson et al., 2010), romantic partners of veterans might engage in actions in order to reduce the pain and distress of traumatized veterans. Indeed, several studies show that veterans’ PTSS may lead to subsequent partners’ accommodation, but such partner accommodation seems only to contribute to survivors’ future situational avoidance symptoms (Campbelle et al., 2017). In another longitudinal study, service members’ PTSS higher than their personal average predicted subsequent increases in partner accommodation, but not vice versa (Allen et al., 2021). To the best of our knowledge, no study has directly examined behavioral accommodation of parents of young-adult veterans.

Parents’ accommodation might serve as a possible mechanism in the links between veterans’ and parents’ DT and posttraumatic reactions. It is plausible that parents’ accommodation may be maintained by their low ability to tolerate distress. For example, parents who report higher distress regarding their child’s anxiety symptoms might report more accommodative behaviors (e.g., Storch et al., 2008). Moreover, a few studies have directly examined the mediation hypothesis and found that family accommodation mediates the association between children and adolescents’ anxiety and their functional impairment (e.g., De-Barros et al., 2020; La Buissonni`ere-Ariza et al., 2018). Given that both theoretical models (Monson et al., 2010) and empirical studies (Sung et al., 2021) view family members’ accommodation as a modifiable intervention target, and specifically that decreases in accommodation are theorized to mediate treatment outcome of cognitive-behavioral conjoint therapy for PTSD (Fredman et al., 2016), the examination of this indirect path bears high theoretical and practical importance.

In light of the literature review, we may posit the following hypotheses: (a) veterans’ PTSS will be positively associated with parents’ SPTSS; (b) veterans’ DT will predict their PTSS and parents’ DT will predict secondary PTSS (actor effects); and c) parents’ accommodation will mediate the association between veterans’ DT and PTSS and parents’ DT and SPTSS.

Method

Participants

In the present study, the inclusion criteria were combat veterans who were Hebrew proficient, had completed their military service, and who were discharged from active combat service in the Israel Defense Forces (IDF) in the past 20 years. One parent of each veteran’s family was also recruited to participate in this study. Of all the veterans contacted, 283 participants began filling out the study questionnaires. Fifteen (5.30%) veterans did not consent to participate in this study. Of those who consented, 14 (4.96%) participants were excluded for not being former combatants. One-hundred and twenty-two (43.10%) participants did not complete the questionnaire. Sixteen (5.65%) participants did not disclose their parents’ contact details; for 14 (4.9%) participants, we did not find a matching parent. Comparisons of participants and those who did not share all socio-demographic and outcome variables were conducted. A Chi square test showed that the gender proportion did not differ between the two groups (χ2 (1) = 87.43, p = .36). Moreover, a series of t-tests revealed no significant differences between the two groups, for their age (t (225) = 1.81, p = .07), PTSS (t (211) = .24, p = .80) and distress tolerance (t (188) = .56, p = .53). Of all the parents contacted, 156 participants began filling out the questionnaires in the study. Twenty-five (16.02%) parents did not consent to participate in this study. Of those who consented, 21 (14.10%) did not complete the questionnaire, and for 8 we did not find a matching veteran offspring. Thus, in the final sample for the present study, 102 dyads of veterans and their parents participated in the study (N = 204).

As can be seen in Table 1, comparing the socio-demographic information of veterans and their parents revealed that veterans were younger and less educated than their parents. As compared to their parents, a higher percentage of veterans identified as cisgender men, single, and born in Israel. A lower percentage of veterans worked part or full time and thus earned below official average income (10,400 NIS). No significant difference was found in religiosity. We note that due to the imbalanced gender ratio, we also compared male and female, veterans and parents, on the main study variables. No significant differences were found in veterans’ PTSS (males M = 13.02, SD = 13.25, females M = 12.78, SD = 13.41; t (1) = .07, p = .94), veterans’ DT (males M = 3.44, SD = .64, females M = 3.45, SD = .56; t (1) = −.04, p = .96), and veterans combat exposure (males M = 4.40, SD = 3.31, females M = 3.78, SD = 2.76; t (1) = .75, p = .45). Moreover, no significant differences were found in parents’ SPTSS (males M = 8.08, SD =12.10, females M = 9.87, SD =10.84; t (1) = −.69, p = .49), parents’ DT (males M = 3.52, SD = .61, females M = 3.43, SD = .57; t (1) = .66, p = .55), and parents’ accommodation (males M = 18.66, SD = 18.99, females M = 21.44, SD = 19.23; t (1) = −.57, p = .56).

Table 1.

Socio-demographic characteristics of veterans and parents.

		Veterans	Parents
Age		M = 25.37 (SD = 2.72)	M = 55.49 (SD = 6.59)	t (202) = −42.66***
Education (years)		M = 12.12 (SD = 1.36)	M = 15.14 (SD = 3.39)	t (202) = −8.35***
Gender	Cisgender women	19 (18.6%)	78 (76.5%)	χ² ₍₁₎= 68.41***
Gender	Cisgender men	83 (81.4%)	24 (23.5%)
Marital status	Single	76 (74.5%)	3 (2.9%)	χ² ₍₂₎= 111.64***
Marital status	Married	25 (24.5%)	84 (82.4%)
	Divorced	1 (1%)	15 (14.7%)
Religiosity	Secular	28 (27.5%)	30 (29.4%)	χ² ₍₃₎= 3.71
Religiosity	Traditional	26 (25.4%)	20 (19.6%)
	Religious	42 (41.2%)	51 (50%)
	Other	6 (5.9%)	2 (1.8%)
Place of birth	Israel	92 (90.2%)	68 (66.7%)	χ² ₍₂₎= 16.69***
Place of birth	Other	10 (9.8%)	34 (33.3%)
Employment	Not working	30 (29.4%)	17 (16.7%)	χ² ₍₂₎= 33.93***
	Part time job	45 (44.1%)	17 (16.7%)
	Full time job	27 (26.5%)	68 (66.7%)
Income	Well below average	61 (59.8%)	13 (12.7%)	χ² ₍₄₎= 58.57***
	Below average	18 (17.6%)	19 (18.6%)
	Average	15 (14.7%)	28 (27.5%)
	Above average	6 (5.9%)	25 (24.5%)
	Well above average	2 (2%)	17 (16.7%)

** = p < .01.

Procedures

Potential participants were recruited between November 2020 to January 2021 in Israel and in several ways: from among volunteers who were active participants in combat veterans’ Websites and communities (e.g., Facebook groups and veterans’ forums); students from a university located in central Israel; and volunteers who responded positively to an advertisement for enrollment in the study. The investigators’ research assistants posted a message briefly explaining that they were conducting a research project focusing on “military service experiences” and asked for possible combat veterans volunteers. Those who agreed to participate received an explanation of the study’s aims and a link to the related online survey through an online data gathering website. Participants were required to affirm willingness to participate, and by their active participation provided informed consent. Following completion, participants were sent a letter of thanks and were compensated with a voucher for a breakfast (approximate value of US $15). After completing their personal questionnaire, veterans were asked to disclose contact information for their parents. A telephone call was made to one of the parents (first on the list); in case the parent could not be reached or did not want to cooperate, contact was made with the second parent. Following the parent’s agreement to participate in the study, a link to the related online survey was sent to him/her with the questionnaire to be completed. Upon completing the questionnaire, parents were also compensated with a voucher for a breakfast. Both veterans and parents completed the socio-demographic, PCL-5, and DT questionnaires. Veterans only completed the CES questionnaire, while parents also completed the LEC-5 and the SORTS questionnaires. Approval for this study was given by the Ariel University’s Internal Review Board.

Measures

Socio-demographic variables were collected from all participants for the following variables: age, gender, country of birth, education, religiosity, income, length of relationship with partner, number of children, and reserve military status of the veteran.

Posttraumatic Stress Disorder Checklist (PCL-5; Weathers et al., 2013): Participants’ PTSS was assessed with the PCL-5 that taps the 20 symptoms listed in the DSM–5 (APA, 2013). Participants were asked to rate how often they suffered from each symptom in the previous month, on a scale ranging from 0 (not at all) to 4 (extremely). Specifically, veterans were asked about their reactions to any very stressful experiences in their military service (e.g., “I have recurrent dreams and nightmares about stressful experiences from my service”). Parents were asked about their SPTSS with reference to their child’s army service (“I have recurrent dreams and nightmares about stressful experiences of my veteran child’s army service”). PTSS was operationalized both as a continuous variable and as a total symptom severity score (range 0–80), by summing the scores for each of the 20 items, and as a dichotomized DSM self-report probable self-rated “diagnosis.” Participants were identified as having PTSS if they exceeded the PCL-5 cut-off point of 33 (Wortmann et al., 2016). The PCL-5 was translated into Hebrew using the back-translation procedure and has been used in previous studies (e.g., Zerach & Magal, 2016). Preliminary results showed an excellent construct validity (α = .92), and good convergent validity (α = .74–.85) with other PTSD measures, such as the PDS or DAPS (Blevins et al., 2015). It also has excellent internal reliability (α = .96), and good test–retest reliability (α = .84) properties (Bovin et al., 2016). The PCL-5 reliability for veterans was Cronbach’s α = .92 and for parents, α = .93.

Distress Tolerance Scale (DT; Simons & Gaher, 2005): The DT is a 15-item self-report measure that taps the extent to which individuals believe they can experience and withstand distressing emotional states (e.g., “I can’t handle feeling distressed or upset”). The DT encompasses four sub-scales: perceived ability to tolerate emotional distress, subjective appraisal of distress, attention absorption by negative emotions, and regulation efforts to alleviate distress. Each item was scored on a 5-point Likert-type scale (1 = “strongly agree” to 5 = “strongly disagree”). Following other studies, the DT total score was employed as a global index of perceived distress tolerance (Leyro et al., 2010). The DT has proven good test–retest reliability, as well as good convergent validity and discriminant validity with other mood measures (Simons & Gaher, 2005; Hsu et al., 2013). The DT reliability for veterans was Cronbach’s α = .84 and for parents, α = .85.

Parents’ accommodation was assessed using the Significant Others’ Responses to Trauma Scale (SORTS; Fredman et al., 2014). Originally, the SORTS was a 14-item, self-report measure of partner accommodation to veterans’ PTSS. In the present study, the wording of the instructions and items were adjusted to substitute parents as partners of a veteran-parent dyad. Each item consists of two questions. In the first question, respondents indicate how often they have performed a particular behavior in response to common PTSS over the past month, rating responses on a scale of 0 (never) to 4 (daily or almost every day). For example, “Avoid doing things, going places, or seeing people with your partner that make him/her anxious or uncomfortable?” The second question asks parents to indicate how distressed they are about engaging in the behavior, with response options ranging from 0 (not at all) to 4 (extremely). The sum of scores was used as a total score. The SORTS psychometric properties are promising with excellent internal consistency, test–retest reliability, and construct validity via associations with partners’ perceptions of patients’ PTSD and relationship satisfaction (Fredman et al., 2014).

In the current study, due to its design, two adjustments to the SORTS were made. First, the SORTS included a “not applicable” option on select items, which was recoded as 0 for scoring (Fredman et al., 2014). As the current sample was expected to show high variability on presence and severity of veterans’ PTSS, the “not applicable” option was included on all items, similarly recoding these to 0 for scoring. Second, the original SORTS referred participants to a “traumatic event.” In the current study, the SORTS items followed a measure focused specifically on the parents’ perceptions of their combat veteran offspring’s possible “traumatic events during their military service.” The DSM’s PTSD symptoms related to military stressors (i.e., a collateral version of the PCL-M). In the current sample, the SORTS demonstrated excellent internal consistency (Cronbach’s α = .97).

Life Events Checklist (LEC-5; Weathers et al., 2013): Parents’ potentially traumatic and negative life events were assessed with the LEC-5 self-report questionnaire composed of 17 PTEs over the participant’s life that could lead to PTSD or psychological distress. The events were selected from empirical and clinical literature, covering possible traumatic life-threatening experiences (e.g., work or car accident and physical or sexual assault) and distressing family conditions (e.g., neglect and abuse). For each item, the respondent marked whether the event happened to him/her personally (0), was witnessed by him/her (1), heard of it (2), not sure (3), or irrelevant (4). Items marked as “happened personally” (0) were encoded as “1,” whereas the other responses (1–4) were coded as “0.” The sum of PTEs to which participants were directly exposed was used for analysis. The LEC-5 was translated into Hebrew using the back-translation procedure for the purposes of the present study. The psychometric properties of the LEC-5 show impressive psychometric properties such as good test–retest reliability (.82) and good convergent validity with other PTSD measures such as the IES or PDS-5 (Rzeszutek et al., 2018). The LEC-5 reliability in this study was Cronbach’s α = .81.

Combat Experiences Scale (CES; Hoge et al., 2004): Combat experiences of veterans were examined with the CES, an 18-item scale, tapping a range of conventional modern combat-related experiences to which an individual may have been exposed (e.g., being attacked or ambushed, shooting or directing fire at the enemy, and handling or uncovering dead bodies or body parts). Respondents were asked to indicate which events they had experienced at any time during a deployment, resulting in a total number of combat experiences, with scores ranging from 0 to 18. For the current sample, Cronbach’s α on the CES items was .77.

Data Analysis

Data analysis was divided into four stages. First, we calculated descriptive statistics of the studied variables, including rates of PTSS and SPTSS, as well as differences between veterans and parents using a paired t-test. Second, the relationships between the study variables were examined with a series of Pearson correlation analyses. Third, the data were screened for missing values. We found no missing values in the studied variables except the SORTS questionnaire with 13.7% of the cases missing. The data was missing completely at random (MCAR), Little’s χ² (6), = 8.37, p = .21. Imputation of missing data has been conducted via a maximum likelihood (ML) module with AMOS software (version 26). Fourth, we introduced an actor–partner interdependence model (APIM: Kenny et al., 2006). In the basic APIM, two kinds of effects are estimated: actor effects and partner effects. In the present case, actor effects are the intrapersonal effects of a participant (i.e., veterans’ DT on their PTSS and parents’ DT on their secondary PTSS). Partner effects are the interpersonal effects of participants (i.e., veterans’ DT on their parents’ secondary PTSS and parents’ DT on their veteran offspring’s PTSS). The APIM provides separate and statistically independent tests of actor and partner paths, in which the effect of each path is estimated while controlling for the other paths (Kenny et al., 2006). We used AMOS 26 to estimate the parameters of this APIM which was implemented on the observed variables in the data (path analysis). A model is judged as fitting well if the χ² statistic is not significant, the comparative fit index (CFI), normed-fit index (NFI), and the Tucker–Lewis index (TLI) are greater than .9, and the root-mean-square error of approximation (RMSEA) is equal to or lower than .1. To assess significance of indirect paths through parents’ accommodation, a bootstrapped confidence interval for the ab indirect effect was utilized, employing Preacher and Hayes’ procedures (2008). 5000 bootstrapped samples were obtained to estimate each indirect effect with the mediator. We computed bias corrected, accelerated 95% confidence intervals (CIs) to measure statistical significance for each mediator’s “ab” paths and the two-step mediation. A “CI” that does not include zero reflects evidence of a significant indirect effect or significant mediation (see Figure 1 for schematic representation of the APIM with mediation).

Figure 1.

Schematic representation of the actor–partner interdependence model with mediation. “a” represents an actor effect; “p” represents a partner effect; “c” represents bivariate correlation; and “m” represents mediated actor and partner effects. Note: PTSS=posttraumatic stress symptoms.

Results

Prevalence of PTSS among veterans and parents

According to the PCL-5, 10 veterans (9.8%) exceeded the suggested 33 cut-off score following stressful experiences in military service according to the DSM-5 (APA, 2013) criteria. Scores on the PCL-C-5 ranged from 0 to 57, with a mean of 12.98 (SD = 13.22). Among parents, four participants (3.9%) exceeded the suggested 33 cut-off score for secondary PTSS following experiences of their offspring veteran’s military service. Scores on the PCL-C-5 ranged from 0 to 50, with a mean of 9.45 (SD = 11.04).

A set of paired t-tests revealed that levels of PTSS/secondary PTSS differed significantly between veterans and parents (t (101) = 2.49, p = .01). Naturally, veterans reported higher levels of PTSS than parents’ secondary PTSS. Moreover, no significant differences were found regarding levels of DT (t (101) = .08, p = .93).

Relationships between the study variables

As can be seen in Table 2, we found that exposure to combat was related to high levels of veterans’ PTSS, but the sum of negative life events was not associated with parents’ secondary PTSS. Moreover, veterans’ PTSS were related to a higher level of parents’ secondary PTSS. Veterans’ DT was negatively associated with their PTSS and their parents’ secondary PTSS. Parents’ DT was negatively associated with their secondary PTSS and their offspring veterans’ PTSS. Furthermore, parents’ accommodation was found to associate with more PTSS and secondary PTSS and lower levels of parents’ DT. Parents with any kind of exposure to item #10 of the LEC-5 (which assesses “Combat or exposure to a war-zone (in the military or as a civilian)”) were also compared to parents without any exposure, regarding veterans’ PTSS and parents’ SPTSS. We have not found any significant associations between these variables (PTSS: t (1) = −.38, p = .70; SPTSS: t (1) = −.97, p = .33). Last, it is worth noting that we also examined potential socio-demographic covariates which we suspected might potentially impact the outcome variables. The socio-demographic variables of gender, age, education, marital status, income and religiosity were not found to be associated with veterans’ and parents’ PTSS. The variable number of children was negatively related to parents’ secondary PTSS (r = −.24, p < .05). Thus, the more children parents have, the lower their levels of secondary PTSS. This variable was treated as a covariate in further analyses.

Table 2.

Descriptive statistics and bivariate correlations between study variables.

	1	2	3	4	5	6	7	M	SD
1. Veterans’ CES	-	.40***	.01	.11	.08	−.03	.04	4.29	3.21
2. Veterans’ PTSS		-	−.36***	.18	.32***	−.23*	.34***	12.98	13.22
3. Veterans’ DT			-	−.13	−.34***	.30**	−.19	3.44	.63
4. Parents’ NLE				-	.13	−.10	.06	2.60	2.13
5. Parents’ PTSS					-	−.40***	.46***	9.45	11.05
6. Parents’ DT						-	−.35***	3.45	.58
7. Parents’ accommodation							-	19.72	18.76

Note. CES = combat exposure; PTSS = posttraumatic stress symptoms; NLE = negative life events; DT = distress tolerance.

* p < .05. ** p < .01. *** p < .001.

Actor–Partner Interdependence Model Analysis

We began with a preliminary APIM analysis with only actor effects. We statistically controlled for parents’ number of children as well as veterans’ combat exposure. Fit indices showed an adequate fit to the data (χ²₍₇₎ = 9.49, p = .22, NFI = .89, CFI = .96, and RMSEA = .06). Next, we continued to the full basic APIM by adding the partner effects. Fit indices showed an excellent fit to the data (χ²₍₆₎ = 3.85 p = .70, NFI = .95, CFI = 1.00, and RMSEA= .00). Comparing the fit indices for these two models showed that the difference between the two chi-squares was significant (Δχ² = 5.64, Δdf = 1, p < .05). Thus, the addition of the partner effects meaningfully contributes to the explained variance of PTSS. This model significantly explained 29% of the variance in veterans’ PTSS and 22% in parents’ PTSS.

As can be seen in Figure 2, our second hypothesis has been partially confirmed. Actor effects in all models were found to be significant for both veterans and parents. Thus, veterans and parents with higher levels of DT also reported lower PTSS and SPTSS, respectively. Veterans and parents did not differ significantly in the magnitude of actor effects (Δχ² = .05, Δdf = 1, p = .83). Regarding partner effects, veterans’ DT had a significant impact on their parents’ secondary PTSS, but parents’ DT did not have a significant impact on veterans’ PTSS. The APIM also confirmed the above mentioned hypothesized positive correlations between veterans’ and parents’ DT but not between veterans’ PTSS and parents’ SPTSS. We note that the control variable veterans’ combat exposure contributed significantly to veterans’ PTSS (β = .40, p < .00).

Figure 2.

Actor–partner interdependence model of the studied variables. Note: The variables are observed and exist in the dataset. Continuous line represents a significant path and dashed line represents non-significant path. Standardized b values are represented above the arrows. Explained variance is located above all dependent variables. PTSS = posttraumatic stress symptoms. ** p < .01. *** p < .001.

Parents’ accommodation mediation of APIM main effects

In order to test our multiple mediation hypotheses, we used the Hayes, Preacher, and Myers’ (2011) multiple step mediation methodology, which employs a bootstrapped confidence interval for the indirect effects (Hayes, 2011). Specifically, we examined whether beyond the “actor” and “partner” direct effects: (a) veterans’ DT is indirectly related to veterans’ PTSS and parents’ SPTSS via parents’ accommodation and (b) parents’ DT is indirectly related to veterans’ PTSS and parents’ SPTSS via parents’ accommodation. We statistically controlled for parents’ number of children and veterans’ combat exposure.

The mediational model showed excellent fit to the observed data (χ² [8] = 2.86, p = .94, NFI = .98, CFI = 1.00, RMSEA = .00). However, comparing the fit indices for these two models showed no significant difference between the two chi-squares (Δχ² = .92, Δdf = 2, p = .05). We first confirmed the existence of significant direct “actor” and “partner” effects. As illustrated in the final model depicted in Figure 3 and Table 3, following the inclusion of parents’ accommodation variable in the model, the direct “actor” path from veterans’ DT to PTSS was significant. However, the “actor” path between parents’ DT to SPTSS was not significant. Moreover, the direct “partner” path from veterans’ DT to parents’ SPTSS also became non-significant.

Figure 3.

The associations between veterans’ and parents’ distress tolerance and their PTSS and secondary PTSS is mediated by parents’ accommodation. Note. The variables are observed and exist in the dataset. Continuous line represents a significant path and dashed line represents a non-significant path. Standardized b values are represented above the arrows. Explained variance is located above all dependent variables. PTSS = posttraumatic stress symptoms.

Table 3.

Bootstrapped unstandardized point estimate for direct and indirect effects and 95% confidence intervals for predicting veterans’ PTSS and parents’ SPTSS by DT through parents’ accommodation.

Veterans’ PTSS				Parents’ SPTSS
	Point estimate	SE	BCa 95% CI (lower, upper)	Point estimate	SE	BCa 95% CI (lower, upper)
Direct effect of veterans’ DT	−5.66	2.02	(−9.43, −2.78)**	−2.02	1.54	(−4.59, .47)
Indirect via parents’ accommodation	−1.30	.72	(−2.90, −.37)**	−1.82	.83	(−3.46, −.63)**
Direct effect of parents’ DT	−.85	1.99	(−3.63, 3.05)	−3.01	1.85	(−5.97, .21)
Indirect via parents’ accommodation	−1.94	1.08	(−4.60, −.68)**	−3.05	1.27	(−5.50, −.1.16)**

Note. PTSS = posttraumatic stress symptoms; SPTSS = secondary posttraumatic stress symptoms; DT = distress tolerance.

* p < .05. ** p < .01. *** p < .001.

Although there was no significant difference between the fits of the basic APIM and the mediational model, we continued to examine the hypothesized indirect effects. As can be seen in Table 3, we found four significant indirect effects. Veterans’ DT was significantly associated with higher levels of parents’ accommodation, which in turn was associated with higher levels of veterans’ PTSS and parents’ SPTSS. Furthermore, parents’ DT was significantly associated with higher levels of parents’ accommodation, which in turn was associated with higher levels of veterans’ PTSS and parents’ SPTSS. Following the trimming of non-significant paths, the final mediational model (see Figure 3) showed excellent fit to the observed data (χ² [10] = 8.87, p = .54, NFI = .94, CFI = 1.00, RMSEA = .00), and significantly explained 35% of the variance in veterans’ PTSS and parents’ SPTSS.

Discussion

This study explored the associations between distress tolerance, posttraumatic stress symptoms and secondary traumatic stress symptoms among Israeli veterans and their parents, and the mediating role of parents’ accommodation in these associations. Our main findings indicated that veterans’ PTSS was positively associated with parents’ SPTSS. Moreover, veterans’ DT contributed to their PTSS, and parents’ DT positively predicted their own SPTSS. Moreover, veterans’ DT also contributed to their parents’ low levels of SPTSS. Importantly, our results shed light on the mediating role of parents’ accommodation as one of the mechanisms for the explanation of veterans’ PTSS and their parents’ SPTSS. To the best of our knowledge, this is the first dyadic study to explore the interrelations between veterans’ PTSS and SPTSS among parents, as well as the psychological and familial factors which possibly contribute to these associations. It should be noted that we did not assess whether veterans and parents currently cohabitating, live together or how much time they spend together and the quality of their relationship. Thus, these caveats might have an impact on the associations between the study variables and the explanations of the results discussed below.

As hypothesized, our first finding is the positive association between veterans’ posttraumatic stress symptoms and parents’ secondary posttraumatic stress symptoms. Some studies (Renshaw et al., 2011) show that spouses of veterans report general psychological distress that is not consistent with their husbands’ combat exposure. Other studies show that partners’ PTSS is associated with both their negative life events and their husbands’ PTSD (Dekel et al., 2016). Our results show that parents’ SPTSS was not related to veterans’ exposure to combat or their own exposure to negative life events but directly to their children’s PTSS. Our results are the first to directly assess associations between veterans’ PTSS and their parents’ PTSS (anchored in the offspring’s military service), thus overcoming some of the caveats of previous studies (Bitton et al., 2017) which lacked direct assessment of veterans’ PTSS and its associations with their parents’ SPTSS. Although the prevalence of SPTSS among the parents in our study was relatively low (3.8%), we indeed extend the literature regarding SPTSS among veterans’ family members such as offspring (O’Toole et al., 2021), and siblings (Zerach & Milevsky, 2020).

According to the predictions of the family systems theory, individuals exist in the context of interconnected family units where members mutually influence the thoughts, emotions, and behaviors of one another (e.g., Bowen, 1978). It could be that during the “emerging adulthood” period, parents of Israeli veterans still play an active role as a “safe base” for their veteran offspring (Inguglia et al., 2015). Thus, it is possible that parents are actually highly exposed to their offspring’s traumatic residues in several ways. For example, some traumatized veterans might have to return to their parents’ residence and thereby increase their parents’ burden financially and sometimes their physical caregiving burden (e.g., Ramchand et al., 2015). Moreover, parents may be overly exposed to emotional, cognitive, and behavioral dysregulation, such as violent outbursts or functional disability of their veteran offspring, that may deplete parental resources and put them at risk for SPTSS (Manguno-Mire et al., 2007). As in the case of spouses of veterans, some of the parents who are deeply invested in caring for traumatized offspring might have strengthened the link between veteran’s PTSS and spousal SPTSS (Dekel et al., 2018).

Our second main finding refers to the associations between veterans’ and parents’ distress tolerance and their own posttraumatic stress symptoms and secondary posttraumatic stress symptoms, respectively. Although high DT is known to be a resiliency factor for PTSS following traumatic events (e.g., Ranney et al., 2020), our results extend this body of knowledge with a dyadic approach to this often-neglected population (parents of veterans) (Banducci et al., 2017). Thus, we suggest that high DT, either as a pre-trauma resource or as an increased posttrauma capability may buffer the tendency to avoid internal or external reminders of the traumatic event(s) (Vujanovic et al., 2011). Higher tolerance of one’s own distress or negative thoughts and emotions as well as containing them, without blocking or avoiding, may improve self-ability to contain emotions and inner strength (Greenberg, 2015).

Interestingly, we found high veteran DT also contributed to their parents’ lower levels of secondary posttraumatic stress symptoms. It is well known that the parent–child relationship changes and evolves into a relationship between two adults, characterized by higher levels of mutuality (Bucx et al., 2012). According to the cognitive-behavioral interpersonal model (Monson et al., 2010), veteran and family member reactions to traumatic combat experiences consist of overlapping behavioral (e.g., conditioning), cognitive (e.g., schemas), and emotional (e.g., shame) mechanisms that affect PTSD and relationship adjustment. It is possible that when parents observed their veteran offspring’s DT as an adaptive coping with his or her distress, it might have changed their cognitive schemas. For example, a parent might have changed their schema regarding the frightening potential of traumatic reminder into a schema of the reminder as frightening, but which could also be contained via certain methods. Thus, more adaptive and constructive schemas might offer thoughts to improve their own adaptive coping with SPTSS.

Last, we found that parents’ accommodation mediated the links between veterans’ and parents’ distress tolerance and their posttraumatic stress symptoms and secondary posttraumatic stress symptoms, respectively. Thus, parents’ behavioral actions aimed to reduce distress of their offspring veteran, or to regulate their own negative emotions due to his or her coping with traumatic residues, might be a mechanism for the link between DT and PTSS. Given that empirical knowledge regarding family members’ accommodation in the context of PTSD is relatively scarce and focused mainly on female partners of traumatized veterans (e.g., Allen et al., 2021), our results extend this literature to parents’ accommodation in families of combat veterans.

The tragedy of accommodation is the natural conflict between parents’ urge to support and help their traumatized offspring, while in the long run, their behavioral changes might maintain their PTSS (Reuman & Thompson-Hollands, 2020). Although family members’ accommodation has been studied thoroughly regarding psychiatric disorders such as the obsessive-compulsive disorder, its empirical study in the context of PTSD is relatively in its infancy. To the best of our knowledge, no study has directly examined behavioral accommodation of parents of young-adult veterans. Indeed, our results are in line with other studies showing that veterans’ PTSS contributes to increased partners’ accommodation (Campbelle et al., 2017). Yet while other studies have shown that increase in partner accommodation was not related to subsequent higher levels of veterans’ PTSS (Allen et al., 2021), our results did show that parents’ accommodation is positively associated with both veterans’ PTSS and parents’ SPTSS. It is possible that this effect might be attributed to the unique parents-offspring relationship, as compared to the spousal relationship, or due to the cross-sectional nature of our study. Future longitudinal studies should validate these patterns of associations.

Our results also show that parents’ accommodation serve as a possible mechanism in the links between veterans’ and parents’ distress tolerance and both posttraumatic stress symptoms and secondary posttraumatic stress symptoms. Both theoretical models (Monson et al., 2010) and empirical studies (Sung et al., 2021) have shown that family members’ accommodation might serve as a crucial mechanism for understanding and mitigating posttraumatic symptoms. Previous studies have reported that parents’ accommodation may be maintained by their low ability to tolerate distress, such as distress about their child’s anxiety symptoms (Storch et al., 2008). Moreover, parents’ accommodation was found to mediate the association between children’s and adolescents’ anxiety and their functional impairment (e.g., De-Barros et al., 2020; La Buissonnière-Ariza et al., 2018). As delineated in the cognitive-behavioral interpersonal model (Monson et al., 2010), we suggest that parents of veterans might also “accommodate” their offspring’s suffering through acts such as avoiding discussing with them future possibilities to avoid clashes, or turning off the television news broadcast when they come to visit with them. Unfortunately, by these behaviors they might increase veterans’ avoidance and, in turn, their PTSS. Alternatively, parents’ accommodation might prove to themselves that they cannot alleviate their own personal tolerance for distress and thus increase their identification with their traumatized offspring and their SPTSS.

This study entails some limitations. First, since our study is cross-sectional and we did not assess participant distress tolerance prior to military service, our ability to draw causal relationships between these variables is very limited. Second, we used electronic, self-report questionnaires which might be biased (e.g., social desirability). Third, we recruited a non-representative, volunteer sample that may not represent accurate rates of PTSS among veterans and SPTSS of their parents, and might hinder the generalizability of the findings and representativeness of this population’s diversity. Moreover, although no significant differences were found between genders on the main study variables, future studies should validate the study’s results with a more gender-balanced sample. Furthermore, we did not assess relevant socio-demographic variables such as disability or sexual orientation, that should be examined in future studies. Fourth, it should be noted that we did not assess whether veterans and parents are currently living together, or how much time they spend together, which might have an impact on the associations between the study variables. Last, we cannot rule out the possible effects of parents’ general distress and/or primary PTSS due to other PTEs and, specifically, military service traumatic events, beyond their exposure to negative life events that were assessed. Thus, although we asked parents to report on secondary PTSS due to their offspring’s experiences, it is possible that their own personal distress colored their experiences and reporting.

To summarize, this study extends the literature by exploration of secondary posttraumatic stress symptoms among parents of combat veterans via a dyadic approach. Our results provide further support for the secondary traumatization phenomena among parents of veterans and, importantly, the close link between veterans’ PTSS and parents’ SPTSS. Sometimes empirically neglected in the focus of the trauma community, parents’ reactions to their adult offspring’s traumatization might manifest distress of these indirectly exposed individuals. This research is also novel in using a dyadic approach to examine associations between DT and posttraumatic reactions among parents and veteran offspring. Although low DT has been proven to be a risk factor for posttraumatic symptoms, we also show that it might be associated with more parents’ accommodating behaviors, which might increase both parents’ and veterans’ PTSS. We have validated the protective role of high DT for both veterans’ PTSS and parents’ SPTSS, as well as the unique “partner” effect of veterans’ DT on their parents’ SPTSS. Thus, personal resources of veterans, within the familial context, may also aid their parents’ adaptation to military trauma, which can disrupt the entire family system. Importantly, family relationships are important for the chronicity of PTSD when facing a traumatic past. Therefore, strengthening military families by focusing on accommodation as a treatment target might provide another invaluable key in terms of positive and adaptive posttraumatic coping by veterans and their parents.

Footnotes

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Open research statement

As part of IARR’s encouragement of open research practices, the author(s) have provided the following information: This research was not pre-registered. The data used in the research are available. The data can be obtained by emailing: gadize@ariel.ac.il. The materials used in the research are available. The materials can be obtained by emailing: gadize@ariel.ac.il.

ORCID iD

Gadi Zerach

References

Akbari

Hosseini

Z. S.

Seydavi

Zegel

Zvolensky

M. J.

Vujanovic

A. A.

(2021). Distress tolerance and posttraumatic stress disorder: a systematic review and meta-analysis. Cognitive Behaviour Therapy, 51(1), 42–71. https://doi.org/10.1080/16506073.2021.1942541

Allen

Renshaw

Fredman

S. J.

Rhoades

Markman

Litz

(2021). Associations between service members’ posttraumatic stress disorder symptoms and partner accommodation over time. Journal of Traumatic Stress, 34(3), 596–606. https://doi.org/10.1002/jts.22645

Banducci

A. N.

Lejuez

C. W.

Dougherty

L. R.

MacPherson

(2017). A prospective examination of the relations between emotional abuse and anxiety: Moderation by distress tolerance. Prevention Science, 18(1), 20–30. https://doi.org/10.1007/s11121-016-0691-y

Basinger

E. D.

Knobloch

L. K.

(2018). A grounded theory of online coping by parents of military service members. Journal of Social and Personal Relationships, 35(5), 702–721. https://doi.org/10.1177/0265407517694769

Ben-Ari

Benarroch

Sela

Margalit

(2020). Risk factors for the development of medical stress syndrome following surgical intervention. Journal of Pediatric Surgery, 55(9), 1685–1690. https://doi.org/10.1016/j.jpedsurg.2019.11.011

Bitton

Tuval-Mashiach

Freedman

(2017). Distress levels among parents of active duty soldiers during wartime. Frontiers in Psychology, 8, 1679. https://doi.org/10.3389/fpsyg.2017.01679

Blevins

C. A.

Weathers

F. W.

Davis

M. T.

Witte

T. K.

Domino

J. L.

(2015). The posttraumatic stress disorder checklist for DSM‐5 (PCL‐5): Development and initial psychometric evaluation. Journal of Traumatic Stress, 28(6), 489–498. https://doi.org/10.1002/jts.22059

Boffa

J. W.

Short

N. A.

Gibby

B. A.

Stentz

L. A.

Schmidt

N. B.

(2018). Distress tolerance as a mechanism of PTSD symptom change: Evidence for mediation in a treatment-seeking sample. Psychiatry Research, 267, 400–408. https://doi.org/10.1016/j.psychres.2018.03.085

Bovin

M. J.

Marx

B. P.

Weathers

F. W.

Gallagher

M. W.

Rodriguez

Schnurr

P. P.

Keane

T. M.

(2016). Psychometric properties of the PTSD checklist for diagnostic and statistical manual of mental disorders–fifth edition (PCL-5) in veterans. Psychological Assessment, 28(11), 1379–1391. https://doi.org/10.1037/pas0000254

10.

Brown

R. A.

Lejuez

C. W.

Kahler

C. W.

Strong

D. R.

Zvolensky

M. J.

(2005). Distress tolerance and early smoking lapse. Clinical Psychology Review, 25(6), 713–733. https://doi.org/10.1016/j.cpr.2005.05.003

11.

Bucx

van Wel

Knijn

(2012). Life course status and exchanges of support between young adults and parents. Journal of Marriage and Family, 74(1), 101–115. https://doi.org/10.1111/j.1741-3737.2011.00883.x

12.

Calvocoressi

Lewis

Harris

Trufan

S. J.

Goodman

W. K.

McDougle

C. J.

Price

L. H.

(1995). Family accommodation in obsessive-compulsive disorder. The American Journal of Psychiatry, 152(3), 441–443. https://doi.org/10.1176/ajp.152.3.441

13.

Campbell

S. B.

Renshaw

K. D.

(2016). Combat veterans with PTSD and their partners: Interpersonally based behaviors and cognitions as mechanisms of distress. In MacDermid Wadsworth

Riggs

(Eds), War and family life (pp. 55–75). : Springer. https://doi.org/10.1007/978-3-319-21488-7_4

14.

Campbell

S. B.

Renshaw

K. D.

Kashdan

T. B.

Curby

T. W.

Carter

S. P.

(2017). A daily diary study of posttraumatic stress symptoms and romantic partner accommodation. Behavior Therapy, 48(2), 222–234. https://doi.org/10.1016/j.beth.2016.04.006

15.

Caspi

Klein

(2012). In the aftermath of trauma: a community study of Bedouin IDF servicemen and their families. Israel Journal of Psychiatry, 49(3), 167–177.

16.

Chardon

M. L.

Brammer

Madan-Swain

Kazak

A. E.

Pai

A. L. H.

(2021). Caregiver religious coping and posttraumatic responses in pediatric hematopoietic stem cell transplant. Journal of Pediatric Psychology, 46(4), 465–473. https://doi.org/10.1093/jpepsy/jsaa126

17.

Crow

J. R.

Myers-Bowman

K. S.

(2011). A fear like I’ve never felt”: Experiences of parents whose adult children deployed to combat zones. Marriage & Family Review, 47(3), 164–195. https://doi.org/10.1080/01494929.2011.577660

18.

de Barros

Polga

Szejko

Miguel

E. C.

Leckman

J. F.

Silverman

W. K.

Lebowitz

E. R.

(2020). Family accommodation mediates the impact of childhood anxiety on functional impairment. Journal of Anxiety Disorders, 76, 102318. https://doi.org/10.1016/j.janxdis.2020.102318

19.

Dekel

Levinstein

Siegel

Fridkin

Svetlitzky

(2016). Secondary traumatization of partners of war veterans: The role of boundary ambiguity. Journal of Family Psychology, 30(1), 63–71. https://doi.org/10.1037/fam0000163

20.

Dekel

Siegel

Fridkin

Svetlitzky

(2018). The double-edged sword: The role of empathy in military veterans’ partners distress. Psychological Trauma: Theory, Research, Practice, and Policy, 10(2), 216–224. https://doi.org/10.1037/tra0000265

21.

Dirkzwager

A. J.

Bramsen

Adèr

van der Ploeg

H. M.

(2005). Secondary traumatization in partners and parents of Dutch peacekeeping soldiers. Journal of Family Psychology, 19, 217–226. https://doi.org/10.1037/0893-3200.19.2.217

22.

Doorley

J. D.

Kashdan

T. B.

Alexander

L. A.

Blalock

D. V.

McKnight

P. E.

(2019). Distress tolerance in romantic relationships: A daily diary exploration with methodological considerations. Motivation and Emotion, 43(3), 505–516. https://doi.org/10.1007/s11031-019-09751-3

23.

Figley

C. R.

(1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. Brunner-Routledge.

24.

Fredman

S. J.

Pukay-Martin

N. D.

Macdonald

Wagner

A. C.

Vorstenbosch

Monson

C. M.

(2016). Partner accommodation moderates treatment outcomes for couple therapy for posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 84(1), 79–87. https://doi.org/10.1037/ccp0000061

25.

Fredman

S. J.

Vorstenbosch

Wagner

A. C.

Macdonald

Monson

C. M.

(2014). Partner accommodation in posttraumatic stress disorder: Initial testing of the Significant Others’ Responses to Trauma Scale (SORTS). Journal of Anxiety Disorders, 28(4), 372–381. https://doi.org/10.1016/j.janxdis.2014.04.001

26.

Fulton

J. J.

Calhoun

P. S.

Wagner

H. R.

Schry

A. R.

Hair

L. P.

Feeling

Elbogen

Beckham

J. C.

(2015). The prevalence of posttraumatic stress disorder in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans: A meta-analysis. Journal of Anxiety Disorders, 31, 98–107. https://doi.org/10.1016/j.janxdis.2015.02.003

27.

Goff

B. S. N.

Ruhlmann

L. M.

Dekel

Huxman

S. A. J.

(2020). Trauma, posttraumatic stress, and family systems. The Handbook of Systemic Family Therapy, 4, 267–296. https://doi.org/10.1002/9781119438519.ch93

28.

Greenberg

P. E.

Fournier

A. A.

Sisitsky

Pike

C. T.

Kessler

R. C.

(2015). The economic burden of adults with major depressive disorder in the United States (2005 and 2010). The Journal of Clinical Psychiatry, 76(2), 155–162. https://doi.org/10.4088/JCP.14m09298

29.

Hayes

A. F.

Preacher

K. J.

Myers

T. A.

(2011). Mediation and the estimation of indirect effects in political communication research. Sourcebook for Political Communication Research: Methods, Measures, and Analytical Techniques, 23(1), 434–465.

30.

Hoge

C. W.

Castro

C. A.

Messer

S. C.

McGurk

Cotting

D. I.

Koffman

R. L.

(2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. Research Support, U.S. Gov't, Non-P.H.S.. The New England Journal of Medicine, 351(1), 13–22. https://doi.org/10.1056/NEJMoa040603

31.

Hsu

S. H.

Collins

S. E.

Marlatt

G. A.

(2013). Examining psychometric properties of distress tolerance and its moderation of mindfulness-based relapse prevention effects on alcohol and other drug use outcomes. Addictive Behaviors, 38(3), 1852–1858. https://doi.org/10.1016/j.addbeh.2012.11.002

32.

Inguglia

Ingoglia

Liga

Lo Coco

Lo Cricchio

M. G.

(2015). Autonomy and relatedness in adolescence and emerging adulthood: Relationships with parental support and psychological distress. Journal of Adult Development, 22(1), 1–13. https://doi.org/10.1007/s10804-014-9196-8

33.

Kenny

D. A.

Kashy

D. A.

Cook

W. L.

(2006). Dyadic data analysis. : Guilford press.

34.

La Buissonnière-Ariza

Wood

J. J.

Kendall

P. C.

McBride

N. M.

Cepeda

S. L.

Small

B. J.

Lewin

A. B.

Kerns

Storch

E. A.

(2018). Presentation and correlates of hoarding behaviors in children with autism spectrum disorders and comorbid anxiety or obsessive-compulsive symptoms. Journal of Autism and Developmental Disorders, 48(12), 4167–4178. https://doi.org/10.1007/s10803-018-3645-3

35.

Lambert

J. E.

Holzer

Hasbun

(2014). Association between parents’ PTSD severity and children's psychological distress: A meta‐analysis. Journal of Traumatic Stress, 27(1), 9–17. https://doi.org/10.1002/jts.21891

36.

Leyro

T. M.

Zvolensky

M. J.

Bernstein

(2010). Distress tolerance and psychopathological symptoms and disorders: a review of the empirical literature among adults. Psychological Bulletin, 136(4), 576–600. https://doi.org/10.1037/a0019712

37.

Lindahl Norberg

Pöder

Ljungman

von Essen

(2012). Objective and subjective factors as predictors of post-traumatic stress symptoms in parents of children with cancer–A longitudinal study. Plos One, 7(5), e36218. https://doi.org/10.1371/journal.pone.0036218

38.

Manguno-Mire

Sautter

Lyons

Myers

Perry

Sherman

Glynn

Sullivan

(2007). Psychological distress and burden among female partners of combat veterans with PTSD. The Journal of Nervous and Mental Disease, 195(2), 144–151. https://doi.org/10.1097/01.nmd.0000254755.53549.69

39.

Marshall‐Berenz

E. C.

Vujanovic

A. A.

Bonn‐Miller

M. O.

Bernstein

Zvolensky

M. J.

(2010). Multimethod study of distress tolerance and PTSD symptom severity in a trauma‐exposed community sample. Journal of Traumatic Stress, 23(5), 623–630.

40.

Mesman

van IJzendoorn

M. H.

Bakermans-Kranenburg

M. J.

(2012). Unequal in opportunity, equal in process: Parental sensitivity promotes positive child development in ethnic minority families. Child Development Perspectives, 6(3), 239–250. https://doi.org/10.1111/j.1750-8606.2011.00223.x

41.

Monk

J. K.

Ruhlmann

L. M.

Nelson Goff

B. S.

Ogolsky

B. G.

(2018). Brief‐systemic programs for promoting mental health and relationship functioning in military couples and families. Journal of Family Theory & Review, 10(3), 566–586. https://doi.org/10.1111/jftr.12280

42.

Monson

C. M.

Fredman

S. J.

Dekel

(2010). Posttraumatic stress disorder in an interpersonal context. t (pp 179–208). In Beck

G. J.

(Ed),.: American Psychological Association. Interpersonal processes in the anxiety disorders

43.

Monson

C. M.

Taft

C. T.

Fredman

S. J.

(2009). Military-related PTSD and intimate relationships: From description to theory-driven research and intervention development. Clinical Psychology Review, 29(8), 707–714. https://doi.org/10.1016/j.cpr.2009.09.002

44.

O'Toole

B. I.

(2021). Intergenerational transmission of posttraumatic stress disorder in Australian Vietnam veterans’ daughters and sons: The effect of family emotional climate while growing up. Journal of traumatic stress. https://doi.org/10.1002/jts.22700

45.

Ramchand

Rudavsky

Grant

Tanielian

Jaycox

(2015). Prevalence of, risk factors for, and consequences of posttraumatic stress disorder and other mental health problems in military populations deployed to Iraq and Afghanistan. Current Psychiatry Reports, 17(5), 37. https://doi.org/10.1007/s11920-015-0575-z

46.

Ranney

R. M.

Bing-Canar

Paltell

K. C.

Tran

J. K.

Berenz

E. C.

Vujanovic

A. A.

(2020). Cardiovascular risk as a moderator of associations among anxiety sensitivity, distress tolerance, PTSD and depression symptoms among trauma-exposed firefighters. Journal of Psychosomatic Research, 139, 110269. https://doi.org/10.1016/j.jpsychores.2020.110269

47.

Renshaw

K. D.

Allen

E. S.

Rhoades

G. K.

Blais

R. K.

Markman

H. J.

Stanley

S. M.

(2011). Distress in spouses of service members with symptoms of combat-related PTSD: secondary traumatic stress or general psychological distress?. Journal of Family Psychology, 25(4), 461–469. https://doi.org/10.1037/a0023994

48.

Reuman

Thompson-Hollands

(2020). Family accommodation in PTSD: Proposed considerations and distinctions from the established transdiagnostic literature. Clinical Psychology: Science and Practice, e12375. https://doi.org/10.1111/cpsp.12375

49.

Rzeszutek

Lis-Turlejska

Palich

Szumiał

(2018). The Polish adaptation of the Life Events Checklist (LEC-5) for PTSD criteria from DSM-5. Psychiatrica Polska, 52(3), 499–510.

(2005). The Distress Tolerance Scale: Development and validation of a self-report measure. Motivation and Emotion, 29(2), 83–102. https://doi.org/10.1007/s11031-005-7955-3

51.

Solomon

Horesh

Ginzburg

(2021). Trajectories of PTSD and secondary traumatization: A longitudinal study. Journal of Psychiatric Research, 138, 354–359. https://doi.org/10.1016/j.jpsychires.2021.03.027

52.

Storch

E. A.

Merlo

L. J.

Larson

M.J.

Geffken

G. R.

Lehmkuhl

H. D.

Jacob

M. L.

Murphy

T. K.

Goodman

W. K.

(2008). Impact of comorbidity on cognitive-behavioral therapy response in pediatric obsessive-compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 47(5), 583–592. https://doi.org/10.1097/CHI.0b013e31816774b1

53.

Sung

J. Y.

Mumper

Schleider

J. L.

(2021). Empowering anxious parents to manage child avoidance behaviors: Randomized control trial of a single-session intervention for parental accommodation. JMIR Mental Health, 8(7), e29538. https://doi.org/10.2196/29538

54.

Tanner

J. L.

Arnett

J. J.

(2016). The emergence of emerging adulthood: The new life stage between adolescence and young adulthood. Routledge handbook of youth and young adulthood (pp. 50–56): Routledge.

55.

Timko

C. A.

Zucker

N. L.

Herbert

J. D.

Rodriguez

Merwin

R. M.

(2015). An open trial of Acceptance-based Separated Family Treatment (ASFT) for adolescents with anorexia nervosa. Behaviour Research and Therapy, 69, 63–74. https://doi.org/10.1016/j.brat.2015.03.011

56.

Vujanovic

A. A.

Bonn-Miller

M. O.

Potter

C. M.

Marshall

E. C.

Zvolensky

M. J.

(2011). An evaluation of the relation between distress tolerance and posttraumatic stress within a trauma-exposed sample. Journal of Psychopathology and Behavioral Assessment, 33(1), 129–135. https://doi.org/10.1007/s10862-010-9209-2

57.

Vujanovic

A. A.

Zegel

(2020). Distress tolerance in PTSD. Emotion in posttraumatic stress disorder (pp. 343–376): Academic Press. https://doi.org/10.1016/b978-0-12-816022-0.00012-0

58.

Waddell

Lawn

Roberts

Henderson

Venning

Redpath

(2020). Why do you stay?”: The lived‐experience of partners of Australian veterans and first responders with Posttraumatic Stress Disorder. Health & Social Care in the Community, 28(5), 1734–1742. https://doi.org/10.1111/hsc.12998

59.

Weathers

F.W.

Litz

B.T.

Keane

T.M.

Palmieri

P.A.

Marx

B.P.

Schnurr

P.P.

(2013). The PTSD checklist for DSM-5. (PCL-5). Scale available from the National Center for PTSD at www.ptsd.va.gov

60.

Wilmoth

J. M.

London

A. S.

(2013). Life-course perspectives on military service: An introduction. In Wilmoth

J. M.

London

A. S.

(Eds), (pp. 1–18). : Routledge.Life course perspectives on military service

61.

Wortmann

J. H.

Jordan

A. H.

Weathers

F. W.

Resick

P. A.

Dondanville

K. A.

Hall-Clark

Foa

E. B.

Young-McCaughan

Yarvis

J. S.

Hembree

E. A.

Mintz

Peterson

A. L.

Litz

B. T.

(2016). Psychometric analysis of the PTSD Checklist-5 (PCL-5) among treatment-seeking military service members. Psychological Assessment, 28(11), 1392–1403. https://doi.org/10.1037/pas0000260

62.

Yehuda

Hoge

C. W.

McFarlane

A. C.

Vermetten

Lanius

R. A.

Nievergelt

C. M.

Hobfoll

S. E.

Koenen

K. C.

Neylan

T. C.

Hyman

S. E.

(2015). Post-traumatic stress disorder. Nature Reviews Disease Primers, 1, 15057. https://doi.org/10.1038/nrdp.2015.57

63.

Zerach

Kanat-Maymon

Aloni

Solomon

(2016). The role of fathers' psychopathology in the intergenerational transmission of captivity trauma: A twenty three-year longitudinal study. Journal of Affective Disorders, 190, 84–92. https://doi.org/10.1016/j.jad.2015.09.072

64.

Zerach

Levi‐Belz

(2021). Exposure to combat incidents within military and civilian populations as possible correlates of potentially morally injurious events and moral injury outcomes among Israeli combat veterans (pp. 1–15). Clinical Psychology & Psychotherapy. https://doi.org/10.1002/cpp.2632

65.

Zerach

Magal

(2016). Anxiety sensitivity among first-time fathers moderates the relationship between exposure to stress during birth and posttraumatic stress symptoms. The Journal of Nervous and Mental Disease, 204, 381–387. https://doi.org/10.1097/NMD.00000000000000482

66.

Zerach

Milevsky

(2020). Brothers in Arms”: Secondary traumatization and sibling relationship quality among siblings of combat veterans. Journal of Interpersonal Violence, 37, 1985–2010. https://doi.org/10.1177/0886260520936364