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Volume 15, Issue 3 (2023)
Iran J War Public Health 2023, 15(3): 249-256 |
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Received: 2023/05/6 | Accepted: 2023/08/16 | Published: 2023/08/28
Received: 2023/05/6 | Accepted: 2023/08/16 | Published: 2023/08/28
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Fallahinezhad S, Mandani G, Tahanzadeh B, Ghasemzadeh R, Salahshouri A. The Experiences of Adult Offsprings of War Veterans with Post-Traumatic Stress Disorder; a Qualitative Study. Iran J War Public Health 2023; 15 (3) :249-256
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1- “Department of Occupational Therapy, Faculty of Rehabilitation Sciences” and “Rehabilitation Research Center”, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
2- Department of Occupational Therapy, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
3- “Department of Speech Therapy, Faculty of Rehabilitation Sciences” and “Rehabilitation Research Center”, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
4- Department of Health Education and Health Promotion, Faculty of Health, Ahvaz Jundishapour University of Medical Sciences, Ahvaz, Iran
2- Department of Occupational Therapy, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
3- “Department of Speech Therapy, Faculty of Rehabilitation Sciences” and “Rehabilitation Research Center”, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
4- Department of Health Education and Health Promotion, Faculty of Health, Ahvaz Jundishapour University of Medical Sciences, Ahvaz, Iran
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Introduction
War, one of the most dangerous and tense events, constantly threatens human life [1] and has always been a serious public health concern for society [2]. War has many consequences for the people of any land, whether those who have directly or indirectly experienced it, as well as future generations, and it will subject them to severe physical, psychological, social, and emotional harm [1, 2]. Research background shows that nearly one in four soldiers returning from war experiences severe psychological problems [3]. One of the psychiatric disorders is post-traumatic stress disorder, which, as the most significant war-related disorder, occurs during times of war and destructive conflicts, akin to a catastrophic incident accompanied by unpredictable, destructive, and long-term consequences for the affected individual, their families, and the society in which they live [4]. Post-traumatic stress disorder is a type of mental disorder observed in some individuals exposed to or witnessed life-threatening events or physical harm to themselves or others [1]. This event can be an accident, a violent crime, a military battle, kidnapping, involvement in a natural disaster, diagnosis or experience of a life-threatening illness, or physical or sexual abuse that may not cause stress disorder in many individuals [5]. The symptoms of post-traumatic stress disorder are very diverse. Still, they are classified into three main groups, including intrusive thoughts, avoidance, and emotional symptoms, which can lead to stress, fear, anger, and guilt [5, 6]. This process continues in individuals with a sense of numbness and emotional detachment, and as a result, these individuals isolate themselves from relationships and are incompatible with those around them [7].
The eight-year war in Iran and its resulting stress have led to psychological disorders among combatants, veterans, and their families. As a group with distinct characteristics, veterans experience a different life than others and are exposed to various damages and pressures based on their physical and mental conditions [3]. Taking care of the veterans puts significant psychological pressure on their families, jeopardizing the mental health of caregivers and negatively affecting their quality of life.
The family is the first environment in which offspring's physical, emotional, and personality patterns are nurtured and gradually take shape. The family, as a center of love, affection, and emotional education, plays a crucial role in shaping individuals' personality and mental and social equilibrium [8]. Family-related factors, including low socioeconomic status, conflicts, lack of family organization, disrupted family communication, weak parent-child attachment, and mental illness among family members, are among the risk factors for developing psychological factors in individuals [5]. Physical and mental illnesses in parents can influence their role within the family [9]. Numerous studies have shown that parents with psychiatric disorders may experience significant challenges and obstacles in providing their offspring with a stable and safe environment. These challenges are often a result of their own mental illness and society's response to these individuals [10].
Findings from multiple research studies on the problems of veterans and their families have shown that veterans and their families face numerous psychological and emotional challenges in life [11-13]. Imani et al. and Erfani & Nasrollah showed the average quality of life lower score for veterans with post-traumatic stress disorder than that of other veteran groups in terms of happiness, social functioning, mental health, and physical functioning [14, 15]. It appears that veterans' experiences affect family relationships, daily functioning, and social life and impact patients' quality of family life.
Based on the research background, post-traumatic stress disorder negatively affects the families and offspring of veterans. The psychological problems of veterans significantly impacted family management, child-rearing, emotional relationships, economic affairs, livelihood, and the educational aspects of family members, beyond the average. These issues also considerably influenced the offspring's personality, the spouses' mental health, marital satisfaction, and divorce [2, 16, 17].
In studies conducted in other countries, offspring with parents who have psychiatric disorders are significantly exposed to mental health issues, behavioral problems, and emotional problems [11-13]. Additionally, higher rates of criminal behavior and suicide have been reported among these individuals [18, 19]. Many individuals may hide their distress and anxiety due to fear of shame and neglect. Instead of expressing their feelings, they may distance themselves from the community and be viewed as unusually quiet and well-behaved. Consequently, these offspring risk experiencing avoidance, neglect, and delayed growth [20].
Given the significant and detrimental effects of war on the mental health of veterans and their families, there was no study aimed at identifying the problems and experiences of offspring of veterans with post-traumatic stress disorder in Iran, particularly in Khuzestan Province. Therefore, this group needs to be studied to better understand their problems and the support they require, ultimately facilitating better services for them. Because this phenomenon is highly personal, it is being assessed qualitatively. The first step in understanding their conditions and needs is to explore the subjects' experiences. Since the ultimate goal of qualitative research is to provide a detailed account of the participants' experiences, this research was conducted qualitatively through semi-structured interviews with the offsprings of veterans with post-traumatic stress disorder who have a history of hospitalization in the Boostan Psychiatric Hospital in Ahvaz.
Participants and Methods
The qualitative study employs a content analysis approach with a contractual focus. The study was conducted on nine (8 females and one male) adult offspring of veterans with post-traumatic stress disorder (PTSD) who had a history of hospitalization in the Boostan Ahvaz Psychiatric Hospital from September, 2020 until August, 2021. The subjects were selected through purposive sampling to ensure a more in-depth understanding of the issues related to their family's experiences with PTSD.
The ethical approval was obtained from the Jundishapur University of Medical Sciences, and the research permission was obtained from the Foundation of Martyrs and Veterans Affairs of Khuzestan Province. In addition, the full and informed consent of the interviewees regarding the research process, voluntary participation, giving the right to withdraw from participation, and adherence to ethical principles of the interviews, including confidentiality and emphasis on the privacy of personal information, were among the ethical considerations that were closely observed during the study. Data was collected through semi-structured interviews conducted in a psychology room. When necessary, follow-up interviews were conducted through phone calls. Each interview lasted between 30 to 60 minutes. The interviews continued until data saturation, meaning no new data emerged. The data analysis process for qualitative data was conducted based on the proposed stages by Graneheim & Lundman [16]. At the end of each session, the notes were typed, and after several reviews, the data was broken down into the smallest meaningful units or codes. Then, the initial codes were compared, and similar codes were grouped into subcategories. Subsequently, the notes were placed within the main categories that contained the primary themes of the research based on their relevance and similarity. To ensure the accuracy and reliability of the data, four recommended criteria by Lincoln and Guba [22] (credibility, confirmability, dependability, and transferability) were considered. To enhance the validity and reliability of the data and data trustworthiness, practices such as allocating sufficient time, quick transcription, and revisiting the entire dataset were incorporated. The results of the data analysis were reviewed by two members of the research team to evaluate the credibility of the results and the confirmability and reliability of the findings. Their assessment contributed to the trustworthiness of the results.
Findings
The mean age of the participants was 25.78±5.19 years (Table 1).
Table 1. Characteristics of the nine participants
The experiences of the offspring of veterans with PTSD constituted were divided into five main categories and 13 sub-categories (Table 2).
Table 2. Main categories and subcategories extracted from the study data
Families of veterans with PTSD experience various challenges and adversities due to the problems and events in their lives. As offsprings of veterans, participants pointed out experiences in their lives, including an unsafe childhood, witnessing their father's endless pain and suffering, challenges in their mother's life, empathy with their father, fears, concerns, and mental struggles. Below, we will delve into each of the five main categories extracted.
Unsafe Childhood
Childhood and adolescence are crucial periods that profoundly impact people's lives. According to the participants, their childhood was marked by an insecure environment, strictness, and a lack of emotional security. They did not experience a normal and vibrant childhood, which led to an unsafe childhood experience.
Turbulent home
According to the participants, their father's groundless anger and the conflicts he had with the family and neighbors made their home environment always filled with tension and restlessness. This led to stress and anxiety among family members.
"Our home is full of tension and restlessness. Someone is always yelling, and everyone is agitated. There's no peace. We always feel this tension and problems in the house, which have decreased, but my younger sister and I have been experiencing this tension and discomfort in our home since childhood." (Participant No. 3)
"The sense of peace was almost absent in our home. Our childhood was full of turmoil." (Participant No. 6)
Lack of emotional security
The severe condition of their father made it so that offspring were not the center of attention in the house. Participants mentioned the lack of emotional support from their father, being disregarded at home, and their needs being ignored.
"In our home, you can't speak, and there's no one to listen to you. I feel like a stranger and alone. If I'm at home, I shouldn't express any opinions. I don't know how to say it; it's very difficult." (Participant No. 1)
Strictness at home
The specific psychological conditions of the father led to offspring being deprived of their natural freedoms at home to a great extent. Expectations were placed on them to understand the living conditions and not do anything that would upset their father.
"When we're together and talking, he gets angry for no reason. He tells us to go to our rooms and locks the door. He wouldn't allow us to watch television. We'd turn it on, and he'd start a fight. We don't get along well at all." (Participant No. 1)
Witnessing the endless suffering of the father
Throughout their lives, the subjects witnessed their father's permanent pain and suffering. They pointed to the pain and suffering their father endured when he was under treatment and the pain resulting from the complications of the disease.
Suffering during treatment
Participants expressed that seeing their father's condition, where he constantly needed hospitalization, had to take a lot of medicine, and endured the side effects of the medications, was very difficult for them. They also mentioned that their father had to endure intense treatments, such as electroshock therapy, which left negative and distressing scenes for them.
"One memory from that time that I remember when I was a child, we went to the hospital. When I opened the door, I saw they were giving my father electroshock therapy. I felt sick, and I haven't been able to forget it until now." (Participant No. 3)
Suffering from disease symptoms
According to the participants, the presence of symptoms and issues like continuous ringing in their father's ears, a constant feeling of noise in his head, insomnia, and night terrors, as well as his unpredictable mood swings and poor health in the presence of others, caused them significant pain and suffering.
"At night, he used to be awake, saying he couldn't sleep. Or if he did fall asleep, he would jump out of bed as if he were in a war." (Participant No. 2)
"Sometimes when my father got angry and started wreaking havoc in the house, the neighbors would come to control him, making us uncomfortable and embarrassed." (Participant No. 7)
Challenges in the Mother's Life
The findings of this research demonstrate that the challenges in the lives of mothers are one of the experiences of the offspring of veterans. According to the participants, marital problems and the heavy burden of family responsibilities placed on mothers are part of the difficulties mothers face in these families.
Marital problems
They believe that their mothers receive no emotional support from their fathers, and in many cases, they are subjected to aggression and physical punishment by their fathers. They are forced to endure their father's outbursts and aggressiveness.
"One night, when I was a child, I saw my mother screaming, and my father had poured boiling water on my mother's legs, and then he ran away. The neighbors took my mother to the hospital. My father's family hired a lawyer to divorce my mother and father and send us to an orphanage instead of helping my mother." (Participant No. 3)
"My mother is afraid of my father. When my father gets angry, he starts swearing at my mother, insulting his own family, and my mother has nothing next to my father respect, no peace." (Participant No. 1)
Bearing the heavy responsibility of the family
The subjects mentioned that their mothers try to maintain the family's life by taking care of their offspring, working outside the home, preserving their offspring's spirits, and making an effort to follow the proper treatment process for their father, bearing the heavy responsibility of the family.
"I can say that my mother takes on all the responsibilities instead of my father. How can I put it? My father was just a name that we dragged like a child, like nothing. She's responsible for our lives." (Participant No. 3)
"My father isn't a good husband for them. Our lives fall apart when my mother isn't at home one day. My mother takes on both the responsibilities of the family head and her motherly duties. All the responsibilities of life are on my mother." (Participant No. 1)
"My mother has tried not to let us become offsprings of divorce. She's tried to create everything that she could with my father. She's forgotten her wishes and tries calming us down and fulfilling our financial and educational needs." (Participant No. 9)
Sympathy with the father
The findings indicate that offspring sympathize with the limited capabilities of their fathers and the behaviors that create prejudices against them by others.
Observing the dependence of the father
According to the participants, their fathers depend on them to perform daily activities. Instead of their fathers taking care of them, they must take care of their fathers.
"We always have to be careful that he takes his medicine. We have to take care of his every need. In a way, we've learned to take care of him so he doesn't get upset. We must watch over him." (Participant No. 2)
"Most of the time, our roles switch with our father. Instead of our father being our support, we must care for him. We must be careful that nothing happens to him and ensure that no one treats him badly." (Participant No. 9)
Discomfort with the behaviors of others towards their father
Participants expressed their discontent with how others, especially outsiders, treat veterans, as they are often unaware of their difficulties. They feel that their fathers are labeled as "nervous" or "mentally unstable," leading to them being looked down upon.
"When he used to go to the hospital, I would feel uncomfortable because I'm sure they wouldn't treat him as he deserves, given the stigma around mental health issues, and he can't defend himself. So, when my father is hospitalized, my mind is preoccupied with it the whole time." (Participant No. 6)
Fears, worries, and mental struggles
Participants shared their fears, worries, and mental struggles resulting from their experiences. They are afraid of the future, fear for the well-being of their family members, and are constantly preoccupied with the events in their households and their father's condition. They also lament the lives of others.
Fear of the future
According to the participants, they fear that the events and conditions they've experienced might repeat in their own lives and the lives of their future offspring. The challenges they face in their family life make them anxious about their future, and some are reluctant to get married.
"I don't intend to have a shared life. It's damaging to the other person. I can't involve others in my family issues. On the other hand, I'm afraid to marry someone who doesn't understand my father's situation, fearing that it would lead to more problems in my life." (Participant No. 9)
"I genuinely can't trust anyone. I'm afraid that my future life will be as full of problems as it has been until now because the problems in our lives are endless; every day, something happens. I'm afraid my offspring will go through the same hardships I've experienced." (Participant No. 3)
Concern for the well-being of family members
Participants mentioned their fears and worries related to the well-being of family members. They are anxious about the possibility of harm coming to their father, mother, or other family members, especially when they are not at home. They fear that something unfortunate might happen in their absence.
"When I was in school, I often came home to find the house in disarray because my father was in a bad mood. Every time I came back from school, I had this specific stress; I thought, 'What scene will I face now?'" (Participant No. 7)
"We're afraid to be asleep, and that he might harm us. When he's upset with me, I'm worried he won't like me, and if he does something in the middle of the night, he might hurt me." (Participant No. 9)
Mental struggles due to household problems
The ongoing conflicts within the family and the resulting harm to family members cause participants to constantly obsess about household events. They feel that these problems are never-ending and are always concerned about the recurrence of issues and problems.
"We, the offsprings of veterans, are always waiting for something bad to happen. We're always prepared for something to happen, and our minds are never at ease because we know that a small act can completely shatter our father and our entire life." (Participant No. 6)
"I often think about why my father went to war, why I had to be born into this world. I contemplate it in solitude and wish I were in another family. I put myself in other people's shoes, thinking, 'I wish my life, my family, were like theirs.'" (Participant No. 5)
Mental struggles due to father's status
Participants often contemplate why their fathers are veterans and whether their lives would be different if they weren't. They compare with others, questioning why their lives differ from those of other people.
"Many times, I think if my father hadn't gone to war, our lives would have been better. We wouldn't have had so many problems, and we could have lived like normal people." (Participant No. 2)
"I think about the differences between us and others. Some things that are normal for ordinary people feel strange to us. Our lives are very different from those of others ..." (Participant No. 9)
"Why do these things happen to me? Why did I have to be born into this situation? I often think about it in solitude, wondering if my life, my family, could be different." (Participant No. 4)
Discussion
The findings of this research elucidate the five main categories that define the negative experiences of the offspring of war veterans with PTSD. Among these, an insecure childhood, witnessing their fathers' endless suffering, challenges in their mothers' lives, empathy towards their fathers, and mental anguish are central experiences. An insecure childhood was almost universally mentioned in interviews and is thus crucial in this study. Collins, in 2018, through a review of studies investigating the impact of parents with PTSD on the mental health of their offspring, indicated that these offspring face behavioral, emotional, and academic difficulties [23]. The parenting abilities of these parents in forming appropriate emotional bonds with their offspring are reduced. In this study, many participants referred to the presence of anxiety and tension within the home due to the constant mental turmoil of the fathers. It was pointed out that family members had to be prepared for potential conflicts and arguments within the household, resulting in the offspring experiencing neglect, a lack of affection, and insufficient support. Furthermore, during their childhood, these offspring were expected to behave according to their father's will, and, like adults, their childlike activities were restricted.
Certainly, war has direct and lasting psychological and emotional effects on survivors. Maleki et al. addressed complaints, including a lack of intimate family relationships, family conflicts, and unhealthy relationships with offspring among a wide range of victims of chemical bombardments in Sardasht, consistent with the present study [2]. Other studies have shown that gender differences in caretaker couples and offspring have different effects on PTSD symptoms. The lack of positive emotions in the family has led to an increase in PTSD symptoms in girls. At the same time, the negative relationship of sons with their mothers has resulted in the development of avoidance behaviors, irritability, and emotional numbness [24]. Risk factors for poor school performance in offspring are present [25]. Offsprings whose parents are affected seek less preventive healthcare, and visits for psychological problems and misbehavior have increased in this group [26].
The findings of this study demonstrated that mothers in families of war veterans with PTSD endure various difficulties and challenges in life. The offspring's experiences include being entrusted with the responsibility of life and striving to meet their needs, maintaining their spirits, providing emotional support to their offspring, and pursuing their spouse's treatment. In some cases, mothers work outside the home to make ends meet. It was also noted that spouses of war veterans lack the necessary support, leading to anger and resentment in many cases, which can sometimes result in physical harm. A study investigating psychological distress among the female partners of war veterans revealed high levels of psychological distress, depression, and suicidal thoughts, which are common among these spouses [27].
Other domestic studies have also indicated a decrease in mental well-being and increased responsibilities of war veterans' spouses. They endure the tolerance of spousal violence, take on the responsibility for all household matters, and preserve the family foundation [28, 29].
This research showed that offsprings of war veterans feel empathy for their fathers' inadequacies and witness their fathers' moments of life struggles. One of the categories of experiences among offspring is empathy for their fathers' weaknesses. Some offsprings of war veterans express empathy for their fathers' weakness in defending their rights against others, their inability to care for themselves, and their dependence on their offspring. They also show concern for their fathers when others insult them due to illness and their psychological state while in the hospital. In society, they feel their fathers, as sacrificers, are not respected or appreciated.
A secure environment for personal growth is essential for everyone, especially during childhood. It depends on how well the living environment meets the needs and desires of the child. According to this research, offsprings of war veterans experience challenges achieving a sense of security. Many do not feel secure and express constant fears and concerns as negative aspects of their lives. Many subjects expressed concerns about the health of their family members, always fearing that their father may be harmed during his seizures. Many offspring also expressed concerns about an uncertain future, especially regarding marriage, as they were of marriageable age. They fear introducing new problems to their lives and being like their families. They also fear the suffering of their offspring in a similar manner. A study by Murphy also referred to concerns about an uncertain future and the introduction of new problems into their lives [16].
Furthermore, the frequent recurrence of unfortunate events in their lives, such as family disintegration and the instability of the home environment, has turned their fear of the permanence of bad life events into anxiety. In a study conducted by Khodabakhshi et al. in 2019, concern about an uncertain future was mentioned, which is consistent with the findings of this study [30]. Some also believe that being together in the family helps them solve problems and cope with life issues. Therefore, some of the offspring of veterans fear leaving their mothers alone, citing the mother's struggle with difficulties. The findings of this report show that offsprings of veterans have mental conflicts that hurt their mental and emotional well-being and quality of life. Most interviews referred to mental preoccupation with concerns about events that might happen when they are not at home. Some also mentioned their mental preoccupation with their father's veteran status, why their father went to war, and their life if he weren't a veteran. Others lamented their perpetual comparisons with others and their families and that they don't have a normal life [30].
The unwillingness of subjects, especially the sons of veterans, to remember difficult days in their lives, such as limitations, was one of the main challenges of this research. They had no interest in talking, and despite inviting many sons of veterans, they did not participate in the interviews. As a result, the majority of participants in this research were women, and it is recommended that future research pay attention to this issue.
Furthermore, given that most of the offsprings of war veterans are often of marriageable age and many of them are married, it is recommended that research be conducted on their parenting capabilities. Additionally, it is advisable to study the mental and emotional challenges that the offspring of veterans face in their education. Through providing individual and family support, many serious mental and psychological issues in these individuals can be prevented. Therefore, identifying the experiences of the families and offsprings of war veterans is highly beneficial for policymakers in organizations such as the Foundation of Martyrs and Veterans, its managers, and individuals involved in providing services to the families of veterans. This knowledge is crucial for offering better and more quality services to this group because it is essential to understand what these individuals go through in their lives and their increased needs in this domain. These individuals require in-depth studies of their challenges and needs by relevant institutions. Since this study was conducted qualitatively, it may not be directly generalizable to a larger population, but its findings can be considered insights from a small sample.
Conclusion
The offspring of veterans with post-traumatic stress disorder continue to face various unpleasant experiences compared to others, which impact their mental health and overall quality of life.
Acknowledgment The authors tend to appreciate the families of veterans and the mental health hospital in Ahvaz.
Ethical Permissions: Ethical approval was obtained from the Jundishapur University of Medical Sciences (Ethical Code: IR.AJUMS.REC.1399.20).
Conflict of Interests: None declared by the authors.
Authors’ Contribution: Fallahinezhad S (First Author), Introduction Writer/ Original Researcher/Discussion Writer (30%); Mandani Gh (Second Author), Methodologist/Original Researcher (15%); Tahanzadeh B (Third Author), Introduction Writer/Methodologist/Original Researcher/Discussion Writer (30%); Ghasemzaade R (Fourth Author), Methodologist/Assistant Researcher (10%); Salahshouri A (Fifth Author), Methodologist/Assistant Researcher/Statistical Analyst (15%)
Funding/Support: This study represents a part of a larger study conducted as a Master's thesis on Empowerment Management at Jundishapur University of Medical Sciences, Ahvaz, Iran.
War, one of the most dangerous and tense events, constantly threatens human life [1] and has always been a serious public health concern for society [2]. War has many consequences for the people of any land, whether those who have directly or indirectly experienced it, as well as future generations, and it will subject them to severe physical, psychological, social, and emotional harm [1, 2]. Research background shows that nearly one in four soldiers returning from war experiences severe psychological problems [3]. One of the psychiatric disorders is post-traumatic stress disorder, which, as the most significant war-related disorder, occurs during times of war and destructive conflicts, akin to a catastrophic incident accompanied by unpredictable, destructive, and long-term consequences for the affected individual, their families, and the society in which they live [4]. Post-traumatic stress disorder is a type of mental disorder observed in some individuals exposed to or witnessed life-threatening events or physical harm to themselves or others [1]. This event can be an accident, a violent crime, a military battle, kidnapping, involvement in a natural disaster, diagnosis or experience of a life-threatening illness, or physical or sexual abuse that may not cause stress disorder in many individuals [5]. The symptoms of post-traumatic stress disorder are very diverse. Still, they are classified into three main groups, including intrusive thoughts, avoidance, and emotional symptoms, which can lead to stress, fear, anger, and guilt [5, 6]. This process continues in individuals with a sense of numbness and emotional detachment, and as a result, these individuals isolate themselves from relationships and are incompatible with those around them [7].
The eight-year war in Iran and its resulting stress have led to psychological disorders among combatants, veterans, and their families. As a group with distinct characteristics, veterans experience a different life than others and are exposed to various damages and pressures based on their physical and mental conditions [3]. Taking care of the veterans puts significant psychological pressure on their families, jeopardizing the mental health of caregivers and negatively affecting their quality of life.
The family is the first environment in which offspring's physical, emotional, and personality patterns are nurtured and gradually take shape. The family, as a center of love, affection, and emotional education, plays a crucial role in shaping individuals' personality and mental and social equilibrium [8]. Family-related factors, including low socioeconomic status, conflicts, lack of family organization, disrupted family communication, weak parent-child attachment, and mental illness among family members, are among the risk factors for developing psychological factors in individuals [5]. Physical and mental illnesses in parents can influence their role within the family [9]. Numerous studies have shown that parents with psychiatric disorders may experience significant challenges and obstacles in providing their offspring with a stable and safe environment. These challenges are often a result of their own mental illness and society's response to these individuals [10].
Findings from multiple research studies on the problems of veterans and their families have shown that veterans and their families face numerous psychological and emotional challenges in life [11-13]. Imani et al. and Erfani & Nasrollah showed the average quality of life lower score for veterans with post-traumatic stress disorder than that of other veteran groups in terms of happiness, social functioning, mental health, and physical functioning [14, 15]. It appears that veterans' experiences affect family relationships, daily functioning, and social life and impact patients' quality of family life.
Based on the research background, post-traumatic stress disorder negatively affects the families and offspring of veterans. The psychological problems of veterans significantly impacted family management, child-rearing, emotional relationships, economic affairs, livelihood, and the educational aspects of family members, beyond the average. These issues also considerably influenced the offspring's personality, the spouses' mental health, marital satisfaction, and divorce [2, 16, 17].
In studies conducted in other countries, offspring with parents who have psychiatric disorders are significantly exposed to mental health issues, behavioral problems, and emotional problems [11-13]. Additionally, higher rates of criminal behavior and suicide have been reported among these individuals [18, 19]. Many individuals may hide their distress and anxiety due to fear of shame and neglect. Instead of expressing their feelings, they may distance themselves from the community and be viewed as unusually quiet and well-behaved. Consequently, these offspring risk experiencing avoidance, neglect, and delayed growth [20].
Given the significant and detrimental effects of war on the mental health of veterans and their families, there was no study aimed at identifying the problems and experiences of offspring of veterans with post-traumatic stress disorder in Iran, particularly in Khuzestan Province. Therefore, this group needs to be studied to better understand their problems and the support they require, ultimately facilitating better services for them. Because this phenomenon is highly personal, it is being assessed qualitatively. The first step in understanding their conditions and needs is to explore the subjects' experiences. Since the ultimate goal of qualitative research is to provide a detailed account of the participants' experiences, this research was conducted qualitatively through semi-structured interviews with the offsprings of veterans with post-traumatic stress disorder who have a history of hospitalization in the Boostan Psychiatric Hospital in Ahvaz.
Participants and Methods
The qualitative study employs a content analysis approach with a contractual focus. The study was conducted on nine (8 females and one male) adult offspring of veterans with post-traumatic stress disorder (PTSD) who had a history of hospitalization in the Boostan Ahvaz Psychiatric Hospital from September, 2020 until August, 2021. The subjects were selected through purposive sampling to ensure a more in-depth understanding of the issues related to their family's experiences with PTSD.
The ethical approval was obtained from the Jundishapur University of Medical Sciences, and the research permission was obtained from the Foundation of Martyrs and Veterans Affairs of Khuzestan Province. In addition, the full and informed consent of the interviewees regarding the research process, voluntary participation, giving the right to withdraw from participation, and adherence to ethical principles of the interviews, including confidentiality and emphasis on the privacy of personal information, were among the ethical considerations that were closely observed during the study. Data was collected through semi-structured interviews conducted in a psychology room. When necessary, follow-up interviews were conducted through phone calls. Each interview lasted between 30 to 60 minutes. The interviews continued until data saturation, meaning no new data emerged. The data analysis process for qualitative data was conducted based on the proposed stages by Graneheim & Lundman [16]. At the end of each session, the notes were typed, and after several reviews, the data was broken down into the smallest meaningful units or codes. Then, the initial codes were compared, and similar codes were grouped into subcategories. Subsequently, the notes were placed within the main categories that contained the primary themes of the research based on their relevance and similarity. To ensure the accuracy and reliability of the data, four recommended criteria by Lincoln and Guba [22] (credibility, confirmability, dependability, and transferability) were considered. To enhance the validity and reliability of the data and data trustworthiness, practices such as allocating sufficient time, quick transcription, and revisiting the entire dataset were incorporated. The results of the data analysis were reviewed by two members of the research team to evaluate the credibility of the results and the confirmability and reliability of the findings. Their assessment contributed to the trustworthiness of the results.
Findings
The mean age of the participants was 25.78±5.19 years (Table 1).
Table 1. Characteristics of the nine participants
The experiences of the offspring of veterans with PTSD constituted were divided into five main categories and 13 sub-categories (Table 2).
Table 2. Main categories and subcategories extracted from the study data
Families of veterans with PTSD experience various challenges and adversities due to the problems and events in their lives. As offsprings of veterans, participants pointed out experiences in their lives, including an unsafe childhood, witnessing their father's endless pain and suffering, challenges in their mother's life, empathy with their father, fears, concerns, and mental struggles. Below, we will delve into each of the five main categories extracted.
Unsafe Childhood
Childhood and adolescence are crucial periods that profoundly impact people's lives. According to the participants, their childhood was marked by an insecure environment, strictness, and a lack of emotional security. They did not experience a normal and vibrant childhood, which led to an unsafe childhood experience.
Turbulent home
According to the participants, their father's groundless anger and the conflicts he had with the family and neighbors made their home environment always filled with tension and restlessness. This led to stress and anxiety among family members.
"Our home is full of tension and restlessness. Someone is always yelling, and everyone is agitated. There's no peace. We always feel this tension and problems in the house, which have decreased, but my younger sister and I have been experiencing this tension and discomfort in our home since childhood." (Participant No. 3)
"The sense of peace was almost absent in our home. Our childhood was full of turmoil." (Participant No. 6)
Lack of emotional security
The severe condition of their father made it so that offspring were not the center of attention in the house. Participants mentioned the lack of emotional support from their father, being disregarded at home, and their needs being ignored.
"In our home, you can't speak, and there's no one to listen to you. I feel like a stranger and alone. If I'm at home, I shouldn't express any opinions. I don't know how to say it; it's very difficult." (Participant No. 1)
Strictness at home
The specific psychological conditions of the father led to offspring being deprived of their natural freedoms at home to a great extent. Expectations were placed on them to understand the living conditions and not do anything that would upset their father.
"When we're together and talking, he gets angry for no reason. He tells us to go to our rooms and locks the door. He wouldn't allow us to watch television. We'd turn it on, and he'd start a fight. We don't get along well at all." (Participant No. 1)
Witnessing the endless suffering of the father
Throughout their lives, the subjects witnessed their father's permanent pain and suffering. They pointed to the pain and suffering their father endured when he was under treatment and the pain resulting from the complications of the disease.
Suffering during treatment
Participants expressed that seeing their father's condition, where he constantly needed hospitalization, had to take a lot of medicine, and endured the side effects of the medications, was very difficult for them. They also mentioned that their father had to endure intense treatments, such as electroshock therapy, which left negative and distressing scenes for them.
"One memory from that time that I remember when I was a child, we went to the hospital. When I opened the door, I saw they were giving my father electroshock therapy. I felt sick, and I haven't been able to forget it until now." (Participant No. 3)
Suffering from disease symptoms
According to the participants, the presence of symptoms and issues like continuous ringing in their father's ears, a constant feeling of noise in his head, insomnia, and night terrors, as well as his unpredictable mood swings and poor health in the presence of others, caused them significant pain and suffering.
"At night, he used to be awake, saying he couldn't sleep. Or if he did fall asleep, he would jump out of bed as if he were in a war." (Participant No. 2)
"Sometimes when my father got angry and started wreaking havoc in the house, the neighbors would come to control him, making us uncomfortable and embarrassed." (Participant No. 7)
Challenges in the Mother's Life
The findings of this research demonstrate that the challenges in the lives of mothers are one of the experiences of the offspring of veterans. According to the participants, marital problems and the heavy burden of family responsibilities placed on mothers are part of the difficulties mothers face in these families.
Marital problems
They believe that their mothers receive no emotional support from their fathers, and in many cases, they are subjected to aggression and physical punishment by their fathers. They are forced to endure their father's outbursts and aggressiveness.
"One night, when I was a child, I saw my mother screaming, and my father had poured boiling water on my mother's legs, and then he ran away. The neighbors took my mother to the hospital. My father's family hired a lawyer to divorce my mother and father and send us to an orphanage instead of helping my mother." (Participant No. 3)
"My mother is afraid of my father. When my father gets angry, he starts swearing at my mother, insulting his own family, and my mother has nothing next to my father respect, no peace." (Participant No. 1)
Bearing the heavy responsibility of the family
The subjects mentioned that their mothers try to maintain the family's life by taking care of their offspring, working outside the home, preserving their offspring's spirits, and making an effort to follow the proper treatment process for their father, bearing the heavy responsibility of the family.
"I can say that my mother takes on all the responsibilities instead of my father. How can I put it? My father was just a name that we dragged like a child, like nothing. She's responsible for our lives." (Participant No. 3)
"My father isn't a good husband for them. Our lives fall apart when my mother isn't at home one day. My mother takes on both the responsibilities of the family head and her motherly duties. All the responsibilities of life are on my mother." (Participant No. 1)
"My mother has tried not to let us become offsprings of divorce. She's tried to create everything that she could with my father. She's forgotten her wishes and tries calming us down and fulfilling our financial and educational needs." (Participant No. 9)
Sympathy with the father
The findings indicate that offspring sympathize with the limited capabilities of their fathers and the behaviors that create prejudices against them by others.
Observing the dependence of the father
According to the participants, their fathers depend on them to perform daily activities. Instead of their fathers taking care of them, they must take care of their fathers.
"We always have to be careful that he takes his medicine. We have to take care of his every need. In a way, we've learned to take care of him so he doesn't get upset. We must watch over him." (Participant No. 2)
"Most of the time, our roles switch with our father. Instead of our father being our support, we must care for him. We must be careful that nothing happens to him and ensure that no one treats him badly." (Participant No. 9)
Discomfort with the behaviors of others towards their father
Participants expressed their discontent with how others, especially outsiders, treat veterans, as they are often unaware of their difficulties. They feel that their fathers are labeled as "nervous" or "mentally unstable," leading to them being looked down upon.
"When he used to go to the hospital, I would feel uncomfortable because I'm sure they wouldn't treat him as he deserves, given the stigma around mental health issues, and he can't defend himself. So, when my father is hospitalized, my mind is preoccupied with it the whole time." (Participant No. 6)
Fears, worries, and mental struggles
Participants shared their fears, worries, and mental struggles resulting from their experiences. They are afraid of the future, fear for the well-being of their family members, and are constantly preoccupied with the events in their households and their father's condition. They also lament the lives of others.
Fear of the future
According to the participants, they fear that the events and conditions they've experienced might repeat in their own lives and the lives of their future offspring. The challenges they face in their family life make them anxious about their future, and some are reluctant to get married.
"I don't intend to have a shared life. It's damaging to the other person. I can't involve others in my family issues. On the other hand, I'm afraid to marry someone who doesn't understand my father's situation, fearing that it would lead to more problems in my life." (Participant No. 9)
"I genuinely can't trust anyone. I'm afraid that my future life will be as full of problems as it has been until now because the problems in our lives are endless; every day, something happens. I'm afraid my offspring will go through the same hardships I've experienced." (Participant No. 3)
Concern for the well-being of family members
Participants mentioned their fears and worries related to the well-being of family members. They are anxious about the possibility of harm coming to their father, mother, or other family members, especially when they are not at home. They fear that something unfortunate might happen in their absence.
"When I was in school, I often came home to find the house in disarray because my father was in a bad mood. Every time I came back from school, I had this specific stress; I thought, 'What scene will I face now?'" (Participant No. 7)
"We're afraid to be asleep, and that he might harm us. When he's upset with me, I'm worried he won't like me, and if he does something in the middle of the night, he might hurt me." (Participant No. 9)
Mental struggles due to household problems
The ongoing conflicts within the family and the resulting harm to family members cause participants to constantly obsess about household events. They feel that these problems are never-ending and are always concerned about the recurrence of issues and problems.
"We, the offsprings of veterans, are always waiting for something bad to happen. We're always prepared for something to happen, and our minds are never at ease because we know that a small act can completely shatter our father and our entire life." (Participant No. 6)
"I often think about why my father went to war, why I had to be born into this world. I contemplate it in solitude and wish I were in another family. I put myself in other people's shoes, thinking, 'I wish my life, my family, were like theirs.'" (Participant No. 5)
Mental struggles due to father's status
Participants often contemplate why their fathers are veterans and whether their lives would be different if they weren't. They compare with others, questioning why their lives differ from those of other people.
"Many times, I think if my father hadn't gone to war, our lives would have been better. We wouldn't have had so many problems, and we could have lived like normal people." (Participant No. 2)
"I think about the differences between us and others. Some things that are normal for ordinary people feel strange to us. Our lives are very different from those of others ..." (Participant No. 9)
"Why do these things happen to me? Why did I have to be born into this situation? I often think about it in solitude, wondering if my life, my family, could be different." (Participant No. 4)
Discussion
The findings of this research elucidate the five main categories that define the negative experiences of the offspring of war veterans with PTSD. Among these, an insecure childhood, witnessing their fathers' endless suffering, challenges in their mothers' lives, empathy towards their fathers, and mental anguish are central experiences. An insecure childhood was almost universally mentioned in interviews and is thus crucial in this study. Collins, in 2018, through a review of studies investigating the impact of parents with PTSD on the mental health of their offspring, indicated that these offspring face behavioral, emotional, and academic difficulties [23]. The parenting abilities of these parents in forming appropriate emotional bonds with their offspring are reduced. In this study, many participants referred to the presence of anxiety and tension within the home due to the constant mental turmoil of the fathers. It was pointed out that family members had to be prepared for potential conflicts and arguments within the household, resulting in the offspring experiencing neglect, a lack of affection, and insufficient support. Furthermore, during their childhood, these offspring were expected to behave according to their father's will, and, like adults, their childlike activities were restricted.
Certainly, war has direct and lasting psychological and emotional effects on survivors. Maleki et al. addressed complaints, including a lack of intimate family relationships, family conflicts, and unhealthy relationships with offspring among a wide range of victims of chemical bombardments in Sardasht, consistent with the present study [2]. Other studies have shown that gender differences in caretaker couples and offspring have different effects on PTSD symptoms. The lack of positive emotions in the family has led to an increase in PTSD symptoms in girls. At the same time, the negative relationship of sons with their mothers has resulted in the development of avoidance behaviors, irritability, and emotional numbness [24]. Risk factors for poor school performance in offspring are present [25]. Offsprings whose parents are affected seek less preventive healthcare, and visits for psychological problems and misbehavior have increased in this group [26].
The findings of this study demonstrated that mothers in families of war veterans with PTSD endure various difficulties and challenges in life. The offspring's experiences include being entrusted with the responsibility of life and striving to meet their needs, maintaining their spirits, providing emotional support to their offspring, and pursuing their spouse's treatment. In some cases, mothers work outside the home to make ends meet. It was also noted that spouses of war veterans lack the necessary support, leading to anger and resentment in many cases, which can sometimes result in physical harm. A study investigating psychological distress among the female partners of war veterans revealed high levels of psychological distress, depression, and suicidal thoughts, which are common among these spouses [27].
Other domestic studies have also indicated a decrease in mental well-being and increased responsibilities of war veterans' spouses. They endure the tolerance of spousal violence, take on the responsibility for all household matters, and preserve the family foundation [28, 29].
This research showed that offsprings of war veterans feel empathy for their fathers' inadequacies and witness their fathers' moments of life struggles. One of the categories of experiences among offspring is empathy for their fathers' weaknesses. Some offsprings of war veterans express empathy for their fathers' weakness in defending their rights against others, their inability to care for themselves, and their dependence on their offspring. They also show concern for their fathers when others insult them due to illness and their psychological state while in the hospital. In society, they feel their fathers, as sacrificers, are not respected or appreciated.
A secure environment for personal growth is essential for everyone, especially during childhood. It depends on how well the living environment meets the needs and desires of the child. According to this research, offsprings of war veterans experience challenges achieving a sense of security. Many do not feel secure and express constant fears and concerns as negative aspects of their lives. Many subjects expressed concerns about the health of their family members, always fearing that their father may be harmed during his seizures. Many offspring also expressed concerns about an uncertain future, especially regarding marriage, as they were of marriageable age. They fear introducing new problems to their lives and being like their families. They also fear the suffering of their offspring in a similar manner. A study by Murphy also referred to concerns about an uncertain future and the introduction of new problems into their lives [16].
Furthermore, the frequent recurrence of unfortunate events in their lives, such as family disintegration and the instability of the home environment, has turned their fear of the permanence of bad life events into anxiety. In a study conducted by Khodabakhshi et al. in 2019, concern about an uncertain future was mentioned, which is consistent with the findings of this study [30]. Some also believe that being together in the family helps them solve problems and cope with life issues. Therefore, some of the offspring of veterans fear leaving their mothers alone, citing the mother's struggle with difficulties. The findings of this report show that offsprings of veterans have mental conflicts that hurt their mental and emotional well-being and quality of life. Most interviews referred to mental preoccupation with concerns about events that might happen when they are not at home. Some also mentioned their mental preoccupation with their father's veteran status, why their father went to war, and their life if he weren't a veteran. Others lamented their perpetual comparisons with others and their families and that they don't have a normal life [30].
The unwillingness of subjects, especially the sons of veterans, to remember difficult days in their lives, such as limitations, was one of the main challenges of this research. They had no interest in talking, and despite inviting many sons of veterans, they did not participate in the interviews. As a result, the majority of participants in this research were women, and it is recommended that future research pay attention to this issue.
Furthermore, given that most of the offsprings of war veterans are often of marriageable age and many of them are married, it is recommended that research be conducted on their parenting capabilities. Additionally, it is advisable to study the mental and emotional challenges that the offspring of veterans face in their education. Through providing individual and family support, many serious mental and psychological issues in these individuals can be prevented. Therefore, identifying the experiences of the families and offsprings of war veterans is highly beneficial for policymakers in organizations such as the Foundation of Martyrs and Veterans, its managers, and individuals involved in providing services to the families of veterans. This knowledge is crucial for offering better and more quality services to this group because it is essential to understand what these individuals go through in their lives and their increased needs in this domain. These individuals require in-depth studies of their challenges and needs by relevant institutions. Since this study was conducted qualitatively, it may not be directly generalizable to a larger population, but its findings can be considered insights from a small sample.
Conclusion
The offspring of veterans with post-traumatic stress disorder continue to face various unpleasant experiences compared to others, which impact their mental health and overall quality of life.
Acknowledgment The authors tend to appreciate the families of veterans and the mental health hospital in Ahvaz.
Ethical Permissions: Ethical approval was obtained from the Jundishapur University of Medical Sciences (Ethical Code: IR.AJUMS.REC.1399.20).
Conflict of Interests: None declared by the authors.
Authors’ Contribution: Fallahinezhad S (First Author), Introduction Writer/ Original Researcher/Discussion Writer (30%); Mandani Gh (Second Author), Methodologist/Original Researcher (15%); Tahanzadeh B (Third Author), Introduction Writer/Methodologist/Original Researcher/Discussion Writer (30%); Ghasemzaade R (Fourth Author), Methodologist/Assistant Researcher (10%); Salahshouri A (Fifth Author), Methodologist/Assistant Researcher/Statistical Analyst (15%)
Funding/Support: This study represents a part of a larger study conducted as a Master's thesis on Empowerment Management at Jundishapur University of Medical Sciences, Ahvaz, Iran.
Keywords:
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